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Wang J, Li J, Yang Z, Duan Y, Li F, Zhou P, Lai J. Trajectory of gestational weight gain is related to birthweight: The TAWS cohort study in China. MATERNAL & CHILD NUTRITION 2024; 20:e13578. [PMID: 38576191 PMCID: PMC11168369 DOI: 10.1111/mcn.13578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/20/2023] [Accepted: 09/29/2023] [Indexed: 04/06/2024]
Abstract
Few studies have reported the timing and amount of gestational weight gain (GWG) to prevent large-for-gestational-age (LGA) or small-for-gestational-age (SGA). This study aimed to evaluate the association of GWG velocity in each trimester with LGA or SGA based on data from the Taicang and Wuqiang cohort study (TAWS, n = 2008). We used a linear mixed model to evaluate the association of trimester-specific GWG velocity with birthweight categories and stratified by prepregnancy body mass index category and parity. For normal-weight pregnant women, mothers with LGA births had higher GWG velocities than mothers with appropriate-for-gestational-age (AGA) births in the first trimester (0.108 vs. 0.031 kg/week, p < 0.01), second trimester (0.755 vs. 0.631 kg/week, p < 0.01) and third trimester (0.664 vs. 0.594 kg/week, p < 0.01); in contrast, mothers with SGA births had lower GWG velocities than mothers with AGA births in the second trimester (0.528 vs. 0.631 kg/week, p < 0.01) and third trimester (0.541 vs. 0.594 kg/week, p < 0.01). For normal-weight pregnant women with AGA births, multiparous women had lower GWG velocities than primiparous women in the second (0.602 vs. 0.643 kg/week, p < 0.01) and third trimesters (0.553 vs. 0.606 kg/week, p < 0.01). Therefore, for normal-weight women, LGA prevention would begin in early pregnancy and continue until delivery and the second and third trimesters may be critical periods for preventing SGA; in addition, among normal-weight pregnant women with AGA births, multiparous women tend to have lower weight gain velocities than primiparous women.
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Affiliation(s)
- Jie Wang
- National Institute for Nutrition and HealthChinese Center for Disease Control and PreventionBeijingChina
- Key Laboratory of Human Milk ScienceChinese Center for Disease Control and PreventionBeijingChina
- Key Laboratory of Trace Element NutritionNational Health Commission of ChinaBeijingChina
| | - Jun Li
- Taicang Service Center for Mother and Child Health and Family Planning, TaicangSuzhouChina
| | - Zhenyu Yang
- National Institute for Nutrition and HealthChinese Center for Disease Control and PreventionBeijingChina
- Key Laboratory of Human Milk ScienceChinese Center for Disease Control and PreventionBeijingChina
- Key Laboratory of Trace Element NutritionNational Health Commission of ChinaBeijingChina
| | - Yifan Duan
- National Institute for Nutrition and HealthChinese Center for Disease Control and PreventionBeijingChina
- Key Laboratory of Human Milk ScienceChinese Center for Disease Control and PreventionBeijingChina
- Key Laboratory of Trace Element NutritionNational Health Commission of ChinaBeijingChina
| | - Fang Li
- Taicang Service Center for Mother and Child Health and Family Planning, TaicangSuzhouChina
| | - Pinjiao Zhou
- Taicang Service Center for Mother and Child Health and Family Planning, TaicangSuzhouChina
| | - Jianqiang Lai
- National Institute for Nutrition and HealthChinese Center for Disease Control and PreventionBeijingChina
- Key Laboratory of Human Milk ScienceChinese Center for Disease Control and PreventionBeijingChina
- Key Laboratory of Trace Element NutritionNational Health Commission of ChinaBeijingChina
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Burt E, Davies MC, Yasmin E, Cameron-Pimblett A, Talaulikar V, La Rosa C, Clarke SA, Conway GS. Fertility and pregnancy outcomes in women with Turner syndrome: A single centre experience. Clin Endocrinol (Oxf) 2024; 101:51-59. [PMID: 38798185 DOI: 10.1111/cen.15078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 04/29/2024] [Accepted: 05/12/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Many women with Turner syndrome (TS) will consider fertility options and pregnancy. We wished to examine the fertility and pregnancy outcomes in women with TS undergoing oocyte donation (OD) treatment or spontaneous pregnancy in a large single-centre cohort. General population reference data or data from those with idiopathic premature ovarian insufficiency were used as comparators. DESIGN A retrospective single-centre cross-sectional study. PATIENTS AND MEASUREMENTS Seventy-four women with TS underwent OD treatment with a total of 105 pregnancies, and 31 women with TS had 71 spontaneous conceptions. Fertility outcomes included clinical pregnancy and live birth rate. Pregnancy outcomes included miscarriage rate, prevalence of hypertension, gestational diabetes, lower segment caesarean section (LSCS), small for gestational age (SGA), prematurity and vertical transmission of TS. RESULTS In those with TS, OD pregnancies were associated with increased rates of LSCS and SGA compared to spontaneous pregnancies; LSCS (OR: 4.19, 95% CI: 1.6-10.8, p = .003) and SGA (OR: 2.92, 95% CI: 1.02-8.38, p = .04). There were no recorded cardiac events but 5 (17.2%) cases of vertical transmissions of TS in daughters were identified. OD in those with TS was associated with a lower live birth rate per cycle started (OR: 0.53, 95% CI: 0.34-0.84, p = .008) and a higher rate of miscarriage compared to women with POI (40% vs. 26.2%, p = .04). CONCLUSIONS We show that pregnancy in women with TS, whether OD or spontaneously conceived, carries obstetric risks, and therefore, women with TS, considering pregnancy, should receive comprehensive pre-pregnancy counselling and optimal obstetric care.
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Affiliation(s)
- Elizabeth Burt
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Melanie C Davies
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Ephia Yasmin
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | | | - Vikram Talaulikar
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Clementina La Rosa
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Sophie A Clarke
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Gerard S Conway
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
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Reinolds EE, Tsiartas P, Hadziosmanovic N, Rodriguez-Wallberg KA. In Vitro Fertilization/Intracytoplasmic Sperm Injection with Autologous Oocytes in Healthy Women of Advanced Maternal Age: A Comparative Study Investigating Obstetric and Perinatal Outcomes Through Single Versus Double Embryo Transfer. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:512-521. [PMID: 39035141 PMCID: PMC11257112 DOI: 10.1089/whr.2023.0178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 07/23/2024]
Abstract
Introduction The aim of this study was to assess whether the choice between double embryo transfer (DET) and single embryo transfer (SET) in healthy women of advanced maternal age (AMA) was associated with an increased risk of adverse outcomes. Materials and Methods Healthy women aged 39-40 years who achieved live birth after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment between 2009 and 2020 at Karolinska University Hospital, Stockholm in Sweden, were included in this prospective, single-center cohort study. Results A total of 310 women, who underwent IVF/ICSI treatments and achieved live births, were included in our analysis. Within this cohort, 78% of the women received SET, while 22% received DET. Nulliparity was common in both the SET (62.7%) and DET (85.3%) groups. Fresh embryo transfers were more prevalent in the DET group (91.2%) than in the SET group (31.1%). The rate of pregnancy-induced hypertension was higher in the SET group (8.3%) compared to the DET group (1.5%, p = 0.048). Furthermore, the DET group had a significantly higher rate of twin pregnancies (13.2%) compared to the SET group (0.4%). No statistically significant differences were observed in composite obstetric and perinatal complications between the SET and DET groups across all model estimates following different adjustments.Clinical Trial Registration number: ClinicalTrials.gov NTC04602962. Conclusions While DET was more common in nulliparous women and associated with a higher rate of twin pregnancies, our analysis did not reveal significant differences in adverse outcomes between the SET and DET groups after comprehensive adjustments. Our study suggests that in the absence of co-morbidities, meticulous patient selection coupled with comprehensive maternal care can potentially mitigate potential DET-associated risks in women of AMA.
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Affiliation(s)
- Ellen-Elena Reinolds
- Division of Gynecology and Reproduction, Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Södertälje Hospital, Stockholm, Sweden
| | - Panagiotis Tsiartas
- Nordic IVF Solna, Eugin Group, Solna, Sweden
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | | | - Kenny A. Rodriguez-Wallberg
- Division of Gynecology and Reproduction, Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Laboratory of Translational Fertility Preservation, Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
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Yin O, Coscia L, Constantinescu S, Moritz MJ, Afshar Y, Irani RA. Pregnancy after deceased donor vs living donor kidney transplant: associated obstetric and graft outcomes. Am J Obstet Gynecol 2024; 230:256.e1-256.e12. [PMID: 37595824 DOI: 10.1016/j.ajog.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/21/2023] [Accepted: 08/11/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Outside of pregnancy, recipients of a deceased donor kidney transplant experience worse graft and overall survival compared with recipients of a living donor kidney transplant. In pregnancy, it is unknown whether the type of donor graft modifies either graft health in the peripartum period or pregnancy outcomes. OBJECTIVE This study aimed to define characteristics and outcomes in pregnancy based on donor type in kidney transplant recipients. STUDY DESIGN This was a retrospective cohort study of adult kidney transplant recipients who received their graft between 2000 and 2019 with a subsequent pregnancy enrolled in the Transplant Pregnancy Registry International. The primary outcome was graft loss within 2 years of delivery. The secondary outcomes included severe maternal morbidity and neonatal composite morbidity. Univariate, multivariable logistic regression, and Cox proportional-hazards models were constructed for statistical analysis, with recipients of a living unrelated donor as the referent. RESULTS Overall, 638 pregnant patients after kidney transplant had pregnancy outcomes that met our inclusion criteria. Of these patients, 168 (26.3%) received a graft from a deceased donor, 310 (48.6%) received a graft from a living related donor, and 160 (25.1%) received a graft from a living unrelated donor. Recipients of a deceased donor were more likely to be nulliparous, have an unplanned pregnancy, and self-identify as non-White. Moreover, recipients of a deceased donor were more likely to experience urinary tract infections (deceased donor: 21.8%; living related donor: 10.1%; living unrelated donor: 20.6%; P=.018). Severe maternal morbidity (deceased donor: 3.4%; living related donor: 2.8%; living unrelated donor: 7.2%) and neonatal composite morbidity (deceased donor: 8.4%; living related donor: 17.1%; living unrelated donor: 14.4%) did not differ by donor type. Deceased donor transplant was associated with graft loss within 2 years of delivery (deceased donor: 6.7%; living related donor: 3.7%; living unrelated donor: 1.3%; adjusted odds ratio, 7.52; 95% confidence interval, 1.53-60.8) and long-term graft loss from transplant (adjusted hazard ratio, 2.08; 95% confidence interval, 1.10-3.95). CONCLUSION Although our study demonstrated an association between deceased donor transplant and graft loss after pregnancy, it did not provide evidence that pregnancy itself causes graft loss. Recipients of a deceased donor kidney transplant should not be discouraged from pursuing pregnancy based on their donor type, but these patients should undergo preconception counseling with a discussion of their individualized obstetrical and graft risks, close intrapartum monitoring for infection and hypertensive disease, and continued surveillance for at least 2 years after delivery with a multidisciplinary obstetrics and transplant team.
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Affiliation(s)
- Ophelia Yin
- Division of Maternal-Fetal Medicine and Reproductive Genetics, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Lisa Coscia
- Transplant Pregnancy Registry International (TPRI), Gift of Life Institute, Philadelphia, PA
| | - Serban Constantinescu
- Transplant Pregnancy Registry International (TPRI), Gift of Life Institute, Philadelphia, PA; Section of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Michael J Moritz
- Transplant Pregnancy Registry International (TPRI), Gift of Life Institute, Philadelphia, PA
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Molecular Biology Institute, University of California, Los Angeles, Los Angeles, CA
| | - Roxanna A Irani
- Division of Maternal-Fetal Medicine and Reproductive Genetics, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA.
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Feria-Ramirez C, Gonzalez-Sanz JD, Molina-Luque R, Molina-Recio G. Influence of gestational weight gain on the nutritional status of offspring at birth and at 5 years of age. Midwifery 2024; 129:103908. [PMID: 38142650 DOI: 10.1016/j.midw.2023.103908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 11/24/2023] [Accepted: 12/07/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE To determine the influence of pre-pregnancy maternal BMI and increases in maternal weight during pregnancy on perinatal and child outcomes at birth and at 5 years. RESEARCH DESIGN/SETTING A prospective cohort study was conducted between November 2016 and December 2021. The participants were a total of 115 women-child dyads, selected from among pregnant women receiving routine prenatal care in different health centres belonging to 2 health districts. Follow-ups were conducted with the women during pregnancy and with their children during the 10 days after birth and at 5 years. FINDINGS The total weight gain during pregnancy is influenced by an inadequate pre-pregnancy BMI (0.03; 95 % CI, 0.004 - 0.25; P=.001) and a greater increase in maternal BMI during the first and second term of pregnancy. A greater increase in BMI during pregnancy was associated with higher breastfeeding rates both in the short term (1.21; 95 % CI, 1.01-1.44; P = 0.04) and the long term (12 months: 1.30; 95 % CI, 1.02 - 1.67; P = 0.04; 24 months: 1.30; 95 % CI, 1.02 - 1.69; P = 0.04). No links were found between gains in maternal weight and the weight of the newborn, nor between maternal weight and/or pre-pregnancy BMI with the nutritional status of the child. KEY CONCLUSIONS After studying these results, it was concluded that promoting and implementing health and education policies focused on enhancing maternal nutritional status is essential to improve the nutritional status of children. IMPLICATIONS FOR PRACTICE Healthy gestational weight gain (GWG) is an important issue to be addressed by the midwife in primary care, both in the preconception period and throughout pregnancy. As a result, it is important that the midwife is trained and has the appropriate resources and tools to work with pregnant women individually and collectively. In addition to paying attention to overweight and obese pregnant women, the midwife should also pay attention to women with a normal BMI, as they seem to have greater difficulty in maintaining a healthy weight gain. Another line of intervention to be addressed is breastfeeding (BF), where the midwife should be the main point of reference from the beginning of this process, taking into account the relationship between BMI and BF.
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Affiliation(s)
- Carmen Feria-Ramirez
- Department of Nursing, Faculty of Nursing, University of Huelva, Avda. Tres de Marzo, s/n, Huelva 21071, Spain
| | - Juan D Gonzalez-Sanz
- Department of Nursing, Faculty of Nursing, University of Huelva, Avda. Tres de Marzo, s/n, Huelva 21071, Spain; COIDESO Research Center, University of Huelva, Avda. Tres de Marzo, s/n, Huelva 21071, Spain.
| | - Rafael Molina-Luque
- Lifestyles, Innovation and Health Research Associate Group, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Avda. Menéndez Pidal, s/n, Córdoba 14004, Spain; Department of Nursing, Pharmacology and Physiotherapy, Faculty of Nursing, University of Cordoba, Avda. Menéndez Pidal, s/n, Córdoba 14004, Spain
| | - Guillermo Molina-Recio
- Lifestyles, Innovation and Health Research Associate Group, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Avda. Menéndez Pidal, s/n, Córdoba 14004, Spain; Department of Nursing, Pharmacology and Physiotherapy, Faculty of Nursing, University of Cordoba, Avda. Menéndez Pidal, s/n, Córdoba 14004, Spain
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Li J, Li Y, Duan Y, Xiao X, Luo J, Luo M. Dose-response associations of maternal age with pregnancy complications and multimorbidity among nulliparas and multiparas: A multicentric retrospective cohort study in southern China. J Glob Health 2023; 13:04117. [PMID: 37767793 PMCID: PMC10535007 DOI: 10.7189/jogh.13.04117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
Background Advanced maternal age is becoming an increasingly common issue worldwide, presenting substantial health risks to pregnant women. However, dose-response associations of maternal age with a comprehensive range of pregnancy complications and their multimorbidity remain unclear. Methods We conducted a retrospective cohort study using data from China's National Maternal Near Miss Surveillance System for 2017-2018, including 18 hospitals in southern China. We included 135 274 pregnant women aged 15-54 years with a singleton birth. We used multivariable logistic regression and restricted cubic spline to examine dose-response associations between maternal age and various pregnancy complications, as well as multimorbidity. We employed the Apriori algorithm to mine the association rules among pregnancy complications and identify frequent multimorbidity patterns. Results We found three distinct patterns of associations between maternal age and specific pregnancy complications. In relation to increasing maternal age, gestational diabetes mellitus, preeclampsia, and gestational hypertension showed nonlinear increasing trends for both nulliparas and multiparas, as did multimorbidity in nulliparas. Conversely, we observed linear increasing trends for placental previa in both nulliparas and multiparas, placental abruption in nulliparas, and multimorbidity in multiparas. Infection and severe anaemia had an approximate J-shaped curve among nulliparas, while postpartum haemorrhage exhibited a similar curve in both nulliparas and multiparas. Advanced maternal age was linked to an elevated risk of multimorbidity during pregnancy or postpartum period, exhibiting more complicated patterns. The most common multimorbidity patterns in this age group were "preeclampsia + gestational diabetes mellitus", "gestational hypertension + gestational diabetes mellitus", "infection + gestational diabetes mellitus", and "placental previa + gestational diabetes mellitus". Conclusions Maternal age was associated with pregnancy complications and multimorbidity in three broad dose-response manners, including approximate J-shaped curves, as well as nonlinear and linear increasing trends, depending on the specific outcome and parity, which may suggest different underlying biological mechanisms. Women with advanced maternal age had a higher risk and more complicated patterns of multimorbidity during pregnancy or postpartum, suggesting that this group should be targeted for more intensive health care.
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Affiliation(s)
- Jingya Li
- Department of Women and Children Health, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China
| | - Yamei Li
- Department of Women Health Care, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan Province, China
| | - Yamei Duan
- Department of Women and Children Health, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China
| | - Xiang Xiao
- Department of Women and Children Health, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China
| | - Jiayou Luo
- Department of Women and Children Health, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China
| | - Miyang Luo
- Department of Epidemiology, Xiangya School of Public Health, Central South University, Changsha, Hunan Province, China
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Rimsza RR, Frolova AI, Kelly JC, Carter EB, Cahill AG, Raghuraman N. Intrapartum electronic fetal monitoring features associated with a clinical diagnosis of nonreassuring fetal status. Am J Obstet Gynecol MFM 2023; 5:101068. [PMID: 37380056 DOI: 10.1016/j.ajogmf.2023.101068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Nonreassuring fetal status detected by continuous electronic fetal monitoring accounts for almost 1 in 4 primary cesarean deliveries. However, given the subjective nature of the diagnosis, there is a need to identify the electronic fetal monitoring patterns that are clinically considered nonreassuring. OBJECTIVE This study aimed to describe which electronic fetal monitoring features are most commonly associated with first-stage cesarean delivery for nonreassuring fetal status, and to evaluate the risk of neonatal acidemia following cesarean delivery for nonreassuring fetal status. STUDY DESIGN This was a nested case-control study in a prospectively collected cohort of patients with singleton pregnancies at ≥37 weeks' gestation, admitted in spontaneous labor or for induction of labor from 2010 to 2014 at a single tertiary care center. Patients with preterm pregnancies, multiple gestations, planned cesarean delivery, or nonreassuring fetal status in the second stage of labor were excluded. Cases were identified as having nonreassuring fetal status on the basis of what was documented in the operative note by the delivering physician. Controls were patients without nonreassuring fetal status within 1 hour of delivery. Cases were matched to controls in a 1:2 ratio by parity, obesity, and history of cesarean delivery. Electronic fetal monitoring data were abstracted by credentialed obstetrical research nurses for the 60 minutes before delivery. The primary exposure of interest was the incidence of high-risk category II electronic fetal monitoring features in the 60 minutes before delivery; in particular, the incidence of minimal variability, recurrent late decelerations, recurrent variable decelerations, tachycardia, and >1 prolonged deceleration were compared between groups. We also compared neonatal outcomes between cases and controls, including fetal acidemia (umbilical artery pH <7.1), other umbilical artery gas analytes, and neonatal and maternal outcomes. RESULTS Of the 8580 patients in the parent study, 714 (8.3%) underwent cesarean delivery for nonreassuring fetal status in the first stage of labor. Patients diagnosed with nonreassuring fetal status requiring cesarean delivery were more likely to have recurrent late decelerations, >1 prolonged deceleration, and recurrent variable decelerations compared with controls. More than 1 prolonged deceleration was associated with 6 times increased rate of nonreassuring fetal status diagnosis resulting in cesarean delivery (adjusted odds ratio, 6.73 [95% confidence interval, 2.47-8.33]). Rates of fetal tachycardia were similar between groups. Minimal variability was less common in the nonreassuring fetal status group compared with controls (adjusted odds ratio, 0.36 [95% confidence interval, 0.25-0.54]). Compared with control deliveries, cesarean delivery for nonreassuring fetal status was associated with nearly 7 times higher risk of neonatal acidemia (7.2% vs 1.1%; adjusted odds ratio, 6.93 [95% confidence interval, 3.83-12.54]). Composite neonatal morbidity and composite maternal morbidity were more likely among patients delivered for nonreassuring fetal status in the first stage (3.9% vs 1.1%; adjusted odds ratio, 5.70 [2.60-12.49]; and 13.3% vs 8.0%; adjusted odds ratio, 1.99 [1.41-2.80]). CONCLUSION Although multiple category II electronic fetal monitoring features have been traditionally linked to acidemia, the presence of recurrent late decelerations, recurrent variable decelerations, and prolonged decelerations seemed to concern obstetricians enough to surgically intervene for nonreassuring fetal status. A clinical intrapartum diagnosis of nonreassuring fetal status in the setting of these electronic fetal monitoring features is also associated with increased risk of acidemia, suggesting clinical validity to the diagnosis of nonreassuring fetal status.
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Affiliation(s)
- Rebecca R Rimsza
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman).
| | - Antonina I Frolova
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman)
| | - Jeannie C Kelly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman)
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman)
| | - Alison G Cahill
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Dell Medical School, The University of Texas at Austin, Austin, TX (Dr Cahill)
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Drs Rimsza, Frolova, Kelly, Carter, and Raghuraman)
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Chung K, Yin O, Kallapur A, Bass L, Coscia L, Constantinescu S, Moritz M, Afshar Y. Emergent prelabor cesarean delivery in solid organ transplant recipients: associated risk factors and outcomes. Am J Obstet Gynecol MFM 2023; 5:100799. [PMID: 36368514 DOI: 10.1016/j.ajogmf.2022.100799] [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: 07/24/2022] [Revised: 10/19/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pregnancies after solid organ transplant are at a higher risk of antepartum admission and pregnancy complications including cesarean delivery. Emergent prelabor cesarean delivery is associated with increased maternal and neonatal morbidity in other high-risk populations, but its incidence and impact in transplant recipients is not well-understood. OBJECTIVE This study aimed to characterize the risk factors and outcomes of emergency prelabor cesarean delivery in kidney and liver transplant recipients. STUDY DESIGN This was a retrospective cohort study of all kidney and liver transplant recipients at >20 weeks gestation enrolled in the Transplant Pregnancy Registry International between 1976 and 2019. Participants admitted antepartum who required emergency prelabor cesarean delivery were compared with those admitted antepartum who underwent nonemergent birth. The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariable logistic regression was conducted for neonatal composite morbidity. RESULTS Of 1979 births, 181 pregnancies (188 neonates) with antepartum admission were included. 51 pregnancies (53 neonates, 28%) were delivered by emergent prelabor cesarean delivery compared with 130 pregnancies (135 neonates, 72%) admitted antepartum who subsequently did not require emergent delivery. The most common indication for emergent delivery was nonreassuring fetal heart tracing (44 pregnancies /51 emergent deliveries = 86%). Pregnant people who underwent emergent prelabor cesarean delivery were less likely to deliver at a transplant center (37.3% vs 41.5%; P=.04) and had increased rates of chronic hypertension (33.3% vs 16.2%; P=.02). There was no significant difference in severe maternal morbidity (3.9% vs 4.6%; P=.84), though there was an increase in surgical site infection in the emergent prelabor cesarean delivery cohort (3.9% vs 0%; P=.02). Among those with emergent prelabor cesarean delivery, there was a significant increase in neonatal composite morbidity (43.4% vs 19.3%; P<.001) with earlier gestational age at delivery (33.4 vs 34.7 weeks; P=.02), lower birthweight (1899 g vs 2321 g; P<.001), lower birthweight percentile (30.3% vs 40.6%; P=.03), increased neonatal intensive care unit admission (52.8% vs 35.6%; P=.03), and increased neonatal mortality (11.3% vs 1.5%; P=.002). After adjusting for year of conception, race, hypertensive disorders, and fetal malformations, there was a persistent increased risk of neonatal morbidity (adjusted odds ratio, 3.01; 95% confidence interval, 1.50-6.08; P=.002) associated with emergent prelabor cesarean delivery after transplant. CONCLUSION Almost one-third of kidney and liver transplant recipients admitted antepartum had an emergency prelabor cesarean delivery, and 63% of this cohort delivered outside of a transplant center. Pregnancies after transplantation should involve multidisciplinary transplant-obstetrics collaboration to ensure optimal antepartum disease management, especially for preexisting hypertension, to prevent and mitigate obstetrical and neonatal morbidity in the setting of emergent cesarean delivery.
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Affiliation(s)
- Kathleen Chung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Ophelia Yin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Aneesh Kallapur
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Lauren Bass
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz)
| | - Serban Constantinescu
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz); Section of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (Dr Constantinescu)
| | - Michael Moritz
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz); Department of Surgery, Lehigh Valley Health Network, Allentown, PA (Dr Moritz); Department of Surgery, Morsani College of Medicine, Tampa, FL (Dr Moritz)
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar).
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9
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Sri Ranjan Y, Ziauddeen N, Stuart B, Alwan NA, Cheong Y. The role of parity in the relationship between endometriosis and pregnancy outcomes: a systematic review and meta-analysis. REPRODUCTION AND FERTILITY 2023; 4:e220070. [PMID: 36821517 PMCID: PMC10083661 DOI: 10.1530/raf-22-0070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 02/23/2023] [Indexed: 02/24/2023] Open
Abstract
Abstract Endometriosis is a chronic and debilitating condition which can affect the entire reproductive life course of women with a potentially detrimental effect on pregnancy. Pregnancy (and increasing parity) can affect endometriosis by modulating disease severity and suppressing symptoms. Multiparous women could be less likely to suffer from endometriosis-related pregnancy complications than primiparous women. We aimed to systematically review the evidence examining the role of parity in the relationship between pregnancy outcomes and endometriosis. A systematic search of MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library was performed from inception to May 2022. We searched for experimental and observational studies. Grading of Recommendations, Assessment, Development, and Evaluation was used to assess the quality of evidence with the risk of bias in non-randomised studies of interventions tool incorporated. Eleven studies were included in the meta-analysis. Primiparous women with endometriosis had almost double the risk of hypertensive disorders of pregnancy (OR: 1.99, 95% CI: 1.50-2.63, P < 0.001) compared to multiparous women with endometriosis. Primiparous women with endometriosis were at significantly increased risk of preterm delivery, caesarean delivery, and placenta praevia compared to primiparous women without endometriosis. There were no significant differences in outcomes when multiparous women with endometriosis were compared to multiparous women without endometriosis. There is limited evidence to suggest that primiparous women with endometriosis may be at higher risk of adverse pregnancy outcomes compared to multiparous women. The modulatory role of parity in the pathophysiology of endometriosis and its impact on pregnancy outcomes should be investigated. Lay summary Endometriosis can adversely affect pregnancy and cause complications that can affect both mother and baby. The severity and symptoms of endometriosis are lessened in pregnancy and with increasing births. Women who have previously given birth could experience fewer pregnancy complications than women giving birth for the first time. We reviewed the literature to compare pregnancy outcomes in women with endometriosis by whether they had given birth before or not. Our review included 11 studies. More women with endometriosis giving birth for the first time had blood pressure disorders in pregnancy than women with endometriosis who had given birth before. First-time mothers with endometriosis tended to have a baby born early, caesarean delivery, and an abnormally located placenta compared to those without endometriosis. This study supports the theory that women with endometriosis in their first pregnancy are at higher risk of complications and may benefit from additional monitoring.
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Affiliation(s)
- Yorain Sri Ranjan
- Human Development and Health, University of Southampton, Southampton, UK
| | - Nida Ziauddeen
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Applied Research Collaboration Wessex, Southampton, UK
| | - Beth Stuart
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nisreen A Alwan
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Applied Research Collaboration Wessex, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ying Cheong
- Human Development and Health, University of Southampton, Southampton, UK
- Complete Fertility, Princess Anne Hospital, Southampton, UK
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10
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Kervinen K, Holster T, Saqib S, Virtanen S, Stefanovic V, Rahkonen L, Nieminen P, Salonen A, Kalliala I. Parity and gestational age are associated with vaginal microbiota composition in term and late term pregnancies. EBioMedicine 2022; 81:104107. [PMID: 35759916 PMCID: PMC9250009 DOI: 10.1016/j.ebiom.2022.104107] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/09/2022] [Accepted: 05/27/2022] [Indexed: 12/11/2022] Open
Abstract
Background Vaginal microbiota and its potential contribution to preterm birth is under intense research. However, only few studies have investigated the vaginal microbiota in later stages of pregnancy or at the onset of labour. Methods We used 16S rRNA gene amplicon sequencing to analyse cross-sectional vaginal swab samples from 324 Finnish women between 37–42 weeks of gestation, sampled before elective caesarean section, at the onset of spontaneous labour, and in pregnancies lasting ≥41 weeks of gestation. Microbiota data were combined with comprehensive clinical data to identify factors associated with microbiota variation. Findings Vaginal microbiota composition associated strongly with advancing gestational age and parity, i.e. presence of previous deliveries. Absence of previous deliveries was a strong predictor of Lactobacillus crispatus dominated vaginal microbiota, and the relative abundance of L. crispatus was higher in late term pregnancies, especially among nulliparous women. Interpretation This study identified late term pregnancy and reproductive history as factors underlying high abundance of gynaecological health-associated L. crispatus in pregnant women. Our results suggest that the vaginal microbiota affects or reflects the regulation of the duration of gestation and labour onset, with potentially vast clinical utilities. Further studies are needed to address the causality and the mechanisms on how previous labour, but not pregnancy, affects the vaginal microbiota. Parity and gestational age should be accounted for in future studies on vaginal microbiota and reproductive outcomes. Funding This research was supported by EU H2020 programme Sweet Crosstalk ITN (814102), Academy of Finland, State Research Funding, and University of Helsinki.
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Affiliation(s)
- Kaisa Kervinen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tiina Holster
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Schahzad Saqib
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Seppo Virtanen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leena Rahkonen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka Nieminen
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne Salonen
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | - Ilkka Kalliala
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
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11
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Educational Multimedia Tool Compared With Routine Care for the Uptake of Postpartum Long-Acting Reversible Contraception in Individuals With High-Risk Pregnancies: A Randomized Controlled Trial. Obstet Gynecol 2022; 139:571-578. [PMID: 35594122 DOI: 10.1097/aog.0000000000004718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/06/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether an intervention with a multimedia educational tool, compared with routine care, would increase the use of long-acting reversible contraceptives (LARC) at 12 weeks postpartum in individuals with high-risk pregnancies. METHODS In this single-center randomized trial, we assigned individuals aged 13-50 years with high-risk pregnancies to either a multimedia educational tool or routine care. Participants were included during pregnancy through postpartum day 1. Those randomized to the multimedia educational tool (MET) group were provided a tablet with the preloaded 3-5-minute multimedia presentation (https://prezi.com/view/jpFrXaPnnxuqRkcI3A4a/), which was viewed without the presence of research staff and resent by secure email every 4 weeks if undelivered. The primary outcome was uptake of LARC (implant or intrauterine device) within 12 weeks of delivery. The secondary outcomes included overall use of any method of contraception and composite maternal and neonatal adverse outcomes. A priori estimates indicated that 380 participants were needed to detect a 40% difference in use of LARC (baseline 40%; alpha=0.05, power=0.8, assumed loss to follow-up 20%). Relative risk (RR) and number needed to treat (NNT), along with 95% CIs, were calculated. RESULTS From July 2020 through December 2020, 536 persons were screened and 380 randomized as follows: 190 for the multimedia educational tool and 190 for routine care. Demographic characteristics were similar between groups. The primary outcome-available for more than 90% of participants-was higher in the MET group (32.4%) than in the routine care (RC) group (20.9%) (RR 1.55; 95% CI 1.09-2.21; NNT nine, with 95% CI 5-42). Overall use of contraception was also higher in the MET group than in the RC group (RR 1.16; 95% CI 1.03-1.32). CONCLUSION Among individuals with high-risk pregnancies, compared with routine care, use of a multimedia-based educational tool increased the uptake of postpartum LARC by 55%. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04291040. FUNDING SOURCE Funded in part by Investigator-Initiated studies of Organon.
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12
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Geng Y, Zhao W, Liu W, Tang J, Zhang H, Ke W, Yao R, Xu J, Lin Q, Li Y, Huang J. Term Neonatal Complications During the Second Localized COVID-19 Lockdown and Prolonged Premature Rupture of Membranes at Home Among Nulliparas With Reference Interval for Maternal C-Reactive Protein: A Retrospective Cohort Study. Front Pediatr 2022; 10:787947. [PMID: 35463873 PMCID: PMC9024135 DOI: 10.3389/fped.2022.787947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/21/2022] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE The COVID-19 lockdown extended premature rupture of membranes (PROM) expectant time among nulliparas and increased the risk of term neonatal complications. This study investigated the impact of term nulliparas with PROM delays at home on neonatal outcomes during the COVID-19 lockdown period, considering the clinical diagnostic application of maternal C-reactive protein (CRP). METHODS This study collected 505 term nulliparous women who underwent PROM at home from five provinces in a non-designated hospital of China in 2020. We analyzed PROM maternal information at home and neonatal complications in the COVID-19 regional lockdown and compared related information in the national lockdown. Poisson regression models estimated the correlation of PROM management at home, maternal CRP, and neonatal morbidity. We constructed two diagnostic models: the CRP univariate model, and an assessed cut-off value of CRP in the combined model (CRP with PROM waiting time at home). RESULTS In the regional lockdown, PROM latency at home and the severity of neonatal complications were extended and increased lower than in the nationwide lockdown, but term neonatal morbidity was not reduced in the COVID-19 localized lockdown. Prolonged waiting time at home (≥8.17 h) was associated with increasing maternal CRP values and neonatal morbidity (adjusted risk ratio 2.53, 95% CI, 1.43 to 4.50, p for trend <0.001) in the regional lockdown period. In the combined model, CRP ≥7 mg/L with PROM latency ≥8.17 h at home showed higher diagnostic sensitivity and AUC than only CRP for initial assessing the risk of adverse neonatal complications in COVID-19 regional lockdowns (AUC, 0.714 vs. 0.534; sensitivity, 0.631 vs. 0.156). CONCLUSION The impact of the acute COVID-19 national blockade on the PROM newborns' health could continue to the COVID-19 easing period. Maternal CRP reference interval (≥7 mg/L) would effectively assess the risk of term neonatal morbidity when nulliparas underwent prolonged PROM expectant at home (≥8.17 h) during the second COVID-19 lockdown.
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Affiliation(s)
- Yang Geng
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Weihua Zhao
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Wenlan Liu
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Jie Tang
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Hui Zhang
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Weilin Ke
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Runsi Yao
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Ji Xu
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Qing Lin
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Yun Li
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Jianlin Huang
- Department of Obstetrics and Gynecology and Center for Perinatal Medical Health, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
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Banke-Thomas A, Avoka C, Olaniran A, Balogun M, Wright O, Ekerin O, Benova L. Patterns, travel to care and factors influencing obstetric referral: Evidence from Nigeria's most urbanised state. Soc Sci Med 2021; 291:114492. [PMID: 34662765 DOI: 10.1016/j.socscimed.2021.114492] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 10/01/2021] [Accepted: 10/14/2021] [Indexed: 11/27/2022]
Abstract
The criticality of referral makes it imperative to study its patterns and factors influencing it at a health systems level. This study of referral in Lagos, Nigeria is based on health records of 4181 pregnant women who presented with obstetric emergencies at one of the 24 comprehensive emergency obstetric care (EmOC) facilities in the state between November 2018 and October 2019 complemented with distance and time data extracted from Google Maps. Univariate, bivariate, and multivariate analyses were conducted. About a quarter of pregnant women who presented with obstetric emergencies were referred. Most referrals were from primary health centres (41.9 %), private (23.5 %) and public (16.2 %) hospitals. Apart from the expected low-level to high-level referral pattern, there were other patterns observed including non-formal, multiple, and post-delivery referrals. Travel time and distance to facilities that could provide needed care increased two-fold on account of referrals compared to scenarios of going directly to the final facility, mostly travelling to these facilities by private cars/taxis (72.8 %). Prolonged/obstructed labour was the commonest obstetric indication for referral, with majority of referred pregnant women delivered via caesarean section (52.9 %). After adjustment, being married, not being registered for antenatal care at facility of care, presenting at night or with a foetus in distress increased the odds of referral. However, parity, presentation in the months following the commissioning of a new comprehensive EmOC facility or with abortion reduced the likelihood of being referred. Our findings underscore the need for health systems strengthening interventions that support women during referral and the importance of antenatal care and early booking to aid identification of potential pregnancy complications whilst establishing robust birth preparedness plans that can minimise the need for referral in the event of emergencies. Indeed, there are context-specific influences that need to be addressed if effective referral systems are to be designed.
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Affiliation(s)
- Aduragbemi Banke-Thomas
- LSE Health, London School of Economics and Political Science, London, United Kingdom; Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria.
| | - Cephas Avoka
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Abimbola Olaniran
- Infectious Disease and Epidemiology, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Mobolanle Balogun
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Ololade Wright
- Centre for Reproductive Health Research and Innovation, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria; Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
| | - Olabode Ekerin
- Department of Obstetrics and Gynaecology, Obafemi Awolowo University, Ile-Ife, Osun, Nigeria
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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14
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Yin O, Kallapur A, Coscia L, Kwan L, Tandel M, Constantinescu SA, Moritz MJ, Afshar Y. Mode of Obstetric Delivery in Kidney and Liver Transplant Recipients and Associated Maternal, Neonatal, and Graft Morbidity During 5 Decades of Clinical Practice. JAMA Netw Open 2021; 4:e2127378. [PMID: 34605918 PMCID: PMC8491100 DOI: 10.1001/jamanetworkopen.2021.27378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/22/2021] [Indexed: 12/23/2022] Open
Abstract
Importance Rates of cesarean delivery (CD) are increased among transplant recipients. There is a need to define the indications for CD and associated outcomes among transplant recipients to determine the safest mode of obstetric delivery. Objective To evaluate the association of mode of obstetrical delivery with maternal and neonatal morbidity among pregnant women who have received a kidney or liver transplant. Design, Setting, and Participants This registry-based retrospective cohort study used data from the Transplant Pregnancy Registry International, which has recruited participants since 1991 from 289 diverse academic and community settings, mainly in North America. Eligible participants were recipients of a kidney or liver transplant who were aged 18 years or older at the time of a live birth at or later than 20 weeks' gestational age and who delivered between 1968 and 2019. The data were analyzed from April 30, 2020, to April 16, 2021. Exposures Scheduled CD, a trial of labor resulting in CD (TOL-CD), or a TOL resulting in vaginal delivery (TOL-VD). Main Outcomes and Measures The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariate regression was conducted to calculate odds ratios (ORs) or β values and 95% CIs with adjustment for differences in maternal comorbidities and gestational age at delivery. Nonmedical indications for CD are those not associated with decreased morbidity or mortality in the obstetric literature. Results This study included 1865 women, of whom 1435 were kidney transplant recipients and 430 were liver transplant recipients. The age range of the participants was 18 to 48 years; the median body mass index among the participants was in the normal range, and the median transplant-to-conception interval was more than 2 years. Compared with a scheduled CD, a TOL was not associated with increased severe maternal morbidity among kidney transplant recipients (TOL-CD: adjusted odds ratio [aOR], 1.80 [95% CI, 0.77-4.22]; TOL-VD: aOR, 1.22 [95% CI, 0.57-2.62]) (for liver transplant recipients, the numbers were too small for multivariate modeling). In the adjusted model, a TOL was associated with a decrease in neonatal composite morbidity among kidney transplant recipients who underwent TOL-CD (aOR, 0.52; 95% CI, 0.32-0.82) and TOL-VD (aOR, 0.36; 95% CI, 0.24-0.53) and liver transplant recipients who underwent TOL-VD (aOR, 0.41; 95% CI, 0.19-0.87) but not for TOL-CD (aOR, 0.58; 95% CI, 0.21-1.61). The main factors associated with CD after labor were placental abruption (aOR, 12.96; 95% CI, 2.85-59.07) and pregestational diabetes (aOR 5.44; 95% CI, 2.54-11.68). The rate of CD was 51.6% (741 of 1435) among kidney transplant recipients and 41.4% (178 of 430) among liver transplant recipients. In total, 229 of 459 kidney transplant recipients (49.9%) and 50 of 105 liver transplant recipients (47.6%) had scheduled CDs performed for either a nonmedical indication or a repeated indication, although women with these indications are candidates for a TOL. Conclusions and Relevance In this cohort study, TOL vs a scheduled CD was associated with improved neonatal outcomes among kidney and transplant recipients and not with increased severe maternal morbidity among kidney transplant recipients. These findings may be used to facilitate multidisciplinary decisions regarding the mode of obstetrical delivery.
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Affiliation(s)
- Ophelia Yin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles
| | - Aneesh Kallapur
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles
| | - Megha Tandel
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles
| | - Serb an Constantinescu
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
- Section of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Michael J. Moritz
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
- Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania
- Department of Surgery, Morsani College of Medicine, Tampa, Florida
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles
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15
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Rangel EL, Castillo-Angeles M, Easter SR, Atkinson RB, Gosain A, Hu YY, Cooper Z, Dey T, Kim E. Incidence of Infertility and Pregnancy Complications in US Female Surgeons. JAMA Surg 2021; 156:905-915. [PMID: 34319353 DOI: 10.1001/jamasurg.2021.3301] [Citation(s) in RCA: 137] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance While surgeons often delay pregnancy and childbearing because of training and establishing early careers, little is known about risks of infertility and pregnancy complications among female surgeons. Objective To describe the incidence of infertility and pregnancy complications among female surgeons in the US and to identify workplace factors associated with increased risk compared with a sociodemographically similar nonsurgeon population. Design, Setting, and Participants This self-administered survey questionnaire was electronically distributed and collected from November 2020 to January 2021 through multiple surgical societies in the US and social media among male and female attending and resident surgeons with children. Nonchildbearing surgeons were asked to answer questions regarding the pregnancies of their nonsurgeon partners as applicable. Exposures Surgical profession; work, operative, and overnight call schedules. Main Outcomes and Measures Descriptive data on pregnancy loss were collected for female surgeons. Use of assisted reproductive technology was compared between male and female surgeons. Pregnancy and neonatal complications were compared between female surgeons and female nonsurgeon partners of surgeons. Results A total of 850 surgeons (692 women and 158 men) were included in this survey study. Female surgeons with female partners were excluded because of lack of clarity about who carried the pregnancy. Because the included nonchildbearing population was therefore made up of male individuals with female partners, this group is referred to throughout the study as male surgeons. The median (IQR) age was 40 (36-45) years. Of 692 female surgeons surveyed, 290 (42.0%) had a pregnancy loss, more than twice the rate of the general population. Compared with male surgeons, female surgeons had fewer children (mean [SD], 1.8 [0.8] vs 2.3 [1.1]; P < .001), were more likely to delay having children because of surgical training (450 of 692 [65.0%] vs 69 of 158 [43.7%]; P < .001), and were more likely to use assisted reproductive technology (172 of 692 [24.9%] vs 27 of 158 [17.1%]; P = .04). Compared with female nonsurgeon partners, female surgeons were more likely to have major pregnancy complications (311 of 692 [48.3%] vs 43 of 158 [27.2%]; P < .001), which was significant after controlling for age, work hours, in vitro fertilization use, and multiple gestation (odds ratio [OR], 1.72; 95% CI, 1.11-2.66). Female surgeons operating 12 or more hours per week during the last trimester of pregnancy were at higher risk of major pregnancy complications compared with those operating less than 12 hours per week (OR, 1.57; 95% CI, 1.08-2.26). Compared with female nonsurgeon partners, female surgeons were more likely to have musculoskeletal disorders (255 of 692 [36.9%] vs 29 of 158 [18.4%]; P < .001), nonelective cesarean delivery (170 of 692 [25.5%] vs 24 of 158 [15.3%]; P = .01), and postpartum depression (77 of 692 [11.1%] vs 9 of 158 [5.7%]; P = .04). Conclusions and Relevance This national survey study highlighted increased medical risks of infertility and pregnancy complications among female surgeons. With an increasing percentage of women representing the surgical workforce, changing surgical culture to support pregnancy is paramount to reducing the risk of major pregnancy complications, use of fertility interventions, or involuntary childlessness because of delayed attempts at childbearing.
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Affiliation(s)
- Erika L Rangel
- Division of General and Gastrointestinal Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Manuel Castillo-Angeles
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah Rae Easter
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rachel B Atkinson
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ankush Gosain
- Department of Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann & Robert Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tanujit Dey
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eugene Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
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16
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Differentiating Acute Rejection From Preeclampsia After Kidney Transplantation. Obstet Gynecol 2021; 137:1023-1031. [PMID: 33957644 DOI: 10.1097/aog.0000000000004389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/15/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the clinical and laboratory characteristics in pregnancy that differentiate preeclampsia from acute renal allograft rejection and to investigate the maternal, neonatal, and graft sequelae of these diagnoses. METHODS We conducted a retrospective case-controlled registry study of data abstracted from Transplant Pregnancy Registry International deliveries between 1968 and 2019. All adult kidney transplant recipients with singleton pregnancies of at least 20 weeks of gestation were included. Acute rejection was biopsy proven and preeclampsia was diagnosed based on contemporary criteria. Variables were compared using χ2, Fisher exact, and Wilcoxon rank sum tests as appropriate. Multivariable linear regression was used to analyze preterm birth. Kaplan-Meier curves with log-rank test and Cox proportional hazards model were used to compare graft loss over time. RESULTS There were 26 pregnant women with biopsy-confirmed acute rejection who were matched by the year they conceived to 78 pregnant women with preeclampsia. Recipients with acute rejection had elevated peripartum serum creatinine levels (73% vs 14%, P<.001), with median intrapartum creatinine of 3.90 compared with 1.15 mg/dL (P<.001). Conversely, only patients with preeclampsia had a significant increase in proteinuria from baseline. Although there were no significant differences in maternal outcomes, graft loss within 2 years postpartum (42% vs 10%) and long-term graft loss (73% vs 35%) were significantly increased in recipients who experienced acute rejection (P<.001 for both). The frequency of delivery before 32 weeks of gestation was 53% with acute rejection and 20% with preeclampsia. After controlling for hypertension and immunosuppressant use, acute rejection was associated with higher frequency of delivery at less than 32 weeks of gestation (adjusted odds ratio 4.04, 95% CI 1.10-15.2). CONCLUSION In pregnancy, acute rejection is associated with higher creatinine levels, and preeclampsia is associated with increased proteinuria. Acute rejection in pregnancy carries a risk of prematurity and graft loss beyond that of preeclampsia for kidney transplant recipients. FUNDING SOURCE The Transplant Pregnancy Registry International is supported in part by an educational grant from Veloxis Pharmaceuticals.
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