Obstetric characteristics and pregnancy outcomes under China's three-child policy: a retrospective cohort study

BACKGROUND AND OBJECTIVES:We examined the effect of body mass index in early pregnancy on pregnancy outcome since no study in Saudi Arabia has addressed this question.METHODS:This prospective cohort study involved women registered for antenatal care during the first month of pregnancy at primary health care centers in Al-Hassa, Saudi Arabia. Data was collected from records and by direct interview.RESULTS:The study included 787 women. Compared to normal weight women (n=307), overweight (n=187) and obese (n=226) women were at increased risk for pregnancy-induced hypertension (RR=4.9 [95% CI 1.6-11.1] and 6.1 [95% CI 2.1-17.8], respectively), gestational diabetes (RR=4.4 [95% CI 1.2-16.3] and 8.6 [95% CI 2.6-28.8]), preeclamptic toxemia (RR=3.8 [95% CI 1.1-14.6] and 5.9 [95% CI 1.7-20.4]), urinary tract infections (RR=1.4 [95% CI 0.5-3.9] and 3.7 [95% CI 1.7-6.2]), and cesarean delivery (RR=2.0 [95% CI 1.3-3.0] in obese women). Neonates born to obese women had an increased risk for postdate pregnancy (RR=3.7 [95% CI 1.2-11.6]), macrosomia (RR=6.8 [95% CI 1.5-30.7]), low 1-minute Apgar score (RR=1.9 [95% CI 1.1-3.6]), and admission to neonatal care units (RR=2.1 [95% CI 1.2-2.7]). On the other hand, low birth weight was less frequent among obese women (RR=0.5 [95% CI 0.3-0.9]) while the risk was high among underweight women (RR=2.3 [95% CI 1.4-3.8])CONCLUSION:Even with adequate prenatal care, overweight and obesity can adversely affect pregnancy outcomes.

Objective To explore the changes in gravida's age and its influences on maternal and neonatal complications under China's two-child policy. Methods This study retrospectively analyzed the clinical data such as adverse gestational complications and fetal condition of 42 771 gravidas delivering at Changzhou Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University from July 2013 to December 2017. According to their age at delivery, they were divided into three groups: the younger maternal age group (1 140 cases, <20 years), the advanced maternal age group (4 307 cases, ≥35 years) and the median maternal age group (37 324 cases, ≥20 and <35 years). Chi-square test was used to compare the differences among groups. Cochran-Armitage test was used for trend analysis. The risks of various complications in younger and advanced maternal age groups were analyzed by binary logistic regression analysis. Results (1) The proportion of advanced maternal age pregnancies tended to rise gradually year by year (Z=-9.909, P<0.001). However, the figure of younger gravidas remained low and presented a downward trend (Z=10.685, P<0.001). (2) The incidence of pregnant complications in the younger, advanced and the median maternal age groups were 52.8% (602/1 140), 72.3% (3 116/4 307) and 56.5% (21 091/37 324), respectively. Compared with the median maternal age group, the advanced maternal age group was at greater risks of premature delivery [9.0% (3 343/37 324) vs 11.6% (499/4 307), χ2=124.233, P<0.001], fetal growth restriction (FGR) [0.6% (218/37 324) vs 1.2% (50/4 307), χ2=20.087, P<0.001], postpartum hemorrhage [5.7% (2 120/37 324) vs 7.8% (336/4 307), χ2=31.299, P<0.05], hypertensive disorders in pregnancy(HDP) [4.2% (1 561/37 324) vs 8.7% (376/4 307), χ2=180.013, P<0.001], gestational diabetes mellitus (GDM) [7.6% (2 845/37 324) vs 15.1% (650/4 307), χ2=280.126, P<0.001] and placenta previa [1.7% (621/37 324) vs 3.8% (165/4 307), χ2=97.904, P<0.001], and the younger maternal age group was at greater risks of HDP [4.2% (1 561/37 324) vs 5.9% (67/1 140), χ2=4.234, P=0.040], fetal distress [3.5% (1 325/37 324) vs 5.1% (58/1 140), χ2=7.546, P=0.006], premature delivery [9.0% (3 343/37 324) vs 15.0% (171/1 140), χ2=48.668, P<0.001] and FGR [0.6% (218/37 324) vs 1.1% (12/1 140), χ2=4.086, P=0.043]. (3) Gestational complications in the younger maternal age group were mainly related to the fetuses such as premature rupture of membranes (PROM) and premature delivery, while the advanced maternal age group had a higher incidence of maternal complications, especially GDM and HDP. (4) Most of the gravidas of advanced maternal age with HDP developed severe preeclampsia (47.9%, 180/376), while mild preeclampsia was dominant in the median maternal aged HDP women (45.4%, 708/1 561). (5) The advanced maternal age group had higher risk of stillbirth, premature delivery, FGR, placenta previa, GDM, HDP and postpartum hemorrhage [OR(95%CI): 1.91 (1.29-2.84), 1.33 (1.21-1.46), 1.66 (1.21-2.28), 2.56 (2.15-3.04), 2.39 (2.19-2.61), 2.36 (2.11-2.65), 1.46 (1.31-1.62); all P<0.05], but lower risks of fetal distress and PROM [OR(95%CI): 0.79 (0.65-0.95) and 0.88 (0.81-0.96); both P<0.05]. The younger maternal age group had a higher risk of premature delivery [OR(95%CI): 1.97 (1.61-2.40); P<0.001], but significant lower risks of PROM and GDM [OR(95%CI): 0.77 (0.62-0.95) and 0.05 (0.02-0.16); both P<0.05]. Conclusions Maternal age is closely related to the adverse outcomes of pregnancy. Two-child policy in China will bring about changes in maternal age and composition of pregnant complications. Key words: Pregnancy; Age factors; Pregnancy outcome

BackgroundEthnic and socioeconomic inequalities in obstetric outcomes are well established. However, the role of induction of labour (IOL) to reduce these inequalities is controversial, in part due to insufficient evidence. This national cohort study aimed to identify adverse perinatal outcomes associated with IOL with birth at 39 weeks of gestation (“IOL group”) compared to expectant management (“expectant management group”) according to maternal characteristics in women with low-risk pregnancies.Methods and findingsAll English National Health Service (NHS) hospital births between January 2018 and March 2021 were examined. Using the Hospital Episode Statistics (HES) dataset, maternal and neonatal data (demographic, diagnoses, procedures, labour, and birth details) were linked, with neonatal mortality data from the Office for National Statistics (ONS). Women with a low-risk pregnancy were identified by excluding pregnancies with preexisting comorbidities, previous cesarean section, breech presentation, placenta previa, gestational diabetes, or a baby with congenital abnormalities. Women with premature rupture of membranes, placental abruption, hypertensive disorders of pregnancy, amniotic fluid abnormalities, or antepartum stillbirth were excluded only from the IOL group. Adverse perinatal outcome was defined as stillbirth, neonatal death, or neonatal morbidity, the latter identified using the English composite neonatal outcome indicator (E-NAOI). Binomial regression models estimated risk differences (with 95% confidence intervals (CIs)) between the IOL group and the expectant management group, adjusting for ethnicity, socioeconomic background, maternal age, parity, year of birth, and birthweight centile. Interaction tests examined risk differences according to ethnicity, socioeconomic background, and parity. Of the 1 567 004 women with singleton pregnancies, 501 072 women with low-risk pregnancies and with sufficient data quality were included in the analysis. Approximately 3.3% of births in the IOL group (1 555/47 352) and 3.6% in the expectant management group (16 525/453 720) had an adverse perinatal outcome. After adjustment, a lower risk of adverse perinatal outcomes was found in the IOL group (risk difference −0.28%; 95% CI −0.43%, −0.12%; p = 0.001). This risk difference varied according to socioeconomic background from 0.38% (−0.08%, 0.83%) in the least deprived to −0.48% (−0.76%, −0.20%) in the most deprived national quintile (p-value for interaction = 0.01) and by parity with risk difference of −0.54% (−0.80%, −0.27%) in nulliparous women and −0.15% (−0.35%, 0.04%) in multiparous women (p-value for interaction = 0.02). There was no statistically significant evidence that risk differences varied according to ethnicity (p = 0.19). Key limitations included absence of additional confounding factors such as smoking, BMI, and the indication for induction in the HES datasets, which may mean some higher risk pregnancies were included.ConclusionsIOL with birth at 39 weeks was associated with a small reduction in the risk of adverse perinatal outcomes, with 360 inductions in low-risk pregnancies needed to avoid 1 adverse outcome. The risk reduction was mainly present in women from more socioeconomically deprived areas and in nulliparous women. There was no significant risk difference found by ethnicity. Increased uptake of IOL at 39 weeks, especially in women from more socioeconomically deprived areas, may help reduce inequalities in adverse perinatal outcomes.

Although maternal age might affect pregnancy outcomes, it remains unclear whether this relationship is linear or curvilinear and if it differs between nulliparous and multiparous women. We aimed to characterize the relationship between maternal age and risks of pregnancy outcomes in a diverse sample of Chinese singleton pregnant women and to evaluate whether the relationship varied by parity. We based this prospective multicenter cohort study on data from 18 495 singleton pregnant women who participated in the University Hospital Advanced Age Pregnant Cohort Study, conducted in eight Chinese public hospitals from 2016 to 2021. We used restricted cubic splines to model nonlinear relationships between maternal age continuum and adverse outcomes, and performed multivariable log-binomial regression to estimate the adjusted relative risk (RR) and 95% confidence interval (CI). Among 18 495 singleton pregnant women (mean age 35.7, standard deviation (SD) = 4.2 years), maternal age was not related to postpartum hemorrhage or small for gestational age, but showed a positive, nonlinear relationship to gestational diabetes mellitus, hypertensive disorders of pregnancy, preeclampsia, placenta accreta spectrum, placenta previa, cesarean delivery, preterm birth, large for gestational age, macrosomia, and fetal congenital anomaly, with inflection points around 35.6-40.4 years. Compared to women younger than 35 years, older women had higher risks of adverse pregnancy outcomes, except for postpartum hemorrhage and small for gestational age. The risks of placenta accreta spectrum, placenta previa, large for gestational age, and macrosomia were highest for women aged 40-44 years, and risks of gestational diabetes mellitus, hypertensive disorders of pregnancy, preeclampsia, cesarean delivery, preterm birth and congenital anomaly were highest for those aged ≥45 years. Most risks were more pronounced in nulliparous than multiparous women (P for interaction <0.02). Delayed childbirth was related to increased risks of adverse pregnancy outcomes, especially for nulliparous women. Appropriate childbearing age, generally before 35 years, is recommended for optimising pregnancy outcomes.

Maternal and paternal age at birth is increasing globally. Maternal age may affect perinatal outcomes, but the effect of paternal age and its joint effect with maternal age are not well established. This prospective, multicenter, cohort analysis used data from the University Hospital Advanced Age Pregnant Cohort Study in China from 2016 to 2021, to investigate the separate association of paternal age and joint association of paternal and maternal age with adverse perinatal outcomes. Of 16,114 singleton deliveries, mean paternal and maternal age (± SD) was 38.0 ± 5.3 years and 36.0 ± 4.1 years. In unadjusted analyses, older paternal age was associated with increased risks of gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy, preeclampsia, placenta accreta spectrum disorders, placenta previa, cesarean delivery (CD), and postpartum hemorrhage, preterm birth (PTB), large-for-gestational-age, macrosomia, and congenital anomaly, except for small-for-gestational-age. In multivariable analyses, the associations turned to null for most outcomes, and attenuated but still significant for GDM, CD, PTB, and macrosomia. As compare to paternal age of < 30 years, the risks in older paternal age groups increased by 31–45% for GDM, 17–33% for CD, 32–36% for PTB, and 28–31% for macrosomia. The predicted probabilities of GDM, placenta previa, and CD increased rapidly with paternal age up to thresholds of 36.4–40.3 years, and then plateaued or decelerated. The risks of GDM, CD, and PTB were much greater for pregnancies with younger paternal and older maternal age, despite no statistical interaction between the associations related to paternal and maternal age. Our findings support the advocation that paternal age, besides maternal age, should be considered during preconception counseling.Trial Registration NCT03220750, Registered July 18, 2017—Retrospectively registered, https://classic.clinicaltrials.gov/ct2/show/NCT03220750.

PurposeFollowing China's universal two-child policy, the number of multiparous women increased by 90 million, coinciding with a rise in gestational diabetes mellitus (GDM). Previous studies have indicated that GDM can be effectively managed through antenatal care and lifestyle interventions. This study aims to explore whether GDM still remains a risk factor for adverse neonatal outcomes among multiparous women after the implementation of the universal two-child policy and the enhancement of antenatal care in China.MethodA total of 7,496 multiparous women were categorized into four groups: those without any complications, those with GDM only, those with non-GDM complications, and those with both GDM and non-GDM complications. Logistic regression models were employed to calculate the adjusted odds ratio (aOR) and its 95% confidence interval (CI) for each outcome. Stratified analysis (based on maternal age) and sensitivity analysis (restricted to multiparas with GDM and/or hypertensive disorders in pregnancy) were carried out to evaluate the robustness of the results.ResultsCompared to infants born to multiparous women with GDM alone, infants born to multiparas without any complications had lower risks of preterm birth (PTB) (aOR 0.57, 95% CI 0.46–0.70), macrosomia (aOR 0.60, 95% CI 0.43–0.83), large for gestational age (aOR 0.53, 95% CI 0.44–0.61). When considering multiparous women with GDM with non-GDM complications, the offspring had higher risks of PTB (aOR 1.98, 95% CI 1.33–2.96), LBW (aOR 2.49, 95% CI 1.54–4.01), and small for gestational age (aOR 4.82, 95% CI 2.41–9.65).ConclusionDespite advancements in China's prenatal care system following the two-child policy, GDM persists as a modifiable, high-impact risk factor for neonatal adverse outcomes in multiparous women. Crucially, the synergistic effects of GDM with other pregnancy complications amplify these risks, necessitating early screening (e.g., first-trimester glucose profiling), intensified glycemic management protocols, and family-centered interventions tailored to China's unique sociodemographic landscape.

Our objective was to investigate the association between maternal outcomes and twin chorionicity in a large, contemporary obstetric population. Retrospective cohort study was conducted at a single, large tertiary care center. Prenatal and inpatient records for all individuals with twin gestations were reviewed from 2000 to 2016. Patients with monoamniotic twins, higher-order multiples reduced to twins, multiple sets of twins in the study period, or undetermined chorionicity were excluded. Patients with monochorionic twins were compared with those with dichorionic twins. The co-primary outcomes were gestational diabetes mellitus and hypertensive disorders of pregnancy. Secondary outcomes included cesarean delivery, preterm delivery, postpartum hemorrhage, and other maternal outcomes. Bivariate and multivariate analyses were performed to assess associations of chorionicity with maternal outcomes. Of the 2,979 patients eligible for inclusion, 2,627 (88.2%) had dichorionic twin gestations and 352 (11.8%) had monochorionic twin gestations. Patients with monochorionic twins were less likely to self-identify as non-Hispanic White and to have conceived via assisted reproductive technology but were more likely to be publicly insured, multiparous and have prenatal care with a maternal-fetal medicine provider. Neither gestational diabetes mellitus (6.8% monochorionic vs. 6.2% dichorionic, p = 0.74; adjusted odds ratio [OR] 1.06, 95% confidence interval (CI) 0.60-1.86) nor hypertensive disorders of pregnancy (21.9% monochorionic vs. 26.3% dichorionic, p = 0.09; adjusted OR 0.99, 95% CI, 0.71-1.38) differed by chorionicity. Of the secondary maternal outcomes, patients with monochorionic twins experienced a lower frequency of cesarean delivery (46.0 vs. 61.8%, p < 0.001), which persisted after multivariate analyses (adjusted OR 0.60, 95% CI 0.46-0.80). There were no differences in preterm delivery, preterm premature rupture of membranes, hemorrhage, hysterectomy, or intrahepatic cholestasis of pregnancy. The odds of gestational diabetes mellitus and hypertensive disorders of pregnancy do not appear to differ by twin chorionicity. · Hypertensive disorders of pregnancy do not differ by twin chorionicity.. · Gestational diabetes mellitus does not differ by twin chorionicity.. · Maternal outcomes are similar for individuals with monochorionic and dichorionic twin gestations..

Cardiovascular risk management following gestational diabetes and hypertensive disorders of pregnancy: a narrative review.

The burden of severe hypertensive disorders of pregnancy on perinatal outcomes: a nationwide case-control study in Suriname

The simultaneous occurrence of gestational diabetes and hypertensive disorders of pregnancy affects fetal growth and neonatal morbidity

BackgroundPrediction of pregnancy-related disorders is usually done based on established and easily measured risk factors. Recent advances in metabolomics may provide earlier and more accurate prediction of women at risk of pregnancy-related disorders.MethodsWe used data collected from women in the Born in Bradford (BiB; n = 8212) and UK Pregnancies Better Eating and Activity Trial (UPBEAT; n = 859) studies to create and validate prediction models for pregnancy-related disorders. These were gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), small for gestational age (SGA), large for gestational age (LGA) and preterm birth (PTB). We used ten-fold cross-validation and penalised regression to create prediction models. We compared the predictive performance of (1) risk factors (maternal age, pregnancy smoking, body mass index (BMI), ethnicity and parity) to (2) nuclear magnetic resonance-derived metabolites (N = 156 quantified metabolites, collected at 24–28 weeks gestation) and (3) combined risk factors and metabolites. The multi-ethnic BiB cohort was used for training and testing the models, with independent validation conducted in UPBEAT, a multi-ethnic study of obese pregnant women.ResultsMaternal age, pregnancy smoking, BMI, ethnicity and parity were retained in the combined risk factor and metabolite models for all outcomes apart from PTB, which did not include maternal age. In addition, 147, 33, 96, 51 and 14 of the 156 metabolite traits were retained in the combined risk factor and metabolite model for GDM, HDP, SGA, LGA and PTB, respectively. These include cholesterol and triglycerides in very low-density lipoproteins (VLDL) in the models predicting GDM, HDP, SGA and LGA, and monounsaturated fatty acids (MUFA), ratios of MUFA to omega 3 fatty acids and total fatty acids, and a ratio of apolipoprotein B to apolipoprotein A-1 (APOA:APOB1) were retained predictors for GDM and LGA. In BiB, discrimination for GDM, HDP, LGA and SGA was improved in the combined risk factors and metabolites models. Risk factor area under the curve (AUC 95% confidence interval (CI)): GDM (0.69 (0.64, 0.73)), HDP (0.74 (0.70, 0.78)) and LGA (0.71 (0.66, 0.75)), and SGA (0.59 (0.56, 0.63)). Combined risk factor and metabolite models AUC 95% (CI): GDM (0.78 (0.74, 0.81)), HDP (0.76 (0.73, 0.79)) and LGA (0.75 (0.70, 0.79)), and SGA (0.66 (0.63, 0.70)). For GDM, HDP and LGA, but not SGA, calibration was good for a combined risk factor and metabolite model. Prediction of PTB was poor for all models. Independent validation in UPBEAT at 24–28 weeks and 15–18 weeks gestation confirmed similar patterns of results, but AUCs were attenuated.ConclusionsOur results suggest a combined risk factor and metabolite model improves prediction of GDM, HDP and LGA, and SGA, when compared to risk factors alone. They also highlight the difficulty of predicting PTB, with all models performing poorly.

164: Perinatal outcome of women aged 50 years and above

Time trends in placenta-mediated pregnancy complications after assisted reproductive technology in the Nordic countries

Hypertensive disorders of pregnancy is a prevalent pregnancy complication worldwide, and the dose-response association between maternal pre-pregnancy body mass index (BMI) and hypertensive disorders of pregnancy has not been precisely studied. The aim of this study was to assess dose-response association between maternal pre-pregnancy BMI and hypertensive disorders of pregnancy, including pregnancy induced hypertension, preeclampsia and eclampsia. This dose-response meta-analysis searched four electronic databases (Pubmed, Web of science, OVID Embase and OVID Medline) for relevant publications up to October, 2023. Cohort studies evaluated the association between pre-pregnancy or early pregnancy maternal BMI and pregnancy induced hypertension, preeclampsia, eclampsia and hypertensive disorders of pregnancy were included. Non-linear or linear dose-response association was modeled. Unadjusted and adjusted effects were pooled separately, and four subgroups, meta-regression, five sensitivity analyses were conducted. Study protocol was registered on the PROSPERO (CRD42022290318). 157 cohort studies involving 51,813,975 pregnancies were finally included. Of 157 studies, multiple outcomes were reported: 58 on pregnancy induced hypertension, 92 on preeclampsia, 6 on eclampsia, and 84 on hypertensive disorders of pregnancy, have assessed the association with pre-pregnancy BMI. A significant linear dose-response relationship was identified between BMI and pregnancy induced hypertension with a crude relative risk (cRR) of BMI per 5-unit increase of 1.73 (95% confidence intervals [CI]: 1.65-1.81), and an adjusted odds ratio (aOR) per 5-unit increase of 1.82 (95% CI: 1.74-1.90). Similar dose-response relationship was observed between BMI and preeclampsia (cRR: 1.63, 1.58-1.69; aOR: 1.70, 1.61-1.80), eclampsia (cRR: 1.40, 1.28-1.53; aOR: 1.36, 1.20-1.53) and hypertensive disorders of pregnancy (cRR: 1.68, 1.63-1.74; aOR: 1.75, 1.68-1.82). Subgroup analyses revealed that the pooled risk of BMI for pregnancy induced hypertension, preeclampsia, eclampsia, and hypertensive disorders of pregnancy was likely higher in Asian pregnant women compared to those in American and European regions. Sensitivity analyses results were mainly consistent with the primary results. This meta-analysis demonstrated a clear and significant dose-response relationship between increasing maternal pre-pregnancy BMI and elevated risks of pregnancy induced hypertension, preeclampsia, eclampsia, and overall hypertensive disorders of pregnancy, underscoring the clinical importance of maintaining a healthy BMI prior to conception. Pre-pregnancy BMI may be an important focus for preconception counseling and subsequent pre-pregnancy weight management for both clinicians and women. National Natural Science Foundation of China (72174132, 82474335, 82225049), Natural Science Foundation of Sichuan Province (2024NSFSC1668, 2024YFFK0152), 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (ZYGD23004).

Impact of Antenatal Care Modifications on Gestational Diabetes Outcomes During the COVID-19 Pandemic