Complications In Subsequent Pregnancies Research Articles

Pregnancy-Associated Stroke and the Recurrence of Stroke and Other Complications in Subsequent Pregnancies: Population-Based Retrospective Cohort Study

Pregnancy-Associated Stroke and the Recurrence of Stroke and Other Complications in Subsequent Pregnancies: Population-Based Retrospective Cohort Study

Sonographic Assessment of Isthmocele and Its Obstetric Complications in Subsequent Pregnancies: A Pictorial Review

Sonographic Assessment of Isthmocele and Its Obstetric Complications in Subsequent Pregnancies: A Pictorial Review

Maternal Malaria and the Risk of Subsequent Pregnancy Complications

Maternal malaria, primarily caused by Plasmodium falciparum, has well-documented immediate effects on pregnancy, including preterm birth, low birth weight, and placental dysfunction. However, its impact extends beyond the current pregnancy, potentially influencing outcomes in subsequent pregnancies. This review examines how maternal malaria affects future pregnancies, focusing on the mechanisms through which previous malaria infections contribute to subsequent complications. Key mechanisms include chronic placental damage, immune system alterations, and persistent inflammation, which can disrupt placental function and increase the risk of adverse outcomes such as preterm labor and placental abruption in future pregnancies. The review highlights evidence that women with a history of maternal malaria are at an elevated risk for complications in subsequent pregnancies, including an increased likelihood of preterm birth and low birth weight. Persistent placental damage and immune dysregulation resulting from past malaria infections contribute to these risks. Understanding these long-term effects is crucial for developing effective public health strategies and interventions aimed at mitigating the risks of adverse pregnancy outcomes in malaria-endemic regions. Keywords: Maternal malaria, Plasmodium falciparum, pregnancy complications, placental damage, immune dysregulation, chronic inflammation, preterm birth

O-200 Association between proton pump inhibitors use and the risk of maternal infections during pregnancy and postpartum: a Swedish population-based cohort study

Abstract Study question Is there an association between use of proton pump inhibitors (PPIs) and maternal infection during or after pregnancy and subsequent pregnancy complications? Summary answer Use of PPIs in the 3 months before pregnancy or during the first trimester was associated with an elevated risk of maternal infection. What is known already PPIs alter gastric acidity and the gut microbiome, which may increase infection risks in the general population, but their impact on pregnant women is unknown. Study design, size, duration We conducted a Nationwide population-based cohort study using data from Swedish healthcare registers. PPIs use was defined as ≥ 1 prescription fill of a PPI in the 90 days before the first day of the last menstrual period (LMP) to the end of the 1st trimester (LMP+97 days). Maternal infections were identified from the start of the 2nd trimester to 90 days postpartum and classified as mild, moderate/ severe infections, and infection-related pregnancy complications. Participants/materials, setting, methods All pregnancies resulting in live or stillbirths between 2006 to 2019 in Sweden, identified using the Medical Birth Register. Log-binomial regression was used to estimate associations (relative risk (RR) and 95% confidence intervals (CI)) between PPIs and maternal infection, adjusting for potential confounders including birth year, maternal age at delivery, early pregnancy BMI, comorbidities, smoking in early pregnancy, maternal country of birth, maternal education, and parity. Main results and the role of chance Among 1,510,560 pregnant women, 42,599 (2.8%) used PPIs, and use increased over the study period time from 1.5% in 2006 to 3.44% in 2019. Compared to pregnant women without PPI use, those with PPI use had higher rates and risks of any infection (49.7% vs 36.8%; adjusted RR 1.30, 95%CI 1.29-1.32), mild infection (20.9% vs 16.1%; adjusted RR 1.30, 95%CI 1.28-1.33), moderate to severe infection (23.4% vs 15%; adjusted RR 1.47, 95%CI 1.45-1.50), and infection-related pregnancy complications (11.2% vs 9.2; adjusted RR 1.12, 95%CI 1.09-1.15). Conclusion Our results show an association between PPI use and an elevated risk of infection in pregnant women. Next steps include the further investigation into the infection types. PPI therapy has benefits and drawbacks that should be carefully weighed, especially in patients who are prone to infections. While our study highlights potential concerns, it does not imply that all pregnant women are at increased risk. More research is needed to understand the underlying mechanisms and assess potential preventive measures. Prescribing PPIs during pregnancy should be determined on a case-by-case basis, considering the patient’s individual health state. We acknowledge the necessity for caution, particularly in vulnerable populations, and more research is needed to demonstrate clinical correlations. Limitations, reasons for caution Potential confounding by indication due to underlying morbidities cannot be fully accounted for. Further research is required to establish clinical connections. Wider implications of the findings Clinicians should carefully weigh the benefits of PPI therapy during pregnancy, particularly in patients prone to infections. Trial registration number not applicable

Associations between the time interval from myomectomy to subsequent pregnancy and the obstetric outcomes: A population-based cohort study.

To investigate the associations between time interval from myomectomy to pregnancy (TIMP) and subsequent pregnancy and obstetric complications, and to explore whether these associations vary according to maternal age at birth. A retrospective population-based cohort study was conducted from 2008 to 2017. Data were extracted from the National Health Insurance Research Database and the Taiwan Maternal and Child Health Database, comprising 2024 379 births from 1 391 856 pregnancies. Eligible cases were identified using diagnostic and procedure codes; 4006 first singleton births in 4006 women after their first laparotomic myomectomy were identified. We estimated the risks of pregnancy and obstetric outcomes according to TIMP (<6, 6-11, and ≥12 months). Subgroup analysis was performed by further dividing according to maternal age at birth (18-34 vs ≥35 years old). We observed higher risks of gestational hypertensive disorders (adjusted odds ratio [aOR] 1.97, 95% confidence interval [CI] 1.22-3.18, P = 0.005) and neonatal death (aOR 4.59, 95% CI 1.49-14.18, P = 0.008) for TIMP of <6 months versus TIMP of 6-11 months. Likewise, a TIMP ≥12 months was associated with increased risks of gestational hypertensive disorders (aOR 1.72, 95% CI 1.14-2.58, P = 0.010), and neonatal death (aOR 3.27, 95% CI 1.16-9.24, P = 0.025) versus a TIMP of 6-11 months. In subgroup analysis, women over 35 years old still had higher risks of gestational hypertensive disorders when TIMP was <6 months (aOR 2.26, 95% CI 1.17-4.37, P = 0.015) or ≥12 months (aOR 2.04, 95% CI 1.17-3.54, P = 0.012), and a higher risk of neonatal death when TIMP was <6 months (aOR 4.05, 95% CI 1.06-15.53, P = 0.041); whereas women aged 18-34 years old did not. This study suggests that a TIMP between 6 and 11 months is associated with lower risks of gestational hypertensive disorders and neonatal death compared with a TIMP <6 months or ≥12 months, especially for women over 35 years old.

Impaired bone morphogenetic protein (BMP) signaling pathways disrupt decidualization in endometriosis

Endometriosis is linked to increased infertility and pregnancy complications due to defective endometrial decidualization. We hypothesized that identification of altered signaling pathways during decidualization could identify the underlying cause of infertility and pregnancy complications. Our study reveals that transforming growth factor β (TGFβ) pathways are impaired in the endometrium of individuals with endometriosis, leading to defective decidualization. Through detailed transcriptomic analyses, we discovered abnormalities in TGFβ signaling pathways and key regulators, such as SMAD4, in the endometrium of affected individuals. We also observed compromised activity of bone morphogenetic proteins (BMP), a subset of the TGFβ family, that control endometrial receptivity. Using 3-dimensional models of endometrial stromal and epithelial assembloids, we showed that exogenous BMP2 improved decidual marker expression in individuals with endometriosis. Our findings reveal dysfunction of BMP/SMAD signaling in the endometrium of individuals with endometriosis, explaining decidualization defects and subsequent pregnancy complications in these individuals.

Single-layer vs double-layer uterine closure during cesarean delivery: 3-year follow-up of a randomized controlled trial (2Close study)

BackgroundThe rising rate of cesarean sections (CS) has led to an increased incidence of long long-term complications, including niche formation in the uterine scar. Niche development is associated with various gynecological complaints and complications in subsequent pregnancies, such as uterine rupture and placenta accreta spectrum disorders. Although uterine closure technique is considered a potential risk factor for niche development, consensus on the optimal technique remains elusive. ObjectiveWe aim to evaluate the effect of single- versus double-layer closure of the uterine incision on live birth rate at a 3-year follow-up with secondary objectives focusing on gynecological, fertility and obstetric outcomes at the same follow-up. Study DesignA multicenter, double-blind, randomized controlled trial was performed at 32 hospitals in the Netherlands. Women ≥18 years undergoing a first CS were randomly assigned (1:1) to receive either single-layer or double-layer closure of the uterine incision. The primary outcome of the long-term follow-up was the live birth rate with secondary outcomes including pregnancy rate, the need for fertility treatment, mode of delivery, and obstetric and gynecologic complications. This trial is registered on the International Clinical Trials Registry Platform www.who.int (NTR5480; trial finished). ResultsBetween 2016 and 2018, the 2Close study randomly assigned 2292 women, with 830/1144 and 818/1148 responding to the 3-year questionnaire in the single-layer and double-layer closure. No differences were observed in live birth rates, also no differences in pregnancy rate, need for fertility treatments, mode of delivery or uterine ruptures in subsequent pregnancies. High rates of gynecological symptoms including spotting (30-32%), dysmenorrhea (47-49%) and sexual dysfunction (FSFI score 23)-are reported in both groups. ConclusionThe study did not demonstrate the superiority of double-layer closure over single-layer closure in terms of reproductive outcomes after a first CS. This challenges the current recommendation favoring double-layer closure, and we propose that surgeons can choose their preferred technique. Furthermore, the high risk of gynecological symptoms after a CS should be discussed with patients.

Prenatal ultrasound screening and pregnancy outcomes in HIV-positive women in Germany: results from a retrospective single-center study at the Charité-Universitätsmedizin Berlin.

The aim of this study was to investigate the rate of Mother-to-child-transmission (MTCT) in women living with HIV (WLWH) in a tertiary care institution. Furthermore, we aimed to assess prenatal ultrasound screening for fetal anomalies and outcomes in high-risk pregnancies due to maternal HIV infection." In this single-center study, retrospective data related to pregnancy and childbirth were collected from 420 WLWH. All data were evaluated descriptively. From January 2014 to December 2020, a total number of 420 pregnant WLWH delivered 428 newborns. 415 (98.8%) were receiving antiretroviral therapy (ART) and 88.8% had a viral load of < 50 cop/ml prior delivery. 46 (11%) of the newborns were born prematurely. Low birth weight < 2500g occurred in 38 (9.1%) of the children. 219 (52.1%) caesarean sections (CS) were performed. The most frequent indication for an elective CS was a previous CS (70.2%). 8 severe malformations were detected using first and second trimester ultrasound. In one child, MTCT was detected postpartum, resulting in an HIV transmission rate of 0.2% in the presented cohort. The low rate of vertical HIV-transmission in our cohort of 0.2% is the result of interdisciplinary prenatal care and high experience of healthcare providers in treatment of WLWH. Despite high ART coverage and adherence, good maternal immune system and very low vertical HIV transmission rate, maternal HIV infection remains a challenge in obstetric care. First and second ultrasound screening should be a part of prenatal care for HIV-infected women and should also be offered to HIV-negative women. A reduction of the rate of unnecessary elective caesarean deliveries in WLWH is necessary to reduce complications in subsequent pregnancies.

Association of Gestational Hypertension with Sociodemographic and Anthropometric Factors, Perinatal Outcomes, Breastfeeding Practices, and Mediterranean Diet Adherence: A Cross-Sectional Study.

Background and Objectives: Gestational hypertension has been associated with several pregnancy short-term and long-term complications, affecting both the mother and her infant's health. The present study aims to assess the potential association of gestational hypertension with sociodemographic and anthropometry factors, perinatal outcomes, breastfeeding habits, and Mediterranean diet (MD) compliance. Materials and Methods: This is a cross-sectional study conducted on 5271 mothers that was carried out after delivery. The anthropometry characteristics and perinatal outcomes were retrieved from the mothers' medical records. Sociodemographic characteristics, MD adherence, and breastfeeding habits were assessed via one-to-one interviews of the assigned women with qualified staff. Results: Maternal older age, being employed, family history of gestational hypertension, overweight/obesity before gestation, and abnormal gestational weight gain (GWG) independently increased the risk of developing gestational hypertension. Moreover, gestational hypertension was independently related with a greater incidence of abnormal childbirth body weight and preterm birth, not exclusively breastfeeding, and lower levels of MD adherence. Conclusions: This study highlights the importance of informing future mothers about the risk factors of gestational hypertension, underlining also that a healthy lifestyle, which simultaneously includes a healthy nutritional pattern such as MD, may decrease the risk of developing gestational hypertension and the subsequent pregnancy complications.

Women with Preexisting CKD and a History of Preeclampsia Have a High Rate of Subsequent Pregnancy Complications but Are Seldom Linked to Adequate Care

Women with Preexisting CKD and a History of Preeclampsia Have a High Rate of Subsequent Pregnancy Complications but Are Seldom Linked to Adequate Care

Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis.

The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Characteristics of pregnancy with placenta previa in Prof. Dr. I. G. N. G. Ngoerah General Hospital, Bali, in 2017

Introduction: Cesarean sections (CS) are rising annually worldwide. Globally, based on data from 121 countries, from 1990-2014, the number of CS increased by 12.4%, with an average increase of 4.4% per year. The high rate of CS increases the risk of complications in subsequent pregnancies, including placenta previa. In a study conducted in England with nearly 400,000 women with a second pregnancy, the incidence rate of placenta previa was 8.7 in 1000 births in women with previous CS history and about 4.4 in 1000 births in women with previous vaginal delivery. This study aimed to determine pregnancy characteristics with placenta previa at Prof. Dr. I. G. N. G. Ngoerah General Hospital in 2017. Methods: This study is a cross-sectional study with a retrospective descriptive approach using medical records of patients admitted from 1st January-31st December 207. This research was conducted at Prof. I. G. N. G. Ngoerah General Hospital, Bali, from February 1 to April 1, 2018. All data from medical records were collected and processed to describe pregnancy characteristics with placenta previa. Results: There were 49 (4.89%) cases of placenta previa from 1001 deliveries in 2017. This number was higher than the placenta previa case in other countries, around 0.3-0.5%. There were 2 cases excluded, and 47 cases were processed for data presentation. Pregnancy characteristics that dominated placenta previa cases in this research were aged 30-34 years old, second to third pregnancy, age of gestation ≥ 37 weeks, no history of vaginal bleeding, no history of curettage, and no history of CS Conclusion: The characteristics of pregnancy in this study which dominated placenta previa cases were aged 30-34 years old, second to third pregnancy, age of gestation ≥ 37 weeks, no history of vaginal bleeding, no history of curettage, and no history of CS Further investigation is required.

P-546 History of caesarean births and risk of miscarriage - secondary analysis of three randomised controlled trials

Abstract Study question Does the history of caesarean births influence miscarriage risk in subsequent pregnancies? Summary answer In women with a history of 3 or more miscarriage(s), the subsequent miscarriage risk may increase with the presence and number of previous caesarean births. What is known already History of caesarean birth increases the risk of complications in subsequent pregnancies, including risks of spontaneous preterm birth. The evidence of association between caesarean births and subsequent miscarriage risk is scant and conflicting. Study design, size, duration We performed a secondary analysis of the dataset from three multicentre, prospective, double-blind, and placebo-controlled randomized trials. Study registration, duration, size, population, and intervention are as follows: 1) PROMISE; ISRCTN92644181; 2010 - 2013, 826 women with a history of unexplained recurrent miscarriages, progesterone. 2) PRISM; ISRCTN14163439; 2015 - 2017, 4038 women who experienced vaginal bleeding in early pregnancy, progesterone. 3) TABLET; ISRCTN15948785; 2011 - 2016, 940 euthyroid women with thyroid peroxidase antibodies, and miscarriages or infertility history, levothyroxine. Participants/materials, setting, methods The primary outcome for this analysis was miscarriage rate, defined as loss of pregnancy &amp;lt;24 weeks of gestation. RR with 95% CI was estimated using the Poisson regression model and adjusted for age, BMI, ethnicity, smoking status, and previous miscarriages. Random-effects two-stage individual participant data meta-analysis approach was used to account for treatment allocation effects. Subgroup analysis was conducted in women with a history of repeated miscarriages (3 or more) at randomisation. Main results and the role of chance After excluding pregnancies with incomplete data, we included 5,039 pregnancies in the final analysis. The overall miscarriage rate was 24.9% (1256/5039). In the non-specific population of women, there was no association between the history of caesarean births and subsequent miscarriage risk (aRR 1.00, 95% CI 0.86 to 1.17; 5,039 pregnancies). In contrast, for the subgroup of women with a history of 3 or more miscarriage(s) at randomisation, the miscarriage rate appears to increase with the history of caesarean births, although with some degree of statistical uncertainty (aRR 1.10, 95% CI 0.97 to 1.26; 1172 pregnancies). The association became significant when the analysis was categorised according to the number of previous caesarean births. With 1 previous caesarean birth, the miscarriage risk increased by 3% (aRR 1.03, 95% CI 1.00 to 1.06; 1080 pregnancies). This risk was increased by 37% with 2 previous caesarean births (aRR 1.37, 95% CI 1.03 to 1.83; 971 pregnancies), therefore indicating the presence of a biological gradient of effect which increases our confidence in the above findings. The history of previous caesarean births may be a valid prognostic risk factor for future miscarriage risk in women with a history of recurrent miscarriage. Limitations, reasons for caution Further analysis by the gestation at miscarriage (early vs. late), the type (elective vs. emergency), indication or cervical dilatation status at caesarean births is required to understand the possible mechanism behind this association and to better identify women at increased risk of miscarriage(s) related to caesarean births. Wider implications of the findings Our findings suggest that a history of caesarean births may be associated with a small increased risk of subsequent miscarriage risk in a subgroup of women with a history of recurrent miscarriage(s). This information may assist women and healthcare providers to reach more informed decisions regarding the mode of delivery. Trial registration number The study is registered with the OSF registry (ve5j4).

Pregnancy-associated stroke and the recurrence of stroke and other complications in subsequent pregnancies: Population-based retrospective cohort study.

To examine the outcomes of the subsequent pregnancies from women with a previous pregnancy-associated stroke (PAS) in comparison to matched controls. Population-based retrospective cohort study. All women with a PAS in Finland 1987-2016 (n = 235) and controls (n = 694). We identified all subsequent deliveries and induced and spontaneous abortions for women with a previous PAS and their matched controls from the Medical Birth Register and the Hospital Discharge Register until 2016. The number, course and outcomes of the subsequent pregnancies were compared. Patient records were studied for PAS recurrence. PAS recurrence and pregnancy complications. Women with a previous PAS had fewer subsequent deliveries: 73 (31.1%) women had 122 deliveries in all, whereas 303 (47.3%) of the controls had 442 deliveries (age-adjusted odds ratio [OR] 0.54, 95% CI 0.38-0.76). Hypertensive disorders of pregnancy (HDP) (17.2% versus 5.7%, age-adjusted OR 4.0, 95% CI 1.7-9.3), especially chronic hypertension (age-adjusted OR 5.9, 95% CI 1.5-24.7), and any diabetes during pregnancy (24.6% versus 14.5%, age-adjusted OR 2.0, 95% CI 1.1-3.8) were more common in cases. Regarding HDP, the difference between groups was explained by underlying factors such as index pregnancy HDP (multivariable OR 2.4, 95% CI 0.8-6.7). PAS recurred in four cases (5.5%). Subsequent pregnancies of women with a history of PAS are more often complicated with hypertensive disorders of pregnancy and any diabetes during pregnancy. PAS recurrence risk is considerable.

Ultrasound evaluation of post-cesarean uterine wound healing based on a figure of eight suturing technique

Link of Video Abstract: https://youtu.be/15Du23GFCWc Introduction: A niche (also called an isthmocele) is a defect or uterine scar that can be detected by ultrasound a few weeks or months after delivery by cesarean section. A niche is often associated with obstetric complications in subsequent pregnancies, including uterine dehiscence and/or rupture, placenta previa, and placenta accreta. Placenta accreta is characterized by abnormal attachment of the placenta to the uterine wall and is one of the leading causes of maternal morbidity and mortality in developing countries. Therefore, this study aims to evaluate the healing of surgical wounds with the figure of eight suturing techniques. Methods: This study included 32 primigravida patients who underwent cesarean section at RSIA (Mother &amp; Child Hospital) Rosiva from March 2006 to July 2006. On day 6 of the puerperium, the uterine sutures were examined with transvaginal ultrasound. Patients were subsequently allowed to return to their homes to receive outpatient treatment. On day 40, the patients were requested to return to the hospital for a follow-up ultrasound examination. Results: On day 6, incomplete wound healing was found in 31 patients (96.9%) and complete wound healing in 1 patient (3.1%). On day 40, 31 patients (96.9%) experienced perfect or complete healing. Statistical analysis showed a significant difference in wound healing between day 6 and day 40 (p = 0.0001). Conclusion: On day 40 after cesarean section, as many as 96.9% of patients showed perfect/complete wound healing (type I) without a niche. Therefore, these patients had a low risk of obstetric complications associated with uterine scarring in subsequent pregnancies.

Immune thrombotic thrombocytopenic purpura: Spotlight on long-term outcomes and survivorship.

Advances in diagnosis and treatment have dramatically improved survival of acute immune thrombotic thrombocytopenic purpura (iTTP) and iTTP has evolved from an acute fatal condition to a chronic relapsing disorder. In addition to the risk of iTTP relapse, iTTP survivors are at risk of multiple adverse health outcomes including higher than expected rates of all-cause mortality, increased rates of stroke and other cardiovascular disease, and higher rates of morbidities such as obesity, hypertension, and autoimmune disorders. iTTP survivors also report neurocognitive impairment, depression, and reduced quality of life. Women with iTTP are at risk for recurrent iTTP, preeclampsia, and other maternal and fetal complications in subsequent pregnancies. ADAMTS13 activity during clinical remission has emerged as an important targetable risk factor for iTTP relapse and other outcomes including stroke and all-cause mortality. This review summarizes current literature regarding the epidemiology and potential mechanisms for adverse long-term sequelae of iTTP, outlines current best practices in iTTP survivorship care, and highlights a research agenda to improve long-term iTTP outcomes.

Prepregnancy Glucose Levels Within Normal Range and Its Impact on Obstetric Complications in Subsequent Pregnancy: A Population Cohort Study.

We sought to identify the influence of prepregnancy glucose levels on obstetric complications in subsequent pregnancy. Women in Republic of Korea who had given birth between January 1st, 2007 and December 31st, 2010 were enrolled. The database of the Health Insurance Review and Assessment Service and data from a national health screening program for infants and children were used. Subjects were divided into seven groups according to their fasting glucose levels. 59,619 women were included for analysis, and 10.4%, 13.7%, 19.1%, 21.5%, 16.0%, 11.6%, and 7.5% women had glucose levels of < 75, 75-79, 80-84, 85-89, 90-94, 95-100 and > 100 mg/dL. Each 5 mg/dL increase in prepregnancy fasting glucose levels was associated with increased risk of gestational diabetes and macrosomia in subsequent pregnancy. Adjusted risk ratio for gestational diabetes per standard deviation prepregnancy glucose > 100 mg/dL was 2.015 (95% confidence interval, 1.649-2.462) and for macrosomia an adjusted risk ratio 1.389 (95% confidence interval, 1.147-1.682). Higher prepregnancy glucose level within normal range was related to gestational diabetes and macrosomia in following pregnancy. Our results may aid in the identification of women at future risk of obstetric complications and may guide to stratify women into normal and intensified care. Higher prepregnancy glucose in normal range is associated with gestational diabetes and macrosomia.

Maternal morbidity and mortality associated with mode of delivery in sickle cell disease

This retrospective observational study compared pregnancy outcomes based on mode of delivery in women with homozygous sickle cell disease (HbSS) to women without (HbAA) using delivery records of 48,600 parturients between January 1992 and January 2020. Fisher’s exact tests and Mann–Whitney’s test were used to analyse variables based on sickle cell status. Vaginal delivery and HbSS were more associated with labour induction/augmentation (AOR = 2.4, (0.7–7.8)), intrapartum complications (AOR = 2.6, (0.5–14)), postpartum haemorrhage (AOR = 2.8 (0.5–15.2)) and postpartum infections (AOR = 9.6 (1.7–54.4)). Caesarean delivery resulted in more postpartum infections in the HbSS group (AOR = 23.6 (0.9–638.4)). Vaginal delivery in HbSS resulted in more intrapartum complications and postpartum haemorrhage but caesarean delivery greatly increased the risk of postpartum infections and hypertensive disorders. Sickle cell disease (SCD) did not confer increased risk of adverse perinatal outcomes regardless of mode of delivery. Impact Statement What is already known on this subject? Women with homozygous sickle cell disease (SCD) are at an increased risk of postpartum infections, undergoing caesarean delivery, admission to the neonatal intensive care unit and overall perinatal mortality when compared to women with normal haemoglobin genotype. Comparisons have been made between homozygous SS disease and haemoglobin SC disease revealing higher rates of maternal and foetal morbidity in both groups. What do the results of this study add? Studies comparing maternal and foetal morbidity based on mode of delivery are lacking. To our knowledge, this study is the first examine maternal and perinatal outcomes in women with SCD undergoing vaginal and abdominal delivery compared to women with normal haemoglobin. We found that vaginal delivery in SCD is associated with more postpartum haemorrhage and caesarean delivery was linked to more hypertensive disorders and postpartum infections then compared to women with normal haemoglobin. Converse to other reports, there was no difference in perinatal outcomes based on mode of delivery. What are the implications of these findings for clinical practice and/or further research? Caesarean delivery and SCD greatly increased the risk of postpartum infections and hypertensive disorders but did not confer a higher risk of postpartum haemorrhage. There were more maternal deaths in SCD women who underwent caesarean vs. vaginal delivery and this requires further study to determine the pregestational predictors of adverse outcomes. Women with SCD who achieve a successful primary vaginal delivery may have reduced risk of complications in subsequent pregnancies, possibly comparable to women without the disease.

Pregnancy Outcomes Subsequent to Stillbirth—A Single Tertiary-Care Center Experience

Background: Currently, there is little evidence to guide clinical management of pregnancies after stillbirth. Our study aims to evaluate the pregnancy outcome in pregnant women with a previous stillbirth, by applying a standardized protocol for etiologic investigations and subsequent treatment of the underlying etiology. Methods: A retrospective cohort study on a group of 100 women with history of stillbirth, occurred in single pregnancy between 2005 and 2021, was performed. All patients were followed up in their subsequent pregnancies (n = 153) in a tertiary university hospital. During the preconception period causes of stillbirth were investigated and a correction of modifiable risk factors was encouraged with a multidisciplinary approach. Data about pregnancy management, obstetric complications, gestational age at delivery, mode of delivery and neonatal outcomes were collected. Results: The analysis of previous stillbirth revealed that, by using the ReCoDe classification, the most common identifiable causes of death were fetal growth restriction (21%), placental abruption (11%) and “other placenta insufficiencies” (26.7%), whereas 15.8% of stillbirth was unexplained. Out of 153 subsequent pregnancies, 131 (85.62%) resulted in live births, 15 (9.8%) in a first trimester miscarriage, and 7 (4.57%) in second trimester miscarriage; no cases of stillbirth recurrence occurred. Obstetric complications in subsequent pregnancies included gestational diabetes (21.4%), gestational hypertensive disorders (6.1%), intrahepatic cholestasis of pregnancy (3.8%), fetal growth restriction (7.6%) and preterm birth (19.8%). The mean gestational age at delivery was 38 weeks with a mean birth weight of 2886.63 g. Conclusions: Our experience is encouraging as reflecting good outcomes in terms of live birth rate in the subsequent pregnancies, with no cases of recurrence. These results are probably due to extensive preconception investigations with a multidisciplinary approach. A preconception evaluation is, thus, essential to improve maternal and fetal outcome in case of history of stillbirth, aiming to minimize the risk of recurrence.

Successful Laparoscopic Surgical Removal of a Caesarean Scar Pregnancy (CSP) Using Temporary Uterine Artery Ligation

To demonstrate a laparoscopic technique to remove a scar pregnancy. Stepwise demonstration of the surgical technique. Santa Croce and Carle Hospital, Cuneo. Patient B.B. is a woman referred to our center for a suspected cesarean scar pregnancy (CSP) at 9 weeks gestation. CSP occurs approximately in 6% of all ectopic pregnancies. The estimated incidence is reported to be 1:1800 to 1:2500 in cesarean deliveries. Depending on its location, CSP can be categorized as either type 1, if the growth is in the uterine cavity, or type 2, if it expands toward the bladder and the abdominal cavity. If inadequately managed, it can lead to severe complications; most of them are hemorrhagic and can threaten the woman's life. There are several therapeutic approaches: local excision seems to be the most effective choice in type 2 CSP. In expert hands, the laparoscopic approach is perhaps the best surgical choice as tissue dissection, electrosurgical hemostasis, and vascular control can be effectively managed with minimal invasive access. Because severe intraoperative bleeding can occur, retroperitoneal vascular control is mandatory in this surgery. In type 1 CSP curettage, aspiration or hysteroscopic approach can be considered if the CSP is of small dimensions. A hysteroscopic approach can also be helpful in type 2 CSP during the laparoscopic removal, as intrauterine guidance. A potassium chloride local injection can be considered in a preoperative stage in the presence of a fetal heart rate. The systemic administration of methotrexate is usually ineffective as single agent, but it can be useful if administered as adjuvant therapy. Uterine artery embolization can be useful in an emergency setting to manage severe bleeding, but it can lead to complications in subsequent pregnancies and, more rarely, to premature ovarian failure. Considering poor bleeding at presentation, feasible dimensions, and the woman's desire for future pregnancy, ultrasound-guided aspiration and curettage was attempted. Because endouterine removal was incomplete, methotrexate injection was proposed as adjuvant therapy, but the administration was postponed as the patient tested positive for coronavirus disease 2019. A month later, beta-human chorionic gonadotropin level dropped from over 16 000 to 271 mU/mL, so an ultrasound and biochemical follow-up was performed. A month later, despite a low beta-human chorionic gonadotropin value, an increase in dimensions was observed at ultrasound, so surgical laparoscopic removal was offered. In this video article, laparoscopic removal of scar pregnancy is discussed in the following surgical steps: (1) Temporary closure of uterine arteries at the origin, using removable clips. (2) Retroperitoneal dissection to safely manage the scar pregnancy. (3) Dissection of the myometrial-pregnancy interface. (4) Double layer suture on the anterior uterine wall. Laparoscopic surgical management is a very effective surgical approach to remove CSP. Knowledge of retroperitoneal dissection and vascular control is necessary to carry out this surgical intervention safely and effectively.