Complications of the third stage of labor in in vitro fertilization pregnancies: an additional expression of abnormal placentation?

Assisted reproductive technology and prolonged third stage of labour: a multicentre study in Japan

RESEARCH QUESTION

What are the risk factors for a prolonged third stage of labour, closely related to postpartum haemorrhage, and what is the effect of assisted reproductive technology (ART) on the third stage of labour?

DESIGN

Clinical data of women who delivered vaginally at term at 12 primary maternity hospitals in Japan (2010-2018) (n = 25,336) were obtained; 1148 (4.5%) conceived through ART and 2246 (8.9%) through non-ART treatments. The risk of a prolonged third stage of labour (defined as ≥20 min) was evaluated by univariable and multivariable regression analyses. Adjusted odds ratios (aOR) of a prolonged third stage of labour were evaluated, stratified by the type of ART, with natural conception as a reference.

RESULTS

Multivariable analysis showed that pregnancy achieved through ART (aOR 4.38, 95% CI 3.12 to 6.15), history of spontaneous miscarriage (OR 1.40, 95% CI 1.06 to 1.84) and prolonged labour (OR 1.52, 95% CI 1.09 to 2.12) were identified as independent risk factors. Frozen embryo transfer (FET), FET in a hormone replacement cycle (HRC-FET) and blastocyst-stage embryo transfer were significantly associated with a prolonged third stage of labour (aOR 4.07, 95% CI 2.75 to 6.04, aOR 4.11, 95% CI 2.58 to 6.57 and aOR 2.13, 95% CI 1.15 to 3.95, respectively). No significant difference was observed in the duration of third stage of labour between natural conception and non-ART treatment (P = 0.61).

CONCLUSION

Pregnancy achieved through ART, particularly FET, HRC-FET and blastocyst-stage embryo transfer, was a significant risk factor for a prolonged third stage of labour.

Is there a relationship between morphokinetic parameters and obstetrical complications? An analysis of singleton live births after single fresh embryo transfer

BACKGROUND

With the advancement in embryology and the introduction of time-lapse monitoring system, the embryologists' goal might be to find not only the embryo with the highest probability of live birth, but also the embryo with the highest probability to progress to a healthy full-term delivery. Thus, we aimed to investigate the association between morphokinetic time-lapse parameters and obstetrical and perinatal complications.

METHODS

A cohort study reviewing fertility and delivery files of all singletone births from IVF patients whose embryos were cultured in a time-lapse monitoring system and had a single fresh embryo transfer at our center between 2013-2019. We conducted multiple comparisons between complicated and uncomplicated pregnancies of each perinatal complication, including: gestational diabetes mellitus (GDM); small for gestational age (SGA); pre-eclamptic toxemia (PET); preterm labor < 37 weeks of gestation (PTL); and third stage of labor complications. A comparison between pregnancies with and without a composite outcome of placental complications including GDM, SGA, PET and PTL was also conducted. Baseline characteristics, treatment and morphokinetic parameters in complicated and uncomplicated gestations were compared. Logistic regression analysis was utilized to adjust results for potential confounders.

RESULTS

One hundred seventy-six single embryo transfers resulted in 176 live births. Morphokinetic time-lapse parameters were similar between the groups, except for a shorter time to full blastulation in the SGA group (tB-tPNf = 75.5 ± 1.3 h vs. 79.5 ± 4.8 in the non-SGA group, p < 0.001), and shorter third cell cycle duration in the PET group (CC3 = 12.4 ± 1.1 h vs. 13.6 ± 2.9 in the non-PET group, p = 0.02). On multivariate regression analysis, none of the morphokinetic parameters were found to be significantly correlated with any of the perinatal complications.

CONCLUSION

Time-lapse morphokinetic parameters of the embryo transferred are not associated with adverse obstetric and perinatal outcomes.

Third-Stage Complications Among In Vitro Fertilization Pregnancies: An Observational Study

OBJECTIVE

This study aimed to determine the third-stage complications and their risk factors in in vitro fertilization (IVF) pregnancies.

METHODS

This prospective observational study was conducted from March 2022 to November 2023 at a tertiary care university hospital in South India. We included a total of 217 women following IVF conception, and details of the third-stage labor complications were documented and expressed as the frequency with percentage. The risk factors were analyzed using a logistic regression model.

RESULTS

Among 217 participants, 51 (23.5%) had third-stage complications. Postpartum hemorrhage (PPH) was the most common, complicating 20% of the deliveries. Multiple gestations (adjusted odds ratio (aOR) 2.7, 95% confidence interval (CI) 1.03-7.46, p = 0.04), operative vaginal delivery (aOR 57, 95% CI 4.2-770, p = 0.002), and emergency cesarean section (aOR 14.8, 95% CI 1.3-160.5, p = 0.026) were the risk factors for PPH. Intrapartum infection was found to be associated with a risk for the retained placenta (aOR 8, 95% CI 1.37-46.4, p = 0.02) and adherent placenta (aOR 6.06, 95% CI 1.07-34.3, p = 0.04). Assisted reproductive technology (ART)-related factors were not found to be significantly associated with third-stage complications.

CONCLUSION

There is a risk of third-stage complications, especially postpartum hemorrhage, among IVF pregnancies. The type of embryo transfer was not associated with third-stage complications.

Risk factors for relaparotomy after a cesarean delivery: a case-control study

BACKGROUND

Relaparotomy following a cesarean delivery (CD) is an infrequent complication, with inconsistency regarding risk factors and indications for its occurrence. We therefore aimed to determine risk factors and indications for a relaparotomy following a CD at a single large tertiary center.

METHODS

A retrospective case-control single-center study (2013-2023). We identified all women who had a relaparotomy up to six weeks following a CD (study group). Maternal characteristics, obstetrical and surgical data were compared to a control group in a 1:2 ratio. Controls were women with a CD before and immediately after each case in the study group, who did not undergo a relaparotomy. Included were CDs occurring after 24 gestational weeks. CD performed at different centers and indications for repeat surgery unrelated to the primary surgery (e.g., appendicitis) were excluded. Logistic regression was used to adjust for potential confounders.

RESULTS

During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD, and 130 patients (0.46%) underwent a relaparotomy. Relaparotomies following a CD occurred during the first 24 h, the first week, and beyond the first week, in 59.2%, 33.1%, and 7.7% of cases, respectively. In the multivariable logistic regression analysis, relaparotomy was significantly associated with Mullerian anomalies (aOR 3.33, 95%CI 1.08-10.24, p = 0.036); uterine fibroids (aOR 3.17, 95%CI 1.11-9.05,p = 0.031); multiple pregnancy (aOR 4.1, 95%CI 1.43-11.79,p = 0.009); hypertensive disorders of pregnancy (aOR 3.46, 95%CI 1.29-9.3,p = 0.014); CD during the second stage of labor (aOR 2.54, 95%CI 1.15-5.88, p = 0.029); complications during CD (aOR 1.62, 95%CI 1.09-3.21,p = 0.045); and excessive bleeding during CD or implementation of bleeding control measures (use of tranexamic acid, a hemostatic agent, or a surgical drain) (aOR 2.23, 95%CI 1.29-4.12,p = 0.012). Indications for relaparotomy differed depending on the time elapsed from the CD, with suspected intra-abdominal bleeding (36.1%) emerging as the primary indication within the initial 24 h.

CONCLUSION

We detected several pregnancy, intrapartum, and intra-operative risk factors for the need for relaparotomy following a CD. Practitioners may utilize these findings to proactively identify women at risk, thereby potentially reducing their associated morbidity.

Risk factors for retained placenta in a first pregnancy-A clinical trial

OBJECTIVE

To evaluate potential risk factors for retained placenta in a first pregnancy.

METHOD

This retrospective case-control study included all primigravida with a singleton, live, vaginal birth at 24 weeks or later, at a tertiary hospital, 2014-2020. The cohort was divided into those with retained placenta versus controls. Retained placenta was defined as the need for manual extraction of the placenta or portions of it, immediately postpartum. Maternal and delivery characteristics, and obstetric and neonatal adverse outcomes, were compared between groups. Multivariable regression was performed to reveal potential risk factors for retained placenta.

RESULTS

Among 10 796 women, 435 (4.0%) had retained placenta and 10 361 (96.0%) controls did not. Multivariable logistic regression revealed nine potential risk factors for retained placenta: abruption (adjusted odds ratio [aOR] 3.58, 95% confidence interval [CI] 2.36-5.43), hypertensive disorders (aOR 1.74, 95% CI 1.17-2.57), prematurity (<37 weeks, aOR 1.63, 95% CI 1.13-2.35), maternal age older than 30 years (aOR 1.55, 95% CI 1.27-1.90), intrapartum fever (aOR 1.48, 95% CI 1.03-2.11), lateral placentation (aOR 1.39, 95% CI 1.01-1.91), oxytocin administration (aOR 1.39, 95% CI 1.11-1.74), diabetes mellitus (aOR 1.35, 95% CI 1.01-1.79), and female fetus (aOR 1.26, 95% CI 1.03-1.53).

CONCLUSION

Retained placentas in first deliveries are associated with obstetric risk factors, some of which could be related to abnormal placentation.

How does IVF conception affect pregnancy complications in an older cohort of women, at least 38 years of age? Study of a population database

PURPOSE

To compare perinatal outcomes in in-vitro fertilization (IVF) pregnancies versus spontaneous conceptions in woman of advanced maternal age (AMA), and to evaluate the effect of increasing age on IVF pregnancies' outcomes.

METHODS

A retrospective population-based cohort study including pregnant women who delivered between 2008-2014 in the US. First, we included women aged 38-43 years and compared those with IVF conceptions (cases) to women with spontaneous conceptions (controls). Thereafter, we compared IVF pregnancies in women aged 38-43 years to IVF pregnancies at < 38 years of age. Multivariate logistic regression was performed to compare both groups regarding pregnancy,delivery, and neonatal outcomes after adjusting for plausible confounders.

RESULTS

Three hundred nine thousand five hundred sixty-seven pregnant women aged 38-43 years were identified, with 2,762 composing the IVF group, and 306,805 composing the control group. After adjusting for confounders, the IVF group had a higher risk of several adverse obstetrical outcomes, including hypertensive disorders of pregnancy (aOR 1.31,95%CI 1.06-1.62), gestational diabetes (aOR 1.26,95%CI 1.13-1.41),preterm delivery (aOR 1.45,95%CI 1.16-1.81), cesarean section (CS) (aOR 1.84,95%CI 1.55- 2.19),postpartum hemorrhage (aOR 1.68,95%CI 1.27- 2.24), and maternal infection (aOR 1.90,95%CI 1.31-2.77), with comparable neonatal outcomes. For the second analysis, 9712 IVF pregnancies were included (n = 6950 < 38 years, and n = 2762 ≥ 38 years). Women ≥ 38 years who underwent IVF were more likely to experience hypertensive disorders of pregnancy, CS, hysterectomy and blood transfusion, with comparable neonatal outcomes.

CONCLUSION

IVF AMA pregnancies have a significant increase in myriad perinatal complications compared to spontaneous AMA pregnancies. Younger women undergoing IVF have mildly less complications than their older counterparts.

Programmed frozen embryo transfer cycles are associated with a higher risk of abnormal placental development: a retrospective cohort study of singleton live births

Introduction

Abnormal placental development can lead to adverse outcomes for both mother and fetus. The effect of different types of endometrium preparation regimens of frozen-thawed cycles on the placental development features associated with the perinatal outcomes remains unclear. Hence, we conducted a retrospective cohort study to assess the impact of specific endometrial preparation regimens on placenta-mediated pregnancy complications in singleton live births.

Methods

A retrospective cohort study was conducted evaluating data of all singleton live births both conceived naturally or by in vitro fertilization (IVF) therapy from 2018 to 2020 at our hospital. Two exposed groups of frozen-thawed embryo transfer (FET) were created by the endometrium preparation regimen as the modified natural cycles (mNC) and the programmed cycles. The nonexposed group was the singleton pregnancies conceived naturally. The obstetrical and perinatal outcomes were compared among the three groups using multivariate analysis to adjust the results for determinants potentially associated with the abnormal placental development.

Results

A total of 2186 pregnant women with singleton live births were included in our final analysis and were divided into three groups as naturally conceived group (n=1334), mNC-FETs group (n=217) and programmed-FETs group(n=635). After adjusting for maternal age and parity, no significant difference was observed on the risk of placental disorders between mNC-FET cycles and natural conceived pregnancies (aOR 1.16; 95%CI 1.31-7.01), while programmed-FET cycles were associated with a higher occurrence of placental disorders (aOR 5.36; 95%CI 3.63-8.05). Using the mNC-FET group as a reference and adjusting for confounders such as maternal age, parity, endometrial thickness, and number of embryos transferred, we found that the main manifestation of abnormal placentation in programmed FET cycles was abnormal placental attachment, including placental adhesion and placenta increta (aOR 2.50, 95%CI 1.36-4.90). The dysfunction of placentation in programmed-FET cycles was independently associated with the type of infertility, the total dose of Femostone and thinner endometrium. Additionally, placental disorders in the programmed-FET group were associated with higher rate of preeclampsia, postpartum hemorrhage and Cesarean section.

Conclusion

Our retrospective study revealed that the programmed-FET has a substantial impact on placental development, resulting in a higher incidence of preeclampsia, postpartum hemorrhage and Cesarean section. These findings have significant implications on clinical decision-making.

Postpartum hemorrhage among twin pregnancies - Medically assisted versus spontaneously conceived

INTRODUCTION

In singleton pregnancies, an increased risk of Postpartum hemorrhage (PPH) have been linked with assisted reproductive technology (ART) and abnormal placentation. It is unknown wheather such association exists in twin pregnancies conceived by Medically assisted reproduction (MAR). The aim of the current study was to compare maternal blood loss among twin pregnancies conceived by different types of MAR treatments to spontaneously conceived twins and to identify the cycle characteristics if an association exits.

METHODS

Retrospective study conducted on data collected between 2011 and 2020. The study cohort included all twin pregnancies conceived by MAR and born at our institution. Controls were spontaneously conceived twins matched for maternal age on a 1:2 (study: controls) ratio.

RESULTS

Overall 113 MAR twin births categorized into three groups; 25 ovulation induction, 59 fresh ART, 29 frozen-thawed ART cycles, and 226 controls were included. The incidence of PPH was higher among MAR twin pregnancies (5.3%) compared to the controls (4%). The highest incidence was observed among women in the frozen-thawed group (13.8%) which differed significantly compared with the controls (p = 0.024). A significant difference was also observed in the mean decrease of postpartum hemoglobin levels between these two groups (2.13 g/dL versus 1.3 g/dL respectively, p = 0.002). Blood transfusion was nearly 2.5 times more common in the frozen-thawed group (3.4%) compared to the control group (1.3%).

DISCUSSION

The present study demonstrates that frozen embryo transfer (FET) ART-conceived twin pregnancies are associated with a markedly increased rate of PPH compared to spontaneously conceived twins.

The effect of oestrogen dose and duration in programmed frozen cycles on obstetric outcomes and placental findings

RESEARCH QUESTION

Does programmed frozen embryo transfer (FET) with high-dose oestrogen affect obstetric outcomes and placental findings?

DESIGN

A retrospective cohort of live singleton deliveries at a single institution between 2009 and 2017, including deliveries attained by IVF with programmed FET; oocyte recipients were excluded. High-dose oestrogen was defined as a daily dose >6 mg throughout treatment. All placentas were evaluated regardless of complication status and the Amsterdam classification was used to analyse findings.

RESULTS

A total of 57 deliveries in the high-dose oestrogen group were compared with 274 controls. The high-dose oestrogen group displayed significantly longer duration of oestrogen treatment (18.8 ± 4.9 versus 13.3 ± 2.7 days, P < 0.001), total cumulative oestrogen dose (149.7 ± 46.1 versus 80.3 ± 16.8 mg, P < 0.001) and lower endometrial thickness (8.5 ± 1.4 versus 9.8 ± 1.7 mm, P < 0.001). After adjustment for confounders, higher dose oestrogen was found to be associated with a lower average birthweight (coefficient -252.4 g, 95% confidence interval [CI] -483.5 to -21.2), a higher rate of low-birthweight neonates (adjusted odds ratio [aOR] 4.88, 95% CI 1.05 to 22.57), bilobated placentas (aOR 3.36, 95% CI 1.04 to 10.89), accessory lobes (aOR 8.74, 95% CI 1.24 to 61.5), accelerated villous maturation (aOR 2.06, 95% CI 1.09 to 3.87), retroplacental haematoma (aOR 5.39, 95% CI 1.11 to 26.13) and maternal malperfusion lesions (aOR 1.46, 95% CI 1.04 to 2.05).

CONCLUSION

A higher daily oestrogen dose in programmed FET is associated with low birthweight and placental changes, although this may relate to altered endometrial properties and not to the treatment itself.

PGT pregnancies have a similar risk for post-partum complications as naturally conceived pregnancies

RESEARCH QUESTION

Do preimplantation genetic testing (PGT) pregnancies have higher post-partum complications compared with naturally conceived pregnancies?

DESIGN

Retrospective cohort study conducted in 2008-2020 at the Shaare Zedek Medical Center (SZMC), including all patients aged 18-45 years old who conceived following PGT with a singleton live birth >24 weeks. Data were collected from computerized hospital databases and patient files. There were two control groups: (i) pregnancies following IVF-ICSI (intracytoplasmic sperm injection); (ii) four neighbourhood controls for each case delivery (two women delivered before and two after) of women with naturally conceived pregnancies.

RESULTS

Overall, 120 PGT, 779 IVF-ICSI and 3507 naturally conceived deliveries were included. Demographic variables were similar apart from slightly higher age in the PGT (P = 0.003) and ICSI (P = 0.002) groups (31.07 ± 4.38 PGT, 31.66 ± 5.03 ICSI, 28.77 ± 5.72 naturally conceived). Composite post-partum placental-related complications (manual lysis of placenta, revision of uterine cavity, haemoglobin drop ≥3 g/dl, post-partum haemorrhage, need for blood transfusion) were more prevalent in both the PGT and IVF-ICSI groups as opposed to naturally conceived (20.0% versus 18.9% versus 10.3%, respectively, P < 0.001, P = 0.007). In a multivariate regression model PGT was not found to be independently associated with composite post-partum placental-related complications (adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 0.83-2.15), while IVF-ICSI pregnancies had increased risk (aOR 1.52, 95% CI 1.20-1.97) compared with natural conception. No difference was found between fresh and frozen cycles or between day 3 and day 5 embryo transfer.

CONCLUSIONS

PGT pregnancies have a comparable risk of post-partum placental-related complications to naturally conceived pregnancies, unlike IVF-ICSI pregnancies. It is possible that infertility itself is the main mediator for post-partum complications in IVF-ICSI pregnancies.

Placental histology following assisted hatching in fresh transfer cycles

PURPOSE

To assess placental histological findings following assisted hatching in fresh transfer in vitro fertilization cycles.

METHODS

Evaluation of a historic cohort of live singleton deliveries after fresh embryo transfer (ET) at a single university medical center between 2009 and 2017. We compared perinatal outcomes and placental histology in cases where assisted hatching was performed prior to ET (AH group) and cases with no AH (no AH group).

RESULTS

Overall, 166 deliveries following AH were compared to 494 deliveries with no AH. Patients' demographics were similar between the groups. Median antral follicle count was significantly lower in the AH group, median 11 (range 1-50) vs. 16 (range 1-80), p < 0.001, and the primary indication for infertility treatment significantly more often diminished ovarian reserve (p < 0.001). Cycle characteristics in the AH group included a higher gonadotropin dose employed, and a lower rate of single and blastocyte transfer. Pregnancies following AH were associated with less low-lying placentas, 0.6% vs. 6.2%, p = 0.001, and comparable for other perinatal outcomes. After adjusting for confounders, the rate of bilobated placentas was higher following AH, aOR 7.10, 95% CI 1.50-33.51. The rate of perivillous depositions was higher with AH, aOR, 95% CI 3.18, 1.46-6.93, and the rate of chorangiosis lower in this group, aOR, 95% CI 0.32, 0.11-0.93. The overall rate of vascular lesions was similar between the groups.

CONCLUSION

Pregnancies following AH are notable for a lower rate of placenta previa, yet a higher rate of bilobated placentas and perivillous depositions and less chorangiosis, warranting further investigation.