Obstetric and neonatal risk of pregnancies after assisted reproductive technology: a matched control study

BACKGROUND: The aim of the study was to evaluate the obstetric and neonatal outcome of pregnancies after assisted reproduction technology (ART) in comparison with matched controls from spontaneous pregnancies. METHODS: A total of 12 920 deliveries at the Department of Obstetrics and Gynecology, University of Szeged, from 1 January 1995 to 31 December 2001 were subjected to retrospective analysis. Two hundred and eighty-four singleton, 75 twin and 17 triplet pregnancies after ovulation induction (n = 114; 30.3%), intrauterine insemination (n = 33; 8.8%) and in vitro fertilization (n = 229; 60.9%) were evaluated. The pregnancy outcome of the singleton and twin pregnancies was compared with that for controls matched with regard to age, gravidity and parity and previous obstetric outcome after spontaneous pregnancies. RESULTS: Twenty-four percent of the assisted reproductive pregnancies were multiple pregnancies. The incidences of singleton intrauterine growth retardation (IUGR) and preterm birth were reasonably similar to those among the controls (IUGR: 6.3% vs. 4.2%; preterm births: 13.0% vs. 9.9%, for the cases and the controls, respectively). As compared with the controls, there was an increased incidence of cesarean section among the singleton (41.2% vs. 34.5%, p = 0.12; OR 1.33; 95% CI 0.95-1.87) and twin assisted reproduction pregnancies (66.7% vs. 60.0%), but without significant differences. CONCLUSIONS: Increased obstetric risk could be observed concerning threatened preterm delivery and cesarean section rate in the study group. The perinatal outcome of singleton and twin pregnancies following assisted reproductive techniques is comparable with that of spontaneously conceived, matched pregnancies.     

Obstetric characteristics and perinatal outcome of pregnancies with uterine leiomyomas

OBJECTIVE: To determine the rate, obstetric characteristics and perinatal outcome of pregnancies with uterine leiomyomas. STUDY DESIGN: A population-based study comparing all singleton deliveries between the years 1988 and 1999 in women with and without uterine leiomyomas was performed. Patients lacking prenatal care were excluded from the analysis. Multivariable analysis, adjusting for possible confounders, such as maternal age, parity and gestational age, was performed to investigate associations between uterine leiomyomas and selected outcomes. RESULTS: There were 105,909 singleton deliveries with 690 (0.65%) complicated by uterine leiomyomas during the study period. Using a multivariable analysis, the following conditions were significantly associated with uterine leiomyomas: nulliparity (odds ratio [OR]=4.0, 95% confidence interval [CI] 3.3-4.7, P<.001), chronic hypertension (OR=1.9, 95% CI 1.6-2.4, P<.001), hydramnios (OR=1.5, 95% CI 1.2-2.0, P<.001), diabetes mellitus (OR=1.4, 95% CI 1.1-1.7, P=.001) and advanced maternal age (OR=1.2, 95% CI 1.1-1.2, P<.001). Higher rates of perinatal mortality (2.2% vs. 1.2%, OR=1.8, 95% CI 1.1-3.2, P<.001) were found in the uterine leiomyoma group as compared to the control group. While adjusting for maternal age, parity, gestational age and malpresentation, pregnancies with uterine leiomyomas had higher rates of cesarean deliveries (OR=6.7, 95% CI 5.5-8.1, P<.001), placental abruption (OR=2.6, 95% CI 1.6-4.2, P<.001) and preterm deliveries (<36 weeks' gestation, OR=1.4, 95% CI 1.1-1.7, P=.009) as compared to pregnancies without uterine leiomyomas. Conversely, no significant differences were noted regarding perinatal mortality (OR=1.4, 95% CI 0.7-2.8, P=.351) after controlling for maternal age, parity and gestational age using a multivariable analysis. CONCLUSION: Uterine leiomyomas increase the risk of adverse pregnancy outcomes, thus emphasizing the importance of appropriate intrapartum management of these high-risk pregnancies.     

Population‐Based Study of Cesarean Section After In Vitro Fertilization in Australia

Abstract: Background: Decisions about method of birth should be evidence based. In Australia, the rising rate of cesarean section has not been limited to births after spontaneous conception. This study aimed to investigate cesarean section among women giving birth after in vitro fertilization (IVF). Methods: Retrospective population‐based study was conducted using national registry data on IVF treatment. The study included 17,019 women who underwent IVF treatment during 2003 to 2005 and a national comparison population of women who gave birth in Australia. The outcome measure was cesarean section. Results: Crude rate of cesarean section was 50.1 percent versus 28.9 percent for all other births. Single embryo transfer was associated with the lowest (40.7%) rate of cesarean section. Donor status and twin gestation were associated with significantly higher rates of cesarean section (autologous, 49.0% vs donor, 74.9%; AOR: 2.20, 95% CI: 1.80, 2.69) and (singleton, 45.0% vs twin gestations, 75.7%; AOR: 3.81, 95% CI: 3.46, 4.20). The gestation‐specific rate (60.1%) of cesarean section peaked at 38 weeks for singleton term pregnancies. Compared with other women, cesarean section rates for assisted reproductive technology term singletons (27.8% vs 43.8%, OR: 2.02 [95% CI: 1.95–2.10]) and twins (62.0% vs 75.7%, OR: 1.92 [95% CI: 1.74–2.11]) were significantly higher. Conclusions: Rates for cesarean section appear to be disproportionately high in term singleton births after assisted reproductive technology. Vaginal birth should be supported and the indications for cesarean section evidence based. (BIRTH 37:3 September 2010)     

Intrapartum Interventions for Singleton Pregnancies Arising From Assisted Reproductive Technologies

Objective: To assess whether singleton pregnancies conceived by assisted reproductive technology (ART) are associated with an increased use of intrapartum interventions when compared with spontaneous singleton pregnancies.MethodsIn total, 1327 ART pregnancies and 5222 spontaneous pregnancies during the period 2004 to 2008 were extracted from BORN (Better Outcomes Registry & Network) Ontario’s information system. The incidences of common intrapartum interventions were compared, and different classification systems for Caesarean section were used to compare the indications for these between singleton pregnancies following ART with or without intracytoplasmic sperm injection and singleton spontaneously conceived pregnancies.ResultsCompared with spontaneous singleton pregnancies, the ART group had increased incidences of internal electronic fetal monitoring (OR 1.60; 95% CI 1.37 to 1.87), artificial rupture of membranes (OR 1.39; 95% CI 1.17 to 1.66), oxytocin augmentation of labour (OR 1.51; 95% CI 1.28 to 1.77), induction of labour (OR 1.31; 95% CI 1.14 to 1.50), and Caesarean section (OR 1.40; 95% CI 1.24 to 1.60).ConclusionSingleton pregnancies resulting from ART were associated with more frequent use of several intrapartum interventions, including Caesarean section.     

Risk factors and outcome of failure to progress during the first stage of labor: a population-based study

BACKGROUND: One of the major indications for Cesarean section (CS) is failure of labor to progress. This study was aimed at defining obstetric risk factors for failure of labor to progress during the first stage, and to determine pregnancy outcome. METHODS: A population-based study comparing all singleton, vertex, term deliveries between the years 1988 and 1999 with an unscarred uterus, complicated with failure of labor to progress during the first stage with deliveries without non-progressive labor (NPL). Multiple logistic regression analysis was performed to investigate independent obstetric risk factors associated with failure of labor to progress during the first stage. RESULTS: Failure to progress during the first stage of labor complicated 1.3% (n = 1197) of all deliveries included in the study (n = 92 918), and resulted in CS. Independent risk factors for failure of labor to progress during the first stage, using a multivariable analysis, were premature rupture of membranes (PROM; OR = 3.8, 95% CI 3.2-4.5), nulliparity (OR = 3.8, 95% CI 3.3-4.3), labor induction (OR = 3.3, 95% CI 2.9-3.7), maternal age > 35 years (OR = 3.0, 95% CI 2.6-3.6), birth weight > 4 kg (OR = 2.2, 95% CI 1.8-2.7), hypertensive disorders (OR = 2.1, 95% CI 1.8-2.6), hydramnios (OR = 1.9, 95% CI 1.5-2.3), fertility treatment (OR = 1.8, 95% CI 1.4-2.4), epidural analgesia (OR = 1.6, 95% CI 1.4-1.8) and gestational diabetes (OR = 1.4, 95% CI 1.1-1.7). Although newborns delivered after failure of labor to progress during the first stage had significantly higher rates of Apgar scores lower than 7 at 1 and 5 min as compared with the controls (18.2% vs. 2.1%; P < 0.001 and 1.3% vs. 0.2%; P < 0.001, respectively), no significant differences were noted between the groups regarding perinatal mortality (0.3% vs. 0.4%; P = O.329). Maternal anemia and accordingly packed cells transfusion (47.4% vs. 22.8%; P < 0.001 and 5.6% vs. 1.0%; P < 0.001, respectively) were higher among pregnancies complicated with failure of labor to progress during the first stage as compared with the controls. CONCLUSIONS: Major risk factors for failure of labor to progress during the first stage were PROM, nulliparity, induction of labor and older maternal age. Indications for labor induction should be carefully evaluated in order to decrease the rate of operative deliveries.     

Clinical Assisted Reproduction: Are Singleton Assisted Reproductive Technology Pregnancies at Risk of Prematurity?

Purpose: Our purpose was to determine the risk of premature delivery among singleton pregnancies derived from assisted reproduction technology (ART).Methods: Ninety-five singleton ART pregnancies and 190 matched spontaneous pregnancies were assessed for preterm delivery rates, pregnancy complications, and cesarean section rates in a retrospective study at an academic medical center.Results: Among the ART singleton deliveries group (n = 95), 19 (20%) were preterm, which was statistically significantly higher than the 4% (8 of 190) found in the control group. Among the pregnancies achieved by intracytoplasmic sperm injection (ICSI) in the severe male-factor infertility subgroup (n = 22), only one preterm delivery occurred (4.5%).Conclusions: Singleton ART pregnancies are at an increased risk of preterm delivery compared to singleton pregnancies after spontaneous conception. The higher rate may be attributed to various infertility cofactors, such as uterine malformations, previous operative procedures that involved cervical dilatation, and a history of pelvic infection. This is supported by the finding that ICSI-derived pregnancies in couples with strict male-factor infertility are not at an increased risk of preterm delivery.     

Short-term maternal and neonatal outcomes by mode of delivery. A case-controlled study

OBJECTIVE: Side-by-side comparisons of short-term maternal and neonatal outcomes for spontaneous vaginal delivery, instrumental vaginal delivery, planned caesarean section and caesarean section during labor in patients matched for clinical condition, age, and week of gestation are lacking. This case-controlled study was undertaken to evaluate short-term maternal and neonatal complications in a healthy population at term by mode of delivery. STUDY DESIGN: Four groups of healthy women, with antenatally normal singleton pregnancies at term, who underwent instrumental vaginal delivery (no. 201), spontaneous delivery (no. 402), planned caesarean section without labor (no. 402) and caesarean section in labor (no. 402) have been retrospectively selected. Outcome measures were maternal and neonatal short-term complications. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Maternal complications were mostly associated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 6.9; 95% CI: 2.9-16.4 and OR 3.0; 95% CI 1.1-8.8, respectively, versus spontaneous deliveries). No significant differences in overall complications were observed between spontaneous vaginal deliveries and caesarean sections, whether planned or in labor. By comparison with caesarean sections in labor, instrumental deliveries significantly increased the risk of complications (OR: 3.2; 95% CI: 1.6-6.5). Neonatal complications were also mostly correlated with forceps-assisted and vacuum-assisted instrumental deliveries (OR: 3.5; 95% CI: 1.9-6.7 and OR 3.8; 95% CI 2.0-7.4, respectively, versus spontaneous deliveries). By comparison with caesarean sections in labor, instrumental vaginal deliveries significantly increased the risk of complications (OR: 4.2; 95% CI: 2.4-7.4). CONCLUSIONS: In healthy women with antenatally normal singleton pregnancies at term, instrumental deliveries are associated with the highest rate of short-term maternal and neonatal complications.     

辅助生殖技术助孕后单胎妊娠早期流产的相关因素分析

目的 探讨辅助生殖技术(assisted reproductive technology,ART)助孕后单胎妊娠发生早期自然流产的相关因素.方法 对2003年1月1日至2008年8月31日在本院生殖中心行常规体外受精/卵母细胞浆内单精子注射的新鲜胚胎移植周期治疗后的1636例单胎妊娠病例进行分析,除外失访、子宫畸形、赠卵、晚期流产及资料不齐全者后,分为早期流产组(n=196)和活产分娩组 (n=1195),分析早期流产的相关因素.同时,比较新鲜胚胎移植周期和冷冻胚胎复苏移植周期(n=386)的流产率.结果 多因素Logistic回归分析早期自然流产的危险因素是孕妇年龄(OR=1.143,95%CI:1.096～1.196)、多囊卵巢综合征因素不孕(OR=4.309,95%CI:2.564～7.243),保护因素是移植胚胎的平均评分(OR=0.808,95%CI:0.717～0.912)、人绒毛膜促性腺激素(human chorionic gonadotropin,hCG)注射日子宫内膜三线型(OR=0.431,95%CI:0.243～0.764).早期流产组和活产分娩组孕妇的年龄[(32.22±4.10)岁和(30.28±3.66)岁]、不孕年限[(5.90±4.26)年和(5.20±3.32)年]、基础卵泡刺激素水平[(6.35±2.30)mIU/ml和(5.95±2.12)mIU/ml]、移植胚胎数[(2.31±0.51)个和(2.18±0.49)个]、hCG注射日雌二醇水平[(2467.1±1588.8)pg/ml和(2934.5±1785.2)pg/ml]、胚胎平均评分(7.03±1.35和7.74±1.25)比较,差异均有统计学意义(P＜0.05),冷冻胚胎复苏移植周期流产率高于新鲜周期[17.36%(67/386)和13.02%(213/1636),χ2=4.296,P=0.023].结论 年龄大、不孕年限长、基础卵泡刺激素高、多囊卵巢综合征因素不孕、移植胚胎的平均评分低、hCG注射日子宫内膜非三线型的妇女ART妊娠后易发生早期流产.冷冻胚胎复苏移植周期的早期自然流产率高于新鲜胚胎移植周期.

Abstract：

Objective To investigate the relative risk factors for early abortion among singleton pregnancies after assisted reproductive technology (ART) treatment. Methods A retrospective analysis was performed on 1636 singleton pregnancies, including 196 early abortion cases and 1195pregnancies with live birth after exclusion of those lost cases during follow-up, or complicated with uterine deformity, or oocyte receptor, or late abortion, or incomplete medical record, following in vitro fertilization(IVF)/ intracytoplasmic sperm injection (ICSI) treatment and the risk factors of early abortion were investigated. The early abortion rate was also compared between fresh IVF/ICSI group and frozen embryo transfer (FET) group (n=386). Results Multivariate Logistic regression analysis indicated that elder women (OR= 1. 143,95%CI: 1. 096-1. 196) and patients with polycystic ovarian syndrome (OR = 4. 309,95 % CI : 2. 564-7.243) were risk factors of spontaneous early abortion,and high mean score of transferred embryos (MSTE) (OR = 0. 808, 95% CI: 0. 717-0. 912) and endometrial triple-lined pattern on the day of human chorionic gonadotropin (hCG) administration (OR=0. 431, 95% CI: 0. 243-0.764)were protective factors. Significant difference were found in the maternal age [(32.22±4. 10) yrs vs (30.28±3. 66) yrs],the duration of infertility [(5. 90±4.26) yrs vs (5.20 ± 3. 32) yrs], basal serum follicle-stimulating hormone (FSH) level [(6. 35 ±2.30) mIU/ml vs (5.95±2.12) mIU/ml], number of transferred embryos (2. 31±0. 51) vs (2. 18±0.49), serum estradiol level on the day of hCG administration [(2467. 1 ± 1588. 8) pg/ml vs (2934. 5 ±1785.2) pg/ml] and MSTE (7.03 ±1.35 vs 7.74 ± 1.25) between the abortion group and livebirth group (all P＜0. 05). The spontaneous abortion rate was higher in the FET group than in the fresh embryo transfer group [17. 36%(67/386) vs 13.02% (213/1636), χ2 =4. 296, P=0. 023].Conclusions Women at elder age, or with long duration of infertility, high basal FSH level,polycystic ovarian syndrome, low MSTE, non-triple-lined pattern of endometrium on the day of hCG administration are at risk of spontaneous early abortion in pregnancies after ART. The rate of spontaneous abortion is higher in FET group than in fresh IVF/ICSI group.     

Perinatal Outcome of Pregnancies After Assisted Reproduction: A Case–Control Study

Purpose: A matched case–control study of all pregnancies obtained after either IVF or ICSI was conducted to investigate the perinatal outcome. Methods: Three hundred eleven singleton and 115 twin pregnancies obtained after assisted reproduction were studied. Controls were selected from a regional register and were matched for maternal age, parity, singleton or twin pregnancy, and date of delivery. Results: No significant difference was observed for gestational age at delivery, birth weight, incidence of congenital anomalies, and incidence of perinatal mortality between ART (singleton and twin) pregnancies and spontaneous controls. ART twin pregnancies showed a higher incidence of preterm deliveries than control pregnancies (52 vs 42%; P < 0.05) and needed more neonatal intensive care (47 vs 26%; P < 0.05). Conclusions: From this case–control study it is concluded that the perinatal outcome of ART singleton pregnancies is not different from that in matched controls. ART twin pregnancies showed a higher incidence of preterm deliveries than control pregnancies and needed more neonatal intensive care.     

Identifying risk factors for peripartum cesarean hysterectomy. A population-based study

OBJECTIVE: To determine the incidence of, and obstetric risk factors for, emergency peripartum hysterectomy. STUDY DESIGN: A population-based study comparing all singleton deliveries between the years 1988 and 1999 that were complicated with peripartum hysterectomy to deliveries without this complication. Statistical analysis was performed with multiple logistic regression analysis. RESULTS: Emergency peripartum hysterectomy complicated 0.048% (n = 56) of deliveries in the study (n = 117,685). Independent risk factors for emergency peripartum hysterectomy from a backward, stepwise, multivariable logistic regression model were: uterine rupture (OR = 521.4, 95% CI 197.1-1379.7), placenta previa (OR = 8.2, 95% CI 2.2-31.0), postpartum hemorrhage (OR = 33.3, 95% CI 12.6-88.1), cervical tears (OR = 18.0, 95% CI 6.2-52.4), placenta accreta (OR = 13.2, 95% CI 3.5-50.0), second-trimester bleeding (OR = 9.5, 95% CI 2.3-40.1), previous cesarean section (OR = 6.9, 95% CI 3.7-12.8) and grand multiparity (> 5 deliveries) (OR = 3.4, 95% CI 1.8-6.3). Newborns delivered after peripartum hysterectomy had lower Apgar scores (< 7) at 1 and 5 minutes than did others (OR = 11.5, 95% CI 6.2-20.9 and OR = 27.4, 95% CI 11.2-67.4, respectively). In addition, higher rates of perinatal mortality were noted in the uterine hysterectomy vs. the comparison group (OR = 15.9, 95% CI 7.5-32.6). Affected women were more likely than the controls to receive packed-cell transfusions (OR = 457.7, 95% CI 199.2-1105.8) and had lower hemoglobin levels at discharge from the hospital (9.9 +/- 1.3 vs. 12.8 +/- 5.7, P < .001). CONCLUSION: Cesarean deliveries in patients with suspected placenta accreta, specifically those performed due to placenta previa in women with a previous uterine scar, should involve specially trained obstetricians. In addition, detailed informed consent about the possibility of emergency peripartum hysterectomy and its associated morbidity should be obtained.     

Maternal risks and perinatal outcome in a Danish national cohort of 1005 twin pregnancies: the role of in vitro fertilization

BACKGROUND: Twin pregnancies constitute 25% of all in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) pregnancies. There is a lack of knowledge on maternal risks and perinatal outcome of IVF/ICSI twin pregnancies. METHODS: National survey by questionnaire (n = 1769). The study population consisted of all IVF/ICSI twin mothers (n = 266) and the two control groups of all IVF/ICSI singleton mothers (n = 764) and non-IVF/ICSI twin mothers (n = 739) who delivered in Denmark in 1997. The response rate was 89% among IVF twin mothers and overall 81%. RESULTS: In terms of maternal risks and perinatal outcome no significant differences were observed between IVF/ICSI twin and non-IVF/ICSI twin pregnancies after stratification for maternal age and parity. Nevertheless, IVF/ICSI twin mothers were more frequently on sick leave (OR 2.5, 95% CI 1.5-4.0) and hospitalized (OR 1.9, 95% CI 1.3-2.8) during pregnancy. Compared with IVF/ICSI singleton pregnancies, IVF/ICSI twin pregnancies were characterized by a higher incidence of preeclampsia (OR 2.4, 95% CI 1.5-4.2) and a higher frequency of sick leave (OR 6.8, 95% CI 4.4-10.5) and hospitalizations during pregnancy (OR 3.5, (95% CI 2.5-4.9); moreover, mean birthweight (p < 0.001) and gestational age (p < 0.001) were lower. No differences were observed in the incidence of pregnancy-induced hypertension and gestational diabetes between IVF/ICSI twin and singleton pregnancies. CONCLUSION: Although this population study indicates that maternal risks in IVF/ICSI twin pregnancies are comparable with non-IVF/ICSI twin pregnancies, the IVF/ICSI twin mothers were more likely to be on sick leave or hospitalized during pregnancy. Furthermore, maternal risks were higher and obstetric outcome poorer in IVF/ICSI twin vs. IVF/ICSI singleton pregnancies.     

Pregnancy outcome of asthmatic patients: a population-based study.

OBJECTIVE: To investigate pregnancy outcome of asthmatic patients. METHODS: A retrospective population-based study comparing all singleton pregnancies in women with and without asthma was conducted. Patients lacking prenatal care (less than three visits in prenatal care facilities) were excluded from the study. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders. RESULTS: During the study period 139 168 singleton deliveries occurred, of which 1.4% in asthmatic patients (n = 963). Using a multivariate analysis, with backward elimination, the following complications were significantly associated with maternal asthma: diabetes mellitus (OR = 1.8, 95%CI 1.5-2.0, p < 0.001), fertility treatments (OR = 1.6, 95%CI 1.3-2.1, p < 0.001), intrauterine growth restriction (IUGR) (OR = 1.5, 95%CI 1.1-1.9, p = 0.004), hypertensive disorders (OR = 1.5, 95%CI 1.2-1.7, p < 0.001) and premature rupture of membranes (OR = 1.2, 95%CI 1.1-1.5, p = 0.013). Higher rates of cesarean deliveries were found among asthmatic patients as compared to the controls (17.1% vs. 11.4%, p < 0.001). This association persisted even after controlling for possible confounders such as failure to progress in labor, mal-presentations, IUGR, etc. No significant differences regarding low Apgar scores (less than 7) at 1 and 5 minutes were noted between the groups (3.9% vs. 4.4%, p = 0.268 and 0.4% vs. 0.6%, p = 0.187, respectively). Likewise, the perinatal mortality rate was similar among patients with and without asthma (1.3% vs. 1.3%, p = 0.798). CONCLUSION: Pregnant women with asthma are at an increased risk for adverse maternal outcome. This association persists after controlling for variables considered to co-exist with maternal asthma. However, perinatal outcome is favorable. Careful surveillance is required in pregnancies of asthmatic patients, for early detection of possible complications.     

Risk factors for arrest of descent during the second stage of labor.

OBJECTIVE: To define obstetrical risk factors for arrest of descent during the second stage of labor and to determine perinatal outcome. STUDY DESIGN: All singleton, vertex, term deliveries with an unscarred uterus, between the years 1988 and 1999 were included. Univariable and multivariable analysis were performed to investigate independent risk factors associated with arrest of descent during the second stage of labor and the perinatal outcome. RESULTS: The study included 93266 deliveries, of these 1545 (1.7%) were complicated with arrest of descent during the second stage of labor. Using a multivariable analysis, the following obstetric risk factors were found to be significantly associated with arrest of descent: nulliparity (OR=7.8, 95% CI=6.9-8.7; P<0.001), birth weight >4 kg (OR=2.3, 95% CI=1.9-2.8; P<0.001), epidural analgesia (OR=1.8, 95% CI=1.6-2.0; P<0.001), hydramnios (OR=1.6, 95% CI=1.3-2.0; P<0.001), hypertensive disorders (OR=1.5, 95% CI=1.3-1.8; P<0.001), gestational diabetes A1 and A2 (OR=1.5, 95% CI=1.2-1.8; P<0.001), male gender (OR=1.4, 95% CI=1.2-1.5; P<0.001), premature rupture of membranes (PROM, OR=1.3, 95% CI=1.04-1.6; P=0.021), and induction of labor (OR=1.2, 95% CI=1.02-1.4; P=0.030). Deliveries complicated by arrest of descent resulted in cesarean section in 20.6%, vacuum extraction in 74.0%, and forceps delivery in 5.4%. Newborns delivered after arrest of descent during the second stage of labor had significantly higher rates of low Apgar scores (<7) at 1 and 5 min, as compared to the controls (12.7 vs. 2.1%, P<0.001; and 0.9 vs. 0.2%, P<0.001, respectively). Nevertheless, no significant differences were noted between the groups regarding perinatal mortality (0.38 vs. 0.44%; P=0.759). CONCLUSIONS: Major risk factors for arrest of descent during the second stage of labor were nulliparity, fetal macrosomia, epidural analgesia, hydramnios, hypertensive disorders and gestational diabetes mellitus. These risk factors should be carefully evaluated during pregnancy in order to actively manage high-risk pregnancies.     

Chronic hypertension and the risk for adverse pregnancy outcome after superimposed pre-eclampsia.

OBJECTIVE: To determine the risk factors and pregnancy outcome of patients with chronic hypertension during pregnancy after controlling for superimposed preeclampsia. METHOD: A comparison of all singleton term (>36 weeks) deliveries occurring between 1988 and 1999, with and without chronic hypertension, was performed. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. RESULTS: Chronic hypertension complicated 1.6% (n=1807) of all deliveries included in the study (n=113156). Using a multivariable analysis, the following factors were found to be independently associated with chronic hypertension: maternal age >40 years (OR=3.1; 95% CI 2.7-3.6), diabetes mellitus (OR=3.6; 95% CI 3.3-4.1), recurrent abortions (OR=1.5; 95% CI 1.3-1.8), infertility treatment (OR=2.9; 95% CI 2.3-3.7), and previous cesarean delivery (CD; OR=1.8 CI 1.6-2.0). After adjustment for superimposed preeclampsia, using the Mantel-Haenszel technique, pregnancies complicated with chronic hypertension had higher rates of CD (OR=2.7; 95% CI 2.4-3.0), intra uterine growth restriction (OR=1.7; 95% CI 1.3-2.2), perinatal mortality (OR=1.6; 95% CI 1.01-2.6) and post-partum hemorrhage (OR=2.2; 95% CI 1.4-3.7). CONCLUSION: Chronic hypertension is associated with adverse pregnancy outcome, regardless of superimposed preeclampsia.     

Pregnancy outcome following recurrent spontaneous abortions

OBJECTIVE: The purpose of the present study was to examine the association between spontaneous consecutive recurrent abortions and pregnancy complications such as hypertensive disorders, abruptio placenta, intrauterine growth restriction and cesarean section (CS) in the subsequent pregnancy. METHODS: A population-based study comparing all singleton pregnancies in women with and without two or more consecutive recurrent abortions was conducted. Deliveries occurred during the years 1988-2002. Stratified analysis, using a multiple logistic regression model was performed to control for confounders. RESULTS: During the study period 154,294 singleton deliveries occurred, with 4.9% in patients with history of recurrent consecutive abortions. Using a multivariate analysis, with backward elimination, the following complications were significantly associated with recurrent abortions-advanced maternal age, cervical incompetence, previous CS, diabetes mellitus, hypertensive disorders, placenta previa and abruptio placenta, mal-presentations and PROM. A higher rate of CS was found among patients with previous spontaneous consecutive recurrent abortions (15.9% versus 10.9%; OR = 1.6; 95% CI, 1.5-1.7; P < 0.001). Another multivariate analysis was performed, with CS as the outcome variable, controlling for confounders such as placenta previa, abruptio placenta, diabetes mellitus, hypertensive disorders, previous CS, mal-presentations, fertility treatments and PROM. A history of recurrent abortion was found as an independent risk factor for CS (OR = 1.2; 95% CI, 1.1-1.3; P < 0.001). About 58 cases of inherited thrombophilia were found between the years 2000-2002. These cases were significantly more common in the recurrent abortion as compared to the comparison group (1.2% versus 0.1%; OR = 11.1; 95% CI, 6.5-18.9; P < 0.001). CONCLUSION: A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions. Careful surveillance is required in pregnancies following recurrent abortions, for early detection of possible complications.     

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.     

Spontaneous embryonic loss after in vitro fertilization with and without intracytoplasmic sperm injection

OBJECTIVE: To determine whether pregnancies after IVF, with and without intracytoplasmic sperm injection (ICSI), have different early spontaneous loss rates. DESIGN: Retrospective analysis of IVF/ICSI dataset. SETTING: The Center of Reproductive Medicine, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy. PATIENT(S): Women undergoing IVF with or without ICSI. INTERVENTION(S): First-trimester sonography at 6-7 weeks to count the number of embryos with positive heartbeat. The number of embryos lost was calculated from a second-trimester sonogram. MAIN OUTCOME MEASURE(S): Embryonic loss rates related to the initial number of embryos, maternal age <35 or > or =35 years, and IVF procedure. RESULT(S): In vitro fertilization and ICSI had similar embryonic loss rates (odds ratio [OR] 1.2, 95% confidence interval [CI] 0.9-1.7, and OR 1.3, 95% CI 0.9-1.8 for women aged <35 years and > or =35 years, respectively). Younger women had fewer losses after IVF (OR 0.7, 95% CI 0.5-0.9). Multiples had lower loss rates compared with singleton pregnancies. CONCLUSION(S): In vitro fertilization and ICSI have similar spontaneous embryonic loss rates. Factors other than the initial number of embryos, maternal age, and IVF technique, such as embryo quality or uterine environment, might be involved in the outcome of multiple pregnancies in assisted reproductive technology procedures.     

Pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy.

OBJECTIVE: The study was designed to investigate obstetric risk factors and pregnancy outcome of patients with pruritic urticarial papules and plaques of pregnancy (PUPPP). METHODS: A population-based study comparing all pregnancies of women with and without PUPPP was conducted. Deliveries occurred during the years 1988-2002 at the Soroka University Medical Center. A multivariable logistic regression model was constructed in order to find independent risk factors associated with PUPPP. RESULTS: During a 15-year period, 159 197 deliveries took place. PUPPP complicated 42 (0.03%) of all pregnancies. Using a multivariable analysis, the following conditions were significantly associated with PUPPP: multiple pregnancies (odds ratio (OR) = 4.9, 95% confidence interval (CI) 1.7-14.1), hypertensive disorders (OR = 2.2, 95% CI 1.1-4.7), and induction of labor (OR = 7.6, 95% CI 4.0-14.5). Higher rates of 5-minute Apgar scores lower than 7 (OR = 8.0, 95% CI 4.4-14.9) and of cesarean deliveries (OR = 2.9, 95% CI 1.5-5.6) were noted in the PUPPP as compared to the comparison group. While investigating other perinatal outcome parameters such as oligohydramnios, intrauterine growth restriction, meconium-stained amniotic fluid and perinatal mortality, no significant differences were observed between the groups. CONCLUSION: Pruritic urticarial papules and plaques of pregnancy is a condition significantly associated with multiple pregnancies, hypertensive disorders, and induction of labor. Perinatal outcome is comparable to pregnancies without PUPPP.     

Maternal and fetal atrial natriuretic peptide levels at delivery from normal and growth retarded pregnancies.

OBJECTIVE: To determine whether circulating fetal levels of the vasodilator atrial natriuretic peptide (ANP) are reduced in pregnancies complicated by intrauterine growth retardation (IUGR). DESIGN: Prospective observational study. SETTING: University teaching hospital and research laboratory. SUBJECTS: 25 normal singleton pregnancies delivered at term by spontaneous vertex delivery (n = 16) or by elective caesarean section (n = 9), and a series of 14 singleton pregnancies complicated by IUGR. INTERVENTION: Measurement of ANP by radio-immunoassay in maternal venous, umbilical artery, and umbilical vein plasma from a series of normal, and IUGR pregnancies. MAIN OUTCOME MEASURES: Comparison of plasma ANP levels between the three groups; relation between fetal ANP, PO2 and pH. RESULTS: Mode of delivery did not influence either maternal, umbilical artery or umbilical vein plasma ANP levels in normal term singleton pregnancies. Umbilical vein ANP levels were significantly higher in the IUGR group when compared with normal pregnancies at term (mean 66 95%, CI 36-122 vs mean 37, 95% CI 29-47 pg/ml, P = 0.03) and were inversely related to umbilical artery pH (R2 = 65%; P = 0.003). CONCLUSIONS: These data suggest that umbilical vein ANP levels are elevated in pregnancies complicated by IUGR, and rise appropriately in response to the stress of acidosis. In the absence of any receptor or second messenger defect within feto-placental vascular smooth muscle, these data suggest that ANP is not directly implicated in the vascular pathophysiology of IUGR.     

Gender does matter in perinatal medicine

OBJECTIVE: To investigate complications and outcome of pregnancies with male and female fetuses. METHODS: A population-based study comparing all singleton deliveries between the years 1988 and 1999 was performed. We compared pregnancies with male vs. female fetuses. Patients with a previous cesarean section (CS) were excluded from the study. Statistical analyses with the Mantel-Haenszel technique and multiple logistic regression models were performed to control for confounders. RESULTS: During the study period there were 55,891 deliveries of male and 53,104 deliveries of female neonates. Patients carrying male fetuses had higher rates of gestational diabetes mellitus (OR = 1.1; 95% CI 1.01-1.12; p = 0.012), fetal macrosomia (OR = 2.0; 95% CI 1.8-2.1; p < 0.001), failure to progress during the first and second stages of labor (OR = 1.2; 95% CI 1.1-1.3; p < 0.001 and OR = 1.4; 95% CI 1.3-1.5; p < 0.001, respectively), cord prolapse (OR = 1.3; 95% CI 1.1-1.6; p = 0.014), nuchal cord (OR = 1.2; 95% CI 1.1-1.2; p < 0.001) and true umbilical cord knots (OR = 1.5; 95% CI 1.3-1.7; p < 0.001). Higher rates of CS were found among male compared with female neonates (8.7 vs. 7.9%; OR = 1.1; 95% CI 1.06-1.16; p < 0.001). Using three multivariate logistic regression models and controlling for birth weight and gestational age, male gender was significantly associated with non-reassuring fetal heart rate patterns (OR = 1.5; 95% CI 1.4-1.6; p < 0.001), low Apgar scores at 5 min (OR = 1.5; 95% CI 1.3-1.8; p < 0.001) and CS (OR = 1.2; 95%CI 1.2-1.3; p < 0.001). Controlling for possible confounders like gestational diabetes, cord prolapse, failed induction, nonprogressive labor, fetal macrosomia, nuchal cord and true umbilical cord knots using the Mantel-Haenszel technique did not change the significant association between male gender and CS. CONCLUSION: Male gender is an independent risk factor for adverse pregnancy outcome.