The Effect of Maternal Age on Adverse Birth Outcomes: Does Parity Matter?

ObjectivesTo examine the effect of parity on the association between older maternal age and adverse birth outcomes, specifically stillbirth, neonatal death, preterm birth, small for gestational age, and neonatal intensive care unit admission.MethodsWe conducted a retrospective cohort study of singleton births in British Columbia between 1999 and 2004. In the cohort, 69 023 women were aged 20 to 29, 25 058 were aged 35 to 39, and 4816 were aged 40 and over. Perinatal risk factors, obstetric history, and birth outcomes were abstracted from the British Columbia Perinatal Database Registry. Logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals for adverse outcomes in the two older age groups compared with the young control subjects.ResultsCompared with younger control subjects, women aged 35 to 39 years had an aOR of stillbirth of 1.5 (95% CI 1.2 to 1.9) and women aged ≥ 40 years also had an aOR of 1.5 (95% CI 1.0 to 2.4). The aOR for NICU admission was 1.2 (95% CI 1.0 to 1.3) in women aged 35 to 39 years and 1.4 (95% CI 1.1 to 17) in women aged ≥ 40 years compared with younger control subjects. The risk of preterm birth and SGA differed by parity. The aOR for preterm birth compared with younger primiparas was 1.5 (95% CI 1.4 to 1.7) for women aged 35 to 39 years and 1.6 (95% CI 1.3 to 2.0) for women aged ≥ 40 years. In multiparas the aOR for preterm birth was 1.1 (95% CI 1.1 to 1.2) in women aged 35 to 39 and 1.3 (95% CI 1.1 to 1.5) in women > 40 years. The aOR for SGA in primiparas was 1.2 (95% CI 1.1 to 1.4) for women aged 35 to 39 and 1.4 (95% CI 1.1 to 1.7) for women aged ≥ 40 years. The risk of neonatal death was not significantly different between groups.ConclusionOlder women were at elevated risk of stillbirth, preterm birth, and NICU admission regardless of parity. Parity modified the effect of maternal age on preterm birth and SGA. Older primiparas were at elevated risk for SGA, but no association between age and SGA was found in multiparas. Older primiparas were at higher risk of preterm birth than older multiparas compared with younger women.     

The Combined Effect of Maternal Obesity and Fetal Macrosomia on Pregnancy Outcomes

ObjectiveTo examine the combined effect of macrosomia and maternal obesity on adverse pregnancy outcomes using a retrospective cohort.MethodsInfants with a birth weight of ≥ 4000g (macrosomia) were identified from an institutional birth cohort. Demographic characteristics and maternal, fetal, neonatal, and pregnancy outcomes of macrosomic infants whose mothers were obese were compared with those whose mothers were non-obese.ResultsPregnancies in obese women resulting in macrosomic infants are more likely to be complicated by gestational diabetes, gestational hypertension, and smoking than pregnancies in non-obese women with macrosomic infants. Mothers whose infants are macrosomic are significantly more likely to require induction of labour (OR 1.42; 95% CI 1.10 to 1.98) and delivery by Caesarean section (OR 1.45; 95% CI 1.04 to 2.01), particularly for maternal indications (OR 3.7; 95% CI 1.47 to 9.34), if they are obese. Finally, macrosomic infants of obese mothers are significantly more likely to require neonatal resuscitation in the form of free flow oxygen (OR 1.57; 95% CI 1.03 to 2.42) than macrosomic infants of non-obese mothers.ConclusionWhen both maternal obesity and macrosomia are present, adverse pregnancy outcomes are more common than when fetal macrosomia occurs in a woman of normal weight.     

Using Estimated Fetal Weight From Ultrasonography at 18 to 22 Weeks to Predict Gestational Diabetes Mellitus and Newborn Macrosomia

ObjectivesTo determine if fetal macrosomia in the second trimester predicts the onset of gestational diabetes mellitus (GDM) or large for gestational age (LGA) birth weight.MethodsWe performed a case–control study using data from the Diabetes in Pregnancy Clinic in our tertiary care hospital. Cases were women with GDM requiring insulin (n = 65) or controlled with diet (n = 65). Control subjects were women who screened negative for GDM at 24 to 28 weeks’ gestation (n = 131). Estimated fetal weight (EFW) was determined by ultrasound at 18 to 22 weeks.ResultsEstimated fetal weight that was one standard deviation (70 g) higher at 18 to 22 weeks was not associated with subsequent GDM (adjusted OR [aOR] 1.00, 95% confidence intervals 0.61 to 1.66), but was associated with a 231 g (95% CI 128 g to 334 g) increase in birth weight and increased odds of LGA (aOR 4.02, 95% CI 1.76 to 9.19) after adjusting for gestational age at the time of estimating fetal weight, maternal age, parity, BMI and GDM treatment.ConclusionEFW at 18 to 22 weeks did not predict the onset of GDM, but did predict LGA.     

The Effect of Gestational Weight Gain by Body Mass Index on Maternal and Neonatal Outcomes

ObjectiveTo evaluate the effects of gestational weight gain on maternal and neonatal outcomes in different body mass index (BMI) classes.MethodsWe compared maternal and neonatal outcomes based on gestational weight gain in underweight, normal weight, overweight, obese, and morbidly obese (BMI ≥ 40.00) women. The study group was a population-based cohort of women with singleton gestations who delivered between April 1, 2001, and March 31, 2007, drawn from the Newfoundland and Labrador Provincial Perinatal Program Database. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking status, partnered status, and gestational age) were performed and odds ratios (ORs) were calculated.ResultsOnly 30.6% of women gained the recommended amount of weight during pregnancy; 52.3% of women gained more than recommended, and 17.1% gained less than recommended. In women with normal pre-pregnancy BMI, excess weight gain was associated with increased rates of gestational hypertension (OR 1.27; 95% CI 1.08–1.49), augmentation of labour (OR 1.09; 95% CI 1.01–1.18), and birth weight ≥ 4000 g (OR 1.21; 95% CI 1.10–1.34). In overweight women, excess weight gain was associated with increased rates of gestational hypertension (OR 1.31; 95% CI 1.10–1.55) and birth weight ≥4000 g (OR 1.30; 95% CI 1.15–1.47). In women who were obese or morbidly obese, excess weight gain was associated with increased rates of birth weight ≥4000 g (OR 1.20; 95% CI 1.07–1.34) and neonatal metabolic abnormality (OR 1.31; 95% CI 1.00–1.70). In morbidly obese women, poor weight gain was associated with less use of epidural analgesia (OR 0.34; 95% CI 0.12–0.95). In women who were of normal weight, overweight, or obese, the rate of adverse outcome (Caesarean section, gestational hypertension, birth weight < 2500 g or birth weight ≥4000 g) was lower in women with recommended weight gain than in those with excess weight gain. Adverse outcomes were reduced in nulliparous morbidly obese women who had poor weight gain (OR 0.18; 95% CI 0.04–0.83).ConclusionThe effects of gestational weight gain on pregnancy outcome depend on the woman’s pre-pregnancy BMI. Pregnancy weight gains of 6.7–11.2 kg (15–25lb) in overweight and obese women, and less than 6.7 kg (15lb) in morbidly obese women are associated with a reduction in the risk of adverse outcome.     

The effect of gestational weight gain on likelihood of referral to obstetric care for women eligible for primary,midwife-led care after antenatal booking

Objectiveto examine the effect of gestational weight gain (GWG) on likelihood of referral from midwife-led to obstetrician-led care during pregnancy and childbirth for women in primary care at the outset of their pregnancy.Designsecondary analysis of data from a prospective cohort study.SettingDutch midwife-led practices.Participantsa cohort of 1288 women of Northern European descent, with uncomplicated, singleton pregnancy at antenatal booking who consequently were eligible for primary, midwife-led care.Measurementsbecause of the absence of an established GWG guideline in the Netherlands, we compared the effect of inadequate and excessive GWG according to two GWG guidelines: the criterion traditionally used, which is based on knowledge of the physiological components of GWG, advising 10–15 kg as a normal GWG irrespective of a woman׳s BMI category, and the 2009 Institute of Medicine recommendations (IOMr) on GWG, which provide BMI related advice. Outcome measures were: number of women referred from midwife-led to obstetrician-led care during pregnancy and during childbirth; indications of referral and birth outcomes.FindingsGWG above traditional criteria (Tc; >15 kg between 12 and 36 weeks) was associated with increased odds for referral during childbirth (adjusted odds ratio (aOR) 1.88; 95% confidence interval (CI) 1.22–2.90), but had no effect on referral during pregnancy (aOR .86; 95% CI .57–1.30). No associations were established between GWG below Tc (<10 kg) and referral during pregnancy (aOR 1.08; 95% CI .78–1.50) or childbirth (aOR 1.08; 95% CI .74–1.56). No associations were found between GWG below and above the IOMr and referral during pregnancy (below IOMr: aOR 1.01; 95% CI .71–1.45; above IOMr: aOR .89; 95% CI .61–1.28) or childbirth (below IOMr: aOR .85; 95% CI .57–1.25; above IOMr: aOR 1.09; 95% CI .73–1.63). With regard to the effect of GWG according to both recommendations on indications for referral and birth outcomes, GWG above Tc was associated with higher rates of referral for hypertensive disorders (aOR 1.91; 95% CI 1.04–3.50) and for meconium stained liquor (aOR 2.22; CI 1.33–3.71) after adjusting for BMI and parity.ConclusionsGWG above Tc – irrespective of BMI category – was associated with doubled odds of referral to specialist care during childbirth. GWG below or above IOMR and GWG below TC were not associated with adverse obstetric outcomes in women who were eligible for primary care at the outset of their pregnancy.Implications for practiceweight gain <15 kg between 12 and 36 weeks is advised for women in all BMI categories in this population. It is important to validate GWG guidelines in a target population before implementing them.     

Caesarean Section Rates in Southwestern Ontario: Changes Over Time After Adjusting for Important Medical and Social Characteristics

Objective: To compare Caesarean section rates in a cohort of women in Southwestern Ontario over time, overall, and in patient subgroups defined by the Robson criteria, after adjusting for important medical and social characteristics.Methods: We obtained data from a perinatal database on deliveries at ≥ 22 weeks’ gestation at a level II centre and a level III centre in London, Ontario between 1999 and 2010. Caesarean section rates were examined overall and in subgroups defined by parity, presentation, plurality, gestational age, and history of previous Caesarean section. Multivariable modified Poisson regression was used to compare Caesarean section rates in 2003–2006 and 2007–2010 versus 1999–2002.Results: In the fully adjusted models, the overall Caesarean section rate was significantly higher in 2007–2010 than in 1999–2002 for the level II centre (adjusted relative risk [aRR] 1.12; 95% CI 1.05 to 1.21). An increase was also seen in the level III centre in both 2003 to 2006 (aRR 1.19; 95% CI 1.14 to 1.24) and 2007 to 2010 (aRR 1.17; 95% CI 1.12 to 1.22). Similar increases were seen over time among patient subgroups. Notably, repeat Caesarean sections without labour increased at the level II centre (2003 to 2006 aRR 1.21; 95% CI 1.01 to 1.45, and 2007 to 2010 aRR 1.44; 95% CI 1.21 to 1.71) and the level III centre (2003 to 2006 aRR 1.72; 95% CI 1.53 to 1.94, and 2007 to 2010 aRR 1.77; 95% CI 1.57 to 2.00).Conclusion: There has been a significant increase over time in the Caesarean section rate overall and in important subgroups. This increase remains even after controlling for other factors which may explain the trend.     

The effect of maternal hypertension on mortality in infants 22, 29 weeks gestation

ObjectiveTo evaluate the effect of maternal hypertension on mortality risk prior to discharge, in infants 22 + 0 to 29 + 6 weeks gestational age.Study designWe evaluated 88,275 North American infants whose births were recorded in Vermont Oxford Network centers between 2008 and 2011 Infants born between 22 + 0 and 29 + 6 weeks gestational age were evaluated in 2-week gestational age cohorts and followed until death or discharge. Logistic regression was used to adjust for birth weight, antenatal steroid exposure, infant sex, maternal race, inborn/outborn, prenatal care and birth year.Results21,896 infants were born to hypertensive mothers; 13% died prior to Neonatal Intensive Care Unit discharge compared to 20% of the 66,379 infants born to mothers without hypertension. After adjustment, infants had significantly lower mortality compared to preterm infants not born to hypertensive mothers, at all gestational ages examined (22/23: odds ratio (OR) = 0.65 (95% Confidence Interval (CI): 0.55, 0.77; 24/25); OR = 0.77 (95% CI: 0.71, 0.84); 26/27: OR = 0.66 (95% CI: 0.59, 0.74); 28/29: OR = 0.58 (95% CI: 0.51, 0.67). Additionally, births associated with maternal hypertension increase dramatically by gestational age, resulting in a larger proportion of births associated with maternal hypertension at later gestational ages.ConclusionsPreterm birth due to any cause carries significant risk of mortality, especially at the earliest of viable gestational ages. Maternal hypertension independently influences mortality, with lower odds of mortality seen in infants born to hypertensive mothers, after adjustment, and should be taken into consideration as an element in counseling parents.     

A New Method of Positioning at Delivery Compared With the Dorsal Recumbent Position: An Exploratory Retrospective Study of Obstetric Outcomes

BackgroundIn the last 30 years, several initiatives have aimed to reintroduce a certain freedom in positioning during labour. The objective of this study was to compare an alternative method of positioning at delivery (APOR B method) with the dorsal recumbent (supine) position.MethodsWe undertook a comparative, retrospective study of 276 singleton deliveries at ≥ 36 weeks The APOR B method used by two general practitioners (GPs) was compared with the dorsal recumbent position used by two other GPs with similar years of experience. We assessed obstetric outcomes with logistic regression analyses.ResultsThe study populations were similar except for more cases of induced labour (40% vs. 27%, P = 0.030) and earlier gestational age at delivery (mean ± SD 39.1 ± 1.4 vs. 39.4 ± 1. 0 weeks of amenorrhea, P = 0.032) in the APOR B group (adjustment provided). Mode of delivery and perineal outcomes were similar, with 74% and 72% (P = 0.816) of spontaneous vaginal deliveries and 38% and 44% (P = 0 368) of intact perineums for APOR B and dorsal recumbent positions, respectively. Women in the APOR B group were less likely to have vaginal tears (15% vs 28%, aOR 0.45, 95% CI 0.23 to 0.89). No differences were observed in the frequency of abnormal fetal heart rate, Apgar score < 7 at five minutes, dystocia, and blood loss. However, umbilical cord arterial pH < 7.20 was more frequent in the APOR B group (32% vs. 20%, aOR 2.0, 95% CI 1. 1 to 3.8).ConclusionThe outcomes of the two methods of positioning at delivery were mostly equivalent, except for fewer vaginal tears and lower umbilical cord arterial pH in the APOR B group. These findings will need to be further assessed in randomized controlled trials.     

Valores extremos del IMC materno: factores determinantes de peores resultados obstétricos y perinatales

ObjectiveTo study the influence of maternal body mass index (BMI) at the beginning of pregnancy on obstetric-perinatal outcomes.Material and methodsObservational-ambispective study. We recruited 1407 patients with singleton gestations and deliveries of foetuses > 24 weeks between 01/12/2017 and 31/07/2019. The sample was stratified according to their BMI following the WHO classification. Variables on pre-pregnancy, gestational disease, obstetric care, and maternal-perinatal outcomes were analysed and compared between the studied groups. The statistical program has been R Core Team 2020, version 3.6.3. P ≤ .05 was considered significant.ResultsClass II-III (BMI 35-39 and BMI ≥ 40 respectively) obese women have a higher risk of chronic arterial hypertension (OR 53.54, 95% CI 18.21-229.02), gestational diabetes (OR 5.24, 95% CI 2.87-9.51) and preeclampsia (OR 2.38, 95% CI 0.95-5.51 with P = .049). The underweight women had more intrauterine growth restriction diagnoses (OR 3.09, 95% CI 1.46-6.17). Inductions of labour and caesarean sections increase as BMI increases (P = .006). Low weight patients also had a higher risk of caesarean section (OR 2.46, 95% CI 1.06-5.20). Neonatal admissions were more frequent in obese and underweight women (OR 2.68, 95% CI 1.39-5.00 and OR 2.56, 95% CI 1.10-5.44 respectively). Obese women had a higher risk of neonatal weight > 4000 g (OR 3.06, 95% CI 1.57-5.77) and low weight pregnant women had a higher risk of neonatal weight < 2500 g (OR 2.94, 95% CI 1.54-5.41).ConclusionExtreme values of maternal BMI at the beginning of gestation are determining factors for an adverse obstetric-perinatal outcome.     

Identificación de factores que se asocian a alto riesgo de desarrollar diabetes gestacional

ObjectivesThe main objective is to determine the current prevalence of recognised risk factors for gestational diabetes mellitus (GDM) in our region, and to define the profile of patients at higher risk of developing this condition. We also investigate patient acceptability of the screening tests.Material and methodsThis is an ambispective study with 1,448 pregnant women recruited between December 2017 and July 2019 from a single centre. Inclusion criteria were no diabetes mellitus prior to the pregnancy, no history of GDM in any previous pregnancy, no history of bariatric surgery before the pregnancy, and GDM screening tests performed.ResultsThe prevalence of GDM was 6.7%. Risk factors associated with development of GDM were: age ≥ 27.5 years (OR: 3.8; 95% CI: 2.01-9.16); BMI ≥ 28.5 kg/m² (OR: 2.3; 95% CI: 1.47-3.59); history of diabetes mellitus in first-degree relatives (OR: 2.3; 95% CI: 1.5-3.66); and multiple pregnancy (OR: 2.8; 95% CI: 0.86-6.36); Prevalence of GDM increased with the number of risk factors presented by patients: from 1.4% with no risk factor, to 25.2% with 3. The O'Sullivan test (50 g glucose) and oral glucose tolerance test (100 g glucose) were perceived as “unpleasant” by 26.8% and 65.4% of patients, respectively.ConclusionsAge ≥ 27.5 years, BMI ≥ 28.5 kg/m², history of diabetes mellitus in first-degree relatives, and multiple pregnancy are factors related to an increased risk of GDM; these factors would be enough to identify most pregnant women developing GDM. Our findings may be used to improve programmes aimed at early diagnosis of gestational diabetes and supporting high-risk mothers in antenatal care.     

Urinary Dipstick Proteinuria Testing: Does Automated Strip Analysis Offer an Advantage Over Visual Testing?

Objective: To compare the diagnostic test properties of automated and visually read urine dipstick screening for detection of a random protein:creatinine ratio (PrCr) ≥ 30 mg/mmol.Methods: Urine samples were collected prospectively from 160 women attending high-risk maternity clinics at a tertiary care facility. Samples were divided into two aliquots; one aliquot was tested using two different urine test strips, one read visually and one by an automated reader. A second aliquot of the same urine was analyzed for urinary protein and creatinine. Performance of visual and automated dipstick results (proteinuria ≥ 1 +) were compared for detection of PrCr ≥ 30 mg/mmol using non-dilute urine samples (urinary creatinine ≥ 3 mmol/L).Results: Both urine test strips showed low sensitivity (visual 56.0% and automated 53.8%). Positive likelihood ratios were 15.0 for visual dipstick testing (95% CI 5.9 to 37.9) and 24.6 for automated (95% CI 7.6 to 79.6). Negative likelihood ratios were 0.46 for visual dipstick testing (95% CI 0.29 to 0.71) and 0.47 for automated (95% CI 0.31 to 0.72).Conclusion: Automated dipstick testing was not superior to visual testing for detection of proteinuria in pregnant women in a primarily outpatient setting. Sensitivity may depend on the test strips and/or analyzer used.     

Late Preterm Delivery in Women With Preterm Prelabour Rupture of Membranes

ObjectiveTo estimate maternal and neonatal outcomes in women with preterm prelabour rupture of membranes (PPROM) who delivered at 34 + 0 to 36 + 6 weeks’ gestation, particularly in those who had an obstetrically indicated delivery.MethodsWe conducted a population-based study of late preterm singleton births complicated by PPROM, using data from the Nova Scotia Atlee Perinatal Database from 1988 to 2006. The study cohort was categorized by type of labour (spontaneous, induced, no labour), and each group’s characteristics prior to delivery, and their outcomes were compared after accounting for potential confounding variables.ResultsFrom a total population of 164 384 pregnancies, 2618 deliveries were identified as having PPROM. Among these, 2180 (83.3%) delivered between 34 + 0 and 36 + 6 weeks’ gestation. Adjusted analyses showed no differences in risk between those women entering labour spontaneously (n = 1296) and those with obstetrically indicated delivery (labour induction or Caesarean section without labour, n = 698). Additional adjusted analyses evaluating only women with obstetrically indicated delivery showed that rates of chorioamnionitis (OR 0.27; 95% CI 0.08 to 0.93), composite perinatal morbidity/mortality (OR 0.39; 95% CI 0.25 to 0.62), neonatal depression at birth (OR 0.22; 95% CI 0.06 to 0.86), and respiratory distress syndrome (OR 0.17; 95% CI 0.06 to 0.47) were significantly lower in those delivering at 36 weeks (n = 458) than in those delivering at 34 to 35 weeks (n = 240).ConclusionsThis large population-based study suggests that in pregnancies complicated by PPROM rates of adverse maternal and perinatal outcomes at 36 weeks’ gestational age are at least comparable to those in pregnancies delivering at 34 to 35 weeks, and these rates may be further reduced by delivery after 36 completed weeks if spontaneous labour has not occurred.     

Placental growth factor as a marker of fetal growth restriction caused by placental dysfunction

IntroductionDiscriminating between placentally-mediated fetal growth restriction and constitutionally-small fetuses is a challenge in obstetric practice. Placental growth factor (PlGF), measurable in the maternal circulation, may have this discriminatory capacity.MethodsPlasma PlGF was measured in women presenting with suspected fetal growth restriction (FGR; ultrasound fetal abdominal circumference <10th percentile for gestational age) at sites in Canada, New Zealand and the United Kingdom. When available, placenta tissue underwent histopathological examination for lesions indicating placental dysfunction, blinded to PlGF and clinical outcome. Lesions were evaluated according to pre-specified severity criteria and an overall severity grade was assigned (0–3, absent to severe). Low PlGF (concentration <5th percentile for gestational age) to identify placental FGR (severity grade ≥ 2) was assessed and compared with routine parameters for fetal assessment. For all cases, the relationship between PlGF and the sampling-to-delivery interval was determined.ResultsLow PlGF identified placental FGR with an area under the receiver-operator characteristic curve of 0.96 [95% CI 0.93–0.98], 98.2% [95% CI 90.5–99.9] sensitivity and 75.1% [95% CI 67.6–81.7] specificity. Negative and positive predictive values were 99.2% [95% CI 95.4–99.9] and 58.5% [95% CI 47.9–68.6], respectively. Low PlGF outperformed gestational age, abdominal circumference and umbilical artery resistance index in predicting placental FGR. Very low PlGF (<12 pg/mL) was associated with shorter sampling-to-delivery intervals than normal PlGF (13 vs. 29.5 days, P < 0.0001).DiscussionLow PlGF identifies small fetuses with significant underlying placental pathology and is a promising tool for antenatal discrimination of FGR from fetuses who are constitutionally-small.     

Neighbourhood Family Income and Adverse Birth Outcomes Among Singleton Deliveries

ObjectiveTo assess the association between neighbourhood family income and adverse birth outcomes.MethodsWe conducted a retrospective cohort study of 334 231 singleton births during 2004 and 2006 based on the Niday Perinatal Database from Ontario. Median neighbourhood family incomes from the 2001 Canadian census were linked with the Niday Perinatal Database by dissemination areas. Generalized estimating equations were applied to estimate the odds ratios of adverse birth outcomes associated with lower neighbourhood income, with adjustment for maternal confounding variables at the individual level.ResultsCompared with the highest neighbourhood income quintile, mothers from the lowest quintile were at increased risk of having small for gestational age neonates (OR 1.51; 95% CI 1.46 to 1.57), low birth weight (OR 1.43; 95% CI 1.36 to 1.50), preterm birth (OR 1.17; 95% CI 1.12 to 1.23), low Apgar score (< 7) at five minutes (OR 1.32; 95% CI 1.21 to 1.44), and stillbirth (OR 1.39; 95% CI 1.19 to 1.62). The risks of women from the lowest income quintiles delivering a macrosomic baby (OR 0.81; 95% CI 0.79 to 0.84) or a large for gestational age baby (OR 0.82; 95% CI 0.80 to 0.85) were significantly decreased. No difference in risk of congenital anomaly was found among different income quintiles.ConclusionA lower level of neighbourhood income is associated with increased risks of small for gestational age babies, low birth weight, preterm birth, low Apgar score at five minutes, and stillbirth.     

Body mass index,physical activity,and survival after endometrial cancer diagnosis: Results from the Women's Health Initiative

ObjectiveWhile low physical activity and high body mass index (BMI) have been associated with higher endometrial cancer incidence, no previous studies have evaluated the association between physical activity and survival after endometrial cancer diagnosis, and studies on BMI and survival have not been performed in a prospective cohort.MethodsWe examined pre-diagnosis BMI and moderate- to vigorous-intensity physical activity in relation to overall and disease-specific survival among 983 postmenopausal women who were diagnosed with endometrial cancer in the Women's Health Initiative Observational Study and Clinical Trials.ResultsOver a median 5.2 (max 14.1) years from diagnosis to death or end of follow-up, 163 total deaths were observed, 66 of which were due to endometrial cancer. We observed a higher all-cause mortality hazard ratio (HR) = 1.85 (95% CI 1.19–2.88) comparing women with a BMI ≥ 35 kg/m² to women with BMI < 25 kg/m². For endometrial cancer-specific mortality the HR = 2.23 (95% CI 1.09–4.54) comparing extreme BMI categories. To examine histologic subtypes we analyzed type I endometrial tumors separately and found an HR = 1.20 (95% CI 1.07–1.35) associated with all-cause mortality for each 5-unit change in BMI. Moderate- to vigorous-intensity physical activity was not associated with all-cause or endometrial cancer-specific mortality.ConclusionsPre-diagnosis BMI, but not physical activity, was associated with survival among women with endometrial cancer. Future studies should investigate mechanisms and timing of BMI onset to better understand the burden of disease attributable to BMI.     

Serial fetal abdominal circumference measurements in predicting normal birth weight in gestational diabetes mellitus

ObjectivesTo construct a clinical management matrix using serial fetal abdominal circumference measurements (ACMs) that will predict normal birth weight in pregnancies complicated by gestational diabetes (GDM) and reduce unnecessary ultrasound examination in women with GDM.Study designRetrospective cohort study of 144 women with GDM in a specialist obstetric-diabetes clinic. Women with GDM who delivered singleton infants were identified from a clinical register. Regression analysis was used to identify associations between serial ACMs, maternal parameters and normal birth weight (birth weight between the 10th and 90th percentiles). Predictive clinical models were designed with the aim of identifying normal birth weight infants with the lowest number of fetal ultrasound scans.ResultsCompared to mothers of large-for-gestational-age (LGA) infants, mothers of normal weight infants had lower fasting glucose measurements at diagnosis (5.9 mmol/l ± 1.0 vs. 6.6 mmol/l ± 0.7, p < 0.05), lower maternal weight at delivery (90 kg ± 17 vs. 96 kg ± 17, p < 0.05), and a lower rate of prior LGA infants (31% vs. 60%, p < 0.05). Maternal weight and a history of prior LGA delivery were identified as useful predictors of fetal birth weight in predictive models. Serial ACMs below the 50th, 75th and 90th percentiles could predict normal birth weight with 100%, 97% and 96% positive predictive value respectively when used in these risk factor based models. Two measurements sufficed in low-risk pregnancies.ConclusionSerial ACMs can predict normal birth weight in GDM.     

Factors Associated With Lower Uterine Segment Thickness Near Term in Women With Previous Caesarean Section

ObjectiveTo estimate the association between potential influencing factors and lower uterine segment (LUS) thickness at term in women with previous Caesarean section.MethodsWe conducted a cohort study of women with previous low-transverse Caesarean section undergoing ultrasonographic measurement of LUS thickness between 35 and 38 weeks’ gestation in a tertiary care centre between 2006 and 2009. Measurements of the full LUS thickness and the myometrial LUS thickness were performed both transabdominally and transvaginally. The thinnest measurements for both full and myometrial LUS thicknesses were considered dependent variables. Non-parametric analyses, multivariate linear regression analyses, and multivariate regression analyses were used to evaluate the relationships between LUS thickness and the potential influencing factors of maternal age, interdelivery interval, prior vaginal delivery, and several characteristics of the previous Caesarean section.ResultsIn 377 women who underwent measurement of LUS thickness, labour before previous Caesarean section was the only characteristic associated with a greater full LUS thickness (an additional 0.9 mm; 95% CI 0.5 to 1.2 mm) in multivariate linear regression analysis. Labour before previous Caesarean section (0.5 mm; 95% CI 0.2 to 0.7 mm) and the use of synthetic sutures (as opposed to catgut sutures) for the closure of the previous hysterotomy incision (0.3 mm; 95% CI 0.02 to 0.5 mm) were the only two variables significantly associated with a thicker myometrial LUS. In multivariate regression analysis, three factors were predictive of a full LUS thickness of > 2.3 mm: the presence of labour, a recurrent indication for Caesarean section, and the use of synthetic sutures for hysterotomy closure at previous Caesarean section (P < 0.05).ConclusionLabour at the time of previous Caesarean section is associated with a thicker LUS near term in the subsequent pregnancy. The use of synthetic sutures for hysterotomy closure is another factor potentially associated with a thicker LUS.     

Prognostic value of responsiveness of neoadjuvant chemotherapy before surgery for patients with stage IB2/IIA2 cervical cancer

ObjectiveTo evaluate the factors that might affect the putative survival benefit from pre-operative neoadjuvant chemotherapy (NAC) in patients with early stage bulky cervical cancer.MethodsA retrospective review for 304 patients with stage IB₂/IIA₂ cervical cancer was performed. Two groups were made according to pre-operative NAC or not: NAC group (n = 154) and primary surgery group (PST, n = 150). Recurrence risks and survival were analyzed.ResultsThe total response rate was 72.1%. For those NAC-responders, NAC decreased the ratio of lymphovascular space invasion (0 vs. 4.7%, p = 0.022; 0 vs. 3.3%, p = 0.052), deep stromal invasion (19.8% vs. 53.5%, p = 0.000; 19.8% vs. 29.3%, p = 0.08), lymph node metastasis (8.1% vs. 25.6%, p = 0.004; 8.1% vs. 17.3%, p = 0.031), and the need of adjuvant radiotherapy (5.5% vs. 30.2%, p = 0.000; 5.4% vs. 15.3%, p = 0.012), whereas improve 5-year PFS rate (94% vs. 86%, p = 0.041; 94% vs. 80%, p = 0.089) and 5-year OS rate (96% vs. 86%, p = 0.015; 96% vs. 82%, p = 0.05), as compared with non-responders and PST. Multivariate analysis suggested that the response to NAC is an independent prognostic factor of PFS (HR 0.221, 95% CI 0.048–1.022, p = 0.053) and OS (HR 0.126, 95% CI 0.016–1.000, p = 0.05); as compared, stage IIA disease demonstrates negative impact upon PFS (HR 4.778, 95% CI 1.490–15.317, p = 0.009) and OS (HR 4.142, 95% CI 1.258–13.639, p = 0.019).ConclusionResponsiveness of NAC before surgery might be an independent prognostic factor for the patients with early stage bulky cervical cancer.     

Preeclampsia,gestational hypertension and subsequent hypothyroidism

ObjectivesTo evaluate the effect of preeclampsia (PE) and gestational hypertension (GH) on subsequent hypothyroidism. Recent studies suggest that women with PE have increased risk for reduced thyroid function, but the association between PE and GH with overt hypothyroidism has not been examined.Study designTwo prospective population-based cohort studies, the Northern Finland Birth Cohorts 1966 and 1986, followed women who had PE (N = 955), GH (N = 1449) or were normotensive (N = 13531) during pregnancy. Finnish national registers were used to confirm subsequent hypothyroidism. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) estimated hypothyroidism risk when comparing women with PE or GH with normotensive women.Main outcome measuresPrimary hypothyroidism during follow-up of 20–40 years.ResultsThe subsequent prevalence of hypothyroidism was higher among women with PE (4.0%) and GH (4.5%) compared with normotensive women (3.5%), but the risk increase was not significant (aHR for PE 1.13, 95% CI 0.80–1.59 and aHR for GH 1.11, 95% CI 0.85–1.45).Subgroup analysis among nulliparous women revealed a significant association between late PE and subsequent hypothyroidism (aHR 1.82, 95% CI 1.04–3.19).Early or recurrent PE was not associated with hypothyroidism (aHR 0.93, 95% CI 0.46–1.81 and aHR 1.35, 95% CI 0.63–2.88, respectively).ConclusionsOverall, PE or GH during pregnancy was not significantly associated with subsequent hypothyroidism in Finnish women after 20–40 years of follow-up. However, late PE in nulliparous women was associated with a 1.8-fold increased risk of subsequent hypothyroidism, a finding that merits further study in other populations.     

Pre-eclampsia and gestational hypertension are less common in HIV infected women

ObjectiveTo determine whether pre-eclampsia and gestational hypertension are less common in HIV infected women.MethodsThis prospective cohort study was performed in the Western Cape province of South Africa. HIV negative and positive pregnant women without chronic renal or chronic hypertensive disease were continuously recruited. During the study period HIV positive patients received either mono- or triple (HAART) antiretroviral therapy for prevention of vertical transmission or maternal care. Only routine clinical management was performed. The development of hypertensive disease during pregnancy was recorded.Results1093 HIV positive and 1173 HIV negative cases were identified during pregnancy and evaluated again after delivery. Significantly fewer cases of pre-eclampsia n = 35 (3.2%) were recorded in the HIV positive group than in the HIV negative group, n = 57 (4.9%) (p = 0.045; OR 0.65 95% CI 0.42–0.99). There were also significantly fewer cases of gestational hypertension recorded in the HIV positive group compared to the HIV negative group (p = 0.026; OR 0.53 95% CI 0.30–0.94). Multiple logistic regression analysis confirmed the reductive effect of HIV on pre-eclampsia and gestational hypertension.ConclusionPre-eclampsia and gestational hypertension are less common in HIV infected women being managed with mono- or triple anti-retroviral therapy.