Restricted fetal growth in sudden intrauterine unexplained death

BACKGROUND: Unexplained antepartum stillbirth is a common cause of perinatal death, and identifying the fetus at risk is a challenge for obstetric practice. Intrauterine growth restriction (IUGR) is associated with a variety of adverse perinatal outcomes, but reports on its impact on unexplained stillbirths by population-based birthweight standards have been varying, including both unexplained and unexplored stillbirths. AIM: We have studied IUGR, assessed by individually adjusted fetal weight standards, in antepartum deaths that remained unexplained despite thorough postmortem investigations. METHODS: Antenatal health cards from a complete population-based 10-year material of 76 validated sudden intrauterine unexplained deaths were compared to those of 582 randomly selected liveborn controls. Birthweight <10th percentile of the individualized standard adjusted for gestational age, maternal height, weight, parity, ethnicity, and fetal gender was defined as growth restriction. RESULTS: 52% of unexplained stillbirths were growth restricted, with a mean gestational age at death of 35.1 weeks. Suboptimal growth was the most important fetal determinant for sudden intrauterine unexplained death (odds ratio 7.0, 95% confidence interval 3.3-15.1). Concurrent maternal overweight or obesity, high age, and low education further increase the risk. Overweight and obesity increase the risk irrespective of fetal growth, and while high maternal age increases the risk of the normal weight fetus, it is not associated to growth restriction as a precursor of sudden intrauterine unexplained death. CONCLUSIONS: IUGR is an important risk factor of sudden intrauterine unexplained death, and this should be excluded in pregnancies with any other risk factor for sudden intrauterine unexplained death.     

A case-control study of intrapartum stillbirths.

OBJECTIVE: To determine antenatal and intrapartum risk factors for intrapartum stillbirths in a total population. DESIGN: Matched case-control study. SETTING: Western Australia 1980-1983. SUBJECTS: Intrapartum stillbirths of > or = 1000 g birthweight (cases) and liveborn infants (controls) individually matched for year of birth, plurality, sex and birthweight of infant and race of mother. RESULTS: Intrapartum stillbirths were more likely than controls to have had placental abruption (OR = 9.55, CI = 2.09-43.69), fetal distress (OR = 4.64, CI = 1.92-11.19), cord prolapse (OR = 10.00, CI = 1.17-85.60) and unhealthy placentas (OR = 2.26, CI = 1.13-4.52), and more likely to have been born by vaginal breech manoeuvre (OR = 3.51, CI = 1.40-8.80) and emergency caesarean section (OR = 2.15, CI = 1.13-4.10); mothers of intrapartum stillbirths were less likely to have had no labour (OR = 0.14, CI = 0.04-0.55) and to have been delivered normally (OR = 0.20, CI = 0.10-0.40). Mothers of cases born by emergency caesarean section had longer labours than mothers of controls born by this method. All intrapartum stillbirths with breech presentation were born by vaginal breech manoeuvre compared with only 53% of the controls; the remainder of the controls were born by caesarean section. CONCLUSIONS: Results indicate that little could have been done early in pregnancy to prevent the intrapartum stillbirths as no antenatal risk factors predicted these deaths. Most of the risk factors identified related to labour and delivery problems. Considering cases born by emergency caesarean section, delivery of the mother earlier in labour may have prevented some of the deaths.     

Determinants of unexplained antepartum fetal deaths

OBJECTIVE: To assess fetal, maternal, and pregnancy-related determinants of unexplained antepartum fetal death. METHODS: We conducted a hospital-based cohort study of 84,294 births weighing 500 g or more from 1961-1974 and 1978-1996. Unexplained fetal deaths were defined as fetal deaths occurring before labor without evidence of significant fetal, maternal, or placental pathology. RESULTS: One hundred ninety-six unexplained antepartum fetal deaths accounted for 27.2% of 721 total fetal deaths. Two thirds of the unexplained fetal deaths occurred after 35 weeks' gestation. The following factors were independently associated with unexplained fetal death: maternal prepregnancy weight greater than 68 kg (adjusted odds ratio [OR] 2.9; 95% confidence interval [CI] 1.85, 4.68), birth weight ratio (defined as ratio of birth weight to mean weight for gestational age) between 0.75 and 0.85 (OR 2.77; 95% CI 1.48, 5.18) or over 1.15 (OR 2.36; 95% CI 1.26, 4.44), fewer than four antenatal visits in women whose fetuses died at 37 weeks or later (OR 2.21; 95% CI 1.08, 4.52), primiparity (OR 1.74; 95% CI 1.26, 2.40), parity of three or more (OR 2.01; 95% CI 1.26, 3.20), low socioeconomic status (OR 1.59; 95% CI 1.14, 2.22), cord loops (OR 1.75; 95% CI 1.04, 2.97) and, for the 1978-1996 period only, maternal age 40 years or more (OR 3.69; 95% CI 1.28, 10.58). Trimester of first antenatal visit, low maternal weight, postdate pregnancy, fetal-to-placental weight ratio, fetal sex, previous fetal death, previous abortion, cigarette smoking, and alcohol use were not significantly associated with unexplained fetal death. CONCLUSION: In this study, we identified several factors associated with an increased risk of unexplained fetal death.     

Trends in the cause of late fetal death, 1982-2000

BACKGROUND: Progress in reducing late fetal deaths has slowed in recent years, despite changes in intrapartum and antepartum care. OBJECTIVES: To describe recent trends in cause-specific fetal death rates. DESIGN: Retrospective cohort study. SETTING: North of England. POPULATION/SAMPLE: 3,386 late fetal deaths (> or = 28 weeks of gestation and at least 500 g), occuring between 1982 and 2000. METHODS: Data on deaths were obtained from the Northern Perinatal Mortality Survey. Data on live births were obtained from national birth registration statistics. Rate ratios (RR) and 95% confidence intervals (CI) for fetal deaths in 1991-2000 compared with 1982-1990 were calculated. MAIN OUTCOME MEASURES: Cause-specific late fetal death rates per 10,000 total births. RESULTS: Mortality in singletons declined from 51.5 per 10,000 births in 1982-1990 to 42.0 in 1991-2000 (RR 0.82, 95% CI 0.76-0.87). There was a greater decline in multiples, from 197.9 to 128.0 per 10,000 (RR 0.65, 95% CI 0.51-0.83). In singletons, the largest reductions occurred in intrapartum-related deaths, and deaths due to congenital anomalies, antepartum haemorrhage and pre-eclampsia. There was little change in the rate of unexplained antepartum death occurring at term (RR 0.97, 95% CI 0.84-1.11) or preterm (RR 0.94, 95% CI 0.82-1.07), these accounting for about half of all late fetal deaths. Unexplained antepartum deaths declined in multiple births and in singletons of birthweight < 1500 g. CONCLUSIONS: While late fetal mortality due to many specific causes has declined, unexplained antepartum death rates have remained largely unchanged. Improved identification of deaths due to growth restriction and infection, which may otherwise be classified as unexplained, is important. Further investigation of the underlying aetiologies of genuinely unexplained deaths is needed.     

Recurrent stillbirths: a matched case-control study of unexplained stillbirths at term.

The aim of this study was to assess the recurrent risk of an unexplained stillbirth at term. A total of 75 women who delivered stillbirths were matched for maternal age and parity with 75 controls. After excluding explained stillbirths, matched cases and controls were compared for maternal age, length of gestation, birth weight and 'interval to next birth'. The main outcome measure was the frequency of recurrence of a stillbirth. Both groups were similar for maternal age and length of gestation. Birth weight was marginally different (odds ratio (OR) = 0.997, 95% confidence interval (CI) 0.996, 0.999) and 'interval to next birth' was longer (OR = 1.08, 95% CI 1.00, 1.17). There were no stillbirths in cases and controls at follow-up. We conclude that a woman who has had an unexplained stillbirth at term has no greater risk of recurrence than a matched control. However, the 'interval to next birth' was significantly longer.     

Risk factors for sudden intrauterine unexplained death: epidemiologic characteristics of singleton cases in Oslo, Norway, 1986-1995

OBJECTIVE: The epidemiologic characteristics of unexplained stillbirths are largely unknown or unreliable. We define sudden intrauterine unexplained death as a death that occurs antepartum and results in a stillbirth for which there is no explanation despite postmortem examinations, and we present risk factors for this type of stillbirth in singleton gestations.Study Design: Singleton antepartum stillbirths (n = 291) and live births (n = 582) in Oslo were included and compared with national data (n = 2025 and n = 575,572, respectively). Explained stillbirths (n = 165) and live births in Oslo served as controls for the cases of sudden intrauterine unexplained death (n = 76) in multiple logistic regression analyses. RESULTS: One fourth of stillbirths remain unexplained. The risk of sudden intrauterine unexplained death (1/1000) increased with gestational age, high maternal age, high cigarette use, low education, and overweight or obesity. Primiparity and previous stillbirths or spontaneous abortions were not associated with sudden intrauterine unexplained death. CONCLUSIONS: Risk factors for sudden intrauterine unexplained death are identifiable by basic antenatal care. Adding unexplored stillbirths to the unexplained ones conceals several risk factors and underlines the necessity of a definition that includes thorough postmortem examinations.     

Obstetric outcome in women with subfertility

BACKGROUND: It has been suggested that a history of subfertility is associated with increased obstetric and perinatal risks. It is unclear if the cause is inherent characteristics in the women or the fertility treatment. OBJECTIVES: To compare the obstetric and perinatal risks of singleton pregnancies in women with a history of subfertility in comparison with the general population. DESIGN: Population cohort. SETTING: Aberdeen, Scotland. POPULATION: Cases were women attending the Fertility Clinic between 1989 and 1999 who subsequently went on to have singleton pregnancies. Controls included the general population of women who delivered singletons over the same period. METHODS: We performed a retrospective cohort study to investigate the obstetric outcome of singleton pregnancies in women with subfertility. The general population of women who delivered singletons over the same period served as controls. MAIN OUTCOME MEASURES: Obstetric and perinatal complications in singleton pregnancies. RESULTS: Maternity records were available for a total of 1437 subfertile women and 21,688 controls. Subfertile women were older [mean (SD) age: 31 (4.7) years vs 27 (5.4) years, P < 0.01] and more likely to be primiparous (70% vs 65%, P < 0.001). After adjusting for age and parity, subfertile women were at increased risk of pre-eclampsia (OR 1.9, 95% CI 1.5-2.5), placenta praevia (OR 3.9, 95% CI 2.2-7.0) and placental abruption (OR 1.8, 95% CI 1.1-3.0), and more likely to undergo induction of labour (OR 1.5, 95% CI 1.3-1.6), caesarean section (OR 2.1, 95% CI 1.8-2.4) and instrumental delivery (OR 2.2, 95% CI 1.8-2.6), and deliver low birthweight (OR 1.4, 95% CI 1.3-1.7) and preterm (OR 1.7, 95% CI 1.2-2.2) infants. There were no differences between treatment-related and treatment-independent pregnancies. CONCLUSION: Subfertile women are at higher risk of obstetric complications, which persist after adjusting for age and parity.     

Unexplained antepartum fetal deaths: what are the determinants?

Objective The objective was to assess fetal, antenatal, and pregnancy determinants of unexplained antepartum fetal death.Methods This is a hospital-based cohort study of 34,394 births weighing 500 g or more from January 1995 to December 2002. Unexplained fetal deaths were defined as fetal deaths occurring before labor, without evidence of significant fetal, maternal or placental pathology.Results Ninety-eight unexplained antepartum fetal deaths accounted for 27.2% of 360 total fetal deaths. Two-thirds of these deaths occurred after 36 weeks gestation. The following factors are independently associated with unexplained fetal deaths: primiparity (OR 1.74; 95% CI 1.21, 2.86); parity of five or more (OR 1.19; 95% CI 1.26, 3.26); low socioeconomic status (OR 1.22; 95% CI 1.14, 2.86); maternal age 40 years or more (OR 3.62; 95% CI 1.22, 4.52); maternal age of 18 years or less (OR 1.79; 95% CI 0.82, 2.89); maternal prepregnancy weight greater than 70 kg (OR 2.20; 95% CI 1.85, 3.68); fewer than three antenatal visits in women whose fetuses died at 31 weeks or more (OR 1.11; 95% CI 1.08, 2.48); birth weight ratio (defined as ratio of birth weight to mean birth weight for gestational age) between 0.85 and 0.94 (OR 1.77; 95% CI 1.28, 4.18) or over 1.45 (OR 2.92; 95% CI 1.75, 3.21); trimester of first antenatal visit. Previous fetal death, previous abortion, cigarette smoking, fetal sex, low maternal weight, fetal-to-placenta weight, and post date pregnancy were not significantly associated with unexplained fetal deaths.Conclusion Several factors were identified that are associated with an increased risk of unexplained fetal deaths.     

Obstetric and perinatal outcome of 1655 ICSI and 3974 IVF singleton and 1102 ICSI and 2901 IVF twin births: a comparative analysis

A total of 3974 IVF and 1655 ICSI singleton births and 2901 IVF and 1102 ICSI twin births were evaluated. Pregnancies after both fresh and frozen transfers were included. IVF and ICSI singleton pregnancies were very similar for most obstetric and perinatal variables. The only significant difference was a higher risk for prematurity (< 37 weeks of amenorrhoea) in IVF pregnancies compared with ICSI pregnancies (12.4 versus 9.2%, OR = 1.39, 95% CI = 1.15-1.70). For twin pregnancies, differences were not statistically different except for a higher incidence of stillbirths in the ICSI group (2.08 versus 1.03%, OR = 2.04, 95% CI = 1.14-3.64). Intrauterine growth retardation with or without pregnancy-induced hypertension was observed more often in the ICSI group. Regression analysis of the data with correction for parity and female age showed similar results for twins. For singletons, this analysis showed similar results with the exception of low birth weight babies (< 2500 g), which were also observed more often in IVF pregnancies (9.6 versus 7.9%, OR = 0.79, CI = 0.65-0.98, P = 0.03). This large case-comparative retrospective analysis showed that the obstetric outcome and perinatal health of IVF and ICSI pregnancies is comparable.     

Are risk factors for stillbirths in low-income countries associated with sensorineural hearing loss in survivors?

Objectives.?To determine associated risk factors for stillbirths in Lagos, Nigeria and to examine possible relationships between these factors and the risk of sensorineural hearing loss (SNHL).

Methods.?Stillbirths in an inner-city maternity hospital from June 2005 to May 2007 were matched with live-birth controls at ratio 1:2. Risk factors and their associated adjusted odds ratio (OR) at 95% confidence interval (CI) were first determined by multiple logistic regression and then correlated with hearing screening failure among survivors who received a two-stage hearing screening with automated otoacoustic emissions and auditory brainstem response.

Results.?Of 201 cases examined and matched with 402 live births, 101 (50.2%) were fresh stillbirths and 100 (49.8%) macerated. Multiparity (OR: 1.92; CI: 1.16–3.20), lack of antenatal care (OR: 7.23; CI: 3.94–13.26), hypertensive conditions (OR: 6.48; CI: 2.94–14.29), antepartum haemorrhage (OR:18.84; CI: 6.96–51.00), premature rupture of membrane (OR:3.36; CI: 1.40–8.05), prolonged obstructed labour (OR: 22.25; CI: 10.07–49.16) and prematurity (OR: 2.30; CI: 1.2–4.01) were associated with increased risk of stillbirths whereas caesarean section (OR: 0.24; CI: 0.12–0.48) was associated with lower risk of stillbirths. Infants delivered by mothers with hypertensive conditions during pregnancy were at risk of SNHL (OR: 2.97; CI: 1.15–7.64).

Conclusion.?Hypertensive conditions during pregnancy increase the risk of stillbirths and place survivors at greater risk of SNHL.     

Physical abuse and low birthweight: a case-control study

Objective To examine whether physical abuse of a woman by her partner was associated with low birthweight.
Design A case—control study.
Setting Department of Gynaecology and Obstetrics, University Hospital of Trondheim, Norway.
Participants/sample Eighty-six women who were delivered of a low birthweight (< 2500 g) infant (cases) and 92 women who were delivered of an infant with birthweight 2500 g (controls).
Methods An in-depth interview, either postpartum at the maternity ward or one year after delivery. Information about abuse was obtained by direct questioning and a modified version of the Conflict Tactics Scales.
Results A total of 17% of the women had experienced abuse by a partner. While 7% had been abused by their current partner before the index pregnancy only one woman reported abuse during pregnancy. Relatively more mothers of low birthweight infants were abused (20%) compared with controls (15%), but the association was not statistically significant (OR 1.37, 95% CI 0.63–2.99). Abused women reported a higher consumption of alcohol and cigarettes in pregnancy compared with nonabused women.
Conclusion Abuse was not found to be a risk factor for low birthweight in this study.     

The relationship between delivery mode and mortality in very low birthweight singleton vertex-presenting infants

OBJECTIVE: To investigate the factors associated with caesarean delivery and the relationship between mode of delivery and mortality in singleton vertex-presenting very low birthweight (< or = 1500 g) live born infants. DESIGN: Observational population-based study. SETTING: Data collected from all 28 neonatal departments comprise the Israel National Very Low Birth Weight Infant Database. POPULATION: 2955 singleton vertex-presenting very low birthweight infants registered in the database from 1995 to 2000, and born at 24-34 weeks of gestation. METHODS: The demographic, obstetric and perinatal factors associated with caesarean delivery and subsequent mortality were studied. The independent effect of the mode of delivery on mortality was tested by multiple logistic regression. MAIN OUTCOME MEASURE: Mortality was defined as death prior to discharge. RESULTS: Caesarean delivery rate was 51.7%. Caesarean delivery was directly associated with increasing maternal age and gestational age, small for gestational age infants, maternal hypertensive disorders and antepartum haemorrhage, and was inversely related to premature labour and prolonged rupture of membranes. Factors associated with increased survival were increasing gestational age, antenatal corticosteroid therapy, maternal hypertensive disorders and no amnionitis. Mortality rate prior to discharge was lower after caesarean delivery (13.2% vs 21.8%), but in the multivariate analysis, adjusting for the other risk factors associated with mortality, delivery mode had no effect on infant survival (OR 1.00, 95% CI 0.74-1.33). In a subgroup with amnionitis, a protective effect of caesarean delivery was found. CONCLUSIONS: Caesarean delivery did not enhance survival of vertex-presenting singleton very low birthweight babies. Caesarean delivery cannot be routinely recommended, unless there are other obstetric indications.     

Maternal anemia during pregnancy is an independent risk factor for low birthweight and preterm delivery

OBJECTIVE: The present study was designed to investigate the outcome of pregnancy and delivery in patients with anemia. METHODS: A retrospective population-based study comparing all singleton pregnancies of patients with and without anemia was performed. Deliveries occurred during the years 1988-2002 in the Soroka University Medical Center. Maternal anemia was defined as hemoglobin concentration lower than 10 g/dl during pregnancy. Patients with hemoglobinopathies such as thalassemia were excluded from the analysis. Multiple logistic regression models were performed to control for confounders. RESULTS: During the study period there were 153,396 deliveries, of which 13,204 (8.6%) occurred in patients with anemia. In a multivariable analysis, the following conditions were significantly associated with maternal anemia: placental abruption, placenta previa, labor induction, previous cesarean section (CS), non-vertex presentation and Bedouin ethnicity. Higher rates of preterm deliveries (<37 weeks gestation) and low birthweight (<2500 g) were found among patients with anemia as compared to the non-anemic women (10.7% versus 9.0%, p < 0.001 and 10.5% versus 9.4%, p < 0.001; respectively). Higher rates of CS were found among anemic women (20.4% versus 10.3%; p < 0.001). The significant association between anemia and low birthweight persisted after adjusting for gender, ethnicity and gestational age, using a multivariable analysis (OR = 1.1; 95% CI 1.0-1.2, p = 0.02). Two multivariable logistic regression models, with preterm delivery (<37 weeks gestation) and low birthweight (<2500 g) as the outcome variables, were constructed in order to control for possible confounders such as ethnicity, maternal age, placental problems, mode of delivery and non-vertex presentation. Maternal anemia was an independent risk factor for both, preterm delivery (OR = 1.2; 95% CI 1.1-1.2, p < 0.001) and low birthweight (OR = 1.1; 95% CI 1.1-1.2, p = 0.001). CONCLUSION: Maternal anemia influences birthweight and preterm delivery, but in our population, is not associated with adverse perinatal outcome.     

New postnatal urinary incontinence: obstetric and other risk factors in primiparae

OBJECTIVE: To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth. DESIGN: Questionnaire survey of women. SETTING: Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION: A total of 3405 primiparous women with singleton births delivered during 1 year. METHODS: Questionnaire responses and obstetric case note data were analysed using multivariate analysis to identify associations with urinary incontinence. MAIN OUTCOME MEASURES: Urinary incontinence at 3 months after delivery first starting in pregnancy or after birth. RESULTS: The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with older maternal age (oldest versus youngest group, OR 2.02, 95% CI 1.35-3.02) and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19-0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92-1.51) or vacuum delivery (OR 1.16, 95% CI 0.83-1.63). Incontinence first occurring during pregnancy and still present at 3 months was associated with higher maternal body mass index (BMI>25, OR 1.68, 95% CI 1.16-2.43) and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12-2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27-0.58) but incontinence was not associated with age. CONCLUSIONS: Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher BMI and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings.     

Maternal height,birthweight and cephalo pelvic disproportion in urban Nigeria and rural Malawi

BACKGROUND: Cephalo pelvic disproportion (CPD) has been attributed to short stature. It has been suggested that nutritional supplementation to promote linear growth would increase birthweight and the risk of CPD. The objective of this study was to examine the factors associated with CPD, with particular reference to birthweight, stature, parity and maternal age. DESIGN: Factors associated with CPD were analyzed using data abstracted from a detailed early hospital report from Ibadan, Nigeria and from a recent rural pregnancy study conducted in the Shire Valley, Malawi. RESULTS: In Nigeria, of 107 CPD cases admitted to hospital in Ibadan during 1953-54, 79% were women > 20 years. Birthweight values increased significantly with age and parity. In 19.6% of cases, the baby had a low birthweight (< 2500 g). In Malawi, among the 1523 women delivering, the incidence of CPD was 2.3%. Of the 35 cases of CPD, only four were adolescents. Birthweights increased with increasing parity, age and height (p < 0.001). In 6.4% of CPD cases, the baby had a low birthweight. Nulliparity (OR 4.0; CI 1.7-9.3; p = 0.0001), birthweight >or= 3400 g (OR 4.6; CI 2.1-10.0; p = 0.0001) and height 相似文献   

Suboptimal care in stillbirths - a retrospective audit study

BACKGROUND: Stillbirth rates have decreased radically over the last decades. One reason for this is improved perinatal care. The aim of this study was to explore whether sub-optimal factors in stillbirths were more frequent among non-western than western women. METHODS: Population-based perinatal audit of 356 stillbirths after gestational week 23, in 2 Norwegian counties during 1998-2003 (4.2 per 1,000 deliveries); of these 31% were born to non-western women. By audit, the stillbirths were attributed to optimal or sub-optimal care factors. Multivariate methods were used to analyse the data. RESULTS: Sub-optimal factors were identified in 37% of the deaths. When compared to western women, non-western women had an increased risk of stillbirth (OR: 2.2; 95% CI: 1.3-3.8), and an increased risk of sub-optimal care (OR: 2.4; 95% CI: 1.5-3.9). More often, non-western women received sub-optimal obstetric care (p<0.001), as e.g. failure to act on non-reassuring fetal status or incorrect assessment of labour progression. A common failure in antenatal care for both groups was unidentified or inadequate management of intrauterine growth restriction or decreased fetal movements. Non-western women were less prone to attend the program for antenatal care or to take the consequences of recommendations from health professionals. Inadequate communication was documented in 47% of non-western mothers; an interpreter was used in 29% of these cases. CONCLUSIONS: Non-western women constituted a risk group for sub-optimal care factors in stillbirths. Possibilities for improvements include a reduction of language barriers, better identification and management of growth restriction for both origin groups, and adequate intervention in complicated vaginal births; with increased vigilance towards non-western women.     

Low prepregnant body mass index and breastfeeding practices.

The relationship of low prepregnant body mass index with breastfeeding was investigated in 1272 women who delivered a term infant with birthweight > or = 2500 g at the San Paolo Hospital in Milan, Northern Italy. Underweight was defined using the Institute of Medicine's cutoff of 19.8 kg/m(2). Women were interviewed via telephone through 12 months postdelivery about breastfeeding practices. Education level (high versus low, odds ratio [OR], 1.41), primiparity (OR, 1.35), vaginal delivery (OR, 0.74), and birthweight of the infant (normal versus high, OR, 1.89) were associated with low, as opposed to normal, pre-pregnant body mass index. After adjustment for these confounders, no difference was found between underweight and normal weight women for initiation or duration of breastfeeding (mean adjusted difference, 0.4; 95% confidence interval [95% CI], -0.1 to 0.9 months) or exclusive breastfeeding (0.1 [95% CI, -0.1 to 0.3] months). Underweight mothers of healthy term infants may not be at increased risk for not initiating or shorter breastfeeding.     

Maternal uterine artery Doppler flow velocimetry and the risk of stillbirth

OBJECTIVE: We sought to relate the risk of antepartum stillbirth to uterine artery Doppler flow velocimetry at 22-24 weeks. METHODS: Data were available from 30,519 unselected women from seven units in the UK who had uterine artery Doppler performed between 22 and 24 weeks of gestation. The risk of stillbirth (n=109) was assessed using time to event and logistic regression analysis. Stillbirths were subdivided into placental (due to abruption, preeclampsia, or growth restriction) or unexplained. RESULTS: The risk of placental stillbirth was increased among women with a mean pulsatility index in the top decile (adjusted hazard ratio [HR] 5.5, 95% confidence interval [CI] 2.8-10.6) and those with a bilateral notch (adjusted HR 3.9, 95% CI 2.0-7.8). The relationship between a mean pulsatility index in the top decile and the risk of unexplained stillbirth was weaker (adjusted HR 2.5, 95% CI 1.1-5.6) and there was no association with a bilateral notch. Placental stillbirths occurred at earlier gestations than unexplained stillbirths (median [interquartile range] 30 [26-36] compared with 38 [36-40], P<.001). Consequently, being in the top 5% of predicted risk of stillbirth on the basis of the combination of mean pulsatility index and notching was a good predictor (sensitivity, specificity, and positive likelihood ratio) of all cause stillbirth up to 32 weeks (58%, 95%, and 12.1, respectively) but a poor predictor of stillbirth at later gestations (7%, 95%, and 1.3, respectively). CONCLUSION: Abnormal uterine artery Doppler was a better predictor of the risk of stillbirth due to placental causes than unexplained stillbirth. Consequently, abnormal uterine artery Doppler was a good predictor of stillbirth at extreme preterm gestations but a poor predictor of stillbirth at term. LEVEL OF EVIDENCE: II.     

Obstetric outcome in women with threatened miscarriage in the first trimester

OBJECTIVE: To assess pregnancy outcomes in women with threatened miscarriage in the first trimester. METHODS: This was a retrospective cohort study based on data extracted from the Aberdeen Maternity and Neonatal Databank. Cases included all primigravid women with first-trimester vaginal bleeding who delivered after 24 weeks of gestation between 1976 and 2004. The control group comprised all other women who had first pregnancies during the same period. Data were analyzed by univariate and multivariate statistical methods. RESULTS: Compared with the control group (n = 31,633), women with threatened miscarriage (n = 7,627) were more likely to have antepartum hemorrhage of unknown origin (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.73-2.01). Elective cesarean (OR 1.30, 95% CI 1.14-1.48) and manual removal of placenta (OR 1.40, 95% CI 1.21-1.62) were performed more frequently in these women, who also had a higher risk of preterm delivery (OR 1.56, 95% CI 1.43-1.71) and malpresentation (OR 1.26, 95% CI 1.13-1.40). Threatened miscarriage in the first trimester is required in 112, 112, 17, 85, 32 patients, respectively, for each additional case of manual removal of placenta, elective cesarean, antepartum hemorrhage of unknown origin, malpresentation, and preterm delivery. CONCLUSION: Pregnancies complicated by threatened miscarriage are at a slightly higher risk of obstetric complications and interventions. LEVEL OF EVIDENCE: II-2.     

Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001.

OBJECTIVE: To identify maternal and fetal risk factors associated with persistent occiput posterior position at delivery, and to examine the association of occiput posterior position with subsequent obstetric outcomes. METHODS: This is a retrospective cohort study of 30 839 term, cephalic, singleton births. Women with persistent occiput posterior (OP) position at delivery were compared to those with occiput anterior (OA) position. Demographics, obstetric history, and labor management were evaluated and subsequent obstetric outcomes examined. Potential confounding variables were controlled for using multivariate logistic regression analysis. RESULTS: The overall frequency of OP position was 8.3% in the study population. When compared to Caucasians, a higher rate of OP was observed among African-Americans (OR = 1.4, 95% CI 1.25-1.64) while no other racial/ethnic differences were noted. Other associated factors included nulliparity, maternal age > or =35, gestational age > or =41 weeks, and birth weight >4000 g, as well as artificial rupture of the membranes (AROM) and epidural anesthesia (p < 0.001 for all). Persistent OP was associated with increased rates of operative vaginal (OR = 4.14, 95% CI 3.57-4.81) and cesarean deliveries (OR = 13.45, 95% CI 11.94-15.15) and other peripartum complications including third or fourth degree perineal lacerations (OR = 2.38, 95% CI 2.03-2.79), and chorioamnionitis (OR = 2.10, 95% CI 1.81-2.44). CONCLUSION: Epidural use, AROM, African-American ethnicity, nulliparity, and birth weight >4000 g are associated with persistent OP position at delivery, with higher rates of operative deliveries and obstetric complications. This information can be useful in counseling patients regarding risks and associated outcomes of persistent OP position.