In Vitro fertilization and adverse obstetric and perinatal outcomes

Most IVF-conceived children are healthy, but IVF has also been associated with adverse obstetric and perinatal outcomes as well as congenital anomalies. There is also literature suggesting an association between IVF and neurodevelopmental disorders as well as potentially long-term metabolic outcomes. The main driver for adverse outcomes is the higher risk of multiple gestations in IVF, but as the field moves toward single embryo transfer, the rate of multiple gestations is decreasing. Studies have shown that singleton IVF pregnancies still have a higher incidence of adverse outcomes compared to unassisted singleton pregnancies. Infertility itself may be an independent risk factor. Animal models suggest that epigenetic changes in genes involved in growth and development are altered in IVF during the hormonal stimulation and embryo culture. Further animal research and prospective human data are needed to elucidate the mechanisms by which IVF may contribute to adverse outcomes and to decrease risks.     

子痫前期及其高危因素对围产儿结局的不良影响

目的:探讨子痫前期(PE)及其高危因素对围产儿结局的影响.方法:根据国内外资料统计的PE高危因素,筛选2011年4月至2012年1月在上海交通大学医学院附属仁济医院妇产科产检和分娩的正常及存在高危因素的孕妇154例,最终发展为PE的孕妇50例,非PE孕妇104例.通过采集病史及实验室检查,追踪妊娠结局,分析PE及存在高危因素PE孕妇的围产儿结局.结果:(1)PE组的新生儿体重及分娩孕周显著小于非PE组(P＜0.05).(2)PE组的胎儿生长受限(FGR)、胎儿窘迫、早产、死胎、新生儿窒息发生率分别是非PE组的4.64倍、2.32倍、4.61倍、2.66倍、6.38倍.两组的FGR、胎儿窘迫、早产的发病率有显著差异(P＜0.05).(3)当MAP≥85 mmHg、蛋白尿、子宫/脐动脉血流异常、D-D＞0.246μg/ml、FDP＞4μg/ml、PAGT＞40％时,易发生围产儿不良结局(P均＜0.05).不同高危因素对围产儿结局的威胁程度不同,其中子宫/脐动脉血流异常时围产不良结局发生率均较高(P＜0.05).结论:PE对围产儿结局有不良影响.孕期可针对高危孕妇进行严格有效的筛查,严密监测围产儿生长发育,警惕PE及围产儿不良结局的发生.     

Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa

Objective

To assess the association between cesarean delivery rates and pregnancy outcomes in African health facilities.

Methods

Data were obtained from all births over 2-3 months in 131 facilities. Outcomes included maternal deaths, severe maternal morbidity, fresh stillbirths, and neonatal deaths and morbidity.

Results

Median cesarean delivery rate was 8.8% among 83 439 births. Cesarean deliveries were performed in only 95 (73%) facilities. Facility-specific cesarean delivery rates were influenced by previous cesarean, pre-eclampsia, induced labor, referral status, and higher health facility classification scores. Pre-eclampsia increased the risks of maternal death, fresh stillbirths, and severe neonatal morbidity. Adjusted emergency cesarean delivery rate was associated with more fresh stillbirths, neonatal deaths, and severe neonatal morbidity—probably related to prolonged labor, asphyxia, and sepsis. Adjusted elective cesarean delivery rate was associated with fewer perinatal deaths.

Conclusion

Use of cesarean delivery is limited in the African health facilities surveyed. Emergency cesareans, when performed, are often too late to reduce perinatal deaths.     

Twin gestation in older women: antepartum, intrapartum complications, and perinatal outcomes

Objective: The aim of this study is to present pregnancy and perinatal outcomes of twin gestations in older women and compare them with that for younger women. Study design: We conducted a retrospective cohort study of twin pregnancies in our department between 1988 and 2003. The women were classified into two groups by maternal age: women of age 35 years and older (study group) and women less than 35 years (control group). Population characteristics, complications during pregnancy and delivery, and neonatal outcomes were assessed. The Student’s t-test, χ² test, Fisher exact test, and binary logistic regression analysis were used to examine the relationship between maternal age and the different variables. Results: A total of 238 twin pregnancies were enrolled (study group, 57 women; control group, 181 women). Spontaneous conceptions were significantly higher in the control group (P<0.001), while conceptions after in vitro fertilization (IVF) were significantly higher in study group (P<0.001). Mean figures of gestational age at delivery and birth weight for the older group did not differ significantly from the younger group. Although the antepartum and intrapartum complications were more common in the study group, they were not statistically significant compared to the control group. This was also true for the perinatal outcomes. Only the very low birth weight (VLBW<1,500 g) rate was significantly higher in the study group. The number of perinatal deaths was similar on comparison by maternal age. Conclusions: Based on our study, advanced maternal age at twin gestation does not seem to affect significantly pregnancy complications and perinatal outcomes. VLBW was the only unfavorable perinatal outcome related to advanced maternal age.     

围生儿尸检500例病因分析及出生缺陷与胎盘病理变化的关系

目的：从500例围生儿尸检结果探讨围生儿死亡原因及出生缺陷和胎盘病理变化的关系。方法：根据1986年3月至2001年12月500例围生儿尸检结果，结合病史、胎盘病理检查分析其死亡原因。结果：新生儿主要死因是肺透明膜病和出生缺陷，死胎、死户主要是胎盘因素和出生缺陷；而出生缺陷儿的胎盘大多伴有病理性变化，如绒毛发育迟缓、胎盘感染等。结论：尸检及全面的胎盘检查对大多数死亡围生儿可提供有价值的信息。     

Abnormal multiple marker screens are associated with adverse perinatal outcomes in cases of intrauterine growth restriction

OBJECTIVE: The purpose of this study was to determine if abnormal multiple marker screens (MMS) are associated with adverse perinatal outcomes in intrauterine growth restriction (IUGR) pregnancies. STUDY DESIGN: This was a case control study of IUGR pregnancies (birth weight <10th percentile for gestational age [GA]) delivered in our unit over 6 years. Cases were compared with controls for the association between abnormal MMS and adverse perinatal outcomes (APO). RESULTS: Of the 261 IUGR pregnancies, 39 (16%) had at least 1 APO. An elevated HCG was significantly associated with an APO (OR 2.6, 95% CI 1.1-6.4). A low uE3 was also associated with an APO (OR 5.5, 95% CI 2.2-14). The association between an elevated AFP and APO was not statistically significant (OR 1.6, 95% CI, 0.6-4.6). CONCLUSION: An elevated HCG and low uE3 were associated with APO in cases of IUGR. This information could be useful in identifying a subset of IUGR cases deserving closer surveillance.     

Impact of placenta previa on obstetric outcome

Objective

To determine the maternal and perinatal outcome for different types of placenta previa (PP).

Methods

A retrospective review of 132 singleton pregnancies with PP. Outcome measures, including the incidence of obstetric hysterectomy, the neonatal Apgar score, and the neonatal weight, were evaluated by logistic regression analysis.

Results

The incidence of PP was 1.0%. Of the women with PP, 51.5% had complete PP, 20.5% had incomplete PP, 5.3% had marginal PP, and 22.7% had a low-lying placenta. Most (93.9%) women were delivered by cesarean delivery. In total, 19.7% women underwent obstetric hysterectomy; of these, 92.3% had complete PP. Mothers with 2 or more previous cesarean deliveries had an increased risk for obstetric hysterectomy (P < 0.01). The gestational age at delivery was a significant linear predictor of the 5-minute Apgar score. Mothers with incomplete PP delivered neonates with lower Apgar scores than did mothers with complete PP.

Conclusion

A history of multiple cesarean deliveries increased the risk for obstetric hysterectomy in women with PP. The type of PP had no effect on maternal and neonatal outcome, with exception of the fact that neonates in the incomplete PP group had lower Apgar scores than neonates in the complete PP group.     

High prevalence of vitamin D deficiency among pregnant women in a Turkish population and impact on perinatal outcomes

Objective: Maternal vitamin D deficiency is a major public health problem. The aim of this study is to investigate the influence of vitamin D deficiency on perinatal results in primigravida.

Methods: One-hundred fifty-two healthy nullipar women were included in the study. Pregnant women with serum vitamin D levels <15ng/ml were defined as Group I and ≥15?ng/dl were defined as Group II; data were evaluated retrospectively. Type of delivery, gestational age at birth, birth weight, intensive care of the newborn, peri-and postpartum complications were recorded. Statistical analyses were performed with SPSS for Windows (version 16.0 ). Categorical variables were assessed using chi-squared test. The numeric variables were analyzed using Student's t-test and one-way ANOVA.

Results: 44.6% of pregnant women were found to have vitamin D deficiency. The mean serum vitamin D levels for Groups I and II were 10.8?±?3.8 and 23.8?±?13.3?ng/ml, respectively. SGA deliveries were detected in 16.66% and 4.87% of the primigravidas with and without vitamin D deficiency, respectively.

Conclusions: This study has shown that maternal vitamin D deficiency is related with an increased risk of SGA delivery. Further studies are needed to explain the relationship with vitamin D deficiency and poor perinatal outcomes.     

Blastocyst transfer is not associated with increased unfavorable obstetric and perinatal outcomes compared with cleavage-stage embryo transfer

Background: Recent studies demonstrated controversial results of whether there are risks in fetal outcomes after blastocyst-stage embryos transfer (BT) compared with cleavage-stage embryos transfer (CT).

Aims: To compare the implantation rates (IR), clinical pregnancy rates (cPR), birth rates (BR), gestational weeks, preterm birth rates, birth weights and low birth weight rates between CT and BT groups.

Methods: A retrospective study of 1627 embryos transfer cycles was performed from May 2014 to April 2015. The cycles were divided into two groups according to transfer stage: CT on Day 3 (n?=?798) and BT on Day 5 (n?=?829). For the CT group, it must have surplus embryos and only surplus embryos developed to available blastocysts, the cleavage-stage embryos could be included. The clinical outcomes of two groups were analyzed.

Results: The IR in CT group was lower than BT group (48.98% vs. 60.68%; p?Conclusion: Blastocysts had higher implantation potential than cleavage-stage embryos. Extended embryo culture was not related to increased adverse obstetric and perinatal outcome.     

肾上腺糖皮质激素对双胎围产儿预后的影响

目的 探讨肾上腺糖皮质激素对双胎妊娠围产儿的作用。方法 56例双胎妊娠孕妇根据是否应用糖皮质激素分成两组,实验组:18例,于分娩前1周到24小时之间曾应用糖皮质激素;对照组:38例,在该时间内未应用糖皮质激素。比较两组围产儿预后间的差别。结果 在分娩孕周≤34周时,实验组的新生儿呼吸窘迫症的发病率和围产儿死亡率明显低于对照组(P<0.05);在孕周>34周时,无一例发生新生儿呼吸窘迫症,围产儿死亡率在实验组反而高于对照组(P<0.05);新生儿窒息的发生率在两组之间无明显的差别。结论 双胎妊娠可能在34周或以前分娩者,肾上腺糖皮质激素可降低新生儿呼吸窘迫症的发生率和围产儿死亡率;在34周以后分娩者,肾上腺糖皮质激素对改善围产儿预后无效。     

Prepregnancy body mass index as an important predictor of perinatal outcomes in Japanese

Objective The influence of maternal body mass index (BMI) before pregnancy and weight gain during pregnancy on perinatal outcomes in the Japanese population remains to be elucidated. Therefore, we estimated the risk of perinatal morbidity of the mother and infant with respect to maternal prepregnancy BMI and weight gain during pregnancy in Japanese. Results In the obese before pregnancy group, the risks of cesarean delivery, preeclampsia, and gestational diabetes were significantly elevated compared with the normal group. In the underweight before pregnancy group, the risks of low birth weight infant and hospitalization of infant were elevated significantly. Conclusion However, weight gain during pregnancy did not show any significant influence on the perinatal outcomes of the mother or infant.     

89例前置胎盘患者临床结局的回顾性分析

目的探讨前置胎盘的类型、阴道出血状况与妊娠结局的关系。方法将89例前置胎盘分为轻度组(43例)及重度组(46例),对其临床表现及妊娠结局做回顾性分析。结果重度组初次出血及诊断时孕周均明显小于轻度组(P＜0.05);而产前出血发生率、出血次数及大出血例数无显著性差异(P＞0.05)。有产前出血者其诊断及分娩时的孕周、新生儿体重均显著低于无出血者(P＜0.01);急诊剖宫产率显著高于无出血者(P＜0.01)。结论前置胎盘患者妊娠结局有很大的差异,没有典型的临床特征可循。其类型及产前出血状况不能预测其结局,也不能据此提前做出处理方案。     

易栓症与不良妊娠结局的病理改变

妊娠期血液处于高凝状态是生理性的血栓前状态,遗传性和获得性易栓症增加了孕妇血栓形成的几率。虽然易栓症与胎盘介导的妊娠期并发症相关,但是否为直接原因仍未证实。妊娠期易栓症不具备特征性的胎盘病变,故易栓症及妊娠不良结局与胎盘异常病理之间的关系值得进一步研究。     

Effects of maternal obesity on antenatal,perinatal and neonatal outcomes

Objective: Obesity is critically important to maternal and fetal health during the perinatal period. We have detected an increasing prevalence of maternal obesity in recent years and investigated its complications during pregnancy.

Methods: A total of 931 pregnant females were investigated between March 2012 and March 2013. The patients were divided into four groups: body mass index (BMI)?<?18.5?kg/m² was underweight, 18.5–24.9?kg/m² was normal weight, 25–29.9?kg/m² was overweight and ≥30?kg/m² was obese. The effects of obesity on fetal and maternal outcomes were investigated.

Results: Significant increases in pregnancy-induced hypertension, gestational diabetes mellitus, cesarean delivery, premature rupture of membranes, shoulder dystocia, meconium-stained amniotic fluid, abnormal heart rate pattern and postpartum infection rates were found in the obese group during the perinatal period. Adverse maternal effects in obese cases were significantly more frequent than those in normal-weight cases. Preterm birth, perinatal mortality, low APGAR scores, newborn intensive care unit requirement, hypoglycemia and macrosomia rates were significantly higher in obese cases than those in non-obese cases. However, low birth weight infant rate was higher in the low BMI cases than that in the other BMI categories (p?<?0.01).

Conclusion: We conclude that obesity is an important factor associated with pregnancy complications and the increase in maternal-fetal morbidity and mortality.     

子宫动脉栓塞术对胎盘前置状态引产患者生育能力及再妊娠结局的影响研究#br#

Objective?To explore the effects of uterine artery embolization on fertility and re-pregnancy outcomes of induced labor patients with placenta previa. Methods?A retrospective analysis of 260 patients with placenta previa induced labor was used as the research object. The control group (n=130) was induced labor with ethacridine lactate+mifepristone, and the observation group (n=130) was treated with uterine artery embolization combined with Lactated ethacridine+mifepristone to induce labor. The differences in induction of labor and postoperative complications between the two groups were compared, and the differences in postoperative fertility [follicle-stimulating hormone (FSH), estradiol (E2), and luteinizing hormone (LH)] between the two groups were investigated. Differences in pregnancy outcomes were analyzed in the two groups. Results?Success rate of labor induction and delivery rate in observation group were higher than those in control group. The total stage of labor, blood loss, hospital stay and menstrual recovery time were less than those in control group (P<0.05). There were no significant differences in incidence rates of postoperative complications, pregnancy rate, induced abortion rate and spontaneous abortion rate between the two groups (P>0.05). 4 months after surgery, the levels of FSH and LH in the two groups were increased while level of E2 was decreased compared to those 2 months after surgery, and levels of FSH and LH were lower while E2 level was higher in observation group compared to control group (P<0.05). Conclusion?The use of uterine artery embolization combined with lactate ethacridine+mifepristone to induce labor in patients with placenta previa is safe, can effectively reduce the impact on fertility, and is conducive to improving the outcome of re-pregnancy.     

Complete versus incomplete placenta previa and obstetric outcome.

OBJECTIVE: To compare obstetric outcome in women with complete versus incomplete placenta previa (PP). METHODS: A 10-year retrospective case-control study was conducted between 1992 and 2001. A 202 singleton pregnancies with PP were analyzed. RESULTS: The incidence of PP was 0.4%. Complete PP comprised 32.7% and incomplete PP 67.3% of cases. No difference was observed in the frequency of antepartum hemorrhage. Women with complete PP had significantly higher requirement for antepartum and postpartum transfusions, higher frequency of postpartum hemorrhage and postpartum hysterectomy. The risk for placenta accreta was increased in complete PP group even after controlling for confounding factors (adjusted OR=3.75, 95% CI=1.11-12.68, p<0.05). No difference in the frequency of preterm delivery was found between the groups. Term infants of mothers with complete PP had significantly lower birth weight (3205 vs. 3360, p=0.04). CONCLUSION: Complete PP is a high-risk subgroup of PP associated with higher maternal morbidity in comparison to incomplete PP.