Composite Adverse Pregnancy Outcome Research Articles

Sexually transmitted infections in pregnancy and adverse pregnancy outcomes: A retrospective cohort study.

There is a high prevalence and incidence rate of asymptomatic sexually transmitted infections (STIs) during pregnancy in adolescent girls and young women in Africa. The association between STIs and pregnancy outcomes in a hyperepidemic HIV setting has not been well described. Pregnant women, HIV-1 negative and <28 weeks' gestation at three primary health clinics in KwaZulu-Natal, South Africa were enrolled from February 2017 to March 2018. Vaginal swabs collected at the first and later antenatal visits were stored and retrospectively tested for HSV-2, Trichomonas vaginalis, Chlamydia trachomatis and Neisseria gonorrhoeae at the end of the study. The association between STIs detected at first and later antenatal visits and pregnancy outcome was assessed using multivariable logistic regression models adjusted for maternal age and treatment received for symptomatic STIs. Testing positive Mycoplasma genitalium at the first antenatal visit was significantly associated with low birth weight (odds ratio [OR] 5.22; 95% confidence interval [CI]: 1.10-15.98). Testing positive for T. vaginalis at the repeat visit was significantly associated with preterm births (OR 2.37; 95% CI: 1.11-5.03), low birth weight (OR 2.56; 1.16-5.63) and a composite adverse pregnancy outcome (OR 2.11; 95% CI: 1.09-4.08). Testing positive for HSV-2 at the repeat visit was also likely associated with experiencing a preterm birth or any adverse pregnancy outcome (OR 3.39; 95% CI: 0.86-13.3) (P = 0.096). Among predominantly asymptomatic STIs, M. genitalium detected at baseline visit was significantly associated with low birth weight, while T. vaginalis detected at the repeat visit in later pregnancy was significantly associated with preterm birth. Further research is warranted to study the impact of etiological testing of STIs at more than one antenatal visit and empirical treatment on pregnancy outcomes.

Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis

Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it. The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them. Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95% CI 66.3%-85.7%) compared to women without AF (17.3%(95% CI 13.3% - 22.1%), p<0.001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, p<0.001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1 - 226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF. Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Maternal ethnicity and socioeconomic deprivation: influence on adverse pregnancy outcomes.

To evaluate the relative importance of ethnicity and socioeconomic deprivation in determining the likelihood and the percentage of composite adverse pregnancy outcomes (CAPO) and composite of severe adverse pregnancy outcomes (CAPO-S) METHODS: This is a single centre retrospective cohort study conducted in a tertiary maternity unit. Data regarding the ethnicity and socioeconomic deprivation were collected for 13,165 singleton pregnant women routinely screened in the first trimester for preeclampsia using the Fetal Medicine Foundation combined algorithm. The prevalence or risk of CAPO was 16.3% for White women, 29.3% for Black women and 29.3% for South Asian women. However, half of all CAPO cases (51.7%) occurred in White women. There is a strong interaction between ethnicity and socioeconomic deprivation (as measured with indices of multiple deprivation). Both influence the prevalence of CAPO and CAPO-S, with the contribution of ethnicity being strongest. Black and Asian ethnicity as well as socioeconomic deprivation influence the prevalence of placentally-mediated adverse pregnancy outcomes. Despite this, most adverse pregnancy outcomes occur in White women, who represent the majority of the population and are also affected by socioeconomic deprivation. For these reasons, inclusion of socioeconomic deprivation should be considered in early pregnancy risk assessment for placentally-mediated CAPO. This article is protected by copyright. All rights reserved.

Weight changes and adverse pregnancy outcomes with dolutegravir- and tenofovir alafenamide fumarate-containing antiretroviral treatment regimens during pregnancy and postpartum.

We evaluated associations between antepartum weight change and adverse pregnancy outcomes and between antiretroviral therapy (ART) regimens and week-50 postpartum body mass index in IMPAACT 2010. Women with HIV-1 in 9 countries were randomized 1:1:1 at 14-28 weeks gestational age (GA) to start dolutegravir(DTG)+emtricitabine(FTC)/tenofovir alafenamide fumarate(TAF) versus DTG+FTC/tenofovir disoproxil fumarate(TDF) versus efavirenz (EFV)/FTC/TDF. Insufficient antepartum weight gain was defined using IOM guidelines. Cox-proportional hazards regression models were used to evaluate the association between antepartum weight change and adverse pregnancy outcomes: stillbirth (≥20 weeks GA), preterm delivery (<37 weeks GA), small for gestational age (SGA<10th percentile), and a composite of these endpoints. 643 participants were randomized: 217 in DTG+FTC/TAF, 215 in DTG+FTC/TDF, and 211 in EFV/FTC/TDF arms. Baseline medians were: GA 21.9 weeks, HIV RNA 903 copies/mL, CD4 count 466 cells/uL. Insufficient weight gain was least frequent with DTG+FTC/TAF (15.0%) versus DTG+FTC/TDF (23.6%) and EFV/FTC/TDF (30.4%). Women in the DTG+FTC/TAF arm had the lowest rate of composite adverse pregnancy outcome. Low antepartum weight gain was associated with higher hazard of composite adverse pregnancy outcome (HR 1.44, 95%CI 1.04, 2.00) and SGA (HR 1.48, 95%CI 0.99, 2.22). More women in the DTG+FTC/TAF arm had body mass index ≥25 kg/m2 at 50 weeks postpartum (54.7%) versus the DTG+FTC/TDF (45.2%) and EFV/FTC/TDF (34.2%) arms. Antepartum weight gain on DTG regimens was protective against adverse pregnancy outcomes traditionally associated with insufficient weight gain, supportive of guidelines recommending DTG-based ART for women starting ART during pregnancy. Interventions to mitigate postpartum weight gain are needed.

Association of MST1 in the First Trimester of Pregnancy with Gestational Diabetes Mellitus and Adverse Pregnancy Outcomes.

We investigate the association of mammalian sterile line 20-like kinase 1 (MST1) in the first trimester with the risks of gestational diabetes mellitus (GDM) and adverse pregnancy outcomes. Pregnancies were recruited during their first antenatal care visit between 8 and 12 gestational weeks. These pregnancies underwent an oral glucose tolerance test between 24 and 28 gestational weeks and were followed up until delivery. Serum MST1 levels at 8-12 gestational weeks and 24-28 gestational weeks were measured using an enzyme-linked immunosorbent assay (ELISA) kit. Logistic regression models were used to evaluate the association between MST1 levels in the first trimester and the risks of GDM and adverse pregnancy outcomes. This cohort study enrolled a total of 231 pregnancies. GDM was present in 42 (18.18%) women. Compared to the normal glucose tolerance (NGT) group, the GDM group had higher levels of FPG, HOMA-IR, and MST1 both in the first and second trimesters, but had lower HOMA-β levels only in the second trimester. Then participants were classified according to the median MST1 value in the first trimester. Incidences of GDM, composite adverse pregnancy outcomes, preterm birth, and macrosomia increased in women with higher MST1 values. Serum MST1 in the first trimester was correlated with FPG, 1hr PG, 2hr PG, and HOMA-IR, while inversely correlated with HOMA-β in the second trimester. Furthermore, after adjusting for traditional risk factors, women with higher first-trimester MST1 values had greater odds of GDM, composite adverse pregnancy outcomes, preterm birth, and macrosomia (aOR 2.276, P=0.030; aOR 2.690, P=0.003; aOR 3.210, P=0.048; aOR 5.488, P=0.010). Elevated levels of MST1 in the first trimester of pregnancies are associated with increased risks of GDM and adverse pregnancy outcomes.

Clinical, Sociodemographic, and Neighborhood Characteristics Associated with Adverse Pregnancy Outcomes.

Background: Cardiovascular risk is increased by a history of adverse pregnancy outcomes (APOs). Efforts to understand and prevent these adverse outcomes may improve both fetal and birthing persons' outcomes in the peripartum period, and over the patient's lifetime. This study aims to assess the association of clinical, sociodemographic, and economic neighbor-hood factors with preterm birth (PTB) and APOs (the composite of stillbirth, small for gestation age, and low birthweight). Materials and Methods: This is a cross-sectional study using the electronic medical records of deliveries from seven Northwell Health hospitals between January 1, 2018 and July 31, 2020. There were 62,787 deliveries reviewed in this study. Deliveries that were not the first for the patient during the study period and multiple gestational pregnancies were excluded. Patients with incomplete data on outcome were also excluded. Main outcomes were PTB and composite APOs. Measures included history of PTB, hypertension, diabetes, body mass index, race/ethnicity, age, preferred language, marital status, parity, health insurance, and median income, percent unemployment, and mean household size by zip code. Results: Of the 62,787 deliveries, 43.3% were from white, Non-Hispanic, and Non-Latino patients. There were 4,552 (7.2%) PTBs and 8,634 (13.8%) APOs. Patients enrolled in public insurance had higher odds of PTB (odds ratio [OR] 1.15, 95% CI 1.06-1.24) and APOs (OR 1.19, 95% CI 1.12-1.25). There was a statistically significant association of both PTB (p = 0.037) and APOs (p = 0.005) when comparing patients that live in a zip code with a median income over 100k to those with an income <100k. In addition, living in a zip code within the second quintile of unemployment was associated with lower odds of APOs (OR 0.92, 95% CI 0.84-0.99). Conclusions: Numerous sociodemographic and clinical factors are associated with both PTB and APOs. Tailored programs addressing these disparities may improve outcomes in pregnant persons.

Intake of Energy Drinks Before and During Pregnancy and Adverse Pregnancy Outcomes

Consumption of energy drinks has increased drastically in recent years, particularly among young people. It is unknown whether intake of energy drinks is associated with health during pregnancy. To examine associations of energy drink intake before and during pregnancy with risk of adverse pregnancy outcomes (APOs). This prospective cohort study included data from women enrolled in the Nurses' Health Study 3 (NHS3) between June 1, 2010, and September 27, 2021, and the Growing Up Today Study (GUTS) who reported 1 or more singleton pregnancy from January 1, 2011, to June 1, 2019. Data were analyzed from October 1, 2021, to September 28, 2023. Intake of energy drinks, assessed by food frequency questionnaire. The main outcomes were self-reported APOs, including pregnancy loss, gestational diabetes, gestational hypertension, preeclampsia, or preterm birth, and a composite APO, defined as development of any of the APOs. Risk of APOs was compared between consumers and nonconsumers of energy drinks. This study included 7304 pregnancies in 4736 participants with information on prepregnancy energy drink intake and 4559 pregnancies in 4559 participants with information on energy drink intake during pregnancy. There were 1691 GUTS participants (mean [SD] age, 25.7 [2.9] years) and 3045 NHS3 participants (mean [SD] age, 30.2 [4.1] years). At baseline, 230 GUTS participants (14%) and 283 NHS3 participants (9%) reported any intake of energy drinks. While no associations were found for pregnancy loss (odds ratio [OR], 0.89; 95% CI, 0.71-1.11), preterm birth (OR, 1.07; 95% CI, 0.71-1.61), gestational diabetes (OR, 0.89; 95% CI, 0.58-1.35), preeclampsia (OR, 0.73; 95% CI, 0.41-1.30), or the composite APO (OR, 1.05; 95% CI, 0.87-1.26), prepregnancy energy drink use was associated with a higher risk of gestational hypertension (OR, 1.60; 95% CI, 1.12-2.29). A significant interaction was found between age and energy drink intake in relation to hypertensive disorders (P = .02 for interaction for gestational hypertension; P = .04 for interaction for any hypertensive disorders), with stronger associations for participants above the median age. No associations of energy drink intake during pregnancy with any of the APOs were found in NHS3 (eg, any APO: OR, 0.86; 95% CI, 0.41-1.79). In this study, energy drink intake before pregnancy was associated with an elevated risk of gestational hypertension. Given the low prevalence of energy drink intake and low consumption levels among users, the results should be interpreted cautiously.

Maternal, Fetal and Neonatal Outcomes Related to Recreational Cannabis Use during Pregnancy: Analysis of a Real-World Clinical Data Warehouse between 2010 and 2019.

Cannabis is the main illicit psychoactive substance used in French childbearing women and very few data are available about adverse events (AEs) related to its use during pregnancy. The aim of this study was to evaluate the association between recreational cannabis use during pregnancy and adverse outcomes from a real-world clinical data warehouse. Data from the Poitiers University Hospital warehouse were analyzed between 1 January 2010 and 31 December 2019. Logistic regression models were used to evaluate associations between outcomes in three prenatal user groups: cannabis alone ± tobacco (C ± T) (n = 123), tobacco alone (T) (n = 191) and controls (CTRL) (n = 355). Pregnant women in the C ± T group were younger (mean age: 25.5 ± 5.7 years), had lower pre-pregnancy body mass index (22.8 ± 5.5 kg/m2), more psychiatric history (17.5%) and were more likely to benefit from universal free health-care coverage (18.2%) than those in the T and CTRL groups. Cannabis use increases the occurrence of voluntary interruption of pregnancy, at least one AE during pregnancy, at least one neonatal AE, the composite adverse pregnancy outcome over 28, prematurity and small for gestational age. Given the trivialization of recreational cannabis use during pregnancy, there is an urgent need to communicate on AEs of cannabis use during pregnancy.

First-trimester neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and systemic immune-response index (SIRI) as predictors of composite adverse outcomes in pregnant women with Familial Mediterranean fever.

To evaluate the utility of the neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and systemic immune-response index (SIRI) in the prediction of adverse pregnancy outcomes in pregnant women with Familial Mediterranean fever (FMF) MATERIAL AND METHODS: This retrospective case-control study was conducted between 2019-2023. First-trimester NLR, SII (NLR X platelet count), and SIRI (NLR X monocyte count) values were compared between pregnant women with FMF (n=85) and without FMF (n=105). Thereafter, pregnant women with FMF were divided into two groups: 1) FMF with perinatal complications (n=30), and 2) FMF without perinatal complications (n=55). NLR, SII, and SIRI values were compared between the two subgroups. Finally, an ROC analysis was performed to determine optimal cut-off values for NLR, SII, and SIRI in the prediction of composite adverse pregnancy outcomes. The FMF group had significantly higher first-trimester NLR, SII, and SIRI values compared to the controls. The FMF with perinatal complications group had significantly higher NLR, SII, and SIRI values than the FMF group without perinatal complications (p<0.05). Optimal cut-off values were 4.89 (80% sensitivity, 78.2% specificity), 1180.6 (76.7% sensitivity, 72.7% specificity), and 1.9 (83.3% sensitivity,72.7% specificity) for NLR, SII, and SIRI, respectively. SII, SIRI, and NLR may be used to predict adverse pregnancy outcomes in pregnant women with FMF.

Safety evaluation of COVID-19 vaccination during early pregnancy: A single-center prospective cohort study of Chinese pregnant women

ABSTRACT This prospective cohort study aimed to evaluate the safety of an inactivated coronavirus disease 2019 (COVID-19) vaccine in pregnant women at a tertiary hospital in Hubei, China. Pregnancy outcomes were compared between pregnant vaccinated and unvaccinated women. Composite adverse pregnancy outcomes were defined as one or more of maternal adverse outcomes (prenatal pyrexia, postpartum hemorrhage, maternal intensive care unit admission, and a prethrombotic state) and adverse neonatal outcomes (premature delivery, intrauterine fetal death or induction of labor, fetal macrosomia, fetal growth restriction, small-for-gestational age, fetal abnormalities, neonatal admission to the neonatal intensive care unit, and birth asphyxia). Of a total of 845 participants in the delivery cohort, 41.2% (348/845) received at least one dose of the COVID-19 vaccination, and 33.6% (284/845) received two doses. In total, 25.3% (88/348) of the vaccinated group were vaccinated at 0–4 weeks of pregnancy. No significant difference was found in the composite adverse outcomes between the vaccinated and unvaccinated participants, regardless of whether vaccination occurred before (44/243 [18.1%] vs. 71/497 [14.3%]; P = .17) or during early pregnancy (14/105 [13.3%] vs. 71/497[14.3%]; P = .79). These findings indicate that the pregnancy outcomes of women who received the COVID-19 vaccination, even if they were vaccinated early in pregnancy, were comparable to those of unvaccinated women. This study was registered with the Chinese Clinical Trial Center (ChiCTR2100051756).

Major trauma in pregnancy: prediction of maternal and perinatal adverse outcomes

Trauma, largely the consequence of motor vehicle crashes, is the leading cause of pregnancy-associated maternal mortality. Prediction of adverse outcomes has been difficult in pregnancy given the infrequent occurrence of traumatic events and anatomic considerations unique to pregnancy. The injury severity score, an anatomic scoring system with weighting dependent on severity and anatomic region of injury, is used in the prediction of adverse outcomes in the nonpregnant population but has yet to be validated in pregnancy. This study aimed to estimate the associations between risk factors and adverse pregnancy outcomes after major trauma in pregnancy and to develop a clinical prediction model for adverse maternal and perinatal outcomes. This was a retrospective analysis of a cohort of pregnant patients who sustained major trauma and who were admitted to 1 of 2 level 1 trauma centers. Three composite adverse pregnancy outcomes were evaluated, namely adverse maternal outcomes and short- and long-term adverse perinatal outcomes, defined as outcomes occurring within the first 72 hours of the traumatic event or encompassing the entire pregnancy. Bivariate analyses were performed to estimate the associations between clinical or trauma-related variables and adverse pregnancy outcomes. Multivariable logistic regression analyses were performed to predict each adverse pregnancy outcome. The predictive performance of each model was estimated using receiver operating characteristic curve analyses. A total of 119 pregnant trauma patients were included, 26.1% of whom met the severe adverse maternal pregnancy outcome criteria, 29.4% of whom met the severe short-term adverse perinatal pregnancy outcome definition, and 51.3% of whom met the severe long-term adverse perinatal pregnancy outcome definition. Injury severity score and gestational age were associated with the composite short-term adverse perinatal pregnancy outcome with an adjusted odds ratio of 1.20 (95% confidence interval, 1.11-1.30). The injury severity score was solely predictive of the adverse maternal and long-term adverse perinatal pregnancy outcomes with odds ratios of 1.65 (95% confidence interval, 1.31-2.09) and 1.14 (95% confidence interval, 1.07-1.23), respectively. An injury severity score ≥8 was the best cutoff for predicting adverse maternal outcomes with 96.8% sensitivity and 92.0% specificity (area under the receiver operating characteristic curve, 0.990±0.006). An injury severity score ≥3 was the best cutoff for the short-term adverse perinatal outcomes, which correlates with a 68.6% sensitivity and 65.1% specificity (area under the receiver operating characteristic curve, 0.755±0.055). An injury severity score ≥2 was the best cutoff for the long-term adverse perinatal outcomes, yielding a 68.3% sensitivity and 72.4% specificity (area under the receiver operating characteristic curve, 0.763±0.042). For pregnant trauma patients, an injury severity score of ≥8 was predictive of severe adverse maternal outcomes. Minor trauma in pregnancy, defined in this study as an injury severity score <2, was not associated with maternal or perinatal morbidity or mortality. These data can guide management decisions for pregnant patients who present after trauma.

The role of first-trimester NLR (neutrophil to lymphocyte ratio), systemic immune-inflammation index (SII), and, systemic immune-response index (SIRI) in the prediction of composite adverse outcomes in pregnant women with systemic lupus erythematosus

To evaluate the utility of neutrophil to lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and systemic immune-response index (SIRI) in the prediction of adverse pregnancy outcomes in pregnant women with systemic lupus erythematosus (SLE). This retrospective case-control study was conducted in Ankara City Hospital perinatology clinic between 2019 and 2023. First-trimester NLR, SII (NLR X platelet count), and SIRI (NLR X monocyte count) values were compared between pregnant women with SLE (n = 29) and low-risk controls (n = 110). Afterward, pregnant women with SLE were divided into two groups: 1) SLE with perinatal complications (n = 15) and 2) SLE without perinatal complications (n = 14). NLR, SII, and SIRI values were compared between the two subgroups. Finally, a ROC analysis was performed to determine optimal cut-off values for NLR, SII, and SIRI in the prediction of composite adverse pregnancy outcomes. The study group had significantly higher first-trimester NLR, SII, and SIRI values compared to the controls. The SLE with perinatal complications group had significantly higher NLR, SII, and SIRI values than the SLE group without perinatal complications (p < 0.05). Optimal cut-off values were 6.5 (66.7% sensitivity,71.4% specificity), 1612.6 (73.3% sensitivity, 71.4% specificity), and, 4.7 (73.3% sensitivity, 77.6% specificity) for NLR, SII, and SIRI, respectively. SII, SIRI, and NLR may be used to predict adverse pregnancy outcomes in pregnant women with SLE.

Adverse pregnancy outcomes in women at increased risk of preterm pre-eclampsia on first-trimester combined screening.

Uteroplacental dysfunction may not only result in pre-eclampsia (PE) but also in preterm birth (PTB), small-for-gestational-age (SGA) birth and stillbirth. The aim of this study is to evaluate the positive predictive value (PPV) of first-trimester combined PE screening for all of these placenta-mediated adverse pregnancy outcomes. Retrospective cohort study. Tertiary referral maternity unit. A total of 13 211 singleton pregnancies. First-trimester combined screening for preterm PE using the Fetal Medicine Foundation (FMF) algorithm. Hypertensive disorders of pregnancy (HDP), PTB, SGA birth and stillbirth were combined to assess composite adverse and severe adverse pregnancy outcomes (CAPO and CAPO-S). The PPVs for CAPO and CAPO-S were calculated for women with a combined risk for preterm PE of ≥1 in 50 and ≥1 in 100. First-trimester combined screening identified 2215 women (16.8%) with a risk of ≥1 in 100 for preterm PE. The PPVs for a risk of ≥1 in 100 for CAPO and CAPO-S were 38.8% and 18.2%, respectively. The equivalent PPVs for a risk of ≥1 in 50 were 45.1% and 21.1%, respectively. Women identified at high risk of preterm PE are also at increased risk of other placenta-mediated adverse pregnancy outcomes, such as PTB, SGA birth and stillbirth. Women at high risk for preterm PE after first-trimester screening may benefit from a higher surveillance care pathway, with interventions to mitigate all the adverse outcomes associated with placental dysfunction.

Allostatic Load and Adverse Pregnancy Outcomes

ABSTRACT Approximately one-fourth of pregnancies experience adverse pregnancy outcomes, such as hypertensive disorders of pregnancy (HDPs), preterm birth, stillbirth, and small-for-gestational age (SGA) neonates. Although an uncertain pathophysiology leading to these outcomes of pregnancy is understood, a major contributing factor may be cumulative stress. Chronic wear and tear on the adaptive system of the body, as well as chronic stress exposure, can be assessed via allostatic load. Chronic stress hailing from circumstances such as food or housing insecurity, racism, unemployment, or a combination of these may contribute to the racial and ethnic disparities observed in pregnancy outcomes. This study aimed to assess the relationship between the allostatic load and adverse pregnancy outcomes, while hypothesizing that higher odds of adverse pregnancy outcomes are directly associated with higher allostatic loads. Second, the authors hypothesized that a significant portion of racial and ethnic disparities in adverse pregnancy outcomes will be accounted for with high allostatic loads. The primary outcome was a composite adverse pregnancy outcome: HDPs, SGA, preterm birth, and stillbirth. Between October 2010 and September 2013, the nuMoM2b study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be) enrolled 10,038 nulliparous individuals with singleton pregnancies. Eligible individuals were nulliparous, had a viable single gestation with an estimated gestational age of 60/7 and 136/7 weeks, and intended delivery at a participating clinical site. Exclusionary criteria were as follows: unable to provide informed consent, age younger than 13 years, planned termination of pregnancy, 3 or more prior pregnancy losses, fetal malformations or aneuploidy upon enrollment, or having a donor ovum pregnancy. Included within the study were 3 study visits during pregnancy and a final visit at delivery. Baseline clinical assessments, standardized questionnaires by trained chart abstracts, and medical record abstraction were used to ascertain maternal characteristics. Assessment of urine and serum collected between 6 and 14 weeks granted insight into allostatic load biomarkers. A total of 4266 pregnant individuals were included in the primary analysis, with high allostatic load being identified in 35% of the population (≥4 biomarkers in the worst quartile). Some 1171 individuals (27.5%) were identified to have adverse pregnancy outcomes: 386 preterm births (8.6%), 586 HDPs (14.0%), 12 stillbirths (0.3%), and 449 SGA neonates (11%). Adverse pregnancy outcomes occurred in the following numbers: 1 adverse outcome for 967 individuals, 2 for 165, 3 for 38, and 1 for all 4. High allostatic load held significant association with composite adverse pregnancy outcome, whereas HDPs differed by self-reported race. After adjustment for maternal age, gravidity, smoking, bleeding in the first trimester, and health insurance, high allostatic load was associated with the composite adverse pregnancy outcome (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.3–1.7) and hypertensive disorders (aOR, 2.5; 95% CI, 2.0–2.9), but not preterm birth or SGA. High allostatic load only partially mediated the association between self-reported race and adverse pregnancy outcomes. The association between allostatic load and hypertensive disorders differed by self-reported race, but it did not differ for the composite adverse pregnancy outcome, preterm birth, or SGA. Limitations of the study included the small number of stillbirths. Furthermore, the study used the 10-factor allostatic load index and did not assess additional cardiovascular and metabolic indicators in the broader allostatic load index. In addition, the cohort only included nulliparous individuals with tertiary care center access, which is not necessarily generalizable to other populations. Strengths of the study included its use of a large, well-characterized prospective cohort, as well as equal weighing of allostatic load biomarkers and a study population that was racially, ethnically, and geographically diverse. In conclusion, the study indicates that early-pregnancy high allostatic loads are associated with subsequent adverse pregnancy outcomes (HDPs in particular). Allostatic load was also a partial mediator between adverse pregnancy outcomes and race. Further evaluation of components of chronic stress and allostatic load as potentially modifiable risk factors is supported by these findings as a means of improving pregnancy outcomes via these potentially modifiable risk factors.

Elevated Hepatic Steatosis Index is Associated with the Development of Adverse Maternal, but Not Adverse Neonatal, Outcomes: A Retrospective Cohort Study.

To determine whether an elevated hepatic steatosis index (HSI), a non-invasive test for possible metabolic dysfunction-associated fatty liver disease (MAFLD), is associated with the development of adverse pregnancy outcomes. A retrospective cohort study was conducted on adult women with singleton pregnancies who delivered at two tertiary hospitals from August 2014 to December 2017. Aspartate aminotransaminase (AST) and alanine aminotransaminase (ALT) levels obtained 12 months pre-gravid, or during pregnancy but prior to screening for gestational diabetes mellitus (GDM), were extracted and linked with oral glucose tolerance test results. The HSI was calculated using the following equation: 8 × (ALT/AST ratio) + BMI (+2 if female; +2 if diabetes mellitus present) and considered elevated if >36. Multiple logistic regression analysis was used to quantify the association between elevated HSI and each composite adverse pregnancy outcome after adjusting for independent maternal risk factors. Over 40-months, 11929 women were eligible and of these, 1885 had liver enzymes collected. Women with an elevated HSI (>36) were more likely multiparous and overweight/obese compared to those women with a non-elevated HSI (≤36). Elevated HSI was significantly associated with a composite of adverse maternal outcomes (adjusted odds ratio (aOR) 1.55 95% CI 1.11-2.17, p=0.01), although a non-significant increased risk of a composite of adverse neonatal outcomes occurred after multivariable adjustment (aOR 1.17, 95% CI 0.94-1.45, p=0.17). Over and above known maternal risk factors, women with elevated HSI were more likely to develop adverse maternal, but not adverse neonatal outcomes.

Risk Factors and Pregnancy Outcomes of Antepartum Hemorrhage in Women with Placenta Previa.

Placenta previa (PP) is one such complication related to several adverse pregnancy outcomes. Adverse outcomes are likely greater if PP coexists with antepartum hemorrhage (APH). This study aims to evaluate the risk factors and pregnancy outcomes of APH in women with PP. This retrospective case-control study included 125 singleton pregnancies with PP who delivered between 2017 and 2019. Women with PP were divided into two groups: PP without APH (n = 59) and PP with APH (n = 66). We investigated the risk factors associated with APH and compared the differences between both groups in placental histopathology lesions due to APH and the resulting maternal and neonatal outcomes. Women with APH had more frequent antepartum uterine contractions (33.3% vs. 10.2%, P = .002) and short cervical length (< 2.5cm) at admission (53.0% vs. 27.1%, P = .003). The placentas from the APH group had lower weight (442.9 ± 110.1 vs. 488.3 ± 117.7g, P = .03) in the gross findings, and a higher rate of villous agglutination lesions (42.4% vs. 22.0%, P = .01) in the histopathologic findings. Women with APH in PP had higher rates of composite adverse pregnancy outcomes (83.3% vs. 49.2%, P = .0001). Neonates born to women with APH in PP had worse neonatal outcomes (59.1% vs. 23.9%, P = .0001). Preterm uterine contractions and short cervical length were the most significant risk factors for APH in PP.

Accuracy and utilization patterns of intraabdominal imaging for major trauma in pregnancy

Imaging protocols for major maternal trauma during pregnancy are not standardized, and it is uncertain whether focused assessment with sonography for trauma or computed tomography of the abdomen/pelvis is preferred for detecting intraabdominal hemorrhage. This study aimed to estimate the accuracy of focused assessment with sonography for trauma compared with computed tomography of the abdomen/pelvis, validate imaging accuracy with clinical outcomes, and describe clinical factors associated with each imaging mode. A retrospective cohort study of pregnant patients evaluated for major trauma at one of two Level 1 trauma centers between 2003 and 2019. We identified 4 imaging groups: no intraabdominal imaging, focused assessment with sonography for trauma only, computed tomography of the abdomen/pelvis only, and both focused assessment with sonography for trauma and computed tomography of the abdomen/pelvis. The primary outcome was a composite maternal severe adverse pregnancy outcome, including death and intensive care unit admission. We estimated sensitivity, specificity, and positive and negative predictive values of focused assessment with sonography for trauma for hemorrhage with computed tomography of the abdomen/pelvis as the reference standard. We performed analysis of variance and chi-square tests to compare clinical factors and outcomes across imaging groups. Multinomial logistic regression was used to estimate associations between selected imaging mode and clinical factors. Of 119 pregnant trauma patients, 31 (26.1%) experienced a maternal severe adverse pregnancy outcome. Intraabdominal imaging modes included none in 37.0%, focused assessment with sonography for trauma only in 21.0%, computed tomography of the abdomen/pelvis only in 25.2%, and both modes in 16.8%. With computed tomography of the abdomen/pelvis as the reference, focused assessment with sonography for trauma had sensitivity, specificity, positive predictive value, and negative predictive value of 11%, 91%, 50%, and 55%, respectively. One patient had a maternal severe adverse pregnancy outcome with a positive focused assessment with sonography for trauma and negative computed tomography of the abdomen/pelvis, and 2 patients with a positive computed tomography of the abdomen/pelvis did not have an adverse outcome. Use of computed tomography of the abdomen/pelvis with or without focused assessment with sonography for trauma was associated with a higher injury severity score, lower systolic blood pressure nadir, higher motor vehicle collision speed, and higher rates of hypotension, tachycardia, bone fracture, maternal severe adverse pregnancy outcome, and fetal demise. The association of computed tomography of the abdomen/pelvis use with higher injury severity score, tachycardia, and lower systolic blood pressure nadir persisted in multivariable analysis. With each 1-point increase in the injury severity score, there was an 11% higher likelihood of using computed tomography of the abdomen/pelvis over focused assessment with sonography for trauma for intraabdominal imaging. The sensitivity of focused assessment with sonography for trauma in detecting intraabdominal hemorrhage in pregnant trauma patients is poor, and computed tomography of the abdomen/pelvis has a low false-negative rate. Providers seem to prefer computed tomography of the abdomen/pelvis to focused assessment with sonography for trauma in patients with the most severe trauma. Computed tomography of the abdomen/pelvis with or without focused assessment with sonography for trauma is more accurate than focused assessment with sonography for trauma alone.

The effect of maternity waiting homes on pregnancy outcomes in West Gojjam, northwest Ethiopia

Background/Aims Maternity waiting homes are temporary shelters for pregnant women located near a hospital or health centre and are designed to reduce adverse maternal and perinatal outcomes. However, studies assessing the association between maternity waiting home use and adverse pregnancy outcomes are limited. This study assessed the association between maternity waiting home use and adverse pregnancy outcomes in northwest Ethiopia. Methods A prospective cohort study was conducted among women attending antenatal care in public health facilities in West Gojjam, northwest Ethiopia. Pregnant women (28 weeks or more gestation) were enrolled and followed up until birth. Maternity waiting home use was classified as if a pregnant woman stayed for at least 1 week in a maternity waiting home before birth. Log-binomial regression analysis was used to calculate the effect of maternity waiting homes on adverse pregnancy outcomes and to control the effect of potential confounders. Results A total of 810 women completed follow up and were included in the analysis. The incidence of composite adverse pregnancy outcomes was lower among maternity waiting home users compared to non-users (16.3% vs 24.5%). Maternity waiting home users had a lower risk of perinatal death (P=0.003), low birth weight (P=0.004) and preterm birth (P=0.007) than non-users. There were no significant differences in the risk of prolonged labour and postpartum haemorrhage between maternity waiting home users and non-users. Conclusions Staying in a maternity waiting home was significantly associated with a lower risk of perinatal death, low birth weight and preterm birth, and maternity waiting home users had approximately 50% lower adverse perinatal outcomes than non-users. Therefore, the Amhara Regional Health Bureau, zonal health departments, district health offices and other stakeholders should strengthen the use of maternity waiting homes.

Development, validation and clinical utility of a risk prediction model for adverse pregnancy outcomes in women with gestational diabetes: The PeRSonal GDM model.

SummaryBackgroundThe ability to calculate the absolute risk of adverse pregnancy outcomes for an individual woman with gestational diabetes mellitus (GDM) would allow preventative and therapeutic interventions to be delivered to women at high-risk, sparing women at low-risk from unnecessary care. We aimed to develop, validate and evaluate the clinical utility of a prediction model for adverse pregnancy outcomes in women with GDM.MethodsA prediction model development and validation study was conducted on data from a observational cohort. Participants included all women with GDM from three metropolitan tertiary teaching hospitals in Melbourne, Australia. The development cohort comprised those who delivered between 1 July 2017 to 30 June 2018 and the validation cohort those who delivered between 1 July 2018 to 31 December 2018. The main outcome was a composite of critically important maternal and perinatal complications (hypertensive disorders of pregnancy, large-for-gestational age neonate, neonatal hypoglycaemia requiring intravenous therapy, shoulder dystocia, perinatal death, neonatal bone fracture and nerve palsy). Model performance was measured in terms of discrimination and calibration and clinical utility evaluated using decision curve analysis.FindingsThe final PeRSonal (Prediction for Risk Stratified care for women with GDM) model included body mass index, maternal age, fasting and 1-hour glucose values (75-g oral glucose tolerance test), gestational age at GDM diagnosis, Southern and Central Asian ethnicity, East Asian ethnicity, nulliparity, past delivery of an large-for-gestational age neonate, past pre-eclampsia, GWG until GDM diagnosis, and family history of diabetes. The composite adverse pregnancy outcome occurred in 27% (476/1747) of women in the development (1747 women) and in 26% (244/955) in the validation (955 women) cohorts. The model showed excellent calibration with slope of 0.99 (95% CI 0.75 to 1.23) and acceptable discrimination (c-statistic 0.68; 95% CI 0.64 to 0.72) when temporally validated. Decision curve analysis demonstrated that the model was useful across a range of predicted probability thresholds between 0.15 and 0.85 for adverse pregnancy outcomes compared to the alternatives of managing all women with GDM as if they will or will not have an adverse pregnancy outcome.InterpretationThe PeRSonal GDM model comprising of routinely available clinical data shows compelling performance, is transportable across time, and has clinical utility across a range of predicted probabilities. Further external validation of the model to a more disparate population is now needed to assess the generalisability to different centres, community based care and low resource settings, other healthcare systems and to different GDM diagnostic criteria.FundingThis work is supported by the Mothers and Gestational Diabetes in Australia 2 NHMRC funded project #1170847.

Shift work and sleep duration are associated with adverse pregnancy outcomes in a predominantly Latinx population with high rates of obesity.

BackgroundShift work has been associated with adverse pregnancy outcomes. The objective of this study was to evaluate the association between sleep disturbances and adverse pregnancy outcomes.Methods and findingsThis was a secondary analysis of a prospective study of participants enrolled in a prospective observational study wherein gravidae were screened for sleep apnea (2010–2012). A screening questionnaire with standard sleep apnea questionnaires as well as novel items about shift work and nocturnal sleep duration was administered at a prenatal care visit. Short sleep duration was defined as less than 7 hours. Prolonged sleep duration was defined as greater than 9 hours.In a cohort of 1125 pregnant people, 9.4% reported shift work at the time of screening. Gravidae who reported shift work were more likely than gravidae who reported no shift work to develop preeclampsia (28.3% versus 13.0%, P<0.001), preeclamspsia with severe features (16.0% versus 8.5%, P = 0.010), gestational diabetes (28.3% versus 19.9%, P = 0.041), and a composite of adverse obstetric outcomes (61.3% versus 47.8%, P = 0.008). After adjusting for potentially confounding variables, shift work was associated with an increased risk for preeclampsia with (adjusted relative risk (aRR) 1.70, 95% CI 1.03–2.79, p = 0.036) and without (aRR 2.03, 95% CI 1.43–2.90, p<0.001) severe features, and gestational diabetes mellitus class A1 (aRR 1.47, 95% CI 1.05–2.05, p = 0.023) and class A2 (aRR 1.67, 95% CI 1.13–2.44, p = 0.009). Sleep duration was associated with gestational diabetes (31.3% among those with short sleep duration, 25.2% among those with normal sleep duration and 14.0% among those with prolonged sleep duration, P<0.001) and gestational diabetes class A2 (29.5%, 17.9%, and 10.1%, respectively, P<0.001). Gravidae with prolonged sleep duration experienced less composite adverse pregnancy outcomes at 42.6% compared to 57.4% for those with short sleep duration or 52.5% for those with normal sleep duration, P = 0.002.ConclusionsShift work and sleep duration are both associated with adverse pregnancy outcomes. Further research on the impact of sleep disturbance on pregnancy outcomes is warranted.