Preventing posttraumatic stress disorder following childbirth: a systematic review and meta-analysis.

OBJECTIVE: Women can develop posttraumatic stress disorder in response to experienced or perceived traumatic, often medically complicated, childbirth; the prevalence of these events remains high in the United States. Currently, no recommended treatment exists in routine care to prevent or mitigate maternal childbirth-related posttraumatic stress disorder. We conducted a systematic review and meta-analysis of clinical trials that evaluated any therapy to prevent or treat childbirth-related posttraumatic stress disorder. DATA SOURCES: PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible trials published through September 2023. STUDY ELIGIBILITY CRITERIA: Trials were included if they were interventional, if they evaluated any therapy for childbirth-related posttraumatic stress disorder for the indication of symptoms or before posttraumatic stress disorder onset, and if they were written in English. METHODS: Independent coders extracted the sample characteristics and intervention information of the eligible studies and evaluated the trials using the Downs and Black's quality checklist and Cochrane's method for risk of bias evaluation. Meta-analysis was conducted to evaluate pooled effect sizes of secondary and tertiary prevention trials. RESULTS: A total of 41 studies (32 randomized controlled trials, 9 nonrandomized trials) were reviewed. They evaluated brief psychological therapies including debriefing, trauma-focused therapies (including cognitive behavioral therapy and expressive writing), memory consolidation and reconsolidation blockage, mother-infant-focused therapies, and educational interventions. The trials targeted secondary preventions aimed at buffering childbirth-related posttraumatic stress disorder usually after traumatic childbirth (n=24), tertiary preventions among women with probable childbirth-related posttraumatic stress disorder (n=14), and primary prevention during pregnancy (n=3). A meta-analysis of the combined randomized secondary preventions showed moderate effects in reducing childbirth-related posttraumatic stress disorder symptoms when compared with usual treatment (standardized mean difference, -0.67; 95% confidence interval, -0.92 to -0.42). Single-session therapy within 96 hours of birth was helpful (standardized mean difference, -0.55). Brief, structured, trauma-focused therapies and semi-structured, midwife-led, dialogue-based psychological counseling showed the largest effects (standardized mean difference, -0.95 and -0.91, respectively). Other treatment approaches (eg, the Tetris game, mindfulness, mother-infant-focused treatment) warrant more research. Tertiary preventions produced smaller effects than secondary prevention but are potentially clinically meaningful (standardized mean difference, -0.37; -0.60 to -0.14). Antepartum educational approaches may help, but insufficient empirical evidence exists. CONCLUSION: Brief trauma-focused and non-trauma-focused psychological therapies delivered early in the period following traumatic childbirth offer a critical and feasible opportunity to buffer the symptoms of childbirth-related posttraumatic stress disorder. Future research that integrates diagnostic and biological measures can inform treatment use and the mechanisms at work.

Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment.

Psychological birth trauma and childbirth-related posttraumatic stress disorder represent a substantial burden of disease with 6.6 million mothers and 1.7 million fathers or co-parents affected by childbirth-related posttraumatic stress disorder worldwide each year. There is mounting evidence to indicate that parents who develop childbirth-related posttraumatic stress disorder do so as a direct consequence of a traumatic childbirth experience. High-risk groups, such as those who experience preterm birth, stillbirth, or preeclampsia, have higher prevalence rates. The main risks include antenatal factors (eg, depression in pregnancy, fear of childbirth, poor health or complications in pregnancy, history of trauma or sexual abuse, or mental health problems), perinatal factors (eg, negative subjective birth experience, operative birth, obstetrical complications, and severe maternal morbidity, as well as maternal near misses, lack of support, dissociation), and postpartum factors (eg, depression, postpartum physical complications, and poor coping and stress). The link between birth events and childbirth-related posttraumatic stress disorder provides a valuable opportunity to prevent traumatic childbirths and childbirth-related posttraumatic stress disorder from occurring in the first place. Childbirth-related posttraumatic stress disorder is an extremely distressing mental disorder and has a substantial negative impact on those who give birth, fathers or co-parents, and, potentially, the whole family. Still, a traumatic childbirth experience and childbirth-related posttraumatic stress disorder remain largely unrecognized in maternity services and are not routinely screened for during pregnancy and the postpartum period. In fact, there are gaps in the evidence on how, when, and who to screen. Similarly, there is a lack of evidence on how best to treat those affected. Primary prevention efforts (eg, screening for antenatal risk factors, use of trauma-informed care) are aimed at preventing a traumatic childbirth experience and childbirth-related posttraumatic stress disorder in the first place by eliminating or reducing risk factors for childbirth-related posttraumatic stress disorder. Secondary prevention approaches (eg, trauma-focused psychological therapies, early psychological interventions) aim to identify those who have had a traumatic childbirth experience and to intervene to prevent the development of childbirth-related posttraumatic stress disorder. Tertiary prevention (eg, trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing) seeks to ensure that people with childbirth-related posttraumatic stress disorder are identified and treated to recovery so that childbirth-related posttraumatic stress disorder does not become chronic. Adequate prevention, screening, and intervention could alleviate a considerable amount of suffering in affected families. In light of the available research on the impact of childbirth-related posttraumatic stress disorder on families, it is important to develop and evaluate assessment, prevention, and treatment interventions that target the birthing person, the couple dyad, the parent-infant dyad, and the family as a whole. Further research should focus on the inclusion of couples in different constellations and, more generally, on the inclusion of more diverse populations in diverse settings. The paucity of national and international policy guidance on the prevention, care, and treatment of psychological birth trauma and the lack of formal psychological birth trauma services and training, highlight the need to engage with service managers and policy makers.

Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes.

The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.

Safe delivery, perinatal outcomes and breastfeeding in women with epilepsy.

Safe delivery and optimal peripartum and postpartum care in women with epilepsy (WWE) is a major concern which has received limited attention in recent years. A diagnosis of epilepsy per se is not an indication for a planned cesarean section or induction of labor, even though epidemiological studies indicate that cesarean delivery is more common among WWE compared to the general population. Pregnancy in WWE is associated with an increased risk of obstetrical complications and increased perinatal morbidity and mortality, and these risks may be greater among WWE taking ASMs. Wherever feasible, pregnant WWE should be directed to specialist care. Risk minimization includes, when appropriate, dose adjustment to compensate for pregnancy-related changes in the pharmacokinetics of some ASMs. With respect to postpartum management, WWE should be advised that the benefits of breastfeeding outweigh the small risk of adverse drug reactions in the infant.

Timing of planned cesarean delivery among patients with two previous cesarean sections.

OBJECTIVES: The timing of planned repeat cesarean delivery (CD) is debateful in clinical practice. Planned repeat CD is typically scheduled before the spontaneous onset of labor to minimize the risk of uterine rupture during labor and the associated risk for fetal compromise. This timing should be balanced with the potential risk of delivering an infant who could benefit from additional maturation in utero. We aim to study the influence of gestational age at the time of repeat CD on maternal and fetal complications. STUDY DESIGN: A population-based retrospective cohort study including all term singleton third CDs (≥ 37 weeks of gestation), between February-2020 and January-2022 at a tertiary medical center was conducted. Maternal and neonatal adverse outcomes were compared by gestational age at the time of the CD. A logistic regression models were constructed to adjust for confounders. RESULTS: The study population included624 third CDs. Among them, two study groups were defined: 199 were at 37 + 0 to 37 + 6 weeks of gestation, and 44 were at ≥ 39 weeks of gestation at the time of delivery. 381 were at 38 + 0 to 38 + 6 weeks. Since our routine practice is to schedule elective CD at 38 + 0 to 38 + 6 weeks of gestation, we defined this group as the comparison group. In a multivariate analysis, both study groups were associated with significantly higher rates of emergent CDs after adjusting for maternal age, parity, ethnicity, premature rapture of membranes, spontaneous onset of labor and birthweight. After adjusting also for emergent CDs, CDs at 37 + 0 to 37 + 6 weeks of gestation were significantly associated with maternal and neonatal length of stay exceeding 4 days. Additionally, CDs at 37 + 0 to 37 + 6 weeks of gestation were also associated with composite of adverse neonatal and maternal outcomes. CONCLUSIONS: Our study demonstrated that scheduling third CD at 38 + 0 to 38 + 6 weeks is associated with reduced risk of emergent CD, as well as beneficial maternal and neonatal outcomes.

Factors contributing to preterm birth in patients presenting at tertiary care hospitals in Punjab.

Objective: To determine the various causes and factors leading to preterm birth in women presenting at tertiary care hospitals. METHODS: The cross-sectional, prospective study was conducted from June 19, 2021, to January 19, 2022, at the Central Park Teaching Hospital, Lahore, Pakistan, in collaboration with other tertiary care teaching hospitals in Lahore, and comprised pregnant women aged 15-45 years with preterm birth. Demographic and obstetric data was collected. Depending on the factors contributing to preterm birth, the subjects were categorised as spontaneous labour group A, preterm prelabour rupture of membrane group B, and iatrogenic preterm birth group C. Data was analysed using SPSS 25. RESULTS: Of the 1,300 recorded births, 200(15.38%) were preterm. Group A had 86(43%) women with mean age 28.55±4.68 years, group B had 43(21,5%) women with mean age 27.14±3.25 years, and group C had 71(35.5%) women with mean age 28.28±3.74 years (p>0.05). There was significant difference among the groups with respect to body mass index (p=0.001) and parity (p=0.021). Vaginal and urinary tract infections were significantly higher in group A compared to the other groups (p<0.05). In group C, pre-eclampsia was the main reason for preterm birth 45(63.38%). Conclusion: Medically indicated preterm birth rate was found to be high, and pre-eclampsia was noted as the main cause in iatrogenic preterm birth.

The ADENO study: ADenomyosis and its Effect on Neonatal and Obstetric outcomes: a retrospective population-based study.

BACKGROUND: Adenomyosis is a benign gynecologic condition arising from the uterine junctional zone. Recent studies suggest a relationship between adenomyosis and adverse obstetrical outcomes, but evidence remains conflicting. There is no large-scale study investigating obstetrical outcomes in women with adenomyosis using the gold standard of histopathologic diagnosis. OBJECTIVE: This study aimed to investigate the prevalence of adverse obstetrical and neonatal outcomes in women with histopathologic adenomyosis and that of the general (Dutch) population. STUDY DESIGN: This retrospective population-based study used 2 Dutch national databases (Perined, the perinatal registry, and the nationwide pathology databank [Pathologisch Anatomisch Landelijk Geautomiseerd Archief], from 1995 to 2018) to compare obstetrical outcomes in women before histopathologic adenomyosis diagnosis to the general Dutch population without registered histopathologic adenomyosis. The adjusted odds ratios (95% confidence interval) were calculated for adverse obstetrical outcomes. The outcomes were adjusted for maternal age, parity, ethnicity, year of registered birth, induction of labor, hypertensive disorders in previous pregnancies, multiple gestation, and low socioeconomic status. RESULTS: The pregnancy outcomes of 7925 women with histopathologic adenomyosis were compared with that of 4,615,803 women without registered adenomyosis. When adjusted for confounders, women with adenomyosis had adjusted odds ratios of 1.37 (95% confidence interval, 1.25-1.50) for hypertensive disorders, 1.37 (95% confidence interval, 1.25-1.51) for preeclampsia, 1.15 (95% confidence interval, 1.07-1.25) for small-for-gestational-age infants, 1.54 (95% confidence interval, 1.41-1.68) for emergency cesarean delivery, 1.24 (95% confidence interval, 1.12-1.37) for failure to progress, 1.29 (95% confidence interval, 1.10-1.48) for placental retention, and 1.23 (95% confidence interval, 1.10-1.38) for postpartum hemorrhage. No increased risk of HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, placental abruption, or operative vaginal delivery or need for oxytocin stimulation was found. CONCLUSION: Women with a histopathologic diagnosis of adenomyosis showed an increased prevalence of hypertensive disorders of pregnancy and small-for-gestational-age infants, failure to progress in labor, and placental retention compared with the general population in previous pregnancies. This suggests that uterine (contractile) function in labor and during pregnancy is impaired in women with adenomyosis.

Autoimmune Hepatitis and Obstetrical Outcomes: A Nationwide Assessment.

INTRODUCTION: Previous research identified AIH as linked to unfavorable obstetrical outcomes in a US nationwide retrospective study from 2012-2016. Our aim is to update the literature and strengthen the AIH-pregnancy outcomes relationship. METHODS: Using the National Inpatient Sample database in the US, from 2016 to 2020, we compared pregnant females with a diagnosis of AIH to those with and without other chronic liver diseases (CLD), using ICD-10-CM codes. Baseline characteristics were analyzed using T-test and Chi-Square, and multivariate regression was used to estimate the differences in maternal outcomes adjusted for age, race, insurance status, geographical location, hospital characteristics, and comorbid conditions. RESULTS: Out of 19,392,328 hospitalizations for pregnant females ≥ 18 years old from 2016 to 2020, 1095 had AIH, 179,655 had CLD, and 19,206,696 had no CLD. No mortality was observed among individuals with AIH. When compared to individuals without CLD, AIH was associated with an 82% increase in the odds of preterm delivery (AIH: 8% vs. Without CLD: 5%, adjusted Odds Ratio = 1.82, 95% CI 1.06-3.14), with no significant differences in gestational diabetes mellitus, hypertensive complications, and postpartum hemorrhage, and a 0.6 day longer hospital stay. Furthermore, there were no significant differences in outcomes between AIH and CLD. CONCLUSIONS: Our study reinforces the association of AIH with adverse obstetrical outcomes (e.g., preterm delivery), however, we found that there is no difference in GDM and hypertensive complications, as suggested in prior studies. Therefore, further investigations are needed to clarify the association between AIH and these obstetrical complications.

Outcome after vaginal delivery of women with a previous medical history of surgically corrected anorectal malformations: a systematic review.

OBJECTIVE: Discussion remains on how to advise women with a past medical history of surgically corrected anorectal malformations (ARMs) regarding vaginal delivery. The aim of this review is to evaluate and review the reported obstetrical complications and outcomes after vaginal delivery for these women. DATA SOURCES: A systematic search was performed from inception up to 25 July 2022 in PubMed, Embase.com and Clarivate Analytics/Web of Science Core Collection, with backward citation tracking. STUDY ELIGIBILITY CRITERIA/APPRAISAL: All articles reported on the outcomes of interest in women with a past medical history of surgically corrected anorectal malformation and had a vaginal delivery were included with the exception of editorial comments or invitational commentaries. Screening, data extraction and risk of bias assessment was done by two authors independently with a third and fourth reviewer in case of disagreement. Tool for Quality assessment depended on the type of article. As low quality evidence was expected no meta-analysis was performed. RESULTS: Only five of the 2377 articles screened were eligible for inclusion with a total of 13 attempted vaginal deliveries in eight women. In three patients complications were reported: failed vaginal delivery requiring urgent cesarean section in two patients, and vaginal tearing in one patient. CONCLUSION: High quality evidence regarding outcomes and complications after vaginal delivery in women with a history of surgically corrected anorectal malformation is lacking. Therefore, based upon this systematic review no formal recommendation can be formulated regarding its safety. Future studies are essential to address this problem. TRIAL REGISTRATION: CRD42020201390. Date: 28-07-2020s.

Impact of Assisted Reproduction Techniques on Adverse Maternal Outcomes and on the Rate of Hospitalization in Maternal Intensive Care.

Background and Objective: The aim of this retrospective cohort study is to evaluate the impact of assisted reproductive treatment (ART) on adverse maternal outcomes and the rate of hospitalization in maternal intensive care (MIC) in a tertiary university center in Liege, Belgium. Materials and Methods: This is a retrospective cohort study comparing two groups, 6557 patients who achieved pregnancy spontaneously and 330 patients who achieved pregnancy after ART, between January 2020 and December 2022. These patients were followed in the academic obstetrics department of Citadelle Hospital, Liège. The database of the ART center was compared with the database of the delivery unit to determine the cohort of patients who conceived after ART. Adverse maternal outcomes and MIC hospitalization rates were compared with between spontaneous pregnancies and ART groups. ART groups were also compared with each other. Results: The rate of hospitalization in maternal intensive care for patients who achieved pregnancy spontaneously was 12.1%, compared to 17.3% after ART. Comparing the rate of pre-eclampsia, 3.5% of spontaneous pregnancies were complicated by pre-eclampsia, while after ART, 10.9% of patients developed this complication during pregnancy. This rate was higher after IVF (12%) compared to intrauterine insemination and particularly after frozen embryo transfer (FET) in artificial cycle (17.9%). The birthweight of newborns after ART was also analyzed. A significant difference was obtained when comparing fresh embryo transfer with FET. Conclusions: Our study confirmed that FET in artificial cycle is a risk factor for pre-eclampsia and that fresh embryo transfer is associated with a higher rate of newborns with a lower percentile of birthweight. Our data showed that the rate of MIC hospitalization was significantly higher after ART but did not differ between groups.

Neutrophil-to-lymphocyte ratios in pregnant women with familial mediterranean fever.

OBJECTIVE: To investigate the association between maternal serum neutrophil-to-lymphocyte ratios (NLRs) and pregnancy outcomes in women with familial mediterranean fever (FMF). BACKGROUND: FMF exists worldwide, it primarily affects Mediterranean countries METHODS: We retrospectively analysed data from 269 pregnant women, who underwent a routine prenatal follow-up and delivery in our hospital from 2016 to 2020. Clinical and demographic data, including age, gravida, parity, abortus, proteinuria in the first trimester, NLR, obstetrical complications, gestational age at delivery, birthweight were retrieved from the patients' medical records. Data from 67 pregnant women with FMF and 202 healthy pregnant women were compared. RESULTS: Patients with FMF showed higher rates of preeclampsia and primary caesarean delivery; however, there were no differences between the groups in terms of other obstetric complications or adverse neonatal outcomes. In both the FMF and control groups, NLRs in the third trimester were significantly higher than those in the first trimester. Additionally, patients in the FMF group demonstrated higher NLRs than patients in the control group in the third trimester. CONCLUSIONS: The NLRs are a haematological parameter that can be used to predict subclinical inflammation and the effects of ongoing subclinical inflammation on the pregnancy outcomes in women with FMF (Tab. 4, Ref. 39).

Placental Location and the Development of Hypertensive Disorders of Pregnancy.

OBJECTIVES: Abnormal placentation is an important factor in the pathogenesis of preeclampsia. As a result of diminished blood flow, the incidence of preeclampsia might be higher in patients with laterally located placentas compared to patients with centrally located placentas. The objective of this study was to evaluate the relationship between placental location and the development of hypertensive disorders of pregnancy. METHODS: Patients with singleton pregnancies who were seen in our ultrasound unit and delivered at our institution from October 2014 to April 2015 were included. The incidence of hypertensive disorders was compared in those with a lateral placental location and those with centrally located placentas (placental locations other than lateral). Baseline characteristics and pregnancy outcomes were compared between groups. The χ2 test, Fisher exact test, Mann-Whitney U test, and t test were used when appropriate. P < .05 was considered significant. RESULTS: We included 464 patients; 411 (88.57%) had centrally located placentas, and 53 (11.42%) had laterally located placentas. The incidence of hypertensive disorders of pregnancy was similar between groups (21% versus 19%; P = .71). Gestational age at delivery (P = .73), and small for gestational age (P = .96) were also similar between our study groups. CONCLUSIONS: In our study, there was no difference in the rate of hypertensive disorders of pregnancy between patients with central and laterally located placentas.

Obstetrical complications of thin endometrium in assisted reproductive technologies: a systematic review.

PURPOSE: The aim of the systematic review is to describe the obstetrical complications associated with pregnancies in the context of a thin endometrial lining. METHODS: Systematic review of the literature. RESULTS: Patients who conceive in the setting of a thin endometrium have a significantly increased risk of early pregnancy loss, namely miscarriage and ectopic pregnancy. These patients also have a twofold increase in low birth weight and preterm delivery, as well as a significantly higher risk of intrauterine growth restriction and composite adverse perinatal outcomes. CONCLUSIONS: In addition to the lower probability of conception, a thin endometrium in assisted reproductive technologies appears to be associated with both early and late pregnancy complications. These pregnancies thus warrant special attention and close follow-up from obstetricians.

MRI measurement of residual cervical length after radical trachelectomy for cervical cancer and the risk of adverse pregnancy outcomes: a blinded imaging analysis.

OBJECTIVE: To determine the association between the residual cervix measured on postoperative MRI after radical vaginal trachelectomy (RVT) and adverse obstetrical outcomes. DESIGN: Observational study. SETTING: Referral Cancer centre. POPULATION: Women who conceived after RVT for cervical cancer at the Royal Marsden Hospital, London, between 1995 and 2015. METHODS: Postoperative MRI scans were analysed by three researchers. The agreement between researchers was assessed by Pearson's correlation coefficient and Bland-Altman plot. Patients were divided into two groups (<10 and ≥10 mm residual cervix) for the analysis of adverse obstetrical outcomes. MAIN OUTCOME MEASURES: Late miscarriage, premature delivery, premature rupture of membranes (PROM) and chorioamnionitis. RESULTS: Thirty-one MRI scans were available; 29 of these women had a pregnancy that progressed beyond the first trimester. There was a strong reproducibility of the measurement of residual cervix (P < 0.001). Nineteen women (65.5%) had <10 mm residual cervix and 10 (34.5%) had ≥10 mm. Among women with <10 mm residual cervix, seven (36.8%) experienced PROM and ten (66.7%) had a preterm birth; No women with ≥10 mm residual cervix had PROM and two (22.2%) had a preterm birth (P = 0.028 and P = 0.035, respectively). Overall, there were nine (16.7%) first-trimester miscarriages, six (11.1%) late fetal losses, 12 (31.6%) preterm births and 36 (66.7%) live births. After a mean follow up of 78.1 months, 36 women were disease-free and one woman had died. CONCLUSIONS: MRI measurements of the residual cervix are reproducible between observers. The incidence of PROM and premature delivery is higher when the residual cervix after RVT is <10 mm. TWEETABLE ABSTRACT: The risk of prematurity after RVT can be predicted from measurements of residual cervical length on postoperative MRI scan.

Postpartum complications in new mothers with juvenile idiopathic arthritis: a population-based cohort study.

Objective: The aim was to evaluate the prevalence of postpartum complications, including depression, in new mothers who had juvenile idiopathic arthritis (JIA) and to assess whether these differ from mothers who never had JIA. Methods: Our cohort study used data from physician billing and hospitalizations covering Quebec, Canada. We identified females with JIA with a first-time birth between 1 January 1983 and 31 December 2010 and assembled a control cohort of first-time mothers without JIA from the same administrative data, matching 4:1 for date of first birth, maternal age and area of residence. We compared the following postpartum complications: major puerperal infection, anaesthetic complications, postpartum haemorrhage, thromboembolism, obstetrical trauma, complications of obstetrical surgical wounds and maternal depression in the first year after delivery, in the JIA vs non-JIA groups, using bivariate analysis and multiple logistic regression. Results: The mean age at delivery was 24.7 years in the JIA group (n = 1681) and 25.0 years for the non-JIA group (n = 6724). Mothers with JIA were more likely to experience complications attributable to anaesthetic [adjusted risk ratio (aRR) 2.17, 95% CI; 1.05, 4.48], postpartum haemorrhage (aRR = 2.75, 95% CI: 2.42, 3.11) and thromboembolism (aRR = 5.27, 95% CI: 1.83, 15.17) but were at lower risk for obstetrical trauma (aRR = 0.78, 95% CI: 0.64, 0.95) or newly to develop depression in the first year postpartum (aRR = 0.52, 95% CI: 0.40, 0.68). Conclusion: Mothers with JIA appear to be at higher risk for complications attributable to anaesthesia, postpartum haemorrhage and thromboembolism. Prevention strategies for postpartum haemorrhage and thromboembolism may be especially important in this population.

Endometriosis increases the risk of obstetrical and neonatal complications.

INTRODUCTION: The objective of this study was to assess obstetrical complications and neonatal outcomes in women with endometriosis as compared with women without endometriosis. MATERIAL AND METHODS: National cohort including all delivering women and their newborns in Denmark 1997-2014. Data were extracted from the Danish Health Register and the Medical Birth Register. Logistic regression analysis provided odds ratios (OR) with 95% confidence intervals (CI). Sub-analyses were made for primiparous women with a singleton pregnancy and for women with endometriosis who underwent gynecological surgery before pregnancy. RESULTS: In 19 331 deliveries, women with endometriosis had a higher risk of severe preeclampsia (OR 1.7, 95% CI 1.5-2.0), hemorrhage in pregnancy (OR 2.3, 95% CI 2.0-2.5), placental abruption (OR 2.0, 95% CI 1.7-2.3), placenta previa (OR 3.9, 95% CI 3.5-4.3), premature rupture of membranes (OR 1.7, 95% CI 1.5-1.8), and retained placenta (OR 3.1, 95% CI 1.4-6.6). The neonates had increased risks of preterm birth before 28 weeks (OR 3.1, 95% CI 2.7-3.6), being small for gestational age (OR 1.5, 95% CI 1.4-1.6), being diagnosed with congenital malformations (OR 1.3, 95% CI 1.3-1.4), and neonatal death (OR 1.8, 95% CI 1.4-2.1). Results were similar in primiparous women with a singleton pregnancy. Gynecological surgery for endometriosis before pregnancy carried a further increased risk. CONCLUSION: Women with endometriosis had a significantly higher risk of several complications, such as preeclampsia and placental complications in pregnancy and at delivery. The newborns had increased risk of being delivered preterm, having congenital malformations, and having a higher neonatal death rate. Pregnant women with endometriosis require increased antenatal surveillance.

A randomized controlled trial: effects of a prenatal depression intervention on perinatal outcomes among Chinese high-risk pregnant women with medically defined complications.

Prenatal psychosocial health has been linked with health behaviors, maternal health, and birth outcomes. This randomized controlled trial evaluated the effects of a prenatal depression intervention on birth outcomes and maternal physical and psychological status at 42 days postpartum. Three hundred fifty-two high-risk pregnant women exposed to obstetric complications with an Edinburgh Postnatal Depression Scale (EPDS) ≥ 9 or a Postpartum Depression Screening Scale (PDSS) ≥ 60 were randomly assigned to the intervention group (n = 176) and control group (n = 176). The intervention group underwent a six-session couple-separated psycho-educational program; the control group received the usual care. All participants were asked to complete questionnaires at late pregnancy (>28 weeks), 3 days postpartum, and 42 days postpartum. The intervention group had a significantly lower cesarean rate and shorter third stage of labor (p < .05). At 42 days after delivery, only 5.1% of participants were lost to follow-up, and the intervention group had significantly less minor and major depression, more sleep time, more satisfaction with their husband and other family members, less concern about taking care of baby, and less breast milk insufficiency than the control group (p < .05). A prenatal psychological intervention model for high-risk pregnant women holds potential as a preventive program that addresses maternal health and birth outcomes. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR-IOR-15006433), http://www.chictr.org.cn/enIndex.aspx (retrospectively registered).

[Female Genital Mutilations : the condition in Liege]. / Les mutilations génitales féminines : le point sur la situation au Centre Hospitalier Régional de la Citadelle.

Due to current migration flows, the practising obstetrician is likely to encounter parturient women carriers of female genital mutilations (FGM). This article describes the obstetrical complications related to the latter. We compared a group of mutilated patients (n = 69) to a control group (n = 162) and studied the data concerning pregnancy, childbirth, newborn, postpartum and length of hospital stay. Among the mutilated patients, 44% were group B streptococcus carriers against 23 % in the control group (p inferior to 0.01). As regards the perineum, an episiotomy was performed in 31 % of patients in the FGM group versus 35 % of the control group; a tear occurred in 42 % of vaginal deliveries in the FGM group against 26 % in the control group.

En raison des flux migratoires actuels, le praticien obstétricien sera amené à prendre en charge des patientes porteuses de mutilations génitales féminines (MGF). Cet article reprend les principales complications obstétricales en relation avec celles-ci. Nous avons comparé un groupe de patientes ayant subi une MGF (n = 69) à un groupe contrôle (n = 162) et étudié les données concernant la patiente, la grossesse en cours, l'accouchement, le nouveau-né, le post-partum et la durée du séjour hospitalier. Dans le groupe MGF, 44 % des patientes sont porteuses de streptocoque B contre 23 % dans le groupe contrôle (p inférieur a 0,01). Concernant le périnée, dans le groupe MGF, une épisiotomie est pratiquée chez 31 % des patientes versus 35 % dans le groupe contrôle; une déchirure survient dans 42 % des accouchements par voie basse dans le groupe MGF contre 26 % dans le groupe contrôle.

Evidence for No Significant Impact of Müllerian Anomalies on Reproductive Outcomes of Twin Pregnancy in Korean Women.

The present article aimed to evaluate the impact of congenital Müllerian anomalies (MA) on twin pregnancy after 24 gestational weeks in Korean women. All records of twin pregnancies in a large maternity hospital in Korea between January 2005 and July 2013 were analyzed. Patients with monochorionic monoamniotic (MCMA) twins, non-Korean patients, patients with twins delivered prior to 24 gestational weeks, and patients with miscarriage of one fetus or intrauterine fetal death (IUFD) before 24 gestational weeks were excluded from data analysis. In total, 1,422 women with twin pregnancy were eligible for data analysis, including 17 (1.2%) who had a known congenital MA (septate uterus, bicornuate uterus, arcuate uterus, and unicornuate uterus). Except for the mode of conception, baseline demographics were similar between women with MA and those without MA. No significant differences were found in pregnancy outcomes of gestational age at delivery (p = .86), birth weight of smaller and larger twins (p = .54 and p = .65), and number of twins with birth weight <5th percentile for gestational age (p = .43).The rates of obstetrical complications such as pre-eclampsia, gestational diabetes mellitus (GDM), placenta previa, cerclage, IUFD, and postpartum hemorrhage were not significantly different between the two groups either. We concluded that the presence of congenital MA may not increase obstetrical risks in outcomes of pregnancy of twins delivered after 24 gestational weeks.

Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair.

OBJECTIVE: To review the evidence relating to obstetrical anal sphincter injuries (OASIS) with respect to diagnosis, repair techniques and outcomes. To formulate recommendations as to patient counselling regarding route of delivery for subsequent pregnancy after OASIS. OPTIONS: Obstetrical care providers caring for women with OASIS have the option of repairing the anal sphincter using end-to-end or overlapping techniques. They may also be involved in counselling women with prior OASIS regarding the route of delivery for future pregnancies. OUTCOMES: The outcome measured is anal continence following primary OASIS repair and after subsequent childbirth. EVIDENCE: Published literature was retrieved through searches of Medline, EMBASE, and The Cochrane Library in May 2011 using appropriate controlled vocabulary (e.g., anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) and key words (obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: Benefits from implementation of these guidelines include: improved diagnosis of OASIS, optimal functional outcomes following repair, and evidence-based counselling of women for future childbirth.

Objectif : Analyser les données probantes traitant des lésions obstétricales du sphincter anal (LOSA) en ce qui concerne leur diagnostic, les techniques visant leur réparation et les résultats de l'intervention. Formuler des recommandations permettant d'éclairer les conseils offerts aux patientes ayant connu des LOSA en ce qui a trait à la voie d'accouchement à privilégier dans le cadre des grossesses subséquentes. Options : Les fournisseurs de soins obstétricaux qui comptent des patientes ayant connu des LOSA disposent de l'option de réparer le sphincter anal en faisant appel à la méthode de suture « bout à bout ¼ (end-to-end) ou à la méthode « en paletot ¼ (overlapping). Ils pourraient également être appelés à conseiller des femmes ayant déjà connu des LOSA en ce qui a trait à la voie d'accouchement à privilégier pour les grossesses subséquentes. Issues : Le critère d'évaluation était la continence anale à la suite d'une réparation primaire de LOSA et à la suite d'un accouchement subséquent. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, EMBASE et The Cochrane Library en mai 2011 au moyen d'un vocabulaire contrôlé (p. ex. anal canal, obstetrics, obstetric labour complication, pregnancy complication, treatment outcome, surgery, quality of life) et de mots clés (p. ex. obstetrical anal sphincter injur*, anus sphincter, anus injury, delivery, obstetrical care, surgery, suturing method, overlap, end-to-end, feces incontinence) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs. Aucune restriction n'a été imposée en matière de date ou de langue. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en septembre 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : Parmi les avantages de la mise en œuvre de la présente directive clinique, on trouve : l'amélioration du diagnostic des LOSA, l'obtention d'issues fonctionnelles optimales à la suite de la réparation et l'offre de conseils reposant sur des données probantes aux femmes en ce qui concerne leurs futures grossesses. Déclarations sommaires 1. Les lésions obstétricales du sphincter anal mènent à des comorbidités considérables, dont l'incontinence anale, les fistules rectovaginales et la douleur. (II-2) 2. Les lésions obstétricales du sphincter anal sont plus souvent associées aux accouchements par forceps qu'aux accouchements par ventouse obstétricale. (II-2) 3. Réparation des lésions obstétricales du sphincter anal : a. L'utilisation de polyglactin 2-0 ou de polydioxanone 3-0 donne lieu, après six semaines, à des taux semblables de morbidité liée aux sutures. (I) b. La réparation du sphincter anal interne est recommandée puisque les femmes chez lesquelles la présence d'une anomalie affectant ce sphincter est révélée au cours de l'échographie postpartum sont plus susceptibles de connaître une incontinence anale. (III) c. La réparation du sphincter anal externe devrait englober la gaine fasciale. Le recours à la technique de suture « en paletot ¼ (chevauchement) nécessite souvent une mobilisation et une dissection de plus grande envergure des extrémités du sphincter; l'utilisation de cette technique n'est possible qu'en présence de déchirures sphinctériennes de degré 3b ou plus. (III) d. La présence persistante d'une anomalie du sphincter anal externe longtemps après l'accouchement pourrait accroître le risque de voir apparaître une aggravation des symptômes à la suite des accouchements vaginaux subséquents. (II-2) 4. Les lésions obstétricales du sphincter anal sont associées à une hausse du risque de rétention urinaire postpartum. (II-2) 5. À la suite de la réparation réussie d'une lésion obstétricale du sphincter anal, la plupart des femmes peuvent connaître un accouchement vaginal en toute sûreté dans le cadre d'une grossesse subséquente. (III) 6. Services de counseling offerts aux femmes au sujet de leurs accouchements subséquents : a. Le risque de récurrence d'une lésion obstétricale du sphincter anal dans le cadre d'un accouchement subséquent est de 4-8 %. (II-2) b. On a calculé que, pour prévenir un cas d'incontinence anale chez des femmes ayant déjà subi une lésion obstétricale du sphincter anal, la tenue de 2,3 césariennes planifiées s'avérerait nécessaire, le tout s'accompagnant alors d'une hausse des risques maternels. (II-2) Recommandations 1. Toutes les femmes devraient faire l'objet d'un examen rigoureux visant la détection de déchirures périnéales ou vaginales; celles qui présentent une déchirure dont la profondeur est plus que superficielle devraient, avant la mise en œuvre d'une réparation, faire l'objet d'un examen rectal systématique cherchant à établir la présence de lésions obstétricales du sphincter anal. (II-2B) 2. Le système de classification de l'Organisation mondiale de la santé devrait être utilisé pour classer les lésions obstétricales du sphincter anal. Ce système permet l'établissement d'une distinction entre le degré de déchirure du sphincter externe (3a < 50 % ou 3b ≥ 50 %) et la présence d'anomalies du sphincter interne (3c). La présence d'une lésion en boutonnière (button-hole injury) constitue un incident distinct et devrait être classée en conséquence. (III-B) 3. Chez les femmes qui connaissent un accouchement vaginal spontané, le taux de lésions obstétricales du sphincter anal est amoindri lorsque le fournisseur de soins obstétricaux ralentit la tête fœtale au moment du dégagement. (II-2A) 4. Épisiotomie : a. Dans le cadre d'un accouchement vaginal spontané ou instrumental, le fournisseur de soins obstétricaux devrait, pour assurer la prévention des lésions obstétricales du sphincter anal, respecter une politique prévoyant une utilisation « restreinte ¼ de l'épisiotomie (c.-à-d. seulement lorsque cela s'avère indiqué), plutôt qu'une utilisation « libre ¼ de cette intervention (c.-à-d. de façon systématique). (I-A) b. Lorsque la tenue d'une épisiotomie est jugée indiquée, l'octroi d'une préférence envers la tenue d'une incision médiolatérale (plutôt qu'envers la tenue d'une incision médiane) devrait être envisagé. (II-2B) L'angle d'incision optimal semble être d'au moins 45 degrés (idéalement, aux alentours de 60 degrés). (II-2B) 5. La réparation peut être différée (pendant 8-12h) sans effets nuisibles. La mise en œuvre d'un délai pourrait s'avérer nécessaire jusqu'à ce que les services d'un fournisseur de soins disposant de l'expérience nécessaire pour procéder à la réparation puissent être retenus. (I-A) 6. L'administration prophylactique d'une dose intraveineuse unique d'antibiotiques (céphalosporine de 2e génération, p. ex. céfotétan ou céfoxitine) devrait être mise en œuvre pour assurer la baisse des taux de complications de lésion périnéale à la suite de la réparation des lésions obstétricales du sphincter anal. (I-A) 7. Des laxatifs (p. ex. lactulose) devraient être prescrits à la suite de la réparation primaire d'une lésion obstétricale du sphincter anal puisqu'ils sont associés à des premières selles moins douloureuses et survenant plus rapidement, et à l'obtention plus rapide du congé de l'hôpital. L'utilisation d'agents constipants et d'agents de gonflement n'est pas recommandée. (I-A) 8. Les anti-inflammatoires non stéroïdiens et l'acétaminophène sont les analgésiques de première intention. Les opioïdes ne devraient être utilisés qu'avec précaution. La constipation devrait être évitée au moyen d'un laxatif ou d'un émollient fécal. (1-A) 9. À la suite de la constatation d'une lésion obstétricale du sphincter anal, les fournisseurs de soins devraient divulguer à leurs patientes le degré de la lésion subie et prendre les dispositions nécessaires à la mise en œuvre d'un suivi. Il est nécessaire de procéder à la documentation détaillée de la lésion et de sa réparation. (III-L) 10. Les femmes qui connaissent une incontinence anale après avoir subi une lésion obstétricale du sphincter anal devraient être orientées vers des services de physiothérapie du plancher pelvien. (I-A).