Complications In Subsequent Pregnancies Research Articles

Donor sperm recipients: fertility treatments, trends, and pregnancy outcomes.

PurposeTo report fertility treatment use and outcomes among patients who use donor sperm for intrauterine insemination (IUI), in vitro fertilization (IVF), and reciprocal IVF (co-IVF).MethodsThis is a retrospective review of patients who used donor sperm at an urban, southeastern academic reproductive center between 2014 and 2020.ResultsAmong the 374 patients presenting for care, 88 (23.5%) were single, 188 (50.3%) were in a same-sex female partnership, and 98 (26.2%) had a male partner with a diagnosis of male factor infertility. Most patients did not have infertility (73.2%). A total of 1106 cycles were completed, of which there were 931 IUI cycles, 146 traditional IVF cycles, and 31 co-IVF cycles. Live birth rates per cycle were 11% in IUI, 42% in IVF, and 61% in co-IVF. Of all resulting pregnancies, hypertensive disorders were most commonly experienced (18.0%), followed by preterm delivery (15.3%), neonatal complications (9.5%), gestational diabetes (4.8%), and fetal growth restriction (4.8%). Of the 198 infants born, fifteen (8.3%) required admission to the neonatal intensive care unit and three (1.7%) demised. Pregnancy and neonatal complications were more likely to occur in older patients and patients with elevated body mass index.ConclusionThe use of donor sperm for fertility treatment is increasing. These data show reassuring live birth rates; however, they also highlight the risks of subsequent pregnancy complications. With the expansion of fertility treatment options for patients, these data assist provider counseling of patients regarding anticipated cycle success rates and possible pregnancy complications.

P-426 Placental pathology following Intrauterine Insemination (IUI) with or without Ovarian Stimulation (OS)

Abstract Study question Do placental weight percentiles (PW %iles) and abnormality rates (PAR) differ in singleton-livebirths following IUI with or without OS [oral medications (OM), and injectable gonadotropins]? Summary answer Following singleton-livebirths, PW did not differ between groups, albeit over half of placentas were ≤25th%ile. Placental anatomic abnormalities were more often seen in OM cycles. What is known already ART data suggest a possible association between stimulation-induced supraphysiologic estradiol levels and increased risk of placental abnormalities, as well as subsequent placental-mediated pregnancy complications, such as preeclampsia. Whether there is an association between OS protocols for IUI and placental pathology remains unknown. Study design, size, duration Data from 975 IUI(±OS) cycles resulting in singleton livebirths at a large academic fertility center between 01/2004 and 01/2021, were retrospectively reviewed. In 386 cycles a full placental pathologic examination was available. Placentas were stratified by OS regimen into three groups: gonadotropins (n = 222), OM [Clomiphene Citrate (CC)/Letrozole (LTZ); n = 129], and unstimulated / natural (n = 35). PW and PAR were compared between groups. Participants/materials, setting, methods Participants: Women delivering a singleton liveborn following IUI(±OS) treatments with placental pathology available. Outcome Measures: PW (grs & %iles), and PAR (classified as anatomic, inflammatory, infectious, and vascular/thrombotic). Statistics: Regression analysis was utilized to compare PW and PAR between groups, adjusting for potential confounders (PW: maternal and gestational age, BMI, infertility diagnosis, medical complications, infant gender; PAR: maternal and gestational age, BMI, race). Adjusted Odds Ratios (adjOR, 95%CI) were calculated for the latter. Main results and the role of chance Mean(±STDEV) PW (grs) were 451.7(±113.3), 449.2(±102.4), and 481.8(±99.8), for the gonadotropins, OM, and natural groups, respectively. Interestingly, over half of the placentas in all three groups were ≤25th %ile (58.6%, 56.1%, and 52.9%, for gonadotropins, OM, and natural, respectively, p=.249), while 41.8%, 46.4%, and 38.2% were below the 10th %ile (for gonadotropins, OM, and natural, respectively, p=.598). Adjusted PW differences, and adjOR for small placenta (≤10th %ile) did not differ between groups [PW OR(95%CI): 5.6(-17.9-29.2), -28.1(-71.4-15.2), -11.7(-52.6-29.3); small placenta OR(95%CI): 1.04(0.62-1.76); 1.27(0.40-4.01), and 0.96(0.34-2.74) for OM vs. gonadotropins, OM vs. natural, and gonadotropins vs. natural, latter as ref. ]. Regarding PAR, anatomic(43.7%, 52.7%, and 40%, p=.192), inflammatory(20.7%, 27.1%, and 20%, p=.354), infectious(32.9%, 33.3%, and 31.4%, p=.978), and vascular/thrombotic(42.3%, 41.9%, and 42.9%, p=.993) abnormalities rates did not differ between gonadotropins, OM, and natural, respectively. AdjORs(95%CI) for inflammatory, infectious, and vascular/thrombotic abnormalities did not differ significantly between groups. However, anatomic abnormalities were more frequent among OM compared to gonadotropin and natural cycles [adjOR(95%CI): 1.76(1.06-2.91), p=.028, gonadotropins as ref.; 2.52(1.05-6.05), p=.038, natural as ref.]. Limitations, reasons for caution This study is limited by its retrospective nature. Unfortunately, placental pathology was available only in conceptions clearly identified as resulting from IUI(±OS) treatments. However, birth weights did not differ between those with and without available placental pathology. Natural/IUI cycles were limited in numbers not allowing meaningful conclusions. Wider implications of the findings Between IUI-conceived, singleton-livebirths with available placental pathology, mean PW did not differ significantly. However, a higher-than-expected percent of placentas were below the expected %iles, suggesting that IUI(±OS) might be associated with altered placental growth. Placental anatomic abnormalities were more common among OM cycles, compared to gonadotropins, and n atural IUI cycles. Trial registration number Not applicable

Immediate weight loss before ovarian stimulation with intrauterine insemination is associated with a lower risk of preeclampsia in women with obesity and unexplained infertility

ObjectiveTo determine whether successful weight loss before ovarian stimulation with intrauterine insemination (OS-IUI) affects the risk of future pregnancy complications among women with obesity and unexplained infertility after fertility treatment.DesignSecondary analysis of the randomized controlled clinical trial Improving Reproductive Fitness Through Pretreatment With Lifestyle Modification in Obese Women With Unexplained Infertility (FIT-PLESE).SettingMultiple academic health centers in the United States.Patient(s)Three hundred seventy-nine women with obesity and unexplained infertility who underwent standard infertility treatment after a lifestyle intervention.Intervention(s)The FIT-PLESE trial evaluated whether prepregnancy lifestyle interventions (diet with weight loss medication and exercise vs. exercise alone) before OS-IUI improved the live birth rate among women with obesity and unexplained infertility. Although the primary outcome of FIT-PLESE was live birth rate, we compared the demographics and subsequent pregnancy complications of women who successfully lost some weight with those of women who did not lose any during the interventions.Main Outcome Measure(s)Obstetric complications by groups were compared using χ2 and Fisher’s exact tests, and continuous variables were compared using Student’s t-tests. Logistic regression was used to assess the odds of preeclampsia after adjustment for the randomized treatment arm in FIT-PLESE.Result(s)There was a nonsignificant trend toward a lower risk of intrauterine growth restriction (4% vs. 16%, P = .124) and preterm delivery (6% vs. 15%, P = .343) among patients who lost at least some weight. The risk of preeclampsia was significantly lower (6% vs.35%, P = .002) in the weight loss group (odds ratio, 0.09; 95% confidence interval, 0.016–0.505; P = .006) after adjustment for treatment assignment.Conclusion(s)Among women with obesity and unexplained infertility who had live births after fertility treatment, prepregnancy weight loss due to lifestyle interventions before OS-IUI was associated with a lower risk of preeclampsia.

Subsequent perinatal outcomes of pregnancy with two consecutive pregnancies with gestational diabetes mellitus: A population-based cohort study.

BackgroundGestational diabetes mellitus (GDM) is glucose intolerance diagnosed during pregnancy. We aimed to explore the different outcomes of women with two consecutive pregnancies with GDM.MethodsThis study included 861 women with recurrent GDM who had two consecutive singleton deliveries at Fujian Maternity and Child Health Hospital between May 2012 and September 2020. Data on pregnancy complications and neonatal and delivery outcomes were collected and analyzed.ResultsAmong those women with recurrent GDM, there was no difference in pregnancy complications in index pregnancy vs subsequent pregnancy. Our data revealed there was a significantly higher incidence of thyroid disease in the subsequent pregnancies than in the index pregnancy. (6% vs 10%, p = .003)In subsequent pregnancies, the birth weight was greater than that of the index pregnancy (3296.63 ± 16.85 vs 3348.99 ± 16.05, p = .025); and the incidence of large for gestational age (LGA) was higher than that of the index pregnancy (16.3% vs 20.6%, p = .021). More cesarean sections occurred in the subsequent pregnancy. (32.9% vs 6.6%, p = .039). Postpartum hemorrhage, premature birth, and placental abruption were not significantly different between the two pregnancies.ConclusionsThe results suggest the effect of GDM on thyroid dysfunction may be persistent. Recurrent gestational diabetes results in a higher rate of cesarean delivery, incidence of LGA, and neonatal admission to the neonatal intensive care unit (NICU) in subsequent pregnancies. We need to pay attention to the postpartum thyroid function of pregnant women with GDM. Further studies are still needed on recurrent GDM to reduce this occurrence of admission to NICU.

The Risk of Complications in Second Pregnancy by Maternal BMI: The Role of First-pregnancy Complications, Pregestational Diabetes and Chronic Hypertension

(Acta Obstet Gynecol Scand. 2021;100:489–496. doi: 10.1111/aogs.14028. Epub November 2, 2020) Obesity, increased pregnancy body mass index (BMI), and past pregnancy complications are associated with future pregnancy complications and adverse short- and long-term maternal and neonatal outcomes. Gestational diabetes (GDM), gestational hypertension (GH), and preeclampsia (PE) are common pregnancy-associated complications. Recurrence of these complications increases when pregestational DM and/or chronic hypertension (cHTN) are present, though little research has been done on how adiposity and prior-pregnancy complications impact the risk of second-pregnancy complications. This study analyzes how complications in the first pregnancy and chronic conditions impact subsequent pregnancy complications and the role of maternal BMI.

Role of male partners in the long-term well-being of women who have experienced severe pre-eclampsia and eclampsia in rural Tanzania: a qualitative study

Men can be essential sources of support in maternal health, even more so in case of severe acute maternal morbidity (SAMM), affecting 1–2% of childbearing women in low-resource settings. In a qualitative study using semi-structured interviews, we explored the perspectives of nine male partners of women who suffered from (pre-)eclampsia six to seven years earlier in rural Tanzania. Male partners considered their role to be pivotal regarding finances, decision-making in healthcare-seeking and family planning and provided physical and emotional support. After SAMM, households may be affected in the long run. Some men took over their female partner’s household duties until up to two years after birth. Providing men with more information on complication readiness and birth preparedness would enable them to extend their role in maternal morbidity prevention. IMPACT STATEMENT What is already known on this subject? The essential role of male partners in maternal health in low- and middle-income countries is well-studied in relation to its impact on care-seeking behaviour. After childbirth, the long-term role of male partners has not yet been studied. What do the results of this study add? We demonstrated the important role of men during, but also after SAMM. Households may be affected years after women suffered from SAMM. For women with the most urgent support needs, this study suggest that at least some men feel responsible for their partner and have different pivotal roles. What are the implications of these findings for clinical practice and/or further research? Because of their motivation to support their female partner, strategies to reduce recurring complications in subsequent pregnancies should include targeting male partners, for example, by increasing birth preparedness and complication readiness. Further studies should confirm the results from our innovative but small-scale study, as well as investigate the long-term role of male partners after uncomplicated births. Other studies could investigate the separation of couples after SAMM, family planning decisions after SAMM and strategies for involving men and increasing complication readiness and birth preparedness.

Online survey on uterotomy closure techniques in caesarean section.

Uterine closure technique in caesarean section (CS) influences the rate of late complications in subsequent pregnancies. As no common recommendation on suture techniques exists, we developed a questionnaire to determine the techniques currently used and the frequencies of late complications. The online questionnaire consisted of 13 questions and was sent to 648 obstetric hospitals (level I-IV) in Germany. Number of CS, rate of vaginal birth after caesarean section (VBAC), the type of uterus suturing technique and the frequency of uterine dehiscences, ruptures and placenta accreta spectrum (PAS) were queried. The answers were anonymous, and results were evaluated descriptively. The response rate was 24.7%. The mean CS rate was 27.3% (±6.2), the repeat CS rate 33.2% (±18.1). After CS, 46.2% (±20.2) women delivered vaginally. To close the uterotomy, 74.4% of hospitals used single layer continuous sutures, 16.3% single layer locked sutures, 3.8% interrupted sutures, 3.1% double layer continuous sutures and 2.5% used other suture techniques. The percentages of observed uterine dehiscences did not differ significantly between the different levels of care nor did the uterotomy suture techniques. There is no uniform suturing technique in Germany. A detailed description of suture technique in surgery reports is required to evaluate complications insubsequent pregnancies. National online surveys on obstetric topics are feasible and facilitate the discussion on the need to define a standardized uterine closure technique for CS.

Miomektomija tokom carskog reza

Myomas (fibroids, leiomyomas) are the most common benign tumors of genital organs in women of reproductive age and represent a significant problem in women's health care. The frequency of cesarean section is higher in women with uterine fibroids. Absolute indications for myomectomy during caesarean section are: fibroids that prevent hysterotomy during caesarean section, impede uterine incision suture, hamper safe fetal extraction and cause uterine torsion. Relative indications for myomectomy during caesarean section are: subserous and pedunculated fibroids, anterior uterine wall fibroids, fibroids that can cause immediate perioperative, and puerperal complications, the patient's desire, fibroids that can cause complications in subsequent pregnancies, and fibroids that can be enucleated without additional hysterotomy. Myomectomy during caesarean section is a complex surgical procedure, associated with the possibility of considerable complications, and defining their actual frequency and risk factors for their occurrence requires further research. Myomectomy during caesarean section is associated with an increased risk of perioperative bleeding. Other perioperative complications of myomectomy during cesarean section are: disseminated intravascular coagulation, paralytic ileus, surgical site infections, sepsis, postoperative febrile morbidity, increased incidence of blood transfusions, and prolonged hospitalization.

Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk

Background The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri. Objective Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy Methods From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group. Results The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors. Conclusion In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.

Current status of fertility preservation for women with collagen disease undergoing gonadotoxic therapy in Nagasaki University Hospital

Alterations in the number and protein/gene expression of Hofbauer cells (HBCs) may play a role in microbial-driven/cytokine-mediated placental inflammation, and in subsequent pregnancy complications such as villitis, histologic chorioamnionitis, and the fetal inflammatory response syndrome. Pyroptosis is an inflammatory form of cell death mediated by the inflammasome, a multi-protein complex which drives the processing and secretion of interleukin 1 beta (IL-1β). Pyroptosis can be triggered by bacterial lipopolysaccharide (LPS) and adenosine triphosphate (ATP) in non-placental macrophages through activation of the NLRP3 inflammasome. However, the role of inflammasome activation and pyroptosis in HBC pathophysiology remains unclear. HBCs isolated from human term placentas were treated with or without LPS or ATP, alone or in combination. Treatment of HBCs with both LPS and ATP induced the rapid secretion of high levels of IL-1β and at the same time, cell death associated with nuclear condensation and cellular swelling. HBC treatment with both LPS and ATP induced caspase-1 activation, gasdermin D (GSDMD) cleavage, which mediates pyroptosis, and IL-1β processing. Caspase-1 activation, GSDMD cleavage, IL-1β processing, and IL-1β secretion were all significantly reduced following NLRP3 knockdown; inhibition of caspase-1; and inhibition of P2X7, the receptor that mediates K+ efflux. Together, our data indicate that LPS and ATP treatment stimulated NLRP3 inflammasome activation and pyroptosis in HBCs leading to the rapid release of IL-1β. Since the localization of HBCs confers a unique ability to influence microbial-associated placental and fetal inflammation, these studies suggest a key role for the inflammasome and pyroptosis in mediating HBC driven inflammation.

NLRP3 inflammasome function and pyroptotic cell death in human placental Hofbauer cells

Alterations in the number and protein/gene expression of Hofbauer cells (HBCs) may play a role in microbial-driven/cytokine-mediated placental inflammation, and in subsequent pregnancy complications such as villitis, histologic chorioamnionitis, and the fetal inflammatory response syndrome. Pyroptosis is an inflammatory form of cell death mediated by the inflammasome, a multi-protein complex which drives the processing and secretion of interleukin 1 beta (IL-1β). Pyroptosis can be triggered by bacterial lipopolysaccharide (LPS) and adenosine triphosphate (ATP) in non-placental macrophages through activation of the NLRP3 inflammasome. However, the role of inflammasome activation and pyroptosis in HBC pathophysiology remains unclear. HBCs isolated from human term placentas were treated with or without LPS or ATP, alone or in combination. Treatment of HBCs with both LPS and ATP induced the rapid secretion of high levels of IL-1β and at the same time, cell death associated with nuclear condensation and cellular swelling. HBC treatment with both LPS and ATP induced caspase-1 activation, gasdermin D (GSDMD) cleavage, which mediates pyroptosis, and IL-1β processing. Caspase-1 activation, GSDMD cleavage, IL-1β processing, and IL-1β secretion were all significantly reduced following NLRP3 knockdown; inhibition of caspase-1; and inhibition of P2X7, the receptor that mediates K+ efflux. Together, our data indicate that LPS and ATP treatment stimulated NLRP3 inflammasome activation and pyroptosis in HBCs leading to the rapid release of IL-1β. Since the localization of HBCs confers a unique ability to influence microbial-associated placental and fetal inflammation, these studies suggest a key role for the inflammasome and pyroptosis in mediating HBC driven inflammation.

Repeat Pregnancy after Prior Aortic Valve-in-Valve Replacement: A Cautionary Tale.

Transcatheter aortic valve replacement (TAVR) within a severely stenotic native aortic valve or previously placed surgical biologic aortic valve replacement (SAVR) is a rare occurrence in pregnant patients. The short- and long-term procedural outcomes for future pregnancies in these women or any woman of child bearing age who have received prior TAVR or TAVR in SAVR, are unknown. We describe the first result of a repeat pregnancy outcome in a woman with a history of prior TAVR in SAVR. Both maternal and fetal outcomes were favorable, but maternal cardiac complications observed in the third trimester emphasize our concerns regarding risk for cardiac complications in subsequent pregnancies in patients with a prior TAVR in SAVR. Despite the maternal complications that occurred during repeat pregnancy in this patient, a successful pregnancy outcome reaffirms our recommendation to utilize a multidisciplinary team for pregnancy management in patients with prior TAVR or TAVR in SAVR and to help in the management of any cardiac complications that may occur during or shortly after pregnancy.

Eclampsia.

Emergency medicine residents and medical students on emergency medicine rotations. Eclampsia is an uncommon but important life-threatening obstetrical emergency, complicating 1.5-10 deliveries per 10,000 pregnancies in resource-rich countries.1 If not recognized and treated promptly, there is risk of significant morbidity or death to both mother and baby. Clinically, eclampsia is defined by new-onset seizures or coma in women with preeclampsia.2 Preeclampsia is defined by maternal hypertension after 20 weeks gestation with or without signs of end organ dysfunction, and, like eclampsia, can develop in the postpartum period.1 Eclampsia manifests as new onset generalized tonicclonic seizures. Eclamptic seizures are usually preceded by neurologic symptoms such as severe or atypical headache, visual disturbances, and non-neurologic symptoms such as severe abdominal pain or proteinuria.1 Emergent treatment involves prompt administration of (intravenous) IV magnesium sulfate.2,3,4 Adjuncts include securing the airway if necessary and administration of IV antihypertensive medications. Like preeclampsia, definitive management is by prompt delivery of the fetus if the mother is still pregnant.1 If untreated, maternal mortality is as high as 14%.1 Women who develop eclampsia are at increased risk of obstetric complications in subsequent pregnancies and at higher risk for cardiovascular disease and metabolic disease later in life. At the end of this oral boards session, examinees will: 1) Demonstrate ability to obtain a complete medical history including a detailed obstetric history. 2) Demonstrate the ability to perform a detailed physical examination in a postpartum female patient who presents with a seizure. 3) Investigate the broad differential diagnoses which include electrolyte imbalances, brain tumor, meningitis or encephalitis, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and eclampsia. 4) List the appropriate laboratory and imaging studies to differentiate eclampsia from other diagnoses (complete blood count, comprehensive metabolic panel, magnesium level, pregnancy testing, urinalysis, and computed tomography [CT] scan of the head). 5) Identify a postpartum eclampsia patient and manage appropriately (administer IV magnesium therapy, administer IV antihypertensive therapy, emergent consultation with an obstetrician). 6) Provide appropriate disposition to the intensive care unit after consulting with an obstetrician. This was envisioned as an oral board testing case due to the multiple aspects which require emergency care. Residents are expected to assess the seriousness of the patient's condition, elicit critical details from her recent medical history, and synthesize that data in order to treat a medically complex patient. Oral board testing is able to incorporate each of these aspects together and provide the resident with a dynamic learning environment.Oral board testing is a way to assess the resident's ability to rapidly obtain and interpret multiple sources of information simultaneously. By utilizing a case that requires pharmaceutical therapy, the clinical competency committee is able to obtain additional milestones which are sometimes difficult to test in the emergency department itself.Learners were assessed using online evaluation tools available, ie, Google forms. Critical actions were subsequently tied to Emergency Medicine Milestones and the results were compiled and used for resident evaluations and clinical competency. Residents were given verbal feedback immediately after the examination, and they were provided with the scores of their online evaluation after all results were compiled. Learners and instructors provided written feedback after the case was administered to assess for strengths and weaknesses of the case, and modifications were then made to better address concerns. Learners answered written multiple-choice questions on high-level concepts, ie, critical actions, at least one month after this exam was completed. Learners found this a challenging, but enjoyable, way to refresh their knowledge and skills regarding preeclampsia, and this was a highly rated part of their mock oral board examination. Overall, residents rated the session 4.3 (1-5 Likert scale, 5 being Excellent) after the oral board review session was completed. Comments from residents included "haven't seen post-partum preeclampsia in residency" and "challenging to remember magnesium dosing." Residents and medical students were evaluated using this method and both enjoyed the activity as a novel way to study as well as exercise their medical knowledge. The content was both highly relevant to the practice of emergency medicine and the format was an effective way to deliver the information to the learners. The case is a good model to evaluate for the high stakes testing of both the written and oral board examinations, but also a way to assess residents' abilities to treat preeclamptic and eclamptic patients in the emergency department. Eclampsia, preeclampsia, seizures, end-organ damage, hypertensive emergency, altered mental status, neurologic emergency, obstetric emergency.

General and reproductive health among women after an episode of severe maternal morbidity: Results from the COMMAG study.

To assess general and reproductive health in women after severe maternal morbidity (SMM). A retrospective cohort study was performed at a tertiary maternity hospital. Women with SMM criteria who delivered during 2008-2012 were included in the SMM group. The control group included a random sample of women without SMM delivering in the same year of cases. Both groups were compared regarding sociodemographic/obstetric characteristics, general and reproductive health, using χ2 , Yates χ2 , Fisher exact, and Mann-Whitney tests. There were 315 women in the SMM group and 323 women in the control group. The SMM group was older and had a history of more medical conditions (hypertension, diabetes, obesity), cesarean deliveries, preterm births, and perinatal deaths. Breastfeeding was negatively affected in these women, as was fertility. The SMM group had a non-significant trend of fewer children after index pregnancy, had new complications in subsequent pregnancies, and required specialized medical care, besides higher risk of death. Women experiencing SMM are at higher risk of general and reproductive health problems after pregnancy, including risk of death. Therefore, their surveillance and follow-up should continue beyond 42days postpartum, highlighting the importance of more specialized health care.

Dramatic Rise in Cesarean Birth in Iran: A Coalition of Private Medical Practices and Women’s Choices

Objectives: Cesarean delivery without medical indication has regularly increased among Iranian women in the last three decades, and Iran has one of the highest rates of cesarean in the world. The present study aimed at reviewing the studies regarding the increase of cesarean in Iran and discussing the root causes for such an increase. Methods: This literature review focused on the existing quantitative and qualitative studies conducted from January 1990 to January 2019 regarding the reasons for an increase in the cesarean section in Iran. The combination of keywords including "cesarean section", "C-section", "cesarean delivery", and "Iran" was searched in several databases such as MEDLINE/PubMed, Embase, ISI Web of Science and Scopus, along with national databases (e.g., SID, MagIran, Iran Medex, and IranDoc). Results: A dramatic rise in cesarean birth stems from a number of factors including the role of health care professionals, insurance companies, socio-cultural factors, and the health policies, all of which have their roots in the medicalization of birth. Conclusions: In general, reducing the cesarean on maternal request necessitates the de-medicalization of birth, cultural awareness through the mass media, informing women of the long-term complications of cesarean, and physical and mental preparation of the mother. In addition, other contributing factors include encouraging inter-professional teamwork and collaboration between midwives and obstetrician-gynecologists, transforming the current curriculum of the midwifery and residency education, applying the midwifery-led care models, and decreasing the fear of litigation in midwifery and obstetrics-gynecology. Otherwise, maternal and fetal mortality will rise in the near future due to increased complications in subsequent pregnancies.

Pregnancy complications recur independently of maternal vascular malperfusion lesions.

Spontaneous abortions, intrauterine growth restriction, and preeclampsia are thought to be caused by defective placentation and are associated with increased risk of adverse outcomes in subsequent pregnancies. However, it is not known whether the recurrence of adverse outcomes is associated with the recurrence of placental pathology. We hypothesized that recurrent maternal vascular malperfusion (MVM) underlies the recurrence of adverse outcomes. Using data from the National Collaborative Perinatal Project, we assessed the recurrence of pregnancy complications and MVM lesions (N = 3865), associations between a history of spontaneous abortions and MVM lesions or adverse outcomes in subsequent pregnancies (N = 8312), and whether the recurrence of pregnancy complications occurred independently of the presence of MVM lesions. The odds of an MVM lesion were higher for a woman who had had an MVM lesion in a previous pregnancy (aOR = 1.6; 95% CI 1.3-1.9), although this was marginally non-significant after adjusting for covariates such as gestational age, race and BMI. The odds of preeclampsia, a small-for-gestational-age infant, premature delivery and early pregnancy loss were 2.7-5.0 times higher if there had been that same adverse outcome in a previous pregnancy. A history of spontaneous abortions was associated with higher risk of a small-for-gestational-age baby (aOR = 2.4; 95% CI 1.7-3.4) and prematurity (aOR = 5.1; 95% CI 2.3-11.5 for extremely preterm), but not preeclampsia. The recurrence of adverse outcomes was significant when restricting analyses to women without MVM lesions. Similarly, associations between adverse outcomes and previous spontaneous abortions were significant when statistically controlling for the presence of MVM lesions, or excluding pregnancies with MVM lesions. Women with adverse outcomes in one pregnancy are at higher risk of complications in subsequent pregnancies. However, there is significant recurrence of adverse outcomes even in the absence of MVM.

Prospective Validation of First-Trimester Ultrasound Characteristics as Predictive Tools for Twin-Twin Transfusion Syndrome and Selective Intrauterine Growth Restriction in Monochorionic Diamniotic Twin Pregnancies

Objective: Monochorionic diamniotic (MCDA) twins are at increased risk of adverse outcome due to unequal placental sharing and placental vascular communications between the fetal circulations. Most centres perform ultrasound examination every 2–3 weeks to identify these complications. Identifying a high-risk cohort of MCDA twins in the first trimester would allow more efficient surveillance. We have attempted to validate first-trimester ultrasound characteristics as predictive tools for twin-twin transfusion syndrome (TTTS) and selective intrauterine growth restriction (sIUGR) in MCDA twins. Material and Methods: This is a prospective cohort study including MCDA twins enrolled at the time of first-trimester combined screening. Differences in crown-rump length (CRL), nuchal translucency (NT) thickness, ductus venosus pulsatility index for veins (DV PIV), presence or absence of tricuspid regurgitation and right ventricular E/A ratio were assessed. Receiver operating characteristic (ROC) curves were used to assess the potential value of these measures as predictive tools for identifying a cohort of MCDA pregnancies at high risk of adverse pregnancy outcome. Results: Sixty-five MCDA pregnancies were included in the analysis. Nine (14%) developed TTTS, 17 (26%) developed sIUGR. The best predictive marker for TTTS was NT discordance of ≥20% (ROC AUC = 0.79; 95% CI 0.59–0.99). Combining measures did not improve performance (AUC = 0.80; 95% CI 0.62–0.99). Conclusion: NT discordance was the most effective characteristic at predicting TTTS but still had a relatively poor positive predictive value (36%). Intertwin differences in CRL, DV PIV and E/A ratio were not predictive of subsequent pregnancy complications. None of these characteristics have sufficient efficacy to be used to triage MCDA twin pregnancies ongoing obstetric surveillance.

Uterine artery embolization for postpartum and postabortion hemorrhage: a retrospective analysis of complications, subsequent fertility and pregnancy outcomes.

To evaluate the impact of UAE for postpartum and postabortion hemorrhage on future infertility, especially in patients undergoing infertility treatment, along with angiographic endpoints. Sixty-two sessions performed emergent or prophylactic UAE for postpartum or postabortion hemorrhage between 2008 and 2017 were selected. Subsequent pregnancy outcomes and complications were investigated as primary outcomes. The cases were divided into two groups based on the presence of massive hemorrhage. The relationships between angiographic endpoints and complications were also evaluated as secondary outcomes. The mean patient age was 34.1 ± 6.5years. Fourteen of the 23 patients (60.9%) with desired fertility achieved pregnancy and 10 patients achieved live births (43.5%). In the patients during infertility treatment, three of the four patients had complications of severe adhesion after caesarean section or placenta accreta. In the group of patients with massive hemorrhage, the occurrence of uterine infection was significantly high (p = 0.014), but the angiographic endpoints were not significant, regardless of the occurrence of uterine infection. It was unnecessary to modify embolic endpoint according to seriousness of the hemorrhage. The pregnancy and live birth rates were acceptable, although patients undergoing infertility treatment had a higher rate of delivery complications.

Placental complications in subsequent pregnancies after prior cesarean section performed in the first versus second stage of labor

Objective To examine whether prior cesarean delivery (CD) in the first stage of labor (non-progressive labor in the first stage – NPL1), when compared with CD in the second stage of labor (non-progressive labor in the second stage – NPL2), is associated with different rates of third stage placental complications in the subsequent delivery. Methods A retrospective cohort study, of all deliveries following a CD due to NLP1 or NLP2 that occurred between the years 1988 and 2013, was undertaken. Multiple gestation pregnancies, known uterine malformations or uterine fibroids were excluded. Rates of third stage complications (retained placenta, adherent/increta/percreta placenta, manual removal of the placenta) were compared between the groups. Univariate analysis was followed by multivariate analysis. Results During the study period, there were 3828 subsequent deliveries of parturients who were operated due to NPL1 and NPL2 (72.91 and 27.09%, respectively). Rates of manual removal of the placenta as well as adherent placenta were significantly higher among parturients following CD due to NPL2 (28.4 versus 24.0%, p = .04, 1.2 versus 0.4% p < .01, respectively). In a multivariate analysis controlling for possible confounders, adherent placenta was found to be independently associated with vaginal delivery following CD due to NPL2 (odds ratio 2.98, 95% confidence interval 1.30–6.77). Conclusions Prior CD due to NPL2 as opposed to NPL1 is independently associated with adherent placenta in the subsequent delivery. A higher index of suspicion may be needed when evaluating these women during pregnancy as well as during management of the delivery.

The mnemonic code of pregnancy: Comparative analyses of pregnancy success and complication risk in first and second human pregnancies

Obstetrical complications such as spontaneous abortion/miscarriage, fetal growth restriction, preeclampsia or preterm birth occur in approx. 15% of human pregnancies. Clinical experts often state that a previous uncomplicated pregnancy reduces the risk for complications in subsequent pregnancies. Vice versa, a prior pregnancy affected by obstetrical complications increases the risk for reoccurrence. However, published evidence directly underpinning these clinical statements is sparse. Considering that the maternal immune adaptation may be causally involved in determining the outcome of subsequent pregnancies, a comprehensive analysis of clinical data was long overdue.We here present a systematic analysis of clinical data using a PubMed-based approach to identify human studies with relevant information on birth weight and incidences of pregnancy complications in first and second pregnancies. From initially 18,592 publications, 37 studies were included in the quantitative data analysis.Women with a previous pregnancy affected by complications where a derailed immune response can be inferred have a 2.2–3.2-fold increased risk to be affected again in a subsequent pregnancy. Conversely, a normally progressing primary pregnancy reduced the risk for complications in a subsequent pregnancy by 35–65%. Moreover, an uncomplicated primary pregnancy was associated with a 4.2% increased birth weight in a following pregnancy without a difference in gestational age at delivery.In conclusion, the increased birth weight after previously uncomplicated pregnancies suggests that an immune memory is mounted during primary pregnancies. This immune memory may promote the successful outcome of subsequent pregnancies or – if missing or compromised – account for a risk perpetuation of pregnancy complications.