Mean maternal second-trimester hemoglobin concentration and outcome of pregnancy: a population-based study.

Both anemia and the lack of physiological maternal plasma volume expansion during the second trimester are associated with higher maternal morbidity and poor fetal outcome. Mean hemoglobin levels between the 14th and 30th gestational weeks were calculated in 4985 consecutive pregnant women and were correlated with outcome data of pregnancy. It was found that 9.4% of participants (n=3959) had normal pregnancy outcome. Mean maternal hemoglobin levels were significantly lower in women with a normal pregnancy (11.96+/-0.94 g/dL) compared with women who had adverse outcome events (preeclampsia, n=423, 12.5 +/- 1.0 g/dL, P< .0001; early birth, n=464, 12.2+/-1.01 g/dL, P< .0001; low birth weight newborn, n=473, 12.2+/-1.10 g/dL, P< .0001; intrauterine growth retardation, n=250, 12.2+/-1.0 g/dL, P< .0001). The risk for any adverse outcome event was lowest with a mean hemoglobin between 11.0 and 12.0 g/dL (odds ratio, 0.625; 95% confidence interval, 0.43-0.89) and highest between 13.0 and 15.0 g/dL (odds ratio, 2.24; 95% confidence interval, 1.54-3.31). In this population-based study from a community in Western Germany, impaired plasma volume expansion was an independent risk factor for the development of an adverse outcome of pregnancy.     

Excess risk of adverse pregnancy outcomes in women with porphyria: a population-based cohort study

The porphyrias comprise a heterogeneous group of rare, primarily hereditary, metabolic diseases caused by a partial deficiency in one of the eight enzymes involved in the heme biosynthesis. Our aim was to assess whether acute or cutaneous porphyria has been associated with excess risks of adverse pregnancy outcomes. A population-based cohort study was designed by record linkage between the Norwegian Porphyria Register, covering 70% of all known porphyria patients in Norway, and the Medical Birth Registry of Norway, based on all births in Norway during 1967–2006. The risks of the adverse pregnancy outcomes preeclampsia, delivery by caesarean section, low birth weight, premature delivery, small for gestational age (SGA), perinatal death, and congenital malformations were compared between porphyric mothers and the rest of the population. The 200 mothers with porphyria had 398 singletons during the study period, whereas the 1,100,391 mothers without porphyria had 2,275,317 singletons. First-time mothers with active acute porphyria had an excess risk of perinatal death [adjusted odds ratio (OR) 4.9, 95% confidence interval (CI) 1.5–16.0], as did mothers with the hereditable form of porphyria cutanea tarda (PCT) (3.0, 1.2–7.7). Sporadic PCT was associated with an excess risk of SGA [adjusted relative risk (RR) 2.0, 1.2–3.4], and for first-time mothers, low birth weight (adjusted OR 3.4, 1.2–10.0) and premature delivery (3.5, 1.2–10.5) in addition. The findings suggest women with porphyria should be monitored closely during pregnancy.     

Coeliac disease in the father and risk of adverse pregnancy outcome: a population-based cohort study

OBJECTIVE: The risk of adverse foetal outcomes was investigated in offspring to men with coeliac disease (CD) diagnosed prior to infant birth and in offspring to men who did not receive a diagnosis of CD until after the delivery. MATERIAL AND METHODS: A cohort study was based on national registry data restricted to women aged 15-44 years with singleton live-born infants, with linkage between the Swedish national birth registry (1973-2001) and the national inpatient registry (1964-2001). A total of 1059 offspring to men who had received a diagnosis of CD were included: 554 offspring to men diagnosed prior to birth and 505 offspring to men diagnosed after infant birth. RESULTS: Undiagnosed CD in the father was associated with an increased risk of caesarean section (adjusted odds ratio (AOR)=1.83; 95% confidence interval (CI) for AOR=1.13-2.95; p=0.014) but was otherwise not linked to adverse pregnancy outcome: (intrauterine growth retardation (OR=1.37; 95% CI=0.91-2.07), low birth-weight (OR=1.41; 95% CI=0.93-2.12), very low birth-weight (OR=1.21; 95% CI=0.39-3.77), preterm birth (OR=1.10; 95% CI=0.74-1.62), and very preterm (OR=0.62; 95% CI=0.09-4.40)). A paternal diagnosis of CD made before infant birth was not associated with adverse foetal outcome. CONCLUSIONS: CD in the father is not a risk factor for unfavourable foetal outcome. The increased risk for caesarean section in offspring to men with undiagnosed CD in this study may be due to multiple comparisons.     

Urinary incontinence in US women: a population-based study

BACKGROUND: Urinary incontinence (UI) is a common disorder that is increasingly important as our population ages. Less is known about UI in younger women, and few large surveys have been able to determine risk factors by linking their data to patients' medical findings. METHODS: We conducted a population-based, age-stratified postal survey of 6000 women aged between 30 and 90 years who were enrolled in a large health maintenance organization in Washington State. RESULTS: The response rate was 64% (n = 3536) after exclusion criteria were applied. The population-based prevalence of UI was 45%. Prevalence increased with age, from 28% for 30- to 39-year-old women to 55% for 80- to 90-year-old women. Eighteen percent of respondents reported severe UI. The prevalence of severe UI also increased notably with age, from 8% for 30- to 39-year-old women to 33% for 80- to 90-year-old women. Older age, higher body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), greater medical comorbidity, current major depression, a history of hysterectomy, and parity increased the odds of having UI. Not being white and having had only cesarean deliveries decreased the odds of having UI. Major depression (odds ratio, 2.48; 95% confidence interval, 1.65-3.72) and obesity, defined as having a BMI of 30 or greater (odds ratio, 2.39; 95% confidence interval, 1.99-2.87), had the strongest association with UI. Among women with UI, age, BMI, medical comorbidity, current major depression, diabetes, a history of hysterectomy, and having had only cesarean deliveries were significantly associated with severe UI. CONCLUSIONS: Urinary incontinence is highly prevalent in women across their adult life span, and its severity increases linearly with age. Age, BMI, race, medical comorbidity, current major depression, a history of hysterectomy, parity, and having only had cesarean deliveries are each independent factors significantly associated with the likelihood of having UI.     

Adverse pregnancy outcomes in women with diabetes

ABSTRACT: Pregnancy affects both the maternal and fetal metabolism and even in nondiabetic women exerts a diabetogenic effect. Among pregnant women, 2 to 17.8% develop gestational diabetes. Pregnancy can also occur in women with preexisting diabetes, that can predispose the fetus to many alterations in organogenesis, growth restriction and the mother to some diabetes-related complications like retinopathy and nephropathy or accelerate the course of these complications if they are already present. Women with gestational diabetes generally start their treatment with diet and lifestyle modification; when these changes fail in keeping an optimal glycemic control, then insulin therapy must be considered. Women with type 2 diabetes in use of oral hypoglycemic agents are advised to change to insulin therapy. Those with preexisting type 1 diabetes must start an intensive glycemic control, preferably before conception. All these procedures are performed aiming to keep glycemic levels normal or near-normal as possible to avoid the occurrence of adverse perinatal outcomes to the mother and to the fetus. The aim of this review is to reinforce the need to improve the knowledge on reproductive health of women with diabetes during gestation and to understand what are the reasons for them failing to attend for prepregnancy care programs, and to understand the underlying mechanisms of adverse fetal and maternal outcomes, which in turn may lead to strategies for its prevention.     

Adverse outcome analyses of observational data: assessing cardiovascular risk in HIV disease

Clinical decisions are ideally based on randomized trials but must often rely on observational data analyses, which are less straightforward and more influenced by methodology. The authors, from a series of expert roundtables convened by the Forum for Collaborative HIV Research on the use of observational studies to assess cardiovascular disease risk in human immunodeficiency virus infection, recommend that clinicians who review or interpret epidemiological publications consider 7 key statistical issues: (1) clear explanation of confounding and adjustment; (2) handling and impact of missing data; (3) consistency and clinical relevance of outcome measurements and covariate risk factors; (4) multivariate modeling techniques including time-dependent variables; (5) how multiple testing is addressed; (6) distinction between statistical and clinical significance; and (7) need for confirmation from independent databases. Recommendations to permit better understanding of potential methodological limitations include both responsible public access to de-identified source data, where permitted, and exploration of novel statistical methods.     

School marks for Swedish children whose mothers had diabetes during pregnancy: a population-based study

Aims/hypothesis To study, at a population level, school performance when leaving compulsory school of Swedish children whose mothers had diabetes during pregnancy compared with a reference population. Methods We linked the Swedish Medical Birth Register with the Swedish School Mark Register, which contains school marks for all children in Sweden when leaving compulsory school. A total of 6,397 children were identified whose mothers had a diagnosis of diabetes during pregnancy in the years 1973 to 1986. Data on these children were compared with 1,300,683 children whose mothers had no diagnosis of diabetes during pregnancy. Risks were estimated as odd ratios (ORs) after adjustment for year of birth, maternal age, parity and educational level of the mother. Results The children’s average numerical school marks (for children leaving school between 1988 and 1997) were statistically significantly lower among children born to mothers with diabetes in pregnancy compared with reference children (3.13 ± 0.01 vs 3.23, p < 0.001). The effect was similar among boys and girls. There was also an effect of maternal diabetes during pregnancy on the risk of the child not completing compulsory school (OR 1.25; 95% CI 1.10–1.43, and after exclusion of infants with certain perinatal characteristics an OR of 1.25; 95% CI 1.02–1.53). When sports and the core subjects mathematics, English and Swedish were studied, there were increased risks of having scores below pass level and decreased probabilities of having scores above pass level for children of mothers with diabetes during pregnancy. Conclusions/interpretation Children of mothers with diabetes during pregnancy performed slightly but significantly less well than reference children when leaving compulsory school at about 16 years old; this was also seen after adjustment for some putative perinatal and social confounders.     

A multicenter Italian study on pregnancy outcome in women with diabetes

Background and aimTo determine pregnancy outcome in women with type 1 and type 2 diabetes.Methods and resultsA prospective study was conducted in 33 centers in Italy between 1999 and 2003, mainly recording preterm delivery, stillbirths, neonatal mortality, congenital malformations and birthweight.Of the 668 women examined, 504 had type 1 diabetes and 164 had type 2. Pre-pregnancy counseling had been provided to 43.9% of the women who had type 1 diabetes and 29.1% of the women who had type 2 diabetes and correlated with a better HbA1c value throughout pregnancy. The preterm delivery rate was significantly higher in type 1 and 2 diabetics than in normal pregnant women and was related to HbA1c values higher than 8%, gestational hypertension, pre-eclampsia and the presence of retinopathy before pregnancy. The stillbirth and neonatal mortality rates were also higher in diabetic pregnant women (1.26% and 0.63%, respectively) than in Italian pregnancies in general (0.30% and 0.32%), and the same was true for major congenital malformations (4.9% for diabetic pregnancies, 0.86% for normal Italian pregnancies).ConclusionsIn our population, pregnancy in diabetic women was still associated with a high rate of stillbirths, neonatal mortality and congenital malformations. Unplanned pregnancies and non-optimal glycemia control may help explain the high rates of maternal and neonatal complications.     

Maternal thyroid function in different conditions of iodine nutrition in pregnant women exposed to mild-moderate iodine deficiency: an observational study

Objective We examined the effect of different conditions of nutritional iodine intake on maternal thyroid function throughout gestation in a cohort of healthy, anti‐thyroid antibody‐negative women from a mild‐moderately iodine‐deficient (ID) area. Design Observational cohort study. Patients The study included 168 women receiving prenatal preparations containing 150 μg of iodine from early pregnancy (150‐I group); 105 women who had regularly used (>2 years) iodized salt prior to becoming pregnant (I‐salt group); 160 women neither taking iodine supplements nor using iodized salt (no‐I group). Measurements Maternal TSH, FT3 and FT4 were determined throughout gestation. Results Mean TSH concentrations were higher among the 150‐I women than in the remaining two groups, and in a high proportion of them, TSH values were found to exceed the upper limit for gestational age. Conversely, the prevalence of low free‐thyroxine levels in the 150‐I women was similar to that observed in the I‐salt women and markedly lower than that recorded for the no‐I group. Conclusions The regular use of iodine‐containing supplements proved effective in reducing the risk of inappropriately low FT4 levels during pregnancy. The observed TSH increase in 150‐I women may be because of a transient stunning effect on the thyroid gland, occurring as a result of the abrupt increase in daily iodine intake. Whilst the importance of gestational iodine supplementation is undisputed, we believe that in mild‐moderately ID areas, women considering conception should be advised to take iodine supplementation for several months prior to pregnancy.