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Gautam Paudel P, Sunny AK, Gurung R, Gurung A, Malla H, Budhathoki SS, Paudel P, Kc N, Kc A. Prevalence, risk factors and consequences of newborns born small for gestational age: a multisite study in Nepal. BMJ Paediatr Open 2020; 4:e000607. [PMID: 32342014 PMCID: PMC7173954 DOI: 10.1136/bmjpo-2019-000607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/24/2020] [Accepted: 03/02/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To identify the prevalence, risk factors and health impacts associated with small for gestational age (SGA) births in Nepal. METHODS A cross-sectional study was conducted in 12 public hospitals in Nepal from 1 July 2017 to 29 August 2018. A total of 60 695 babies delivered in these hospitals during the study period were eligible for inclusion. Clinical information of mothers and newborns was collected by data collectors using a data retrieval form. A semistructured interview was conducted at the time of discharge to gather sociodemographic information from women who provided the consent (n=50 392). Babies weighing less than the 10th percentile for their gestational age were classified as SGA. Demographic, obstetric and neonatal characteristics of study participants were analysed for associations with SGA. The association between SGA and likelihood of babies requiring resuscitation or resulting in stillbirth and neonatal death was also explored. RESULTS The prevalence of SGA births across the 12 hospitals observed in Nepal was 11.9%. After multiple variable adjustment, several factors were found to be associated with SGA births, including whether mothers were illiterate compared with those completing secondary and higher education (adjusted OR (AOR)=1.73; 95% CI 1.09 to 2.76), use of polluted fuel compared with use of clean fuel for cooking (AOR=1.51; 95% CI 1.16 to 1.97), first antenatal care (ANC) visit occurring during the third trimester compared with first trimester (AOR=1.82; 95% CI 1.27 to 2.61) and multiple deliveries compared with single delivery (AOR=3.07; 95% CI 1.46 to 6.46). SGA was significantly associated with stillbirth (AOR=7.30; 95% CI 6.26 to 8.52) and neonatal mortality (AOR=5.34; 95% CI 4.65 to 6.12). CONCLUSIONS Low literacy status of mothers, use of polluted fuel for cooking, time of first ANC visit and multiple deliveries are associated with SGA births. Interventions encouraging pregnant women to attend ANC visits early can reduce the burden of SGA births.
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Affiliation(s)
- Pragya Gautam Paudel
- Department of Public Health, University of Tennessee Knoxville, Knoxville, Tennessee, USA.,Research Division, Golden Community, Lalitpur, Nepal
| | | | - Rejina Gurung
- Research Division, Golden Community, Lalitpur, Nepal
| | | | - Honey Malla
- Research Division, Golden Community, Lalitpur, Nepal
| | - Shyam Sundar Budhathoki
- Research Division, Golden Community, Lalitpur, Nepal.,Department of Public Health, Imperial College London, London, UK
| | - Prajwal Paudel
- Department of Public Health, Government of Nepal Ministry of Health and Population, Kathmandu, Nepal
| | - Navraj Kc
- Department of Public Health, Government of Nepal Ministry of Health and Population, Kathmandu, Nepal
| | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Diet as a counteracting agent of the effect of some well-known risk factors for small for gestational age. Nutrition 2019; 72:110665. [PMID: 31982727 DOI: 10.1016/j.nut.2019.110665] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/10/2019] [Accepted: 11/18/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study was to assess whether diet variables can neutralize the risk produced by three well-known risk factors for being small for gestational age: smoking, body mass index (BMI) ˂20 kg/m2, and having a previous preterm/low birth weight (LBW) newborn. METHODS A matched case control study was conducted (518 cases and 518 controls of pregnant women) in Spain. We collected data on demographic characteristics, socioeconomic status, toxic habits, and diet. Dietary intake during pregnancy was assessed using a validated food frequency questionnaire, categorized into quintiles. Adjusted odds ratios (aORs) and their 95% confidence intervals (CI) were estimated by conditional regression logistic models. RESULTS Women who smoked during pregnancy had a 78% increased risk for having an SGA newborn (aOR, 1.78; 95% CI, 1.28-2.74). Lean women (BMI ˂ 20 kg/m2 before pregnancy) augmented the risk 139% (aOR, 2.39; 95% CI, 1.68-3.40), and those with a previous SGA-LBW an increase of 160% (aOR, 2.60; 95% CI, 1.53-4.37). Smoking in women with a fruit intake of ≥421 g/d was not associated with a higher risk for SGA versus non-smoking women with the same fruit intake (aOR, 0.98; 95% CI, 0.41-2.33). A BMI <20 kg/m2 with an intake of ≥33 g/d of legumes did not increase the risk for SGA versus women with a BMI ≥20 kg/m2 with the same legume intake (aOR, 1.35; 95% CI, 0.54-3.37). Diet did not modify the risk by having a previous SGA-LBW newborn. CONCLUSIONS Smoking and leanness increased the SGA risk; nevertheless foods such as fruit, fish, and legumes, as well as intake of vitamins D and B3 and ω-3 marine fatty acids, may "at" least partially counteract this increase.
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Skeith L, Le Gal G, de Vries JIP, Middeldorp S, Goddijn M, Kaaja R, Gris JC, Martinelli I, Schleußner E, Petroff D, Langlois N, Rodger MA. The risk of cesarean delivery after labor induction among women with prior pregnancy complications: a subgroup analysis of the AFFIRM study. BMC Pregnancy Childbirth 2019; 19:455. [PMID: 31783795 PMCID: PMC6884748 DOI: 10.1186/s12884-019-2615-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background To determine the risk of cesarean delivery after labor induction among patients with prior placenta-mediated pregnancy complications (pre-eclampsia, late pregnancy loss, placental abruption or intrauterine growth restriction). Methods The AFFIRM database includes patient level data from 9 randomized controlled trials that evaluated the role of LMWH versus no LMWH during pregnancy to prevent recurrent placenta-mediated pregnancy complications. The primary outcome of this sub-study was the proportion of women who had an unplanned cesarean delivery after induction of labor compared to after spontaneous labor. Results There were 512 patients from 7 randomized trials included in our sub-study. There was no difference in the risk of cesarean delivery between women with labor induction (21/148, 14.2%) and spontaneous labor (79/364, 21.7%) (odds ratio (OR) 0.60, 95% CI, 0.35–1.01; p = 0.052). Among 274 women who used LMWH prophylaxis during pregnancy, the risk of cesarean delivery was lower among those that underwent labor induction (9.8%) compared to spontaneous labor (22.4%) (OR 0.38, 95% CI, 0.17–0.84; p = 0.01). Conclusions The risk of cesarean delivery is not increased after labor induction among a higher risk patient population with prior pregnancy complications. Our results suggest that women who receive LMWH during pregnancy might benefit from labor induction.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, C210 Foothills Medical Centre, 1403 29th Street, NW, Calgary, Alberta, T2N 2T9, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Grégoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Johanna I P de Vries
- Department of Obstetrics and Gynecology, VU Medical Center, Amsterdam, the Netherlands
| | - Saskia Middeldorp
- Academic Medical Center, Department of Vascular Medicine, Amsterdam, the Netherlands
| | - Mariëtte Goddijn
- Academic Medical Center, Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Amsterdam, the Netherlands
| | - Risto Kaaja
- Department of Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Jean-Christophe Gris
- Department of Hematology, Nimes University Hospital and University of Montpellier, Montpellier, France
| | - Ida Martinelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Ekkehard Schleußner
- Department of Obstetrics and Gynecology, Jena University Hospital Friedrich Schiller University, Jena, Germany
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany
| | - Nicole Langlois
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marc A Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
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Neighbourhood Income and Risk of Having an Infant With Concomitant Preterm Birth and Severe Small for Gestational Age Birth Weight. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 42:156-162.e1. [PMID: 31679923 DOI: 10.1016/j.jogc.2019.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Socioeconomic position gradients have been individually demonstrated for preterm birth (PTB) at <37 weeks gestation and severe small for gestational age birth weight at <5th percentile (SGA). It is not known how neighbourhood income is related to the combination of PTB and severe SGA, a state reflective of greater placental dysfunction and higher risk of neonatal morbidity and mortality than PTB or severe SGA alone. METHODS This population-based study comprised all 1 367 656 singleton live births in Ontario from 2002 to 2011. Multinomial logistic regression was used to estimate the odds of PTB with severe SGA, PTB without severe SGA, and severe SGA without PTB, compared with neither PTB nor severe SGA, in relation to neighbourhood income quintile (Q). The highest income quintile, Q5, served as the exposure referent. Adjusted odds ratios (aORs) were adjusted for maternal age at delivery, parity, marital status, and world region of birth (Canadian Task Force Classification II-2). RESULTS Relative to women residing in Q5 (2.3 per 1000), the rate of PTB with severe SGA was highest among those in Q1 (3.6 per 1000), with an aOR of 1.34 (95% confidence interval [CI] 1.20-1.50). The corresponding aORs were 1.23 (95% CI 1.09-1.37) for Q2, 1.14 (95% CI 1.02-1.28) for Q3, and 1.06 (95% CI 0.95-1.20) for Q4. Less pronounced aORs were seen for each individual outcome of PTB and severe SGA. CONCLUSION Women residing in the lowest-income areas are at highest risk of having a fetus born too small and too soon. Future research should focus on identifying those women most predisposed to combined PTB and severe SGA.
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Correlates of Obstetric Risk Perception and Recognition of Danger Signs in Kano, Northern Nigeria. Ann Glob Health 2019; 85:121. [PMID: 31646140 PMCID: PMC6777197 DOI: 10.5334/aogh.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Risk perception and recognition of danger signs are important cues for accessing obstetric care. These measures are not well documented in many resource-limited settings, including northern Nigeria, a region with poor maternal health indices. Objective: To assess community level obstetric risk perception, danger sign recognition and their predictors in Kano, northern Nigeria. Method: This is a community-based cross-sectional study. Participants were surveyed using structured, pretested questionnaires. Knowledge of obstetric risk factors and danger sign recognition were analyzed, and their predictors modeled using logistic regression to generate adjusted odds ratios (AORs). Results: The obstetric risk factors identified by the 400 respondents included: maternal age (64.3%), history of abortion (37.0%), postpartum haemorrhage (36.0%), previous operative delivery (31.8%), and high parity (31.3%). The most frequently recognised danger signs during pregnancy were: vaginal bleeding (76.8%), seizures (44.5%), and severe abdominal pain (34.8%). Common intrapartum danger signs recognised included: severe bleeding (77.8%), seizures (55.5%), and loss of consciousness (38.3%). Severe bleeding (80.5%), seizures (42.0%), and high fever (28.5%) were the top three danger signs identified in the postpartum period. At multivariate level, respondent sex (female vs. male) (aOR = 3.10, 95% CI = 1.67–5.74), ethnicity (Yoruba vs. Hausa) (aOR = 7.53, 95% CI = 2.51–22.6), occupation (employed vs. unemployed) (aOR = 4.07, 95% CI = 1.87–8.84) and parity (≥5 versus 0) (aOR = 0.23, 95% CI = 0.06–0.92) predicted good obstetric risk perception. Participants’ ethnicity (Yoruba vs. Hausa) (aOR = 4.40, 95% CI = 1.10–19.2) and obstetric risk perception (good vs. poor) (aOR = 12.0, 95% CI = 6.8–21.2) predicted danger sign recognition. Conclusion: The perception of obstetric risk and recognition of danger signs were influenced by participant sex, parity, employment status, and ethnicity. Targeted communication strategies and community-based education are essential to enhance effective utilisation of emergency obstetric services.
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Anto EO, Roberts P, Coall D, Turpin CA, Adua E, Wang Y, Wang W. Integration of suboptimal health status evaluation as a criterion for prediction of preeclampsia is strongly recommended for healthcare management in pregnancy: a prospective cohort study in a Ghanaian population. EPMA J 2019; 10:211-226. [PMID: 31462939 DOI: 10.1007/s13167-019-00183-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022]
Abstract
Background Normotensive pregnancy may develop into preeclampsia (PE) and other adverse pregnancy complications (APCs), for which the causes are still unknown. Suboptimal health status (SHS), a physical state between health and disease, might contribute to the development and progression of PE. By integration of a routine health measure in this Ghanaian Suboptimal Health Cohort Study, we explored the usefulness of a 25-question item SHS questionnaire (SHSQ-25) for early screening and prediction of normotensive pregnant women (NTN-PW) likely to develop PE. Methods We assessed the overall health status among a cohort of 593 NTN-PW at baseline (10-20 weeks gestation) and followed them at 21-31 weeks until 32-42 weeks. After an average of 20 weeks follow-up, 498 participants returned and were included in the final analysis. Hematobiochemical, clinical and sociodemographic data were obtained. Results Of the 498 participants, 49.8% (248/498) had 'high SHS' at baseline (61.7% (153/248) later developed PE) and 38.3% (95/248) were NTN-PW, whereas 50.2% (250/498) had 'optimal health' (17.6% (44/250) later developed PE) and 82.4% (206/250) were NTN-PW. At baseline, high SHS score yielded a significantly (p < 0.05) increased adjusted odds ratio, a wider area under the curve (AUC) and a higher sensitivity and specificity for the prediction of PE (3.67; 0.898; 91.9% and 87.8%), PE coexisting with intrauterine growth restriction (2.86, 0.838; 91.5% and 75.9%), stillbirth (2.52; 0.783; 96.6% and 60.0%), hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome (2.08; 0.800; 97.2% and 63.8%), acute kidney injury (2.20; 0.825; 95.3% and 70.0%) and dyslipidaemia (2.80; 0.8205; 95.7% and 68.4%) at 32-42 weeks gestation. Conclusions High SHS score is associated with increased incidence of PE; hence, SHSQ-25 can be used independently as a risk stratification tool for adverse pregnancy outcomes thereby creating an opportunity for predictive, preventive and personalized medicine.
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Affiliation(s)
- Enoch Odame Anto
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia.,2Department of Molecular Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Roberts
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia
| | - David Coall
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia
| | | | - Eric Adua
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia
| | - Youxin Wang
- 4Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
| | - Wei Wang
- 1School of Medical and Health Sciences, Edith Cowan University, Perth, WA Australia.,4Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China.,5School of Public Health, Taishan Medical University, Taian, China
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Yu YH, Bodnar LM, Brooks MM, Himes KP, Naimi AI. Comparison of Parametric and Nonparametric Estimators for the Association Between Incident Prepregnancy Obesity and Stillbirth in a Population-Based Cohort Study. Am J Epidemiol 2019; 188:1328-1336. [PMID: 31111944 DOI: 10.1093/aje/kwz081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 11/13/2022] Open
Abstract
While prepregnancy obesity increases risk of stillbirth, few studies have evaluated the role of newly developed obesity independent of long-standing obesity. Additionally, researchers have relied almost exclusively on parametric models, which require correct specification of an unknown function for consistent estimation. We estimated the association between incident obesity and stillbirth in a cohort constructed from linked birth and death records in Pennsylvania (2003-2013). Incident obesity was defined as body mass index (weight (kg)/height (m)2) greater than or equal to 30. We used parametric G-computation, semiparametric inverse-probability weighting, and parametric/nonparametric targeted minimum loss-based estimation (TMLE) to estimate the association between incident prepregnancy obesity and stillbirth. Compared with pregnancies from women who stayed nonobese, women who became obese prior to their next pregnancy were estimated to have 2.0 (95% confidence interval (CI): 0.5, 3.5) more stillbirths per 1,000 pregnancies using parametric G-computation. However, despite well-behaved stabilized inverse probability weights, risk differences estimated from inverse-probability weighting, nonparametric TMLE, and parametric TMLE represented 6.9 (95% CI: 3.7, 10.0), 0.4 (95% CI: 0.1, 0.7), and 2.9 (95% CI: 1.5, 4.2) excess stillbirths per 1,000 pregnancies, respectively. These results, particularly those derived from nonparametric TMLE, were highly sensitive to covariates included in the propensity score models. Our results suggest that caution is warranted when using nonparametric estimators to quantify exposure effects.
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Affiliation(s)
- Ya-Hui Yu
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa M Bodnar
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Maria M Brooks
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine P Himes
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Ashley I Naimi
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kapaya H, Dimelow ER, Anumba D. Is portable foetal electrocardiogram monitor feasible for foetal heart rate monitoring of small for gestational age foetuses in the home environment. J OBSTET GYNAECOL 2019; 39:1081-1086. [PMID: 31195856 DOI: 10.1080/01443615.2019.1587394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Small-for-gestational-age (SGA) foetuses are at greater risk of complications than normal foetuses. Studies have demonstrated that foetal electrocardiogram (ECG) device (Monica-AN24) can be employed for monitoring foetal heart rate (FHR). However, its reliability and acceptability has not been assessed in SGA foetuses. This study was aimed at: (a) determining the acceptability of wearing the device more than once, (b) investigating the reliability of acquiring successful FHR data at different gestation. Patients with singleton non-anomalous foetus >24 weeks gestation and an estimated foetal weight below tenth percentile were recruited. Thirty-five women wore the device once. Twenty-four of these wore second time (68.6%). Overall, success-rate of FHR signals was 48.6% and increased to 68.8% beyond 34 weeks gestation. Foetal ECG is a promising method for monitoring SGA foetus >34 weeks gestation. Compared to day recordings, foetal signals were more reliable at night. Further studies are required before its clinical utility can be ascertained. IMPACT STATEMENT What is already known on this subject? Pregnancies that are affected by small-for-gestational-age (SGA) foetus pose a major public health problem and are associated with increased perinatal morbidity and mortality. There is no consensus on the optimal timing of delivery. Current methods employed for monitoring SGA foetuses include ultrasound scans for foetal-biometry and Doppler assessments. However, they provide a snapshot of information on foetal well-being, restrict patient mobility and cannot be employed over long-time periods. It is plausible that ambulatory foetal-ECG device that enable monitoring over a longer time period may better inform decisions about the timing of delivery. What do the results of this study add? Trans-abdominal foetal-ECG is a promising method of monitoring SGA foetus in the home setting with a success rate of acquiring reliable foetal heart rate (FHR) data over 90% at night time. What are the implications of these findings for clinical practice and/or further research? Overall, the study approved the concept of long-term home monitoring and has highlighted the facilitators and barriers to wearing the monitor in clinical care. These observations can be used to undertake robust research to assess the use of foetal-ECG monitor singly or in conjunction with current monitoring techniques for optimal foetal surveillance.
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Affiliation(s)
- Habiba Kapaya
- Obstetrics and Gynaecology, Sheffield Teaching Hospital NHS Foundation Trust , Sheffield , UK
| | - Emma R Dimelow
- Obstetrics and Gynaecology, Sheffield Teaching Hospital NHS Foundation Trust , Sheffield , UK
| | - Dilly Anumba
- Obstetrics and Gynaecology, The University of Sheffield Medical School , Sheffield , UK.,Maternal and Fetal Medicine, The University of Sheffield Medical School , Sheffield , UK
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Gunnarsdottir J, Akhter T, Högberg U, Cnattingius S, Wikström AK. Elevated diastolic blood pressure until mid-gestation is associated with preeclampsia and small-for-gestational-age birth: a population-based register study. BMC Pregnancy Childbirth 2019; 19:186. [PMID: 31138157 PMCID: PMC6537437 DOI: 10.1186/s12884-019-2319-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/25/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Gestational hemodynamic adaptations, including lowered blood pressure (BP) until mid-gestation, might benefit placental function. We hypothesized that elevated BP from early to mid-gestation increases risks of preeclampsia and small-for-gestational-age birth (SGA), especially in women who also deliver preterm (< 37 weeks). METHODS In 64,490 healthy primiparous women, the change in systolic and diastolic BP from early to mid-gestation was categorized into lowered (≥ 0 mmHg decreased), and elevated (≥ 1 mmHg increase). Women with chronic hypertension, chronic renal disease, pre-gestational diabetes and systemic lupus erythematosus were excluded. Risks of preeclampsia and SGA birth were estimated by logistic regression, presented with adjusted odds ratio (aOR) and 95% confidence intervals (CI). Further, the effect of BP change in combination with stage 1 hypertension (systolic BP 130-139 mmHg or diastolic BP 80-89 mmHg) in early gestation was estimated. RESULTS Compared to women with lowered diastolic BP from early to mid-gestation, those with elevated diastolic BP had increased risks of preeclampsia (aOR: 1.8 [1.6-2.0]) and SGA birth (aOR: 1.3 [1.2-1.5]). The risk estimates were higher for preeclampsia and SGA when combined with preterm birth (aORs: 2.2 [1.8-2.8] and 2.3 [1.8-3.0], respectively). The highest rate of preeclampsia (9.9%) was seen in women with stage 1 hypertension in early gestation and a diastolic BP that was elevated until mid-gestation. This was three times the risk, compared to women with normal BP in early gestation and a diastolic BP that was decreased until mid-gestation. The association between elevated systolic BP from early to mid-gestation and preeclampsia was weak, and no significant association was found between changes in systolic BP and SGA births. CONCLUSION Elevated diastolic BP from early to mid-gestation was associated with increased risks of preeclampsia and SGA, especially for women also delivering preterm. The results may imply that the diastolic BP starts to increase around mid-gestation in women later developing placental dysfunction disorders.
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Affiliation(s)
- J Gunnarsdottir
- Department of Women's and Children's Health, Uppsala University, SE-75185, Uppsala, Sweden.
| | - T Akhter
- Department of Women's and Children's Health, Uppsala University, SE-75185, Uppsala, Sweden
| | - U Högberg
- Department of Women's and Children's Health, Uppsala University, SE-75185, Uppsala, Sweden
| | - S Cnattingius
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - A K Wikström
- Department of Women's and Children's Health, Uppsala University, SE-75185, Uppsala, Sweden.,Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Pacora P, Romero R, Jaiman S, Erez O, Bhatti G, Panaitescu B, Benshalom-Tirosh N, Jung Jung E, Hsu CD, Hassan SS, Yeo L, Kadar N. Mechanisms of death in structurally normal stillbirths. J Perinat Med 2019; 47:222-240. [PMID: 30231013 PMCID: PMC6349478 DOI: 10.1515/jpm-2018-0216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 07/20/2018] [Indexed: 01/05/2023]
Abstract
Objectives To investigate mechanisms of in utero death in normally formed fetuses by measuring amniotic fluid (AF) biomarkers for hypoxia (erythropoietin [EPO]), myocardial damage (cardiac troponin I [cTnI]) and brain injury (glial fibrillary acidic protein [GFAP]), correlated with risk factors for fetal death and placental histopathology. Methods This retrospective, observational cohort study included intrauterine deaths with transabdominal amniocentesis prior to induction of labor. Women with a normal pregnancy and an indicated amniocentesis at term were randomly selected as controls. AF was assayed for EPO, cTnI and GFAP using commercial immunoassays. Placental histopathology was reviewed, and CD15-immunohistochemistry was used. Analyte concentrations >90th centile for controls were considered "raised". Raised AF EPO, AF cTnI and AF GFAP concentrations were considered evidence of hypoxia, myocardial and brain injury, respectively. Results There were 60 cases and 60 controls. Hypoxia was present in 88% (53/60), myocardial damage in 70% (42/60) and brain injury in 45% (27/60) of fetal deaths. Hypoxic fetuses had evidence of myocardial injury, brain injury or both in 77% (41/53), 49% (26/53) and 13% (7/53) of cases, respectively. Histopathological evidence for placental dysfunction was found in 74% (43/58) of these cases. Conclusion Hypoxia, secondary to placental dysfunction, was found to be the mechanism of death in the majority of fetal deaths among structurally normal fetuses. Ninety-one percent of hypoxic fetal deaths sustained brain, myocardial or both brain and myocardial injuries in utero. Hypoxic myocardial injury was an attributable mechanism of death in 70% of the cases. Non-hypoxic cases may be caused by cardiac arrhythmia secondary to a cardiac conduction defect.
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Affiliation(s)
- Percy Pacora
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Sunil Jaiman
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Offer Erez
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Gaurav Bhatti
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Bogdan Panaitescu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Neta Benshalom-Tirosh
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Eun Jung Jung
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan
| | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Nicholas Kadar
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
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Pirnat A, DeRoo LA, Skjaerven R, Morken NH. Risk of having one lifetime pregnancy and modification by outcome of pregnancy and perinatal loss. Acta Obstet Gynecol Scand 2019; 98:753-760. [PMID: 30648732 DOI: 10.1111/aogs.13534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/29/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION With increasing cesarean section rates, adverse pregnancy outcomes such as preterm delivery and small-for-gestational-age continue to be public health challenges. Besides having high co-occurrence and interrelation, it is suggested that these outcomes, along with preeclampsia, are associated with reduced subsequent fertility. On the other hand, the loss of a child during the perinatal period is associated with increased reproduction. Failure to consider this factor when estimating the effects of pregnancy outcomes on future reproduction may lead to erroneous conclusions. However, few studies have explored to what degree a perinatal loss contributes to having a next pregnancy in various adverse pregnancy outcomes. MATERIAL AND METHODS This was a population-based study of mothers giving birth to their first singleton infant (≥22 gestational weeks) during 1967-2007 who were followed for the occurrence of a second birth in the Medical Birth Registry of Norway until 2014. Relative risks with 95% confidence intervals for having one lifetime pregnancy by preterm delivery, small-for-gestational-age, preeclampsia and cesarean section were obtained by generalized linear models for the binary family and adjusted for maternal age at first birth, education and year of first childbirth. Main outcome measure was having one lifetime pregnancy. RESULTS Nearly 900 000 women gave birth to their first singleton infant in 1967-2007, of which 16% had only one lifetime pregnancy. These women were older at first delivery, had less education and there was a higher proportion of unmarried women than women with two or more births. In women with pregnancy complications where the infant survived the perinatal period, there were the following relative risks for one lifetime pregnancy: increased preterm delivery: 1.21 (1.19-1.22)], small-for-gestational-age: 1.13 (1.12-1.15), preeclampsia: 1.09 (1.07-1.11), cesarean section: 1.24 (1.23-1.25). The risk was significantly reduced if the child was lost (preterm delivery: 0.63 [0.59-0.68], small-for-gestational-age: 0.57 [0.51-0.63], preeclampsia: 0.69 [0.59-0.80], cesarean section: 0.67 [0.56-0.79]), compared with women with no perinatal loss and no adverse outcome. CONCLUSIONS The associations between adverse outcomes of pregnancy and the risk of having one lifetime pregnancy were strongly modified by child survival in the perinatal period.
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Affiliation(s)
- Aleksandra Pirnat
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Lisa A DeRoo
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Rolv Skjaerven
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Fertility Center, Norwegian Institute of Public Health, Bergen, Norway
| | - Nils-Halvdan Morken
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
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62
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Malhotra A, Allison BJ, Castillo-Melendez M, Jenkin G, Polglase GR, Miller SL. Neonatal Morbidities of Fetal Growth Restriction: Pathophysiology and Impact. Front Endocrinol (Lausanne) 2019; 10:55. [PMID: 30792696 PMCID: PMC6374308 DOI: 10.3389/fendo.2019.00055] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/22/2019] [Indexed: 12/11/2022] Open
Abstract
Being born small lays the foundation for short-term and long-term implications for life. Intrauterine or fetal growth restriction describes the pregnancy complication of pathological reduced fetal growth, leading to significant perinatal mortality and morbidity, and subsequent long-term deficits. Placental insufficiency is the principal cause of FGR, which in turn underlies a chronic undersupply of oxygen and nutrients to the fetus. The neonatal morbidities associated with FGR depend on the timing of onset of placental dysfunction and growth restriction, its severity, and the gestation at birth of the infant. In this review, we explore the pathophysiological mechanisms involved in the development of major neonatal morbidities in FGR, and their impact on the health of the infant. Fetal cardiovascular adaptation and altered organ development during gestation are principal contributors to postnatal consequences of FGR. Clinical presentation, diagnostic tools and management strategies of neonatal morbidities are presented. We also present information on the current status of targeted therapies. A better understanding of neonatal morbidities associated with FGR will enable early neonatal detection, monitoring and management of potential adverse outcomes in the newborn period and beyond.
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Affiliation(s)
- Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- *Correspondence: Atul Malhotra
| | - Beth J. Allison
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Suzanne L. Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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63
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Leite DFB, Morillon AC, Melo Júnior EF, Souza RT, Khashan AS, Baker PN, Kenny LC, Cecatti JG. Metabolomics for predicting fetal growth restriction: protocol for a systematic review and meta-analysis. BMJ Open 2018; 8:e022743. [PMID: 30530473 PMCID: PMC6286473 DOI: 10.1136/bmjopen-2018-022743] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/11/2018] [Accepted: 10/12/2018] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Fetal growth restriction (FGR) is a relevant research and clinical concern since it is related to higher risks of adverse outcomes at any period of life. Current predictive tools in pregnancy (clinical factors, ultrasound scan, placenta-related biomarkers) fail to identify the true growth-restricted fetus. However, technologies based on metabolomics have generated interesting findings and seem promising. In this systematic review, we will address diagnostic accuracy of metabolomics analyses in predicting FGR. METHODS AND ANALYSIS Our primary outcome is small for gestational age infant, as a surrogate for FGR, defined as birth weight below the 10th centile by customised or population-based curves for gestational age. A detailed systematic literature search will be carried in electronic databases and conference abstracts, using the keywords 'fetal growth retardation', 'metabolomics', 'pregnancy' and 'screening' (and their variations). We will include original peer-reviewed articles published from 1998 to 2018, involving pregnancies of fetuses without congenital malformations; sample collection must have been performed before clinical recognition of growth impairment. If additional information is required, authors will be contacted. Reviews, case reports, cross-sectional studies, non-human research and commentaries papers will be excluded. Sample characteristics and the diagnostic accuracy data will be retrieved and analysed. If data allows, we will perform a meta-analysis. ETHICS AND DISSEMINATION As this is a systematic review, no ethical approval is necessary. This protocol will be publicised in our institutional websites and results will be submitted for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018089985.
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Affiliation(s)
- Debora Farias Batista Leite
- Department of Maternal and Child Health, Clinics Hospital of Federal University of Pernambuco, Recife, Brazil
- Department of Gynaecology and Obstetrics, University Campinas, Sao Paulo, Brazil
| | - Aude-Claire Morillon
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Elias F Melo Júnior
- Department of Maternal and Child Health, Clinics Hospital of Federal University of Pernambuco, Recife, Brazil
| | - Renato T Souza
- Department of Gynaecology and Obstetrics, University Campinas, Sao Paulo, Brazil
| | - Ali S Khashan
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- School of Public Health, University College Cork, Cork, Ireland
| | - Philip N Baker
- College of Life Sciences, University of Leicester, Leicester, UK
| | - Louise C Kenny
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Women's and Children's Health, Faculty of Health and Life Sciences, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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64
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Ladhani NNN, Fockler ME, Stephens L, Barrett JF, Heazell AE. No 369 - Prise en charge de la grossesse aprés une mortinaissance. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1684-1700. [DOI: 10.1016/j.jogc.2018.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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65
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No. 369-Management of Pregnancy Subsequent to Stillbirth. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1669-1683. [DOI: 10.1016/j.jogc.2018.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Finken MJJ, van der Steen M, Smeets CCJ, Walenkamp MJE, de Bruin C, Hokken-Koelega ACS, Wit JM. Children Born Small for Gestational Age: Differential Diagnosis, Molecular Genetic Evaluation, and Implications. Endocr Rev 2018; 39:851-894. [PMID: 29982551 DOI: 10.1210/er.2018-00083] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 06/21/2018] [Indexed: 12/25/2022]
Abstract
Children born small for gestational age (SGA), defined as a birth weight and/or length below -2 SD score (SDS), comprise a heterogeneous group. The causes of SGA are multifactorial and include maternal lifestyle and obstetric factors, placental dysfunction, and numerous fetal (epi)genetic abnormalities. Short-term consequences of SGA include increased risks of hypothermia, polycythemia, and hypoglycemia. Although most SGA infants show catch-up growth by 2 years of age, ∼10% remain short. Short children born SGA are amenable to GH treatment, which increases their adult height by on average 1.25 SD. Add-on treatment with a gonadotropin-releasing hormone agonist may be considered in early pubertal children with an expected adult height below -2.5 SDS. A small birth size increases the risk of later neurodevelopmental problems and cardiometabolic diseases. GH treatment does not pose an additional risk.
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Affiliation(s)
- Martijn J J Finken
- Department of Pediatrics, VU University Medical Center, MB Amsterdam, Netherlands
| | - Manouk van der Steen
- Department of Pediatrics, Erasmus University Medical Center/Sophia Children's Hospital, CN Rotterdam, Netherlands
| | - Carolina C J Smeets
- Department of Pediatrics, Erasmus University Medical Center/Sophia Children's Hospital, CN Rotterdam, Netherlands
| | - Marie J E Walenkamp
- Department of Pediatrics, VU University Medical Center, MB Amsterdam, Netherlands
| | - Christiaan de Bruin
- Department of Pediatrics, Leiden University Medical Center, RC Leiden, Netherlands
| | - Anita C S Hokken-Koelega
- Department of Pediatrics, Erasmus University Medical Center/Sophia Children's Hospital, CN Rotterdam, Netherlands
| | - Jan M Wit
- Department of Pediatrics, Leiden University Medical Center, RC Leiden, Netherlands
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67
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Deshmukh H, Way SS. Immunological Basis for Recurrent Fetal Loss and Pregnancy Complications. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2018; 14:185-210. [PMID: 30183507 DOI: 10.1146/annurev-pathmechdis-012418-012743] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pregnancy stimulates an elaborate assortment of dynamic changes, allowing intimate approximation of genetically discordant maternal and fetal tissues. Although the cellular and molecular details about how this works remain largely undefined, important clues arise from evaluating how a prior pregnancy influences the outcome of a future pregnancy. The risk of complications is consistently increased when complications occurred in a prior pregnancy. Reciprocally, a prior successful pregnancy protects against complications in a future pregnancy. Here, we summarize immunological perturbations associated with fetal loss, with particular focus on how both harmful and protective adaptations may persist in mothers. Immunological aberrancy as a root cause of pregnancy complications is also considered, given their shared overlapping risk factors and the sustained requirement for averting maternal-fetal conflict throughout pregnancy. Understanding pregnancy-induced immunological changes may expose not only new therapeutic strategies for improving pregnancy outcomes but also new facets of how immune tolerance works that may be applicable to other physiological and pathological contexts.
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Affiliation(s)
- Hitesh Deshmukh
- Division of Pulmonary Biology, Center for Inflammation and Tolerance, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA
| | - Sing Sing Way
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA.,Division of Infectious Diseases, Center for Inflammation and Tolerance, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA;
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Murphy HR, Bell R, Dornhorst A, Forde R, Lewis-Barned N. Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes. Diabet Med 2018; 35:292-299. [PMID: 29337383 DOI: 10.1111/dme.13579] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 01/02/2023]
Abstract
Our aim was to review the data from the National Pregnancy in Diabetes (NPID) audit, and to identify the challenges and opportunities for improving pregnancy outcomes in women with diabetes. We reviewed three years of NPID data and relevant diabetes and obstetric literature, and found that there has been little change in pregnancy preparation or outcomes over the past 3 years, with substantial clinic-to clinic variations in care. Women with Type 2 diabetes remain less likely to take 5 mg preconception folic acid (22.8% vs. 41.8%; P < 0.05), and more likely to take potentially harmful medications (statin and/or ACE inhibitor 13.0% vs. 1.8%; P < 0.05) than women with Type 1 diabetes. However, women with Type 1 diabetes are less likely to achieve the recommended glucose control target of HbA1c < 48 mmol/mol (6.5%) (14.9% vs. 38.1%; P < 0.05). The following opportunities for improvement were identified. First, the need to integrate reproductive health into the diabetes care plans of all women with diabetes aged 15-50 years. Second, to develop more innovative approaches to improve uptake of pre-pregnancy care in women with Type 2 diabetes in primary care settings. Third, to integrate insulin pump, continuous glucose monitoring and automated insulin delivery technologies into the pre-pregnancy and antenatal care of women with Type 1 diabetes. Fourth, to improve postnatal care with personalized approaches targeting women with previous pregnancy loss, congenital anomaly and perinatal mortality. A nationwide commitment to delivering integrated reproductive and diabetes healthcare interventions is needed to improve the health outcomes of women with diabetes.
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Affiliation(s)
- H R Murphy
- Norwich Medical School, University of East Anglia, Norwich
- Division of Women's & Children's Health, Kings College London
| | - R Bell
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne
| | - A Dornhorst
- Department of Medicine, Imperial College London
| | - R Forde
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London
| | - N Lewis-Barned
- Northumbria Diabetes and Endocrinology Service, Wansbeck Hospital, Ashington, UK
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