Gestational Age Of Delivery Research Articles

Length of chronic exposure to particulate matter and adverse birth outcomes: A population-based cohort study

Background/Aim: Previous studies have shown associations between particulate matter (PM) air pollution and adverse birth outcomes. However, most studies focused on relatively short periods of prenatal exposure to PM and in a low to moderate polluted areas. We examined the possible impact of exposure to particulate matter with diameter ≤10 μm (PM10) and ≤2.5 μm (PM2.5) for a number of years before delivery on the occurrence of adverse birth outcomes: term low birth weight (TLBW), preterm delivery (PTB), and small for gestational age (SGA) in a region exposed to long-range dust transport. Methods: This study was based on a cohort of births (N=90,505) that occurred in Israel during 2013-2015. We calculated prenatal PM averages during 1, 5, and 10 years prior to delivery. Logistic regression models with mother-level as a random intercept were used to determine the association between exposure and adverse birth outcomes, adjusting for a priori known covariates. Results: In fully adjusted models, a 10-μg/m3 increase in PM2.5 during 1-, 5- and 10-years prior to delivery was associated with a monotonically increasing risk of TLBW [odds ratio (OR)=1.51 95% confidence interval (CI): (1.14-1.99), 1.54 (1.12-2.14) and 1.70 (1.21-2.41), respectively] and SGA [1.25 (1.03-1.49), 1.43 (1.16-1.77) and 1.45 (1.16-1.80), respectively]. ORs increased with the length of exposure period also for PM10. For example, ORs for TLBW in association with a 20-μg/m3 increase in PM10 over 1-, 5-, and 10-years prior to delivery were 1.25 (1.00-1.58), 1.32 (1.01-1.72) and 1.46 (1.11-1.90), respectively. PTB was not associated with neither PM2.5 nor PM10. For example, the OR for PTB in association with a 10-μg/m3 increase in PM2.5 over 10-years prior to delivery was 1.19 (0.91-1.52).Conclusions The magnitude of the estimated associations between maternal exposure to both PM2.5 and PM10 exposure and birth outcomes increased with the length of the exposure period.

Predictors of Transplant-Free Survival After the Norwood Procedure

Birth weight, preterm delivery, and size for gestational age are surrogate markers for development that are commonly used in congenital heart surgery. Understanding the associations of these variables with patient outcomes is of great importance. This study included all patients with hypoplastic left heart syndrome who underwent a Norwood procedure at a single institution from 1995 to 2018. Low birth weight was defined as weight less than 2.5 kg, and preterm delivery occurred at less than 37 weeks' gestation. Overall and conditional analyses were performed to evaluate for association with outcomes after the Norwood procedure. Secondary analyses evaluated the association of development measures with postoperative length of stay and ventilator duration. In total, 303 neonates (60% male) underwent the Norwood procedure and were followed for a median of 3.9 years (interquartile range, 0.5 to 10.4 years). Median birth weight was 3.1 kg (interquartile range, 2.8 to 3.4 kg). Patients with low birth weight had decreased transplant-free survival compared with patients with a normal birth weight (hazard ratio, 1.7; 95% confidence interval, 1.03 to 2.82; P= .039). When conditioning on survival to second-stage palliation, patients born small for gestational age had decreased transplant-free survival compared with patients born at appropriate size for gestational age (hazard ratio, 2.8; 95% confidence interval, 1.31 to 6.09; P= .008). Patients delivered preterm had a longer hospital length of stay (median, 55 days vs 31 days; P= .02) and more ventilator days compared with patients delivered at term (median, 7 days vs 4 days; P= .004). Various developmental markers have differing prognostic importance for patients undergoing the Norwood procedure. Understanding these differences can help guide preoperative decision making and patient selection.

The relationship between the anti-Porphyromonas gingivalis immunoglobulin G subclass antibody and small for gestational age delivery: a longitudinal study in pregnant Japanese women

Maternal serum IgG antibody against Porphyromonas gingivalis is an indicator of both periodontitis and adverse pregnancy outcomes. This study aims to evaluate the anti-P. gingivalis IgG and IgG subclasses1-4 in threatened preterm labour (TPL) patients and their association with small for gestational age (SGA). Serum, saliva and subgingival plaque samples were collected from 47 TPL patients compared with 48 healthy pregnant women. The amount of P. gingivalis was measured in saliva and plaque using real-time polymerase chain reaction. The serum anti-P. gingivalis IgG titre and anti-P. gingivalis subclasses IgG 1-4 concentration were measured using enzyme-linked immunosorbent assay. The amount of anti-P. gingivalis IgG-1 was significantly lower in the TPL group than in the healthy group. Fourteen subjects delivered SGA infants in the TPL group. The pocket probing depth (PPD), clinical attachment loss, PPD≥5mm%, amount of P. gingivalis in plaque, anti-P. gingivalis IgG and anti-P. gingivalis IgG-4 were significantly higher in the TPL-SGA group than in the TPL-normal weight group. Moreover, logistic regression analysis revealed the detection frequency of P. gingivalis in plaque and placenta weight were significantly correlated with SGA in TPL.In the receiver operating characteristic curve analysis, an amount of P. gingivalis in plaque≥86.45 copies showed a sensitivity of 0.786and a specificity of 0.727 (AUC 0.792) for predicting SGA in TPL. Lower anti-P. gingivalis IgG-1 amounts are related to TPL, while higher anti-P. gingivalis IgG and IgG-4 are related with SGA in TPL. Further, greater colonisation of P. gingivalis in plaque might increase the risk of SGA and can be useful in prediction of SGA in TPL.

Outcomes before and after Adopting Guidelines for Expectant Management of Severe Preeclampsia.

This study aimed to compare maternal and neonatal outcomes in women with severe preeclampsia before and after implementation of the American College of Obstetricians and Gynecologists (ACOG) taskforce hypertensive guidelines. Single-center retrospective cohort study of women with severe preeclampsia delivering live nonanomalous singletons 23 to 342/7 weeks from 2013 to 2017. In 2015, the ACOG guidelines for expectant management of severe preeclampsia were implemented at our institution. Based on this, patients were categorized as preguideline (January 2013-December 2015) or postguideline adoption (January 2016-December 2017). Primary outcomes included composite maternal morbidity and composite neonatal morbidity; secondary outcomes included composite components, length of stay, birth weight, and delivery gestational age. Groups were compared with Student's t-test, Chi-square, and Wilcoxon's rank-sum tests; adjusted odds ratios (aOR; 95% confidence intervals [CIs]) were calculated. Yearly composite outcomes were compared using the Cochran-Armitage trend test. We estimated a sample size of 250 per group would provide 80% power at α = 0.05 to detect a 50% reduction in neonatal morbidity from a baseline rate of 21.5%. From 2013 to 2017, a total of 543 women with severe preeclampsia were identified: 278 (51%) preguideline and 265 (49%) postguideline. Baseline characteristics were overall similar between groups. There were no significant differences in maternal (aOR = 0.96, 95% CI: 0.6-1.41) or neonatal (aOR = 0.88, 95% CI: 0.61-1.28) composite morbidity between groups. Furthermore, there were no differences in composite maternal or neonatal morbidity over time. Perinatal outcomes were similar before and after implementation of severe preeclampsia management guidelines at our institution. Studies to evaluate if benefits are limited to subsets of this population, such as earlier gestational ages, are needed. · Expectant management of severe preeclampsia has yet to be fully evaluated outside of trial conditions.. · We did not see a significant improvement in neonatal composite morbidity/mortality.. · We also did not see a worsened composite maternal morbidity/mortality..

Stillbirth in women with diabetes: a retrospective analysis of fetal autopsy reports

Introduction Diabetes in pregnancy is associated with an increased rate of stillbirth. There are a wide variety of factors that have been implicated including placental insufficiency, hypoxia, hyperinsulinemia and impaired cardiac function. Furthermore, there is evidence that diabetic pregnancies have an increased rate of fetal cardiomyopathy as compared to non-diabetic pregnancies. Prior studies have indicated that this association can also be an etiology for diabetic stillbirth. The purpose of this study was to determine if diabetic pregnancies have an increased risk of fetal cardiomyopathy identified on fetal autopsy as compared to non-diabetic women with a stillbirth in a cohort of pregnancies that had evaluation with a fetal autopsy. Materials and methods Retrospective cohort study of women with a stillbirth who consented to fetal autopsy at an academic medical center from 2011 to 2017. Stillbirth was defined as an intrauterine fetal demise at ≥20 weeks’ gestation. Women with diabetes defined as pre-gestational diabetes type 1, pre-gestational diabetes type 2, and gestational diabetes were compared to women without diabetes. Primary outcome was fetal cardiomyopathy. Other etiologies for stillbirth were also evaluated and classified according to the Stillbirth Collaborative Research Network (SCRN) initial causes of fetal death. Fisher exact test, χ2 test, and Mann Whitney U tests were performed as appropriate, with p < .05 considered significant. Generalized linear models were performed for fetal organ weights controlling for gestational age of delivery, maternal chronic hypertension, delivery body mass index, and birthweight. Results A total of 78 women elected to have fetal autopsy examinations during the study period. Of these, 75 had complete information available for review. A total of 60 women did not have diabetes and 15 women had diabetes. Of pregnancies complicated by diabetes, 11 had insulin dependent diabetes and 4 had non-insulin dependent diabetes. Fetal cardiomyopathy was diagnosed on autopsy for 7 (46.7%) of pregnancies with diabetes and 2 (3.3% of pregnancies without diabetes (RR 14.00 [95% CI 3.23–60.65], p < .001). These associations were still significant even when analyzing only those pregnancies without fetal congenital heart disease (7 [46.7%] diabetic pregnancies with cardiomyopathy versus 1 [2.0%] nondiabetic pregnancy with cardiomyopathy, RR 23.80 [95% CI 3.17–178.46], p < .001). There was no difference between diabetic and non-diabetic pregnancies in regards to other causes for stillbirth. Stillbirths in pregnancies with diabetes also had larger fetal heart, liver, and adrenal weights on fetal autopsy. Conclusion Women with diabetes have 14 times the risk of fetal cardiomyopathy identified at fetal autopsy as compared to women without diabetes. As the prediction and prevention of diabetic stillbirth is limited, information on potential causes of stillbirth may help future research identify those pregnancies at the greatest risk for adverse outcome.

Analysis of scoring system of twin pregnancy vaginal delivery

Objective: To Analyze the prenatal factors and forecast the success rate of vaginal delivery of twin pregnancy. Methods: Totally, 114 cases of twin pregnant women who were under the systematic antenatal care and had deliveries in Beijing Obstetrics and Gynecology Hospital from January 2017 to March 2019 were collected. The inclusive criteria were uncomplicated twin pregnancy with head downward position of the first fetus, not monochorioallantoic twin twins, and the willingness for vaginal delivery. Two groups were classified based on their successful vaginal delivery. 96 cases in vaginal delivery group (study group) and 18 cases in the comparison groupwhich were transferred to Caesarean sections during trial delivery. The evaluated prenatal factors included: (1) Fetal factors: the chorionicity of the twin pregnancy, position of the second fetus, fetal weights and the weight difference of two fetuses. (2) Maternal factors:the maternal age, delivery gestational age, parity, body mass index (BMI), reasonability of weight gain during pregnancy, pregnancy complications, such as gestational diabetes mellitus (GDM), hypertensive disorder of pregnancy, and the application of assisted reproductive technology. (3) The technical title of the delivery doctor, modes of labour (spontaneous labor or induced labour and its mode) and the application of labor analgesia, etc. Single-factor logistic analysis and multiple-factor logistic regression were used to do statistical analysis and nomograms were plotted, finally receiver operating characteristic (ROC) curves and standard curves were formed for internal verifications and Youden index were utilized to determine the cut-off values. Results: Five variables:maternal age,complicated GDM, reasonability of weight gain during pregnancy, parity, and the weight of the second fetus is less than the firsthad obvious influence on the success rate of vaginal delivery in twin pregnancy. After quantifying the influence weight, the influence of each factor was as follows:the age of the mother <35 years old: 64; no GDM: 100, no insulin application in GDM: 47, and application of insulin: 0; reasonability of weight gain during pregnancy: 82; parity≥2: 58; and the weight of the second fetus was less than the first: 57. The ROC curve was plotted and the area under the curve (AUC) is 0.856 1, which were able to forecast the success rates well, the maximum value of the Youden index was 0.564 7 and the corresponding score was 168. Conclusions: maternal age, reasonability of weight gain during pregnancy, the complication of GDM, parity, and the weight of the second fetus less than the first are the influential prenatal factors on vaginal delivery of twin pregnancy. After assigning the influence weight of each influencing factor, when the total score reaches 168 the success rate of vaginal delivery is significantly improved.

SUN-632 The Impact of Vitamin D Deficiency on Pregnancy in Type 1 Diabetes

Vitamin D deficiency during pregnancy may not only impair maternal skeletal preservation and fetal skeletal formation but also influence fetal “imprinting” that may affect chronic disease susceptibility soon after birth as well as later in life.Vitamin D deficiency has been linked to multiple adverse perinatal outcomes in pregnancy including; pre-eclampsia, gestational diabetes, low birth weight, bacterial vaginosis, pre-term delivery and caesarean section. Aim: to assess 25-hydroxy vitamin D (25OHD) concentrations in women with type 1 diabetes (T1DM) during pregnancy, post-delivery and also foetal (cord blood) 25OHD concentrations and to examine relationships between these. The second aim of the study to examine potential relationships between maternal 25OHD and glycosylated haemoglobin (HbA1c) throughout pregnancy. Materials and methods: This was an observational study of 42 pregnant controls without diabetes and 39 pregnant women with T1DM. Maternal serum 25OHD was measured serially throughout the pregnancy and post-delivery. Cord blood 25OHD was measured at delivery. 25OHD was measured by liquid chromatography tandem mass spectrometry (LC-MS/MS). HbA1c was measured serially throughout the pregnancy. Control and T1DM groups were not significantly different in age or number of previous miscarriages. As expected, the T1DM group exhibited significantly higher HbA1c levels, and also had significantly increased incidence of preeclampsia (2 of 42 cases (4,8%) in control group and 5 of 39 cases in T1DM group (12,8%)) (p= 0,03). Delivery gestational age was significantly lower for babies born to mothers with T1DM (39,6±1,4 weeks in control group and 37,6±2,1 in T1DM group (p= 0,001).Vitamin D deficiency, defined as 25OHD levels,25 nmol/L, was apparent in both the control and the T1DM groups across the entire pregnancy. Greater than 90% of pregnant women were classified as insufficient at each time-point, regardless of whether they had T1DM or not. This meant that 10% of this pregnant population were at a sufficient level at some point throughout pregnancy. Similar to maternal vitamin D levels, the neonates had a high incidence of 25OHD deficiency at birth. Also were shown correlations between cord blood and maternal vitamin D. Maternal 25OHD correlated positively with cord 25OHD at all 3 trimesters in the T1DM group. Conclusions: in T1DM pregnancy, low vitamin D levels persist throughout gestation and post-delivery; maternal vitamin D levels exhibit a significant negative relationship with HbA1c levels, supporting a potential role for this vitamin in maintaining glycaemic control; larger studies investigating whether low vitamin D levels are a risk factor for preterm delivery and preeclampsia in women with diabetes are needed.

Maternal nutritional status mediates the association between maternal age and birth outcomes.

Young maternal age during pregnancy is linked with adverse birth outcomes. This study examined the role of maternal nutritional status in the association between maternal age and small for gestational age (SGA) delivery and birth length. We used data from a birth cohort study in Ethiopia, involving women who were 15–24 years of age and their newborns. A mediation analysis was fitted in a sample of 1,422 mother infant dyads for whom data on birth length were available, and 777 dyads for whom gestational age and birth weight was measured. We used commands, medeff for the mediation analysis and medsens for sensitivity analysis in STATA 14. Maternal nutritional status, measured by mid‐upper arm circumference, mediated 21% of the association between maternal age and birth length and 14% of the association with SGA delivery. The average direct effect (ADE) of maternal age on birth length was (β = 0.45, 95% CI [0.17, 0.99]) and the average causal mediated effect (ACME) was (β = 0.12, 95% CI [0.02, 0.15]). We also found an ADE (β = 0.31, 95% CI [0.09, 0.47]) and an ACME of (β = 0.05, 95% CI [0.003, 0.205]) of maternal age on SGA delivery. The sensitivity analysis suggests an unmeasured confounder with a positive correlation of 0.15 and 0.20 between the mediator and the outcome could explain the observed ACME for birth length and SGA, respectively. We cannot make strong causal assertions as the findings suggest the mediator partly explained the total effect of maternal age on both outcomes.

17-P for Women With Congenital Uterine Anomalies: Does it Impact Preterm Birth Risk? [01K

INTRODUCTION: The effectiveness of 17P in the prevention recurrent of preterm birth (PTB) among women with congenital uterine anomalies (CUA) is unknown. This study evaluate association between 17P and delivery gestational age among women with CUA and a previous spontaneous PTB. METHODS: This study is a retrospective cohort of women with CUA who delivered at 2 health systems from 2013-2019. Women with ≥1 prior spontaneous PTB carrying non-anomalous, singleton gestations were included. The primary outcome was delivery gestational age. Secondary outcomes included delivery &lt;37 and &lt;34 weeks. Women receiving 17P were compared to those who did not receive 17P using Wilcoxon rank sum, Fisher’s exact, and chi-square. RESULTS: Of the 48 women with prior PTB, 11 (22.9%) received 17P. Demographic, medical, and obstetric characteristics were similar between women who did and did not get 17P. The subtype of CUA was also similar by 17P status. The initial cervical length was more than 35mm in both groups and did not differ, nor did rates of PPROM (25% vs 12.5%, 0.63). The median delivery gestational age was similar between groups [37.7 (IQR 30.7-38.3) vs. 37.1 (IQR 31-38.4) weeks] for those who did and did not receive 17P, respectively. Rates of recurrent PTB 0.99) and 0.99) were also similar in those who did and did not receive 17P. CONCLUSION: In this cohort of women with prior PTB and CUA, recurrent PTB was common, and though 17P was used in fewer than 1 in 4 women, use of 17P did not appear to impact this risk.

Pregnancy Outcomes in Patients With Inadequate Gestational Weight Gain [31N

INTRODUCTION: The objective of this study is to compare the risks for small for gestational age (SGA) neonates and composite adverse neonatal outcomes (CANO) in patients with inadequate gestational weight gain (IWG) versus adequate gestational weight gain (AWG). METHODS: This is a secondary analysis of a prospective study of women undergoing fetal growth assessment. Participants were sorted into AWG and IWG cohorts based on IOM guidelines. Primary outcomes were SGA and CANO (neonatal ICU admission, death, seizures, IVH, respiratory distress syndrome, necrotizing enterocolitis, and pH &lt;7.10). Secondary outcomes included: hypertensive disorders of pregnancy, preterm delivery (PTD), gestational diabetes (GDM), and large for gestational age (LGA) newborns. We performed chi square, t-test, and adjusted multivariable logistical regression. A stratified analysis was performed by pre-pregnancy BMI category. RESULTS: 214 patients experienced IWG and 282 patients experienced AWG. The risk of SGA was increased in patients with IWG, 47 patients (22.0%) compared to 34 patients (12.2%) with AWG (aOR 1.99, CI 1.19–3.33). CANO were similar between groups (14.5% versus 11.8%, P=.384). IWG was associated with decreased risk of LGA (aOR 0.29, CI 0.12–0.71) but did not have an effect on GDM, PTD, gestational hypertension, or preeclampsia. In obese patients, IWG was protective against GDM (RR 0.44, CI 0.21–0.93) and LGA neonates (RR 0.10, CI 0.03–0.44) without increased risk of SGA neonates. CONCLUSION: IWG increases risk of SGA but did not increase neonatal morbidity. IWG was protective against GDM and LGA without increasing other risks in obese patients, suggesting lower weight gain in this population may be beneficial.

Preterm Birth Risk and Recurrence Among Multiparous Women With Congenital Uterine Anomalies [26K

INTRODUCTION: Women with congenital uterine anomalies (CUA) are known be at high risk for preterm birth (PTB). We sought to determine the risk of PTB among multiparous women with known CUA as stratified by previous pregnancy history. METHODS: A retrospective cohort of women with a known CUA who delivered at 2 tertiary health systems, 2013-2019. We included multiparous women who were carrying non-anomalous, singleton gestations. The primary outcome was PTB before 37 weeks; secondary outcomes included PTB before 34weeks and median delivery gestational age (GA). Women with a history of PTB were compared to those without a history of PTB using Wilcoxon rank sum, ANOVA, Fisher’s exact, chi-square, and Kaplan-Meier survival curves. RESULTS: 122 multiparous women with CUA met inclusion criteria; 48 (39.3%) had a prior PTB. The most common CUA was bicornuate (43.4%) followed by septate (27.9%), unicornuate (11.5%), didelphys (10.7%), and arcuate (6.7%). PTB before 37 weeks was more common among women with a prior PTB (45.8% vs. 25.7%, P=.02), as was PTB before 34 weeks (27.1% vs. 12.2%, P=.04). In addition, women with a prior PTB delivered earlier [median 37.1 (IQR 30.9-38.4) vs. 39.0 (IQR 36.9-39.4), P=.002]. CONCLUSION: Multiparous women with CUA are at high risk for PTB. While a history of preterm birth increases risk, even women with prior term birth(s) had high rates of PTB. Overall use of prophylactic treatments such as cerclage and progestogen supplementation was low. Future studies should investigate therapeutic options for the prevention of PTB among women with CUA, irrespective of prior pregnancy history.

Maternal serum levels of C-reactive protein at early pregnancy to predict fetal growth restriction and preterm delivery: A prospective cohort study.

BackgroundA considerable evidence suggests that maternal inflammation dysregulation may play as a risk factor for both maternal and neonatal outcomes. Objective: The study's objectives were designed to evaluate the correlation between serum C-reactive protein (CRP) levels, as an inflammation factor, preterm delivery, and small for gestational age (SGA) births.Materials and MethodsThis prospective cohort study was conducted on 120 singleton pregnant women with gestational age less than 20 wk. Maternal CRP serum concentration was measured before 20 wk gestation. Patients were followed-up until the delivery and final outcomes of pregnancy were recorded in terms of preterm delivery and SGA births. Results: Serum CRP levels in participants with normal fetuses and SGA births were 4.09 1.35 mg/l and 6.04 3.29 mg/l, respectively (p = 0.19), while in cases of preterm delivery, it was 9.63 5.78 mg/l (p 0.001). By using receiver operating characteristic (ROC) curve, serum CRP levels (cut-off point 5.27 mg/l, area 0.836) had acceptable diagnostic accuracy value in distinguishing preterm delivery (sensitivity (75%), specificity (86.1%), positive predictive value (37.5%), negative predictive value (96.87%), accuracy (85%)) and serum CRP levels (cut-off point 6.67 mg/l, area 0.673) in distinguishing SGA births (sensitivity (50%), specificity (91.2%), positive predictive value (23.07%), and negative predictive value (97.19%), and accuracy (89.16 %)).ConclusionHigher maternal serum CRP levels measured early in pregnancy may associate with higher risk of preterm delivery and SGA.

Kidney function, blood pressure and proteinuria were associated with pregnancy outcomes of pregnant women with chronic kidney disease: a single-center, retrospective study in the Asian population.

Studies among pregnant Asian women with chronic kidney disease (CKD) have not been widely performed; therefore, clinical criteria for these patients have not been well established. We conducted a retrospective study among pregnant women with CKD who received prenatal care at our institution for 8 consecutive years. Primary outcome was the development of severe adverse events (SAEs). We analyzed correlations between primary outcome and CKD parameters [age, body mass index (BMI), estimated glomerular filtration rate (eGFR), urinary protein-creatinine ratio (UP), systolic blood pressure (SBP), diastolic blood pressure (DBP), and not normal blood pressure (non-NBP)] at the time of referral. Secondary outcomes were low birth weight (LBW), preterm delivery (PreD), and small for gestational age (SGA). We divided into two categories, CKD stage G1, and G2 or higher according to eGFR, and proteinuria negative and proteinuria positive according to UP, respectively. We observed 89 pregnancies. SAE was observed in 28 pregnancies. In live birth cases, there were 28 PreD, 28 LBW and 13 SGA. Major SAEs included preeclampsia, superimposed preeclampsia, unscheduled cesarean section, neonatal intensive care unit admission, and fetal death. Stepwise logistic regression analysis selected eGFR (OR = 0.847, p = 0.026), SBP (OR = 1.897, p = 0.006) and proteinuria positive (OR = 2.96, p = 0.046) as the significant predictors of SAEs. There were no significant differences among the baseline characteristics stratified by SGA. This is the first study to report pregnancy outcomes among Japanese non-disease-oriented patients with CKD. In Asians, especially in the Japanese population, kidney function, blood pressure and proteinuria might affect pregnancy outcomes.

SAT-200 INCREASED RISK OF LONG-TERM RENAL DISEASE IN WOMEN WHO DELIVER PRETERM INFANTS: A POPULATION-BASED COHORT STUDY

Chronic kidney disease (CKD) is a major cause of global morbidity, with estimated prevalence of 7-12% among women. Preterm delivery is a common adverse pregnancy outcome, and an independent risk factor for maternal cardiovascular disease. Little is known about the association between preterm delivery and subsequent maternal renal function, and whether any association is independent of preeclampsia or intra-uterine growth restriction. We aimed to determine whether women who deliver preterm infants are at increased risk of CKD and end-stage renal disease (ESRD). Using data from the Swedish Medical Birth Register, singleton live births from 1973-2012 were identified and linked to data from the Swedish Renal Register and National Patient Register (up to 2013). Women with pre-pregnancy renal disease, cardiovascular disease, diabetes, hypertension, systemic lupus erythematosus were excluded. Preterm delivery was the main exposure, and treated as a time-dependent variable. Primary outcomes were maternal CKD or ESRD. Cox regression was used for analysis, adjusting for maternal age, year of delivery, country of origin, parity, inter-pregnancy interval, smoking, BMI, gestational diabetes. Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were estimated. Models were stratified by history of preeclampsia or small for gestational age (SGA) delivery. The sample comprised 1,943,716 women with 3,760,429 live-births. Overall, 162,918 women (8.4%) delivered preterm. The mean (±SD) follow-up was 20.3 (±11.6) years. 18,001 women (0.9%) developed CKD, and 1,268 (0.07%) developed ESRD. Women with history of preterm delivery were at increased risk of CKD (aHR 1.46, 95% CI 1.39-1.53) and ESRD (aHR 2.52, 95% CI 2.17-2.93) compared with women who delivered at term (≥37 weeks). Women with history of extremely preterm delivery (<28 weeks) were at particularly high risk of CKD (aHR 1.94, 95% CI 1.60-2.34) and ESRD (aHR 3.99, 95 %CI 2.25-7.06). The risk of renal disease was greatest in women who experienced preterm delivery complicated by preeclampsia (vs. normal term deliveries, for CKD, aHR 2.81, 95% CI 2.46-3.20; for ESRD, aHR 6.70, 95% CI 4.70-9.76). However, spontaneous preterm delivery was also associated with significantly increased risk of CKD and ESRD independent of all other factors. Women who deliver preterm infants are at higher risk of CKD and ESRD, particularly those with very/extremely preterm deliveries. This association persists independently of preeclampsia or SGA. Preterm delivery warrants consideration as part of overall CKD risk prediction models. Women and clinicians should be informed of this heightened risk to plan for appropriate preventive interventions.

Stillbirth is associated with increased risk of long-term maternal renal disease: a nationwide cohort study

BackgroundStillbirth is a devastating adverse pregnancy outcome that may occur without any obvious reason or may occur in the context of fetal growth restriction, preeclampsia, or other obstetric complications. There is increasing evidence that women who experience stillbirths are at greater risk of long-term cardiovascular disease, but little is known about their risk of chronic kidney disease and end-stage renal disease. We conducted the largest study to date to investigate the subsequent risk of maternal chronic kidney disease and end-stage renal disease following stillbirth.ObjectiveTo identify whether pregnancy complicated by stillbirth is associated with subsequent risk of maternal chronic kidney disease and end-stage renal disease, independent of underlying medical or obstetric comorbidities.Study Design/MethodsWe conducted a population-based cohort study using nationwide data from the Swedish Medical Birth Register, National Patient Register, and Swedish Renal Register. We included all women who had live births and stillbirths from 1973 to 2012, with follow-up to 2013. Women with preexisting renal disease were excluded. Cox proportional hazard regression models were used to estimate adjusted hazard ratios and 95% confidence intervals for associations between stillbirth and maternal chronic kidney disease and end-stage renal disease respectively. We controlled for maternal age, year of delivery, country of origin, parity, body mass index, smoking, gestational diabetes, preeclampsia, and small for gestational age deliveries. Women who had a history of medical comorbidities, which may predispose to renal disease (prepregnancy cardiovascular disease, hypertension, diabetes, lupus, systemic sclerosis, hemoglobinopathy, or coagulopathy), were excluded from the main analysis and examined separately.ResultsThere were 1,941,057 unique women who had 3,755,444 singleton pregnancies, followed up over 42,313,758 person-years. The median follow-up time was 20.7 years (interquartile range, 9.9–30.0 years). 13,032 women (0.7%) had at least 1 stillbirth. Women who had experienced at least 1 stillbirth had a greater risk of developing chronic kidney disease (adjusted hazard ratio, 1.26; 95% confidence interval, 1.09–1.45) and end-stage renal disease (adjusted hazard ratio, 2.25; 95% confidence interval, 1.55–3.25) compared with women who only had live births. These associations persisted after removing all stillbirths that occurred in the context of preeclampsia, and small for gestational age or congenital malformations (for chronic kidney disease, adjusted hazard ratio, 1.33; 95% confidence interval, 1.13–1.57; for end-stage renal disease, adjusted hazard ratio, 2.95; 95% confidence interval, CI 1.86–4.68). There was no significant association observed between stillbirth and either chronic kidney disease or end-stage renal disease in women who had preexisting medical comorbidities (chronic kidney disease, adjusted hazard ratio, 1.13; 95% confidence interval, 0.73–1.75 or end-stage renal disease, adjusted hazard ratio, 1.49; 95% confidence interval, 0.78–2.85).ConclusionWomen who have a history of stillbirth may be at increased risk of chronic kidney disease and end-stage renal disease compared with women who have only had live births. This association persists independently of preeclampsia, and small for gestational age, maternal smoking, obesity, and medical comorbidities. Further research is required to determine whether affected women would benefit from closer surveillance and follow-up for future renal disease.

Mediation of Adverse Pregnancy Outcomes in Autoimmune Conditions by Pregnancy Complications: A Mediation Analysis of Autoimmune Conditions and Adverse Pregnancy Outcomes.

Autoimmune conditions are associated with an increased risk of adverse pregnancy complications and outcomes, suggesting that pregnancy complications may mediate the excess risk. We performed a causal mediation analysis to quantify the mediated effects of autoimmune conditions on adverse pregnancy outcomes. We queried a California birth cohort created from linked birth certificates and hospital discharge summaries. From 2,963,888 births, we identified women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriasis, and inflammatory bowel disease (IBD). Pregnancy complications included preeclampsia/hypertension, gestational diabetes mellitus, and infection in pregnancy. Adverse pregnancy outcomes were preterm birth, cesarean delivery, and small for gestational age. We performed a mediation analysis to estimate the total effects of each autoimmune condition and adverse pregnancy outcome and the indirect effects through pregnancy complications. All 4 autoimmune conditions were associated with preterm birth and cesarean delivery, and RA, SLE, and IBD were associated with offspring that were small for gestational age. The strongest mediator of RA, SLE, and psoriasis was preeclampsia/hypertension, accounting for 20-33% of the excess risk of preterm births and 10-19% of excess cesarean deliveries. Gestational diabetes mellitus and infections generally mediated <10% of excess adverse pregnancy outcomes. Of the 4 autoimmune conditions, selected pregnancy complications mediated the least number of adverse pregnancy outcomes among women with IBD. We found evidence that some excess risk of adverse pregnancy outcomes is mediated through pregnancy complications, particularly preeclampsia/hypertension. Quantifying excess risk and associated pathways provides insight into the underlying etiologies of adverse pregnancy outcomes and can inform intervention strategies.

Gestational Age of Delivery in Pregnancies Complicated by Diabetes.

Background: The recommended gestational age to deliver pregnancies complicated by diabetes ranges from 34 to 39 weeks of gestation. The objective of this study was to determine the optimal gestational age for delivery of patients with diabetes to minimize perinatal death.Methods: We extracted a population-based cohort of singleton, nonanomalous infants of diabetic pregnancies from the Missouri birth registry for the period January 1, 1989 to December 31, 2005 and compared perinatal outcomes of planned deliveries at 37, 38, 39, and 40 weeks to expectant management. Planned deliveries were identified by induction or cesarean delivery without documented medical or obstetric indications. The primary outcome was perinatal death, defined as stillbirth or neonatal death within 28 days of birth. Secondary outcomes were independent stillbirth, independent neonatal death, and a composite adverse neonatal event of assisted ventilation >30 minutes, birth injury, seizures, or 5-minute Apgar score ≤3. Groups were compared using t test and chi-square as appropriate.Results: In 4,905 diabetic pregnancies reaching 37 weeks, 1,012 (20.6%) patients were insulin dependent. Overall, the risk of perinatal death at any gestational age examined was low (3/1,000 births or lower), as was the risk of the adverse perinatal outcome (<2%). When only patients who were insulin dependent were included in the analysis, the risk of perinatal death at any gestational age remained low at 6 per 1,000 births or fewer.Conclusion: Delivery as early as 37 weeks is reasonable for women who have diabetes, although the absolute risk of perinatal death is low at 37 to 39 weeks.

719: Maternal genotype varies by delivery gestational age

719: Maternal genotype varies by delivery gestational age

583: Placental malperfusion in term and near-term births and referral for developmental delay at age three

Placental malperfusion is associated with adverse neurologic outcomes and lifelong neurologic disability, however, the association between malperfusion and subtler differences in neurodevelopment is not well understood. This analysis evaluated associations between placental malperfusion and placental gene expression with child developmental outcomes at age 3. Developmental outcomes were assessed for 48 children delivered between 2014-2015 via medical chart review at a single suburban hospital. Children were included if they were part of the Stress, Pregnancy and Health Study, had delivery gestational age ≥35’0 weeks’, and placenta collection at delivery. Suspected delay was indicated by physician referral to early intervention (EI) therapy by age 3. Placentas were grossed and assessed for vascular malperfusion, including fetal (FVM) and/or maternal vascular malperfusion (MVM), by a single perinatal pathologist. Associations between delay and malperfusion were assessed using a chi-square test. Differentially expressed genes (DEGs) from fresh chorionic villous biopsies were identified based on a fold-change of ≥1.25. In this sample 9/48 (18.6%) children were referred to EI by 3 years, and 7/9 (77.8%) were referred with concern for language development. There was not a significant difference in gestational age between those with delay and those without. The presence of placental malperfusion was significantly associated with delay (p=0.03). Children with delay had increased proportions of high grade FVM and MVM, though this was not statistically significant (Table 1). There was no difference in frequency of low grade villitis between groups, and only one case of high-grade villitis. Villous biopsies of those with delay had decreased expression of genes associated with vascular remodeling, including EGFL6, CTHRC1, and VCAM1. These results suggest that placental vascular malperfusion may be related to placental gene expression and developmental delay. Future work should investigate these associations in a larger sample.

627: OB/GYN resident and MFM fellow trainee surgical participation and transvaginal cervical cerclage outcomes

Cervical cerclage is among the most effective options to prolong pregnancy in women with cervical insufficiency, but surgical placement can be technically challenging. We sought to investigate whether transvaginal cerclage outcomes differed by OB/GYN resident and/or MFM fellow participation and surgical team member role. Retrospective cohort of women carrying a singleton, non-anomalous pregnancy 2012-2019, who underwent history-, ultrasound- or physical exam-indicated transvaginal cervical cerclage by ≥1 MFM provider at a single tertiary center. Cerclage operative notes were reviewed to determine (1) the primary surgeon; classified as a MFM fellow (fellow-primary) or BC/BE MFM (attending-primary) and (2) assistant surgeons; classified as MFM-fellows (fellow-assist) and/or OB/GYN residents (resident-assist). The primary outcome was delivery gestational age (GA). Secondary were delivery < 37, < 34, and < 28 weeks. Statistical analysis was by chi2, ANOVA, and cox regression. 232 women met inclusion criteria; 35 (15%) cases were fellow-primary and 197 (85%) attending-primary. Of the attending-primary procedures, 57 (28.9%) were fellow-assist. Demographic and obstetric characteristics are listed in Table 1. The median delivery GA was 37.0 (IQR 32.2-39.0) weeks; neither delivery GA nor PTB < 37, < 34, or < 28 weeks’ differed between fellow-primary and attending-primary cerclages (Table 1). Median delivery GA was similar in resident-assist and no resident-assist procedures [37.1 (IQR 33.7-39.0) vs. 36.4 (IQR 26-39) weeks, p=0.137]; delivery GA also did not vary by resident trainee level. The delivery GA was lower in cases with any fellow (as primary or assist) vs. those without fellows [36.1 (IQR 31.6-38.4) vs. 37.4 (IQR 33.5-39.0) weeks, p=0.021], but this finding was not significant in regression models (Table 2). In this cohort with a high rate of PTB, where 44% of cerclages were ultrasound- or exam-indicated, delivery GA was similar regardless of resident and/or fellow surgical participation, and also did not vary if the fellow was the primary surgeon vs. assistant.View Large Image Figure ViewerDownload Hi-res image Download (PPT)