Recurrent Risk of Adverse Pregnancy Outcome

Excess maternal mortality in Brazil: Regional inequalities and trajectories during the COVID-19 epidemic

BACKGROUND

The COVID-19 pandemic has exceeded 6 million known disease-related deaths and there is evidence of an increase in maternal deaths, especially in low- and middle-income countries. We aimed to estimate excess maternal deaths in Brazil and its macroregions as well as their trajectories in the first 15 months of the COVID-19 epidemic.

METHODS

This study evaluated maternal deaths from the Mortality Information System of the Ministry of Health, with excess deaths being assessed between March 2020 and May 2021 by quasi-Poisson generalized additive models adjusted for overdispersion. Observed deaths were compared to deaths expected without the pandemic, accompanied by 95% confidence intervals according to region, age group, and trimester of occurrence. Analyses were conducted in R version 3.6.1 and RStudio version 1.2.1335.

RESULTS

There were 3,291 notified maternal deaths during the study period, resulting in a 70% excess of deaths regardless of region, while in the North, Northeast, South and Southeast regions, excess deaths occurred regardless of age group. Excess deaths occurred in the March-May 2021 trimester regardless of region and age group. Excess deaths were observed in the Southeast region for the 25-36-year-old age group regardless of the trimester assessed, and in the North, Central-West and South regions, the only period in which excess deaths were not observed was September-November 2020. Excess deaths regardless of trimester were observed in the 37-49-year-old age group in the North region, and the South region displayed explosive behavior from March-May 2021, with a 375% excess of deaths.

CONCLUSIONS

Excess maternal deaths, with geographically heterogenous trajectories and consistently high patterns at the time of the epidemic's greatest impact, reflect not only the previous effect of socioeconomic inequalities and of limited access to maternal health services, but most of all the precarious management of Brazil's health crisis.

Anti-phospholipid antibodies and reproductive failures

Anti-phospholipid syndrome (APS) recapitulates the link between autoimmunity and pregnancy failure: Acquired anti-phospholipid antibodies (aPL) play a pathogenic role in pregnancy complications. The diagnosis of obstetric APS can easily be pursued when women present with laboratory and clinical features fulfilling the international classification criteria. Standard therapeutic approach to obstetric APS consists in the association of anti-platelet agents and anticoagulants. Most patients achieve a live birth thanks to conventional treatment; however, approximately 20% fail to respond and are managed with additional therapeutic tools added on the top of conventional treatment. Surely, a refinement of risk stratification tools would allow early identification of high-risk pregnancies that warrant tailored treatment. In real life, obstetricians and rheumatologists face complex diagnostic scenarios including women with pregnancy morbidities other than those mentioned in classification criteria such as one or two early losses and premature birth after 34 weeks due to preeclampsia or placental insufficiency, women with low-titer aPL not fulfilling criteria laboratory requirements, women with positive non-criteria aPL, asymptomatic aPL carriers, and infertile women found to be aPL-positive. This review focuses on some of the several unanswered questions related to diagnostic, prognostic, and therapeutic aspects in obstetric APS.

Interpregnancy Interval and Childbirth Outcomes in California, 2007-2009

Objectives The goals of interconception care are to optimize women's health and encourage adequate spacing between pregnancies. Our study calculated trends in interpregnancy interval (IPI) patterns and measured the association of differing intervals with birth outcomes in California. Methods Women with "non-first birth" deliveries in California hospitals from 2007 to 2009 were identified in a linked birth certificate and patient discharge dataset and divided into three IPI birth categories: <6, 6-17, and 18-50 months. Trends over the study period were tested using the Cochran-Armitage two-sided linear trend test. Chi square tests were used to test the association between IPI and patient characteristics and selected singleton adverse birth outcomes. Results Of 645,529 deliveries identified as non-first births, 5.6 % had an IPI <6 months, 33.1 % had an IPI of 6-17 months, and 61.3 % had an IPI of 18-50 months. The prevalence of IPI <6 months declined over the 3-year period (5.8 % in 2007 to 5.3 % in 2009, trend p value <0.0001).Women with an IPI <6 months had a significantly higher prevalence of early preterm birth (<34 weeks), low birthweight (<2500 g), neonatal complications, neonatal death and severe maternal complications than women with a 6-17 month or 18-50 month IPI (p < 0.005). Comparing those with a 6-17 month vs 18-50 month IPI, there were increased early preterm births and decreased maternal complications, complicated delivery, and stillbirth/intrauterine fetal deaths among those with a shorter IPI. Conclusions for Practice In California, women with an IPI <6 months were at increased risk for several birth outcomes, including composite morbidity measures.

Request and fulfillment of postpartum tubal ligation in patients after high-risk pregnancy

OBJECTIVE

Female sterilization is one of the most prevalent methods of contraception in the United States. Prior studies have shown that nearly half of postpartum tubal ligation (PPTL) requests go unfulfilled. This study seeks to establish whether obstetric or medical risk status influences patients' request for or subsequent completion of PPTL.

METHODS

This study was a retrospective cohort study of women delivering at a university hospital in 2009-2010 who received prenatal care in the faculty and resident clinics. High-risk status was defined by Society for Maternal-Fetal Medicine guidelines. Documentation of contraceptive plan and administration of contraceptive methods was abstracted from patient records. Subsequent pregnancies through March 1, 2013, were abstracted.

RESULTS

Of 3063 participants (2048 low risk and 1015 high risk), 231 requested PPTL (7.5%). This was more likely among high-risk patients than low-risk patients (10.0% vs. 6.3%, p<.001), those with public insurance (13.8% vs. 3.2%, p<.001) and those with an unintended index pregnancy (13.8% vs. 4.1%, p<.001). Of the patients requesting PPTL, 118 (51.1%) underwent the procedure immediately postpartum. Completion was not associated with high-risk status (54.0%), or with race, insurance status or parity. Among 113 women with an unfulfilled PPTL request, there were 17 subsequent pregnancies (15.0%) during the 27 months of follow-up.

CONCLUSIONS

Though women with high-risk pregnancies were more likely to request PPTL, they were not more likely to complete the procedure. Over one third of high-risk patients' requests were unfulfilled, indicating that significant barriers may remain.

IMPLICATIONS

Though women with high-risk pregnancies were more likely to request PPTL, they were not more likely to complete the procedure. Providers should consider these procedures urgent, especially in high-risk women, and advocate for their patients' access to this procedure.

EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome

Objectives

Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS).

Methods

Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus.

Results

Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease.

Conclusions

Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.

Placental expression of VEGF is increased in pregnancies with hydatidiform mole: possible association with developing very early onset preeclampsia

BACKGROUND

Hydatidiform mole is an abnormal pregnancy with over-proliferation of the placenta, which causes the dysfunction of placenta. Although more than 80% of hydatidiform moles are benign with good outcome, hydatidiform moles are associated with developing very early onset preeclampsia. However the association between hydatidiform mole and very early onset preeclampsia is unclear. Preeclampsia is associated with altered levels of angiogenic factors, like vascular endothelial growth factor (VEGF) and soluble endoglin.

AIM

The aim of this study is to investigate the levels of VEGF and endoglin in hydatidiform molar placenta.

STUDY DESIGN

21 placentas from complete hydatidiform mole, 9 placentas from partial hydatidiform mole and 18 placentas from gestation matched placenta were collected in this study.

SUBJECTS

The subjects of this study are human placentas.

OUTCOME MEASURES

The protein levels and mRNA levels of VEGF and endoglin were measured using immunohistochemistry, western blotting and real time PCR.

RESULTS

The protein levels of VEGF measured by immunohistochemistry and western blotting were significant increased, as well as mRNA levels of VEGF quantified by real time PCR in hydatidiform molar placenta in comparison to normal controls. There was no difference in the protein levels of VEGF between complete and partial hydatidiform moles. In contrast, the levels of protein and mRNA in endoglin were no difference between hydatidiform molar placenta and normal controls.

CONCLUSION

In this study our data show that hydatidiform moles produce more VEGF than normal early pregnant placenta. The increased levels of angiogenic factors VEGF in hydatidiform moles may link to the mechanism of developing very early onset preeclampsia.

The role of prenatal care in recurrent preterm birth

OBJECTIVE

To assess the independent role of prenatal care in preventing recurrent preterm delivery (<37 weeks gestation) and in reducing adverse pregnancy outcomes in recurrent preterm delivery.

STUDY DESIGN

A population-based retrospective cohort study. Participants were 1470 Bedouin women in Southern Israel who at their first delivery (parity 1) gave birth preterm (<37 weeks) and had a consecutive birth (parity 2) at Soroka University Medical Center, the only birth hospital in the area. Multiple gestations were excluded.

RESULTS

The incidence of recurrent preterm delivery was 24.6% (362/1470) and it was not associated with having had prenatal care in the second pregnancy. In a multivariable logistic analysis, young maternal age, pregnancy complications and fetal abnormalities in the second pregnancy, as well as previous miscarriages, short inter-pregnancy interval, and length of gestation in the first pregnancy were significantly associated with recurrence. The incidence of adverse pregnancy outcomes (perinatal mortality, small for gestational age, gestational age <34 weeks, Apgar ≤ 7) in recurrent preterm delivery was 44.8% (162/362). Lack of prenatal care was significantly associated with adverse pregnancy outcomes (odds ratio: 4.03; 95% confidence interval: 2.04-7.97) in a multivariable logistic analysis controlling for all variables significantly associated with adverse pregnancy outcomes at the univariate analysis.

CONCLUSIONS

Prenatal care may reduce the risk of adverse pregnancy outcomes in recurrent preterm delivery, even if recurrence cannot be prevented. It is therefore important that quality prenatal care is accessible to women who had a preterm delivery in the past.

The role of fetal autopsy and placental examination in the causes of fetal death: a retrospective study of 132 cases of stillbirths

PURPOSE

To investigate the most plausible cause of stillbirth by evaluating clinical records and postmortem examination findings including placental analysis.

METHODS

A retrospective cohort study concerning 132 stillbirths from 124 pregnancies occurred in the Mother-Infant Department of the University Hospital of Modena, Italy, from January 2000 to December 2004. Collected data were reviewed and classified according to the Gardosi ReCoDe system.

RESULTS

A reasonable cause of fetal death was identified in 99/124 pregnancies (79.84%). No associated relevant factors were disclosed in 25 fetuses (20.16%) classified as unexplained stillbirths. A succeeding scrupulous analysis of the placenta and an accurate clinical record review were useful to detect other conditions in 82 cases, including 5 cases of unexplained stillbirth. The major relevant conditions associated to stillbirths were feto-placental infection especially in the early fetal gestation age, under the 24th week of gestation, and placental insufficiency occurred both in early and late gestation age fetuses and mainly associated with a IUGR (<10th customized percentile). The main frequent secondary conditions were represented by placental anomalies including cluster of avascular villi with stromal fibrosis associated to thrombosis in minor and/or major vessel(s). Through the further analysis of the placenta, we were able to reduce the unexplained stillbirth rate from 20.16 to 15%.

CONCLUSION

Accurate fetal autopsy and placental examination related to meticulous clinical collecting data are requisites in the valuation of stillbirth and could play an important role in reduction of unexplained stillbirth rate.

Recurring complications in second pregnancy

OBJECTIVE

To clarify the obstetric consequences in a second pregnancy after a first singleton pregnancy complicated by spontaneous preterm delivery or preeclampsia and stratified by the variation in fetal growth.

METHODS

In a registry-based cohort study, we identified women having a first and second singleton delivery in Denmark from 1978 to 2007 (n=536,419). The exposures and endpoints were preterm delivery, preeclampsia, fetal growth, placental abruption, and stillbirth after 20 weeks of gestation. We used chi and t test to compare differences between incidences on first and second pregnancies.

RESULTS

Compared with a spontaneous first delivery at term, a delivery between 32 and 36 weeks of gestation increased the risk of preterm delivery in the second pregnancy from 2.7% to 14.7% (odds ratio [OR] 6.12, 95% confidence interval [CI] 5.84-6.42) and the risk of preeclampsia from 1.1% to 1.8% (OR 1.60, 95% CI 1.41-1.81); a delivery before 28 weeks increased the risk of a second preterm delivery to 26.0% (OR 13.1, 95% CI 10.8-15.9) and a second pregnancy with preeclampsia to 3.2% (OR 2.96, 95% CI 1.80-4.88). A first delivery in preeclamptic women between 32 and 36 weeks, compared with delivery after 37 weeks, increased the risk of preeclampsia in a second pregnancy from 14.1% to 25.3% (OR 2.08, 95% CI 1.87-2.31) and a small for gestational age infant from 3.1% to 9.6% (OR 2.82, 95% CI 2.38-3.35). Compared with the mean, fetal growth 2 to 3 standard deviations below mean in the first pregnancy increased the risk of preeclampsia from 1.1% to 1.8% (OR 1.62, 95% CI 1.34-1.96) in the second pregnancy.

CONCLUSION

Spontaneous preterm delivery, preeclampsia, and fetal growth deviation tend to recur and predispose to each other in a second pregnancy. Severe complications further increase these risks.

LEVEL OF EVIDENCE

II.