Preterm Neonatal Death Research Articles

Vaccine safety surveillance in pregnancy in low- and middle-income countries using GAIA case definitions: A feasibility assessment

BackgroundGlobal efforts to adequately monitor safety of new vaccines for pregnant women in low and middle-income countries (LMICs) are needed. The Global Alignment of Immunization Safety Assessment in pregnancy (GAIA) project recently published case definitions based on levels of diagnostic certainty for pregnancy- and neonatal outcomes and maternal vaccination. As a preliminary step to assessing the applicability of these definitions in LMICs, WHO selected sites and conducted a feasibility assessment to evaluate their ability to identify and classify selected outcomes (preterm birth, neonatal death, neonatal invasive bloodstream infection (NI-BSI), stillbirth) and maternal vaccination. MethodsCandidate sites were initially screened using a questionnaire. For each outcome, eligible sites were asked to retrospectively identify and collect information for three individuals born in 2016. Subsequently, outcomes were classified by level of diagnostic certainty. ResultsFifty-one sites (15 countries) were screened; 32 of them (9 countries) participated in the assessment and identified 315 subjects with the outcomes of interest. Twenty-four sites (8 countries) identified at least one subject per outcome and agreed to continue participating. The majority (80%) of preterm births, neonatal deaths, and NI-BSI subjects, but only 50% of stillbirths, could be assessed for diagnostic certainty. The main reasons for not classifying stillbirths were insufficient information to distinguish between antepartum and intrapartum stillbirth (29%); or that not all data for one subject fit into a single level of diagnostic certainty (35%). Forty-nine percent of mothers were considered vaccinated, 6% not-vaccinated, and vaccination status could not be assessed in 44% of them. DiscussionGAIA case definitions for four neonatal outcomes and maternal vaccination were successfully piloted in 24 sentinel sites across four WHO regions. Our assessment found that modification of the stillbirth definition could help avoid potential misclassification. Vaccine safety monitoring in LMICs will benefit from systematic recording of all vaccinations during pregnancy.

Association Between Prepregnancy Body Mass Index and Severe Maternal Morbidity

(JAMA 2017;318(18):1777–1786) Overweight and obesity are associated with increased risks of adverse maternal and neonatal events such as preterm birth, stillbirth, and neonatal or infant death; underweight is also associated with adverse outcomes. However, it is unclear if the risk of severe maternal morbidity increases as body mass index (BMI) increases. This study aimed to determine the association between prepregnancy BMI and severe maternal morbidity or mortality.

Lipid-based nutrient supplements for maternal, birth, and infant developmental outcomes.

Ready-to-use lipid-based nutrient supplements (LNS) are a highly nutrient-dense supplement, which could be a good source of macro- and micronutrients for pregnant women who need to supplement their nutrient intake. To assess the effects of LNS for maternal, birth and infant outcomes in pregnant women. Secondary objectives were to explore the most appropriate composition, frequency and duration of LNS administration. In May 2018, we searched CENTRAL, MEDLINE, Embase, 22 other databases and two trials registers for any published and ongoing studies. We also checked the reference lists of included studies and relevant reviews, and we contacted the authors of included studies and other experts in the field to identify any studies we may have missed, including any unpublished studies. We included randomised controlled trials (RCTs) and quasi-RCTs that compared LNS given in pregnancy to no intervention, placebo, iron folic acid (IFA), multiple micronutrients (MMN) or nutritional counselling. We used standard Cochrane procedures. We included four studies in 8018 pregnant women. All four studies took place in stable community settings in low- and middle-income countries: Bangladesh, Burkina Faso, Ghana and Malawi. None were in emergency settings. The oldest trial was published in 2009. Of the four included studies, one compared LNS to IFA, one compared LNS to MMN, and two compared LNS to both IFA and MMN.We considered the included studies to be of medium to high quality, and we rated the quality of the evidence as moderate using the GRADE approach.LNS versus IFAMaternal outcomes: there was no difference between the LNS and IFA groups as regards maternal gestational weight gain per week (standard mean difference (SMD) 0.46, 95% confidence interval (CI) -0.44 to 1.36; 2 studies, 3539 participants). One study (536 participants) showed a two-fold increase in the prevalence of maternal anaemia in the LNS group compared to the IFA group, but no difference between the groups as regards adverse effects. There was no difference between the two groups for maternal mortality (risk ratio (RR) 0.53, 95% CI 0.12 to 2.41; 3 studies, 5628 participants).Birth and infant outcomes: there was no difference between the LNS and IFA groups for low birth weight (LBW) (RR 0.87, 95% CI 0.72 to 1.05; 3 studies, 4826 participants), though newborns in the LNS group had a slightly higher mean birth weight (mean difference (MD) 53.28 g, 95% CI 28.22 to 78.33; 3 studies, 5077 participants) and birth length (cm) (MD 0.24 cm, 95% CI 0.11 to 0.36; 3 studies, 4986 participants). There was a reduction in the proportion of infants who were small for gestational age (SGA) (RR 0.94, 95% CI 0.89 to 0.99; 3 studies, 4823 participants) and had newborn stunting (RR 0.82, 95% CI 0.71 to 0.94; 2 studies, 4166 participants) in the LNS group, but no difference between the LNS and IFA groups for preterm delivery (RR 0.94, 95% CI 0.80 to 1.11; 4 studies, 4924 participants), stillbirth (RR 1.14; 95% CI 0.52 to 2.48; 3 studies, 5575 participants) or neonatal death (RR 0.96, 95% CI 0.14 to 6.51). The current evidence for child developmental outcomes is not sufficient to draw any firm conclusions.LNS versus MMNMaternal outcomes: one study (662 participants) showed no difference between the LNS and MMN groups as regards gestational weight gain per week or adverse effects. Another study (557 participants) showed an increased risk of maternal anaemia in the LNS group compared to the MMN group.Birth and infant outcomes: there was no difference between the LNS and MMN groups for LBW (RR 0.92, 95% CI 0.74 to 1.14; 3 studies, 2404 participants), birth weight (MD 23.67 g, 95% CI -10.53 to 57.86; 3 studies, 2573 participants), birth length (MD 0.20 cm, 95% CI -0.02 to 0.42; 3 studies, 2567 participants), SGA (RR 0.95, 95% CI 0.84 to 1.07; 3 studies, 2393 participants), preterm delivery (RR 1.15, 95% CI 0.93 to 1.42; 3 studies, 2630 participants), head circumference z score (MD 0.10, 95% CI -0.01 to 0.21; 2 studies, 1549 participants) or neonatal death (RR 0.88, 95% CI 0.36 to 2.15; 1 study, 1175 participants). Findings from this review suggest that LNS supplementation has a slight, positive effect on weight at birth, length at birth, SGA and newborn stunting compared to IFA. LNS and MMN were comparable for all maternal, birth and infant outcomes. Both IFA and MMN were better at reducing maternal anaemia when compared to LNS. We did not find any trials for LNS given to pregnant women in emergency settings.Readers should interpret the beneficial findings of the review with caution since the evidence comes from a small number of trials, with one-large scale study (conducted in community settings in Bangladesh) driving most of the impact. In addition, effect sizes are too small to propose any concrete recommendation for practice.

Contraception after pregnancy: Making the right choices

The postpartum period is a high-risk time for unintended pregnancy. Increasing access to postpartum contraception should reduce this risk. Unintended pregnancy may lead to abortion or miscarriage, but if the pregnancy continues and has been conceived within 12 months of a previous delivery, a short inter-pregnancy interval will occur. Short inter-pregnancy intervals are associated with a higher risk of negative consequences for the baby such as preterm birth and neonatal death. Most contraceptive methods can be safely initiated after childbirth, and immediate provision from within maternity services has significant advantages. Women should receive accurate information about available methods during the antenatal and postpartum periods, as well as the risks of unintended and short inter-pregnancy intervals. This can support informed decision-making about future reproductive intentions with better outcomes for mothers and babies. Hospital and community services can work together to increase the provision of contraceptive services after pregnancy.

The project to understand and research preterm pregnancy outcomes and stillbirths in South Asia (PURPOSe): a protocol of a prospective, cohort study of causes of mortality among preterm births and stillbirths

BackgroundIn South Asia, where most stillbirths and neonatal deaths occur, much remains unknown about the causes of these deaths. About one-third of neonatal deaths are attributed to prematurity, yet the specific conditions which cause these deaths are often unclear as is the etiology of stillbirths. In low-resource settings, most women are not routinely tested for infections and autopsy is rare.MethodsThis prospective, cohort study will be conducted in hospitals in Davengere, India and Karachi, Pakistan. All women who deliver either a stillbirth or a preterm birth at one of the hospitals will be eligible for enrollment. With consent, the participant and, when applicable, her offspring, will be followed to 28-days post-delivery. A series of research tests will be conducted to determine infection and presence of other conditions which may contribute to the death. In addition, all routine clinical investigations will be documented. For both stillbirths and preterm neonates who die ≤ 28 days, with consent, a standard autopsy as well as minimally invasive tissue sampling will be conducted. Finally, an expert panel will review all available data for stillbirths and neonatal deaths to determine the primary and contributing causes of death using pre-specified guidance.ConclusionThis will be among the first studies to prospectively obtain detailed information on causes of stillbirth and preterm neonatal death in low-resource settings in Asia. Determining the primary causes of death will be important to inform strategies most likely to reduce the high mortality rates in South Asia.Trial registrationClinicaltrials.gov (NCT03438110) Clinical Trial Registry of India (CTRI/2018/03/012281).

Maternal and Neonatal Outcomes of Appendicitis in Pregnancy [19D

INTRODUCTION: We sought to determine the differences in pregnancy outcomes seen in women with diagnosed appendicitis when compared to women who do not have this diagnosis. METHODS: A retrospective cohort study of 1,853,219 women in California with singleton, vertex, non-anomalous, term gestations was performed to assess the prevalence of maternal and neonatal outcomes in women with appendicitis during pregnancy as compared to unaffected women. Maternal outcomes included chorioamnionitis, placental abruption, cesarean delivery, post-partum hemorrhage, and maternal sepsis. Neonatal outcomes included preterm delivery (divided into <37, <34, and <32 weeks gestational age), intrauterine fetal demise (IUFD), respiratory distress syndrome (RDS), and neonatal death. Multivariate regression analyses and chi-square tests were employed for statistical comparisons. RESULTS: Women with appendicitis had an increased risk of adverse outcomes in pregnancy. Appendicitis was associated with a statistically significant increase in cesarean delivery (odds ratio [OR], 7.37; 95% confidence interval [CI], 4.58-11.84), preterm delivery prior to 37 weeks (OR, 11.92; CI, 7.85-18.09), and blood transfusion (OR 20.56, CI, 10.86-38.89). It was also associated with several statistically significant adverse neonatal outcomes, including intrauterine death (OR, 4.16 (CI, .56-30.88), respiratory distress syndrome (OR, 14.78; CI, 7.89-27.64), and neonatal death (OR 19.29, CI (5.70-65.19). CONCLUSION: Women with appendicitis in pregnancy are at higher risk of complications than all-comers, with a statistically significant rates of both preterm delivery, cesarean delivery, and neonatal death. Whether this increased risk was due to confounding factors, impact of surgical treatment, or disease pathophysiology, and how these risks can be mitigated through health care practice advancements deserves further consideration.

Pregnancy Outcomes in Patients Without Gestational Diabetes Stratified by Maternal Age [39L

INTRODUCTION: To compare pregnancy outcomes and rates of complications in women without gestational diabetes stratified by maternal age. METHODS: We designed a retrospective cohort analysis using data compiled from singleton, non-anomalous gestations in the United States. Using multivariate regression and χ2 tests, we examined maternal and neonatal outcomes stratified by maternal age at time of delivery. Women ages 20–25 severed as reference values. Outcomes examined included preterm delivery, birth weight >4,000 g, small for gestational age, intrauterine fetal demise, neonatal death, cesarean section, abruption, chorioamnionitis, and post-partum hemorrhage. P-value less than 0.05 was considered statistically significant. RESULTS: In a population of 1.85 million non-anomalous singleton deliveries, 1,718,481 women without gestational diabetes were identified. Women ≤20 year old had higher rates of preterm deliveries <32 w (OR 1.28; 95% CI 1.20–1.25) compared to women ≥40 (OR 0.95; 95% CI 1.11–1.28). Women 35–40 had increased IUFD (OR 1.68; 95% CI 1.40–2.02). Women 35–40 and ≥40 had higher cesarean section (OR 1.60; 95% CI 1.59–1.62 and OR 1.29; 95% CI 1.26–1.31) and post-partum hemorrhage (OR 1.09; 95% CI 1.05–1.12 and OR 1.10; 95% CI 1.04–1.16) rates. Women ≤20 had lower rates of placental abruption rates (OR 0.98; 95% CI 0.81–0.93) and chorioamnionitis (OR 0.74; 95% CI 0.72–0.77). CONCLUSION: Among women without gestational diabetes, younger maternal age is associated with lower risk of cesarean section, placental abruption and chorioamnionitis. Women of advanced maternal age face increased risk for SGA, IUFD, cesarean sections and post-partum hemorrhage. Women at extremes of maternal age have greater risk of preterm delivery and neonatal death.

Risk Factors Associated with Preterm Neonatal Mortality: A Case Study Using Data from Mt. Hope Women's Hospital in Trinidad and Tobago.

Preterm neonatal mortality contributes significantly to the high incidence of death among children under five years of age. Neonatal mortality also serves as an indicator of maternal health in society. The aim of the study is to examine the risk factors for preterm neonatal mortality at the neonatal intensive care unit (NICU) at Mount Hope Women’s Hospital in Trinidad and Tobago (MHWH). In this retrospective study, we included infants (N = 129), born < 37 weeks gestational age, between 1 January and 31 December 2015. Two binary logistic regression models (infant and maternal variables) were constructed to identify predictors of preterm neonatal mortality. Roughly 12% of the infants died after being admitted to the NICU. The binary logistic regression (infant model) had an excellent fit (area under the curve (AUC): 0.904, misclassification rate: 11.7%) whilst the maternal binary logistic model had a fair fit (AUC: 0.698). Birth weight, length of time on the ventilator and obstetric complications proved to significantly influence the odds of preterm neonatal death. The estimated models show that improvement in neonatal as well as maternal variables has direct impact on preterm neonatal mortality.

Assisted reproductive technologies: a hierarchy of risks for conception, pregnancy outcomes and treatment decisions.

The use of assisted reproductive technologies (ART) for the treatment of infertility has grown exponentially over the last 20 years, and now accounts for 4% of all births in Australia, and over 1 m births annually around the globe. There is consistent reporting of increased risk of adverse perinatal outcomes and birth defects following infertility treatment. However, change in practice has been stymied by critical knowledge gaps with regards to (a) the relative contribution of patient and treatment factors to adverse outcomes, (b) the independent contribution of specific contemporary treatments and treatment combinations to outcomes, (c) the impact of innovations in laboratory and clinical practice on treatment success and observed risk and (d) changes over time in patient characteristics. Here we summarize key findings from the South Australian Birth Cohort, which is a whole-of-population cohort of over 300,000 births from 1986 to 2002. Relative to spontaneous conceptions, singletons from assisted conception were more likely to be stillborn [odds ratio (OR)=1.82; 95% confidence interval (CI) 1.34-2.48], while survivors as a group were comprehensively disadvantaged at birth, including lower birth weight (OR=2109 g; 95% CI 2129-289), very low birth weight (OR=2.74; 95% CI 2.19-3.43), very preterm birth (OR=2.30; 95% CI 1.82-2.90) and neonatal death (OR=2.04; 95% CI 1.27-3.26). Major birth defects, including cardiac, urogenital and musculoskeletal defects are doubled after fresh ICSI cycles, which is a particular concern as ICSI now accounts for 70% of all treatment cycles globally. Future study is needed to provide contemporary, precise evidence to inform patient and clinic decision making, and generate knowledge for future innovation in ART laboratory methods and clinical practice, thereby optimizing treatment and health outcomes while reducing adverse events.

Pregnancy outcome in more than 5000 births to women with viral hepatitis: a population-based cohort study in Sweden

Previous studies have shown inconsistent results with respect to hepatitis B (HBV), hepatitis C (HCV) and pregnancy outcome. The aim of this study was to investigate pregnancy outcome in women with HBV or HCV. In a nationwide cohort of births between 2001 and 2011 we investigated the risks of adverse pregnancy outcomes in 2990 births to women with HBV and 2056 births to women with HCV using data from Swedish healthcare registries. Births to women without HBV (n = 1090 979), and births without HCV (n = 1091 913) served as population controls. Crude and adjusted relative risks (aRR) were calculated using Poisson regression analysis. Women with HCV were more likely to smoke (46.7 vs. 8.0%) and to have alcohol dependence (18.9 vs. 1.3%) compared with population controls. Most women with HBV were born in non-Nordic countries (91.9%). Maternal HCV was associated with a decreased risk of preeclampsia (aRR: 0.39, 95% CI: 0.24–0.64), but an increased risk of preterm birth (aRR: 1.32, 95% CI: 1.08–1.60) and late neonatal death (7–27 days: aRR: 3.79, 95% CI: 1.07–13.39) Preterm birth were also more common in mothers with HBV, aRR: 1.21 (95% CI: 1.02–1.45). Both HBV and HCV are risk factors for preterm birth, while HCV seems to be associated with a decreased risk for preeclampsia. Future studies should corroborate these findings.

The role of maternal age in twin pregnancy outcomes

There are limited data on how maternal age is related to twin pregnancy outcomes. The purpose of this study was to assess the relationship between maternal age and risk for preterm birth, fetal death, and neonatal death in the setting of twin pregnancy. This population-based study of US birth, fetal death, and period-linked birth-infant death files from 2007-2013 evaluated neonatal outcomes for twin pregnancies. Maternal age was categorized as 15-17, 18-24, 25-29, 30-34, 35-39, and ≥40 years of age. Twin live births and fetal death delivered at 20-42 weeks were included. Primary outcomes included preterm birth (<34 weeks and <37 weeks), fetal death, and neonatal death at <28 days of life. Analyses of preterm birth at <34 and <37 weeks were adjusted for demographic and medical factors, with maternal age modeled with the use of restricted spline transformations. A total of 955,882 twin live births from 2007-2013 were included in the analysis. Preterm birth rates at <34 and <37 weeks gestation were highest for women 15-17 years of age, decreased across subsequent maternal age categories, nadired for women 35-39 years old, and then increased slightly for women ≥40 years old. Risk for fetal death generally decreased across maternal age categories. Risk for fetal death was 39.9 per 1000 live births for women 15-17 years old, 24.2 for women 18-24 years old, 17.8 for women 25-29 years old, 16.4 for women 30-34 years old, 17.2 forwomen 35-39 years old, and 15.8 for women ≥40 years old. Risk forneonatal death at <28 days was highest for neonates born to women 15-17 years old (10.0 per 1,000 live births), decreased to 7.3 for women 18-24 years old and 5.5 for women 25-29 years old and ranged from 4.3-4.6 for all subsequent maternal age categories. In adjusted models, risk for preterm birth at <34-<37 weeks gestation was not elevated for women in their mid-to-late 30s; however, risk was elevated for women <20 years old and increased progressively with age for women in their 40s. Although twin pregnancy is associated with increased risk for most adverse perinatal outcomes, this analysis did not find advanced maternal age to be an additional risk factor for fetal death and infant death. Preterm birth risk was relatively low for women in their late 30s. Risks for adverse outcomes were higher among younger women; further research is indicated to improve outcomes for this demographic group. It may be reasonable to counsel women in their 30s that their age is not a major additional risk factor for adverse obstetric outcomes in the setting of twin pregnancy.

Interpregnancy Interval and Childbirth Outcomes in California, 2007-2009.

Objectives The goals of interconception care are to optimize women's health and encourage adequate spacing between pregnancies. Our study calculated trends in interpregnancy interval (IPI) patterns and measured the association of differing intervals with birth outcomes in California. Methods Women with "non-first birth" deliveries in California hospitals from 2007 to 2009 were identified in a linked birth certificate and patient discharge dataset and divided into three IPI birth categories: <6, 6-17, and 18-50 months. Trends over the study period were tested using the Cochran-Armitage two-sided linear trend test. Chi square tests were used to test the association between IPI and patient characteristics and selected singleton adverse birth outcomes. Results Of 645,529 deliveries identified as non-first births, 5.6 % had an IPI <6 months, 33.1 % had an IPI of 6-17 months, and 61.3 % had an IPI of 18-50 months. The prevalence of IPI <6 months declined over the 3-year period (5.8 % in 2007 to 5.3 % in 2009, trend p value <0.0001).Women with an IPI <6 months had a significantly higher prevalence of early preterm birth (<34 weeks), low birthweight (<2500g), neonatal complications, neonatal death and severe maternal complications than women with a 6-17 month or 18-50 month IPI (p < 0.005). Comparing those with a 6-17 month vs 18-50 month IPI, there were increased early preterm births and decreased maternal complications, complicated delivery, and stillbirth/intrauterine fetal deaths among those with a shorter IPI. Conclusions for Practice In California, women with an IPI <6 months were at increased risk for several birth outcomes, including composite morbidity measures.

Application of ICD-PM to preterm-related neonatal deaths in South Africa and United Kingdom.

We explore preterm-related neonatal deaths using the WHO application of the International Classification of Disease (ICD-10) to deaths during the perinatal period: ICD-PM as an informative case study, where ICD-PM can improve data use to guide clinical practice and programmatic decision-making. Retrospective application of ICD-PM. South Africa, and the UK. Perinatal death databases. Descriptive analysis of neonatal deaths and maternal conditions present. Causes of preterm neonatal mortality and associated maternal conditions. We included 98 term and 173 preterm early neonatal deaths from South Africa, and 956 term and 3248 preterm neonatal deaths from the UK. In the South African data set, the main causes of death were respiratory/cardiovascular disorders (34.7%), low birthweight/prematurity (29.2%), and disorders of cerebral status (25.5%). Amongst preterm deaths, low birthweight/prematurity (43.9%) and respiratory/cardiovascular disorders (32.4%) were the leading causes. In the data set from the UK, the leading causes of death were low birthweight/prematurity (31.6%), congenital abnormalities (27.4%), and deaths of unspecified cause (26.1%). In the preterm deaths, the leading causes were low birthweight/prematurity (40.9%) and deaths of unspecified cause (29.6%). In South Africa, 61% of preterm deaths resulted from the maternal condition of preterm spontaneous labour. Among the preterm deaths in the data set from the UK, no maternal condition was present in 36%, followed by complications of placenta, cord, and membranes (23%), and other complications of labour and delivery (22%). ICD-PM can be used to appraise the maternal and newborn conditions contributing to preterm deaths, and can inform practice. ICD-PM can be used to appraise maternal and newborn contributors to preterm deaths to improve quality of care.

Adverse pregnancy outcomes following syphilis treatment in pregnancy in the UK.

Syphilis infection in pregnancy is known to cause a number of severe adverse pregnancy outcomes, including second-trimester miscarriage, stillbirth, very pre-term delivery and neonatal death, in addition to congenital syphilis. A retrospective review of women with positive syphilis serology and a pregnancy outcome between 2005 and 2012 in Leeds, UK, was performed. In all, 57 cases of positive syphilis serology in pregnancy were identified: 24 with untreated syphilis treated in the current pregnancy (Group 1); seven with reported but unconfirmed prior treatment who were retreated (Group 2); and 26 adequately treated prior to pregnancy (Group 3). The rate of severe adverse pregnancy outcomes in Group 1 at 21% was significantly higher than the 0% outcome of Group 3 (p = 0.02). The severe adverse pregnancy outcomes were two second-trimester miscarriages, two pre-term births at 25 and 28 weeks and one stillbirth at 32 weeks. There were no cases of term congenital syphilis or term neonatal death, but we observed high rates of other adverse pregnancy outcomes despite treatment during pregnancy. Rapid referral for treatment is needed before 18 weeks in order to minimise adverse pregnancy outcomes.

Effect of Young Maternal Age on Obstetric and Perinatal Outcomes: Results from the Tertiary Center in Turkey.

Young maternal age is variously defined in studies of its effect on obstetrics and perinatal outcomes. Also, pregnancy has been reported as the leading cause of death in adolescent girls in low- and middle-income countries. The aim of the study was to evaluate whether young maternal age was associated with an increased risk of obstetrics and perinatal adverse outcomes. Case-control study. This case-control study was derived from a database of the medical records between January 2008 and December 2012. In the present study, 1374 teenage pregnancy and 1294 adult pregnancy cases were included. After restriction of analyses to singleton primiparous women, 1282 teenage pregnancy and 735 adult pregnancy cases were analyzed. Maternal age was separated into three groups: 15 and less, 16-19, and 20-34 years. Adjusted odds ratios (ORs) were derived through logistic regression models for the potential confounding factors. Adolescents aged 15 years and younger had higher risks of preterm delivery, early preterm delivery, intrauterine fetal death and neonatal death compared with women aged 20 to 34 years after adjustment for confounding factors. In addition, both groups of adolescents had higher risks for anemia and episiotomy and lower risk of cesarean delivery. The rates of preeclampsia, gestational diabetes, chronic diseases, intrauterine growth restriction (IUGR) were higher in the adult group. Younger maternal age was correlated with increased risks of preterm delivery, fetal and neonatal death and anemia.

Variations in Multiple Birth Rates and Impact on Perinatal Outcomes in Europe.

ObjectiveInfants from multiple pregnancies have higher rates of preterm birth, stillbirth and neonatal death and differences in multiple birth rates (MBR) exist between countries. We aimed to describe differences in MBR in Europe and to investigate the impact of these differences on adverse perinatal outcomes at a population level.MethodsWe used national aggregate birth data on multiple pregnancies, maternal age, gestational age (GA), stillbirth and neonatal death collected in the Euro-Peristat project (29 countries in 2010, N = 5 074 643 births). We also used European Society of Human Reproduction and Embryology (ESHRE) data on assisted conception and single embryo transfer (SET). The impact of MBR on outcomes was studied using meta-analysis techniques with random-effects models to derive pooled risk ratios (pRR) overall and for four groups of country defined by their MBR. We computed population attributable risks (PAR) for these groups.ResultsIn 2010, the average MBR was 16.8 per 1000 women giving birth, ranging from 9.1 (Romania) to 26.5 (Cyprus). Compared to singletons, multiples had a nine-fold increased risk (pRR 9.4, 95% Cl 9.1–9.8) of preterm birth (<37 weeks GA), an almost 12-fold increased risk (pRR 11.7, 95% CI 11.0–12.4) of very preterm birth (<32 weeks GA). Pooled RR were 2.4 (95% Cl 1.5–3.6) for fetal mortality at or after 28 weeks GA and 7.0 (95% Cl 6.1–8.0) for neonatal mortality. PAR of neonatal death and very preterm birth were higher in countries with high MBR compared to low MBR (17.1% (95% CI 13.8–20.2) versus 9.8% (95% Cl 9.6–11.0) for neonatal death and 29.6% (96% CI 28.5–30.6) versus 17.5% (95% CI 15.7–18.3) for very preterm births, respectively).ConclusionsWide variations in MBR and their impact on population outcomes imply that efforts by countries to reduce MBR could improve perinatal outcomes, enabling better long-term child health.

Neonatal outcomes in relation to sex differences: a national cohort survey in Taiwan.

BackgroundAn extensive assessment investigating the association between sex differences and neonatal outcomes is lacking. In the current study, we estimated the correlation of gender with adverse birth outcomes in a large cohort population.MethodsNational population-based data containing maternal and neonatal information in 2001 to 2010 were derived from the Health Promotion Administration, Taiwan. Singletons without high-risk pregnancy were further analyzed for the sex ratio of live births in relation to neonatal outcomes—including preterm birth, birth weight, neonatal death, delivery mode, and congenital anomaly. A multivariate logistic regression model was used to adjust for possible confounders.ResultsIn total, 2,123,100 births were valid for the analysis. Overall, the sex ratio at birth (male/female) was 1.096. Compared to multiple births, the sex ratio was significantly higher with singleton births (p < 0.001). Among multiple births, the incidence of stillbirths was significantly higher in males than in females (p < 0.05). The sex ratio at gestational age (GA) <37 weeks was 1.332, and it declined proportionally with a rise in the GA to 0.899 at GA of ≥41 weeks. In contrast, the sex ratio was 0.850 at birth weight <3000 g, and it rose proportionally with a rise in the birth weight to 1.902 at birth weight ≥4000 g (macrosomia). Operative delivery was more common in males than in females (p < 0.001). The regression analysis showed greater risks of preterm birth, macrosomia, operative delivery, neonatal death, and congenital anomaly among male newborns.ConclusionsMale gender carried higher risks of adverse neonatal outcomes, including preterm birth, macrosomia, operative delivery, neonatal death, and congenital anomaly. The data have clinical implications on health surveillance for plotting strategies in response to the unbalanced sex ratio in relation to the boy preference.

Antenatal dietary education and supplementation to increase energy and protein intake.

Antenatal dietary education and supplementation to increase energy and protein intake.

Outcomes of Pregnancy After Bariatric Surgery

Maternal obesity is associated with increased risk of pregnancy complications such as gestational diabetes, stillbirth, preterm birth, and congenital malformations. While small studies have looked into the effect of prepregnancy bariatric surgery on gestational diabetes, these studies have been inconclusive and have not considered presurgery body mass index (BMI) as a confounder. Some systematic reviews have found a lower risk of neonatal complications after bariatric surgery but included heterogeneous studies with small sample sizes. Taking presurgery BMI into account, this study aims to investigate the risks of adverse perinatal outcomes including gestational diabetes in women who have had bariatric surgery versus women who have not. This population-based study used data from Swedish registries nationwide, which include prenatal, obstetric, and neonatal records. Of 627,693 singleton pregnancies between 2006 and 2011, 670 were in women who had undergone bariatric surgery with presurgery weight documented. Up to 5 control pregnancies in obese women were matched for BMI, age, level of education, years, and smoking history for each pregnancy in the intervention cohort. For controls, weight during early pregnancy was used to calculate BMI. For the study group, BMI was calculated with weight and height measurements at the time of surgery. Outcomes included gestational diabetes, low birth weight, macrosomia, stillbirth, large- and small-for-gestational-age, preterm birth, neonatal death, and major congenital malformations detected during the first year of life. Gestational diabetes was diagnosed by a 2-hour plasma glucose level of 10.0 mmol/L or higher during a glucose tolerance test (with a 75-g loading dose) or a fasting plasma glucose level of 7.0 mmol/L or higher. In the study, 1.9% of the postsurgery pregnancies versus 6.8% of the control pregnancies had gestational diabetes (odds ratio, 0.25; 95% confidence interval [CI], 0.13–0.47; P < 0.001; Table 2). The median gestation time of the diagnosis was 32 weeks for both groups, considering women for whom the diagnosis date was available. The surgery cohort, compared with controls, was associated with an increased risk of small-for-gestational-age infants (15.6% vs 7.6%; odds ratio, 2.20; 95% CI, 1.64–2.95; P < 0.001) and increased risk for low birth weight, although that was not statistically significant (6.8% vs 4.5%; odds ratio, 1.34; 95% CI, 0.88–2.04; P = 0.17). Alternatively, the surgery group had a lower risk for large-for-gestational-age infants compared with the control group (8.6% vs 22.4%; odds ratio, 0.33; 95% CI, 0.24–0.44; P < 0.001) and lower risk of macrosomia (1.2% vs 9.5%; odds ratio, 0.11; 95% CI, 0.05–0.24; P < 0.001). There was no significant difference between the 2 groups in terms of risk of preterm birth (10.0% vs 7.5%; odds ratio, 1.28; 95% CI, 0.92–1.78; P = 0.15), nor in terms of congenital malformations. One limitation of this study was that nearly all (98%) of the surgery procedures were gastric bypass surgery, so it is not clear as to whether these findings apply to other types of bariatric surgery. While the study found that bariatric surgery was associated with reduced risks of large-for-gestational-age infants as well as gestational diabetes, bariatric surgery was also associated with increased odds of small-for-gestational age infants, so increased attention during these pregnancies is recommended.

Associations of maternal atopic diseases with adverse pregnancy outcomes: a national cohort study.

Maternal asthma has been associated with adverse pregnancy outcomes. Little is known about the influence of other atopic diseases on pregnancy outcomes. We assessed how various maternal atopic diseases might affect preterm birth, stillbirth, and neonatal death. By linking Norwegian national registries, we acquired information on maternal health, socio-demographic factors, pregnancy, birth, and neonatal outcome on all births in Norway from 1967 to 2003. A total of 1 974 226 births were included. Of these, 1.8% had a record of maternal asthma, 3.4% of maternal atopic dermatitis, and 0.4% of maternal allergic rhinoconjunctivitis. Overall rates of preterm birth, stillbirth, and neonatal death were 6.0%, 0.6%, and 0.5%, respectively. After adjustments for possible confounders, maternal asthma was associated with increased risk of preterm birth (relative risk (RR), 1.15, [95% confidence interval (CI) 1.10, 1.21]). In contrast, maternal atopic dermatitis was associated with decreased risk of preterm birth (RR 0.90, [95% CI 0.86, 0.93]), stillbirth (RR 0.70, [95% CI 0.62, 0.79]), and neonatal death (RR 0.76, [95% CI 0.65, 0.90]). Similarly, maternal allergic rhinoconjunctivitis was associated with decreased risk of preterm birth (RR 0.84, [95% CI 0.76, 0.94]) and stillbirth (RR 0.40, [95% CI 0.25, 0.66]). We confirmed the previously reported association of maternal asthma with increased risk for preterm birth. Unexpectedly, maternal atopic dermatitis and allergic rhinoconjunctivitis were associated with decreased risk of preterm birth and stillbirth. Mechanisms for these protective associations are unclear, and our findings require confirmation in further studies.