Obstetric outcomes subsequent to intrauterine death in the first pregnancy

Objective  To compare obstetric outcomes in the pregnancy subsequent to intrauterine death with that following live birth in first pregnancy.
Design  Retrospective cohort study.
Setting  Grampian region of Scotland, UK.
Population  All women who had their first and second deliveries in Grampian between 1976 and 2006.
Methods  All women delivering for the first time between 1976 and 2002 had follow up until 2006 to study their next pregnancy. Those women who had an intrauterine death in their first pregnancy formed the exposed cohort, while those who had a live birth formed the unexposed cohort.
Main outcome measures  Maternal and neonatal outcomes in the second pregnancy, including pre-eclampsia, placental abruption, induction of labour, instrumental delivery, caesarean delivery, malpresentation, prematurity, low birthweight and stillbirth.
Results  The exposed cohort ( n = 364) was at increased risk of pre-eclampsia (OR 3.1, 95% CI 1.7–5.7); placental abruption (OR 9.4, 95% CI 4.5–19.7); induction of labour (OR 3.2, 95% CI 2.4–4.2); instrumental delivery (OR 2.0, 95% CI 1.4–3.0); elective (OR 3.1, 95% CI 2–4.8) and emergency caesarean deliveries (OR 2.1, 95% CI 1.5–3.0); and prematurity (OR 2.8, 95% CI 1.9–4.2), low birthweight (OR 2.8, 95% CI 1.7–4.5) and malpresentation (OR 2.8, 95% CI 2.0–3.9) of the infant as compared with the unexposed cohort ( n = 33 715). The adjusted odds ratio for stillbirth was 1.2 and 95% CI 0.4–3.4.
Conclusion  While the majority of women with a previous stillbirth have a live birth in the subsequent pregnancy, they are a high-risk group with an increased incidence of adverse maternal and neonatal outcomes.     

Effect of interpregnancy interval on outcomes of pregnancy after recurrent pregnancy loss

Abstract

Objective: To examine the effect of interpregnancy interval (IPI) on outcomes of pregnancy after recurrent pregnancy loss (RPL).

Methods: A retrospective cohort study including 325 patients treated at a RPL clinic, with two or more consecutive pregnancy losses followed by a subsequent (index) pregnancy, of whom 163 had IPI?≤?6 months, and 212 had IPI?>?6 months.

Results: Pregnancy loss rate in the index pregnancy was positively associated with increased IPI (18.6% in women with IPI?≤?6 months, and 29.7% in women with IPI?>?6 months; p?=?0.029). In a multivariable logistic analysis, excluding women with fertility problems, and adjusting for maternal age and ethnicity, the OR for pregnancy loss rate for IPI longer than 6 months compared to shorter IPI was 1.76 (95%CI: 0.96–3.22, p?=?0.067).

Conclusions: Our results suggest that IPI shorter than 6 months, in women with no fertility problems, is associated with lower rate of subsequent miscarriage. Further studies are needed to substantiate this finding.     

Subsequent pregnancy outcome after preterm breech delivery,a population based cohort study

Objective: The objective of this study is to investigate the effect of the mode of delivery in women with preterm breech presentation on neonatal and maternal outcome in the subsequent pregnancy.

Methods: Nationwide population-based cohort study in the Netherlands of women with a preterm breech delivery and a subsequent delivery in the years 1999–2007. We compared planned caesarean section versus planned vaginal delivery for perinatal outcomes in both pregnancies.

Results: We identified 1543 women in the study period, of whom 259 (17%) women had a planned caesarean section and 1284 (83%) women had a planned vaginal delivery in the first pregnancy. In the subsequent pregnancy, perinatal mortality was 1.1% (3/259) for women with a planned caesarean section in the first pregnancy and 0.5% (6/1284) for women with a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31–10.1). Composite adverse neonatal outcome was 2.3% (6/259) versus 1.5% (19/1284), (aOR 1.5; 95% CI 0.55–4.2). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49–1.9).

Conclusion: In women with a preterm breech delivery, planned caesarean section does not reduce perinatal mortality, perinatal morbidity, or maternal morbidity rate over the course of two pregnancies.     

Pregnancy outcomes in young Turkish women

STUDY OBJECTIVE: We documented adolescent pregnancies that were thought to be at high risk for increased obstetric complications. DESIGN, SETTING, PARTICIPANTS: This study covered 442 pregnant women who were under 19 years of age and who delivered in Cukurova University, School of Medicine, Department of Obstetrics and Gynecology between January 1, 1993 and December 31, 1997, retrospectively. RESULTS: The patients' mean age was 18.24 years and their mean gestational age was 38.2 weeks. The newborns' mean birthweight was 3093.05 g and their mean birth height was 45.75 cm. Apgar score in the 1st minute was 6.79 and at the 5th minute 8.37. Cesarean section rate was 28.5%. The most common causes were pregnancy-induced hypertension (PIH) and breech delivery. There were 32 stillborns and 5 early neonatal deaths. The most frequent obstetric complications were PIH (14.5%), preterm delivery (7.0%), and low birthweight (< 2000 g) (10.2%). The pregnant adolescents with obstetric problems (44.4%) had poor obstetric results. CONCLUSIONS: Adolescent pregnancies are considered high risk with many obstetric complications and poor obstetric results. To decrease the complications adolescent pregnancies must be followed-up as high risk pregnancies, especially in developing countries where socioeconomic factors are more pronounced.     

Perinatal outcomes associated with intrahepatic cholestasis of pregnancy*

Objective: The objective of this study is to examine perinatal outcomes associated with cholestasis of pregnancy according to bile acid level and antenatal testing practice.

Study design: Retrospective cohort study of women with symptoms and bile acid testing from 2005 to 2014. Women were stratified by bile acid level: no cholestasis (<10?μmol/L), mild (10–39?μmol/L), moderate (40–99?μmol/L), and severe (≥100?μmol/L). The primary outcome was composite neonatal morbidity (hypoxic ischemic encephalopathy, severe intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, or death).

Results: 785 women were included; 487 had cholestasis (347 mild, 108 moderate, 32 severe) and 298 did not. After controlling for gestational age (GA), severe cholestasis was associated with the composite neonatal outcome (aRR 5.6, 95% CI 1.3–23.5) and meconium-stained fluid (aRR 4.82, 95%CI 1.6–14.2). Bile acid levels were not correlated with the frequency of testing (p?=?.50). Women who underwent twice weekly testing were delivered earlier (p?=?.016) than women tested less frequently, but the difference in GA was?≤4?d. Abnormal testing prompting delivery was uncommon. Among women with cholestasis, there were three stillbirths. One of these women was undergoing antenatal testing, which was normal 1 d prior to the fetal demise.

Conclusion: Severe cholestasis is associated with neonatal morbidity which antenatal testing may not predict.     

Outcome of pregnancy following second- or third-trimester intrauterine fetal death

Objective

To investigate the outcomes of a pregnancy after a second- or third-trimester intrauterine fetal death (IUFD).

Methods

A prospective observational study was conducted at Trousseau Hospital (Paris, France) between 1996 and 2011. The first ongoing pregnancy in women who had had a previous IUFD was monitored. Management of their treatment was according to a standardized protocol. Recurrence of fetal death was the main outcome criterion.

Results

The subsequent pregnancies of 87 women who had experienced at least one previous IUFD were followed up. The cause of previous IUFD was placental in 50 (57%) women, unknown in 19 (22%), adnexal in 12 (14%), metabolic in 2 (2%), and malformative in 4 (5%). Three (3%) participants had another stillbirth. Overall, obstetric complications occurred in 34 (39%) pregnancies (including 22 [25%] preterm births, 5 [6%] small for gestational age, and 6 [7%] maternal vascular complications). Obstetric complications were significantly more common among women whose previous stillbirth had been due to placental causes than among those affected by other causes (P = 0.02).

Conclusion

Most pregnancies after IUFD resulted in a live birth; however, adverse obstetric outcomes were more common when the previous stillbirth was due to placental causes.     

Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a summary of the PITCHES study and its clinical implications

Intrahepatic cholestasis of pregnancy is characterized by maternal itchiness and raised maternal serum bile acids. It affects 0.7% of pregnancies in the UK and is associated with increased risk of adverse perinatal outcomes. The mainstay of treatment has been ursodeoxycholic acid, despite limited evidence for its efficacy. PITCHES is the largest randomized controlled trial to date comparing ursodeoxycholic acid with placebo in women with intrahepatic cholestasis of pregnancy, in which 605 women were randomized to active treatment or placebo. PITCHES demonstrated that although ursodeoxycholic acid appears to be safe in pregnant women, it is not effective in reducing adverse perinatal outcomes. No subgroup was identified, based on characteristics at randomization, that might benefit from targeted treatment. Women taking ursodeoxycholic acid had a small reduction in itch severity, which was not considered clinically significant by women and clinicians. The routine use of ursodeoxycholic acid should be reconsidered.     

Perinatal outcomes from the use of antiepileptic drugs during pregnancy: a case-control study

Objective: To evaluate the perinatal results from epileptic women using antiepileptic drugs during prenatal care.

Methods: This was a retrospective longitudinal study assessing the perinatal results of women exposed to antiepileptic drugs during pregnancy, and we compared these results with those of pregnant women who were not exposed. The development of pregnancy, gestational age at delivery, Apgar scores, biometric data, morbidity, stillbirths and neonatal mortality were analyzed. The chi-square test and Fisher’s exact test were used for the categorical variables, while Student’s t-test was used for independent numerical variables.

Results: Over a 10-year period, 12?790 singleton gestations were analyzed, among which 104 (0.8%) consisted of epileptic pregnant women. From this total, 82 evolved to childbirth and their neonatal data were compared with those of 316 newborns from non-epileptic women. The most-used antiepileptic drug was phenobarbital in 70% of the cases. There was greater neonatal mortality (p?=?0.006), occurrence of neonatal hemorrhagic disorders (p?=?0.005), and occurrence of minor congenital anomalies (p?=?0.03) among the children of women exposed to antiepileptic drugs.

Conclusion: The antenatal exposure to antiepileptic drugs is associated mainly with occurrences of hemorrhagic complications during the neonatal period; furthermore, great prevalence of newborns presenting minor congenital anomalies and elevated risk of neonatal mortality.     

Risk for recurrence of preeclampsia and outcome of subsequent pregnancy in women with preeclampsia in their first pregnancy

Objective: To assess subsequent pregnancy outcome and to identify risk factors for recurrence of preeclampsia (PET) in women with PET in their first pregnancy. Methods: A retrospective cohort study of all nulliparous women diagnosed with PET during the years 1996–2008 (PET group, N = 600). Outcome of subsequent pregnancy was compared with a control group of nulliparous women without PET matched by maternal age in a 3:1 ratio (N = 1800). Results: Subsequent pregnancies in the PET group were characterized by a higher rate of preterm delivery at less than 37 and 34 weeks (15.2% vs. 5.7%, p < 0.001 and 3.8% vs. 0.8%, p < 0.001, respectively), placental abruption (1.7% vs. 0.2%, p = 0.004), IUGR (2.8% vs. 0.9%, p = 0.016), and PET (5.9% vs. 0.8%, p < 0.001). Risk factors for PET and adverse outcome in the subsequent pregnancy included: PET complicated by placental abruption in the index pregnancy (OR = 10.8, 95%-CI = 1.8–34.6), PET requiring delivery prior to 34 weeks in the index pregnancy (OR = 6.5, 95%-CI = 1.6–22.5), chronic hypertension (OR = 5.3, 95%-CI = 1.9–12.7), and maternal age > 35 (OR = 4.3, 95%-CI = 1.2–20.5). Conclusion: PET in the first pregnancy is independently associated with an increased risk for adverse pregnancy outcome and recurrence of PET in the subsequent pregnancy in a manner that is related to the severity of PET in the first pregnancy.     

Management of pregnancy complications in women of advanced maternal age

The average age of women at childbirth in high resource obstetric settings has been increasing steadily for approximately 30 years. Women aged 35 years or over have an increased risk of gestational hypertensive disease, gestational diabetes, placenta praevia, placental abruption, perinatal death, preterm labour, fetal macrosomia and fetal growth restriction. Unsurprisingly, rates of obstetric intervention are higher among older women. Of particular concern is the increased risk of antepartum stillbirth at term in women of advanced maternal age. In all maternal age groups, the risk of stillbirth is higher among nulliparous women than among multiparous women. Women of advanced maternal age (>40 years) should be given low dose aspirin in the presence of an additional risk factor for pre-eclampsia and offered serial ultrasounds for fetal growth and wellbeing. Given the increased risk of antepartum stillbirth, induction of labour from 39 weeks’ gestation should be discussed with woman.     

Previous pregnancy outcomes and subsequent pregnancy anxiety in a Quebec prospective cohort

Introduction: Pregnancy anxiety is an important psychosocial risk factor that may be more strongly associated with adverse birth outcomes than other measures of stress. Better understanding of the upstream predictors and causes of pregnancy anxiety could help to identify high-risk women for adverse maternal and infant outcomes. The objective of the present study was to measure the associations between five past pregnancy outcomes (live preterm birth (PTB), live term birth, miscarriage at <20 weeks, stillbirth at ≥20 weeks, and elective abortion) and pregnancy anxiety at three trimesters in a subsequent pregnancy.

Methods: Analyses were conducted using data from the 3D Cohort Study, a Canadian birth cohort. Data on maternal demographic characteristics and pregnancy history for each known previous pregnancy were collected via interviewer-administered questionnaires at study entry. Pregnancy anxiety for the index study pregnancy was measured prospectively by self-administered questionnaire following three prenatal study visits.

Results: Of 2366 participants in the 3D Study, 1505 had at least one previous pregnancy. In linear regression analyses with adjustment for confounding variables, prior live term birth was associated with lower pregnancy anxiety in all three trimesters, whereas prior miscarriage was significantly associated with higher pregnancy anxiety in the first trimester. Prior stillbirth was associated with greater pregnancy anxiety in the third trimester. Prior elective abortion was significantly associated with higher pregnancy anxiety scores in the first and second trimesters, with an association of similar magnitude observed in the third trimester.

Discussion: Our findings suggest that the outcomes of previous pregnancies should be incorporated, along with demographic and psychosocial characteristics, into conceptual models framing pregnancy anxiety.     

Pregnancy after perinatal loss: association of grief,anxiety and attachment

Objectives: The aim of this study was to explore the psychological experience of pregnancy after a previous perinatal loss and to bring to light the risk factors of psychological distress and disorders in instituting antenatal attachment with the subsequent child. Methods: 96 pregnant women, having experienced a previous perinatal loss answered several questionnaires which measured the feelings of perinatal grief (PGS), anxio‐depressive symptomatology (HADS), acceptance of pregnancy, identification with the maternal role (PSEQ) and perinatal attachment (MAAS). The control group included 74 women with no experience of perinatal loss. Results: Women having suffered from perinatal loss reported significantly higher scores of grief and anxio‐depressive symptoms compared to the control group. These variables were significant predictors of prenatal attachment. Conclusion: Findings reveal the intense psychological distress during pregnancy following a perinatal loss and underscore the need for psychosocial and clinical care when there is a perinatal loss, care that should be extended up to the birth of the subsequent child.     

Predictive factors for pregnancy during the first four intrauterine insemination cycles using gonadotropin

Abstract

Purpose: Although a variety of factors have been reported as affecting pregnancy rates after intrauterine insemination (IUI), there have been conflicting results on prognostic factors. This study aimed to determine predictive factors for pregnancy in patients undergoing the first four IUI cycles.

Methods: A total of 348 IUI cycles using clomiphene citrate or letrozole combined with gonadotropin, or gonadotropin only were analyzed. Baseline clinical characteristics, variables related to ovulation induction and sperm parameters were compared between pregnant (n?=?54) and non-pregnant groups (n?=?294). Logistic regression analysis was performed to identify factors that could predict a pregnancy.

Results: The overall clinical pregnancy rate was 15.5% (54/348) per cycle and 30.0% (54/180) per couple. During the first four IUI cycles, logistic regression analysis revealed that woman who were 39 years or older (OR: 0.263, 95% CI: 0.076–0.906, p?=?0.034), longer duration of infertility (OR: 0.967, 95% CI: 0.942–0.993, p?=?0.012), endometriosis (versus unexplained infertility; OR: 0.177, 95% CI: 0.040–0.775, p?=?0.022) and endometrial thickness below 7?mm (OR: 0.114, 95% CI: 0.015–0.862, p?=?0.035) were unfavorable factors to predict clinical pregnancy.

Conclusions: Women with old age, longer duration of infertility, the presence of endometriosis or thin endometrium in the preovulatory phase may have unfavorable outcomes during the first four IUI cycles.     

Substance use during pregnancy: risk factors and obstetric and perinatal outcomes in South Australia

OBJECTIVE: To determine the prevalence of self-reported substance use during pregnancy in South Australia, the characteristics of substance users, their obstetric outcomes and the perinatal outcomes of their babies. METHODS: Multivariable logistic regression with STATA statistical software was undertaken using the South Australian perinatal data collection 1998-2002. An audit was conducted on every fifth case coded as substance use to identify the actual substances used. RESULTS: Substance use was reported by women in 707 of 89 080 confinements (0.8%). Marijuana (38.9%), methadone (29.9%), amphetamines (14.6%) and heroin (12.5%) were most commonly reported, with polydrug use among 18.8% of the women audited. Substance users were more likely than non-users to be smokers, to have a psychiatric condition, to be single, indigenous, of lower socio-economic status and living in the metropolitan area. The outcome models had poor predictive powers. Substance use was associated with increased risks for placental abruption (OR 2.53) and antepartum haemorrhage from other causes (OR 1.41). The exposed babies had increased risks for preterm birth (OR 2.63), small for gestational age (OR 1.79), congenital abnormalities (1.52), nursery stays longer than 7 days (OR 4.07), stillbirth (OR 2.54) and neonatal death (OR 2.92). CONCLUSIONS: Substance use in pregnancy is associated with increased risks for antepartum haemorrhage and poor perinatal outcomes. However, only a small amount of the variance in outcomes can be explained by the substance use alone. Recent initiatives to improve identification and support of women exposed to adverse health, psychosocial and lifestyle factors will need evaluation.     

Association between first trimester maternal serum pregnancy associated plasma protein-A and adverse pregnancy outcome

AIMS: To investigate whether low pregnancy associated plasma protein-A (PAPP-A) levels in the first trimester of pregnancy are associated with subsequent intrauterine fetal growth restriction, stillbirth and preterm delivery. METHODS: A retrospective review of pregnancy outcomes was undertaken in women who had PAPP-A carried out in the first trimester of pregnancy at the time of nuchal translucency scan. Pregnancy outcomes were assessed by the review of medical records, and postal questionnaires. Delivery details were collected, including livebirth, neonatal birthweight and gestational age at delivery. The chi2 test was used to investigate the association between low first trimester serum PAPP-A levels and adverse fetal outcomes. Unpaired t-test was used for continuous variables. Sensitivities and specificities were then calculated. RESULTS: A total of 894 women who had blood collected for PAPP-A were identified, and data was obtained for 827 deliveries. Each had a normal karyotype. There were six intrauterine deaths, 13 babies with birthweights below the 3rd centile, 55 babies weighing below the 10th centile, and 96 women who delivered prematurely. Four of six intrauterine deaths had low PAPP-A levels (<0.5 multiples of the median), with a relative risk of 13.75. Low PAPP-A levels were associated with fetal weight below the 10th centile (P = 0.01) but not the 3rd centile. There was no statistically significant association between low maternal serum PAPP-A levels and preterm delivery. CONCLUSION: At 11-13 weeks' gestation, low maternal serum PAPP-A levels are associated with fetal death in utero and birthweight below the 10th centile. First trimester PAPP-A may be a useful tool for identifying pregnancies at risk of adverse fetal outcomes.     

Extraamniotic prostaglandin F2 alpha for intrauterine death and fetal abnormality.

Prostaglandin F2 alpha was administered extraamniotically for termination of pregnancy in 15 cases of intrauterine fetal death between 18 and 39 wk gestation and in 10 cases of fetal abnormality or hydatidiform mole between 16 and 28 wk gestation. Although delivery was achieved with minimal side effects in all cases, the best results were obtained in patients with intrauterine fetal death. It is concluded that discontinuous extraamniotic prostaglandin therapy constitutes a safe and effective approach for the active management of intrauterine fetal death.