Antenatal Admissions Research Articles

Maternal and Perinatal Morbidity and Mortality Associated With Anemia in Pregnancy.

To estimate the incidence of anemia in pregnancy and compare the maternal and perinatal outcomes of women with and without anemia. We conducted a population-based retrospective cohort study on all pregnant women in British Columbia who had a live birth or stillbirth at or after 20 weeks of gestation between 2004 and 2016. Women were diagnosed with anemia based on two criteria: third-trimester hemoglobin value or a delivery admission diagnosis of anemia (made before delivery). Anemia was categorized into no anemia (hemoglobin 11 g/dL or greater), mild (9-10.9 g/dL), moderate (7-8.9 g/dL), severe (less than 7 g/dL), or anemia of unspecified severity (with diagnosis made before delivery). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% CIs expressing the association between anemia and maternal and perinatal outcomes. Of 515,270 women in the study population, 65,906 (12.8%) had anemia: 11.8%, 0.43%, and 0.02% had mild, moderate, and severe anemia, respectively, and 0.58% had anemia of unspecified severity. Anemic women had longer hospitalization duration and more antenatal admissions, and rates of preeclampsia, placenta previa and cesarean delivery were higher among women with anemia. The intrapartum-postpartum blood transfusion rate was 5.1 per 1,000 among women without anemia, and higher among women with anemia (aOR 2.45, 95% CI 1.74-3.45 for mild anemia; 21.3, 95% CI 12.2-37.3 for moderate anemia; not analyzable for severe anemia; and 48.3, 95% CI 6.60-353.9 for anemia of unspecified severity). Anemia was associated with preterm birth (mild anemia, aOR 1.09, 95% CI 1.05-1.12; moderate anemia, aOR 2.26, 95% CI 2.02-2.54; anemia of unspecified severity, aOR 2.27, 95% CI 2.06-2.50), small-for-gestational-age live birth, low 5-minute Apgar score, neonatal death, and perinatal death. Maternal anemia in pregnancy represents a common and potentially reversible risk factor associated with antepartum, intrapartum, and postpartum maternal morbidity and perinatal morbidity and mortality.

HOspital care versus TELemonitoring in high-risk pregnancy (HOTEL): study protocol for a multicentre non-inferiority randomised controlled trial

IntroductionPregnant women faced with complications of pregnancy often require long-term hospital admission for maternal and/or fetal monitoring. Antenatal admissions cause a burden to patients as well as hospital resources and...

Support during pregnancy for women at increased risk of low birthweight babies.

Background Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programs offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programs may include advice and counseling (about nutrition, rest, stress management, alcohol, and recreational drug use), tangible assistance (e.g., transportation to clinic appointments, household help), and emotional support. The programs may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or combination of lay and professional workers. Objectives The primary objective was to assess effects of programs offering additional social support compared with routine care, for pregnant women believed at high risk for giving birth to babies that are either preterm or weigh less than 2500 gm, or both, at birth. Secondary objectives were to determine whether effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay woman). Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010). Selection criteria Randomized trials of additional support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional support as some form of emotional support (e.g., counseling, reassurance, sympathetic listening) and information or advice or both, either in home visits or during clinic appointments, and could include tangible assistance (e.g., transportation to clinic appointments, assistance with care of other children at home). Data collection and analysis Two review authors evaluated methodological quality. We performed double data entry. Main results We included 17 trials (12,264 women). Programs offering additional social support for at-risk pregnant women were not associated with improvements in any perinatal outcomes, but there was a reduction in the likelihood of antenatal hospital admission (three trials; n = 737; RR 0.79, 95% CI 0.68 to 0.92) and caesarean birth (nine trials; n = 4522; RR 0.87, 95% CI 0.78 to 0.97). Authors' conclusions Pregnant women need the support of caring family members, friends, and health professionals. While programs which offer additional support during pregnancy are unlikely to prevent the pregnancy from resulting in a low birthweight or preterm baby, they may be helpful in reducing the likelihood of antenatal hospital admission and caesarean birth.

Development of a novel bedside index for the early identification of severe maternal infection

ObjectivesInternational consensus reports have recently recommended that the Systemic Inflammatory Response Syndrome (SIRS) criteria for the diagnosis of sepsis should cease and that new bedside criteria need to be developed to improve prevention, early diagnosis and treatment.The aim of this retrospective audit was to evaluate a suite of four bedside clinical criteria, called the Early Maternal Infection Prompts (EMIP), in helping to identify women with a suspected severe infection who were admitted to a High Dependency Unit (HDU) in a large tertiary referral stand-alone maternity hospital. Study designThe four EMIP criteria were decided based on existing national obstetric guidelines and a review of the recent literature on maternal critical illnesses. Cases were identified from the HDU registry for the three years 2015-2017. Individual charts were retrieved, and the four EMIP parameters were measured at the time of the clinical assessment that led to the HDU admission. Clinical and sociodemographic details were computerised for analysis. ResultsOf 73 women admitted with suspected severe maternal infection, the handwritten records were available in 69. The mean age was 31.3 years, 71% were multiparous and 26.1% were obese. Three quarters of cases were antenatal admissions. Infection was confirmed microbiologically in 56 (81.1%) of cases. There were no maternal deaths. There was no case of organ dysfunction diagnosed but two women required vasopressors to maintain blood pressure. Recordings of the maternal vital signs were not always fully completed before admission. In 69.1% (n = 47) of cases the temperature was elevated ≥ 37.5 C, in 81.2% (n = 56) of cases the heart rate was increased ≥ 100 bpm, in 51.9% (n = 27) cases the respiratory rate was increased ≥ 20 bpm, and in 25.4% (n = 17) cases the systolic blood pressure was ≤100 mmHg. At least one of the four EMIP criteria was abnormal in 91.3% (n = 63) of cases of suspected severe infection. ConclusionsThe audit confirmed that this bedside index has potential in helping to identify maternal infection early before sepsis develops. Prospective studies are required to evaluate the index in different settings, for different infections and at the different stages of maternal infection.

282: Risk of stillbirth after antepartum hospitalization for gestational hypertension or preeclampsia

Hypertensive diseases of pregnancy (HDP), including gestational hypertension and preeclampsia, are associated with increased risk for stillbirth. Patients with HDP may be admitted antenatally and then discharged with increased surveillance. For women with HDP at delivery, we sought to determine if preceding antenatal admission for HDP was associated with increased risk of stillbirth. This study used the 2010-2014 Nationwide Readmission Database. Deliveries hospitalizations with HDP occurring October to December each year were analyzed. We defined an antenatal admission with HDP as the primary diagnosis occurred within 9 months preceding each delivery. Our primary outcomes were stillbirth and stillbirth with placental abruption during delivery hospitalization. Subgroup analyses were conducted among patients admitted antenatally for HDP with primary predictors of number of admissions and cumulative antepartum length of stay. Log linear regression models including demographic and hospital factors were fit to characterize the adjusted effect of antepartum HDP admission on stillbirth. 3.9 million deliveries occurred in this time period, with 319,105 (8.2%) HDP deliveries occurred in this time period, (overall 8.2%), 0.8% with stillbirth (n=2,464), and 0.2% (n=553) with stillbirth and abruption. 3.2% (n=10,297) required antepartum admission for HDP. Among women with HDP, antepartum HDP admission was associated with higher risks of stillbirth and stillbirth/abruption (1.2% vs. 0.8%, 0.3% vs. 0.2%, respectively, p<0.01). In adjusted analysis, patients with HDP antepartum admissions were at increased risk of stillbirth/abruption (RR=1.52, 95% CI: 1.04, 2.21) (Table 1) and of stillbirth alone (RR=1.32, 95% CI: 1.10, 1.58). Among those with antepartum HDP admissions, >1 admission was associated with 3-fold higher risk of stillbirth/abruption (RR=3.39, 95% CI: 1.58, 7.28) (Table 2). Antepartum admission for HDP is a significant risk factor for stillbirth. Risk for stillbirth/abruption rose with number of antenatal admissions. Admission may be a proxy for disease activity; these high-risk patients require specialized care. For patients with an antenatal HDP diagnosis managed on an outpatient basis, close surveillance with regular fetal testing is indicated. Further research is warranted to identify optimal management strategies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

466: The risk of anticipated delivery in asymptomatic women presenting with short cervix in early viability

While it is known that an asymptomatic short cervical length (CL) is an independent risk factor for spontaneous preterm birth (sPTB), it is unclear when the delivery will take place. Subsequently, management decisions such as timing of antenatal corticosteroid (ACS) administration or hospital admission may be suboptimal. Therefore, the purpose of this study was to determine the risk of anticipated delivery in asymptomatic women presenting with a short CL in early viability. A retrospective cohort study of asymptomatic women with short cervix, (CL ≤ 25mm) between 23 and 28 weeks’ gestation, at a single center from January 2015 to March 2018 was performed. Women with multiple gestations, fetal anomalies and cervical cerclage were excluded. Demographic information as well as risk factors for sPTB were collected. Cases were divided into 4 groups based on CL measurement (≤ 10mm, 11-15mm, 16-20mm, 21-25mm). The primary outcome was time interval from presentation to delivery (Δt). Secondary outcomes included delivery within 2 weeks of presentation and gestational age (GA) at delivery. Continuous variables were compared using the Kruskal-Wallis test, while categorical variables were compared using Chi-squared or Fisher’s exact test as appropriate. The Wilcoxon test for difference in survival time was used to compare GA at delivery among the 4 CL groups with data stratified based on GA at presentation. 126 pregnancies met inclusion criteria. Baseline characteristics were similar among all four groups. Primary and secondary outcomes are reported in Table 1. The probability of delivery as a function of Δt is presented in Figure 1. There was a direct correlation between shorter CL and shorter Δt (p = 0.003). Regardless of the CL at presentation, delivery within 2 weeks was uncommon (1 patient; 0.8%). As expected, the risk for sPTB in asymptomatic women with short cervix increases as the CL shortens, with CL ≤10mm associated with the highest risk. Nevertheless, regardless of the CL, delivery within 2 weeks is highly unlikely. Therefore, we suggest that the timing of administration of ACS in this population should be delayed until additional indications are present.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

\u201cBabies born early?\u201d - silences about prematurity and their consequences

BackgroundThe principal aim of this study was to understand how communication between parents and health professionals concerning prematurity occurs, from delivery to admission to the neonatal Intensive Care Unit.MethodsThis is an exploratory, descriptive study with a qualitative methodology. Data were collected using tape-recorded and Focal Groups technique interview with mothers of premature newborns and health professionals involved in caring for preterm infants, at southeast Brazil.ResultsThe word “premature” was not said or heard during prenatal care. From the narratives, it was observed that there was a lack of information available to pregnant women about preterm birth, failure in medical care regarding signs and symptoms reported by pregnant women, and lack of communication between the medical teams, mothers and family during delivery and Neonatal Intensive Care Unit (NICU) admission.ConclusionThere is a fine line between born too soon and die too soon, that increases stress, fear and distance impacting negatively over communication between mothers and health professionals during antenatal care, childbirth and NICU admission.

The relationship between intimate partner violence reported at the first antenatal booking visit and obstetric and perinatal outcomes in an ethnically diverse group of Australian pregnant women: a population-based study over 10 years

ObjectivesIntimate partner violence (IPV) is a global health issue affecting mainly women and is known to escalate during pregnancy and impact negatively on obstetric and perinatal outcomes. The aim of...

Hypertension in pregnancy: Gaining insight into women's mental health and birth experience 6–12 months postpartum

𝘉𝘢𝘤𝘬𝘨𝘳𝘰𝘶𝘯𝘥 Pregnancy and childbirth, while usually joyful experiences, can be traumatic leading to depression, anxiety and post-traumatic stress disorder (PTSD). Women may be more prone to psychological morbidity following a complicated pregnancy and/or birth. Hypertension in pregnancy (HIP) is the most common medical complication of pregnancy. Women diagnosed with HIP require more intensive monitoring, antenatal admissions, a longer postnatal stay that may include acute care, and some give birth to a preterm baby requiring time in a nursery. There are reports of the short and long term health risks following HIP, particularly cardiovascular health, but there is limited knowledge about the impact on mental health, birth experience, and whether the care received influences women’s experiences. 𝘈𝘪𝘮 The aim of this study was to investigate the mental health (depression, anxiety and posttraumatic stress disorder) and childbirth experiences at six to 12 months postpartum in women who had HIP and those who had normal blood pressure (normotensive) in pregnancy. 𝘔𝘦𝘵𝘩𝘰𝘥𝘴 This was a longitudinal prospective observational study using mixed methods. There were two phases: 1) the mental health of women and their birth experience following a normotensive pregnancy or one complicated by hypertension, using a quantitative design; and, 2) the experience of women who had HIP, using a qualitative approach. At six months postpartum, women completed four screening instruments: the Edinburgh Postnatal Depression (EPDS), General Anxiety Disorder (GAD), Posttraumatic Stress Diagnostic, and Maternal Infant Bonding (MIB) scales. Birth experience data were collected using a seven point Likert Scale and two open ended questions. The qualitative component used individual, face-to-face, semi-structured interviews with a subset of 20 women at 10-12 months postpartum. Descriptive statistics, univariate and multivariate logistic regression and ordinal regression analyses were conducted on the quantitative data, with a thematic analysis undertaken on the interview transcripts. 𝘙𝘦𝘴𝘶𝘭𝘵𝘴 There were 237 women in the normotensive (NT) group and 84 in the hypertensive (HT) group. Both groups had similar demographic characteristics. Compared to the NT group, the HT group experienced more interventions during labour and birth, with the HT group having higher rates of induction of labour (70% versus 29%, p=<0.001) and caesarean sections (43% versus 18%, p=<0.001) compared to the NT group. Women in the HT group recorded significantly higher mean EPDS score (p=0.03) and more scored above the threshold for possible depression (p=0.03) compared to women in the NT group. There were no differences in anxiety, PTSD or bonding scores between groups. The proportion of women who identified their birth experience as traumatic was greater in the HT group (p=0.006). The strongest predictor of possible depression in the whole cohort was being a first time mother (AOR 5.03; 95% CI 1.19-21.3), and for PTSD it was having a preterm baby (AOR 7.46; 95% CI…

Is time of birth a predictor of adverse perinatal outcome? A hospital-based cross-sectional study in a low-resource setting, Tanzania

BackgroundInconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes.MethodsA cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients’ socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05.ResultsOff-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50–1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45–0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07–2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07–2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31–2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3–2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7–8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1–2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02–2.6, p = 0.004, for abnormal breech deliveries).ConclusionOff-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths.

Obstetrical Clostridium difficile Infection: A Retrospective Cohort Study [30D

INTRODUCTION: Clostridium difficile infections (CDIs) occurring in pregnancy and the peripartum period have been reported with increasing frequency. The aim of this study was to evaluate the risk factors and morbidity associated with obstetrical CDI. METHODS: We performed a retrospective cohort study, using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. The admission and delivery records of pregnant women were reviewed between 1999 and 2013. After adjusting for demographic data, the antenatal admission record and delivery outcomes of women with CDI in pregnancy were compared to pregnancies without CDI, using unconditional logistic regression. RESULTS: Of the total 12,592,178 births in our cohort, we identified 2757 admissions complicated by CDI. During the study period, the rate of antenatal admission for CDI doubled from 15 to 30 admissions per 100 000 deliveries per year (p &lt; 0.001). Risk factors associated with CDI in pregnancy include: age over 35, multiple gestations, smoking, Crohn’s disease, ulcerative colitis, long-term antibiotic use, pneumonia, pyelonephritis, as well as cesarean or perineal wound infection. CDI in pregnancy was associated with a significant increase in maternal death (OR 56.82, 95% CI 35.83-90.10). Further, there was an increase in sepsis (OR 59.10, 95% CI 48.80-71.57), paralytic ileus (OR 33.08, 95% CI 27.51-39.78), venous thromboembolism (OR 8.14, 95% CI 6.52-10.16) and hospital stays greater than 2 weeks (OR 24.34, 95% CI 21.59-27.44). CONCLUSION: CDIs in pregnancy have increased over the last fifteen-years and are associated with significant maternal morbidity and increased mortality.

Location and content of counselling and acceptance of postpartum IUD in Sri Lanka

BackgroundThe immediate postpartum IUD (PPIUD) is a long-acting, reversible method of contraception that can be used safely and effectively following a birth. To appropriately facilitate the immediate postpartum insertion of IUDs, women must be informed of the method’s availability and must be counselled on its benefits and risks prior to entering the delivery room. We examine the relationship between the location and quality of antenatal counselling and women’s acceptance of immediate postpartum IUD (PPIUD) in four hospitals in Sri Lanka.MethodsData were collected between January 2015 and May 2015. Modified Poisson regressions with robust standard errors are used to assess the relationships between place of counselling, indicators of counselling quality, and PPIUD uptake following delivery.ResultsWe find that women who were counselled in hospital antenatal clinics and admission wards were much more likely to have a PPIUD inserted than women who were counselled in field clinics or during home visits. Hospital-based counselling had higher quality indicators for providing information on PPIUD, and women were more likely to receive PPIUD information leaflets in hospital locations than in lower-tiered clinics or during home visits. Women who were counselled at hospital locations also reported a higher level of satisfaction with the counselling that they received. Receipt of hospital-based counselling was also linked to higher PPIUD uptake, in spite of the fact that women were more likely to be given information about the risks and alternatives to PPIUD in hospitals. The information about the risks of and alternatives to PPIUD, whether provided in hospital or in non-hospital settings, tended to lower the likelihood of acceptance to have a PPIUD insertion. Counselling in hospital admission wards was focused on women who had not been counselled at field clinics.ConclusionsThe study findings call for efforts that improve the training of midwives who provide PPIUD counselling at field clinics and during the home visits. We also recommend that routine PPIUD counselling be conducted in hospitals, even if women have already been counselled elsewhere.

Home uterine monitoring for detecting preterm labour.

To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed. To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with care that does not include home uterine activity monitoring. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), CENTRAL (Cochrane Library 2016, Issue 5), MEDLINE (1966 to 28 June 2016), Embase (1974 to 28 June 2016), CINAHL (1982 to 28 June 2016), and scanned reference lists of retrieved studies. Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk of preterm birth, compared with care that does not include home uterine activity monitoring. Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We did not attempt to contact authors to resolve queries. We assessed the evidence using the GRADE approach. There were 15 included studies (6008 enrolled participants); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; three studies, 1596 women; fixed-effect analysis) (GRADE high). This difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75, 95% CI 0.57 to 1.00; one study, 1292 women). There was no difference in the rate of perinatal mortality (RR 1.22, 95% CI 0.86 to 1.72; two studies, 2589 babies) (GRADE low).There was no difference in the number of preterm births at less than 37 weeks (average RR 0.85, CI 0.72 to 1.01; eight studies, 4834 women; random-effects, Tau2 = 0.03, I2 = 68%) (GRADE very low). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77, 95% CI 0.62 to 0.96; five studies, 2367 babies; random-effects, Tau2 = 0.02, I2 = 32%) (GRADE moderate). This difference was not maintained when we restricted the analysis to studies at low risk of bias (RR 0.86, 95% CI 0.74 to 1.01; one study, 1292 babies). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.48, 95% CI 0.31 to 0.64; two studies, 1994 women) (GRADE moderate). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21, 95% CI 1.01 to 1.45; seven studies, 4316 women; random-effects, Tau2 = 0.03, I2 = 62%), but this difference was no longer evident when we restricted the analysis to studies at low risk of bias (average RR 1.22, 95% CI 0.90 to 1.65; three studies, 3749 women; random-effects, Tau2 = 0.05, I2 = 76%) (GRADE low). The number of antenatal hospital admissions did not differ between home groups (RR 0.91, 95% CI 0.74 to 1.11; three studies, 1494 women (GRADE low)). We found no data on maternal anxiety or acceptability. Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but in more unscheduled antenatal visits and tocolytic treatment; the level of evidence is generally low to moderate. Important group differences were not evident when we undertook sensitivity analysis using only trials at low risk of bias. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

Is use of multiple antihypertensive agents to achieve blood pressure control associated with adverse pregnancy outcomes?

ObjectiveWe assessed whether requiring >1 medication for blood pressure control is associated with adverse pregnancy outcomes.Study DesignRetrospective cohort of 974 singletons with chronic hypertension at a tertiary care center. Subjects on >1 antihypertensive agent were compared to those on 1 agent < 20 weeks gestational age with results stratified by average blood pressure (<140/90 and ≥140/90 mmHg) from prenatal visits. The primary maternal outcome was preeclampsia; the primary neonatal outcome was small for gestational age (<10th percentile).ResultAmong women with blood pressure ≥140/90 mmHg, women on multiple agents had the greatest risk of preeclampsia, severe preeclampsia, antenatal admissions to rule out preeclampsia, preterm birth < 35 weeks and composite neonatal adverse outcomes.ConclusionCompared to use of a single agent when blood pressure is ≥140/90 mmHg, use of multiple agents increases adverse risks, while no such finding exists when blood pressure is controlled below 140/90 mmHg.

Comparison of serum selenium levels among hypertensive and normotensive pregnant women

ABSTRACTObjective: To correlate serum selenium levels with hypertensive disorders of pregnancy (HDP) in a selected population and evaluate this mineral as a possible protective factor. Methods: This case–control study included 32 normotensive, 20 hypertensive (chronic and gestational hypertension), and 38 preeclamptic pregnant women. All patients were recruited from antenatal or obstetric admissions of a tertiary hospital in Brazil. Serum selenium was measured at the time of inclusion. Patients were followed up until hospital discharge after delivery. Results: Groups did not differ with regard to maternal age, ethnicity, educational attainment, parity, or smoking prevalence. Normotensive patients had lower body mass index and were included in the study earlier. These patients also had a higher prevalence of comorbidities other than hypertension. Continuous use of medication and a history of HDP in previous pregnancies were more common in preeclamptic patients. Serum selenium levels were not significantly different between groups, with an average of 56.4 ± 15.3 μg/L in the control group, 53.2 ± 15.2 μg/L in the hypertension group, and 53.3 ± 16.8 μg/L in the preeclampsia group (p = 0.67). Among patients with preeclampsia, 52.6% had the severe form. Serum selenium levels in these patients also did not differ significantly from those of controls (p = 0.77). Preeclampsia was associated with earlier termination of pregnancy and lower birth weight (p < 0.05). There were no significant differences across groups in other outcomes of interest. Conclusion: Serum selenium levels did not differ significantly between groups. Thus, we could not establish whether selenium is a protective factor against these conditions.

Placental growth factor (alone or in combination with soluble fms-like tyrosine kinase 1) as an aid to the assessment of women with suspected pre-eclampsia: systematic review and economic analysis.

Pre-eclampsia (PE) prediction based on blood pressure, presence of protein in the urine, symptoms and laboratory test abnormalities can result in false-positive diagnoses. This may lead to unnecessary antenatal admissions and preterm delivery. Blood tests that measure placental growth factor (PlGF) or the ratio of soluble fms-like tyrosine kinase 1 (sFlt-1) to PlGF could aid prediction of PE if either were added to routine clinical assessment or used as a replacement for proteinuria testing. To evaluate the diagnostic accuracy and cost-effectiveness of PlGF-based tests for patients referred to secondary care with suspected PE in weeks 20-37 of pregnancy. Systematic reviews and an economic analysis. Bibliographic databases including MEDLINE, EMBASE, Web of Science and The Cochrane Library and Database of Abstracts of Reviews of Effects were searched up to July 2015 for English-language references. Conferences, websites, systematic reviews and confidential company submissions were also accessed. Systematic reviews of test accuracy and economic studies were conducted to inform an economic analysis. Test accuracy studies were required to include women with suspected PE and report quantitatively the accuracy of PlGF-based tests; their risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. The economic studies review had broad eligibility criteria to capture any types of economic analysis; critical appraisal employed standard checklists consistent with National Institute for Health and Care Excellence criteria. Study selection, critical appraisal and data extraction in both reviews were performed by two reviewers. An independent economic analysis was conducted based on a decision tree model, using the best evidence available. The model evaluates costs (2014, GBP) from a NHS and Personal Social Services perspective. Given the short analysis time horizon, no discounting was undertaken. Four studies were included in the systematic review of test accuracy: two on Alere's Triage® PlGF test (Alere, Inc., San Diego, CA, USA) for predicting PE requiring delivery within a specified time and two on Roche Diagnostics' Elecsys® sFlt-1 to PlGF ratio test (Roche Diagnostics GmbH, Mannheim, Germany) for predicting PE within a specified time. Three studies were included in the systematic review of economic studies, and two confidential company economic analyses were assessed separately. Study heterogeneity precluded meta-analyses of test accuracy or cost-analysis outcomes, so narrative syntheses were conducted to inform the independent economic model. The model predicts that, when supplementing routine clinical assessment for rule-out and rule-in of PE, the two tests would be cost-saving in weeks 20-35 of gestation, and marginally cost-saving in weeks 35-37, but with minuscule impact on quality of life. Length of neonatal intensive care unit stay was the most influential parameter in sensitivity analyses. All other sensitivity analyses had negligible effects on results. No head-to-head comparisons of the tests were identified. No studies investigated accuracy of PlGF-based tests when used as a replacement for proteinuria testing. Test accuracy studies were found to be at high risk of clinical review bias. The Triage and Elecsys tests would save money if added to routine clinical assessment for PE. The magnitude of savings is uncertain, but the tests remain cost-saving under worst-case assumptions. Further research is required to clarify how the test results would be interpreted and applied in clinical practice. This study is registered as PROSPERO CRD42015017670. The National Institute for Health Research Health Technology Assessment programme.

Use of complementary and alternative medicine in pregnancy and its impact on obstetric outcome

ObjectiveTo evaluate the prevalence of use of complementary and alternative medicine (CAM) in a Malaysian antenatal population and its impact on obstetric outcome. DesignCross sectional study. SettingObstetric Unit, Hospital Sultanah Bahiyah, Alor Setar, Kedah. Material and MethodWomen attending antenatal clinic and Patient Admission Centre (PAC) above 30 weeks gestation were given structured questionnaires to fill. Pregnancy outcome measures were documented and analyzed in relation to the information gathered through the questionnaire. SPSS Version 21 was used to analyze all data obtained. ResultsOut of 447 women, the overall prevalence of CAM usage in pregnancy was 85.2%. It was popular among pregnant mothers aged between 26 and 35 years old and most commonly used in the third trimester (p = 0.0.010) to facilitate labour. Other sociodemographic factors such as race, parity, education, occupation and residence were not significantly important. Traditional herbs was the commonest type of CAM used in pregnancy (58.3%) followed by selusuh (24.3%). About 78.5% of the CAM users delivered vaginally (p = 0.020) but a significant proportion (14.3%) had fetal distress (p = 0.035) compared to non CAM users. The most common type of herbs used was akar kayu bunga Fatimah (37.7%) and gamat (13.4%). In our study, usage of selusuh product and akar kayu bunga Fatimah had a significant impact in achieving vaginal delivery and shortened the duration of labour particularly in multiparae. The usage of Kacip Fatimah and Salindah was associated with preterm labour (p = 0.04)Tongkat Ali herbal coffee had a significant association with hypertensive disorders in pregnancy (p = 0.011) and fetal distress (p = 0.04) Meanwhile, the usage of Jamu Mustika Ratu was significantly associated with low birth weight in grandmultiparae (p = 0.026)and spirulina was significantly associated with oligohydramnios (p = 0.04). ConclusionUsage of CAM in pregnancy in the Malaysian population is of high prevalence CAM in pregnancy has beneficial and adverse obstetric outcomes. More research is needed to establish the safety of usage of various forms of CAM in pregnancy.

Closed-Loop Insulin Delivery during Pregnancy in Women with Type 1 Diabetes

BackgroundIn patients with type 1 diabetes who are not pregnant, closed-loop (automated) insulin delivery can provide better glycemic control than sensor-augmented pump therapy, but data are lacking on the efficacy, safety, and feasibility of closed-loop therapy during pregnancy.MethodsWe performed an open-label, randomized, crossover study comparing overnight closed-loop therapy with sensor-augmented pump therapy, followed by a continuation phase in which the closed-loop system was used day and night. Sixteen pregnant women with type 1 diabetes completed 4 weeks of closed-loop pump therapy (intervention) and sensor-augmented pump therapy (control) in random order. During the continuation phase, 14 of the participants used the closed-loop system day and night until delivery. The primary outcome was the percentage of time that overnight glucose levels were within the target range (63 to 140 mg per deciliter [3.5 to 7.8 mmol per liter]).ResultsThe percentage of time that overnight glucose levels were in the target range was higher during closed-loop therapy than during control therapy (74.7% vs. 59.5%; absolute difference, 15.2 percentage points; 95% confidence interval, 6.1 to 24.2; P=0.002). The overnight mean glucose level was lower during closed-loop therapy than during control therapy (119 vs. 133 mg per deciliter [6.6 vs. 7.4 mmol per liter], P=0.009). There were no significant differences between closed-loop and control therapy in the percentage of time in which glucose levels were below the target range (1.3% and 1.9%, respectively; P=0.28), in insulin doses, or in adverse-event rates. During the continuation phase (up to 14.6 additional weeks, including antenatal hospitalizations, labor, and delivery), glucose levels were in the target range 68.7% of the time; the mean glucose level was 126 mg per deciliter (7.0 mmol per liter). No episodes of severe hypoglycemia requiring third-party assistance occurred during either phase.ConclusionsOvernight closed-loop therapy resulted in better glucose control than sensor-augmented pump therapy in pregnant women with type 1 diabetes. Women receiving day-and-night closed-loop therapy maintained glycemic control during a high proportion of the time in a period that encompassed antenatal hospital admission, labor, and delivery. (Funded by the National Institute for Health Research and others; Current Controlled Trials number, ISRCTN71510001.)

73 Comparison of serum selenium levels among hypertensive and normotensive pregnant women from southern brazil: A Case control-study

Introduction The hypertensive disorders of pregnancy (HDP) are the leading cause of maternal death in the world; however, its pathogenesis is not fully understood. It is believed that a dysfunction in the placentation process leads to oxidative stress, thus antioxidants like selenium could be a protective factor Objectives To correlate serum selenium levels with HDP in our population, considering a possible protective factor of this mineral. Methods This case-control study included 32 normotensive pregnant women, 20 with hypertension (chronic and gestational hypertension) and 38 patients with preeclampsia. All patients were derived from antenatal or obstetric admission of a tertiary hospital Southern Brazil. Serum selenium was measured at the time of inclusion in the study. Patients were followed until hospital discharge after delivery. The significance level was 5% (p ⩽ 0.05) and analyzes were performed using SPSS version 18. Values were expressed as mean ± standard deviation. Chi-square test was utilized for the categorical variables. Continuous variables were first tested using the Shapiro–Wilk test and then applied an independent-sample t test, Mann–Whitney U test, one-way analysis of variance (with post hoc Student–Newman–Keul) or Kruskal–Wallis test according with the groups. Results The patients did not differ with regard to maternal age, ethnicity, years of education, parity, and smoking prevalence. Normotensive patients had lower body mass index and were included in the study earlier. In addition, these patients had a higher prevalence of other comorbidities excluding hypertension. Patients with preeclampsia had higher levels of systolic blood pressure on admission. Continuous use of medication and HDP history in previous pregnancies were more common in patients with preeclampsia. Serum selenium levels were not significantly different between groups, with an average of 56.4 ± 15,3 μg/L in the control group, 53.2 ± 15,2 μg/L in the hypertension group and 53.3 ± 16,8 μg/L in the group with preeclampsia (P = 0.67). Of patients with preeclampsia, 52.6% had severe preeclampsia. Serum selenium levels of these patients did not differ significantly from the control group (P = 0.77). Preeclampsia was associated with earlier interruption of pregnancy and lower birth weight (P Conclusions There was no significant difference in the concentration of serum selenium between normotensive and hypertensive women, thus not being possible to establish selenium as a protective factor. Besides, we found that our population is extremely selenium deficient. One may speculate that population-wide low plasma concentrations of selenium may be one etiology accounting for the higher incidence of preeclampsia and may conjecture that selenium supplementation might lower this incidence.

Implementation of foetal fibronectin testing: Admissions, maternal interventions and costs at 1 year

Foetal fibronectin testing (fFN) has a high negative predictive value for preterm delivery, but it has a cost implication. This two-stage prospective study evaluated the real patient costs and clinical impact of introducing the fFN test in women presenting acutely with threatened preterm labour in a tertiary UK obstetric hospital. Introduction of the fFN test for women with threatened preterm labour reduced antenatal admissions and in utero transfers, and reduced steroid treatment and tocolysis, even at 1 year after implementation. The total number of bed days for women with threatened preterm labour who did not deliver during admission fell from 132 (mean 8.8 days) to 25 days (mean 3.6 days). The mean cost of admission per woman before introduction of the fFN test was £1032 (95% CI £880 to £1184); after it was £339 (95% CI £261 to £417). In this small single centre study, the introduction of the test produced a cost saving of £693 per woman (95% CI, £464 to £922) which over 12 months potentially saves £74844 (95% CI £50,112 to £99,576). Further studies are needed to formally evaluate the cost-effectiveness of the fFN test and its impact on clinical decision-making in large populations.