Maternal Loss Research Articles

Vaccine Safety in Pregnancy

Immunize dubious infectious disease are accountable for significant maternal, neonatal and young infant despair and loss of life. While there is emerging confirmation as well as theoretical thought indicating that certain. Vaccine Sarerisk free for pregnant women and fetuses, policy– formulation is difficult because of behold potential danger to the fetus. The immature adaptive immune system of neonate impulsive infant build them particularly vulnerable despair and loss of life due to infection. Vaccinated pregnant women can defend the fetus. It can also directly defend the fetus via specific transplant from the mother in time of pregnancy. Keywords :Theoretical; Policy-formulation; Vulnerable; Transplant.

Charité Caesarean Birth Improves Birth Experience in Planned and Unplanned Caesarean Sections While Maintaining Maternal and Neonatal Safety: A Prospective Cohort Study

Background: In this study, we aimed to assess the safety of a modified caesarean delivery (Charité caesarean birth) in an extended frame of indications, and to examine its impact on parents’ birth experience and long-term effects. Methods: This prospective cohort study was performed from January to June 2019. A standardized questionnaire was given to all women who gave birth as an inpatient delivery. Eight months after hospital discharge, all women who gave consent were sent a follow-up questionnaire including questions on current feelings, breast feeding, bonding, and support system, as well as a screening for postnatal depression. Indications for caesarean delivery included preterm birth, fetal malpresentation, fetal malformation, twin pregnancy, and maternal pre-existing conditions. Results: The study cohort included 110 women. The mode of delivery was spontaneous in 49%, per vacuum extraction in 15%, conventional caesarean section in 7%, and Charité caesarean birth in 29%. The groups with Charité versus conventional caesarean delivery did not significantly differ in neonatal admission rates, umbilical cord parameters, maternal blood loss, or duration of surgery. Compared to conventional caesarean delivery, women who underwent a Charité caesarean delivery were significantly more satisfied with their birth experience. At follow-up, the mode of delivery was not associated with significant differences in postnatal depression, breast feeding, or bonding parameters. Conclusions: Outside of emergency situations, Charité caesarean birth improves patients’ well-being, without increased maternal and neonatal morbidity.

Evaluation of the maternal and developmental toxicity of 6-methylmercaptopurine riboside in rats

Thiopurine prodrugs (azathioprine, AZA, and 6-mercaptopurine, 6MP) are embryotoxic to rodents and rabbits. Little is known about the developmental toxicity of 6-methylmercaptopurine riboside (6MMPr), a thiopurine drug metabolite that is thought to mediate its liver toxicity. A limb bud assay found that 6MMPr impairs the in vitro morphogenetic differentiation of mouse limb extremities, being more potent than 6MP in the assay. This study evaluated the embryotoxicity of 6MMPr (0, 7.5, 15, 30 mg/kg bw sc) in rats after single-dose exposure in mid organogenesis (GD10). One group of pregnant rats was similarly treated with 6MP (15 mg/kg bw sc). After C-section (GD21), fetuses were weighed, and examined for external abnormalities. One third of each litter was examined for soft-tissue abnormalities while the remaining fetuses were cleared and stained for skeleton evaluation. 6MMPr caused a dose-dependent maternal weight loss followed by recovery before term pregnancy. Except for a nonsignificant increase in embryolethality and slight reduction in fetal weight at 30 mg/kg bw, no indication of embryotoxicity was noted at this dose or at lower doses of 6MMPr. In contrast, 6MP led to nearly 98 % of post-implantation losses in the presence of slight-to-mild maternal toxicity. These results are consistent with the notion that maternal treatment with 6MMPr affects embryo development, causing a nonsignificant increase in embryolethality and a slight reduction in fetal weight at 30 mg/kg bw. However, there was no increase in abnormalities at this dose, which was severely toxic to the dams, as reflected in the maternal weight gain data.

The Impact of Mode of Delivery on Maternal and Neonatal Outcomes during Periviable Birth (22-25 Weeks).

The objective of our study was to compare the maternal and neonatal complications of periviable birth by the delivery route. A retrospective cohort study of periviable deliveries (220/7-256/7weeks) from 2013 to 2020 at a tertiary teaching institution was conducted. Deliveries were grouped by the mode of delivery. Excluded deliveries included pregnancy termination, anomaly, or undesired neonatal resuscitation. The primary composite maternal outcome included death, intensive care admission, sepsis, surgical site infection, unplanned operation, or readmission. Secondary outcomes included maternal blood loss, length of stay, neonatal survival, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), and retinopathy of prematurity (ROP). Outcomes were compared using Student's t-test, Wilcoxon-Mann-Whitney and Chi-squared tests. Relative risk (RR) and 95% confidence intervals were calculated with log-binomial regression. p-Values <0.05 were considered significant. Demographic and intervention variables associated with the outcome and the exposure were included in an adjusted relative risk (aRR) model. Subgroup analyses of singleton pregnancies and 220/7 to 236/7 weeks deliveries were conducted. After exclusion, 230 deliveries were included in the cohort. Maternal characteristics were similar between cohorts. For the primary outcome, cesarean delivery was associated with a trend toward increased maternal morbidity (22.6 vs. 10.7%, RR = 2.11 [1.03-4.43], aRR = 1.95 [0.94-4.03], p-value 0.07). Administration of magnesium sulfate, antenatal corticosteroids, and tocolytics were similar between cohorts. Neonatal survival to discharge was not different between the groups (54/83, 65.1% vs. 118/191, 61.8%, aRR = 0.93 [0.77-1.13]). Among the 172 neonates discharged alive, there was no difference in BPD, IVH, NEC, PDA, ROP, or intact survival. Periviable birth has a high rate of maternal morbidity with a trend toward the highest risk among women undergoing cesarean delivery. These risks should be included in shared decision-making. · Periviable birth has high maternal morbidity (19%) and is highest after cesarean delivery (23%).. · Route of delivery does not impact neonatal survival or intact neonatal survival.. · Head entrapment is rare during vaginal breech delivery..

Compliance with clinical guidelines increases the safety of vacuum-assisted delivery.

Vacuum-assisted delivery (VAD) is a common and safe obstetric procedure. However, occasionally serious complications may occur. Clinical guidelines and College Statements have been developed to reduce the risk of serious adverse events. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) College Statement C-Obs 16 has not been evaluated to see if advice improves outcomes. The aim was to evaluate whether compliance with RANZCOG College Statement C-Obs 16 advice reduced the risk of serious adverse outcomes, specifically clinically significant subgaleal haemorrhage and major birth trauma. Retrospective audit of VADs in a level five hospital (NSW Maternity and Neonatal capability framework) from January 2020 to 2021. There were 1960 women who delivered in the study period, of whom 252 (12.8%) delivered by vacuum, and complete data were available from 241 cases. Statement compliance was observed in 81%. The main deviation from Statement compliance was pulls exceeding three. Statement compliance was associated with a significant reduction in the incidence of subgaleal haemorrhage (0% vs 11%, P= 0.0002), major birth trauma (3% vs 22%, P= 0.0001), requirement for neonatal resuscitation (14% vs 35%, P= 0.0026) and Apgar scores at oneminute less than six (5% vs 22% P= 0.0006). Statement compliance was associated with a significant reduction in maternal blood loss at delivery (388 mL vs 438 mL, P= 0.01). Noncompliance with Statement advice was observed significantly more often in pregnancy complicated by gestational diabetes (3% vs 15%, P= 0.02) and birth requiring instrument change (4% vs 13% P= 0.031). Compliance with a College Statement is associated with lower rates of subgaleal haemorrhage and major neonatal trauma. The main deviation from compliance was pulls in excess of three. Keyword: birth trauma, clinical guidelines, quality and safety in healthcare, subgaleal haemorrhage, vacuum delivery.

‘괴물-아이’의 엄마 되기: 『다섯째 아이』와 모성서사의 비판적 잠재성

This essay reads Doris Lessing’s maternal narrative in The Fifth Child as a critique of the myth of the autonomous individual and family, claiming that the novel’s depictions of motherhood as institution and as experience invite us to rethink the main premises of the neoliberal gender regime. In the first section, I examine how the novel reveals the fundamental vulnerability of life facing the ills of society outside the Lovatt family circle. It turns out that what eventually supports their happy life is nothing but sheer luck, while it constantly demands maternal sacrifice and loss of agency. Recuperation of maternal agency, however, is not what this novel’s critical stance aims at. Rather, as I argue in the second section, ethical dimensions of mothering emerge at the pivotal point of the narrative when Harriet takes the responsibility of caring for Ben and becomes his mother despite the impossibility of motherly love. Unlike her husband, Harriet cannot deny the claims of trans-individual connection with Ben. While this may be taken as yet another instance of self-sacrifice and subjection, Harrient’s acceptance of Ben indicates the potential of maternal subjectivity that debunks the myths of the autonomous individual and moves towards communal notions of self and society.

Maternal and Paternal Hauntings in the Evolution of the Self: Commentary on “Where is my Mother? Childhood Trauma and the Configuration of the Self”

ABSTRACT In this commentary, I engage with selected ideas from Mendes’ paper, examining childhood trauma and the (dis) configuration of the Self. First, I focus on what the possibilities of a more triadically-inflected analysis of the relationship between the patient, her mother, and father may offer us in understanding the recalcitrant effects of trauma inside a culturally gendered triad. Second, I reflect on the foregrounded traumatogenic events surrounding the patient’s maternal loss, and highlight the role of her father as a potential driver of iatrogenic traumatic outcomes that are further consolidated within the Self. Third, I reflect obliquely on issues of training, focusing on the centrality of language in conveying clinical material, as a critical basis for generating compelling and credible sources of evidence in psychoanalytic writing. Finally, I conclude with reflections on the possibilities and limitations of theoretical diversity and pluralism, that have characterized much of the contemporary Relational Paradigm.

Maternal Hypertension and Offspring Cardiometabolic Disease Risk is Attenuated after Weight Loss in Obese Preeclamptic‐like BPH/5 Female Mice

Preeclampsia (PE) is a life‐threatening disorder of pregnancy that presents as late gestational hypertension and at least one other sign/symptom, such as proteinuria. It occurs in ~10% of pregnant women worldwide and the cause is unknown. Pre‐existing maternal hypertension and obesity has been associated with adverse outcomes, including PE and fetal growth restriction (FGR). To better understand the relationship of maternal PE risk (hypertension/obesity) and outcomes, we utilized the hyperphagic obese hypertensive BPH/5 mouse model of superimposed PE. We hypothesized that monitored food intake, via pair‐feeding the amount of normal chow consumed by age‐ and gestation‐matched lean normotensive C57 to BPH/5 mice, would attenuate maternal and offspring PE adverse outcomes.We have shown that adult BPH/5 female mice have an adverse cardiometabolic phenotype, hypertension, obesity with increased white adipose tissue (WAT), and dyslipidemia that is exaggerated by pregnancy. To test our hypothesis, BPH/5 and C57 females were instrumented with carotid catheters for radiotelemetric blood pressure monitoring prior to pregnancy. As previously described, pair‐feeding (PF) non‐pregnant BPH/5 female mice decreases body weight and WAT mass. When PF was performed for 10 days, we found a decrease in mean arterial pressure in BPH/5 PF versus ad libitum (AL) fed females (PF:121±2.8 vs AL:133±6 mmHg; n=3; p&lt;0.05). When PF was performed in BPH/5 beginning at copulatory plug detection, embryonic day (e) 0.5, they failed to show a late‐gestational blood pressure rise from baseline (n=3; p&gt;0.05) and attenuated proteinuria (PF: 84±15 vs AL: 177±16.5mg/dL; n=5; p&lt;0.05). The PF paradigm increased median BPH/5 litter size (PF: 7, max‐min: 3‐8 vs AL:3, max‐min: 1‐6; n=26; p&lt;0.05) and improved symmetrical FGR at e18.5 as assessed by fetal liver: body weight (PF: 13.63±0.7 vs AL:10.51±1.3; n=10; p&lt;0.05).As BPH/5 female offspring age, they exhibit excessive catch‐up growth with FGR at birth and obesity with hyperleptinemia by adulthood (8 weeks) unlike male littermates. Adult female BPH/5 have cardiomegaly, hypertension, and bradycardia (n=7; p&lt;0.05). Furthermore, adult female BPH/5 have hepatomegaly with microvesicular steatosis (p&lt;0.05, n=3‐9). Importantly, adult BPH/5 female offspring born to PF BPH/5 mothers do not display these cardiometabolic risk factors: obesity (PF: 18±1.8 vs AL: 21±0.3g; n=16; p&lt;0.05), hyperleptinemia (PF: 5.5±0.8 vs AL: 12.6±3.1ng/mL; n=6; p&lt;0.05), hepatomegaly (PF: 1178±27 vs AL: 1475±69mg; n=16; p&lt;0.05), and cardiomegaly (PF: 135.1±5.1 vs AL: 166.8±12.8mg; n=6; p&lt;0.05) with age. Further investigations are necessary to understand the mechanism whereby maternal hyperphagia prevention and weight loss in BPH/5 improves offspring cardiometabolic disease as they age in a sex‐dependent manner. Finally, we seek to determine if interventions during pregnancy not only improve maternal cardiometabolic health, but also that of subsequent generations through augmented fetal programming during PE.

Iron Deficiency Anemia in Pregnancy

This article examines the effects of maternal anemia and iron deficiency on pregnancy outcomes. The effects of iron supplementation on the health of the mother and her baby during pregnancy and after childbirth are still well understood. Anemia is a common problem in childbirth and maternity care. True anemia is defined as a hemoglobin level below 10.5 g/dL, excluding the age of pregnancy. Malnutrition, viral and bacterial infections, and congenital red cell illnesses like Thalassemia are the most common causes of anaemia during pregnancy. In pregnant women, iron deficiency is a prevalent cause of anaemia. Eliminated iron reserves, iron-free erythropoiesis without anaemia, and iron deficiency anaemia, which is the most common form of iron shortage, are the stages of iron insufficiency. Conclusion: Iron supplements should be given in the most efficient way. Oral metal formulas are widely used due to their performance and low cost. Parental therapy should only be used in the treatment of reasonable and severe anaemia when quick iron rehabilitation is required. The World Health Assembly has proposed the goal of reducing maternal anaemia by 5025 by 2025, and the U.S. Global Health Effort's Feed the Future has focused on maternal blood loss as a major concern.

Impact of “natural” cesarean delivery on peripartum blood loss: a randomized controlled trial

Early skin-to-skin contact after vaginal delivery increases milk production and may increase oxytocin release, leading to a reduction in the rate of postpartum hemorrhage. This study aimed to examine the effect of "natural" cesarean deliveries on perioperative maternal blood loss. This was a randomized controlled trial conducted at a single university-affiliated medical center, between August 2016 and February 2018. Term singleton pregnancies scheduled for a planned cesarean delivery under spinal anesthesia were included. Women were randomized at a ratio of 1:1 to natural cesarean delivery (study group) or traditional cesarean delivery (control group) during the routine preoperative assessment. Women in the study group watched fetal extraction, had early skin-to-skin contact, and breastfed until the end of surgery. Neonates in the control group were presented to the mother for a few minutes. Blood samples were drawn from all women, during fascia closure, to determine oxytocin levels using an enzyme-linked immunosorbent assay kit. The laboratory component was performed after recruitment completion and was accomplished in February 2019. The primary outcome was postpartum hemoglobin levels. To detect a difference of 0.5 g/dL between the groups with α=0.05 and β=80%, 214 women were needed. Of 214 randomized women, 23 were excluded. There was no difference in demographic and obstetrical variables between the groups. Postpartum hemoglobin levels were 10.1±1.1 and 10.3±1.3 g/dL in the study and control groups, respectively (P=.19). There was no difference in the rates of postpartum hemorrhage and blood transfusion. Maternal pain scores, satisfaction, and exclusive breastfeeding were comparable. Maternal oxytocin blood levels were 389.5±183.7 and 408.5±233.6 pg/mL in the study and control groups, respectively (P=.96). The incidence of neonatal hypothermia was comparable between the groups (P=.13). Natural cesarean delivery did not affect perioperative hemoglobin level or maternal oxytocin blood concentration.

Preconception weight loss improves fertility and maternal outcomes in obese mice

Women with obesity have higher incidences of infertility, with longer time to conception and increased risk of pregnancy complications compared to women with normal body weight. There is a lack of evidence demonstrating the benefit of preconception maternal weight loss on fertility and pregnancy outcomes. We aimed to determine if preconception weight loss, either with diet modification or glucose-like peptide 1 receptor agonist liraglutide, improves maternal weight, fertility, and pregnancy outcomes. C57BL/6 female mice were fed either a high-fat diet (HFD) or chow for 8 weeks. HFD-fed dams were administered liraglutide (0.3 mg/kg, s.c., for 4 weeks) or switched to chow to induce weight loss. Prior to mating, liraglutide was ceased and mice continued on HFD. Mice in the 'diet switch' group continued on chow. Pregnancy rates were recorded. Maternal anthropometry and glucose tolerance were measured before and after the intervention and at late gestation. Offspring outcomes were assessed. Liraglutide or diet switch led to weight reduction, improved insulin resistance (P< 0.001), and enhanced fertility, particularly in the liraglutide group (P< 0.005). Liraglutide-treated mice had significantly higher gestational weight gain (GWG) compared to the diet switch group (P< 0.05), with similar weight and glucose tolerance in late gestation to HFD mice. In contrast, diet switch maintained similar weight and glucose tolerance in late gestation to control mice. Pre-pregnancy weight intervention with liraglutide was effective at restoring fertility. Diet modification also improved fertility and avoided catch up weight gain in pregnancy. Liraglutide may be a therapeutic strategy for weight loss to prepare for pregnancy. However, our study provides caution about the potential for excessive GWG without diet intervention in pregnancy.

Leaving Home for Marital and Non-marital Reasons in the Netherlands, 1850–1940: The Impact of Parental Death and Parental Remarriage

Previous research shows that parentally bereaved children in north-western Europe in the past left home earlier than children who lived together with both biological parents. This article analyses the mechanisms behind this phenomenon with a special focus on the routes out of the parental household and the entry of step-parents and step-siblings. The Historical Sample of the Netherlands is exploited which contains detailed information about household composition and life courses of more than 22,000 female and male adolescent and young adult children born between 1850 and 1922. Event-history analysis is applied, and two exclusive routes out of the parental household, for marital and non-marital reasons, are studied in a competing risk design. The results show that parental loss does not increase the risk of early marriage before age 23, but strongly enhances the chances for leaving home for non-marital reasons, which are mainly work-related. This is especially true in case of maternal loss. No support is found for the hypothesis that the entry of a step-parent and step-siblings increases the risk of leaving home compared to living with a single widowed parent. Tensions with step-parents therefore do not suffice to explain why parentally bereaved children left earlier for non-marital reasons. Instead, we argue that children’s exit was in the interest of both the single widowed parent and the bereaved child.

Protein Digestion Kinetics Influence Maternal Protein Loss, Litter Growth, and Nitrogen Utilization in Lactating Sows

Body protein losses in lactating sows have a negative impact on sow and litter performance. Improving dietary amino acid utilization may limit protein mobilization. The effects of dietary protein kinetics on sow body condition loss, blood plasma metabolites, and plasma insulin-like growth factor-1 (IGF-1), and also on litter gain during lactation, were investigated in this study. In total, 57 multiparous sows were fed one of three lactation diets with the same crude protein level: low level of slow protein diet (LSP) (8% slowly degradable protein of total protein), medium level of slow protein diet (MSP) (12% slowly degradable protein of total protein), or high level of slow protein diet (HSP) (16% slowly degradable protein of total protein) in a complete block design. Our results showed that HSP sows lost the least body weight compared to MSP and LSP sows (11.9 vs. 17.3 and 13.5 kg, respectively; p = 0.01), less body protein than MSP sows (1.0 vs. 2.1 kg; p = 0.01), and tended to lose less loin muscle thickness than LSP sows (1.7 vs. 4.9 mm; p = 0.09) between Day 2 to Day 21 post-farrowing. LSP sows had greatest plasma urea level on Day 6 than MSP and HSP sows (4.9 vs. 3.6 and 3.1 mmol/L, respectively; p < 0.01) and on Day 13 (5.6 vs. 4.1 and 3.7 mmol/L, respectively; p < 0.01). HSP sows had the lowest plasma urea level at Day 20 compared to LSP and MSP sows (4.0 vs. 5.5 and 4.9 mmol/L, respectively; p < 0.01). The average plasma urea level of Days 6, 13, and 20 post-farrowing was negatively correlated with slow protein intake (r = −0.49, p < 0.01). Litter gain, milk composition, and nitrogen output to the environment did not differ significantly among the treatment groups. Therefore, the dietary protein kinetics affected mobilization of maternal reserves in multiparous sows during lactation, with a high fraction of slow protein-sparing protein mobilization.

Lack of catch-up in weight gain may intermediate between pregnancies with hyperemesis gravidarum and reduced fetal growth: the Japan Environment and Children\u2019s Study

BackgroundWomen with nausea and vomiting of pregnancy (NVP) have higher birth weight infants, while those with hyperemesis gravidarum, a severe manifestation of NVP, have lower birth weight infants. We aimed to investigate the associations between maternal weight loss (a consequence of hyperemesis gravidarum), NVP, and infant birth weight.MethodsThis study was a secondary analysis of a nationwide birth cohort in Japan. Singleton pregnancies delivered at 28–41 weeks of gestation were included in the analysis. Women were categorized based on their weight change in the 1st trimester (as a proportion to their pre-pregnancy weight: > + 3%, > 0 to + 3%, > -3 to 0%, > -5 to -3%, ≤ -5%) and severity of NVP (no nausea, only nausea, vomiting but able to eat, vomiting and unable to eat). The effects of weight change and severity of NVP on infant birth weight and small for gestational age (SGA) were assessed using regression models. We further examined how these effects could be modified by maternal weight gain up to the 2nd trimester.ResultsAmong 91,313 women, 5,196 (5.7%) lost ≥ 5% of their pre-pregnancy weight and 9,983 (10.9%) experienced vomiting and were unable to eat in the 1st trimester. Women with weight loss ≥ 5% in the 1st trimester had infants 66 (95% CI: 53, 78) g lighter and higher odds of SGA (aOR: 1.29; 95% CI: 1.14, 1.47) than women who gained > 3% during the same period. However, when adjusting for weight gain up to the 2nd trimester, women with weight loss ≥ 5% in the 1st trimester had infants 150 (95% CI: 135, 165) g heavier and lower odds of SGA (aOR: 0.39; 95% CI: 0.33, 0.46) than those who gained > 3% during the same period. In contrast, women with more severe NVP tended to have infants with larger birth weight and lower odds of SGA compared to women without NVP. These trends were strengthened when adjusting for weight gain up to the 2nd trimester.ConclusionsOur study suggests the possibility that reduced fetal growth in pregnancies with hyperemesis gravidarum may be caused by the lack of catch-up in gestational weight gain up to the 2nd trimester.

Weight gain in pregnancy: can metformin steady the scales?

Objective Metformin has been associated with modest weight reduction in the non-pregnant population. Our hypothesis is that metformin exposure will lead to a higher incidence of appropriate weight gain during pregnancy. Study Design This was a retrospective cohort study in a single center between 2009 and 2019. We included all pregnant women with type 2 diabetes or prediabetes. We compared women exposed to metformin in any trimester. The primary outcome was appropriate weight gain defined by the Institute of Medicine guidelines. Secondary outcomes included excessive weight gain, weight loss, suspected fetal growth restriction (FGR), and mean birth weight. Adjusted odds ratios or group differences were calculated using logistic or linear regression, controlling for confounders. Results Of 41,472 deliveries during the study period, 511 pregnancies met inclusion criteria. 284 pregnancies had no metformin exposure; 227 did have metformin exposure, of which 169 (72.2%) were initiated on metformin in the first trimester. Women exposed to metformin in any trimester were statistically not more likely to have appropriate weight gain (aOR 1.53 (95% CI 1.00–2.34, p = .048), but did have less excess weight gain (aOR 0.45, 95% CI 0.30–0.66, p < .001), and more maternal weight loss (aOR 2.17, 95% CI 1.18–3.98, p = .012) than the unexposed group. Women exposed to metformin in the first trimester of pregnancy were less likely to have excess weight gain (aOR 0.39, 95% CI 0.25–0.61, p < .001) and more likely to have maternal weight loss (aOR 2.56, 95% CI 1.30–5.07, p = .007) than the unexposed cohort. There was no difference in FGR (5.3% vs 2.5% p = .094) or mean birth weight (3235.6 vs 3352.4 gm p = .122) in the metformin exposed group vs non-exposed groups, respectively. Conclusions Metformin exposure in pregnancy was associated with less excess weight gain and a higher rate of weight loss. There was no difference in FGR or mean birth weight in metformin exposed neonates. This suggests that metformin may help avoid excess weight gain and its associated comorbidities.

The association of hourly second-stage documentation with cesarean delivery and maternal blood loss

Purpose of the article Cesarean rates and maternal morbidity increase with the duration of the second stage of labor. We studied the effect of hourly evaluation and documentation during the second stage of labor on maternal and fetal outcomes. Materials and methods We performed a retrospective cohort study of all women who delivered at our urban, tertiary care hospital and underwent a second stage of greater than 60 min between 1 June 2016 and 31 May 2019. There were 1498 patients with complete data. Four hundred forty patients had hourly evaluation and documentation throughout the second stage and 1058 did not. We performed t-tests, Chi-squared, and regression analyses to compare cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage and blood transfusion rates, and fetal outcomes. We performed regression analyses to evaluate for independent effect of this intervention on each outcome. Results Patients with hourly evaluation and documentation had a decreased likelihood of cesarean delivery (8.2% vs. 20.3%, p < .001), shorter second-stage of labor (98.1 min vs. 177.5 min, p < .001), decreased quantitative blood loss (514.4 mL vs. 667.7 mL, p < .001), and hemorrhage rate (12.5% vs. 19.9%, p < .001). Hourly evaluation was associated with decreased transfusion rates (3.2% vs. 5.6%, p = .05) but was not related to the number of units transfused. Regression analyses confirmed the impact of hourly documentation when potential confounders were included. These differences in outcomes were also noted when evaluation was performed and documented within every 75 min. Hourly second-stage evaluation and documentation did not affect other maternal or infant morbidities. Conclusion Hourly evaluation and documentation in the second stage was associated with decreased cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage, and transfusion.

Association of Peripartum Management and High Maternal Blood Loss at Cesarean Delivery for Placenta Accreta Spectrum (PAS): A Multinational Database Study

(Acta Obstet Gynecol Scand. 2021;100(suppl 1):29–40. doi: 10.1111/aogs.14103. Epub February 21, 2020) Though there has been a global decline in maternal mortality rates, the cesarean delivery (CD) rate continues to rise, resulting in an increase of placenta accreta spectrum (PAS). PAS is associated with postpartum hemorrhage (PPH) and cesarean hysterectomy, severely impacting maternal morbidity and mortality. PAS pregnancy and delivery management vary greatly between institutions. This study investigates which management and epidemiologic factors correspond with maternal outcomes, specifically high and extraordinarily high maternal blood loss during CD when PAS is present.

Clinical impact of vivax malaria: A collection review.

BackgroundPlasmodium vivax infects an estimated 7 million people every year. Previously, vivax malaria was perceived as a benign condition, particularly when compared to falciparum malaria. Reports of the severe clinical impacts of vivax malaria have been increasing over the last decade.Methods and findingsWe describe the main clinical impacts of vivax malaria, incorporating a rapid systematic review of severe disease with meta-analysis of data from studies with clearly defined denominators, stratified by hospitalization status. Severe anemia is a serious consequence of relapsing infections in children in endemic areas, in whom vivax malaria causes increased morbidity and mortality and impaired school performance. P. vivax infection in pregnancy is associated with maternal anemia, prematurity, fetal loss, and low birth weight. More than 11,658 patients with severe vivax malaria have been reported since 1929, with 15,954 manifestations of severe malaria, of which only 7,157 (45%) conformed to the World Health Organization (WHO) diagnostic criteria. Out of 423 articles, 311 (74%) were published since 2010. In a random-effects meta-analysis of 85 studies, 68 of which were in hospitalized patients with vivax malaria, we estimated the proportion of patients with WHO-defined severe disease as 0.7% [95% confidence interval (CI) 0.19% to 2.57%] in all patients with vivax malaria and 7.11% [95% CI 4.30% to 11.55%] in hospitalized patients. We estimated the mortality from vivax malaria as 0.01% [95% CI 0.00% to 0.07%] in all patients and 0.56% [95% CI 0.35% to 0.92%] in hospital settings. WHO-defined cerebral, respiratory, and renal severe complications were generally estimated to occur in fewer than 0.5% patients in all included studies. Limitations of this review include the observational nature and small size of most of the studies of severe vivax malaria, high heterogeneity of included studies which were predominantly in hospitalized patients (who were therefore more likely to be severely unwell), and high risk of bias including small study effects.ConclusionsYoung children and pregnant women are particularly vulnerable to adverse clinical impacts of vivax malaria, and preventing infections and relapse in this groups is a priority. Substantial evidence of severe presentations of vivax malaria has accrued over the last 10 years, but reporting is inconsistent. There are major knowledge gaps, for example, limited understanding of the underlying pathophysiology and the reason for the heterogenous geographical distribution of reported complications. An adapted case definition of severe vivax malaria would facilitate surveillance and future research to better understand this condition.

Placenta accreta spectrum: We can do better.

Placenta accreta spectrum (PAS) has a high risk of maternal morbidity, and requires meticulous antenatal and peripartum management. To compare the management and outcomes of PAS between women with and without antenatally suspected disease, and to evaluate the effect of multidisciplinary team (MDT) management. A retrospective cohort study identified all hysterectomy specimens with a histopathological diagnosis of PAS in the Western Sydney Local Health District between January 2006 and December 2019, and analysed each patient's clinical course. Seventy patients had PAS diagnosed on hysterectomy specimens, of which 38 cases (54%) were antenatally suspected. Women with suspected PAS were more likely to have a previous caesarean section (100% vs 68%, P<0.001), placenta praevia (92% vs 56%, P<0.001) and anterior placenta (95% vs 66%. P=0.011). Suspected PAS was associated with less maternal blood loss (median blood loss 2000mL vs 4000mL, P<0.001), fewer red blood cell transfusions (median four units vs nine units, P<0.001), and shorter intensive care or high dependency unit admission (mean stay one day vs three days, P=0.037). There were no significant differences in other maternal morbidities. MDT management was associated with a clinically significant reduction in maternal blood loss (1500mL vs 2520mL, P=0.09) and red blood cell transfusion (one unit vs six units, P=0.04). The mean gestation of delivery was 37weeks in both groups with no differences in neonatal morbidity. Both antenatally diagnosed PAS and MDT management reduced blood loss and blood transfusion. Elective delivery at 37weeks gestation reduces the neonatal risks of preterm delivery.

Maternal Loss in Situations of Conflict: A Case Study

Maternal Loss in Situations of Conflict: A Case Study