Rates Of Pregnancy Complications Research Articles

Patient and provider perspectives of a new prenatal care model introduced in response to the coronavirus disease 2019 pandemic

BackgroundRandomized controlled trials document the safety and efficacy of reduced frequency prenatal visit schedules and virtual visits, but real-world data are lacking. Our institution created a prenatal care delivery model incorporating these alternative approaches to continue safely providing prenatal care during the coronavirus disease 2019 pandemic.ObjectiveTo evaluate institutional-level adoption and patient and provider experiences with the coronavirus disease 2019 prenatal care model.Study DesignWe conducted a single-site evaluation of a coronavirus disease 2019 prenatal care model incorporating a reduced frequency visit schedule and virtual visits deployed at a suburban academic institution on March 20, 2020. We used electronic health record data to evaluate institution-level model adoption, defined as changes in overall visit frequency and proportion of virtual visits in the 3 months before and after implementation. To evaluate the patient and provider experience with the coronavirus disease 2019 model, we conducted an online survey of all pregnant patients (>20 weeks’ gestation) and providers in May 2020. Of note, 3 domains of care experience were evaluated: (1) access, (2) quality and safety, and (3) satisfaction. Quantitative data were analyzed with basic descriptive statistics. Free-text responses coded by the 3 survey domains elucidated drivers of positive and negative care experiences.ResultsAfter the coronavirus disease 2019 model adoption, average weekly prenatal visit volume fell by 16.1%, from 898 to 761 weekly visits; the average weekly proportion of prenatal visits conducted virtually increased from 10.8% (97 of 898) to 43.3% (330 of 761); and the average visit no-show rate remained stable (preimplementation, 4.3%; postimplementation, 4.2%). Of those eligible, 74.8% of providers (77 of 103) and 15.0% of patients (253 of 1690) participated in the surveys. Patient respondents were largely white (180 of 253; 71.1%) and privately insured (199 of 253; 78.7%), reflecting the study site population. The rates of chronic conditions and pregnancy complications also differed from national prevalence. Provider respondents were predominantly white (44 of 66; 66.7%) and female (50 of 66; 75.8%). Most patients and almost all providers reported that virtual visits improved access to care (patients, 174 of 253 [68.8%]; providers, 74 of 77 [96.1%]). More than half of respondents (patients, 124 of 253 [53.3%]; providers, 41 of 77 [62.1%]) believed that virtual visits were safe. Nearly all believed that home blood pressure cuffs were important for virtual visits (patients, 213 of 231 [92.2%]; providers, 63 of 66 [95.5%]). Most reported satisfaction with the coronavirus disease 2019 model (patients, 196 of 253 [77.5%]; providers, 64 of 77 [83.1%]). In free-text responses, drivers of positive care experiences were similar for patients and providers and included perceived improved access to care through decreased barriers (eg, transportation, childcare), perceived high quality of virtual visits for low-risk patients and increased safety during the pandemic, and improved satisfaction through better patient counseling. Perceived drivers of negative care experience were also similar for patients and providers, but less common. These included concerns that unequal access to virtual visits could deepen existing maternity care inequities, concerns that the lack of home devices (eg, blood pressure cuffs) would affect care quality and safety, and dissatisfaction with poor patient-provider continuity and inadequate expectation setting for the virtual visit experience.ConclusionReduced visit schedules and virtual visits were rapidly integrated into real-world care, with positive experiences for many patients and providers. Future research is needed to understand the health outcomes and care experience associated with alternative approaches to prenatal care delivery across more diverse patient populations outside of the coronavirus disease 2019 pandemic to inform broader health policy decisions.

Comparison of fertility outcomes after laparoscopic myomectomy for barbed versus nonbarbed sutures

To assess the impact on women's reproductive outcomes of barbed sutures to repair uterine breaches during laparoscopic myomectomy compared with traditional smooth sutures. Retrospective, monocentric cohort study, with information on subsequent pregnancies prospectively acquired for some women. Tertiary-level academic referral center. Women older than 18 years who had undergone a laparoscopic myomectomy and had sought pregnancy afterward, divided into two groups based on type of suture used to repair the uterine wall: group A (nonbarbed) and group B (barbed). Laparoscopic removal of FIGO types 3, 4, 5, and 6 uterine leiomyomas by use of either only barbed sutures or only traditional smooth sutures to reconstruct the uterine defect. Pregnancy achievement rates, delivery modes, main pregnancy complications, perioperative complications for both kinds of suture, and the trend of the use of barbed sutures over time at our center. Of 164 patients included, 83 were in group A and 81 in group B. Ninety-one patients (55.5%) experienced at least one postoperative pregnancy, with no differences between the groups (group A 60.5%; group B 50.6%). Of the 103 recorded postoperative pregnancies, 70 (68%) resulted in live births, 29 (28.1%) in first-trimester miscarriages, and 4 (3.9%) were ongoing. Barbed sutures have a similar impact on reproductive outcomes as smooth conventional threads, both in terms of pregnancy and obstetric complication rates, after laparoscopic myomectomy.

Maternal and neonatal pregnancy outcomes in ankylosing spondylitis

Objective: To evaluate maternal and neonatal pregnancy outcomes in ankylosing spondylitis (AS) patients.Subjects and methods. The prospective study included 36 pregnant women with AS (modified New York AS criteria, 1984), all participants were followed. Mean patients’ age was 31.6±4.8 years, age at disease onset – 21.8±10.9 years, duration of the disease – 134,9±89.3 months. Stage II-III sacroiliitis was diagnosed in 88.9% of women, stage IV – in 11.1%. AS activity levels measured by mean BASDAI score in I, II and III trimesters were 2,8±1,7 – 3,2±1,9 – 3,3±2,1, respectively.Results. 34 pregnancies resulted in live births at median 39 [38; 40] weeks of gestation. Adverse pregnancy outcomes were documented in 2 cases (5.6%): a missed miscarriage at 18 weeks of gestation in a woman with burdened maternal obstetric history and moderate AS activity; and medical abortion at 23d week of gestation because of fetal critical condition owing to persistent high AS activity with severe axial and extra-articular manifestations of the disease. Most common pregnancy complications included threatened early miscarriage (11.1%), threatened premature labor (11.8%), infectious and inflammatory conditions (pyelonephritis in pregnancy, acute respiratory viral infections – 36,1%), iron-deficiency anemia (19,4%), gestational hypothyroidism (11,1%). Preterm birth was documented in 5,9% patients. No association was found between disease activity, therapy, and preterm birth. There were no cases of preeclampsia. 52.9% of the patients had vaginal delivery, and 47.1% had a caesarean section (CS), which was elective in 87.5% of all CS cases. Indications for elective CS included severe hip joints involvement with altered function, and scar on the uterus. Emergency C-section was performed in cases of uterine inertia and preterm discharge of amniotic fluid. Average birthweight of newborns was 3384.4±382.0 g, and length –51.5±2.0 cm, Apgar score was 8.0±0.4/8.9±0.4. Early neonatal complications were documented in 14,3% newborns, Congenital abnormalities were registered in 3 (8.6%) newborns: a slit-like defect of the atrial septum, a defect of the interventricular septum, and unilateral hydronephrosis.Conclusion. Pregnancy outcomes in AS patients practically do not differ from those in general population, except for higher rates of elective C-sections, being generally favorable given AS activity is adequately controlled and gestation &delivery are thoroughly monitored. AS is not associated with higher rates of severe pregnancy complications and preterm birth. AS seemed to have no negative impact on newborn anthropometric data and health condition in general. No severe neonatal complications occurred. Considering the small sample size, it is impossible to draw definite conclusions about occurrence of various malformations in newborn to mothers with AS at this particular stage of the research. Interdisciplinary consensus is necessary in place to optimize pregnancy and birth management in AS patients

Pregnancy outcomes in nulliparous women with positive first-trimester preterm preeclampsia screening test: the Great Obstetrical Syndromes cohort study

The Fetal Medicine Foundation proposed a competing risks model for early identification of women at a high risk of preterm preeclampsia, typically associated with deep placentation disorders. The Great Obstetrical Syndromes include a spectrum of pregnancy complications (preeclampsia, intrauterine growth restriction, preterm birth, late spontaneous abortion, and abruptio placentae) that are also associated with deep placentation disorders. This study aimed to estimate the rate of placenta-mediated pregnancy complications in nulliparous women with a positive first-trimester Fetal Medicine Foundation preterm preeclampsia screening test. We conducted a prospective cohort study of nulliparous women recruited at 11 to 14 weeks of gestation. Maternal characteristics, mean arterial blood pressure, levels of maternal serum biomarkers (pregnancy-associated plasma protein-A, placental growth factor, and soluble fms-like tyrosine kinase-1), and mean uterine artery pulsatility index were obtained to calculate the risk of preterm preeclampsia according to the Fetal Medicine Foundation algorithm. The predicted risks were dichotomized as a positive or negative test according to 2 risk cutoffs (1 in 70 and 1 in 100). The detection rate, false-positive rate, and positive and negative predictive values were calculated for placenta-mediated complications, including preeclampsia, small for gestational age (birthweight <10th percentile), fetal death, preterm birth, and a composite outcome, including any of the foregoing. The same analyses were computed for a composite of severe outcomes, including preterm preeclampsia, severe small for gestational age (less than third percentile), and fetal death. We included 4575 participants with complete observations, of whom 494 (10.8%) had an estimated risk of preterm preeclampsia of ≥1 in 70 and 728 (15.9%) had a risk of ≥1 in 100. The test based on a risk cutoff of 1 in 70 could have correctly predicted up to 27% of preeclampsia, 55% of preterm preeclampsia, 18% of small for gestational age, 24% of severe small for gestational age, and 37% of fetal deaths at a 10% false-positive rate. The test based on a cutoff of 1 in 100 could have predicted correctly up to 35% of preeclampsia, 69% of preterm preeclampsia, 25% of small for gestational age, 30% of severe small for gestational age, and 53% of fetal deaths at a 15% false-positive rate. The positive predictive value of a screening test for preterm preeclampsia of ≥1 in 70 was 3% for preterm preeclampsia, 32% for the composite outcome, and 9% for the severe composite outcome. Nulliparous women with a first-trimester positive preterm preeclampsia Fetal Medicine Foundation screening test are at a higher risk of both preterm preeclampsia and other severe placenta-mediated pregnancy complications. Approximately 1 woman of 10 identified as high risk by the Fetal Medicine Foundation algorithm developed at least 1 severe placenta-mediated pregnancy complication.

Testing for gestational diabetes during the COVID-19 pandemic. An evaluation of proposed protocols for the United Kingdom, Canada and Australia

AimsWe assessed how altered diagnostic processes and criteria for gestational diabetes mellitus (GDM) recommended by the United Kingdom (UK), Canada and Australia for use during the COVID-19 pandemic would affect both GDM frequency and related adverse outcomes. MethodsSecondary analysis of 5974 HAPO study women with singleton pregnancies who underwent 75 g OGTTs and HbA1c assays between 24 and 32 weeks’ gestation and who received no treatment for GDM. ResultsAll post COVID-19 modified pathways reduced GDM frequency – UK (81%), Canada (82%) and Australia (25%). Canadian women whose GDM would remain undetected post COVID-19 (missed GDMs) displayed similar rates of pregnancy complications to those with post COVID-19 GDM. Using UK modifications, the missed GDM group were at slightly lower risk whilst the women missed using the Australian modifications were at substantially lower risk. ConclusionsThe modifications in GDM diagnosis proposed for the UK, Canada and Australia result in differing reductions of GDM frequency. Each has both potential benefits in terms of reduction in potential exposure to COVID-19 and costs in terms of missed opportunities to influence pregnancy and postpartum outcomes. These factors should be considered when deciding which protocol is most appropriate for a particular context.

A Message from the Human Placenta: Structural and Immunomodulatory Defense against SARS-CoV-2.

The outbreak of the coronavirus disease 2019 (COVID-19) pandemic has caused a global public health crisis. Viral infections may predispose pregnant women to a higher rate of pregnancy complications, including preterm births, miscarriage and stillbirth. Despite reports of neonatal COVID-19, definitive proof of vertical transmission is still lacking. In this review, we summarize studies regarding the potential evidence for transplacental transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), characterize the expression of its receptors and proteases, describe the placental pathology and analyze virus-host interactions at the maternal-fetal interface. We focus on the syncytium, the barrier between mother and fetus, and describe in detail its physical and structural defense against viral infections. We further discuss the potential molecular mechanisms, whereby the placenta serves as a defense front against pathogens by regulating the interferon type III signaling, microRNA-triggered autophagy and the nuclear factor-κB pathway. Based on these data, we conclude that vertical transmission may occur but rare, ascribed to the potent physical barrier, the fine-regulated placental immune defense and modulation strategies. Particularly, immunomodulatory mechanisms employed by the placenta may mitigate violent immune response, maybe soften cytokine storm tightly associated with severely ill COVID-19 patients, possibly minimizing cell and tissue damages, and potentially reducing SARS-CoV-2 transmission.

Complications of pregnancy, childbirth and condition of newborns in women with pneumonia (review)

The aim is to study the complications of pregnancy, childbirth and the condition of newborns in women with pneumonia based on the conducted analysis of scientific literature. The incidence of pneumonia and mortality rate due to its complications in pregnant women is higher than in non-pregnant women. This fact is associated with immune suppression during pregnancy, the presence of chronic diseases, nicotine intoxication and the emergence of new pathogens. The analysis of articles, systematic reviews of domestic and foreign authors indicates the inequality of the results and factors that influence the outcomes of pregnancy, childbirth and health of the newborns. Frequent complications of women pregnancy with acute respiratory diseases are: placental disorders (15.2-100%), preeclampsia (25%), oligohydramnios and polyhydramnios (20%). According to the literature analysis the incidence of spontaneous miscarriage in the early stages is from 13 to 42%, in the later stages is from 20 to 25%. Premature birth is diagnosed in 16-52.3% of pregnant women. The rate of pregnancy complications depends on the body mass index, the presence of anemia during pregnancy and the gestational period of pneumonia. During the analyzed data, we can say that the condition of the newborns will depend on the severity of pneumonia. The newborns of pneumonia-positive mothers have a high risk of low birth weight, intrauterine infection, and cerebral ischemia. Summarizing the published information on complications in pregnant women with pneumonia caused by COVID-19, it is impossible to draw a definitive conclusion. In a number of researches in pregnant women with pneumonia caused by COVID-19, spontaneous miscarriage was diagnosed in every third, premature birth in every fourth, of which 20.7% were diagnosed with premature rupture of membranes. Other studies do not confirm a high percentage of pregnancy complications, but a high risk of surgical delivery in this group of pregnant women is shown. The perinatal mortality rate in the researches reached 11.1%. In each research, the vertical transmission pathway was evaluated by taking amniotic fluid, umbilical cord blood, and a throat swab from a newborn. There is no evidence of COVID-19 vertical transmission in the sources. A review of the data shows the need for further research in this area.

4161 Contraceptive Decision Making Among Women with Diabetes Mellitus: A Mixed Methods Study

OBJECTIVES/GOALS: Women with diabetes (DM) have higher rates of unplanned pregnancy and pregnancy complications, indicating a need for DM-specific counseling. Our aim is to use the Health Belief Model (HBM), widely applied to DM interventions, to create a conceptual model of contraceptive decision-making for women with DM. METHODS/STUDY POPULATION: Our convergent mixed methods study integrates quantitative survey data and qualitative interview data from women aged 18-50 with DM. We will interview until theoretical saturation is achieved. Descriptive statistics will be calculated to summarize demographics, health history, and contraceptive use and knowledge. Using a grounded theory approach, qualitative analysis will be conducted by JW and EJ with special focus on exploring HBM constructs. A joint display will be used to integrate key quantitative variables by qualitative themes. Finally, we will aim to implement these HBM constructs within the context of contraceptive decision-making for women with DM. RESULTS/ANTICIPATED RESULTS: To date, we have interviewed 16 women with average age of 35 and an equal mix of type 1 vs. type 2 DM and those who identify their health as poor/fair vs. good/very good. The following HBM domains have emerged as relevant to contraceptive decision-making: perceived threats, perceived barriers, cues to action and self-efficacy. An analysis of the cues to action domain suggests that patients’ responses to provider counseling are substantially dependent on provider tone and awareness of patient context. Effective cues were delivered supportively with focus on health promotion, while ineffective cues focused on adverse outcomes or were delivered to women not at risk of pregnancy. DISCUSSION/SIGNIFICANCE OF IMPACT: The application of the HBM to contraceptive decision making among women with DM will provide insight into critical factors that inform both patient and provider attitudes and behaviors and can be targeted for future interventions to reduce unplanned pregnancy in this vulnerable population.

OR11-04 Effect of Preconception Intensive vs. Standard Lifestyle Intervention on Birth Outcomes in Obese Women With Unexplained Infertility: A Multicenter Randomized Trial

We hypothesized that weight loss with an intensive preconception lifestyle (IL) intervention of caloric restriction with meal replacements, daily orlistat and increased physical activity in women with obesity and unexplained infertility (UI) was more likely to result in Good Birth Outcome than a standard lifestyle modification (SL) with increased physical activity alone. The 16 week period of lifestyle modification was followed by an open label empiric infertility treatment regimen of 3 cycles of ovarian stimulation with clomiphene, ovulation triggering with hCG and intrauterine insemination. We randomized 379 obese women 18-40y with UI (regular menses, normal ovarian reserve, patent reproductive tract and normal male factor). A Good Birth Outcome (GBO) was the primary outcome, defined as a live birth of an infant born at ≥37wks with a birthweight between 2500-4000g and no major congenital anomaly. Key secondary outcomes were live birth, pregnancy loss and pregnancy complication rates. The study had 80% power and an alpha of 0.05 to detect an absolute 15% difference in GBO. An Intention-to-Treat analysis was used. Both groups (SL N=191, IL N =188) were well matched at baseline(e.g. weight (kg), mean ± SD, SL:107±21, IL: 108 ±23). Women in the IL arm lost significantly more weight preconception than SL (SL -0.3±3.4 vs IL -7.3±6.6 kg, P<.001) with similar decreases in associated biometric and biochemical parameters. Overall 59.4% of the IL group lost >5% weight vs 6.5% in SL group(P<.001). Despite achieving the targeted weight loss, GBO rate between groups was not significantly different (IL12.2% vs SL 15.2%, IL Rate Ratio, 95% CI: 0.8, 0.5-1.3) or in live birth (IL 20.2% vs SL 22.0%, IL RR: 0.9, 0.6-1.4). Pregnancy loss among women who conceived trended higher in the IL group (IL 38.1% vs SL 23.7%, IL RR:1.6, 0.9-2.8) but miscarriage rates (loss after visualized intrauterine pregnancy), were significantly higher in IL (IL 20.6% vs SL 3.4%, IL RR: 6.1, 1.4-25.8, P=0.005). Birthweights were similar in both groups (IL: 3199±712 vs SL: 3106±794g). Major pregnancy complications trended lower in IL: Preterm Labor (IL 3.2% vs SL 10.2%), Pre-eclampsia (IL 6.3% vs SL 11.9%), Gestational DM (IL 9.5% vs SL 16.9%). Adverse events were more common in the IL group, i.e. increased GI side effects of bloating, flatulence, diarrhea and steatorrhea, likely related to use of orlistat. Moderate weight loss prior to conception does not improve live birth or GBO rates compared to exercise alone in obese women. Of concern, early pregnancy loss is more common when conception occurs after IL intervention. However a benefit to IL modification preconception may be lower perinatal morbidity, although further larger studies are necessary to confirm this potential benefit.

Looking beyond the ovary for oncofertility care in women: uterine injury as a potential target for fertility-preserving treatments.

Treatment for cancer has the potential to significantly diminish fertility and, further, to negatively impact the obstetrical outcomes of pregnancies that do occur. Cancer survivors have decreased rates of fertility and increased rates of pregnancy complications, such as preterm birth and low birth weight, after exposure to chemotherapy. To date, research on the impact of chemotherapy and radiotherapy on fertility and pregnancy outcomes has focused largely on the gonadotoxic effect of cancer treatments on ovaries, while the uterus and endometrium have not been extensively studied. It is intuitive, however, that decreased fertility and poorer obstetrical outcomes may be substantially mediated through injury to a highly mitotic tissue like the endometrium, which is also central to embryo implantation and utero-placental exchange. Pregnancy complications in cancer survivors might be due to compromised blood supply to the endometrium and myometrium affecting placentation or altered remodeling of the pregnant uterus secondary to radiation fibrosis. Alterations in endometrial receptivity at the molecular level could affect pregnancy implantation and early pregnancy loss, but later complications also can occur. This review focuses on understanding the unintended effects of chemotherapy and radiotherapy on uterine function in female cancer survivors and the impact on pregnancy, and summarizes mechanisms to protect and treat the uterus before and after cancer chemotherapy and radiotherapy.

The Effects of Late Preterm Betamethasone in Multiple Gestations [30K

INTRODUCTION: The administration of late preterm betamethasone in singleton gestations is an effective intervention for reducing neonatal respiratory morbidity. However, this intervention has not been studied in multiple gestations, which have higher rates of pregnancy complications resulting in admission and delivery from 34 to 36 weeks gestation. We aimed to evaluate the effects of betamethasone in multiple gestations during the late preterm period. METHODS: We conducted a retrospective chart review of multiple gestations who delivered between 34/0 and 36/6 weeks. The study included 322 women with 645 neonates. The primary outcome was a composite respiratory outcome that included the need for any respiratory support within 72 hours after birth, as defined as the need for continuous positive airway pressure (CPAP) or high-flow nasal cannula for at least 2 consecutive hours or supplemental oxygen with a fraction of inspired oxygen of at least 30% for at least 4 continuous hours. Secondary outcomes included rates of mechanical ventilation and hypoglycemia. RESULTS: The primary outcome occurred in 132 of 388 infants (34%) in the betamethasone group and 75 of 249 (30.1%) in the non-betamethasone group (P=.380). There was no difference in need for mechanical ventilation (P=.987). Neonatal hypoglycemia was significantly more common in the betamethasone group (41% vs 27.3%, P=.004). CONCLUSION: Administration of betamethasone to women with multiple gestations did not reduce the rate of neonatal respiratory complications in the late preterm period, but increased the rate of hypoglycemia.

Pregnancy outcomes of fresh IVF conceived pregnancies after embryo transfer at different stages of early embryonic development

Objective To compare pregnancy outcomes between pregnancies following day 2, day 3, and days 5/6 fresh embryo transfer (ET). Methods A retrospective cohort study including all pregnancies following fresh IVF/intracytoplasmic sperm injection (ICSI) ET cycles performed between January 2014 and December 2015 at Fertility and In Vitro Fertilization (IVF) Unit of the tertiary Soroka University Medical Center. The study groups consisted of 48, 72, 120, and 144 hours embryos. Pregnancies were confirmed by a serum beta-human chorionic gonadotropin measurement. Data regarding patients’ medical history, infertility workup, fertility treatment characteristics, and outcome, as well as obstetrical outcome, were collected from patients’ medical records and IVF Laboratory database. Multiple regression models were constructed to control for confounders. Patients who underwent fertility preservation treatment, cycles of oocyte donation or in vitro maturation oocytes, and cases of preimplantation genetic testing were excluded. Results A total of 534 pregnancies following fresh IVF/ICSI ET on day 2 (n = 189, 35.4%), day 3 (n = 200, 37.5%), and days 5 or 6 (n = 145, 27.2%) were included. Live birth rate demonstrated a linear association to the developmental stage at ET with the highest rates in blastocysts and gradually lower in day 3 and day 2 ET (79.2, 65.8, and 60.6%, respectively, p = .001). A positive linear association was also observed between ET age and clinical pregnancy rate (77.3, 87.5, and 90.3% for days 2, 3, and 5/6, respectively, p = .002), as well as with combined pregnancy complication rate (29, 37.3, and 43.3%, p = .026). However, using multivariate logistic regression model controlling for ET age, maternal age, smoking, obesity, initial HCG level and peak E2 level, live birth rate was comparable between the study groups regardless of ET age. Pregnancy complications were comparable between the groups; however, a composite pregnancy complications variable was higher in the blastocyst pregnancies compared to cleavage embryos pregnancies. Conclusions The common approach of blastocyst transfer, as high quality of the embryo, has not proven beneficial in terms of live birth rate. Moreover, cleavage stage embryos were not associated with adverse perinatal outcomes. The current data suggest maternal age has an independent effect on live birth.

DETEKSI DINI KOMPLIKASI KEHAMILAN, PERILAKU HIDUP BERSIH DAN SEHAT SERTA DETEKSI DINI GANGGUAN PERTUMBUHAN DAN PERKEMBANGAN BAYI DAN BALITA DI WILAYAH KERJA PUSKESMAS PEGAMBIRAN KOTA PADANG

Puskesmas Pegambiran is located in Lubuk Begalung Sub-district, Padang City has five villages with a pregnancy complication rate of 19.9% and neonatal complications of 11.74% (2016). The general objective that will be achieved is to increase the number of better health degrees for pregnant women, infants, toddlers, and pre-school age children through promotive and preventive activities. The method used is by conducting surveys and interviews, conduct counseling, demonstrate clean and healthy living habits, anthropometric measurements of infants, toddlers, and pre-school children, observation, pregnancy checks, hemoglobin checks, and counseling. The results obtained were counseling and demonstrations on clean and healthy living behaviors in pre-school age children at Alya Zahira Kindergarten, which all students could participate in and run smoothly. 98% of kindergarten students demonstrated healthy hygiene habits, including washing hands, brushing teeth, and mentioning healthy snacks. Anthropometric measurements of infants and toddlers and pre-school age children showed that weight for age was within normal limits, height/length according to age, and expected limits. 3.7% thin and short toddlers and 1.2% of toddlers have speech delays, 1.2% children under five with a history of epilepsy, and need further treatment, so referrals are made. 1.2% of children under five were referred to because they did not recognize colors. All pregnant women (100%) have normal hemoglobin levels (10 g / dl), and pregnancy conditions are appropriate for their gestational age. It is hoped that further community service activities will be carried out by applying the partnership midwifery practice model (mentoring) to the above targets for several months. There are changes in behavior patterns for promotive and preventive actions that have been given.

Pregnancy outcome after multifetal pregnancy reduction of triplets to twins versus reduction to singletons.

Does fetal reduction of triplet pregnancies to singleton result in superior obstetric and neonatal outcomes compared with triplets reduced to twins? A historical cohort study including 285 trichorionic and dichorionic triplet pregnancies that underwent abdominal fetal reduction at 11-14 weeks in a single tertiary referral centre. The study population comprised two groups: reduction to twins (n = 223) and singletons (n = 62). Main outcome measures were rates of pregnancy complications, preterm delivery and neonatal outcomes. Non-parametric statistical methods were employed. Triplet pregnancies reduced to twins delivered earlier (36 versus 39 weeks, P < 0.001) with higher prevalence of Caesarean section (71.1% versus 32.2%, P < 0.001) compared with triplets reduced to singletons. Preterm delivery rates were significantly higher in twins compared with singletons prior to 37 weeks (56.9% versus 13.6%, P < 0.001), 34 weeks (20.2% versus 3.4%, P = 0.002) and 32 weeks (9.6% versus 0%, P = 0.01). No significant difference was found in the rate of pregnancy loss before 24 weeks (1.3% in twins versus 4.8% in singletons, P = 0.12) or in the rate of intrauterine fetal death after 24 weeks (0.4% versus 0%, P = 1.0). Both groups had comparable obstetrical complications and neonatal outcomes, except for higher rates of neonatal intensive care unit admission in twins (31.9% versus 6.8%, P < 0.001). Reduction of triplets to singletons rather than twins resulted in superior obstetric outcomes without increasing the procedure-related complications. However, because the rate of extreme prematurity in pregnancies reduced to twins was low, the overall outcome of those pregnancies was favourable. Therefore, the option of reduction to singletons should be considered in cases where the risk of prematurity seems exceptionally high.

Do cancer therapies damage the uterus and compromise fertility?

As cancer survival rates improve, understanding and preventing the adverse off-target and long-term impacts of cancer treatments, including impacts on fertility, have become increasingly important. Cancer therapy-mediated damage to the ovary and depletion of the primordial follicle reserve are well characterised. However, our knowledge of the full extent of damage to the rest of the female reproductive tract, in particular the uterus, is limited. Improving our understanding of the off-target effects of cancer therapies on the entire female reproductive tract is a critical step towards developing truly effective strategies to protect the fertility of cancer survivors. The objective of this narrative review was to critically evaluate the available literature regarding the capacity for the uterus to sustain a healthy pregnancy following exposure to radiotherapy or chemotherapy. The authors performed PubMed (Medline) searches using the following key words: uterus, cancer survivors, radiotherapy, chemotherapy, pregnancy outcome, fertility preservation, infertility. There were no limits placed on time of publication. Overall, there were major limitations to the current available literature, meaning that interpretations should be taken with caution. Despite these drawbacks, data suggest that the uterus may sustain off-target damage, with the extent of damage dependent on the type of cancer treatment and patient age. Specifically, uterine growth is stunted and resistant to hormone replacement therapy in prepubertal girls receiving abdominal, pelvic or whole-body radiotherapy. In contrast, females treated with radiotherapy post-puberty can benefit from hormone replacement therapy, as demonstrated by increased uterine volume and function. No live births have been reported in women previously exposed to radiotherapy after transplantation of cryopreserved ovarian tissue, even when menstruation returns. However, this technique has proven to be a successful fertility preservation method for women previously treated with chemotherapy. Obstetricians commonly report that women who maintain sufficient ovarian function can achieve pregnancy naturally following radiotherapy, but they have thin and/or fibrotic myometrium at delivery, compromising safe delivery and subsequent pregnancy. Furthermore, women exposed to either radiotherapy or chemotherapy have a higher prevalence of preterm birth and low birth weight infants, even in those with normal ovarian function or when oocyte donation is utilised. The mechanisms of potential uterine damage are poorly understood. While the myometrium, vasculature and endometrial progenitor cells are possibly targets, further studies are clearly required and well-controlled animal models could provide the best avenue for these types of future investigations. Female cancer survivors experience greater rates of early pregnancy loss and complications, suggesting that cancer therapy-induced damage to the uterus contributes to infertility. Despite clinical reports dating back to 1989, we highlight a surprising lack of detail in the literature regarding the precise nature and extent of off-target damage inflicted to the uterus in response to cancer therapies. Young women requiring cancer treatment, and the clinicians treating them, must be equipped with accurate information to aid informed decision-making regarding cancer treatment regimens as well as the development and use of effective fertility preservation measures. As the current literature on the impacts of cancer treatments is limited, we hope that our narrative review on this subject will stimulate more research in this important field.

Psoriasis and Pregnancy: Retrospective Evaluation of 47 Pregnancies in a Tertiary Center

Objective: To evaluate the impact of psoriasis on pregnancy outcomes.Study Design: Data of pregnant women with chronic plaque psoriasis who were followed up at Ha­cet­­tepe University Hospital between January 1, 2010 and December 31, 2017 were evaluated. Pregnant women with singleton pregnancies who had chronic plaque psoriasis were included in the study. Patients were divided into two groups based on the clinical course of psoriasis: group 1 (improvement/disease-stable), and group 2 (deterioration). Median maternal age, gravida, parity, gestational week at birth, birthweight, 5th minute APGAR score together with the rates of cesarean section, neonatal intensive care unit admission and pregnancy complications (spontaneous abortion, preterm delivery, fetal growth restriction and preeclampsia) were compared between the groups.Results: There were 29 (61.7%) patients in group 1 and 18 (38.3%) patients in group 2. Mean values for maternal age, gravida and parity were comparable between the groups (p values were 0.32, 0.09 and 0.17, respectively). Median values for gestational week at birth (39.2 vs 36.1, p =0.002), birthweight (3200 vs 2310, p =0.002) and 5th minute APGAR score (9 vs 7, p &lt;0.001) were statistically significantly lower in group 2. Cesarean section (33.3% vs 71.4%, p =0.02), neonatal intensive care unit admission (11.1% vs 64.3%, p &lt;0.001) and pregnancy complication rates (p =0.003) were statistically significantly higher in group 2. Frequencies of spontaneous abortion, preterm delivery, fetal growth restriction and preeclampsia were 6.9%, 10.3%, 3.4% and 3.4% in group 1, and 22.2%, 27.8%, 16.7% and 16.7% in group 2, respectively.Conclusion: Deterioration of psoriasis in pregnancy was associated with adverse obstetric outcome.

Prevalence and determinants of stillbirth in Nigerian referral hospitals: a multicentre study

BackgroundIn 2015, Nigeria’s estimated 317,700 stillbirths accounted for 12.2% of the 2.6 million estimated global stillbirths. This suggests that Nigeria still makes substantial contribution to the global burden of stillbirths. This study was conducted to determine the prevalence and identify the causes and factors associated with stillbirth in eight referral hospitals in Nigeria.MethodsThis was a cross-sectional study of all deliveries over a period of 6 months in six general hospitals (4 in the south and 2 in the north), and two teaching hospitals (both in the north) in Nigeria. The study population was women delivering in the hospitals during the study period. A pre-tested study protocol was used to obtain clinical data on pregnancies, live births and stillbirths in the hospitals over a 6 months period. Data were analyzed centrally using univariate, bivariate and multivariate logistic regression analyses. The main outcome measure was stillbirth rate in the hospitals (individually and overall).ResultsThere were 4416 single births and 175 stillbirths, and a mean stillbirth rate of 39.6 per 1000 births (range: 12.7 to 67.3/1000 births) in the hospitals. Antepartum (macerated) constituted 22.3% of the stillbirths; 47.4% were intrapartum (fresh stillbirths); while 30.3% was unclassified. Acute hypoxia accounted for 32.6% of the stillbirths. Other causes were maternal hypertensive disease (6.9%), and intrapartum unexplained (5.7%) among others. After adjusting for confounding variables, significant predictors of stillbirth were referral status, parity, past experience of stillbirth, birth weight, gestational age at delivery and mode of delivery.ConclusionWe conclude that the rate of stillbirth is high in Nigeria’s referral hospitals largely because of patients’ related factors and the high rates of pregnancy complications. Efforts to address these factors through improved patients’ education and emergency obstetric care would reduce the rate of stillbirth in the country.Trial registrationTrial Registration Number NCTR91540209.Nigeria Clinical Trials Registry. http://www.nctr.nhrec.net/Registered April 14th 2016.

Pregnancy after direct cerebral bypass for moyamoya disease.

Moyamoya disease (MMD) disproportionately affects young to middle-aged women. The main treatment for this challenging disease is cerebral bypass surgery. Vascular neurosurgeons often need to counsel women regarding pregnancy following bypass for MMD, but there is a paucity of data. The authors set out to examine neurological and obstetric outcomes in an extensive cohort of MMD patients who had pregnancies following cerebral revascularization at the Stanford Medical Center. The authors identified all patients at their institution who underwent cerebral bypass for MMD from 1990 through 2018 and who later became pregnant. Some of these patients also had pregnancies prior to undergoing bypass surgery, and the authors examined these pregnancies as well. They performed a chart review and brief telephone survey to identify obstetric complications, transient ischemic attacks (TIAs), and strokes. Neurological and obstetric outcomes were compared to published rates. They also compared pre- and post-bypass pregnancy complication rates using logistic regression techniques. There were 71 pregnancies among 56 women whose mean age was 30.5 years. Among 59 post-bypass pregnancies, there were 5 (8%) perinatal TIAs. There were no MRI-confirmed strokes or strokes with residual deficits. Among 12 pre-bypass pregnancies, there were 3 (25%) TIAs and 2 (17%) MRI-confirmed strokes. There were no hemorrhagic complications in either group. In the generalized estimating equations analysis, performing cerebral revascularization prior to pregnancy versus after pregnancy was associated with lower odds of perinatal stroke or TIA (OR 0.15, p = 0.0061). Nine pregnancies (13%) were complicated by preeclampsia, and there was one (1%) instance of eclampsia. The overall rate of cesarean delivery was 39%. There were 2 miscarriages, both occurring in the first trimester. There were no maternal deaths. The authors present neurological and obstetric outcomes data in a large cohort of MMD patients. These data indicate that post-bypass pregnancy is accompanied by low complication rates. There were no ischemic or hemorrhagic strokes among post-bypass pregnant MMD patients. The rate of obstetric complications was low overall. The authors recommend close collaboration between the vascular neurosurgeon and the obstetrician regarding medical management, including blood pressure goals and continuation of low-dose aspirin.

Factors associated with pregnancy outcomes in women with a history of cerebral sinus venous thrombosis.

To collect and summarize pregnancy outcomes among women with a history of cerebral sinus vein thrombosis (CSVT). A retrospective multicenter case-control study. The study group comprised all women diagnosed with CSVT during 2004-2018 at four university hospitals, and with follow-up data of pregnancy. A control group of women with a singleton pregnancy was established by matching, four-to-one, according to maternal age. The data of 74 pregnancies of 65 women with CSVT were analyzed. The median time-to-pregnancy interval from the CSVT was 4.2 [2.7-6.8] years. Anticoagulation therapy in the form of enoxaparin was administered in 68 (91.9%) pregnancies. Adjunctive low-dose aspirin was used throughout 12 (16.2%) pregnancies. Overall, 54 (73.0%) of the pregnancies ended in live births and 20 (27.0%) in miscarriage. The use of anticoagulation therapy during pregnancy was positively associated with live birth outcome (P < 0.001). Late adverse outcomes were encountered in 19 (25.7%) pregnancies, including the delivery of a small for gestational age infant (n = 12), gestational hypertensive disorders (n = 6) and placental abruption (n = 3). The use of adjunctive aspirin was associated with a lower rate of late adverse pregnancy outcomes (P = 0.03). No recurrent CSVT, thrombosis at other sites, and major bleeding episodes were observed during pregnancy. Live-birth rate was higher (P = 0.007) and the rate of late adverse outcome was lower (P = 0.01) for the control (n = 296) than the study group. Among pregnant women with a prior CSVT, no recurrent thrombosis events were observed during gestation. The use of prophylactic anticoagulation was associated with live birth. The use of adjunctive aspirin should be further studied in this setting, as its utilization correlated with a lower rate of late pregnancy complications.

940 Pregnancy Outcomes After Liver Transplantation

INTRODUCTION: Liver transplantation is a safe and effective intervention for patients with acute liver failure and cirrhosis. Given that the number of liver transplantations in women of childbearing age is increasing, it is important to recognize complications during pregnancy in these patients. Previous studies have noted an increased risk of complications, specifically hypertension and preeclampsia. This study aims to evaluate complications during pregnancy in patients after liver transplantation and the effect these complications have on patient and hospital outcomes. METHODS: Utilizing the Nationwide Inpatient Sample, a retrospective database analysis was performed on pregnant patients aged greater than 18 between 2005 and 2013. Patients were selected with the use of ICD-9 codes. Multivariable and propensity weighted analyses were used to evaluate the impact of liver transplantation on pregnancy complications and hospital outcomes including hospital length of stay and costs. RESULTS: A total of 38,449,030 pregnant patients were included in this study including 1,469 patients with a history of liver transplantation. Patients with a history of liver transplant were more likely to undergo a caesarean delivery and have a pregnancy related complication including miscarriage, intrauterine growth restriction, postpartum hemorrhage, hypertension during pregnancy, preeclampsia and venous thromboembolism (P &lt; 0.001). Propensity weighted analysis revealed higher rates of pregnancy complications (OR 2.11, 95% CI 1.63, 2.73), higher cost of admission ($3,023, 95% CI 850, 5,197) and longer length of stay (1.52 days, 95% CI 0.62, 2.41) among those with a liver transplant. A subset analysis among pregnant patients with a history of liver transplantation revealed 823 (56%) of these patients suffer from at least one pregnancy related complication. On multivariable analysis, patients that experienced a pregnancy related complication had a longer length of stay (2.45 days, 95% CI 1.44, 3.45) and higher cost of admission (5,205, 95% CI 2,848, 7,561). CONCLUSION: Pregnancy after liver transplant is associated with higher rates of pregnancy complications and worse patient and hospital outcomes. Further studies should be completed in order to improve outcomes in these patients.