Primary postpartum haemorrhage adversely impacts breastfeeding initiation in Victoria, Australia.

PROBLEM: Breastfeeding has many important benefits for both mother and baby but sustained breastfeeding is sub-optimal. BACKGROUND: Identifying women who need increased support to establish breastfeeding has the potential to improve this. Analysis of the relationship between primary postpartum haemorrhage (PPH) and primary severe PPH and breastfeeding may prove informative as PPH has potentially negative impacts on breastfeeding. AIM: To determine the relationship between PPH and severe PPH and breastfeeding at postnatal discharge and formula use for breastfed babies in hospital. METHODS: Population-based retrospective cohort study using the Victorian Perinatal Data Collection for all liveborn singleton births at ≥ 37 weeks' gestation (n = 339,854) for 2009-13 in Victoria. Estimated blood loss was categorised as PPH ≥ 500 mL and severe PPH ≥ 1500 mL. Descriptive analysis was conducted and multivariable logistic regression was used to determine the adjusted odds ratio for the relationship between PPH/severe PPH and breastfeeding outcomes after adjustment for relevant confounders. FINDINGS: Overall, 94.9% of women initiated breastfeeding. Babies whose mother had a PPH or severe PPH were less likely than others to be exclusively breastfeeding at discharge (aOR 0.88; (95% CI 0.86, 0.90) and aOR 0.57; (95% CI 0.53, 0.61) respectively). Formula - given to 25.9% of all breastfed babies - was more likely for those whose mothers had a PPH or severe PPH (aOR 1.15; (95% CI 1.12, 1.17) and aOR 2.15; (95% CI 2.01, 2.29) respectively. CONCLUSIONS: Women have greater challenges establishing exclusive breastfeeding following PPH and severe PPH. Improving support in hospital for women following PPH may increase breastfeeding success.

Risk factors for severe postpartum haemorrhage: A population-based retrospective cohort study.

BACKGROUND: Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. AIM: To identify risk factors for severe PPH. MATERIALS AND METHODS: Population-based retrospective cohort study of all women who gave birth in Victoria in 2009-2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500 mL). RESULTS: Severe PPH occurred in 1.4% of all births (n = 5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in-labour caesarean section, birth at a gestation other than 37-41 weeks, duration of labour 12 to <24 h, and use of oxytocin infusions in labour. Planned pre-labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n = 104) of women with none of the identified risk factors. CONCLUSIONS: Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity.

Incidence, trends and severity of primary postpartum haemorrhage in Australia: A population-based study using Victorian Perinatal Data Collection data for 764 244 births.

BACKGROUND: Increasing incidence and severity of postpartum haemorrhage, together with postpartum haemorrhage-associated morbidities, have been reported in many high-resource countries. In-depth analysis of such factors in Victorian births since 2002 was lacking. AIMS: Our aim was to determine the incidence and trends for primary postpartum haemorrhage (World Health Organization and International Classification of Diseases 10th revision, Australian Modification definitions) for all confinements in Victoria, Australia, for the years 2003-2013 and the incidence and trends for severe postpartum haemorrhage (≥1500 mL) for 2009-2013. MATERIALS AND METHODS: In this population-based cross-sectional study de-identified data from the Victorian Perinatal Data Collection were analysed for confinements (excluding terminations) from 2003 to 2013 (n = 764 244). Perinatal information for all births ≥20 weeks (or of at least 400 g birthweight if gestation was unknown) were prospectively collected. RESULTS: One in five women (21.8%) who gave birth between 2009 and 2013 experienced a primary postpartum haemorrhage and one in 71 women (1.4%) experienced a severe primary postpartum haemorrhage. The increasing trends in incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage, blood transfusion, admission to an intensive care or high dependency unit and peripartum hysterectomy were significant (P < 0.001). Women who had an unassisted vaginal birth had the lowest incidence of primary postpartum haemorrhage. The highest incidence was experienced by women who had an unplanned caesarean section birth. Women who had a forceps birth had the highest incidence of severe primary postpartum haemorrhage. CONCLUSIONS: The incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage and associated maternal morbidities have increased significantly over time in Victoria.

Women's views and experiences of publicly-funded homebirth programs in Victoria, Australia: A cross-sectional survey.

BACKGROUND: It is critical women's voices are heard if there is to be more widespread implementation of midwifery-led continuity models. Publicly-funded homebirth is one such model, yet there has been limited systematic evaluation from the women's perspective. AIM: Examine women's experiences of and views about the two publicly-funded homebirth programs in Victoria, Australia. METHODS: A cross-sectional design was used. All eligible women enrolled in the two pilot homebirth programs in metropolitan Melbourne whose infants were eight weeks of age or more during the evaluation period were invited to participate in a postal survey. A structured questionnaire was used, with some open-ended questions to enable extra comments. We explored women's reasons for choosing homebirth; views of care; experience of labour and birth; views on transfer; and overall experience of the homebirth program. Data were analysed using descriptive statistics. Simple thematic analysis was used for open-ended questions. FINDINGS: The survey response rate was 71% (96/136). A high percentage of women rated their care as 'Very good': pregnancy 81%; labour and birth 90%; and the early postpartum period 83%. Women reported low levels of anxiety during labour and birth, were able to express their feelings, felt in control, and coped physically and emotionally better than they had expected. They felt well supported by midwives and overall reported very positive experiences of the homebirth programs. CONCLUSIONS: These two publicly-funded homebirth pilot programs demonstrated very positive care ratings by women. These findings, along with the clinical outcomes (reported separately), support the continuation and expansion of the program.

Estimating Direct Cost of Cystic Fibrosis Care Using Irish Registry Healthcare Resource Utilisation Data, 2008-2012.

BACKGROUND: Understanding the determinants of cost of cystic fibrosis (CF) care and health outcomes may be useful for financial planning for the delivery of CF services. Registries contain information otherwise unavailable to healthcare activity/cost monitoring systems. We estimated the direct medical cost of CF care using registry data and examined how cost was affected by patient characteristics and CF gene (CF Transmembrane Conductance Regulator [CFTR]) mutation. METHODS: Healthcare resource utilisation data (2008-2012) were obtained for CF patients enrolled with the Irish CF Registry by 2013 from linked registry and national hospitalisation database records. Mean annual hospitalisation and medication per-patient costs were estimated by demographic profile, CFTR mutation, clinical status, and CF co-morbidity, and were presented in 2014 euro values. A mixed-effects regression model was used to examine the effect of demographic, CFTR mutation, and clinical outcomes on the log10 cost of direct medical CF care. RESULTS: Using 4261 observations from 1100 patients, we found that the median annual total cost per patient increased over the period 2008-2012 from €12,659 to €16,852, inpatient bed-day cost increased from €14,026 to €17,332, and medication cost increased from €5863 to €12,467. Homozygous F508-CFTR mutation (class II) cost was highest and milder mutation (class IV/V) cost was 49% lower. Baseline estimated cost in 2008 for a hypothetical underweight, homozygous F508del-CFTR 6-year-old female without chronic Pseudomonas aeruginosa/Staphylococcus aureus, CF-related diabetes (CFRD) or methicillin-resistant S. aureus (MRSA), and with a poor percent predicted forced expiratory volume in 1 s (ppFEV1) was €10,113, and was €21,082 in a 25-year-old with the same hypothetical profile. Chronic P. aeruginosa infection increased baseline cost by 39%, CF co-morbidity diabetes by 18%, and frequency of pulmonary exacerbation by 15%. Underweight, declining ppFEV1, chronic S. aureus colonisation, and time also influenced cost. CONCLUSIONS: CFTR mutation is an important factor influencing the cost of CF care. Costs differ among cohorts of CF patients eligible to access new and emerging CFTR repair therapies. These findings support the evaluation of outcome-associated cost in CFTR mutation-specific CF patient groups.

Publicly-funded home birth in Victoria, Australia: Exploring the views and experiences of midwives and doctors.

OBJECTIVE: to explore midwives' and doctors' views and experiences of publicly-funded homebirthing models. DESIGN: cross-sectional survey implemented two years after the introduction of publicly-funded homebirthing models. SETTING: two public hospitals in Victoria, Australia. PARTICIPANTS: midwives and doctors (obstetric medical staff). MAIN OUTCOME MEASURES: midwives' and doctors' views regarding reasons women choose home birth; and views and experiences of a publicly-funded home birth program, including intrapartum transfers. FINDINGS: of the 44% (74/167) of midwives who responded to the survey, the majority (86%) supported the introduction of a publicly-funded home birth model, and most considered that there was consumer demand for the model (83%). Most thought the model was safe for women (77%) and infants (78%). These views were stronger amongst midwives who had experience working in the program (compared with those who had not). Of the 25% (12/48) of doctors who responded, views were mixed; just under half-supported the introduction of a publicly-funded home birth model, and one was unsure. Doctors also had mixed views about the safety of the model. One third agreed it was safe for women, one third were neutral and one third disagreed. Half did not believe the home birth model was safe for infants. The majority of midwives (93%) and doctors (75%) believed that intrapartum transfers from home to hospital were easier when the homebirthing midwife was a member of the hospital staff (as is the case with these models). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: responding midwives were supportive of the introduction of publicly-funded home birth, whereas doctors had divergent views and some were concerned about safety. To ensure the success of such programs it is critical that all key stakeholders are engaged at the development and implementation stages as well as in the ongoing governance.

Human cord blood stem cells enhance neonatal right ventricular function in an ovine model of right ventricular training.

BACKGROUND: Nonischemic right ventricular dysfunction and cardiac failure is a source of considerable morbidity in children with congenital heart disease. Cell transplantation has not previously been studied in the pediatric setting in which enhancing ventricular function in response to supraphysiologic workloads might be beneficial. METHODS: Engraftment and differentiation of human cord blood stem cells were studied in an immunosuppressed neonatal ovine model of right ventricular training. Week-old sheep underwent pulmonary artery banding and epicardial injection of cord blood stem cells (n=8) or pulmonary artery banding and placebo injection (n=8). Control groups received cord blood stem cells (n=6) or placebo (n=6) injection without pulmonary artery banding. Right ventricular function was measured at baseline and 1 month later using conductance catheter. RESULTS: Cord blood stem cells were detected in the myocardium, spleen, kidney, and bone marrow up to 6 weeks after transplantation and expressed the hematopoietic markers CD45 and CD23. We identified neither differentiation nor fusion of transplanted human cells. In the groups undergoing pulmonary artery banding, cord blood stem cell transplantation was accompanied by functional benefits compared with placebo injection: end-systolic elastance increased by a mean of 1.4 +/- 0.2 mm Hg/mL compared with 0.9 +/- 0.1 mm Hg/mL, and the slope of preload recruitable stroke work increased by 21.1 +/- 2.9 mm Hg compared with 15.8 +/- 2.5 mm Hg. Cord blood stem cell transplantation had no significant effect on right ventricular function in the absence of pulmonary artery banding. CONCLUSIONS: Our data demonstrate that in the presence of increased workload, cord blood stem cells engraft and augment right ventricular function. Transplanted cells adopt hematopoietic fates in the myocardium, bone marrow, and spleen.

Molecular markers of preterm labor in the choriodecidua.

Because relevant biochemical changes are known to begin at the choriodecidual interface some weeks before actual clinical onset of labor, we hypothesized that the preterm choriodecidua may display gene and protein expression patterns specific to preterm labor. Transcriptomic (microarray) and proteomic (2-dimensional gel electrophoresis [2DGE]) profiling methodologies were used to compare changes in choriodecidual tissue collected from women who delivered before 35 weeks of gestation following spontaneous preterm labor (n = 12) and gestation-matched nonlaboring controls (n = 7). Additionally, 2DGE was used to compare differences in protein expression during term and preterm labor and to construct a choriodecidual proteome map. Overall, expressed transcripts and proteins indicated active tissue remodeling independent of labor status and an association with inflammatory processes during labor. Spontaneous, infection-induced and abruption-associated preterm deliveries were each defined by distinct transcriptional profiles. Proteins osteoglycin and progesterone receptor component 2 (PGRMC2) were upregulated during term and preterm labor while galectin 1, annexin 3, annexin 5, and protein disulfide isomerase (PDI) were upregulated only during preterm labor, suggesting a probable association with the underlying pathology. Together, these results represent novel data that warrant further investigations to elucidate plausible causal relationships of these molecules with spontaneous preterm delivery.

Congenital cystic adenomatoid malformation: monitoring the antenatal and short-term neonatal outcome.

OBJECTIVE: To determine the antenatal and short-term neonatal outcome of antenatally detected congenital cystic adenomatoid malformation (CCAM). METHODS: A retrospective review was conducted on all women with an antenatal diagnosis of CCAM who attended the Royal Women's Hospital, Melbourne, between January 1995 and December 2005. RESULTS: An antenatal diagnosis of CCAM was made in 38 singleton pregnancies. Serial ultrasounds were performed in 34 cases. Thirteen lesions (38%) appeared to resolve, ten lesions (29%) appeared to decrease, four lesions (12%) appeared to remain unchanged and seven lesions (21%) appeared to increase in size. Four pregnancies (10.5%) were complicated by hydrops fetalis which was associated with a poor outcome. Thirty-seven babies were liveborn. Seven babies (18.9%) developed respiratory distress. Two of these babies died within two days of birth resulting in three deaths in total. Two babies were lost to follow up (n=33). Sixty per cent of babies in whom the CCAM appeared to resolve on antenatal ultrasound had an abnormal chest X-ray (CXR). All computed tomography (CT) scans (eight of eight) in this group were abnormal. Of the surviving babies, 27.3% (nine of 33) have had surgery to date. CONCLUSIONS: The antenatal diagnosis of CCAM is associated with a good short-term prognosis. The pregnancy should initially be managed at a tertiary centre with serial ultrasound. Asymptomatic babies should have a postnatal CT even if the CCAM appears to have resolved or decreased on antenatal ultrasound.

A new way of looking at Caesarean section births.

AIMS: To implement the Robson Ten Group Classification System (TGCS) at the Royal Women's Hospital (RWH), Melbourne, in order to determine the main contributors to the rising Caesarean section (CS) rate. METHODS: The TGCS divides women into ten groups according to parity, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labour/delivery. The TGCS was applied retrospectively to the population of women who had a registered birth at the RWH between January 2005 and 31 December 2005. RESULTS: A total of 5833 women gave birth to 6011 babies during the study period. A total of 1651 women (28.3%) had a CS birth. The total CS rates ranged from 3.7% (group 3) to 100% (group 9). Women in groups 1 and 2 were the greatest contributors to the emergency CS rate, 4.2% and 4.9%, respectively. Women in group 5 were the single greatest contributor to both the elective CS rate and the total CS rate. CONCLUSIONS: The TGCS was successfully implemented at the RWH in 2005. The TGCS is ongoing, enabling monitoring of CS rates. The Robson TGCS demonstrates the need to focus on the care of women in groups 1, 2 and 5 in particular, if CS rates are to be reduced.

Women's and health professionals' preferences for prenatal testing for Down syndrome in Australia.

AIM: To describe and compare women's and health professionals' preferences for prenatal screening tests for Down syndrome. DESIGN: Cross-sectional questionnaire survey. PARTICIPANTS AND SETTING: Women (n = 322) attending for a glucose challenge test at 26 weeks gestation and health professionals (266 midwives and 34 obstetricians) at the Royal Women's Hospital, Melbourne, between 13 December 2002 and 30 April 2003. OUTCOME MEASURES: The relative value participants attach to attributes of Down syndrome screening tests as determined by conjoint analysis and ranking scales. RESULTS: Women and health professionals shared similar relative values regarding the importance of detection rate of screening tests, according to coefficients from conjoint analysis models. However, health professionals placed higher relative values on timing of prenatal tests and risk associated with the subsequent diagnostic test than did women. Comparison of coefficients suggests that, compared with health professionals, women would wait longer and accept a greater decrease in detection rate for a test if it was safer. Using the more traditional ranking scale, the safest test was ranked first by 56% of women while 47% of health professionals ranked a test with the highest detection rate first. Equal proportions ( approximately 10%) in both groups ranked the earliest test first. CONCLUSION: There is a general agreement between pregnant women and health professionals regarding the relative importance they attach to different attributes of a test. However, health professionals appeared to favour earlier timing of tests while women placed greater emphasis on safety. Utilising two different measures of preference demonstrated the complexity of decision-making.

A comparison of Australian and UK obstetricians' and midwives' preferences for screening tests for Down syndrome.

OBJECTIVE: To establish and compare obstetricians' and midwives' preferences for hypothetical prenatal screening tests for Down syndrome. METHODS: A cross-sectional questionnaire survey was completed by 296 obstetricians and midwives at two teaching hospitals: one in Melbourne, Australia (n = 175), and one in London, UK (n = 94). Conjoint analysis was undertaken using random effects probit regression. RESULTS: No significant differences were seen in any measurements when comparing obstetricians in Australia and the UK or midwives in Australia and the UK. Obstetricians and midwives shared similar relative values regarding the importance of the detection rate of the screening tests. However, obstetricians placed higher relative values on both timing of prenatal tests and risk associated with the subsequent diagnostic test than did midwives when considering optimal tests to offer women. Marginal rates of substitution suggest that, compared with midwives, obstetricians would wait longer and accept a greater decrease in detection rate for a test if it was safer. Younger midwives placed higher value on both detection rate and safety of prenatal tests than older midwives. Female obstetricians placed higher value on the timing of a test than male obstetricians. CONCLUSION: Obstetricians in Australia and UK placed almost identical importance on test attributes, as did the midwives in the two countries. However, different attitudes towards tests were seen between obstetricians and midwives.

An emerging role for comprehensive proteome analysis in human pregnancy research.

Elucidation of underlying cellular and molecular mechanisms is pivotal to the comprehension of biological systems. The successful progression of processes such as pregnancy and parturition depends on the complex interactions between numerous biological molecules especially within the uterine microenvironment. The tissue- and stage-specific expression of these bio-molecules is intricately linked to and modulated by several endogenous and exogenous factors. Malfunctions may manifest as pregnancy disorders such as preterm labour, pre-eclampsia and fetal growth restriction that are major contributors to maternal and perinatal morbidity and mortality. Despite the immense amount of information available, our understanding of several aspects of these physiological processes remains incomplete. This translates into significant difficulties in the timely diagnosis and effective treatment of pregnancy-related complications. However, the emergence of powerful mass spectrometry-based proteomic techniques capable of identifying and characterizing multiple proteins simultaneously has added a new dimension to the field of biomedical research. Application of these high throughput methodologies with more conventional techniques in pregnancy-related research has begun to provide a novel perspective on the biochemical blueprint of pregnancy and its related disorders. Further, by enabling the identification of proteins specific to a disease process, proteomics is likely to contribute, not only to the comprehension of the underlying pathophysiologies, but also to the clinical diagnosis of multifactorial pregnancy disorders. Although the application of this technology to pregnancy research is in its infancy, characterization of the cellular proteome, unearthing of functional networks and the identification of disease biomarkers can be expected to significantly improve maternal healthcare in the future.

Applications of proteomic methodologies to human pregnancy research: a growing gestation approaching delivery?

Maternal and perinatal morbidity and mortality rates are significantly higher in pregnancies complicated by preterm labor, pre-eclampsia and fetal growth restriction. Decades of research have not translated into a clear understanding of the underlying pathophysiologies or effective identification of women who are at high risk of developing these complications. Often the severity of these diseases does not correlate with the clinical symptoms, and current diagnostic methods are unable to accurately predict the conditions prior to clinical presentation. Though several potential markers have been proposed for each of these disorders, to date none have proven clinical utility. Emerging proteomic technology is only beginning to be employed in pregnancy research. A comprehensive analysis of gestational tissues can be expected to contribute to the elucidation of the complex molecular mechanisms of pregnancy and related complications. Comparison of the expression profiles of normal and pathogenic tissues and biofluids may also highlight novel candidate marker proteins that have so far remained undetected. More interestingly, rapidly evolving technologies using sophisticated bioinformatic tools are demonstrating their potential in disease diagnostics by using overall protein profiles to detect diseases. The clinical significance of these methodological advances is enormous. Early diagnosis together with improved understanding of underlying molecular mechanisms can enhance outcomes and increase effective management and therapeutic options.