Risk Of Emergency Caesarean Section Research Articles

The ratio of soluble fms-like tyrosine kinase 1 to placental growth factor predicts time to delivery and mode of birth in patients with suspected preeclampsia: a secondary analysis of the INSPIRE trial

BackgroundThe ratio of soluble fms–like tyrosine kinase 1 to placental growth factor (sFLT1/PLGF) is a useful biomarker for preeclampsia. Since it is a measure of placental dysfunction, it could also be a predictor of clinical deterioration and fetal tolerance to intrapartum stress. ObjectivesWe tested the hypothesis that sFLT1/PLGF ratio predicts time to delivery. Secondary objectives were to examine associations between the sFLT1/PLGF ratio and mode of birth, fetal distress, need for labor induction and birthweight z-score. Study designSecondary analysis of the INSPIRE trial, a randomized interventional study on prediction of preeclampsia/eclampsia in which women with suspected preeclampsia were recruited and their blood sFLT1/PLGF ratio was assessed. We stratified participants into three groups according to the ratio result: category 1 (sFLT1/PLGF≤38); category 2 (sFLT1/PLGF>38 and <85); and category 3 (sFLT1/PLGF≥85). We modelled time from sFLT1/PLGF determination to delivery using Kaplan-Meier curves and compared the three ratio categories adjusting for gestational age at sFLT1/PLGF determination and trial arm with Cox Regression. The association between ratio category and mode of delivery, induction of labour and fetal distress was assessed using a multivariable logistic regression adjusting for gestational age at sampling and trial arm. The association between birthweight z-score and sFLT1/PLGF ratio was evaluated using multiple linear regression. Subgroup analysis was conducted in women with no preeclampsia and spontaneous onset of labor; women with preeclampsia; and participants in the non-reveal arm. ResultsHigher ratio categories were associated with a shorter latency from sFLT1/PLGF determination to delivery (37 vs 13 vs 10 days for ratios categories 1-3 respectively), hazards ratio for category 3 ratio of 5.64 (95%CI 4.06-7.84, p<0.001). A sFLT/PlGF ratio≥85 had specificity of 92.7%(95%CI 89.0-95.1%) and sensitivity of 54.72% (95% CI, 41.3-69.5) for prediction of preeclampsia indicated delivery within 2 weeks. A ratio category 3 was also associated with decreased odds of spontaneous vaginal delivery (OR 0.47, 95%CI 0.25-0.89); an almost six fold increased risk of emergency cesarean section (OR 5.89, 95%CI 3.05-11.21); and a three-fold increased risk for intrapartum fetal distress requiring operative delivery or cesarean section (OR 3.04, 95%CI 1.53-6.05) when compared to patients with ratios≤38. Higher ratio categories were also associated with higher odds of induction of labor when compared to ratios category 1 (category 2, OR 2.20, 95%CI 1.02-4.76; category 3, OR 6.0, 95%CI 2.01-17.93); and lower median birthweight z-score. Within subgroups of women a)without preeclampsia and with spontaneous onset of labor and b)women with preeclampsia, the log ratio was significantly higher in patients requiring intervention for fetal distress or failure to progress compared to those who delivered vaginaly without intervention. In the subset of women with no preeclampsia and spontaneous onset of labour, those who required intervention for fetal distress or failure to progress had a significantly higher log ratio than those who delivered vaginaly without needing intervention. ConclusionThe sFLT1/PLGF ratio might be helpful in risk-stratification of patients who present with suspected preeclampsia regarding clinical deterioration, intrapartum fetal distress and mode of birth (including the need for intervention in labour).

Associations between artificial reproductive technologies (ART) and newborn size, as well as perinatal risk factors among singleton births in Vienna, Austria.

Background: The use of ssisted reproductive technologies (ART) such as fertilization (IVF) and intracytoplasmic sperm injection (ICSI) has increased markedly during the last four decades. ART, however, is still discussed critically, as there is no consensus on whether these treatments have a negative effect on fetal growth or increase the risk of preterm birth, low birth weight, and perinatal complications. Objectives: The aim of this study is the analysis of association patterns between ART (IVF or ICSI) and newborn size, preterm birth rate, and the mode of delivery. Sample and Methods: In this single-center medical record-based study data concerning the conception mode (spontaneous versus IVF or ICSI), preterm birth, newborn sex and size, child presentation, delivery mode, labor induction as well as parity, maternal age, body height, weight, and gestational weight gain of 5867 singleton-term births taking place in Vienna from 2015 to 2023 were included. 178 newborns (3.0%) were conceived by IVF or ICSI. Results: ART (IVF or ICSI) increased the risk of preterm birth by a factor of 3.4, and the risk of emergency cesarean section by a factor 2.3. ART was not independently associated with newborn size as well as breech presentation. The most important factor for newborn size was the gestational week of delivery, but also maternal parameters such as body height, gestational weight gain, and age. Conclusion: Preterm birth is a major cause of small newborn size and complications at birth. Therefore, ART can also be interpreted with caution as an indirect risk factor for small newborn size with all its long-term consequences.

Intrapartum use of sildenafil citrate to prevent fetal compromise and emergency operative birth in term pregnancies in the United Kingdom and Australia: Apreliminary cost-effectiveness analysis.

To compare cost-effectiveness of oral sildenafil citrate, administered after onset of labor, with standard care to health system funders in the UK and Australia. We conducted a modeled cost-effectiveness analysis, measuring costs and quality adjusted life years (QALYs), using a decision-analytic model covering onset of labor to 1 month post-birth. The relative risk of emergency cesarean section and operative vaginal birth was taken from a Phase 2 placebo controlled double blinded randomized control trial. Both options of care resulted in the same QALYs gained over the model time period (0.08). Sildenafil citrate was cost-saving compared with standard care, saving £92 per birth in the UK (AU$303 per birth in Australia). Sensitivity analyses did not identify any areas of uncertainty that stopped sildenafil citrate being cost saving compared with standard care. Threshold analysis revealed that sildenafil citrate would be cost saving up to a per birth drug or administration cost of £152.32 in the UK (AU$333.61 in Australia). Oral sildenafil citrate may be cost saving compared with standard care; however, the effects on neonatal outcomes still need to be demonstrated in large randomized trials.

Risk factors of emergency cesarean section in pregnant women with severe placenta accreta spectrum: a retrospective cohort study.

Placenta accreta spectrum (PAS) may cause enormous and potentially life-threatening hemorrhage in the intrapartum and postpartum periods in emergency cesarean section. How to reduce the occurrence of emergency cesarean section in patients with severe PAS is the key to reducing the adverse outcomes of them. This study aimed to investigate the impact of emergency cesarean section on the perioperative outcomes of pregnant women with PAS and neonates, and also aimed to explore the risk factors of emergency cesarean section in pregnant women with PAS. A retrospective investigation was conducted among 163 pregnant women with severe PAS. Of these, 72 were subjected to emergency cesarean sections. Data on the perioperative characteristics of the mothers and neonates were collected. Multivariable linear regression analysis was used to detect associations between maternal and perioperative characteristics and volume of intraoperative bleeding. Binary logical regression was used to analyze the association between maternal preoperative characteristics and emergency cesarean section. Linear regression analysis is used to analyze the relationship between gestational age and emergency cesarean section. The risks of emergency cesarean section increase 98, 112, 124, and 62% when the pregnant women with PAS accompanied by GHD, ICP, more prior cesarean deliveries and more severe PAS type, respectively. Noteworthy, the risk of emergency cesarean section decreases 5% when pre-pregnancy BMI increases 1 kg/m2 (OR: 0.95; CI: 0.82, 0.98; p = 0.038). Moreover, there is no significant linear correlation between emergency cesarean section and gestational age. GHD, ICP, multiple prior cesarean deliveries and severe PAS type may all increase the risk of emergency cesarean section for pregnant women with PAS, while high pre-pregnancy BMI may be a protective factor due to less activity level. For pregnant women with severe PAS accompanied by these high risk factors, more adequate maternal and fetal monitoring should be carried out in the third trimester to reduce the risk of emergency cesarean section.

Second trimester abnormal uterine artery Dopplers and adverse obstetric and neonatal outcomes when PAPP-a is normal

Objectives To explore the association between abnormal uterine artery Dopplers (combined PI > 2.5) - with normal PAPP-A - and adverse obstetric/neonatal outcomes. Methods This was a retrospective cohort study of 800 patients between 1 March 2019 − 23 November 2021 in a tertiary UK hospital, where it is routine to measure uterine artery Dopplers of all pregnancies during their anomaly scans. 400 nulliparous women/birthing people with complete data were included. 400 nulliparous controls scanned in the same time frame (1.5 years) with normal PAPP-A and uterine artery Dopplers were matched for age and BMI. Outcomes included: mode of birth, postpartum complications, birth weight/centile, Apgar score, gestational age at delivery, neonatal unit admission, and clinical neonatal hypoglycemia. Multivariable analysis was used. Results Compared to controls, pregnancies with abnormal uterine artery Dopplers and normal PAPP-A were at increased risk of induction (46.5% vs 35.5%, p = .042), cesarean section (46.0% vs 38.0%, p = .002), emergency cesarean section (35.0% vs 26.5%, p = .009), and pre-eclampsia 5.8% vs 2.5%, p = .021). Their babies were more likely to be admitted to the neonatal unit – mostly for prematurity (15.3% vs 6.3%, p = .0004), hypoglycemia (4.0% vs 1.0%, p = .007), be small for gestational age (26.5% vs 11.5%, p = .0001), had intrauterine growth restriction (10.8% vs 1.3%, p = .0001), and be born prematurely (10.0% vs 3.5%, p = .002). Routine measurement of uterine artery Dopplers increased the detection rate of small for gestational age fetuses by 15.1%. Over half of the babies admitted with neonatal hypoglycemia in pregnancies with abnormal uterine artery Dopplers had an unexplained cause. Conclusions Pregnancies with abnormal uterine Dopplers are not only at increased risk of pre-eclampsia and small for gestational age fetuses/intrauterine growth restriction, but are also at increased risk of emergency cesarean section and adverse neonatal outcomes. The increased incidence of neonatal hypoglycemia is likely driven to some degree by prematurity and placental complications, but possibly also by undiagnosed glucose dysmetabolism. This may warrant routine measurement of uterine artery Dopplers in all pregnancies (regardless of risk), where feasible, to aid antenatal management and counseling.

Effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries: a systematic review and meta-analysis

BackgroundMidwifery-led care is an evidence-based practice in which a qualified midwife provides comprehensive care for low-risk pregnant women and new-borns throughout pregnancy, birth, and the postnatal period. Evidence indicates that midwifery-led care has positive impacts on various outcomes, which include preventing preterm births, reducing the need for interventions, and improving clinical outcomes. This is, however, mainly based on studies from high-income countries. Therefore, this systematic review and meta-analysis aimed to assess the effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries.MethodsWe used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Three electronic databases (PubMed, CINAHL, and EMBASE) were searched. The search results were systematically screened by two independent researchers. Two authors independently extracted all relevant data using a structured data extraction format. Data analysis for the meta-analysis was done using STATA Version 16 software. A weighted inverse variance random-effects model was used to estimate the effectiveness of midwifery-led care on pregnancy outcomes. Odds ratio with a 95% confidence interval (CI) was presented using a forest plot.ResultsTen studies were eligible for inclusion in this systematic review, of which five studies were eligible for inclusion in the meta-analysis. Women receiving midwifery-led care had a significantly lower rate of postpartum haemorrhage and a reduced rate of birth asphyxia. The meta-analysis further showed a significantly reduced risk of emergency Caesarean section (OR = 0.49; 95% CI: 0.27–0.72), increased odds of vaginal birth (OR = 1.14; 95% CI: 1.04–1.23), decreased use of episiotomy (OR = 0.46; 95% CI: 0.10–0.82), and decreased average neonatal admission time in neonatal intensive care unit (OR = 0.59; 95% CI: 0.44–0.75).ConclusionsThis systematic review indicated that midwifery-led care has a significant positive impact on improving various maternal and neonatal outcomes in low- and middle-income countries. We therefore advise widespread implementation of midwifery-led care in low- and middle-income countries.

УСТАНОВЛЕНИЕ ФАКТОРОВ, СПОСОБСТВУЮЩИХ ЗАВЕР-ШЕНИЮ РОДОВ ПУТЕМ ОПЕРАЦИИ КЕСАРЕВА СЕЧЕНИЯ

One of the urgent problems in obstetric practice is the disclosure of patho-genetic mechanisms of violation of the contractile activity of the uterus during childbirth, which is accompanied by an increase in the risk of emergency cae-sarean section. Among the reasons, a significant role is assigned to anomalies of labor activity (10–25 %), in which labor activity is inhibited for unknown reasons. The appointment of drugs that stimulate the contractile function of the uterus during childbirth, with a mechanical obstruction not diagnosed in a timely manner, is accompanied by an increased risk of fetal asphyxia, birth trauma and leads to a belated caesarean section. Timely prediction of the course of the birth process and the selection of pregnant women for controlled delivery are one of the main medical problems. In view of the foregoing, we have established factors that are directly related to the formation of the cause of an emergency caesarean section. A retrospective study was conducted based on the analysis of medical documentation (history of childbirth) of 99 puerper-as hospitalized in the 3rd City Clinical Hospital named after E. V. Klumov" in Minsk in 2021–2022. The main group consisted of 52 women after spontane-ous childbirth (the average age of the patients was 26.7 ± 3.6). 49 puerperas of the comparison group were examined after emergency operative delivery (the average age of the patients was 27.6 ± 2.5). All puerperas of the compared groups were prescribed oxytocin infusions during labor in accordance with the clinical protocol. According to the results of our research, most of the signs that contribute to the completion of labor by caesarean section are related to mechanical difficulties. Undoubtedly significant predictors of the completion of labor by caesarean section were: acute fetal hypoxia, chronic decompensation according to cardiotocography and incorrect insertion of the fetal head. The most significant predictors were a decrease in contractile activity (OR = 21.0, CI 11.68–37.09, p &lt; 0.001), cervical dystocia (OR = 10.0, CI 2.41–18.90, p &lt; 0.001) and discoordination of labor according (OR = 6.0, CI 1.6–17.9, p = 0.006), the presence of which increases the chances of operative delivery by 21.0; 10.0 and 6.0 times, respectively. Weakness of labor activity and uter-ine atony in labor are a fairly common cause of emergency caesarean section due to the lack of effect of the therapy or violation of the fetal condition, but the mechanisms of their formation remain unidentified.

Timing of Elective Repeat Cesarean Delivery at 38 Weeks versus 39 Weeks: Rate of Spontaneous Onset of Labor before Planned Cesarean Section and Impact on Maternal Outcome: A Retrospective Cohort Study

Background: The timing of elective repeat cesarean delivery at 38 weeks versus 39 weeks is still a debatable subject, both regarding maternal and neonatal outcomes. In the Saudi context, there is lack of local data to aid decision-making regarding the timing of elective repeat cesarean delivery. Objectives: To estimate the rate of spontaneous onset of labor before the planned gestational age for repeat cesarean section in women who were booked at gestational age of (39 0/7 - 39 6/7) weeks (W39) versus (38 0/7 - 38 6/7) weeks (W38) and to compare the rate of maternal composite outcome between these groups. Design: Retrospective cohort. Setting: This study was conducted at King Abdulaziz Medical City, Jeddah, KSA. Method: Delivery registry books were reviewed to identify all deliveries from 1 January 2014 to 31 December 2016 (3 years). All low-risk pregnant women who had 2 or more cesarean deliveries and who met the inclusion criteria were included. Results: A total of 440 women were included of whom 318 (72.3%) were planned for elective cesarean section at W38 gestational age and 122 women at W39 gestational age. Mothers planned at W39 had higher rate of emergency cesarean deliveries versus those planned at W38 (18.0% versus 10.4%, p = 0.030; RR = 13.06), most frequently due to early onset of contractions (16.4% versus 8.2%, p = 0.012; RR = 12.17) or cervical dilatation (11.6% versus 5.4%, p = 0.024, RR = 16.15). No difference in the incidence of individual or composite maternal complications was noted between the two groups. Mother’s age (OR 0.93, p = 0.018) and schedule date at W39 (OR = 1.94, p = 0.028) were independently associated with spontaneous onset of labor before the scheduled gestational age, while no association was found with parity, previous number of spontaneous vaginal deliveries, number of previous cesarean deliveries or interval from last cesarean delivery. Conclusion: Elective cesarean section scheduled at 39 weeks of gestation or beyond carries a higher risk of emergency cesarean section, with no significant increase in maternal complications. The identification of factors associated with spontaneous onset of labor before the planned gestational age should be carefully identified to determine the optimal timing.

Deriving a prediction model for emergency cesarean delivery following induction of labor in singleton term pregnancies.

To derive a prediction model combining various clinical factors associated with increased risk of emergency cesarean section following induction of labor in women with unfavorable cervix. All women with singleton term pregnancies undergoing induction of labor and fulfilling inclusion criteria were included in this cross-sectional study after supplying consent. Women with a Bishop score of 6 or less were induced with dinoprostone gel. Multiple regression analysis was used to find the most significant independent predictive factors and these factors were used to develop the predictive model and calculator. After multiple logistic regression, risk of emergency cesarean after induction of labor was significantly associated with the following variables: height (adjusted odds ratio [aOR] 0.955, P= 0.033), nulliparity (aOR 3.987, P< 0.001), closed cervix (aOR 2.030, P= 0.030), fetal station -3 above ischial spine (aOR 2.719, P= 0.043), firm or medium cervical consistency (aOR 2.028, P= 0.004), cervical length 3cm or longer (aOR 3.090, P= 0.015), posterior cervix (aOR 2.112, P= 0.002). Use of a prediction model would help to reduce the number of emergency cesarean sections secondary to unsuccessful inductions and help in the reduction of maternal and perinatal morbidity.

Adverse Pregnancy Outcomes and International Immigration Status: A Systematic Review and Meta-analysis.

Background:Disparities in health outcomes between immigrant and native-origin populations, particularly pregnant women, pose significant challenges to healthcare systems. The aim of this systematic-review and meta-analysis was to investigate the risk of adverse pregnancy outcomes among immigrant-women compared to native-origin women in the host country.Methods:PubMed (including MEDLINE), Scopus, and Web of Science were searched to retrieve studies published in English language up to September 2020. All observational studies examining the prevalence of at least one of the short-term single pregnancy outcomes for immigrants who crossed international borders compared to native-origin pregnant population were included. The meta-prop method was used for the pooled-estimation of adverse pregnancy-outcomes’ prevalence. For pool-effect estimates, the association between the immigration-status and outcomes of interest, the random-effects model was applied using the model described by DerSimonian and Laird. I2 statistic was used to assess heterogeneity. The publication bias was assessed using the Harbord-test. Meta-regression was performed to explore the effect of geographical region as the heterogeneity source.Findings:This review involved 11 320 674 pregnant women with an immigration-background and 56 102 698 pregnant women as the native-origin population. The risk of emergency cesarean section (Pooled-OR = 1.1, 95%CI = 1.0–1.2), shoulder dystocia (Pooled-OR = 1.1, 95%CI = 1.0–1.3), gestational diabetes mellites (Pooled-OR = 1.4, 95%CI = 1.2–1.6), small for gestational age (Pooled-OR=1.3, 95%CI = 1.1–0.4), 5-min Apgar less than 7 (Pooled-OR = 1.2, 95%CI = 1.0–1.3) and oligohydramnios (Pooled-OR = 1.8, 95%CI = 1.0–3.3) in the immigrant women were significantly higher than those with the native origin background. The immigrant women had a lower risk of labor induction (Pooled-OR = 0.8, 95%CI = 0.7–0.8), pregnancy induced hypertension (Pooled-OR = 0.6, 95%CI = 0.5–0.7) preeclampsia (Pooled-OR = 0.7, 95%CI = 0.6–0.8), macrosomia (Pooled-OR = 0.8, 95%CI = 0.7–0.9) and large for gestational age (Pooled-OR = 0.8, 95%CI = 0.7–0.8). Also, the risk of total and primary cesarean section, instrumental-delivery, preterm-birth, and birth-trauma were similar in both groups. According to meta-regression analyses, the reported ORs were not influenced by the country of origin.Conclusion:The relationship between the immigration status and adverse perinatal outcomes indicated a heterogenous pattern, but the immigrant women were at an increased risk of some important adverse pregnancy outcomes. Population-based studies with a focus on the various aspects of this phenomena are required to explain the source of these heterogenicities.

RISK FACTORS FOR CAESAREAN DELIVERY IN INDUCED LABOR AT TERM

Background: Labor inductions have increased steadily over the past two decades and caesarean delivery in induced labour is seen more over the general caesarean cases. This study was designed to assess the factors which are associated with greater risk of cesarean delivery when induced at term. Methodology: This prospective observational study was carried out at department of Obstetrics and Gynecology in our hospital between March 2018- December 2020 in 120 pregnant women. Induction of labor by cervical ripening with Prostaglandin E2 gel ( 0.5 mg in 3ml) instilled intracervically followed by reassessment after 6 hours. If progress was not satisfactory, repeat gel induction was done after 24 hours, maximum of 3 doses of Prostaglandin E2 gels were used. Results:The cesarean delivery rate in the study was 39% which was greater than the general cesarean rate. Patients with poor Bishop score, obesity, gestational diabetes, IUGR and cholestasis were at high risk for emergency cesarean section. Conclusion: It can be concluded that a number of factors are implicated in increased cesarean rate after induction of labor. Unnecessary cesarean sections should therefore be avoided.

P298 Pregnancy in Crohn’s and Colitis - Observations, Levels and Outcomes Extension (PICCOLO-X) Study: Biological therapy reduces faecal calprotectin and the need for corticosteroids in pregnant women with Inflammatory Bowel Disease

Abstract Background Active Inflammatory Bowel Disease (IBD) in pregnancy is associated with adverse obstetric and neonatal outcomes. PICCOLO-X is an ongoing prospective cohort study of pregnant women with IBD, aiming to describe rates of biochemically active IBD in the current therapeutic landscape, and associations with adverse outcomes. Methods Participants were evaluated preconception, in each trimester and postpartum with clinical and biochemical data collected. Univariate and multivariate logistic regression was performed to identify the relative risk (RR) of adverse outcomes by relevant exposures. Fischer’s exact test was used to compare group medians. Results 164 completed pregnancies were included, with 62% exposed to biologic therapy and 56% having Crohn’s Disease (Table 1). Clinically active disease (PGA ≥1) was reported in 23.9% in trimester 1 (T1), 18.8% in trimester 2 (T2) and 17.5% in trimester 3 (T3), and was less common in biologic exposed patients (Table 2 &amp; 3). The median faecal calprotectin (FC) was &amp;lt;50μg/g in all trimesters, and was lower in those receiving biologics (24.9 vs 86μg/g T1 p=0.02, 26.25 vs 46μg/g T2 p=0.02, 30 vs 58μg/g T3 p=0.04) (Table 3). Adverse pregnancy outcome rates were equivalent to the normal population (Table 2). Corticosteroid (CCS) exposure in T2 was associated with an increased risk of preterm delivery (PTD) on multivariate analysis (RR 8.12, 95%CI 1.23–53.72, p=0.03). T1 FC ≥250μg/g (RR 2.41 95% CI 0.5–4.31, p=0.01), clinically active disease in T3 (RR 4.7, 95% CI 1.02–26.61, p&amp;lt;0.01) &amp; T3 FC 100–250 (RR 6.8 95% CI 1.71–26.0, p&amp;lt;0.01), but not T3 FC ≥250μg/g (RR 1.6, 95% CI 0.41–8.25, p=0.6) were associated with an increased risk of PTD on univariate analysis (Table 4). Biologic exposure was associated with a reduced need for CCS; no participants on a biologic had CCS in T1, with RR 0.14 (95% CI 0.03–0.66, p=0.01) in T2 and 0.11 (95% CI 0.02–0.46, p=0.003) in T3. On multivariate analysis, FC &amp;gt;100μg/g in T2 was associated with an increased risk of emergency caesarean section (RR 1.65, 95% CI 0.47–2.82, p&amp;lt;0.01), whilst FC &amp;gt;100μg/g in T2 (RR 1.65 95% CI 0.4–2.91 p=0.01) and T3 (RR 2.47,95% CI 1.36–8.82, p&amp;lt;0.01) were associated with an increased risk of neonatal intensive care unit admission. Conclusion PICCOLO X describes low rates of biochemical and clinical active disease in pregnant women with IBD as compared to historical cohorts, possibly due to the cohort’s high rate of biologic use. Pregnancy outcomes were favourable overall. Clinical and biochemical inflammation and CCS exposure were associated with an elevated risk of adverse pregnancy outcomes. Biologic therapy reduces FC and the need for steroids.

Vaginal dysbiosis in pregnancy associates with risk of emergency caesarean section: a prospective cohort study

ObjectivesTo investigate changes in vaginal microbiota during pregnancy, and the association between vaginal dysbiosis and reproductive outcomes. MethodsA total of 730 (week 24) and 666 (week 36) vaginal samples from 738 unselected pregnant women were studied by microscopy (Nugent score) and characterized by 16S rRNA gene sequencing. A novel continuous vaginal dysbiosis score was developed based on these methods using a supervised partial least squares model. ResultsAmong women with bacterial vaginosis in week 24 (n = 53), 47% (n = 25) also had bacterial vaginosis in week 36. In contrast, among women without bacterial vaginosis in week 24, only 3% (n = 18) developed bacterial vaginosis in week 36. Vaginal samples dominated by Lactobacillus crispatus (OR 0.35, 95% CI 0.20–0.60) and Lactobacillus iners (OR 0.40, 95% CI 0.23–0.68) in week 24 were significantly more stable by week 36 when compared with other vaginal community state types. Vaginal dysbiosis score at week 24 was associated with a significant increased risk of emergency, but not elective, caesarean section (OR 1.37, 955 CI 1.15–1.64, p < 0.001), suggesting a 37% increased risk per standard deviation increase in vaginal dysbiosis score. ConclusionsChanges in vaginal microbiota from week 24 to week 36 of pregnancy correlated with bacterial vaginosis status and vaginal community state type. A novel vaginal dysbiosis score was associated with a significantly increased risk of emergency, but not elective, caesarean section. This was not found for bacterial vaginosis or any vaginal community state type and could point to the importance of investigating vaginal dysbiosis as a nuanced continuum instead of crude clusters.

Fertility and pregnancy outcomes in women with spondyloarthritis: a systematic review and meta-analysis.

The aim of this study was to determine the impact of SpA and its treatments on fertility and pregnancy outcomes, as well as the impact of pregnancy on disease activity. A systematic review and meta-analyses were performed, including studies in women with SpA [axial (axSpA) and peripheral SpA, including PsA]. The heterogeneity between studies was quantified (I2), and in the case of substantial heterogeneity, the results were reported in a narrative review. Of 4397 eligible studies, 21 articles were included, assessing a total of 3566 patients and 3718 pregnancies, compared with 42 264 controls. There is a lack of data on fertility in the literature. We found an increased risk of preterm birth [pooled odds ratio (OR) 1.64 (1.15-2.33), I2 =24% in axSpA and 1.62 (1.23-2.15), I2 =0.0% in PsA], small for gestational age [pooled OR 2.05 (1.09-3.89), I2 =5.8% in axSpA], preeclampsia [pooled OR 1.59 (1.11-2.27], I2 =0% in axSpA] and caesarean section [pooled OR 1.70 (1.44-2.00), I2 =19.9% in axSpA and 1.71 (1.14-2.55), I2 =74.3% in PsA], without any other unfavourable pregnancy outcome. Further analysis showed a significantly higher risk of elective caesarean section [pooled OR 2.64 (1.92-3.62), I2 =0.0% in axSpA and 1.47 [1.15-1.88], I2 =0,0% in PsA), without increased risk of emergency caesarean section in PsA. During pregnancy, there appears to be a tendency for unchanged or worsened disease activity in axSpA and unchanged or improved disease activity in PsA. Both conditions tend to flare in the postpartum period. SpA seems to be associated with an increased risk of preterm birth, small for gestational age, preeclampsia, and caesarean section.

Association between Maternal Origin, Pre-Pregnancy Body Mass Index and Caesarean Section: A Nation-Wide Registry Study.

Aims: To explore the association between maternal origin and birthplace, and caesarean section (CS) by pre-pregnancy body mass index (BMI) and length of residence. Methods: We linked records from 118,459 primiparous women in the Medical Birth Registry of Norway between 2013 and 2017 with data from the National Population Register. We categorized pre-pregnancy BMI (kg/m2) into underweight (<18.5), normal weight (18.5–24.9) and overweight/obese (≥25). Multinomial regression analysis estimated crude and adjusted relative risk ratios (RRR) with 95% confidence intervals (CI) for emergency and elective CS. Results: Compared to normal weight women from Norway, women from Sub-Saharan Africa and Southeast Asia/Pacific had a decreased risk of elective CS (aRRR = 0.57, 95% CI 0.37–0.87 and aRRR = 0.56, 0.41–0.77, respectively). Overweight/obese women from Europe/Central Asia had the highest risk of elective CS (aRRR = 1.42, 1.09–1.86). Both normal weight and overweight/obese Sub-Saharan African women had the highest risks of emergency CS (aRRR = 2.61, 2.28-2.99; 2.18, 1.81-2.63, respectively). Compared to women from high-income countries, the risk of elective CS was increasing with a longer length of residence among European/Central Asian women. Newly arrived migrants from Sub-Saharan Africa had the highest risk of emergency CS. Conclusion: Women from Sub-Saharan Africa had more than two times the risk of emergency CS compared to women originating from Norway, regardless of pre-pregnancy BMI.

Physical activity and sedentary time during pregnancy and associations with maternal and fetal health outcomes: an epidemiological study

BackgroundPhysical activity is generally considered safe for the pregnant woman as well as for her fetus. In Sweden, pregnant women without contraindications are recommended to engage in physical activity for at least 30 min per day most days of the week. Physical activity during pregnancy has been associated with decreased risks of adverse health outcomes for the pregnant woman and her offspring. However, there are at present no recommendations regarding sedentary behavior during pregnancy. The aim was to examine the level of physical activity and sedentary time in a representative sample of the pregnant population in Sweden, and to explore potential effects on gestational age, gestational weight gain, birth weight of the child, mode of delivery, blood loss during delivery/postpartum, self-rated health during pregnancy and risk of pregnancy-induced hypertension and preeclampsia.MethodsThis was an epidemiological study using data from the prospective, population-based NorthPop study in Northern Sweden and information on pregnancy outcomes from the national Swedish Pregnancy Register (SPR). A questionnaire regarding physical activity and sedentary time during pregnancy was answered by 2203 pregnant women. Possible differences between categories were analyzed using one-way Analysis of variance and Pearson’s Chi-square test. Associations between the level of physical activity/sedentary time and outcome variables were analyzed with univariable and multivariable logistic regression and linear regression.ResultsOnly 27.3% of the included participants reported that they reached the recommended level of physical activity. A higher level of physical activity was associated with a reduced risk of emergency caesarean section, lower gestational weight gain, more favorable self-rated health during pregnancy, and a decreased risk of exceeding the Institute of Medicine’s recommendations regarding gestational weight gain. Higher sedentary time was associated with a non-favorable self-rated health during pregnancy.ConclusionsOur study showed that only a minority of pregnant women achieved the recommended level of physical activity, and that higher physical activity and lower sedentary time were associated with improved health outcomes. Encouraging pregnant women to increase their physical activity and decrease their sedentary time, may be important factors to improve maternal and fetal/child health outcomes.

Economic burden of IADPSG gestational diabetes diagnostic criteria in China: propensity score matching analysis from a 7-year retrospective cohort

IntroductionThe International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria for gestational diabetes mellitus (GDM) increased the morbidity significantly, but the cost and effectiveness of its application are still...

Timing and mode of delivery with advancing maternal age.

In 2017, 23% of all live births in the United Kingdom were to women aged over 35 years. Decisions around the timing of delivery for such women must balance the risks of prolongation of the pregnancy and of iatrogenic harm from timed delivery. Women of advanced maternal age have a small age-related elevated risk of term stillbirth. Antenatal monitoring and the route of delivery should not differ from those for younger women. The induction of labour at 39 weeks for such women does not appear to increase the risk of emergency caesarean section or to have any short-term adverse effects on mother or baby. There have been no studies on the long-term effects of induction in this group. Nevertheless, it seems reasonable to offer women of advanced maternal age, induction of labour at 39 weeks where resources are available to safely provide this.

Methodological issue on prediction of emergency cesarean section by measurable maternal and fetal characteristics

Dear Editor, We read with great interest the study by Ping Guan et al . The authors aimed to develop a simple and distinctive scoring system for predicting the risk...

Predictors of emergency cesarean section in women with preexisting diabetes

ObjectivePreexisting diabetes in pregnancy is associated with a high risk of emergency cesarean section (CS), which is associated with increased risk of maternal and neonatal complications. Thus, the aim of this study was to identify possible predictors of emergency CS in women with preexisting diabetes. Study designThis is a secondary analysis of a prospective observational study of 204 women with preexisting diabetes (118 with type 1 diabetes and 86 with type 2) with singleton pregnancies recruited at Rigshospitalet, Copenhagen, Denmark from August 2015 to February 2018. Mode of delivery (trial of labor or planned CS) was individually planned in late pregnancy based on clinical variables reflecting maternal and fetal health including glycemic control and ultrasonically estimated fetal weight. Univariate and multivariable analyses were performed to identify possible predictors of in labor emergency CS. ResultsTrial of labor was planned in 79 % (n = 162) of the women of whom 65 % (n = 105) were delivered vaginally and 35 % (n = 57) by an emergency CS, while the remaining 21 % (n = 42) were offered a planned CS. Nulliparity (adjusted odds ratio (aOR) 5.6 95 % CI 1.7–18.8), presence of a hypertensive disorder (aOR 2.8, 95 % CI 1.2–6.7) and previous CS (aOR 6.7, 95 % CI 1.5–28.9) were independently associated with an emergency CS. Maternal height was inversely associated with emergency CS (aOR 0.6 95 %, CI 0.5-0.9 per 5 cm decrease). Neither maternal HbA1c nor ultrasonically estimated fetal size in late pregnancy were associated with emergency CS. Women scheduled for a planned CS were characterized by poorer glycemic control and higher estimated fetal size than those offered a trial of labor. ConclusionNulliparity, presence of a hypertensive disorder, previous CS and shorter maternal height were predictors of emergency CS in women with a planned trial of labor, whereas this not was the case for late pregnancy maternal Hba1c or fetal size estimated by ultrasound.