Maternal mortality and the rising cesarean rate

ObjectiveTo review maternal mortality in a large stand-alone maternity hospital in a European city and to determine whether the increased cesarean rate was associated with an increase in maternal deaths.MethodsThe details of maternal deaths at Coombe Women and Infants University Hospital, Dublin, Ireland, as published in the hospital's Annual Clinical Reports for 1995–2009, were reviewed. Maternal mortality ratio was defined as the number of maternal deaths per 100 000 live births.ResultsOver 15 years, 112 326 women delivered 114 170 infants weighing at least 500 g. The cesarean rate increased from 14.1% in 1995 to 26.5% in 2009 (20.0% overall). The maternal mortality ratio was low at 2.7 per 100 000 live births. There were 2 maternal deaths following cesarean, neither of which was attributable to the operation.ConclusionIn Ireland, a large stand-alone maternity hospital can achieve a low maternal mortality ratio, according to international standards, despite an increase in cesarean rate over the past 2 decades. There was no evidence that the increased cesarean rate had an adverse impact on maternal mortality ratio.     

Advancing obstetric and neonatal care in a regional hospital in Ghana via continuous quality improvement

ObjectiveTo reduce maternal and neonatal death at a large regional hospital through the use of quality improvement methodologies.MethodsIn 2007, Kybele and the Ghana Health Service formed a partnership to analyze systems and patient care processes at a regional hospital in Accra, Ghana. A model encompassing continuous assessment, implementation, advocacy, outputs, and outcomes was designed. Key areas for improvement were grouped into “bundles” based on personnel, systems management, and service quality. Primary outcomes included maternal and perinatal mortality, and case fatality rates for hemorrhage and hypertensive disorders. Implementation and outcomes were evaluated tri-annually between 2007 and 2009.ResultsDuring the study period, there was a 34% decrease in maternal mortality despite a 36% increase in patient admission. Case fatality rates for pre-eclampsia and hemorrhage decreased from 3.1% to 1.1% (P < 0.05) and from 14.8% to 1.9% (P < 0.001), respectively. Stillbirths were reduced by 36% (P < 0.05). Overall, the maternal mortality ratio decreased from 496 per 100 000 live births in 2007 to 328 per 100 000 in 2009.ConclusionMaternal and newborn mortality were reduced in a low-resource setting when appropriate models for continuous quality improvement were developed and employed.     

Improving maternal mortality at a university teaching hospital in Nnewi, Nigeria

ObjectiveTo evaluate the impact of the introduction of the Service Compact with all Nigerians (SERVICOM) contract on maternal health at Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.MethodsA retrospective and comparative study of maternal deaths between 2004 and 2010 was carried out. The main outcome measures were yearly maternal mortality ratio (MMR), relative risk (RR) of maternal mortality, and presentation–intervention interval. The yearly MMR and the RR of maternal mortality were compared with the figures from 2004, which represented the pre-SERVICOM era.ResultsThere were 4916 live births and 54 maternal deaths during the study period, giving an MMR of 1098 per 100 000 live births. Pre-eclampsia/eclampsia was the most common direct cause (25.0%), followed by hemorrhage (18.8%) and sepsis (8.3%). Anemia (12.5%) was the most common indirect cause. There was a progressive reduction in MMR and RR of maternal mortality, with a corresponding increase in live births. The presentation–intervention interval improved significantly from 2006.ConclusionA positive change in the attitude of health workers and the elimination of fee-for-service in emergency obstetric care would reduce type 3 delays in public health facilities, and consequently reduce maternal mortality.     

Community-driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India

ObjectiveTo assess the effect on maternal health outcomes of a community-based behavior change management intervention for essential newborn care leading to a reduction in neonatal mortality.MethodsA cluster-randomized controlled trial involving 1 control and 2 intervention arms was conducted in Shivgarh, India, between January 2004 and May 2005. Risk-enhancing domiciliary newborn care behaviors, including those posing a concomitant risk to maternal health, were targeted through home visits and community meetings. Secondary outcomes included knowledge of maternal danger signs, self-reported complications, maternal care practices, care-seeking from trained providers, and maternal mortality ratio (MMR). The intervention arms were combined for analysis, which was done by intention to treat.ResultsSignificant improvements were observed in maternal health equity and outcomes including knowledge of danger signs, care practices, self-reported complications, and timely care-seeking from trained providers. The difference in adjusted MMR was not significant (relative risk 0.44; 95% confidence interval, 0.14–1.43; P = 0.11) owing to the inadequate sample size for this outcome, but may suggest a decline in MMR given improvements in other outcomes in the causal pathway to mortality.ConclusionCommunity-based strategies focused on prevention and care-seeking effectively complemented facility-based strategies toward improving maternal health, while synergizing with newborn care interventions.     

Association of hemoglobin values at booking with adverse maternal outcomes among Peruvian populations living at different altitudes

ObjectiveTo determine hemoglobin values associated with adverse maternal outcomes among Peruvian populations at different altitudes.MethodsA retrospective cohort study was conducted using data from the Perinatal Information System. Adverse maternal outcomes were assessed.ResultsRisk of pre-eclampsia increased at maternal hemoglobin levels above 14.5 g/dL (OR 1.27; 95% CI, 1.18–1.36) or below 7.0 g/dL (OR 1.52; CI 95%, 1.08–2.14). Altitude above 2000 m reduced risk (OR 0.65; 95% CI 0.62–0.68). Risk of postpartum hemorrhage (PPH) increased with moderate/severe anemia (OR 6.15; 95% CI, 3.86–9.78) and at moderate altitudes (OR 1.26; 95% CI, 1.12–1.43). Mild anemia at any altitude was associated with reduced risk of pre-eclampsia (OR 0.85, 95% CI, 0.81–0.89) and PPH (OR 1.01; 95% CI, 0.88–1.15). Risk of premature rupture of membranes was reduced at high hemoglobin values. Maternal mortality increased at hemoglobin levels below 9.0 g/dL (OR 5.68; 95% CI, 2.97–10.80) and above 14.5 g/dL (OR 2.18; 95% CI, 1.22–3.91). Maternal mortality increased at moderate altitudes (OR 29.2; 95% CI, 2.62–324.60) and high altitudes (OR 66.4; 95% CI, 6.65–780.30) when hemoglobin levels were below 9.0 g/dL.ConclusionElevated altitude and hemoglobin levels influence maternal outcomes.     

Comparison of misoprostol-only and combined mifepristone-misoprostol regimens for home-based early medical abortion in Tunisia and Vietnam

ObjectiveTo assess the potential advantages of combined mifepristone–misoprostol versus misoprostol-only for early medical abortion.MethodsA double-blind randomized placebo controlled study was conducted that enrolled 441 pregnant women (< 63 days since last menstrual period) at 2 hospitals in Tunisia and Vietnam. The mifepristone–misoprostol group (n = 220) received 200 mg of mifepristone on day 1 and 800 μg buccal misoprostol followed by placebo 3 hours later on day 2. The misoprostol-only group (n = 221) received placebo on day 1 and 1600 μg of misoprostol (2 doses of 800 μg, given 3 hours apart) on day 2. All medications were self-administered at home with follow-up 1 week later. The primary outcome was complete uterine evacuation without surgical intervention.ResultsSuccessful uterine evacuation occurred for 78.0% (n = 170) of women with misoprostol only versus 92.9% (n = 195) of women with mifepristone–misoprostol (relative risk 0.84, 95% CI, 0.78–0.91; P < 0.001). Ongoing pregnancy occurred for 13.8% (n = 30) of women given misoprostol-only and 1.4% (n = 3) of women given mifepristone–misoprostol (relative risk 9.63, 95% CI 2.98–31.09; P < 0.001).ConclusionMifepristone plus misoprostol is significantly more effective than misoprostol-only for early medical abortion.Clinical trials.gov registration number: NCT00680394.     

Perinatal outcomes associated with subsequent pregnancy among adolescent mothers in Peru

ObjectiveTo assess the perinatal outcomes of a subsequent pregnancy among adolescent mothers living in Peru.MethodsA large hospital-based retrospective cohort study was conducted to evaluate singleton births during a 9-year period (2001–2009). The study population was divided into 3 groups: adolescents aged 15–19 years who had 1 previous parturition (n = 2074), nulliparous adolescents (n = 20 721), and multiparous adults aged 20–29 years (n = 23 129).ResultsNo significant differences were found between multiparous adolescents and the 2 control groups with regard to preterm delivery, perinatal death, and 5-minute Apgar score below 7. Logistic regression analysis showed no significant differences in the rates of cesarean delivery or preterm birth before 34 or 37 weeks. After adjusting for confounding factors, low birth weight (LBW) and small for gestational age (SGA) were more likely to occur during a subsequent pregnancy among adolescent mothers than during the 1st pregnancy among nulliparous adolescents. The odds ratios were 1.38 (95% CI, 1.14–1.67) and 1.27 (95% CI, 1.02–1.56), respectively.ConclusionMultiparous adolescents are more likely to experience LBW or SGA than are nulliparous adolescents. No significant differences in other perinatal outcomes were found among the 3 study groups.     

Costs and benefits of multidrug, multidose antiretroviral therapy for prevention of mother-to-child transmission of HIV in the Dominican Republic

ObjectiveTo investigate whether costs of multidose antiretroviral regimens (MD-ARVs), including highly active antiretroviral therapy (HAART), for prevention of mother-to-child transmission (PMTCT) of HIV might be offset by savings gained from treating fewer perinatally acquired infections.MethodsRates of MTCT reported in the Dominican Republic among mother-infant pairs treated with single-dose nevirapine (SD-NVP; n = 39) and MD-ARVs (n = 91) for PMTCT were compared. Annual births to women infected with HIV were estimated from seroprevalence studies. Antiretroviral costs for both PMTCT and for HAART during the first 2 years of life (in cases of perinatal infection) were based on 2008 low-income country price estimates.ResultsRates of MTCT were 3.3% and 15.4% for the MD-ARV and SD-NVP groups, respectively (P = 0.02). Assuming that 5775 of 231 000 annual births (2.5%) were to HIV-positive women, it was estimated that 191 perinatally acquired infections would occur using MD-ARVs and 889 using SD-NVP. High costs of maternal MD-ARVs (HAART, US$914,760 versus SD-NVP, $1155) would be offset by lower 2-year HAART costs ($250,344 versus $1,168,272 for infants in the SD-NVP group) for the lower number of children with prenatally acquired infection (191 versus 889) associated with the use of MD-ARVs for PMTCT (net national saving $3168).ConclusionDespite the high costs, use of MD-ARVs, such as HAART, for PMTCT offer societal savings because fewer perinatally acquired infections are anticipated to require treatment.     

Maternal death reviews at a rural hospital in Malawi

ObjectiveTo analyze maternal deaths at Nkhoma Church of Central Africa Presbyterian (CCAP) Hospital and identify factors causing delays in care.MethodsMaternal death audits are performed after every maternal death at Nkhoma CCAP Hospital. Information regarding the care provided at the health facility, the referral process, and any delays in the community was collected by an audit team using a structured approach. Data from August 2007 to September 2011 were analyzed retrospectively.ResultsIn total, 61 maternal deaths occurred during the study period, of which 58 were analyzed. Most deaths were categorized as indirect (n = 34 [58.6%]). Non-pregnancy-related infections were the leading cause of indirect death (n = 22), with meningitis the most common (n = 13). Most patients experienced a delay in seeking care (n = 37 [63.8%]), a transport delay (n = 43 [74.1%]), or a delay in receiving adequate care (n = 34 [58.6%]).ConclusionMost maternal deaths had indirect causes and were associated with delays in all phases. An audit makes clear which part of the referral chain needs to be strengthened. Nkhoma CCAP Hospital has taken steps to address all phases of delay.     

Postpartum sexuality concerns among first-time parents from one U.S. academic hospital

IntroductionSexual perceptions and activities are influenced by pregnancy and childbirth due to both physical and emotional changes.AimOur goal was to illuminate the sexuality issues of concern to first‐time parents (mothers and fathers) of healthy, singleton newborns in one U.S. academic hospital.Main Outcome MeasuresNumber of sexuality concerns and self‐reported degree of resolution by months postpartum and gender of parent.MethodsAnonymous, cross‐sectional postal survey of two first‐time parent cohorts: 4 months postpartum (113 responses/404 mailed = 28.0%) and 12 months postpartum (99 responses/394 mailed = 25.1%).ResultsApproximately half of the parents reported questions or concerns on between two and eight of 19 sexuality topics. Only 11% of participating mothers and 17% of participating fathers had one or no concerns (P = 0.27 by gender), and 17% of mothers and 9% of fathers had >13 concerns (P = 0.12 by gender). There were fewer maternal concerns if they did not live with the father (P = 0.01), slightly fewer if the delivery was vaginal vs. cesarean (P = 0.07), and no differences by forceps/vacuum use or episiotomy/vaginal tear. The top concerns at 4 months postpartum were quite similar by gender and included when to resume intercourse, birth control, and the sexual impact of physical recovery from delivery. At 12 months, mothers and fathers both frequently reported a sexuality impact from the mother’s body image concerns and desire discrepancy. One year postpartum, there were three sexuality topics with fairly high prevalence (more than one‐third parents had this concern) that persisted (no self‐reported resolution among at least one‐third of parents): child‐rearing differences with spouse, greater desire by the man than the woman, and the mother’s body image.ConclusionsNew mothers and fathers both have postpartum sexuality concerns/questions, many of which can be addressed by healthcare providers. Pastore L, Owens A, and Raymond C. Postpartum sexuality concerns among first‐time parents from one U.S. academic hospital. J Sex Med 2007;4:115–123.     

Pregnancy outcomes in women with heart disease: Experience of a tertiary center in the Netherlands

ObjectivesClinical data of pregnant women with heart disease were obtained with the intention to provide input for local counseling and management guidelines.Study designRetrospective data from all pregnant women with congenital or acquired heart disease between 2000 and 2011 in the VU University Medical Centre Amsterdam.Main outcome measuresMaternal and neonatal outcomes were evaluated.ResultsData of 122 women with 160 pregnancies were obtained. The most common heart diseases were congenital heart disease (n = 65, 53.3%) and arrhythmia (n = 20, 16.4%). Based on the functional criteria of the New York Heart Association (NYHA), 114/122 patients (93.4%) were classified NYHA class I–II. Patients in NYHA class III–IV (n = 8/122, 6.6%), mainly had a history of myocardial infarction or pulmonary hypertension. There were 156 singleton and 4 twin pregnancies. 22 (13.5%) pregnancies were complicated by hypertensive disorders. Heart failure developed in 11 women (9.0%), 37.5% in NYHA class III–IV and 6.5% in NYHA class I–II. Mean gestational age and birth weight were 270 days and 3196 g in NYHA class I–II compared to 237 days and 1972 g for NHYA class III–IV. There were two maternal deaths (1.6%) and 5 fetal deaths (3.1%). There were 29 (12.8%) preterm births, 20 (12.8%) neonates small for gestational age and 34 (21.8%) admittances on the Neonatal Intensive Care Unit (NICU).ConclusionsPregnancy in women with pre-existing heart disease in all NYHA classes is associated with increased maternal morbidity and perinatal morbidity. Risk of structural fetal anomalies is especially high in women with congenital heart disease.     

Prenatal Smoking among Adolescents and Risk of Fetal Demise before and during Labor

Study ObjectiveTo investigate the relationship between smoking during pregnancy and the occurrence of stillbirth phenotypes among adolescent mothers.DesignRetrospective cohortSettingSingleton births in Missouri from 1978 through 1997.ParticipantsTwo groups of “younger” (<15 years) and “older” (15–19 years) adolescent mothers were compared to “mature” mothers (age 20–24 years).Main Outcome MeasuresCox Proportional Hazards Regression models generated adjusted risk estimates of the association between intrauterine nicotine exposure and the risk of total, antepartum, and intrapartum stillbirth in each age group.ResultsApproximately 32% (N = 205,887) of the total 633,849 singleton births analyzed were among adolescent mothers. The overall prevalence of smoking was 31.2%, with the lowest prevalence (14.1%) among the youngest mothers while older adolescents had the highest (31.7%). The risk for intrapartum stillbirth among smoking adolescents <15 years of age was twice the risk for older adolescent and mature mothers. The risk of intrapartum stillbirth among smokers decreased as maternal age increased: [adjusted hazard ratio (AHR), 95% confidence interval (CI) for young mothers: 4.0, 95%CI = 0.6–28.7; for older adolescents AHR = 1.5, 95%CI = 1.1–2.1 and for mature mothers AHR = 1.8, 95% CI = 1.4–2.2], respectively.ConclusionsIn utero tobacco exposure has maternal age-related differential and lethal effects on the fetus. Young maternal age tends to potentiate these effects. There is a public health need to develop appropriate smoking cessation messages targeted specifically to this high risk group.     

Use of an oxytocin antagonist in in vitro fertilization-embryo transfer for women with repeated implantation failure: a retrospective study

ObjectiveThis retrospective study aimed to investigate the use of an oxytocin antagonist in improving the pregnancy outcome of in vitro fertilization–embryo transfer (IVF–ET) in patients with repeated implantation failure (RIF).Materials and MethodsA total of 150 infertile couples with RIF undergoing IVF–ET were divided into three groups. Patients who did not receive atosiban were used as controls (Group 1; n = 80). Forty patients received a single bolus dose (6.75 mg, 0.9 mL/vial) of atosiban before ET (Group 2), and 30 patients received a bolus dose of 6.75 mg atosiban followed by infusion at 18 mg/hr for 3 hours immediately after ET (Group 3).ResultsA significantly higher implantation rate (30.21%) was noted in Group 2 compared with Groups 1 and 3 (11.8% and 15.9%, respectively; p = 0.0006). The clinical pregnancy rate of Group 2 (37.5%) was significantly higher than that of Groups 1 (12.5%) and 3 (20%) (p = 0.0057). The live birth rate was significantly higher in Group 2 (35%) than in Groups 1 and 3 (10% and 16.67%, respectively; p = 0.0031).ConclusionThese results suggest that IVF–ET using lower dosage of atosiban may improve pregnancy outcomes of patients with RIF.     

Impact of the creation of a specialized clinic for prenatal blood sampling and follow-up care in pregnant women

ObjectiveTo evaluate (1) the effect on gestational diabetes mellitus (GDM) screening rates of having a specialized clinic for pregnant women offering blood sampling and screening for GDM, and (2) the impact on perinatal outcomes of having early GDM screening and follow-up provided by the specialized clinic.MethodsWe performed a retrospective cohort study, based on electronic health records. We compared data from women who delivered during a period when the Blood Sampling in Pregnancy (BSP) clinic was operating (2008–2009; n = 2780) to a time period before the clinic was established (2006–2007; n = 2591). During the 2008–2009 period, we compared data from women who had GDM screening in the first trimester with women who had screening during the second trimester and with women who were not screened.ResultsFollowing the creation of the BSP clinic, overall GDM screening rates reached 72.4% in 2008–2009, compared with 48.9% in 2006-2007 (P < 0.001) and GDM screening was more likely to be performed in the first trimester (36.7% vs. 0.4%; P < 0.001). During the period when the BSP clinic was operating (2008-2009), women who had GDM screening in the first trimester had lower rates of Caesarean section (15.7% vs. 22.1 %; P < 0.001) and neonatal complications (bradycardia: 3.6% vs. 6.8%; P = 0.003; respiratory distress: 9 6% vs 13 2%; P = 0 02; and admission to NICU: 15.4% vs. 26.8%; P < 0.001) than women who did not perform GDM screening.ConclusionIn our population, creation of a clinic offering specialized care to pregnant women improved GDM screening rates. With the support of the BSP clinic, women who had early GDM screening were less likely to undergo Caesarean section and their offspring had fewer perinatal complications.     

The Maternal and Newborn Health Registry Study of the Global Network for Women's and Children's Health Research

ObjectiveTo implement a vital statistics registry system to register pregnant women and document birth outcomes in the Global Network for Women's and Children's Health Research sites in Asia, Africa, and Latin America.MethodsThe Global Network sites began a prospective population-based pregnancy registry to identify all pregnant women and record pregnancy outcomes up to 42 days post-delivery in more than 100 defined low-resource geographic areas (clusters). Pregnant women were registered during pregnancy, with 42-day maternal and neonatal follow-up recorded—including care received during the pregnancy and postpartum periods. Recorded outcomes included stillbirth, neonatal mortality, and maternal mortality rates.ResultsIn 2010, 72 848 pregnant women were enrolled and 6-week follow-up was obtained for 97.8%. Across sites, 40.7%, 24.8%, and 34.5% of births occurred in a hospital, health center, and home setting, respectively. The mean neonatal mortality rate was 23 per 1000 live births, ranging from 8.2 to 48.5 per 1000 live births. The mean stillbirth rate ranged from 13.7 to 54.4 per 1000 births.ConclusionThe registry is an ongoing study to assess the impact of interventions and trends regarding pregnancy outcomes and measures of care to inform public health.ClinicalTrial.gov Trial Registration: NCT01073475     

The association of maternal and fetal glucose homeostasis with fetal adiposity and birthweight

ObjectiveTo examine the association between maternal and fetal glucose levels and fetal adiposity and infant birthweight.Study designThis is a prospective study of 479 healthy, non-diabetic mother and infant pairs attending the National Maternity Hospital in Ireland. Fasting glucose was measured in early pregnancy (11.8 ± 2.3 weeks). At 28 weeks gestation a repeat fasting glucose was measured and 1 h glucose challenge testing (1 h GCT) was performed. At 34 weeks’ gestation (33 + 5–34 + 5 weeks) fetal growth and fetal anterior abdominal wall width, a marker of fetal adiposity, were measured. At delivery cord glucose was measured and neonatal anthropometry recorded.ResultsThere was a positive correlation between fasting glucose concentration during pregnancy and both infant birthweight and fetal anterior abdominal wall width at 34 weeks gestation. The incidence of macrosomia (birthweight > 4.5 kg) was significantly greater for maternal and cord blood glucose levels in the highest quartile compared to the lowest quartile (20.7% vs. 11.7%, p < 0.05 in the first trimester, 21.3% vs. 7.2%, p < 0.05, at 28 weeks, and 33.3% vs. 10%, p < 0.05, in cord blood). Maternal glucose concentrations at each time point, though not cord glucose, were related to early pregnancy maternal body mass index (r = 0.19, p < 0.001 in first trimester, r = 0.25, p < 0.001 at 28 weeks, r = 0.15, p < 0.01 with 1 h GCT).ConclusionMaternal glucose homeostasis is an important determinant of fetal size. We have shown that even small variations in fasting glucose concentrations can influence fetal growth and adiposity. This effect is seen from the first trimester and maintained until delivery.     

Reuse of carboplatin and paclitaxel in patients with relapsed endometrial cancer--the British Columbia Cancer Agency experience

ObjectiveTo evaluate the efficacy of reusing carboplatin and taxol in women with relapsed endometrial cancer.MethodsRetrospective analysis of our database of newly diagnosed high-risk patients with endometrial cancer treated with carboplatin–paclitaxel at diagnosis, with subsequent relapse for the period of 1995–2007.Results111 patients of 200 relapsed. They had either endometroid or papillary serous histologies. Strategies utilized upon first relapse were: no treatment (n = 33), surgery (n = 4), hormones (n = 8), irradiation (n = 14) and chemotherapy (n = 52). Carboplatin and paclitaxel was reused in 31 (60% of 52 retreated with chemotherapy or 29% of the total cohort of 111). There was no statistically significant difference in stage at diagnosis or grade at diagnosis between those retreated with chemotherapy or not or with carboplatin–paclitaxel versus another regimen. The patients retreated were a selected subgroup as only those with initial response or treated adjuvantly were offered carboplatin–paclitaxel. CR or PR were achieved in 8 (42%) patients with endometroid type cancer. In the papillary serous group 6 (50%) had CR or PR. Median PFS from first relapse was 8 months for endometroid and 9 months for papillary serous histology. OS was 15 months and 26 months respectively from first relapse.ConclusionCarboplatin–taxol regimen is an efficacious treatment. Due to the patient selection these outcomes reported are likely to be an overstatement of what could be achieved in practice.     

The role of platelet counts in the assessment of inpatient women with preeclampsia

ObjectivePlatelet count has been proposed as a screening test for generalized coagulopathy in women with preeclampsia. We performed this study to determine the relationship between platelet counts and the risk of abnormal coagulation and adverse maternal outcomes in women with preeclampsia.MethodsWe used data from women in the PIERS (Pre-eclampsia Integrated Estimate of RiSk) database. Abnormal coagulation was defined as either an international normalized ratio result greater than and/or a serum fibrinogen level less than the BC Women’s Hospital laboratory’s pregnancy-specific normal range. The relationship between platelet counts and adverse maternal outcomes was explored using a logistic regression analysis. The sensitivity, specificity, positive predictive value, and negative predictive value of platelet counts in identifying abnormal coagulation or adverse maternal outcomes were calculated.ResultsAbnormal coagulation occurred in 105 of 1405 eligible women (7.5%). The odds of having abnormal coagulation were increased for women with platelet counts < 50 × 10⁹/L (OR 7.78; 95% CI 3.36 to 18.03) and between 50 and 99 × 10⁹/L (OR 2.69; 95% CI 1.44 to 5.01) compared with women who had platelet counts above 150 × 10⁹/L. Platelet counts < 100 × 10⁹/L were associated with significantly increased odds of adverse maternal outcomes, most specifically blood transfusion. A platelet count of < 100 × 10⁹/L had good specificity in identifying abnormal coagulation and adverse maternal outcomes (92% [95% CI 91% to 94%] and 92% [95% CI 91% to 94%], respectively), but poor sensitivity (22% [95% CI 15% to 31%] and 16% [95% CI 11% to 23%], respectively).ConclusionA platelet count < 100 × 10⁹/L is associated with an increased risk of abnormal coagulation and maternal adverse outcomes in women with preeclampsia. However, the platelet count should not be used in isolation to guide care because of its poor sensitivity. Whether or not a platelet count is normal should not be used to determine whether further coagulation tests are needed.     

Influence of early self-diagnosis and treatment of bacterial vaginosis on preterm birth rate

ObjectiveTo assess whether early self-diagnosis and treatment of bacterial vaginosis (BV) could lower the preterm birth rate among a group of Indonesian women.MethodsA randomized controlled trial of 331 pregnant women (14–18 weeks) was conducted. Participants were randomly assigned to either the active model group (n = 176) or the control group (n = 155). Women in the active model group were equipped with a kit to self-evaluate vaginal pH; those with a positive test result were treated with a twice daily dose of 500 mg of metronidazole for 7 days. The primary end point was preterm birth rate.ResultsThere were 6 (3.8%) and 8 (5.4%) preterm births in the active model and control groups, respectively (P = 0.468). No spontaneous abortions were recorded in either group. When compared with the gold standard (Gram staining), the vaginal acidity test had low ability to detect BV, with 88.7% specificity and 36.9% sensitivity. The positive predictive value of the test was 35.0% PPV, while the negative predictive value was 89.4%.ConclusionEarly self-diagnosis and treatment of BV did not reduce the preterm birth rate of the study group.ClinicalTrial.gov number: NCT01232192.     

Incidence of gestational diabetes mellitus in Bahrain from 2002 to 2010

ObjectiveTo determine the incidence and trends of gestational diabetes mellitus (GDM) in Bahrain from 2002 to 2010, and to investigate 2 possible risk factors within the affected population.MethodsIn a retrospective survey, data on maternal body weight and age were collected from women who gave birth in government maternity units in Bahrain and who were screened for GDM during pregnancy using the 2-step approach and criteria of the US Expert Committee on the diagnosis and classification of diabetes.ResultsAmong 49 552 pregnant women, 4982 (10.1%) were diagnosed with gestational diabetes. The Cox–Stuart test for trend analysis suggested that there was an increase in the incidence of gestational diabetes from 7.2% in 2002 to 12.5% in 2010 (P < 0.01). For the period 2006–2010, maternal age, and weight at onset of pregnancy and at time of delivery were positively associated with risk of GDM with an odds ratio (95% confidence interval) of 1.094 (1.081–1.107), 1.081 (1.001–1.104), and 1.027 (1.013–1.040), respectively.ConclusionA combination of increasing maternal weight, maternal age, and incidence of GDM among women in Bahrain indicates a significant future burden on health services.