Higher Rates Of Preterm Delivery Research Articles

G112 Chorioamnionitis in preterm infants is not associated with brain size and maturation at term equivalent age

Introduction Chorioamnionitis is a risk factor for adverse neurodevelopment in preterm infants but the effect on brain size or maturation is unclear. This study aimed to determine the association between perinatal characteristics and histological chorioamnionitis in a cohort of preterm infants. We also aimed to establish the association between chorioamnionitis and brain size and maturation. Methods A large prospective cohort of preterm infants was identified and data from placental histology reports were collected and chorioamnionitis, characterised into either no inflammatory response, maternal response only or both fetal and maternal response. All infants had brain MRI scans at term equivalent age. T1 and T2 weighted images were systematically scored for size of cerebral structures, degree of myelination, gyral maturation, signal abnormalities and presence of cysts. Differences between groups were compared using linear regression for continuous variables and logistic regression for categorical variables. Results Of the 237 infants included in this study, 58 (24.5%) had histological evidence of chorioamnionitis. Table 1 summarises the demographic data. Infants with evidence of chorioamnionitis on placental histology had higher rates of preterm delivery (p Chorioamnionitis, however, was not associated with brain injury or delayed maturation on qualitative MRI assessment. The MRI scoring data is shown in Table 2.

Pregnancy Outcomes following Robot-assisted Laparoscopic Myomectomy

Review study question: What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri? Summary answer: Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy. Study design: Review study. Participants/material, setting, methods: An extensive search for articles related to the topic and review the studies. Main results: The mean time to conception was 12 to 18 months. Assisted reproduction techniques were employed in 22 to 24% of these women. Spontaneous abortions occurred in 18 to 20%. Preterm delivery prior to 35 weeks of gestational age occurred in 17%. One uterine rupture was documented in all studies together. Pelvic adhesions were discovered in 11 to 16% of patients delivered by cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision. None of the myoma characteristics were related to spontaneous abortion.

Adverse pregnancy outcomes associated with adenomyosis with uterine enlargement.

The aim of this study was to elucidate the risk of poor pregnancy outcomes in women with adenomyosis by comparing their outcomes to those of women without uterine abnormalities. The subjects were 36 women diagnosed with adenomyosis before pregnancy who were managed at a tertiary care center between January 2002 and December 2012. Our hospital database was retrospectively reviewed to identify pregnancy outcomes associated with adenomyosis. The control group consisted of 144 women without uterine abnormalities who gave birth during the same period and whose age at delivery was adjusted by applying propensity scores. Pregnancy outcomes were compared between the adenomyosis and control groups. The main outcomes were gestational age at delivery, preterm delivery, preterm premature rupture of membranes, fetal malpresentation, cesarean delivery, small-for-gestational age, 5-min Apgar score < 7, umbilical arterial pH < 7.1, and neonatal intensive care unit admission. The data are presented as medians (range) or frequencies (percentage). The adenomyosis group had significantly higher rates of preterm delivery (41.7% vs 12.5%), preterm premature rupture of membranes (19.4% vs 4.2%), small-for-gestational age (33.3% vs 10.4%), fetal malpresentation (27.8% vs 8.3%), and cesarean delivery (58.3% vs 24.3%), as compared with the control group. No significant differences were observed in 5-min Apgar score < 7 or umbilical arterial pH < 7.1 between the two groups. Pregnancies in women with adenomyosis were associated with a higher preterm delivery rate and more frequent occurrences of fetal growth restriction and fetal malpresentation, such that both pregnancy and delivery outcomes were poor.

Pregnancy in patients with sickle cell disease: maternal and perinatal outcomes

Objective: To compare obstetrical, hematological and neonatal outcomes of pregnant women with or without sickle cell disease (SCD).Methods: A prospective study of 60 pregnancies of 58 women with SCD (29 SCD-SS and 29 SCD-SC) compared with 192 pregnancies in 187 healthy pregnant women was carried out from January 2009 to August 2011.Results: Compared to controls, the SCD group had higher rate of preterm delivery (p < 0.001, OR = 4.96, 95% CI 2.57–9.59), higher cesarean rate (p < 0.001, OR = 5.00, CI 2.65–9.45), more frequent deep vein thrombosis (p = 0.003), and urinary infection (p = 0.001, OR = 3.31, CI 1.63–6.73), higher prevalence of small for gestational age babies (p = 0.019, OR = 2.66, CI 1.15–6.17), and more frequent baby admissions to progressive care unit (p < 0.001, OR = 4.89, CI 2.26–10.6). Maternal death rate was also higher among women with SCD (p = 0.056). All adverse events were more frequent in the SS subgroup. Babies from the SS subgroup had the lowest weight at birth (2080 g) compared to SC (2737 g; p < 0.001) and controls (3035 g). A multivariate analysis confirmed painful episodes and SS genotype as factors contributing to preterm delivery.Conclusion: SCD pregnant women – especially those in the SS subgroup – are more prone to experience perinatal and maternal complications in comparison with pregnant women without SCD.

English

BACKGROUND: Pregnancy induced Hypertension (PIH) is one of the common complications which contributes to significant maternal and perinatal morbidity and mortality. Effective management improves outcome of both mother and the baby OBJECTIVES: To study the morbidity and mortality in babies born to mothers with pregnancy induced hypertension, assess the reasons for the outcome of the baby and monitor the growth and development till the age of 6 months. METHODS: This study was conducted at Niloufer Institute of Child Health, Hyderabad a teaching institution which caters to high risk obstetric patients and also has a tertiary level NICU care. Study was conducted over a period of 9 months and 100 cases of PIH were included over a period of 3 months and the babies were followed up till the age of 6 months. A structured proforma was designed and analyzed using Epi info for window statistical software. RESULTS: Out of 1461 deliveries, we enrolled 100 PIH cases as per inclusion criteria and studied during 3 months period. Of the study group, 48% were with mild PIH (n=48) and 52% were with severe PIH (n=52). When compared to mild PIH, severe PIH was associated with higher rates of preterm deliveries and it was statistically significant (P 2). In NICU admissions Meconium aspiration syndrome (MAS), Hyaline membrane disease (HMD), Birth asphyxia (BA) and sepsis were observed. All the complications were more in severe PIH than mild PIH. After discharge infants were fallowed up till the age of 6 months. Out of 75 babies discharged, 24 cases were lost to follow up and in the remaining 51 babies, 33 were born to mild PIH mothers, 18 were born to severe PIH mothers. CONCLUSION: PIH is one of the major causes of morbidity and mortality in the fetus and newborn. The more severe the PIH, the more adverse is the outcome. Our goal is early detection and prompts Management.

Smoking among older childbearing women - a marker of risky health behaviour a registry-based study in Finland

BackgroundSmoking during pregnancy is known to negatively affect pregnancy outcomes and it has been associated with numerous complications during pregnancy. Smoking is more common in younger pregnant women, but previous research has shown that adverse pregnancy outcomes related to older maternal age and smoking are even more harmful than with younger smokers. The aim of this study was to compare pregnancy outcomes among smoking and non-smoking pregnant women aged <35 years and ≥35 years.MethodsIn this registry-based study, the data were collected from three national Finnish health registries: Finnish Medical Birth Register, Finnish Hospital Discharge Register, and Register of Congenital Malformations between the years 1997 and 2008. The data included information on 80 260 women who were smoking during pregnancy, of which 11 277 (9%) were ≥35 years and 68 983 (13%) were <35 years old. In multivariate modelling, the main outcome measures were preterm delivery, low Apgar scores at 1 min., low birth weight, small for gestational age, fetal death and preeclampsia.ResultsFewer older women smoked during pregnancy (9%) than younger women did (13%). Smoking increased the risk of adverse pregnancy outcomes, most in the older group. Multivariate logistic regression using non-smoking women aged <35 years as a reference group indicated that smoking women <35 years had higher rates of preterm delivery (OR 1.27 CI 1.20-1.35), SGA (OR 2.18 CI 2.10-2.26) and LBW (OR 1.73 CI 1.62-1.84).Non-smoking women ≥35 had higher rates of preterm delivery (OR 1.15 CI 1.10-1.20), fetal death (OR 1.36 CI 1.12-1.64), preeclampsia (OR 1.14 CI 1.09-1.20) and LBW (OR 1.13 CI 1.07-1.19).Smoking women ≥35 had higher rates of preterm delivery (OR 1.60 CI 1.40-1.82), SGA (OR 2.55 CI 2.34-2.79), fetal death (OR 2.70 CI 1.80-4.05) and LBW (OR 2.50 CI 2.20-2.80).ConclusionsSmoking during pregnancy increased the risk of adverse pregnancy outcomes in all women, but the rates were the highest for women aged ≥35 years. Pregnant women aged ≥35 years smoking during pregnancy was a distinctly high risk group. Maternity care should identify these women and support them in cessation of smoking during the first trimester of pregnancy.

The Relationship Between Black Race, Maternal Infection and NEC in the Preterm Infant

Higher rates of necrotizing enterocolitis (NEC) in black preterm infants have been attributed to the higher rates of preterm delivery in this population. The focus however has been on preterm infant risk factors with minimal investigation into the contribution of antepartum differences among black women and how they may contribute to poorer outcomes in the black preterm infant. Retrospective cohort controlled study design examined the relationship between maternal infection, preterm infant infection, race and NEC. Black women were found to experience an increased number of maternal infections when compared to white and Hispanic women. Of the black mothers who experienced infection during pregnancy their preterm infants had a more cycles of antibiotic administration than white and Hispanic infants. Preterm infants who experienced increased exposure to antibiotics had higher risk for necrotizing enterocolitis.

Obstetric and neonatal outcome in patients with anxiety disorders

Objective: To investigate whether a diagnosis of anxiety disorder is a risk factor for adverse obstetric and neonatal outcome.Methods: A retrospective population-based study was conducted comparing obstetric and neonatal complications in patients with and without a diagnosis of anxiety. Multivariable analysis was performed to control for confounders.Results: During the study period 256 312 singleton deliveries have occurred, out of which 224 (0.09%) were in patients with a diagnosis of an anxiety disorder. Patients with anxiety disorders were older (32.17 ± 5.1 versus 28.56 ± 5.9), were more likely to be smokers (7.1% versus 1.1%) and had a higher rate of preterm deliveries (PTD; 15.2% versus 7.9%), as compared with the comparison group. Using a multiple logistic regression model, anxiety disorders were independently associated with advanced maternal age (OR 1.087; 95% CI 1.06–1.11; p = 0.001), smoking (OR 4.51; 95% CI 2.6–7.29; p = 0.001) and preterm labor (OR 1.92; 95% CI 1.32-–2.8; p = 0.001). In addition, having a diagnosis of an anxiety disorder was found to be an independent risk factor for cesarean section (adjusted OR 2.5; 95% CI 1.82–3.46; p < 0.001), using another multivariable model. No association was noted between anxiety disorders and adverse neonatal outcomes including small for gestational age, low Apgar scores and perinatal mortality.Conclusion: Anxiety disorders are independent risk factors for spontaneous preterm delivery and cesarean section, but in our population it is not associated with adverse perinatal outcome.

The impact of total parenteral nutrition support on pregnancy outcome in women with hyperemesis gravidarum

Objective: To assess pregnancy outcome among women with hyperemesis gravidarum (HEG) with and without total parenteral nutrition (TPN) support.Study design: A retrospective study of all pregnant women with singleton pregnancies who were hospitalized due to HEG between 1997 and 2011. Pregnancy outcome was compared with a control group without HEG matched by maternal age and parity in a 3:1 ratio.Results: Overall 599 women were admitted during the study period with the diagnosis of HEG and subsequently delivered in our center. Of those, 122 (20.4%) received TPN support. Women in the HEG group were characterized by a higher rate of severe preeclampsia (1.3% versus 0.5%, p = 0.04), and a higher rate of preterm delivery at less than 37 and 34 weeks (10.9% versus 6.9%, p < 0.001 and 4.7% versus 1.6%, p < 0.001, respectively). Neonates in the HEG group were characterized by a lower birth weight (3074 ± 456 g versus 3248 ± 543 g, p < 0.001), higher rate of birth weight < 10th percentile (12.7% versus 6.8%, p < 0.001), and a higher rate of neonatal morbidity (8.7% versus 3.8%, p < 0.001). These associations persisted after adjustment for potential confounders, and were of most notable among women with HEG who did not receive TPN support.Conclusion: HEG is an independent risk factor for adverse pregnancy outcome. TPN support during early pregnancy is associated with a decreased risk for perinatal morbidity.

Adverse pregnancy outcomes in women with nausea and vomiting of pregnancy

Objective: To examine the influence of nausea and vomiting of pregnancy (NVP) on pregnancy outcomes.Methods: Outcomes were compared for primigravidas with a current singleton gestation enrolled at <20 weeks’ gestation in a maternity risk screening and education program (n = 81 486). Patient-reported maternal characteristics and pregnancy outcomes were compared for women with and without NVP and within the NVP group for those with and without poor weight gain.Results: 6.4% of women reported NVP as a pregnancy complication. Women reporting NVP were more likely to be younger, obese, single and smoke. They had higher rates of preterm delivery, pregnancy-induced hypertension and low birth weight <2500 g. Almost one-quarter of women with NVP had lower than recommended weight gain. Poor weight gain was associated with a higher incidence of adverse outcomes. Obesity, tobacco use and poor pregnancy weight gain independently increased the odds of an adverse outcome.Conclusion: NVP and subsequent poor weight gain may be associated with adverse pregnancy outcomes.

PF.51 Expectant Management of Prenatally Diagnosed Fetal Aneuploidy

It is essential to counsel patients about all options following the prenatal diagnosis of fetal aneuploidy (FA). We sought to ascertain the prenatal course and pregnancy outcomes in those with...

Is there an association between short interval from previous cesarean section and adverse obstetric and prinatal outcome?

Objective: To investigate whether a short interdelivery interval from cesarean section (CS) to a subsequent delivery is associated with adverse obstetric outcomes, and specifically uterine rupture.Study design: A retrospective study was conducted, comparing all patients who delivered following CS during the years 1988–2010. Time interval was defined as the time from the day of CS to the day of the subsequent delivery. Women with multiple gestations or more than one previous CS were excluded from the study.Results: Three-thousand one-hundred and seventy-six deliveries were included in the study. Of these, 176 patients had an interval <12 month, 728 had an interval of 13–18 months, 635 had an interval of 19–24 months and 1637 had an interval of more than 24 months. The rate of uterine rupture did not differ between the groups. Patients with short interval of less than 12 month had higher rates of preterm deliveries (11.9% versus 4.9–6.6% in the other groups; p < 0.001). The rate of post partum perinatal death was comparable between the groups.Conclusion: Short time interval is not a risk factor for major maternal and neonatal complications such as uterine rupture and post-partum death. However, in our population, it is a risk factor for preterm delivery.

Is There an Association between Platelet Count during the First Trimester and Preeclampsia or Other Obstetric Complications Later in Pregnancy?

Objective. To examine whether an association exists between platelet (PLT) count in the first trimester of pregnancy and the risk for hypertensive disorders or other obstetric complications. Methods. The study population included all registered births with available PLT count from the first trimester of pregnancy during 2000–2010. Thrombocytopenia was defined as PLT count below 100,000/μL. A comparison was performed between women with and without thrombocytopenia. Multiple logistic regression models were used to control for confounders. Results. The study population included 33,890 deliveries; of these, 119 (0.35%) were with thrombocytopenia. Women with thrombocytopenia had significantly higher rates of preterm delivery (16.0% vs. 9.4%; p = 0.015). There was no significant difference between the groups regarding hypertensive disorders. Conclusions. Hypertensive disorders cannot be predicted based on PLT count during the first trimester of pregnancy. Nevertheless, thrombocytopenia during the first trimester is a risk factor for preterm delivery.

Effect of adopting host-country nationality on perinatal mortality rates and causes among immigrants in Brussels

ObjectivesPerinatal mortality rates vary between ethnic groups but the relation with immigrant status is unclear. Previous research suggested that birth outcomes may either improve or deteriorate with duration of residence, depending on the migrant group. The objectives of this study are to describe and measure inequalities in pregnancy outcomes, perinatal mortality and causes of perinatal deaths according to current citizenship versus national origin of the mother, in Brussels. Study designThis is a population-based cohort study using data from linked birth and death certificates from the Belgian civil registration system. The data relate to all babies born between 1998 and 2008, whose mothers were living in Brussels, irrespective of the place of delivery. We used a logistic regression to estimate the odds ratios (ORs) for the association between mortality, causes of deaths and nationality. ResultsWomen from Morocco, sub-Saharan Africa and Turkey experience an 80% excess in perinatal mortality (p<0.0001) compared to Belgians, but this excess of perinatal mortality is not observed for mothers with Belgian citizenship at delivery. For sub-Saharan African women, this excess is caused mainly by immaturity-related conditions and reflects a high rate of preterm deliveries, low birth weight and a low socio-economic level. Moroccan and Turkish mothers have favourable pregnancy outcomes that persist after adopting Belgian nationality, but they experience a strong excess of perinatal mortality, mainly due to congenital anomalies and asphyxia or unexplained deaths prior to the onset of labour. ConclusionIn Brussels, perinatal mortality varies according to nationality but those differences do not persist after adopting Belgian nationality. The explanation of this positive effect is probably due to a mix of determinants such as acculturation, use of health services or cultural contexts. Further analysis should help to better understand the results observed.

Pregnancy Outcomes of Women With Physical Disabilities: A Matched Cohort Study

To document pregnancy outcomes of women with moderate-to-severe physical disabilities and to evaluate maternal and fetal outcomes compared with those of nondisabled 1:1 matched controls within the same hospital system. A retrospective matched cohort. A multidisciplinary outpatient reproductive health care clinic for women with physical disabilities, situated in an urban rehabilitation hospital and affiliated with a large tertiary medical care center. Women with physical disabilities. A chart review of 755 women with physical disabilities who were seen at a multidisciplinary specialty reproductive health care clinic, in which 48 total pregnancies of 34 women with physical disabilities were found. Thirty-four of these pregnancies were carried to delivery in 25 of these women with physical disabilities. Obstetric and disability-related pregnancy and delivery complications. Twenty-nine of the 34 pregnancies (85%) occurred in women with moderate-to-severe neurologic disabilities who were wheelchair users, with 33 resultant infants (1 twin pregnancy), and 2 instances of intrauterine fetal demise. Forty percent of the women delivered prematurely, although only 3 of 34 delivered before 32 weeks (9%). Thirty-four percent of the infants (12) were of low birthweight, all of whom were preterm. Although there was a higher rate of pregnancy-related complications (P = .003) in the disabled cohort, there were no maternal deaths, and few of the complications were severe or life threatening. Rates of urinary tract infections and other maternal infections were significantly higher in the disabled cohort and were correlated with both increased preterm delivery and lower birthweight infants (P = .009 and 0.023, respectively). Thirty-eight percent of the infants were delivered by cesarean section. The disabled cohort had lower rates of augmentation of labor (P = .03) and breastfeeding (P = .02) compared with nondisabled controls. Although bladder and functional status changes were noted during the pregnancies of women with physical disabilities, these women reverted to their prepregnancy functional status by 6 weeks postpartum. Our study describes a cohort of women who had moderate-to-severe physical disabilities who historically have been discouraged from pregnancy. Women with physical disabilities experienced higher rates of preterm deliveries, low birthweight infants, and pregnancy complications. The pregnancy complications in most cases were not severe and were readily managed. Although it was common to experience functional changes during pregnancy, these changes had largely resolved by 6 weeks postpartum. Larger observational studies are needed to better understand the etiology and prevention of preterm labor and low-birthweight infants in this population, and, in particular, the role of maternal infections.

Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study

To estimate the incidence of multiple repeat caesarean section (MRCS) (five or more) in the UK and to describe the outcomes for women and their babies relative to women having fewer repeat caesarean sections. A national population-based prospective cohort study using the UK Obstetric Surveillance System (UKOSS). All UK hospitals with consultant-led maternity units. Ninety-four women having their fifth or greater MRCS between January 2009 and December 2009, and 175 comparison women having their second to fourth caesarean section. Prospective cohort and comparison identification through the UKOSS monthly mailing system. Incidence, maternal and neonatal complications. Relative risk, unadjusted (OR) and adjusted (aOR) odds ratio estimates. The estimated UK incidence of MRCS was 1.20 per 10 000 maternities [95% confidence interval (CI), 0.97-1.47]. Women with MRCS had significantly more major obstetric haemorrhages (>1500 ml) (aOR, 18.6; 95% CI, 3.89-88.8), visceral damage (aOR, 17.6; 95% CI, 1.85-167.1) and critical care admissions (aOR, 15.5; 95% CI, 3.16-76.0), than women with lower order repeat caesarean sections. These risks were greatest in the 18% of women with MRCS who also had placenta praevia or accreta. Neonates of mothers having MRCS were significantly more likely to be born prior to 37 weeks of gestation (OR, 6.15; 95% CI, 2.56-15.78) and therefore had higher rates of complications and admissions. MRCS is associated with greater maternal and neonatal morbidity than fewer caesarean sections. The associated maternal morbidity is largely secondary to placenta praevia and accreta, whereas higher rates of preterm delivery are most likely a response to antepartum haemorrhage.

Can leukocyte count during the first trimester of pregnancy predict later gestational complications?

To examine whether an association exists between maternal leukocyte count in the first trimester of pregnancy and the risk for development of obstetric complications. The study population included all the registered births (n = 33,866) with available white blood cell count (WBC) from the first trimester of pregnancy, during 2000-2010 in a tertiary medical center. The leukocyte count was sorted by the following groups: WBC < 3.5 10 × 9/l, WBC = 3.5 10 × 9/l-13.8 10 × 9/l, and WBC > 13.8 10 × 9/l. These groups were compared regarding obstetrical characteristics and perinatal outcomes. Multiple logistic regression models were used to control for confounders. The study population included 33,866 deliveries, of these 0.94 % had leukocytosis WBC > 13.8 10 × 9/l. Women with leukocytosis delivered significantly earlier, were more likely to be Jewish, and in their first pregnancy. There were significantly higher rates of preterm delivery before 37 weeks, fertility treatments, hypertensive disorders, gestational diabetes mellitus, and cesarean section among these patients. There was no significant difference between the groups regarding preterm premature rupture of membranes (PPROM) and chorioamnionitis. Women with leukocytosis during the first trimester had significantly higher rates of fetuses who were small for gestational age and with birth weight <2,500 g. Multivariable analysis showed a significant association between preterm delivery before 37 weeks and leukocytosis during the first trimester of pregnancy (p = 0.003). Leukocytosis during the first trimester is significantly associated with an increased risk for obstetrical complications, in particular preterm delivery. Nevertheless, further studies should focus on women with leukocytosis during the first trimester in order to verify our results.

Pregnancy outcomes following robot-assisted myomectomy

What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri? Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy in our cohort, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy. Reproductive outcomes after traditional laparoscopic myomectomy are well documented. However, reproductive outcomes following robotic myomectomy are not well studied. This paper describes the pregnancy outcomes for a large cohort of women after robotic myomectomy. This is a retrospective cohort of women who became pregnant after robot-assisted myomectomy at three centers. Of the 872 women who underwent robotic myomectomy during the period October 2005-November 2010, 107 subsequently conceived resulting in 127 pregnancies and 92 deliveries through 2011. Women of reproductive age with fibroids who wanted a minimally invasive treatment option and desired uterine preservation were recruited. We conducted a multicentre study with three centers, two in a private practice and one in an academic setting. Pregnancy outcomes and their relationship to myoma characteristics were analyzed. Mean ± SD age at myomectomy was 34.8 ± 4.5 years and 57.4% [95% confidence interval (CI) 48.0, 66.3] of women were overweight or obese. The mean number of myomas removed was 3.9 ± 3.2 with a mean size of 7.5 ± 3.0 cm and mean weight of 191.7 ± 144.8 g. Entry of the myoma into the endometrial cavity occurred in 20.6% (95% CI 15.0, 27.7) of patients. The mean time to conception was 12.9 ± 11.5 months. Assisted reproduction techniques were employed in 39.4% (95% CI 32.6, 46.7) of these women. Seven twin pregnancies and two triplet pregnancies occurred, for a multiple pregnancy birth rate of 9.8% (95% CI 5.0, 17.8). Spontaneous abortions occurred in 18.9% (95% CI 13.0, 26.6). Preterm delivery prior to 35 weeks of gestational age occurred in 17.4% (95% CI 10.9, 26.5). One uterine rupture (1.1%; 95% CI 0.3, 4.7) was documented. Pelvic adhesions were discovered in 11.4% (95% CI 7.0, 18.0) of patients delivered by Cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision (compared with all other sites) in logistic regression analyses (P = 0.01). None of the myoma characteristics were related to spontaneous abortion. Given the retrospective nature of the data collection, some pregnancies may not have been captured. In addition, owing to the high prevalence of infertility patients in this cohort, the data cannot be used to counsel women who are undergoing RALM about fertility rates after surgery. Prospective studies are needed to determine if the results shown in our cohort are generalizable to all women seeking a minimally invasive option for the conservative treatment of symptomatic fibroids with pregnancy as a desired outcome. There was no funding source for this study.

Safety of Tumor Necrosis Factor Inhibitors during Pregnancy and Breastfeeding.

Tumor necrosis factor (TNF) inhibitors are useful in the treatment of numerous inflammatory and immunologic disorders. Since many of these conditions occur in women of childbearing age, safety during pregnancy and breastfeeding is of considerable importance. This paper is a review of the literature on the safety of TNF inhibitors during pregnancy and breastfeeding published between 2001 and 2011. TNF inhibitors do not appear to be associated with a high risk of teratogenicity or intrauterine death. However, a small magnitude increase in risk cannot be ruled out given the paucity of data on the subject. Although TNF inhibitor use may be associated with a higher rate of preterm delivery, this may in fact be due to an active, underlying disease. Therefore, the decision to use these medications should be made on a case-by-case basis. If the disease cannot be managed with first line agents, TNF inhibitors may be helpful in reducing the number of disease exacerbations. Nevertheless, when using TNF inhibitors, it is prudent to discontinue treatment around the third trimester when transfer across the placenta is greatest and to restart postpartum.

Pregnancy after renal transplantation

Renal transplantation offers women with end-stage kidney disease the opportunity to become pregnant with a high chance of successful outcomes. However, data reveal a high rate of complications, including pre-eclampsia, pre-term delivery and low birth weight. Careful consideration needs to be given to the potential conflict between safety of the fetus and of the allograft, particularly in the choice of immunosuppressants. To optimise the chances of a successful outcome, pregnancies should be carefully planned at a time of graft stability and medication changed to minimise the risk of congenital malformations.