[Peculiarities of treatment of ulcerative gastrointestinal hemorrhage in pregnant women].

The occurrence rate of gastrointestinal hemorrhage (GIH) of nonvaricosal genesis in pregnant women was analyzed. The risk of complications occurrence in the pregnancy course while performing local endoscopic hemostasis and prophylaxis of the hemorrhage recurrence occurrence was established. Application of elaborated treatment method for GIH of nonvaricosic genesis in pregnant women have promoted reduction of the severe complications rate in the pregnancy course, applying elimination of the vasoconstrictor and uterotonic effects of adrenalin, reduction of esophagogastroduodenoscopy duration. While application of this procedure in pregnant women of a main group operative cessation of GIH was not applied. In a comparison group a hemostasis, using operative way, was done in 2 (13.3%) women patients with subsequent occurrence of preeclampsy, what resulted in antenathal fetal death.

Geographic variation of reproductive health indicators and outcomes in the United States: place matters.

The social determinants of health are the circumstances in which people are born, grow up, live, work, and age and the systems put in place to deal with illness. These circumstances, in turn, are shaped by a wider set of forces: economics, social policies, and politics. Reproductive health indicators and conditions that are germane to obstetricians and gynecologists vary across states and regions in the United States as well as within regions and states. The aim of this article is to illustrate this variation with the use of examples of gynecologic malignancies, sexually transmitted infections, teen birth rates, preterm birth rates, and infant mortality rates. Using the example of infant death, the difficulties in "unpacking" the construct of place will be discussed, and a special emphasis is placed on the interaction of race, place, and disparities in shaping perinatal outcomes. Finally, readily available and easy-to-use online data resources will be provided so that obstetricians and gynecologists will be able to assess geographic variation in health indicators and outcomes in their own localities.

Maternal body mass index and the risk of fetal death, stillbirth, and infant death: a systematic review and meta-analysis.

IMPORTANCE: Evidence suggests that maternal obesity increases the risk of fetal death, stillbirth, and infant death; however, the optimal body mass index (BMI) for prevention is not known. OBJECTIVE: To conduct a systematic review and meta-analysis of cohort studies of maternal BMI and risk of fetal death, stillbirth, and infant death. DATA SOURCES: The PubMed and Embase databases were searched from inception to January 23, 2014. STUDY SELECTION: Cohort studies reporting adjusted relative risk (RR) estimates for fetal death, stillbirth, or infant death by at least 3 categories of maternal BMI were included. DATA EXTRACTION: Data were extracted by 1 reviewer and checked by the remaining reviewers for accuracy. Summary RRs were estimated using a random-effects model. MAIN OUTCOMES AND MEASURES: Fetal death, stillbirth, and neonatal, perinatal, and infant death. RESULTS: Thirty eight studies (44 publications) with more than 10,147 fetal deaths, more than 16,274 stillbirths, more than 4311 perinatal deaths, 11,294 neonatal deaths, and 4983 infant deaths were included. The summary RR per 5-unit increase in maternal BMI for fetal death was 1.21 (95% CI, 1.09-1.35; I2 = 77.6%; n = 7 studies); for stillbirth, 1.24 (95% CI, 1.18-1.30; I2 = 80%; n = 18 studies); for perinatal death, 1.16 (95% CI, 1.00-1.35; I2 = 93.7%; n = 11 studies); for neonatal death, 1.15 (95% CI, 1.07-1.23; I2 = 78.5%; n = 12 studies); and for infant death, 1.18 (95% CI, 1.09-1.28; I2 = 79%; n = 4 studies). The test for nonlinearity was significant in all analyses but was most pronounced for fetal death. For women with a BMI of 20 (reference standard for all outcomes), 25, and 30, absolute risks per 10,000 pregnancies for fetal death were 76, 82 (95% CI, 76-88), and 102 (95% CI, 93-112); for stillbirth, 40, 48 (95% CI, 46-51), and 59 (95% CI, 55-63); for perinatal death, 66, 73 (95% CI, 67-81), and 86 (95% CI, 76-98); for neonatal death, 20, 21 (95% CI, 19-23), and 24 (95% CI, 22-27); and for infant death, 33, 37 (95% CI, 34-39), and 43 (95% CI, 40-47), respectively. CONCLUSIONS AND RELEVANCE: Even modest increases in maternal BMI were associated with increased risk of fetal death, stillbirth, and neonatal, perinatal, and infant death. Weight management guidelines for women who plan pregnancies should take these findings into consideration to reduce the burden of fetal death, stillbirth, and infant death.

Risk of late-preterm stillbirth and neonatal morbidity for monochorionic and dichorionic twins.

OBJECTIVE: The purpose of this study was to determine the prospective risk of intrauterine fetal death (IUFD) at ≥34 weeks' gestation for monochorionic and dichorionic twins receiving intensive antenatal fetal surveillance. The secondary objective was to calculate the incidence of prematurity-related neonatal morbidity/mortality rates that have been stratified by gestational week and chorionicity. STUDY DESIGN: A retrospective cohort study of all twins at ≥34 weeks' gestation who were delivered at the Medical University of South Carolina (1987-2010) was performed. Twins were cared for in a longstanding Twin Clinic with standardized treatment and surveillance protocols and supervised by a consistent Maternal-Fetal Medicine specialist. Gestational age-specific fetal/neonatal mortality rates and composite neonatal morbidity rates were compared by chorionicity. A generalized linear mixed model was used to identify variables that were associated with increased composite neonatal morbidity. RESULTS: Among 768 twin gestations (601 dichorionic and 167 monochorionic), only 1 dichorionic IUFD occurred. The prospective risk of IUFD at ≥34 weeks' gestation was 0.17% for dichorionic twins and 0% for monochorionic twins. Composite neonatal morbidity decreased with each gestational week (P < .0001). Morbidity was increased by white race, gestational diabetes mellitus, and elective indication for delivery. The nadir of composite neonatal morbidity occurred at 36/0-36/6 weeks' gestation for monochorionic twins and 37/0-37/6 weeks' gestation for dichorionic twins. CONCLUSION: Our data do not support concern for an increased risk of stillbirth in uncomplicated intensively monitored monochorionic twins at ≥34 weeks' gestation. However, our data do show significantly increased rates of neonatal morbidity in late preterm monochorionic twins that cannot be justified by a corresponding reduction in the risk of stillbirth. We believe that our data support delivery of uncomplicated monochorionic twins at 37 weeks' gestation.

Routine ultrasound examination at 41 weeks of gestation and risk of post-term severe adverse fetal outcome: a retrospective evaluation of two units, within the same hospital, with different guidelines.

OBJECTIVE: To study whether a routine with a routine ultrasound examination (routine scan) at 41 gestational weeks as compared with ultrasound on clinical indication (indicated scan), lowered the risk of severe adverse fetal outcome in post-term period. DESIGN: A retrospective cohort study. SETTING: Karolinska University Hospital, Stockholm, Sweden. POPULATION: Eight years of deliveries, 2002-2009. METHOD: One of the two delivery units at Karolinska University Hospital used a routine scan at 41 week of gestation and the other unit used an indicated scan. Severe adverse fetal outcome were defined: severe asphyxia, death or cerebral damage. The study was analysed using logistic regression with adjustment for potential confounders. MAIN OUTCOME MEASURES: Differences in post-term severe adverse fetal outcome. RESULTS: No increased risk of post-term severe adverse fetal outcome was seen at the unit using a routine scan; conversely, a 48% significantly increased risk was seen at the unit using an indicated scan (OR 0.89, 95% confidence interval, CI, 0.5-1.5 and OR 1.48, 95% CI 1.06-2.1, respectively). Comparing post-term periods, there was no significantly increased risk at the unit using indicated scans (OR 1.6, 95% CI 0.9-3.0). There was a 60% increased prevalence of small-for-gestational age (SGA) newborns in the post-term period at the unit using indicated scans (OR 1.6, 95% CI 1.1-2.4), but no differences in operative delivery. CONCLUSION: A policy to use routine scans at 41 weeks of gestation seems to normalise an increased post-term risk of severe adverse fetal outcome, possible due to increased awareness of SGA and/or oligohydramniosis.

Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study.

BACKGROUND: Expertise and resources may be important determinants of outcome for extremely preterm babies. We evaluated the effect of place of birth and perinatal transfer on survival and neonatal morbidity within a prospective cohort of births between 22 and 26 weeks of gestation in England during 2006. METHODS: We studied the whole population of 2460 births where the fetus was alive at the admission of the mother to hospital for delivery. Outcomes to discharge were compared between level 3 (most intensive) and level 2 maternity services, with and without transfers, and by activity level of level 3 neonatal unit; ORs were adjusted for gestation at birth and birthweight for gestation (adjusted ORs (aOR)). FINDINGS: Of this national birth cohort, 56% were born in maternity services with level 3 and 34% with level 2 neonatal units; 10% were born in a setting without ongoing intensive care facilities (level 1). When compared with level 2 settings, risk of death in level 3 services was reduced (aOR 0.73 (95% CI 0.59 to 0.90)), but the proportion surviving without neonatal morbidity was similar (aOR 1.27 (0.93 to 1.74)). Analysis by intended hospital of birth confirmed reduced mortality in level 3 services. Following antenatal transfer into a level 3 setting, there were fewer intrapartum or labour ward deaths, and overall mortality was higher for those remaining in level 2 services (aOR 1.44 (1.09 to 1.90)). Among level 3 services, those with higher activity had fewer deaths overall (aOR 0.68 (0.52 to 0.89)). INTERPRETATION: Despite national policy, only 56% of births between 22 and 26 weeks of gestation occurred in maternity services with a level 3 neonatal facility. Survival was significantly enhanced following birth in level 3 services, particularly those with high activity; this was not at the cost of increased neonatal morbidity.

Risk of invasive Haemophilus influenzae infection during pregnancy and association with adverse fetal outcomes.

IMPORTANCE: Unencapsulated Haemophilus influenzae frequently causes noninvasive upper respiratory tract infections in children but can also cause invasive disease, especially in older adults. A number of studies have reported an increased incidence in neonates and suggested that pregnant women may have an increased susceptibility to invasive unencapsulated H. influenzae disease. OBJECTIVE: To describe the epidemiology, clinical characteristics, and outcomes of invasive H. influenzae disease in women of reproductive age during a 4-year period. DESIGN, SETTING, AND PARTICIPANTS: Public Health England conducts enhanced national surveillance of invasive H. influenzae disease in England and Wales. Clinical questionnaires were sent prospectively to general practitioners caring for all women aged 15 to 44 years with laboratory-confirmed invasive H. influenzae disease during 2009-2012, encompassing 45,215,800 woman-years of follow-up. The final outcome was assessed in June 2013. EXPOSURES: Invasive H. influenzae disease confirmed by positive culture from a normally sterile site. MAIN OUTCOMES AND MEASURES: The primary outcome was H. influenzae infection and the secondary outcomes were pregnancy-related outcomes. RESULTS: In total, 171 women had laboratory-confirmed invasive H. influenzae infection, which included 144 (84.2%; 95% CI, 77.9%-89.3%) with unencapsulated, 11 (6.4%; 95% CI, 3.3%-11.2%) with serotype b, and 16 (9.4%; 95% CI, 5.4%-14.7%) with other encapsulated serotypes. Questionnaire response rate was 100%. Overall, 75 of 171 women (43.9%; 95% CI, 36.3%-51.6%) were pregnant at the time of infection, most of whom were previously healthy and presented with unencapsulated H. influenzae bacteremia. The incidence rate of invasive unencapsulated H. influenzae disease was 17.2 (95% CI, 12.2-24.1; P < .001) times greater among pregnant women (2.98/100,000 woman-years) compared with nonpregnant women (0.17/100,000 woman-years). Unencapsulated H. influenzae infection during the first 24 weeks of pregnancy was associated with fetal loss (44/47; 93.6% [95% CI, 82.5%-98.7%]) and extremely premature birth (3/47; 6.4% [95% CI, 1.3%-17.5%]). Unencapsulated H. influenzae infection during the second half of pregnancy was associated with premature birth in 8 of 28 cases (28.6%; 95% CI, 13.2%-48.7%) and stillbirth in 2 of 28 cases (7.1%; 95% CI, 0.9%-23.5%). The incidence rate ratio for pregnancy loss was 2.91 (95% CI, 2.13-3.88) for all serotypes of H. influenzae and 2.90 (95% CI, 2.11-3.89) for unencapsulated H. influenzae compared with the background rate for pregnant women. CONCLUSIONS AND RELEVANCE: Among women in England and Wales, pregnancy was associated with a greater risk of invasive H. influenzae infection. These infections were associated with poor pregnancy outcomes.

Outcome of deliveries among adolescent girls at the Yaoundé central hospital.

BACKGROUND: Adolescent pregnancies are a growing public health problem in Cameroon. We sought to study the outcome of such pregnancies, in order to inform public health action. METHODS: A cross-sectional analysis of 5997 deliveries which compared the outcome of deliveries in adolescent (10-19 years old) pregnant women registered at the Yaoundé Central Hospital between 2008 and 2010 to that of their non-adolescent adult (≥ 20 years old) counterparts. Variables used for comparison included socio-demographic and obstetric characteristics of parturients, referral status, and maternal and fetal outcomes. Predictors of maternal and of perinatal mortality were determined through binomial logistic modeling. RESULTS: Adolescent deliveries represented 9.3% (560) of all pregnancies registered. Adolescent pregnancies had significantly higher rates of both gestational duration extremes: preterm as well as post-term deliveries (29.3% versus 24.5%, p = 0.041 OR 1.28 95% CI 1.01-1.62 and 4.9 versus 2.4%, p = 0.014 OR 2.11 95% CI 1.46-3.87 respectively). Both groups did not differ significantly with respect to mean blood loss, rates of cesarean or instrumental deliveries. Adolescent deliveries however required significantly twice as many episiotomies (OR 2.15 95% CI 1.59-2.90). The likelihood of perineal tears in the adolescent group was significantly higher than that in the adult group on assuming episiotomies done would have been tears if they had not been carried out (OR 1.45 95% CI 1.16-1.82). Adolescent parturients had a higher likelihood of apparent fetal death at birth as well as perinatal fetal death after resuscitation efforts (AOR 1.75 95% CI 1.25-2.47 and AOR 1.69 95% CI 1.17-2.45 respectively).Comparisons of pregnancy outcomes between early (10-14 years), middle (15-17 years) and late adolescence (18-19 years) found no significant differences. Predictors of maternal death included having been referred, having had ≥5 deliveries and preterm deliveries. These were also predictors of perinatal death, as well as being a single mother, primiparous, and multiple gestations. CONCLUSIONS: Adolescent pregnancies in Cameroon compared to those in adults are associated with poorer outcomes. There is need for adolescent-specific services to prevent teenage pregnancies as well as interventions to prevent and manage the above mentioned predictors of in-facility maternal and perinatal mortality.

Obesity and the risk of stillbirth: a population-based cohort study.

OBJECTIVE: Obesity is a known risk factor for stillbirth. However, this relationship has not been characterized fully. We attempted to further examine this relationship with a focus on delivery near and at term. STUDY DESIGN: We designed a retrospective cohort study of singleton nonanomalous live births and stillbirths in the states of Washington and Texas to examine the associations of maternal prepregnancy body mass index (BMI) and risk of stillbirth. Confounder-adjusted hazard ratio of stillbirth in relation to BMI was estimated through Cox proportional hazards regression model. The hazard ratio was used to estimate the population-attributable risk. We also estimated the fetuses who were at risk for stillbirth based on gestational age. RESULTS: Among 2,868,482 singleton births, the overall stillbirth risk was 3.1 per 1000 births (n = 9030). Compared with normal-weight women, the hazard ratio for stillbirth was 1.36 for overweight women, 1.71 for class I obese women, 2.00 for class II obese women, 2.48 for class III obese women, and 3.16 for women with a BMI of ≥50 kg/m(2). The fetuses who are at risk for stillbirth increased after 39 weeks' gestation for each obesity class; however, the risk increased more rapidly with increasing BMI. Women with a BMI of ≥50 kg/m(2) were at 5.7 times greater risk than normal weight women at 39 weeks' gestation and 13.6 times greater at 41 weeks' gestation. Obesity was associated with nearly 25% of stillbirth that occurred between 37 and 42 weeks' gestation. CONCLUSION: There is a pronounced increase in the risk of stillbirth with increasing BMI; the association is strongest at early- and late-term gestation periods. Extreme maternal obesity is a significant risk factor for stillbirth.

Fetal demise and associated factors following umbilical cord prolapse in Mulago hospital, Uganda: a retrospective study.

BACKGROUND: Umbilical cord prolapse is an obstetric complication associated with high perinatal morbidity and mortality. A few interventions may improve fetal outcome. In developed countries these have advanced to giving intrauterine fetal resuscitation. Conditions in low resource settings do not allow for some of these advanced techniques. Putting the mother in knee chest position and immediate delivery may be the only options possible.We set out to determine the incidence of fetal demise and associated factors following umbilical cord prolapsed (UCP) in Mulago Hospital, Uganda. METHODS: In a retrospective study conducted in Mulago hospital, Uganda, file records of mothers who delivered between 1st January 2000 to 31st December 2009 and had pregnancies complicated by umbilical cord prolapse with live fetus were selected. We collected information on referral status, cord position, cervical dilatation, fetal heart state at the time of diagnosis of UCP, diagnosis to delivery interval, use of knee chest position, mode of delivery, birth weight and fetal outcome.We computed incidence of fetal demise following UCP and determined factors associated with fetal demise in pregnancies complicated by UCP. RESULTS: Of 438 cases with prolapsed cord, 101(23%) lost their babies within 24 hours after birth or were delivered dead. This gave annual cumulative incidence of fetal death following UCP of 23/1000 live UCP cases delivered /year.The major factors associated with fetal outcome in pregnancies complicated by UCP included; diagnosis to delivery interval <30 min, RR 0.79 (CI 0.74-0.85), mode of delivery, RR 1.14 (CI 1.02-1.28), knee chest position, RR 0.81 (CI 0.70-0.95). CONCLUSIONS: The annual cumulative incidence of fetal death in our study was 23/1000 live UCP cases delivery per year for the period of 10 years studied. Cesarean section reduced perinatal mortality by a factor of 2. Diagnosis to delivery interval <30 minutes and putting mother in knee chest position were protective against fetal death.

Brief report: Risk of adverse fetal outcomes associated with immunosuppressive medications for chronic immune-mediated diseases in pregnancy.

OBJECTIVE: To assess the risk of adverse fetal outcomes following exposure to individual immunosuppressive drugs in pregnant women with chronic immune-mediated diseases. METHODS: Health plan data were obtained from the Tennessee Medicaid and Kaiser Permanente Northern California and Southern California claims databases, with linkage to both vital records and medical records. Women with inflammatory arthropathies, those with systemic lupus erythematosus, and those with inflammatory bowel disease who filled prescriptions for immunosuppressive treatments during pregnancy were included. Major congenital malformations, fetal deaths, and life-threatening neonatal complications were identified from the electronic data and validated with medical record review. RESULTS: The cohort included 608 infants, including 437 with exposure to immunosuppressive drugs during the mother's pregnancy (402 during the first trimester, and 35 during the second and third trimester only) and 171 whose mothers filled prescriptions for immunosuppressive treatments before, but not during, pregnancy. There were 25 pregnancies (4.1% of the cohort) with confirmed major congenital malformations, and 10 fetal deaths (1.6% of the cohort). Among 113 preterm infants with exposures during pregnancy, 23 (20.4%) had life-threatening neonatal complications, and among 485 term infants, 10 (2.1%) had life-threatening complications. Compared to the reference group (treatment before, but not during, pregnancy), the risk ratios (RRs) for adverse fetal outcomes associated with immunosuppressive treatments (by exposure category) during pregnancy included the following: methotrexate (RR 1.39, 95% confidence interval [95% CI] 0.43-4.53), tumor necrosis factor inhibitors (RR 0.98, 95% CI 0.38-2.55), hydroxychloroquine (RR 1.33, 95% CI 0.69-2.55), and other immunosuppressive medications (RR 0.98, 95% CI 0.48-1.98). CONCLUSION: In this study, there was no evidence of a large increase in risk of adverse fetal outcomes from first-trimester exposure to immunosuppressive medications, although the confidence intervals for the risk ratios were wide. Further studies will be needed as use of these medications increases over time.

Chronic endometritis in women with recurrent early pregnancy loss and/or fetal demise.

OBJECTIVE: To assess the prevalence of chronic endometritis in women with a history of recurrent early pregnancy loss (REPL) and/or fetal demise (FD). DESIGN: Observational cohort study using prospectively collected data. SETTING: Recurrent pregnancy loss program in an academic medical center. PATIENT(S): Three hundred ninety-five women with a history of two or more pregnancy losses of less than 10 weeks' size or a fetal demise of 10 or more weeks' size. INTERVENTION(S): All women had an endometrial biopsy. Chronic endometritis was treated with antibiotics, and a second endometrial biopsy was recommended as a "test of cure." MAIN OUTCOME MEASURE(S): Subsequent live-birth rate (LBR). RESULT(S): The overall prevalence of chronic endometritis was 9% (35/395) in this cohort; 7% (21/285) in the REPL group, 14% (8/57) in the FD group, and 11% (6/53) in the combined REPL/FD group. The cure rate was 100% after a course(s) of antibiotics. The subsequent cumulative LBR was 88% (21/24) for the treated chronic endometritis group versus 74% (180/244) for the group without chronic endometritis. The per-pregnancy LBR for the treated chronic endometritis group was 7% (7/98) before treatment versus 56% (28/50) after treatment. CONCLUSION(S): There was a high prevalence of chronic endometritis in this cohort. The test of cure was 100% with antibiotics. Subsequent LBRs after treatment were encouraging.

Association between stillbirth and illicit drug use and smoking during pregnancy.

OBJECTIVE: To compare illicit drug and smoking use in pregnancies with and without stillbirth. METHODS: The Stillbirth Collaborative Research Network conducted a case-control study from March 2006 to September 2008, covering more than 90% of deliveries to residents of five a priori-defined geographically diverse regions. The study attempted to include all stillbirths and representative liveborn controls. Umbilical cord samples from cases and controls were collected and frozen for subsequent batch analysis. Maternal serum was collected at delivery and batch analyzed for cotinine. RESULTS: For 663 stillbirth deliveries, 418 (63%) had cord homogenate and 579 (87%) had maternal cotinine assays performed. For 1,932 live birth deliveries, 1,050 (54%) had cord homogenate toxicology and 1,545 (80%) had maternal cotinine assays performed. A positive cord homogenate test for any illicit drug was associated with stillbirth (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.16-3.27). The most common individual drug was cannabis (OR 2.34 95% CI 1.13-4.81), although the effect was partially confounded by smoking. Both maternal self-reported smoking history and maternal serum cotinine levels were associated in a dose-response relationship with stillbirth. Positive serum cotinine less than 3 ng/mL and no reported history of smoking (proxy for passive smoke exposure) also were associated with stillbirth (OR 2.06, 95% CI 1.24-3.41). CONCLUSION: Cannabis use, smoking, illicit drug use, and apparent exposure to second-hand smoke, separately or in combination, during pregnancy were associated with an increased risk of stillbirth. Because cannabis use may be increasing with increased legalization, the relevance of these findings may increase as well. LEVEL OF EVIDENCE: II.