Subsequent Perinatal Outcomes Research Articles

Interpregnancy interval after vacuum delivery and subsequent perinatal outcomes.

To evaluate whether a short interpregnancy interval (IPI) after vacuum extraction (VE), poses similar perinatal risks in a subsequent pregnancy. This was a retrospective, single-center cohort study between 2011 and 2021. Nulliparous women with term, singleton VE deliveries and with known pregnancy outcomes in their subsequent pregnancy were eligible for inclusion in the study. Each woman was allocated into one of two groups based on the IPI, <18 months and between 18 and 60 months. The primary outcome was the risk of spontaneous preterm birth (PTB) <37 weeks in the consecutive birth. We included 1094 pregnancies: 212 (19.4%) with IPI <18 months and 882 (80.6%) with IPI between 18 and 60 months following the previous VE delivery. The VE characteristics were comparable between the groups. Young maternal age was a risk factor for a short IPI (28.0 ± 4.8 vs 30.3 ± 4 years, P < 0.01). Spontaneous PTB <37 weeks was significantly higher in the IPI <18 months group with 18-60 months (7.1% vs 2.6%, P = 0.002). Polynomial regression analysis also confirmed a significantly increased risk of preterm birth <37 weeks (P < 0.01). Short IPI <18 months was also associated with an increase in the risk of low birthweight <2500 g (6.1% vs 2.8%, P = 0.02) and admission to the neonatal intensive care unit (6.1% vs 2.6%, P = 0.013). The incidence of recurrent VE, albeit significant (2.3% vs 4.9%, P = 0.049), was low in both groups. No differences were noted in any of the other secondary outcomes. Short IPI (<18 months) following term VE delivery is associated with higher neonatal risks, particularly PTB, in the subsequent pregnancy. These findings are particularly important when counseling women planning an optimal IPI.

Nonpronuclear- and monopronuclear-derived blastocysts do not impair subsequent perinatal and maternal outcomes.

The routine clinical practice is to prioritize the transfer of blastocysts derived from 2PN embryos if they are available. For women who only have blastocysts resulting from 0PN and 1PN embryos, whether to transfer these embryos or discard them has been an ongoing debate over the years. To investigate the perinatal and obstetric outcomes following the transfer of vitrified-warmed single blastocysts derived from 0PN and 1PN zygotes. Retrospective cohort study. University-affiliated IVF center. This study included singletons born to women who had undergone 0PN and 1PN vitrified-warmed single blastocyst transfers, compared to those resulting from 2PN vitrified-warmed single blastocyst transfers from 2012 to 2020. None. Perinatal and obstetric outcomes. A total of 7,284 women were included in the final analysis. Of these, 386, 316, and 6582 cycles resulted from 0PN-, 1PN-, and 2PN-derived blastocysts transfer, respectively. The rates of clinical pregnancy, miscarriage, and live birth were similar across the study cohorts in both unadjusted and adjusted analyses. When comparing the 0PN and 2PN groups, no differences were found in birth outcomes after adjusting for confounders. Similarly, maternal complications and mode of delivery were comparable between these two study cohorts. Birth parameters were also similar between the 1PN and 2PN blastocyst groups, except for more male births in the 1PN cohort. Furthermore, a comparison between the 1PN and 2PN groups did not reveal any significant differences in maternal outcomes. The current study showed that the transfer of 0PN and 1PN blastocysts did not compromise reproductive outcomes or increase maternal and perinatal complications. This information is valuable for clinicians to counsel couples effectively and guide them in making informed decisions.

Integrative Review of Black Birthing People's Interactions With Clinicians During the Perinatal Period.

Maternal morbidity and mortality disproportionately affect Black birthing people. Multiple factors contribute to these disparities, including variations in quality health care, structural racism, and implicit bias. Interactions between Black patients and perinatal clinicians could further affect perinatal care use and subsequent perinatal outcomes. This integrative review aims to synthesize quantitative and qualitative literature published in peer-reviewed journals in English within the past 10 years that address patient-clinician interactions during the perinatal period for Black birthing people in the United States. A systematic search of CINAHL, PubMed, PsycINFO, MEDLINE, and Embase recovered 24 articles that met the eligibility criteria for inclusion in this review. The following themes emerged from synthesizing Black patients' interactions with perinatal clinicians: Care Quality, Communication, Power Dynamic, and Established Relationships. Mutual respect, effective communication, and shared decision-making may be key modifiable factors to address through clinician education to improve perinatal care for many Black persons.

Subsequent perinatal outcomes of pregnancy with two consecutive pregnancies with gestational diabetes mellitus: A population-based cohort study.

BackgroundGestational diabetes mellitus (GDM) is glucose intolerance diagnosed during pregnancy. We aimed to explore the different outcomes of women with two consecutive pregnancies with GDM.MethodsThis study included 861 women with recurrent GDM who had two consecutive singleton deliveries at Fujian Maternity and Child Health Hospital between May 2012 and September 2020. Data on pregnancy complications and neonatal and delivery outcomes were collected and analyzed.ResultsAmong those women with recurrent GDM, there was no difference in pregnancy complications in index pregnancy vs subsequent pregnancy. Our data revealed there was a significantly higher incidence of thyroid disease in the subsequent pregnancies than in the index pregnancy. (6% vs 10%, p = .003)In subsequent pregnancies, the birth weight was greater than that of the index pregnancy (3296.63 ± 16.85 vs 3348.99 ± 16.05, p = .025); and the incidence of large for gestational age (LGA) was higher than that of the index pregnancy (16.3% vs 20.6%, p = .021). More cesarean sections occurred in the subsequent pregnancy. (32.9% vs 6.6%, p = .039). Postpartum hemorrhage, premature birth, and placental abruption were not significantly different between the two pregnancies.ConclusionsThe results suggest the effect of GDM on thyroid dysfunction may be persistent. Recurrent gestational diabetes results in a higher rate of cesarean delivery, incidence of LGA, and neonatal admission to the neonatal intensive care unit (NICU) in subsequent pregnancies. We need to pay attention to the postpartum thyroid function of pregnant women with GDM. Further studies are still needed on recurrent GDM to reduce this occurrence of admission to NICU.

COVID-19 in Pregnancy: An Experience at a Dedicated Tertiary Care COVID Facility in Western Uttar Pradesh

Introduction: COVID-19 in pregnancy has put all perinatal services at a slog pace due to restricted movement and fear associated with the unknown challenges that the entire world is facing. At a tertiary care center, where a majority of the cases are referred from adjoining areas, the incidence of complications encountered was more. The present study discusses the impact of COVID-19 in pregnant females and subsequent perinatal outcomes. Aims: To study the perinatal outcomes in COVID-19-diagnosed pregnancy. Type of study: Observational analytical study. Methodology: All the pregnant females with COVID-19-diagnosed pregnancy were studied for their demographic profile, symptomatology, laboratory results, obstetric outcome, and neonatal performance between June 18, 2020, and September 30, 2020. Results: A total of 114 obstetric patients were admitted at this particular level two-facility center. Out of this, 21 were symptomatic, 22 delivered by cesarean, two cases of ruptured tubal ectopic pregnancy were seen, two cases of ruptured uterus were there, nine cases were received in obstructed labor, four cases of incomplete abortion, and three stillbirths were reported at our center. None of the neonates was tested positive for COVID-19. Oligohydramnios was seen in 25.4% of cases and thrombocytopenia was a significant finding in 33.3% of the patients. Conclusion: COVID-19 has affected the obstetric population with varied outcomes all throughout pregnancy. Even in asymptomatic patients, complications like oligohydramnios and thrombocytopenia were seen. Obstetric services were poorly catered at the periphery as many patients were received in emergency as cases of obstructed labor and ruptured uterus. COVID-19 has negatively affected each dimension of service care provisions and the health and outcome of the obstetric population.

MiRNAs Regulating Oxidative Stress: A Correlation with Doppler Sonography of Uteroplacental Complex and Clinical State Assessments of Newborns in Fetal Growth Restriction.

Overproduction of reactive oxygen species (ROS) and, as a result, uncontrolled oxidative stress (OS) can play a central role in disorders of fetal hemodynamics and subsequent development of adverse perinatal outcomes in newborns with fetal growth restriction (FGR). Given the epigenetic nature of such disorders, the aim of our study was to evaluate the expression of miRNAs associated with OS and endothelial dysfunction (miR-27a-3p, miR-30b-5p, miR-125b-5p, miR-221-3p, miR-451a and miR-574-3p) in umbilical cord blood using real-time quantitative RT-PCR. ΜiRNA expression was evaluated in patients with FGR delivery before (n = 9 pregnant) and after 34 weeks of gestation (n = 13 pregnant), and the control groups corresponding to the main groups by gestational age (13 pregnant women in each group, respectively). A significant increase in miR-451a expression was detected in late-onset FGR and correlations with fetoplacental and cerebral circulation were established (increase of resistance in the umbilical artery (pulsatility index, PI UA (umbilical artery): r = −0.59, p = 0.001) and a decrease in cerebral blood flow (CPR: r = 0.48, p = 0.009)). The change in miR-125b-5p expression in the placenta is associated with reduced Doppler of cerebral hemodynamics (CPR: r = 0.73, p = 0.003; PI MCA (middle cerebral artery): r = 0.79, p = 0.0007), and newborn weight (r = 0.56, p = 0.04) in early-onset FGR. In addition, significant changes in miR-125b-5p and miR-451a expression in umbilical cord blood plasma were found in newborns with neonatal respiratory distress syndrome (NRDS) (in early-onset FGR) and very low birth weight (VLBW) (in late-onset FGR). A number of key signaling pathways have been identified in which the regulation of the studied miRNAs is involved, including angiogenesis, neurotrophin signaling pathway and oxidative stress response. In general, our study showed that changes of the redox homeostasis in the mother-placenta-fetus system in FGR and subsequent perinatal outcomes may be due to differential expression of oxidative stress-associated miRNAs.

The association between longer durations of the latent phase of labor and subsequent perinatal processes and outcomes among midwifery patients.

To evaluate the association between the duration of the latent phase of labor and subsequent processes and outcomes. Secondary analysis of prospectively collected data among 1,189 women with low-risk pregnancies and spontaneous labor. Longer latent phase duration was associated with labor dystocia (eg, nulliparous≥mean [compared with<mean] aOR 3.95 [2.70-5.79]; multiparous≥mean [compared with<mean] aOR 5.45 [3.43-8.65]), interventions to ameliorate dystocia, and epidurals to cope or rest (eg, oxytocin augmentation: nulliparous>80th% [compared with<80th%] aOR 6.39 [4.04-10.12]; multiparous≥80th% [compared with<80th%] aOR 6.35 [3.79-10.64]). Longer latent phase duration was also associated with longer active phase and second stage. There were no associations between latent phase duration and risk for cesarean delivery or postpartum hemorrhage in a practice setting with relatively low rates of primary cesarean. Newborns born to multiparous women with latent phase of labor durations at and beyond the 80th% were more frequently admitted to the NICU (≥80th% [compared with<80th%] aOR 2.7 [1.22-5.84]); however, two-thirds of these NICU admissions were likely for observation only. Longer duration of the spontaneous latent phase of labor among women with low-risk pregnancies may signal longer total labor processes, leading to an increase in diagnosis of dystocia, interventions to manage dystocia, and epidural use. Apart from multiparous neonatal NICU admission, no other maternal or child morbidity outcomes were elevated with longer duration of the latent phase of labor.

The Yield of Intraoperative Fetal Monitoring During Nonobstetric Surgery [34K

INTRODUCTION: While ACOG supports indicated surgery for pregnant patients, there is no clear consensus on optimal fetal monitoring for such cases. We examined whether continuous intraoperative electronic fetal monitoring (ciEFM) for nonobstetric surgeries after viability impacts decision for obstetric intervention and subsequent perinatal outcomes. METHODS: IRB approval was obtained for this retrospective cohort study conducted at a single academic center between January 2013 and March 2019. Demographic and outcome data were compared between ciEFM vs pre/post-procedure EFM. Multiple logistic regression was applied to adjust for clinical covariates. RESULTS: Of 1,060 cases reviewed, 43 (4.1%) were performed after viability (gestational age (GA) range: 23.7 to 36.4 weeks). ciEFM was used in 24 cases (56%). Two cases required intraoperative resuscitation in the ciEFM group, one with fluid bolus and one with emergent delivery (P=.49). ciEFM cases lasted longer (105 vs 40 minutes, P&lt;.01) and were more likely to be performed under general anesthesia (83.3% vs 26.3%, P&lt;.01). ciEFM had no association with non-reassuring postoperative EFM (18.2% vs 15.4%, P=1.00), postoperative tocolytic use (29.2% vs 10.5%, P=.26), or GA at delivery (37.1 vs 37.2, P=.92). There was no association on the rate of preterm delivery when adjusted for type, or length of surgery, and type of anesthesia (aOR 1.82, 95% CI 0.20-16.4, P=.59). CONCLUSION: ciEFM does not significantly affect intraoperative or postoperative obstetrical outcomes. This data can help obstetric providers allocate limited resources, reassure other surgical providers, and appropriately counsel patients who are about to undergo nonobstetric surgery.

Adverse effects of endometriosis on pregnancy: a case-control study

BackgroundEndometriosis is a common disease occurring in 1–2% of all women of reproductive age. Although there is increasing evidence on the association between endometriosis and adverse perinatal outcomes, little is known about the effect of pre-pregnancy treatments for endometriosis on subsequent perinatal outcomes. Thus, this study aimed to evaluate maternal and neonatal outcomes in pregnant women with endometriosis and to investigate whether pre-pregnancy surgical treatment would affect these outcomes.MethodsThis case-control study included 2769 patients who gave birth at Nagoya University Hospital located in Japan between 2010 and 2017. Maternal and neonatal outcomes were compared between the endometriosis group (n = 80) and the control group (n = 2689). The endometriosis group was further divided into two groups: patients with a history of surgical treatment such as cystectomy for ovarian endometriosis, ablation or excision of endometriotic implants, or adhesiolysis (surgical treatment group, n = 49) and those treated with only medications or without any treatment (non-surgical treatment group, n = 31).ResultsIn the univariate analysis, placenta previa and postpartum hemorrhage were significantly increased in the endometriosis group compared to the control group (12.5% vs. 4.1%, p < 0.01 and 27.5% vs. 18.2%, p = 0.04, respectively). In the multivariate analysis, endometriosis significantly increased the odds ratio (OR) for placenta previa (adjusted OR, 3.19; 95% confidence interval [CI], 1.56–6.50, p < 0.01) but not for postpartum hemorrhage (adjusted OR, 1.14; 95% CI, 0.66–1.98, p = 0.64). Other maternal and neonatal outcomes were similar between the two groups. In patients with endometriosis, patients in the surgical treatment group were significantly associated with an increased risk of placenta previa (OR. 4.62; 95% CI, 2.11–10.10, p < 0.01); however, patients in the non-surgical treatment group were not associated with a high risk (OR, 1.63; 95% CI, 0.19–6.59, p = 0.36). Additionally, other maternal and neonatal outcomes were similar between the two groups.ConclusionWomen who have had surgical treatment for their endometriosis appear to have a higher risk for placenta previa. This may be due to the more severe stage of endometriosis often found in these patients. However, clinicians should be alert to this potential increased risk and manage these patients accordingly.

Association of self-reported personal care product use with blood glucose levels measured during pregnancy among women from a fertility clinic

BackgroundPersonal care products (PCPs), known sources of endocrine disrupting chemicals (EDCs) such as phthalates and parabens, are widely used among women of reproductive age. EDCs have been linked to pregnancy complications such as gestational diabetes (GDM), and PCP use could represent a modifiable source of exposure in this sensitive time window. Yet, to our knowledge, no study has directly evaluated the association between pregnancy use of PCP and late pregnancy glucose levels, established risk factors for complications such as GDM. MethodsA total of 233 women from the Environment and Reproductive Health (EARTH) Study had data available on 1st and/or 2nd trimester PCP use, assessed through self-reported use over the previous 24 h, and blood glucose levels after the glucose loading test (GLT), taken at late 2nd trimester. Associations between each individual PCP and total PCP with glucose levels were evaluated in multivariable adjusted linear regression models. ResultsBoth positive and negative differences in glucose levels were observed when comparing users vs. non-users of several PCPs including 2nd trimester use of deodorant (adjusted mean difference: 12.2 mg/dL, 95% CI: −0.6, 24.9); bar soap (6.9 mg/dL, 95% CI: −0.9, 14.7 mg/dL); and liquid soap (−13.3, 95% CI: −26.8, 0.1 mg/dL), and 1st trimester use of sunscreen (−14.6 mg/dL, 95% CI: −27.8, −1.5 mg/dL). Total number of PCPs used in the 2nd trimester was also associated with higher glucose levels, with the largest difference of 20 mg/dL when comparing individuals who used eight vs none PCPs (95% CI: 3–37). ConclusionsIn a pregnancy cohort of women seeking care at a fertility clinic, we found the use of several PCPs to be positively or negatively associated with glucose levels in the late second trimester, which may reflect increased risk of GDM and subsequent perinatal outcomes. These results strengthen the role of product use as a potentially modifiable source of EDCs that may impact glucose levels.

175: Perinatal outcomes after implementing a hemorrhage risk assessment at admission

To evaluate the impact of a novel assessment of hemorrhage risk at admission on subsequent perinatal outcomes. This retrospective cohort analysis of a multicenter database included women admitted to labor and delivery from January 2015 to June 2018. A novel nursing assessment developed by Association of Women's Health, Obstetric and Neonatal Nurses was used to categorize patients as low, medium or high risk for hemorrhage. This was implemented 6/1/2016 across the centers. Perinatal outcomes related to blood transfusion, estimated blood loss (EBL) ≥ 1000cc, ICU admission, chorioamnionitis, general anesthesia, oxytocin use and cesarean delivery were evaluated before and after implementation. There were a total of 109,719 women included, with 38,751 women included prior to implementation of the hemorrhage risk assessment and 70,968 women after implementation. Rates of any blood transfusion (0.5 to 0.4%, p=0.02) and EBL ≥ 1000cc (6.3 to 6.0%, p=0.02) were significantly lower after implementation. Incidence of ICU admission, chorioamnionitis and general anesthesia did not change overall in the time period studied. There were higher rates of oxytocin use (83.4 to 85.2%, p<0.0001) and spontaneous vaginal delivery (58.8 to 59.9%, p=0.01). Details on perinatal outcomes are included (Table). After implementation of a hemorrhage risk assessment at admission, we found a 20% reduction in rates of blood transfusion and EBL ≥ 1000cc. Significantly increased oxytocin use was also observed. Further analysis must be done to assess if any other changes could account for these trends.

The prevalence of nuchal cords noted during nuchal translucency screens and subsequent perinatal outcomes

The prevalence of nuchal cords noted during nuchal translucency screens and subsequent perinatal outcomes

Diabetic ketoacidosis complicating pregnancy.

Although diabetic ketoacidosis (DKA) in pregnancy can result in significant adverse consequences for both mother and fetus, the response to treatment, time course of recovery, and perinatal outcomes have not been well studied in pregnancy. We examined the precipitating factors, laboratory abnormalities, treatment strategies, and clinical recovery in pregnancies complicated by DKA. This is a retrospective cohort study of pregnancies complicated by DKA between October 1999 and June 2015. The diagnosis was verified by hyperglycemia; anion gap >12 mEq/L, pH <7.3, HCO3 <15 mEq/L; and the presence of ketones. Each episode of DKA was reviewed and subsequent perinatal outcomes analyzed. During this period, we identified 33 women with 40 admissions (incidence: 0.2%). The majority of women had type 1 diabetes (67%), and almost all presented with nausea and vomiting (97%). Over half had poor compliance with prescribed insulin. The initial mean blood glucose was 380 mg/dL, within 6 hours, it was <200 mg/dL. By 12 hours, the acidosis had resolved in 90% of patients. Nausea and vomiting is a prominent presenting feature of DKA in pregnancy. With aggressive insulin and resuscitation, hyperglycemia and acidosis improve rapidly. With current treatment, good perinatal outcomes can be expected.

Identifying Maternal Constraints on Fetal Growth and Subsequent Perinatal Outcomes Using a Multiple Embryo Implantation Model.

IntroductionAlthough the majority of singleton births after in vitro fertilization (IVF) are uncomplicated, studies have suggested that IVF pregnancies may be independently associated with low birth weight (LBW), preterm birth (PTB), and perinatal mortality. These outcomes complicate multiple gestations as expected, but have also been reported in singletons. A multiple embryo implantation model allows for assessment of the early in utero environment, and therefore, assessment of any maternal constraints on developing fetuses. We question whether adverse perinatal outcomes associated with assisted reproductive techniques (ART) occur as a result of maternal physiologic adaptations.Patients and MethodsThis is a retrospective, single center study of ART cycles, specifically intracytoplasmic sperm injection (ICSI) cycles during a 16-year period. For each positive pregnancy test 9–11 days after embryo transfer, an ultrasonogram was performed at 7 weeks of gestation to record the number of implanted fetal poles with cardiac activity. Controlled ovarian stimulation (COS), hCG trigger, oocyte retrieval and sperm injection were performed as per our standard protocols. First trimester implantation sites that resulted in live births were defined as “true” to distinguish them from those that spontaneously reduced called “virtual.” Birth outcomes analyzed included birth weight and gestational age at delivery.ResultsA total of 17,415 cycles were analyzed. The average maternal age was 36.9 (±5.0) years. An overall fertilization rate of 73.4% generated approximately 48,708 good quality cleavage-stage embryos. In most patients (92.8%), an average of 3 embryos were transferred. The clinical pregnancy rate was 39.2% (n = 6,281). The overall occurrence of multiple gestations was 38.2% (n = 2,608) consisting of 2,038 twin, 511 triplet, and 59 quadruplet pregnancies. Of these multiple gestations, 18.6% of twin, 54.2% of triplet and 76.3% of quadruplet gestations spontaneously reduced. Failure of the implanted embryo to progress was not related to maternal age. Singleton newborns resulting from multiple implantation sites had lower birth weights (P<0.01) and shorter gestational ages (P<0.01) than those from a single implanted embryo. The number of embryos transferred did not affect the gestational length of singleton newborns. Although the birth weights of singletons from multiple implantation sites (virtual singletons) were lower than true singletons, the birth weight of virtual singletons were comparable to the birth weights of true twin, triplet, and quadruplet live births. Multiple logistic regression revealed that virtual singletons were an independent risk factor for PTB (odds ratio: 4.55, 95% CI 2.23–9.29) and LBW (odds ratio: 3.61, 95% CI 1.78–7.32), even after controlling for the number of oocytes, stimulation protocol type, sperm source, total gonadotropins administered, age, embryo quality, and day of embryo transfer.ConclusionsOur study highlights that embryonic implantation sites during early gestation set the growth profile of each embryo, dictating later growth patterns. Specifically, spontaneous reduction of an embryo after multiple embryo implantations can confer greater perinatal risk in the form of LBW and PTB to the surviving fetus. Our findings suggest that maternal constraints or physiologic adaptations maybe one of the mechanisms mediating adverse perinatal outcomes when multiple embryo implantation occurs.

Cost Implications for Subsequent Perinatal Outcomes After IVF Stratified by Number of Embryos Transferred: A Five Year Analysis of Vermont Data

In states in the USA without in vitro fertilzation coverage (IVF) insurance coverage, more embryos are transferred per cycle leading to higher risks of multi-fetal pregnancies and adverse pregnancy outcomes. To determine frequency and cost of selected adverse perinatal complications based on number of embryos transferred during IVF, and calculate incremental cost per IVF live birth. Medical records of patients who conceived with IVF (n=116) and delivered at >20weeks gestational age between 2007 and 2011 were evaluated. Gestational age at delivery, low birth weight (LBW) term births, and delivery mode were tabulated. Healthcare costs per cohort, extrapolated costs assuming 100 patients per cohort, and incremental costs per infant delivered were calculated. The highest prematurity and cesarean section rates were recorded after double embryo transfers (DET), while the lowest rates were found in single embryo transfers (SET). Premature singleton deliveries increased directly with number of transferred embryos [6.3% (SET), 9.1% (DET) and 10.0% for ≥3 embryos transferred]. This trend was also noted for rate of cesarean delivery [26.7% (SET), 36.6% (DET), and 47.1% for ≥3 embryos transferred]. The proportion of LBW infants among deliveries after DET and for ≥3 embryos transferred was 3.9 and 9.1%, respectively. Extrapolated costs per cohort were US$718,616, US$1,713,470 and US$1,227,396 for SET, DET, and ≥3 embryos transferred, respectively. Attempting to improve IVF pregnancy rates by permitting multiple embryo transfers results in sharply increased rates of multiple gestation and preterm delivery. This practice yields a greater frequency of adverse perinatal outcomes and substantially increased healthcare spending. Better efforts to encourage SET are necessary to normalize healthcare expenditures considering the frequency of very high cost sequela associated with IVF where multiple embryo transfers occur.

Clinical characteristics and outcome of cancer diagnosed during pregnancy.

ObjectiveThe aim of this study is to describe the clinical characteristics and outcome of cancer diagnosed during pregnancy.MethodsThis is a retrospective cohort study of women who were diagnosed with cancer during pregnancy at a tertiary academic hospital between 1995 and 2013. Maternal characteristics, gestational age at diagnosis, and type, stage, symptoms and signs of cancer for each patient were retrieved from the medical records. The cancer treatment, pregnancy management and the subsequent perinatal and maternal outcomes for each cancer were assessed.ResultsA total of 87 women were diagnosed with cancer during pregnancy (172.6 cases per 100,000 deliveries). The most common cancer was breast cancer (n=20), followed by gastrointestinal (n=17), hematologic (n=13), thyroid (n=11), central nervous system (n=7), cervical (n=7), ovarian (n=5), lung (n=3), and other cancers (n=4). Eighteen (20.7%) patients terminated their pregnancies. In the 69 (79.3%) patients who maintained their pregnancies, one patient miscarried and 34 patients delivered preterm. Of the preterm babies, 24 (70.6%) were admitted to the neonatal intensive care unit and 3 (8.8%) of those expired. The maternal mortality rate was 31.0%, with highest rate seen with lung cancers (66.7%), followed by gastrointestinal (50.0%), central nervous system (50.0%), hematologic (30.8%), breast (25.0%), ovarian (20.0%) cervical (14.3%), and thyroid cancers (0%).ConclusionThe clinical characteristics and outcome of cancer during pregnancy were highly variable depending on the type of cancer. However, timely diagnosis and appropriate management of cancer during pregnancy may improve both maternal and neonatal outcome.

An observational study of the impact of an antenatal asthma management service on asthma control during pregnancy

ObjectiveWe sought to investigate the impact of introducing an antenatal asthma management service (AMS) on asthma control during pregnancy and subsequent perinatal outcomes. Study designProspective, observational cohort study of pregnant asthmatic women attending a tertiary hospital antenatal clinic. Asthmatic women were recruited from the antenatal clinic and were followed prospectively with visits at 12, 20, 28 and 36 weeks gestation. A new nurse-led AMS was introduced offering asthma self-management education and support. Outcomes were compared between women recruited before and after the AMS was introduced (n=89 and 80, respectively) and included; prevalence of exacerbations during pregnancy, asthma control throughout pregnancy and perinatal outcomes, including preterm birth and small-for-gestational-age (SGA). ResultsThe relative risk for exacerbations (0.69; CI: 0.33–1.42), loss of control (0.67; CI 0.46–0.99) and persistent uncontrolled asthma (0.48; CI 0.26–0.9) were all reduced with attendance to AMS during pregnancy. AMS was associated with non-statistically significant reductions in asthma exacerbations (19.1–15.0%; p=0.480) and uncontrolled asthma at ≥2 study visits (21.3–11.3%; p=0.078). ConclusionsThese findings demonstrate the potential impact of an AMS in improving asthma control during pregnancy, supporting the need for an adequately powered RCT to determine its clinical- and cost-effectiveness.

Interpregnancy interval and subsequent perinatal outcomes among women delaying initiation of childbearing

While delayed initiation of childbearing is associated with adverse perinatal outcomes, whether or not risk persists and whether interpregnancy interval (IPI) affects the subsequent pregnancy remains unclear. To examine second-pregnancy perinatal outcomes for women initiating childbearing age > or = 30 compared to those initiating childbearing aged 20-29, specifically examining the distribution of adverse perinatal outcomes, and their associations with the interpregnancy interval. Retrospective cohort study using the Missouri maternally linked files 1978-1997. Perinatal outcomes included fetal death, low birthweight, preterm birth and small-for-gestational age. Predictor variables included maternal age at first pregnancy and IPI between the first and second pregnancy. With an increasing maternal age at first pregnancy, rates of very low birthweight (P = 0.0095), preterm delivery (P = 0.0126), moderately preterm (P = 0.0458), and extremely preterm (P = 0.0008) in the second pregnancy increased, while the rate of small-for-gestational age (P < 0.0001) declined. Interpregnancy intervals <6 and > or = 60 months were associated with a higher rate of adverse outcomes after controlling for maternal age at first pregnancy. Intervals of 12-17 months had the lowest rate of adverse outcomes for mothers 35+. Maternal age > or = 35 years at first pregnancy and IPI <6 months were independent risk factors for an adverse outcome in the second pregnancy, however no statistical interaction between these factors was observed. Delayed initiation of childbearing is associated with a persistent risk of adverse perinatal outcomes in the second pregnancy, with a short IPI contributing to this risk. As numbers of women delaying childbearing beyond age 30 increase, providers should consider these risks in counseling women about their reproductive plans.

The impact of past pregnancy experience on subsequent perinatal outcomes

In perinatal epidemiology, the basic unit of analysis has traditionally been the individual pregnancy. In this study, we sought to explore the idea of a 'reproductive life'-based approach to modelling the effects of reproductive exposures and outcomes, where the basic unit of analysis is a woman's entire reproductive experience. Our objective was to explore whether a first pregnancy risk factor, excess gestational weight gain, has a direct effect on the birthweight outcomes of a subsequent pregnancy, independent of the weight gain and other risk factors of the second pregnancy. A study population was created by linking the obstetric records of 1220 women who delivered their first and second offspring at a McGill University teaching hospital in Montreal, Canada. Multivariable linear and logistic regression analyses were used to model the effects of gestational weight gain above recommendation on the birthweight Z-score and risk of large-for-gestational age (LGA) subsequent offspring. After adjusting for the risk factors of the second pregnancy, an independent effect from the first pregnancy was seen on the birthweight Z-score, (effect size OR 0.17 [95% CI 0.05, 0.28] but not risk of LGA of the second pregnancy 1.30 [95% CI 0.89, 1.89]). We concluded that a pregnancy-centred approach to research that conceptualizes pregnancies as self-contained and interchangeable events may not always be appropriate, and propose that analytical methods for some perinatal research questions may need to consider a given pregnancy in the context of a woman's past reproductive experiences.

LOW BIRTH WEIGHT IN RURAL GUATEMALA: INDOOR AIR POLLUTION AS A CONTRIBUTING FACTOR

ISEE-257 Introduction: Low birth weight (LBW, < 2500 grams) is used to delimit populations at risk for adverse health outcomes in infancy. Recent studies have found associations between LBW and common airborne pollutants, including ETS and biofuel smoke. In Guatemala, low birth weight is estimated at 13%. Aim: We examined indoor air pollution (IAP) as a risk factor for LBW among pregnant women participating in the Randomized Stove Intervention Trial, conducted in the western Guatemalan highlands between October 2002 and December 2004. Methods: 535 households of indigenous Mayans participated in the study, which examined the impact of IAP on acute lower respiratory infection incidence among children <18 months. Pregnant women, or households with children younger than 4 months, were randomly assigned to either receive a vented stove called a “plancha”, or continue cooking over their open fire until the end of the study (at which time they received a plancha). 283 singleton births were monitored by project staff. All women delivered in their homes, and fieldworkers attempted to visit the home as soon as possible to measure birth weight. Results: 191 (67.5%) newborns were measured within 48 hours of delivery and 45 (23.5%) weighed less than 2,500 grams. Newborn weight measurements (mean ± SD) were: 2.78 ± 0.42 kilograms (n=99) among intervention (“plancha ”) households and 2.73 ± 0.38 kilograms (n=92) among control (open fire) households, 48 grams (95% CI: -163, 66 grams) higher among plancha households. This difference was not statistically significant: p-value = 0.41 (pooled variances, t = -0.83, α=.95, 2-tailed, d.f.=189). Of the 225 infants measured within 7 days of delivery, 50 (22.2%) weighed less than 2,500 grams. Among this group, infant weights (mean ± SD) were: 2.83 ± 0.45 kilograms (n=120) among intervention, and 2.76 ± 0.43 kilograms (n=105) among control households, representing an insignificant difference between the two groups: p-value = 0.23 (pooled variances, t = -1.20, α=.95, 2-tailed, d.f.=223). The mean ± SD days between birth and initial measurement were the same for both intervention and control groups. Results indicated significant differences in kitchen IAP levels to particulate matter (PM1,plancha: 92 μg/m3; open fire: 1440 μg/m3), although all pregnant women in the study averaged only 59 days (range:1-165 days) with the plancha stove prior to delivery, thus limiting differential exposure mostly to the third trimester. Discussion: The Guatemalan Stove Intervention Trial offered a unique opportunity to monitor the health of pregnant women and subsequent perinatal outcomes residing in one of the poorest regions in Guatemala. Plancha stoves were able to reduce kitchen air pollution by 94%. LBW was a secondary measure of the study and methodological limitations include lack of information about gestational age, and inability to arrive at all home births within 48 hours, which may bias the findings toward the null. Despite these limitations, current results demonstrate a weak, but consistent, relationship between IAP and increased LBW, among this very vulnerable population.