Termination of pregnancy among very preterm births and its impact on very preterm mortality: results from ten European population-based cohorts in the MOSAIC study

Objective  To study the impact of terminations of pregnancy (TOP) on very preterm mortality in Europe.
Design  European prospective population-based cohort study.
Setting  Ten regions from nine European countries participating in the MOSAIC (Models of OrganiSing Access to Intensive Care for very preterm babies) study. These regions had different policies on screening for congenital anomalies (CAs) and on pregnancy termination.
Population or sample  Births 22–31 weeks gestational age.
Methods  The analysis compares the proportion of TOP among very preterm births and assesses differences in mortality between the regions.
Main outcome measures  Pregnancy outcomes (termination, antepartum death, intrapartum death and live birth) and reasons for termination, presence of CAs and causes of death for stillbirths and live births in 2003.
Results  Pregnancy terminations constituted between 1 and 21.5% of all very preterm births and between 4 and 53% of stillbirths. Most terminations were for CAs, although some were for obstetric indications (severe pre-eclampsia, growth restriction, premature rupture of membranes). TOP contributed substantially to overall fetal mortality rates in the two regions with late second-trimester screening. There was no clear association between policies governing screening and pregnancy termination and the proportion of CAs among stillbirths and live births, except in Poland, where neonatal deaths associated with CAs were more frequent, reflecting restrictive pregnancy termination policies.
Conclusion  Proportions of TOP among very preterm births varied widely between European regions. Information on terminations should be reported when very preterm live births and stillbirths are compared internationally since national policies related to screening for CAs and the legality and timing of medical terminations differ.     

Preeclampsia as a cause of preterm and late preterm (near-term) births

Gestational hypertension-preeclampsia is the most common medical disorder of pregnancy. It is also a major cause of maternal and perinatal morbidities. The majority of adverse pregnancy outcomes occur in patients who develop severe hypertension or severe preeclampsia, and in those who develop the clinical manifestations before 34 weeks' gestation. There is some concern regarding neonatal morbidity in the late preterm (near term) infant (34 0/7 through 36 6/7 weeks' gestation) as a result of gestational hypertension and preeclampsia. A review of the available data suggests that most deliveries of the late preterm infant in such women are justified because of the concerns about maternal and fetal safety with continued gestation. In addition, the rate of preterm delivery at 34 to 36 weeks' gestation in women with gestational hypertension or preeclampsia is low. Indeed, most admissions to Neonatal Intensive Care Unit in such pregnancies occur in those at > or =37 weeks' gestation. There is urgent need for research to assess the reasons behind preterm delivery at 34 to 36 weeks' gestation in women with hypertension and preeclampsia. In addition, there is need for research to assess the reasons for admission to the NICU in term infants born of mothers with varying severities of hypertension and preeclampsia. In this paper, the phrase "late-preterm" has been used instead of "near term," as the former was considered more appropriate to reflect this subgroup of preterm infants in a workshop on this topic held in July 2005, organized by the National Institute of Child Health and Human Development.     

Cervical dimensions and risk of preterm birth: a prospective cohort study

OBJECTIVE: To examine the relation between cervical dilatation and length and the risk of spontaneous preterm birth, including its subtypes preterm labor and preterm premature rupture of membranes (PROM). METHODS: Cervical dimensions assessed by clinical examination were recorded prospectively at 24-29 weeks' gestation in 871 subjects with singleton pregnancies who were followed to delivery. Relative risks (RRs) of preterm birth, preterm labor, and preterm PROM were calculated for clinically distinguishable categories of cervical dilatation and length and for cervical score (length minus dilatation). Regression analysis was used to adjust for confounding. Time to delivery from baseline examination was summarized using survival analysis. RESULTS: There were 73 spontaneous preterm births (8.3%), 46 preterm labors and 27 cases of preterm PROM. All cervical measurements were associated with increased risks of preterm birth, with increasing abnormality more strongly predictive of risk. The adjusted RR for preterm birth with dilatation of at least 0.5 cm was 2.9 (95% confidence interval [CI] 1.2, 7.3); for length of 1.5 cm or less, the RR was 2.1 (95% CI 1.0, 4.5), and for cervical score less than 2.0, the RR was 2.8 (95% CI 1.4, 5.6). The association with cervical measurements was stronger for preterm PROM than for preterm labor, although precision was limited. These measurements had high specificity (93-99%) and low sensitivity (8-20%) for predicting preterm birth. CONCLUSION: In asymptomatic women at 24-29 weeks' gestation, greater cervical dilatation and shorter length were associated with increased risk of spontaneous preterm delivery, particularly preterm PROM.     

The effect of maternal fasting during Ramadan on preterm delivery: a prospective cohort study

Please cite this paper as: Awwad J, Usta I, Succar J, Musallam K, Ghazeeri G, Nassar A. The effect of maternal fasting during Ramadan on preterm delivery: a prospective cohort study. BJOG 2012;119:1379-1386. Objective To determine the effect of fasting during the month of Ramadan on the rate of preterm delivery (PTD). Design A prospective cohort study of women with singleton pregnancies who elected to fast and matched controls. Setting Four medical centres in Beirut, Lebanon. Population Women presenting for prenatal care (20-34?weeks of gestation) during the month of Ramadan, September 2008. Methods Data were collected prospectively. The frequency of PTD was evaluated in relation to the duration of fasting and the stage of gestation at the time of fasting. Main outcome measures The primary endpoint was the percentage of pregnant women who had PTD, defined as delivery before 37 completed weeks of gestation. Results A total of 468 women were approached, of whom 402 were included in the study. There were no differences in smoking history and employment. There was no difference in the proportion of women who had PTD at <37?weeks (10.4% versus 10.4%) or PTD at <32?weeks (1.5% versus 0.5%) in the Ramadan-fasted group and the controls, respectively. The PTD rate was also similar in those who fasted before or during the third trimester. The mean birthweight was lower (3094?±?467?g versus 3202?±?473?g, P?=?0.024) and the rate of ketosis and ketonuria was higher in the Ramadan-fasted women. On multivariate stepwise logistic regression analysis, fasting was not associated with an increased risk of PTD (odds ratio 0.72; 95% confidence interval 0.34-1.54; P?=?0.397). The only factor that had a significant effect on the PTD rate was body mass index (odds ratio 0.43; 95% confidence interval 0.20-0.93; P?=?0.033). Conclusions Fasting during the month of Ramadan does not seem to increase the baseline risk of preterm delivery in pregnant women regardless of the gestational age during which this practice is observed.     

The role of stillbirth prevention and late preterm (near-term) births

Stillbirth remains an important cause of fetal loss in both the term and late-preterm (near-term) pregnancy. As ongoing research further elucidates the causes of intrauterine fetal demise (IUFD), strategies can be tested to reduce its occurrence. Currently, reduction of IUFD in the term and late preterm infants should focus on reduction or elimination of risk factors (eg, smoking and control of medical conditions) and enhanced fetal surveillance in those pregnancies identified to be at increased risk.     

Risk factors and adverse pregnancy outcomes among births affected by velamentous umbilical cord insertion: a retrospective population-based register study

Objective

To identify risk factors associated with velamentous cord insertion (VCI) and to evaluate the association between adverse pregnancy outcomes and VCI in singleton pregnancies.

Study design

The total population of women (n = 26,849) with singleton pregnancies delivered in Kuopio University Hospital during the study period between 2000 and 2011 was reviewed. Risk factors and the risk of adverse pregnancy outcomes (admission to a neonatal unit, fetal death, preterm delivery, low birth weight (LBW < 2500 g), the infant being small for its gestation age (SGA), low Apgar scores (<7) at 1 and 5 min and fetal venous pH < 7.15) were evaluated separately among women with and without VCI by means of logistic regression analyses.

Results

The incidence of VCI among women with singleton pregnancies was 2.4% (n = 633 of 26,849). Independent risk factors for VCI were nulliparity, obesity, fertility problems, placenta previa and maternal smoking. VCI was associated with a 1.38-, 2.01-, 3.93- and 1.39-fold increased risk of admission to a neonatal unit, preterm delivery (<37 gestation weeks), LBW and SGA, respectively compared to pregnancies involving normal cord insertion. Of the women with VCI, 15.3% underwent non-elective cesarean section compared to 8.3% (p ≤ 0.001) of women without VCI.

Conclusions

The results suggest that the incidence of VCI increases along with an increase in fertility problems and maternal obesity. VCI is a moderate risk condition increasing the risks of prematurity and impaired fetal growth.     

Risk factors and peripartum outcomes of failed epidural: a prospective cohort study

Purpose

Awareness to rate, risk factors, and the associated peripartum outcomes of failed epidural analgesia (FEA) may improve expectations and labor management. We aimed to identify risk factors for FEA and to examine peripartum outcomes associated with failure.

Methods

A prospective cohort study conducted between March 2015 and August 2015, at a single university medical center. Laboring women at ≥34 weeks, receiving epidural analgesia, were eligible. Pain was evaluated using a 0–10 cm visual analogue scale (VAS). FEA was defined as VAS score ≥5, 30 min after the loading dose. The primary outcome was to identify risk factors for FEA. In addition, second-stage duration and operative vaginal delivery rate were also examined. Univariate logistic regression and stepwise multivariate logistic regression were performed to estimate the predictors for FEA.

Results

Of all 414 women included, 35 (8.5%) had FEA. Multivariate stepwise logistic regression revealed that fetal head station 1 cm above the ischial spines (p?=?0.002, adjusted OR 5.4, 95% CI 1.9–16.0), oxytocin use (p?=?0.026, adjusted OR 2.8, 95% CI 1.1–6.8), and seniority of the anesthesiologist (p?=?0.046, adjusted OR 0.97, 95% CI 0.93–0.99) at epidural insertion were found as significant variables associated with FEA. Second-stage duration and operative vaginal delivery rate did not differ significantly between women with failed and successful epidural.

Conclusion

Higher fetal head station and oxytocin use may be associated with higher failure rate. Labor outcomes related to epidural use, occurred at comparable rates, among women with failed and successful epidural.

     

Fetal volume measurements with three dimensional ultrasound in the first trimester of pregnancy, related to pregnancy outcome, a prospective cohort study

Background

Spontaneous coronary and vertebral artery dissections are rare events occurring most commonly in otherwise healthy women during pregnancy or the post-partum period.

Case presentation

This report describes a 35-year-old female who presented with an acute inferior ST elevation myocardial infarction 7 months post-partum secondary to spontaneous dissection of the left obtuse marginal coronary artery. Despite appropriate medical therapy with dual anti-platelet therapy, the patient presented four weeks later with a spontaneous dissection of the right vertebral artery.

Conclusion

We review the presentation, diagnosis, and management of spontaneous dissections of the vasculature in the peri-partum period.     

First trimester vaginal bleeding and adverse pregnancy outcomes among Chinese women: from a large cohort study in China

Objectives: To examine the effect of first trimester vaginal bleeding on adverse pregnancy outcomes including preterm delivery, low birth weight and small for gestational age. Methods: This is a prospective population-based cohort study. A questionnaire survey was conducted on 4342 singleton pregnancies by trained doctors. Binary logistic regression was used to estimate risk ratios (RRs) and 95% con?dence intervals (95% CI). Results: Vaginal bleeding occurred among 1050 pregnant women, the incidence of vaginal bleeding was 24.2%, 37.4% of whom didn’t see a doctor, 62.6% of whom saw a doctor for vaginal bleeding. Binary logistic regression demonstrated that bleeding with seeing a doctor was significantly associated with preterm birth (RR 1.84, 95% CI 1.25–2.69) and bleeding without seeing a doctor was related to increased of low birth weight (RR 2.52, 95% CI 1.34–4.75) and was 1.97-fold increased of small for gestational age (RR 1.97, 95% CI 1.19–3.25). Conclusions: These results suggest that first trimester vaginal bleeding is an increased risk of low birth weight, preterm delivery and small for gestational age. Find ways to reduce the risk of vaginal bleeding and lower vaginal bleeding rate may be helpful to reduce the incidence of preterm birth, low birth weight and small for gestational age.     

Conception,early pregnancy loss,and time to clinical pregnancy: a population-based prospective study

OBJECTIVE: To examine rates of conception and pregnancy loss and their relations with time to clinical pregnancy and reproductive outcomes. DESIGN: A prospective observational study. SETTING: Population-based cohort in China. PATIENT(S): Five hundred eighteen healthy newly married women who intended to conceive. Upon stopping contraception, daily records of vaginal bleeding and daily first-morning urine specimens were obtained for < or =1 year or until a clinical pregnancy was achieved. Daily urinary hCG was assayed to detect early pregnancy loss (EPL). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Conception, pregnancy loss, and time to clinical pregnancy. RESULT(S): The conception rate per cycle was 40% over the first 12 months. Of the 618 detectable conceptions, 49 (7.9%) ended in clinical spontaneous abortion, and 152 (24.6%) in EPL. Early pregnancy loss was detected in 14% of all the cycles without clinically recognized pregnancy, but the frequencies were lower among women with delayed time to clinical pregnancy. Early pregnancy loss in the preceding cycle was associated with increased odds of conception (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.8-3.9), clinical pregnancy (OR, 2.0; 95% CI, 1.3-3.0), and EPL (OR, 2.4; 95% CI, 1.4-4.2) but was not associated with spontaneous abortion, low birth weight, or preterm birth in the subsequent cycle. CONCLUSION(S): We demonstrated substantial EPL in the non-clinically pregnant cycles and a positive relation between EPL and subsequent fertility.     

Worldwide prevalence of adverse pregnancy outcomes associated with in vitro fertilization/intracytoplasmic sperm injection among multiple births: a systematic review and meta-analysis based on cohort studies

Purpose

To perform a systematic review and meta-analysis of reported estimates of adverse pregnancy outcomes among multiple births conceived with in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

Methods

PubMed, Google Scholar, Cochrane Libraries and Chinese databases were searched through May 2016 for cohort studies assessing adverse pregnancy outcomes associated with IVF/ICSI multiple births. Random-effects meta-analyses were used to calculate pooled estimates of adverse pregnancy outcomes and, where appropriate, heterogeneity was explored in group-specific analyses.

Results

Sixty-four studies, with 60,210 IVF/ICSI multiple births and 146,737 spontaneously conceived multiple births, were selected for analysis. Among IVF/ICSI multiple births, the pooled estimates were 51.5% [95% confidence interval (CI): 48.7–54.3] for preterm birth, 12.1% (95% CI: 10.4–14.1) for very preterm birth, 49.8% (95% CI: 47.6–52.0) for low birth weight, 8.4% (95% CI: 7.1–9.9) for very low birth weight, 16.2% (95% CI: 12.9–20.1) for small for gestational age, 3.0% (95% CI: 2.5–3.7) for perinatal mortality and 4.7% (95% CI: 4.0–5.6) for congenital malformations. When the data were restricted to twins, the pooled estimates also showed a high prevalence of adverse outcomes. There was a similar prevalence of poor outcomes among multiple births conceived with IVF/ICSI and naturally (all P?≥?0.0792). Significant differences in different continents, countries, and income groups were found.

Conclusions

The IVF/ICSI multiple pregnancies have a high prevalence of adverse pregnancy outcomes. However, population-wide prospective adverse outcomes registries covering the entire world population for IVF/ICSI pregnancies are needed to determine the exact perinatal prevalence.

     

Maternal and neonatal outcomes among pregnant women with fibromyalgia: a population-based study of 12 million births

Purpose: Fibromyalgia (FM) is a rheumatologic disorder marked by chronic, widespread pain and associated comorbid conditions. The purpose of our study was to evaluate the effect of FM on maternal and neonatal outcomes.

Methods: Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2013, we conducted a population-based retrospective cohort study consisting of women who delivered during that period. Logistic regression was used to compare maternal and neonatal outcomes among pregnancies in women with and without FM.

Results: Of 12 584 918 births during the 15-year study period, 7758 (0.06%) were to women with FM with rates increasing over the study period. Women with FM were more commonly older in age, overweight or obese, and users of alcohol, tobacco, and illicit drugs. They were more likely to experience anxiety, depression, and bipolar disorder. Women with FM were at greater risk of gestational diabetes, preterm premature rupture of membranes, and placental abruption. Women with FM more commonly had cesarean deliveries (odds ratios (OR): 1.11, 95% CI: 1.05–1.16) and births complicated by venous thromboembolism (OR: 2.34, 95% CI: 1.91–2.86). Infants of women with FM were more likely to be premature (OR: 1.35, 95% CI: 1.25–1.46) and have intrauterine growth restriction (OR: 1.48, 95% CI: 1.30–1.68).

Conclusions: The prevalence of FM in pregnancy is rising in the US. FM is a high-risk pregnancy condition associated with adverse maternal and newborn outcomes.     

A prospective observational cohort study of exposure to womb-like sounds to stabilize breathing and cardiovascular patterns in preterm neonates

Purpose: We exposed premature infants to womb-like sounds to evaluate such exposure on breathing and cardiovascular patterns. We hypothesized that these sounds would reduce apnea and intermittent hypoxemia, enhance parasympathetic outflow, and improve cardiovascular patterns.

Methods: A total of 20 cases and 5 control infants at ≤32–36?weeks corrected gestational age participated in a prospective observational cohort study. Twenty-four hours of continuous ECG, respiratory and oxygen saturation data were collected in all infants. Womb-like sounds were played intermittently in 6-hour blocks. Salivary samples were collected at study beginning and end for cortisol. Apnea, intermittent hypoxemia, and bradycardia were evaluated, and heart rate variability was assessed by time domain and spectral techniques.

Results: Intermittent hypoxemia and bradycardia significantly declined after sound exposure. No significant differences in apnea, cortisol levels, or heart rate variability were evident among the study infants.

Conclusions: Exposing premature infants to womb-like sounds has the potential to reduce hypoxemic and bradycardic events, and be used as an intervention to stabilize breathing and cardiac control in preterm infants.