Subsequent obstetrics outcomes after intrauterine death during the first pregnancy

Abstract

Objective: We aimed to determine whether the risks of adverse outcomes were greater in women who had pregnancies ending in stillbirth than in those with no previous history of stillbirth.

Methods: This retrospective cohort study included all women who had undergone their first and second deliveries at Bakirkoy Women’s and Children’s Education and Research Hospital between 2002 and 2011. Women who delivered following a previous stillbirth after 20 complete weeks of gestation were compared with those who had delivered but had no history of stillbirth after 20 weeks of gestation.

Results: We compared 201 subsequent births to women with previous histories of stillbirth with 402 live births to women with no such history. The rates of pre-eclampsia [odds ratio (OR), 3.4; 95% confidence interval (CI), 1.5–7.4], HELLP syndrome (OR, 3.1; 95% CI, 1.2–9.6), low birth weight (OR, 1.6; 95% CI, 0.7–3.5) and malpresentation (OR, 2.9; 95% CI, 1.6–4.8) were significantly higher in the case group. Howewer, the rates of stillbirth were similar between the groups.

Conclusion: We found increased rates of obstetric and perinatal complications in subsequent pregnancies in women with histories of stillbirth. Thus, the results of this study suggest that pregnant women with histories of stillbirth should be followed closely, beginning in the early gestational period.     

Emergency Peripartum Hysterectomy in a Developing Country

BackgroundEmergency peripartum hysterectomy (EPH) is a life-saving surgical procedure that is associated with maternal morbidity and mortality, especially in developing countries. The advent of newer medical and conservative surgical methods of controlling postpartum hemorrhage will influence both the rate and the outcomes of the procedure.ObjectiveTo study the rate of EPH, the influence of sociodemographic characteristics on the rate of the procedure, the modality of treatment used in each of the indications, and maternal–fetal morbidity and mortality.MethodsWe conducted a case–control study of 30 patients who underwent EPH between June 1, 2003, and 31 May 31, 2008, at Aminu Kano Teaching Hospital, Kano, Nigeria, a tertiary institution in a developing country.ResultsThe rate of EPH in this study was 4.0 per 1000 deliveries. Ruptured uterus (73.3%) was the most common indication. Factors showing a significant association with EPH were being 31 to 40 years old (OR 6.7; 95% CI 3.9 to 15.7), being para ≥ 5 (OR 4.1; 95% CI 1.87 to 9.1), having unbooked status (OR 9.1; 95% CI 3.6 to 24.9), and being in a low social class (OR 7.5; 95% CI 1.7 to 45.3). Ruptured uterus (OR 164.3; 95% CI 67.9 to 410.0) and placenta previa accreta (OR 36.1; 95% CI 10.0 to 117.3) were significantly associated with EPH. The most common morbidity was wound sepsis (60%). The case fatality rate was 13.3%, and perinatal mortality was 73.3%.ConclusionThe rate of EPH in our institution is high, and maternal–fetal outcome is poor. Antenatal care and hospital delivery should be encouraged.     

Pregnancy outcomes in liver transplant patients,a population-based study

Objective: To determine the incidence of pregnancy in liver transplant (LT) patients in a large population-based cohort and to determine the maternal and fetal risks associated with these pregnancies.

Methods: We conducted an age-matched cohort study using the US Healthcare and Utilization project–Nationwide Inpatient Sample from 2003–2011. We used unconditional logistic regression, adjusted for baseline characteristics, to estimate the likelihood of common obstetric complications in the LT group compared with age-matched nontransplant patients.

Results: There were 7?288?712 deliveries and an estimated incidence of 2.1 LTs/100?000 deliveries over the nine-year study period. LT patients had higher rates of maternal complications including hypertensive disorders (OR 6.5, 95% CI: 4.4–9.5), gestational diabetes (OR 1.9, 95% CI: 1.0–3.5), anemia (OR 3.2, 95% CI: 2.1–4.9), thrombocytopenia (OR 27.5, 95% CI: 12.7–59.8) and genitourinary tract infections (OR 4.2, 95% CI: 1.8–9.8). Deliveries among women with LT had higher risks of cesarean section (OR 2.9, 95% CI: 2.0–4.1), postpartum hemorrhage (OR 3.2, 95% CI: 1.7–6.2) and blood transfusion (OR 18.7, 95% CI: 8.5–41.0). Fetal complications in LT patients included preterm delivery (OR 4.7, 95% CI: 3.2–7.0), intrauterine growth restriction (OR 4.1, 95% CI: 2.1–7.7) and congenital anomalies (OR 6.0, 95% CI: 1.1–32.0).

Conclusion: Although pregnancies in LT recipients are feasible, they are associated with a high rate of maternal and fetal morbidities. Close antenatal surveillance is recommended.     

Severe Maternal Morbidity and Maternal Mortality Associated with Assisted Reproductive Technology

ObjectiveTo assess the association between use of assisted reproductive technologies (ART) and severe maternal morbidity and maternal mortality (SMM).MethodsWe carried out a cohort study that included all hospital deliveries at ≥20 weeks gestation in Canada (excluding Québec) between April 2009 and March 2018. Outcomes of interest included composite SMM and SMM types (e.g., severe preeclampsia, HELLP syndrome, and eclampsia; severe hemorrhage; acute renal failure). Multivariable regression was used to estimate crude and adjusted rate ratios (RR and aRR) and 95% confidence intervals (CI).ResultsThe study included 2 535 056 women, of whom 72 023 (2.8%) delivered following the use of ART. The composite SMM rate for women who used ART was 34.7 per 1000 deliveries (95% CI 33.0–36.0) versus 11.5 per 1000 deliveries (95% CI 11.4–11.6) for women who did not use ART (RR 3.01; 95% CI 2.89–3.14). ART use was associated with SMM types such as severe preeclampsia, HELLP syndrome, and eclampsia (RR 3.50; 95% CI 3.27–3.73), severe hemorrhage (RR 3.58, 95% CI 3.27–3.92), and acute renal failure (RR 6.79; 95% CI 5.78–7.98). Associations between ART and composite SMM were attenuated but remained elevated after adjusting for maternal characteristics (aRR 2.34; 95% CI 2.24–2.45). Women who used ART and had a multi-fetal pregnancy had a 4.7 times higher rate of composite SMM compared with women who did not use ART and delivered singletons.ConclusionWomen who deliver following the use of ART have increased risks of SMM and require counselling that includes mention of the lower risks of SMM associated with ART-conceived singleton pregnancy.     

Cannabis Use in Pregnancy in British Columbia and Selected Birth Outcomes

ObjectiveThis study sought to determine the association between cannabis use in pregnancy and stillbirth, small for gestational age (SGA) (<10th percentile), and spontaneous preterm birth (<37 weeks).MethodsThe study used abstracted obstetrical and neonatal medical records for deliveries in British Columbia from April 1, 2008 to March 31, 2016 that were contained in the Perinatal Data Registry of Perinatal Services British Columbia. Chi-square tests were conducted to compare maternal sociodemographic characteristics by cannabis use. Logistic regression was conducted to determine the association between cannabis use and SGA and spontaneous preterm births. Cox proportional hazards regression modelling was used to identify the association between cannabis use and stillbirth. Secondary analyses were conducted to ascertain differences by timing of stillbirth (Canadian Task Force Classification II-2).ResultsMaternal cannabis use has increased in British Columbia over the past decade. Pregnant women who use cannabis are younger and more likely to use alcohol, tobacco, and illicit substances and to have a history of mental illness. Using cannabis in pregnancy was associated with a 47% increased risk of SGA (adjusted OR 1.47; 95% CI 1.33–1.61), a 27% increased risk of spontaneous preterm birth (adjusted OR 1.27; 95% CI 1.14–1.42), and a 184% increased risk of intrapartum stillbirth (adjusted HR [aHR] 2.84; 95% CI 1.18–6.82). The association between cannabis use in pregnancy and overall stillbirth and antepartum stillbirth did not reach statistical significance, but it had comparable point estimates to other outcomes (aHR 1.38; 95% CI 0.95–1.99 and aHR 1.34; 95% CI 0.88–2.06, respectively).ConclusionCannabis use in pregnancy is associated with SGA, spontaneous preterm birth, and intrapartum stillbirth.     

Prevalence of Pre-Pregnancy Diabetes,Obesity, and Hypertension in Canada

ObjectivePre-existing diabetes mellitus (D), obesity (O), and chronic hypertension (H) can each alter the natural course of pregnancy, especially when they cluster together. Because the prevalence of various combinations of D, O, and H is unknown, the current study was undertaken.MethodsThis population-based cross-sectional study included 506 483 singleton and twin live birth and stillbirth deliveries in Ontario, occurring at ≥20 weeks gestation. All hospital births from 2012 to 2016 were identified in the Better Outcomes Registry and Network information system. The prevalence per 1000 births (95% confidence interval [CI]) of D, O, and H and their combinations were calculated. Prevalence estimates were stratified by twin and singleton gestations, maternal age, parity, and ethnicity (Canadian Task Force Classification II-2).ResultsDuring the study period, 5493 women (10.8 per 1000 births; 95% CI 10.6–11.1) had D, 90,177 (178.2; 95% CI 177.0–179.3) had O, and 5667 (11.2; 95% CI 10.9–11.5) had H. The prevalence per 1000 of DO was 4.8, DH 1.0, and OH 5.5, whereas 359 women (0.71 per 1000) had all three. D and H each linearly increased with rising maternal age, along with their combinations, and to some degree with higher parity. The combination of O and H was highest among women of Black ancestry (14.5 per 1000) and lowest among those of Asian ancestry (3.0 per 1000).ConclusionD, O, and H are common conditions in pregnancy, both alone and in various combinations. These data can be used to assess the impact of each state on perinatal health.     

Impact of Episiotomy During Operative Vaginal Delivery on Obstetrical Anal Sphincter Injuries

ObjectiveThe purpose of this study was to describe associations between episiotomy at the time of forceps or vacuum-assisted delivery and obstetrical anal sphincter injuries (OASIS).MethodsThis population-based retrospective cohort study used delivery information from a provincial perinatal clinical database. Full-term, singleton, in-hospital, operative vaginal deliveries of vertex-presenting infants from April 1, 2006 to March 31, 2016 were identified. Odds ratios (ORs) and 95% confidence intervals (CIs) for associations between episiotomy and third- or fourth-degree lacerations were calculated in multiple logistic regression models (Canadian Task Force Classification II-2).ResultsEpisiotomy was performed in 34% of 52 241 operative vaginal deliveries. OASIS occurred in 21% of forceps deliveries and 7.6% of vacuum deliveries. Episiotomy was associated with increased odds of severe perineal lacerations for vacuum deliveries among women with (OR 2.48; 95% CI 1.96–3.13) and without (OR 1.12; 95% CI 1.02–1.22) a prior vaginal delivery. Among forceps deliveries, episiotomy was associated with increased odds of OASIS for those with a previous vaginal delivery (OR 1.52; 95% CI 1.12–2.06), but it was protective for women with no previous vaginal delivery (OR 0.73; 95% CI 0.67–0.79). Midline compared with mediolateral episiotomy increased the odds of OASIS in forceps deliveries (OR 2.73; 95% CI 2.37–3.13) and vacuum deliveries (OR 1.94; 95% CI 1.65–2.28).ConclusionIn conclusion, results suggest that episiotomy should be used with caution, particularly among women with a previous vaginal delivery and in the setting of vacuum-assisted delivery. Episiotomy may protect against OASIS in forceps-assisted deliveries for women without a prior vaginal delivery.     

Effects of parity and mode of delivery on urinary incontinence among postmenopausal women in Taiwan

ObjectiveTo investigate the association between the prevalence of urinary incontinence and parity or mode of delivery among Taiwanese women aged 60 years or older.MethodsBetween July 1999 and December 2000, a nationwide epidemiologic study was conducted in Taiwan among 2410 women selected by a multistage random sampling method. Face-to-face interviews with 1517 women were conducted. The relationship between the prevalence of urinary incontinence and the number of vaginal deliveries or number of cesarean deliveries was assessed by frequency and Pearson χ² test using a significance level of less than 0.05. Logistic regression was used to investigate the significance of dichotomous dependent variables.ResultsDecades ago, most Taiwanese women (1435 of 1511 respondents, 94.97%,) gave birth via vaginal delivery and the rate of cesarean delivery was low (20 of 1513 respondents, 1.32%). Parity (odds ratio [OR], 2.42; 95% confidence interval [CI], 0.87–6.71; P = 0.091), vaginal delivery (OR, 0.76; 95% CI, 0.39–1.47; P = 0.408), and cesarean delivery (OR, 1.47; 95% CI, 0.59–3.70; P = 0.409) did not increase the risk of urinary incontinence.ConclusionThere was no association between urinary incontinence and parity or mode of delivery among Taiwanese postmenopausal women decades after their first delivery.     

Risk factors and complications of manual placental removal after vaginal delivery – how common are additional invasive procedures?

Purpose: The purpose of this study is to assess risk factors and complications of manual placental removal.

Materials and methods: An historical prospective study of all parturients undergoing manual placental removal between 2012 and 2014. Parturients were matched by time of delivery with parturients delivering vaginally with spontaneous placental separation. Multiple gestations, preterm deliveries, incomplete placental separation and uterine malformations were excluded. Delivery characteristics and short-term complications were studied. Telephone questionnaires were conducted to assess the likelihood of invasive procedures performed for retained products of conception (RPOC) up to 12 weeks postpartum.

Results: Overall 293 (1.5% of all vaginal deliveries) were complicated by manual placental removal. Independent risk factors included advanced maternal age (odds ratio (OR) 1.08, 95% CI 1.03–1.12), previous manual removal (OR 9.27, 95% CI 3.15–27.31), regional anesthesia (OR 3.49, 95% CI 2.14–5.70), and labor induction (OR 1.80, 95% CI 1.12–2.88). Short-term complications included blood product transfusions (OR 18.26 95% CI 5.37–62.13) and prolonged hospitalization (OR 1.51 95% CI 1.06–2.16). Invasive procedures for removal of RPOC occurred in 12.2% of women in the study groups and in none of the women in the control group (p?Conclusions: Manual placental removal harbors short- and long-term complications, including a high likelihood of RPOC necessitating further invasive procedures.     

Severe and acute maternal morbidity: Lithuanian experience and review

OBJECTIVE: To measure the incidence of severe acute maternal morbidity (SAMM) and to find the risk factors that could be useful in trying to predict the development of SAMM. METHODS: The data were collected prospectively in 7 maternity units from different Lithuanian regions over a 1-year period. Every woman with a clinical diagnosis of severe preeclampsia, eclampsia, Hemolysis, Elevated Liver enzymes, and Low Platelet count (HELLP) syndrome, severe hemorrhage, uterine rupture, or severe sepsis during pregnancy or delivery or until the 42nd day post partum was included after verification of diagnosis by using clinical criteria. RESULT: One hundred and six cases of SAMM and one maternal death were identified during the study among 13,399 deliveries (7.91/1000 deliveries 95% CI 6.48-9.56). There were 57 cases of severe preeclampsia, 3 cases of eclampsia, 38 cases of severe hemorrhage, 3 cases of uterine rupture, and 4 cases of severe sepsis. One maternal death occurred due to HELLP syndrome, so the case-fatality ratio for severe morbidity was 0.99%. CONCLUSIONS: The incidence of SAMM and case-fatality rate in Lithuania are similar to those in other European countries. The main risk factors for SAMM were previous peripartum hemorrhage, previous hypertension, previous renal diseases, lack of antenatal care, and dystocia.     

Trends and risk factors of stillbirth in New Jersey 1997–2005

Introduction: The purpose of this study was to examine the trends in the rates of stillbirth by race and ethnicity and to determine the risk factors of stillbirth. Methods: We used New Jersey data (1997–2005) for live births and fetal deaths. Cox proportional hazards model was used to estimate the risk of stillbirth associated with maternal risk factors and pregnancy complications. Results: The rate of stillbirth was 4.4/1000 total births (3.4 for white and 7.9 for black non-Hispanics and 4.4 for Hispanics/1000 total births). The rates of stillbirth decreased from 3.8 in 1997 to 2.7/1000 total births in 2005 for white non-Hispanics but remained unchanged for other race/ethnicity groups. Adjusted relative risks for the risk factors associated with stillbirth were 1.3 (95% CI, 1.2–1.4) for maternal age ≥ 35 years, 1.9 (95% CI, 1.7–2.1) for black non-Hispanics, 2.8 (95% CI, 2.4–3.3) for no prenatal care, 40.2 (95% CI, 36.9–43.9) for placental abruption, 5.3 (95% CI, 3.4–8.2) for eclampsia, 3.5 (95% CI, 2.8–4.3) for diabetes mellitus and 1.7 (95% CI, 1.3–2.2) for preeclampsia. Conclusion: There was a decline in the rate of stillbirth but there were persistent racial disparities with the highest rates of stillbirth for black non-Hispanics.     

Maternal age over 40 years and pregnancy outcome: a hospital-based survey

Objective: Increased risk for adverse pregnancy outcomes with advancing maternal age has been described but the strength of association remains debated, particularly in presence of confounding factors such as parity, twin pregnancy and pregnancy from assisted reproductive technologies. The aim of this study was to evaluate pregnancy outcomes in a large cohort of women aged over 40 years. The hypothesis was that advanced maternal age may be an independent risk factor for adverse pregnancy outcome.

Study design: We reviewed the clinical records of 56,211 women who delivered at Sant’Anna University Hospital, Turin, Italy, in the period between 2009 and 2015. Of these, 3798 women aged over 40 years were divided into two age groups (40???44 years and ≥45 years). Women of any parity, with singleton or twin pregnancies, or with assisted reproductive technology pregnancies were included. Women aged less than 40 years were considered as controls. Primary outcome measures were maternal and perinatal complications. Comparisons were performed using Chi-square test and Fisher’s exact test. Univariate analysis and logistic regression analysis were performed to test the possible independent role of maternal age as a risk factor for adverse pregnancy outcome.

Results: Maternal age was an independent risk factor for gestational diabetes (age 40–44 years: odds ratios (OR) 2.10, 95% CI 1.80–2.45; age ≥45 years: OR 2.83, 95% CI 1.79–4.46) and early-onset preeclampsia (age 40–44 years: OR 2.10, 95% CI 1.63–2.70; age ≥45 years: OR 3.16, 95% CI 1.68–5.94). The risk for placenta praevia was higher in the women aged 40–44 years (OR 1.87, 95% CI 1.36–2.57). Neonatal outcomes were similar among groups, except for the rate of birth weight less than 2500?g, which was higher in women aged 40–44 years (OR 1.27, 95% CI 1.12–1.42). However, older women showed an overall higher incidence of preterm birth.

Conclusions: Maternal age over 40 years is an independent risk factor for adverse pregnancy outcomes, particularly for the mother. Pregnancies in women over 40 years should be considered at risk and carefully monitored with individualized care protocols.     

Obstetric outcomes subsequent to intrauterine death in the first pregnancy

Objective  To compare obstetric outcomes in the pregnancy subsequent to intrauterine death with that following live birth in first pregnancy.
Design  Retrospective cohort study.
Setting  Grampian region of Scotland, UK.
Population  All women who had their first and second deliveries in Grampian between 1976 and 2006.
Methods  All women delivering for the first time between 1976 and 2002 had follow up until 2006 to study their next pregnancy. Those women who had an intrauterine death in their first pregnancy formed the exposed cohort, while those who had a live birth formed the unexposed cohort.
Main outcome measures  Maternal and neonatal outcomes in the second pregnancy, including pre-eclampsia, placental abruption, induction of labour, instrumental delivery, caesarean delivery, malpresentation, prematurity, low birthweight and stillbirth.
Results  The exposed cohort ( n = 364) was at increased risk of pre-eclampsia (OR 3.1, 95% CI 1.7–5.7); placental abruption (OR 9.4, 95% CI 4.5–19.7); induction of labour (OR 3.2, 95% CI 2.4–4.2); instrumental delivery (OR 2.0, 95% CI 1.4–3.0); elective (OR 3.1, 95% CI 2–4.8) and emergency caesarean deliveries (OR 2.1, 95% CI 1.5–3.0); and prematurity (OR 2.8, 95% CI 1.9–4.2), low birthweight (OR 2.8, 95% CI 1.7–4.5) and malpresentation (OR 2.8, 95% CI 2.0–3.9) of the infant as compared with the unexposed cohort ( n = 33 715). The adjusted odds ratio for stillbirth was 1.2 and 95% CI 0.4–3.4.
Conclusion  While the majority of women with a previous stillbirth have a live birth in the subsequent pregnancy, they are a high-risk group with an increased incidence of adverse maternal and neonatal outcomes.     

Iranian primigravid women's awareness of the risks associated with delayed childbearing

Abstract

Objectives To explore older (35 years +) primigravid women's knowledge of the risks of delayed childbearing and to identify the characteristics of those with limited knowledge.

Methods A cross-sectional survey involving 675 primigravid women in Tehran, Iran, using a cluster random sampling method at the first prenatal visit. A validated questionnaire assessed the women's awareness of delayed-childbearing risks.

Results Women variously identified conception difficulties, gestational diabetes, hypertension, multiple birth, caesarean section, preterm delivery, stillbirth, Down's syndrome, congenital abnormality, and low birth weight, as associated with delayed childbearing. Awareness of infant risks ranged between 10 and 72%. Awareness of maternal risks were independently related to the women’s educational levels (odds ratio [OR]: 1.95; 95% confidence interval [CI]: 1.12–3.38), planned pregnancy (OR: 1.87; 95% CI: 1.25–2.78) and maternal age ≥ 40 (OR: 1.24; 95% CI: 1.14–2.53). Women aware of infant risks were significantly likely to be aged ≥ 40 (OR: 1.87; 95% CI: 0.01–5.12), have post-graduate education (OR: 2; 95% CI: 1.90–4.42), and have a planned pregnancy (OR: 1.99; 95% CI: 1.03–5.12).

Conclusion Women are largely unaware of the potential complications of delayed childbirth. Understanding the risks is important for reproductive healthcare providers and policy makers in providing appropriate information to enable women to make informed decisions on the timing of conception.     

Effect of maternal age on the risk of stillbirth: a population-based cohort study on 37 million births in the United States

The objective of our study was to evaluate the incidence and effect of maternal age on the risk of stillbirth. We conducted a population-based cohort study using the Centers for Disease Control and Prevention's "Linked Birth-Infant Death" and "Fetal Death" data files. We excluded all births of gestational age under 24 weeks and those with reported congenital malformations. We estimated the adjusted effect of maternal age on the risk of stillbirth using logistic regression analysis. There were 37,504,230 births that met study criteria, of which 130,353 (3.5/1,000) were stillbirths. Rates of stillbirth remained constant throughout the 10 years. As compared with women between the ages of 25 and 30, decreasing maternal age was associated with the following risk of stillbirth: odds ratio (OR) 0.95 (95% confidence interval [CI] 0.93 to 0.97) for ages 20 to 25; OR 0.97 (95% CI 0.94 to 0.99) for ages 15 to 20; and OR 1.32 (95% CI 1.18 to 1.47) for ages <15. Increasing maternal age was associated with an increasing risk of stillbirth: OR 1.02 (95% CI 0.99 to 1.04) for ages 30 to 35, OR 1.25 (95% CI 1.21 to 1.28) for ages 35 to 40, OR 1.60 (95% CI 1.53 to 1.67) for ages 40 to 45, and OR 2.22 (95% CI 1.91 to 2.53) for ages >45. Although the overall risk is low, the risk of stillbirth increases considerably in women at the extremes of the reproductive age spectrum. Antenatal surveillance may be justified in these women.     

Comparison of the effect of caseload midwifery program and standard midwifery-led care on primiparous birth outcomes: A retrospective cohort matching study

BackgroundThe effectiveness of continuity of care during the perinatal period is well documented, but implementing continuity of care model to practice requires evaluation.AimTo evaluate the effect of a caseload midwifery program (CMP) on birth outcomes and rates of perinatal interventions at a metropolitan tertiary hospital in Australia, compared with standard midwifery-led care (SMC).MethodsThis was a retrospective, matched-cohort study. We extracted the data of 1000 nulliparous women from records of 19,001 women who gave birth at the hospital from 2011 to 2014. We used basic statistical tests to compare baseline demographic data, and logistic regression to calculate odds ratios, to evaluate maternal and neonatal outcomes.ResultsAdjusted regression analysis for the primary outcome showed that compared with women who received SMC, women who received care through CMP had an increased rate of normal vaginal birth (69% vs. 50%, OR = 1.79, 95%, CI = 1.38–2.32). Assessment of secondary outcomes showed that the women in CMP group had decreased rates of instrumental birth (15% vs. 26%, OR = 0.48, 95% CI = 0.35–0.66), episiotomy (23% vs. 40%, OR = 0.43, 95% CI = 0.33–0.57), epidural analgesia (33% vs. 43%, OR = 0.64, 95% CI = 0.50–0.83) and amniotomy (35% vs. 50%, OR = 0.56, 95% CI = 0.43–0.72). The CMP group also had greater rates of water immersion (54% vs. 22%, OR = 4.18, 95% CI = 3.17–5.5), physiological 3rd stage (7% vs. 1%, OR = 11.71, 95% CI = 3.56–38.43) and 2nd degree tear (34% vs. 24%, OR = 1.60, 95% CI = 1.21–2.11). There were no significant differences between the two groups for rates of other secondary outcomes including Caesarean section, cervical ripening procedures, third- and fourth-degree tears, postpartum haemorrhage and neonatal outcomes.ConclusionCMP care is associated with increased rate of normal vaginal birth which supports wider implementation of the model. In addition, using routinely collected data and a cohort matching design can be an effective approach to evaluate maternal and neonatal outcomes.     

Incidence,predictors and outcomes of congenital diaphragmatic hernia: a population-based study of 32 million births in the United States

Abstract

Objectives: To evaluate the incidence, risk factors and neonatal outcomes associated with a congenital diaphragmatic hernia (CDH).

Study design: We conducted a population-based cohort study using the CDC’s Linked Birth-Infant Death and Fetal Death data files on all births and foetal deaths in USA between 1995 and 2002. We estimated the yearly incidence of CDH and measured its adjusted effect on various outcomes using unconditional logistic regression analysis.

Results: About 32?145?448 births during the 8-year study period met the study’s inclusion criteria. The incidence of CDH was 1.93/10?000 births. Risk factors for the development of CDH included foetal male gender [OR 1.12, 95% CI: 1.06, 1.17], maternal age beyond 40 [OR 1.51, 95% CI: 1.26, 1.80], Caucasian ethnicity [OR 1.15, 95% CI: 1.10, 1.21], smoking [OR 1.34, 95% CI: 1.22, 1.46] and alcohol use during pregnancy [OR 1.37, 95% CI: 1.05, 1.79]. As compared to foetuses with no CDH, foetuses with CDH were at an increased risk of preterm birth [OR 2.90, 95% CI: 2.72, 3.11], intrauterine growth restriction [OR 3.84, 95% CI: 3.51, 4.18], stillbirth [OR 9.65, 95% CI: 8.20, 11.37] and overall infant death [OR: 94.80, 95% CI: 88.78, 101.23]. The 1-year mortality was 45.89%.

Conclusion: Congenital diaphragmatic hernia is strongly associated with an increased risk of adverse pregnancy, foetal and neonatal outcomes. These findings may be helpful in counselling pregnancies affected by CDH, and may aid in the understanding of the burden of this condition at the public health level.     

Trend of medically induced monozygotic twin deliveries according to age,parity, and type of assisted reproductive technique during the period 2007–2017 in Lombardy Region,Northern Italy: a population-based study

Purpose

The risk of monozygotic (MZT) twinning is increased in pregnancies after assisted reproductive technologies (ART). However, determinants remain poorly understood. To shed more light on this issue, we analyzed the estimated frequency of MZT twins from ART in Lombardy, Northern Italy, during the period 2007–2017.

Methods

This is a population-based study using regional healthcare databases of Lombardy Region. After having detected the total number of deliveries of sex-concordant and sex-discordant twins from ART, we calculated MZT rate using Weinberg’s method. Standardized ratios (SRs) and corresponding 95% confidence intervals (CI) of MZT deliveries, adjusted for maternal age, were computed according to calendar period, parity, and type of ART.

Results

On the whole, 19,130 deliveries from ART were identified, of which 3,446 were twins. The estimated rate of MZT births among ART pregnancies was higher but decreased over time (p-value = 0.03); the SRs being 1.33 (95% CI: 1.18–1.51), 0.96 (95% CI: 0.83–1.11), and 0.92 (95% CI: 0.79–1.07) for the periods 2007–2010, 2011–2014, and 2015–2017, respectively. The SRs of MZT among women undergoing first-level techniques, conventional in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) were 0.47 (95% CI: 0.38–0.57), 1.02 (95% CI: 0.88–1.17), and 1.43 (95% CI: 1.27–1.61) (p-value < 0.0001). The ratio of MZT births was significantly higher in women younger than 35 years (p-value < 0.0001) and slightly higher among nulliparae (p-value < 0.0001).

Conclusion

Despite a reduction of MZT rate from ART over the time, the risk remains higher among ART pregnancies rather than natural ones. Younger women and women undergoing ICSI showed the highest risk of all.

     

The incidence and risk factors for retained placenta after vaginal delivery – a single center experience

Abstract

Objective: We aimed to determine the incidence and risk factors for retained placenta immediately after vaginal delivery in a single, university-affiliated tertiary center.

Methods: A case-control study. Women who delivered vaginally and diagnosed with suspected retained placenta were compared to control group of women with spontaneous vaginal delivery with spontaneous non-complicated placental separation between the years 2007 and 2012. Eligibility was limited to singleton fetuses in vertex presentation with no history of more than one cesarean section, stillbirth or major fetal anomaly.

Results: Overall, 33?925 women delivered vaginally, of them, 491 (1.4%) underwent revision of uterine cavity due to suspected retained placenta. Women with retained placenta were characterized by a higher rate of previous cesarean section (OR 1.71, 95% CI 1.23–2.36), previous abortions, lower parity (OR 0.79, 95% CI 0.68–0.91), lower gestational age at delivery. Hypertensive disorders, oligohydramnios and labor and delivery interventions as induction of labor (OR 1.84, 95% CI 1.30–2.59), neuro-axial analgesia (OR 1.60, 95% CI 1.27–2.00) and vacuum delivery (OR 1.89, 95% CI 1.48–2.41) were independently associated with uterine revision for retained placenta.

Conclusion: Risk factors for manual revision due to retained placenta can be recognized. This data should be taken into consideration in the assessment of women immediately after delivery.     

Severe maternal morbidity during childbirth hospitalisation: a comparative analysis between the Republic of Ireland and Australia

Objective

To determine the population-based rates of severe maternal morbidity during childbirth hospitalisation and associated characteristics in the Republic of Ireland and to directly compare incidence rates with Australia.

Study design

Retrospective cohort study of 330,955 childbirth hospitalisations between 2005 and 2009. Using validated diagnostic criteria from Australia, we examined hospital discharge records (ICD-10-AM) to identify likely cases of severe maternal morbidity. We derived overall and category-specific morbidity incidence rates and examined five-year trends. Unadjusted relative risks were computed to assess sociodemographic and obstetric factors associated with morbidity status.

Results

The severe maternal morbidity five-year incidence rate was 1.34 per 100 deliveries. Between 2005 and 2009, the overall rate of severe morbidity significantly increased from 1.31 to 1.55 cases per 100 deliveries (test for trend p-value <0.001). Similar to Australia, the most frequently diagnosed severe morbidity indicators in Ireland were blood transfusion (112.6 per 10,000 deliveries), evacuation of haematoma (7.2 per 10,000 deliveries) and dilation and curettage with general anaesthesia (3.9 per 10,000 deliveries). In the Irish cohort, the risk of severe morbidity was more than three-fold (RR 3.48; 95% CI: 3.06–3.95) among women carrying multiple gestations and more than four-fold (RR 4.37; 95% CI: 3.66–5.22) among women with a stillbirth. Further, severe morbidity risk was 2.62 times higher among women with a pre-existing medical condition (RR 2.62; CI 2.03–3.37).

Conclusion

Our use of low-cost administrative data to identify severe maternal morbidity contributes to a growing body of international initiatives to inform preventive efforts. The ability to directly compare morbidity rates is advantageous, underscoring the need for a uniform definition of severe morbidity to promote accurate and reliable international comparisons.