Pregnancy Complications and Long-Term Mortality in a Diverse Cohort.

BACKGROUND: Pregnancy complications are associated with increased risk of development of cardiometabolic diseases and earlier mortality. However, much of the previous research has been limited to White pregnant participants. We aimed to investigate pregnancy complications in association with total and cause-specific mortality in a racially diverse cohort and evaluate whether associations differ between Black and White pregnant participants. METHODS: The Collaborative Perinatal Project was a prospective cohort study of 48 197 pregnant participants at 12 US clinical centers (1959-1966). The Collaborative Perinatal Project Mortality Linkage Study ascertained participants' vital status through 2016 with linkage to the National Death Index and Social Security Death Master File. Adjusted hazard ratios (aHRs) for underlying all-cause and cause-specific mortality were estimated for preterm delivery (PTD), hypertensive disorders of pregnancy, and gestational diabetes/impaired glucose tolerance (GDM/IGT) using Cox models adjusted for age, prepregnancy body mass index, smoking, race and ethnicity, previous pregnancies, marital status, income, education, previous medical conditions, site, and year. RESULTS: Among 46 551 participants, 45% (21 107 of 46 551) were Black, and 46% (21 502 of 46 551) were White. The median time between the index pregnancy and death/censoring was 52 years (interquartile range, 45-54). Mortality was higher among Black (8714 of 21 107 [41%]) compared with White (8019 of 21 502 [37%]) participants. Overall, 15% (6753 of 43 969) of participants had PTD, 5% (2155 of 45 897) had hypertensive disorders of pregnancy, and 1% (540 of 45 890) had GDM/IGT. PTD incidence was higher in Black (4145 of 20 288 [20%]) compared with White (1941 of 19 963 [10%]) participants. The following were associated with all-cause mortality: preterm spontaneous labor (aHR, 1.07 [95% CI, 1.03-1.1]); preterm premature rupture of membranes (aHR, 1.23 [1.05-1.44]); preterm induced labor (aHR, 1.31 [1.03-1.66]); preterm prelabor cesarean delivery (aHR, 2.09 [1.75-2.48]) compared with full-term delivery; gestational hypertension (aHR, 1.09 [0.97-1.22]); preeclampsia or eclampsia (aHR, 1.14 [0.99-1.32]) and superimposed preeclampsia or eclampsia (aHR, 1.32 [1.20-1.46]) compared with normotensive; and GDM/IGT (aHR, 1.14 [1.00-1.30]) compared with normoglycemic. P values for effect modification between Black and White participants for PTD, hypertensive disorders of pregnancy, and GDM/IGT were 0.009, 0.05, and 0.92, respectively. Preterm induced labor was associated with greater mortality risk among Black (aHR, 1.64 [1.10-2.46]) compared with White (aHR, 1.29 [0.97-1.73]) participants, while preterm prelabor cesarean delivery was higher in White (aHR, 2.34 [1.90-2.90]) compared with Black (aHR, 1.40 [1.00-1.96]) participants. CONCLUSIONS: In this large, diverse US cohort, pregnancy complications were associated with higher mortality nearly 50 years later. Higher incidence of some complications in Black individuals and differential associations with mortality risk suggest that disparities in pregnancy health may have life-long implications for earlier mortality.

The neutrophil-to-lymphocyte ratio: A low-cost antenatal indicator of placental chorioamnionitis in women who deliver preterm without clinical signs and symptoms of infection.

Chorioamnionitis is present in up to 70% of spontaneous preterm births and is associated with poor maternal, fetal and neonatal outcomes. OBJECTIVE: To explore the relationship between the neutrophil-to-lymphocyte ratio and histological chorioamnionitis in women who delivered preterm with no clinical signs or symptoms of infection. STUDY DESIGN: This was a retrospective analysis of a cohort of women who delivered spontaneously between 16 and 36+6 weeks at a tertiary UK hospital. Only women with placental histology and no signs of clinical infection were included. The neutrophil-to-lymphocyte ratio was calculated from a full blood count sample taken routinely within 24 h of delivery. The neutrophil-to-lymphocyte ratio was also calculated from first trimester booking bloods (<13 + 6 weeks) in a subgroup. Placental histopathology was categorised as either inflammatory (i.e. histologic chorioamnionitis, with or without evidence of fetal inflammatory response) or non-inflammatory (vascular pathology or a normal placenta). RESULTS: 169 women had available placental pathology and were included in the analysis. 70 % (118/169) had confirmed placental inflammation. The mean neutrophil-to-lymphocyte ratio was significantly raised in this group compared to those with normal (n = 24) or vascular (n = 27) pathology (inflammatory neutrophil-to-lymphocyte ratio 9.81 vs non-inflammatory neutrophil-to-lymphocyte ratio 6.53, p = 0.002. The delivery neutrophil-to-lymphocyte ratio had an area under the receiver operating characteristic curve of 0.69 (0.60 to 0.78) for predicting placental inflammation. A raised neutrophil-to-lymphocyte ratio (>6) was associated with an odds ratio of 5.2 (95 % CI 2.55 to 10.56) for histological chorioamnionitis, with a sensitivity of 80 % and negative predictive value of 86 %. A higher cut-off of 9 had a negative predictive value of 79 % for fetal inflammatory response. CONCLUSIONS: A raised neutrophil-to-lymphocyte ratio is associated with a 5-fold increased risk of histological chorioamnionitis in women who delivered early without signs or symptoms of infection. It was also raised at the time of preterm labour compared to the first trimester. A full blood count is an almost universal investigation in women admitted in preterm labour, often repeated, making this inexpensive and non-invasive ratio a useful additional antenatal biomarker in women admitted in spontaneous preterm labour at risk of subclinical chorioamnionitis and its associated poor outcomes.

Evolución y costes de la prematuridad por indicación médica en un hospital de tercer nivel / Evolution and costs of the medically indicated preterm birth in a tertiary care university hospital

INTRODUCCIÓN Y OBJETIVO: Analizar la evolución y los costes de los partos prematuros iatrogénicos en un hospital universitario de tercer nivel. MÉTODOS: Estudio de cohortes retrospectivo de los partos con edad gestacional comprendida entre 24 y 36+6 semanas en dos periodos temporales: 2001-2005 y 2011-2016. Se identificaron los partos prematuros por indicación médica o iatrogénicos (PPI). Se analizaron variables demográficas y de resultado. Los costes se calcularon mediante el grupo relacionado con el diagnóstico (GRD) de cada ingreso. RESULTADOS: Se obtuvo una muestra de 620 partos prematuros iatrogénicos. La tasa de prematuridad global se mantuvo estable en 9%. La tasa de prematuridad iatrogénica experimentó un incremento relativo del 9,7%. Entre las pacientes con un PPI se apreció un incremento en la edad materna de 27,7 a 32,9 años, de la obesidad (32,2% a 55,5%) y del uso de técnicas de reproducción asistida (6% a 11,1%). Preeclampsia y retraso del crecimiento (CIR) fueron las principales causas de PPI, en los que se incrementó la tasa de cesáreas de 66,9% a 78%, la estancia media de 7,8 días a 9,6 y el coste por paciente de 3.068,6 a 7.331,9 euros. CONCLUSIONES: Se observa un aumento de PPI en el segundo periodo, manteniéndose la prematuridad global. Los cambios demográficos podrían explicar este incremento. Estos cambios están implicados en la fisiopatología de la preeclampsia y el CIR y en el aumento de su incidencia. La prevención primaria y secundaria de esas complicaciones podría reducir la incidencia y los costes de la prematuridad iatrogénica.

INTRODUCTION AND OBJECTIVES: To evaluate the incidence, evolution, causes and costs of premature births (PB) due to medical indication (iatrogenic) in a tertiary care university hospital METHODS: Retrospective cohort study of all deliveries with gestational age between 24 and 36+6 weeks, in two periods 2001-2005 and 2011-2016. Iatrogenic births were identified. Clinical, epidemiological, diagnostic and economic variables were analysed. RESULTS: A sample size of 620 iatrogenic deliveries was obtained. We found a 9.7% relative increase in iatrogenic prematurity rate in the second period as well as an increase in maternal age from 27.7 to 32.9, obesity from 32.2% to 55.5% and the use of assisted reproductive techniques from 6% to 11.1%. Preeclampsia and intrauterine growth restriction were found to be the main causes of iatrogenic premature delivery. In these cases the rates of cesarean section increased from 66.9% to 78%. The average stay per patient and the cost calculated by diagnosis related group (DRG) also showed a statistically significant increase from 7.8 days and 3,068.6 euros to 9.6 days and 7,331.9 euros. CONCLUSIONS: We observed an increase in iatrogenic prematurity in the second period despite the unchanged rate of spontaneous PB. Demographic changes in the population, as well as an increase in obstetric related conditions, seem to be responsible for this increase. Primary and secondary prevention of clinical characteristics may reduce the incidence and costs derived from this type of prematurity.

Cerclage is associated with the increased risk of preterm birth in women who had cervical conization.

BACKGROUND: The aim of this study was to determine the effect of cerclage in women who underwent cervical conization. METHODS: Study data were collected from the Korea National Health Insurance Claims Database of the Health Insurance Review and Assessment Service for 2009-2013. Women who had a conization in 2009 and a subsequent first delivery between 2009 and 2013 in Korea were enrolled. RESULTS: Among the women who had conization in 2009, 1075 women had their first delivery between 2009 and 2013. A cerclage was placed in 161 of the women who were treated by conization. The rate of preterm birth was higher in the women who were treated with cerclage following a conization compared with those without cerclage (10.56 vs 4.27, p < 0.01, respectively). The multivariate regression analysis revealed that the women who were treated cerclage following a conization had an increased risk of preterm delivery compared with women without cerclage (odds ratio (OR), 2.6, 95% confidence interval (CI), 1.4-4.9). CONCLUSION: Our study showed that cerclage associated with an increased risk of preterm birth and preterm premature rupture of membranes in women who underwent conization. Further studies are required to clarify the mechanism by which cerclage affects the risk of preterm birth.

[Birth and pregnancy outcomes of drug addicted women].

INTRODUCTION: Illegal drug abuse causes significant health problems with consequences to the mother and the neonate, and an economic burden to the health system. OBJECTIVES: The present study aimed to investigate pregnancy and perinatal outcome in women using illegal drugs prior to and during pregnancy. METHODS: A retrospective cohort study comparing pregnancy and neonatal outcomes of drug addicted women to the outcomes of other Jewish women. The study population includes all women who gave birth between the years 1989-2008 at the Soroka University Medical Center. RESULTS: From a total of 106,000 deliveries, 119 women were known to be drug addicted. No significant differences were found between the groups regarding maternal age and origin, but more women in the addicted group smoked, and tacked prenatal care. More women in the addicted group had obstetrics complications such as: recurrent abortions, placenta previa, pLacental abruption and preterm labor. Illegal drug abuse was significantly associated with adverse perinatal outcomes such as low birth weight, congenital anomalies, peripartum death and prolonged hospitalizations. CONCLUSIONS: Illegal drug abuse is an independent risk factor for adverse obstetric and perinatal outcomes. DISCUSSION: This study investigated a significant problem that may be underestimated in our population. The higher incidence of pLacental abruption, placenta previa, preterm tabor and low birth weight could be a sign for placentaL insult. SUMMARY: Illegal drug abuse is an independent risk factor for adverse perinatal outcomes and causes an economic burden. Further national studies are needed to characterize the problem, and to develop appropriate intervention programs.

The relationship of socioeconomic status to preterm contractions and preterm delivery.

Spontaneous preterm labor precedes approximately 50% of preterm births. One to 10% of pregnant women are hospitalized for preterm labor. This study examines the relationship of socioeconomic indicators, family income, education and type of insurance, with preterm contractions and subsequent preterm delivery. Data were from the pregnancy risk assessment monitoring system on 107,926 women who had singleton births during 2000-2002. Data on preterm contractions, family income, and type of insurance during pregnancy were from the maternal questionnaire. Maternal education and gestational age were derived from birth certificate data. Predicted marginal probabilities from logistic regression models were used to calculate the adjusted cumulative incidence and cumulative risk ratio of preterm contractions and preterm delivery. Median annual household income was approximately $30,000. More than one-fourth (28.1 95% CI: 27.7, 28.6) of women experienced preterm contractions, and these women were 3 times as likely (18 vs. 5%) to deliver preterm as women without preterm contractions. Only 58% of women who delivered preterm reported contractions. Lower income and Medicaid-paid care were independently associated with an increased risk of preterm contractions but not with preterm delivery. The association of lower income and Medicaid enrollment with preterm contractions but not preterm delivery suggests that SES is associated with the initiation of the pathway to spontaneous preterm delivery rather than access to or the success of interventions to prevent delivery following the onset of contractions.

The frequency and clinical significance of intra-amniotic inflammation in women with preterm uterine contractility but without cervical change: do the diagnostic criteria for preterm labor need to be changed?

OBJECTIVE: The objective of this study was to determine the frequency and clinical significance of intra-amniotic inflammation in patients with preterm increased uterine contractility with intact membranes but without cervical change. METHODS: Amniocentesis was performed in 132 patients with regular uterine contractions and intact membranes without cervical change. Amniotic fluid was cultured for bacteria and mycoplasmas and assayed for matrix metalloproteinase-8 (MMP-8). Intra-amniotic inflammation was defined as an elevated amniotic fluid MMP-8 concentration (>23 ng/mL). RESULTS: (1) Intra-amniotic inflammation was present in 12.1% (16/132); (2) Culture-proven intra-amniotic infection was diagnosed in 3% (4/132) of patients without demonstrable cervical change on admission or during the period of observation; and (3) Patients with intra-amniotic inflammation had significantly higher rates of preterm delivery and adverse outcomes, and shorter amniocentesis-to-delivery intervals than those without intra-amniotic inflammation (P < 0.05 for each). Adverse outcomes included chorioamnionitis, funisitis, and neonatal death. CONCLUSION: Intra-amniotic inflammation was present in 12% of patients with regular uterine contractions without cervical change, while culture-proven intra-amniotic infection was present in 3%. The presence of intra-amniotic inflammation was a significant risk factor for adverse neonatal outcomes. These observations question whether cervical changes should be required for the diagnosis of preterm labor, because patients without modifications in cervical status on admission or during a period of observation are at risk for adverse pregnancy outcomes.

[Clinical and economic challenges of moderate preterm babies born between 32+0 and 36+6 weeks of gestation]. / Klinische und ökonomische Herausforderung der moderaten Frühgeburt zwischen 32+0 und 36+6 SSW.

BACKGROUND: Preterm births show a worldwide increasing incidence. The majority of preterm births occur between 32+0 and 36+6 weeks of gestation and are associated with an increased rate of maternal and neonatal morbidity. The focus of our research is the clinical and economical analysis of all preterm births between 32+0 and 36+6 weeks of gestation in a German level 1 perinatal centre over a period of 3 years. MATERIALS AND METHODS: A retrospective analysis of all preterm births between 32+0 and 36+6 weeks of gestation in the University Hospital Mainz from 2007 to 2009 was undertaken. Data were collected using our electronic documentation system. Gestational age at delivery, mode of birth, indication for delivery, duration of the peripartum treatment, treatment of the newborn in the children's hospital, birth weight and therapy costs were evaluated. RESULTS: We recorded 407 moderate preterm births in total; this amounts to a rate of of 10% of all births. Major causes of prematurity were PPROM, preterm labour and preeclampsia/HELLP. Maternal and fetal systemic diseases were more uncommon. Rates of Caesarean sections (62%) and of neonatal inpatient treatment needs (58.5%) were high. Maternal treatment costs were 332 Euro/day. The mean duration of maternal inpatient treatment was 13.15 days. DISCUSSION: Moderate preterm birth is associated with maternal morbidity frequently due to a high rate of Caesarean sections. Neonatal morbidity is also increased. In comparison with previous research, we saw an increased rate of pregnancy complications. This could be typical for a level 1 perinatal centre. Moderate preterm birth is seen as the cause of considerable treatment costs.

An updated review of of evidence to discourage douching.

PURPOSE: To review current studies on vaginal douching. DATA SOURCES: MEDLINE PubMed, CINAHL, and Cochrane databases from 2002 to 2008 using MeSh terms "vaginal AND irrigation or vaginal and douching" from 2002 to 2003 and "vaginal douching" and "vaginal douching and adverse effects" from 2004 to 2008. STUDY SELECTION: MEDLINE PubMed included 156 records, CINAHL 15, and Cochrane 10. Articles in English were reviewed, and those pertaining to vaginal douching and reproductive and gynecologic outcomes were included. References from these articles were reviewed and included when appropriate. 2008 Web sites of the Centers for Disease Control and Prevention were also included. DATA EXTRACTION: Articles were reviewed and summarized. RESULTS: Vaginal douching is a common practice for almost one-third of women in the United States. Douching is associated with adverse pregnancy outcomes including ectopic pregnancy, low birth weight, preterm labor, preterm birth, and chorioamnionitis. Douching is more prevalent among non-Hispanic black women than among white women or Hispanic women. Douching alters the vaginal flora and predisposes women to develop bacterial vaginosis (BV), which is also more prevalent among women who douche and among black women. Douching is also associated with serious gynecologic outcomes, including increased risk of cervical cancer, pelvic imflammatory disease, endometritis, and increased risk for sexually transmitted infections, including HIV. Many factors influence women's douching behaviors, including social, cultural, and educational factors. Healthcare providers can influence women to stop douching. CLINICAL IMPLICATIONS: Healthcare providers may not be aware of the mounting evidence of negative health outcomes associated with the practice of douching. At every opportunity, healthcare providers should ask women whether they douche and inquire about vaginal douching practices and beliefs associated with the practice. Douching should be discouraged because it places women at risk for multiple health problems.

Importance of background rates of disease in assessment of vaccine safety during mass immunisation with pandemic H1N1 influenza vaccines.

Because of the advent of a new influenza A H1N1 strain, many countries have begun mass immunisation programmes. Awareness of the background rates of possible adverse events will be a crucial part of assessment of possible vaccine safety concerns and will help to separate legitimate safety concerns from events that are temporally associated with but not caused by vaccination. We identified background rates of selected medical events for several countries. Rates of disease events varied by age, sex, method of ascertainment, and geography. Highly visible health conditions, such as Guillain-Barré syndrome, spontaneous abortion, or even death, will occur in coincident temporal association with novel influenza vaccination. On the basis of the reviewed data, if a cohort of 10 million individuals was vaccinated in the UK, 21.5 cases of Guillain-Barré syndrome and 5.75 cases of sudden death would be expected to occur within 6 weeks of vaccination as coincident background cases. In female vaccinees in the USA, 86.3 cases of optic neuritis per 10 million population would be expected within 6 weeks of vaccination. 397 per 1 million vaccinated pregnant women would be predicted to have a spontaneous abortion within 1 day of vaccination.

[The shortening of the duration of pregnancy due to smoking and associated costs for perinatal health care in Germany]. / Erhöhung der Frühgeborenenrate durch Rauchen in der Schwangerschaft und daraus resultierende Kosten für die Perinatalmedizin in Deutschland.

BACKGROUND: As about 20 % of pregnant women smoke, 137,000 of the 685,795 neonates delivered in Germany in 2005 have been affected by smoking during pregnancy. Caring for neonates born prematurely because of smoking results in additional costs. We have attempted to estimate these costs. MATERIAL AND METHODS: Data of 1,815,318 pregnancies were collected from the German perinatal statistics of 1995-1997. In 876,645 cases there was information regarding smoking. Of these, 699,134 pregnant women were non-smokers and 177,511 were smokers. To determine the number of preterm births due to smoking, we compared the distribution of the duration of pregnancy of the non-smoking cohort to that of the smoking cohort. From the difference between this and the actual distribution of the duration of pregnancy among smokers we determined the number of additional preterm births caused by smoking. For the analysis of the associated costs we used the actual costs of care and daily rates used in neonatology. RESULTS: For 2002 we estimate 43 million Euros of additional costs due to neonates born prematurely because of smoking. CONCLUSIONS: We present a rough estimate of the additional health care costs for neonates because of smoking. Costs were estimated only with regard to premature deliveries. Other effects of smoking during pregnancy on neonatal health were not considered. More detailed cost analyses will likely reveal even higher costs.

Intimate partner violence and the childbearing year: maternal and infant health consequences.

Intimate partner violence (IPV) against women is a significant public health problem with negative physical and mental health consequences. Pregnant women are not immune to IPV, and as many as 4% to 8% of all pregnant women are victims of partner violence. Among pregnant women, IPV has been associated with poor physical health outcomes such as increased sexually transmitted diseases, preterm labor, and low-birth-weight infants. This article focuses on the physical health consequences of IPV for mothers and their infants. The purpose of this review is therefore to examine timely research ranging from 2001 to 2006 on IPV during pregnancy, the morbidity and mortality risks for mothers and their infants, and the association between IPV and perinatal health disparities. It will also identify gaps in the published empirical literature and make recommendations for practice, policy, and research.

Respiratory consequences of preterm birth.

Approximately 8% of Australia's 250,000 annual births occur preterm (before 37 weeks completed gestation). Preterm infants represent 75% of all neonatal deaths in Australia, with the vast majority of these deaths caused by pulmonary disease. 2. The respiratory consequences for survivors of preterm birth include the immediate challenges of breathing with underdeveloped lungs, usually manifest as respiratory distress syndrome (RDS), and, in the long term, with persisting pulmonary abnormalities. Therapies to prevent neonatal lung disease now permit survival of preterm infants born as early as 22 weeks gestational age, but not without consequences. 3. Preterm infants are at risk of developing chronic lung disease/bronchopulmonary dysplasia (BPD). The lungs of infants dying from BPD are inflamed and have fewer, larger alveoli than normal and exhibit abnormal pulmonary vascular development. There is now a growing appreciation of the contribution of intrauterine inflammation to the aetiology of BPD. 4. Impaired airway function is commonly reported in follow-up studies of children born preterm. Decreased expiratory flow rates have been associated with preterm birth per se, but airway function appears more affected in survivors of RDS and BPD. Observations in survivors of BPD suggest persisting abnormalities in the structure of the lung parenchyma and airways. 5. Follow-up studies of preterm infants into adulthood are lacking, as are experimental examinations of the long-term physiological and anatomical effects of preterm birth. Both are necessary to understand the causes of the long-term respiratory consequences of preterm birth.

[Risk assessment for preterm delivery in pregnant women with active periodontitis]. / Próba oceny ryzyka porodu przedwczesnego u ciezarnych z aktywnym zapaleniem tkanek przyzebia.

INTRODUCTION: Premature labor has been regarded as a highly problematic clinical event not only due to its relation with perinatal mortality but also in the light of the remote results of the prematurity. Therefore many ongoing studies concentrate on evaluation of potentially avoidable risk factors of premature labor. Relatively few studies have suggested chronic periodontitis as such a determinant. OBJECTIVES: Prospective evaluation of periodontium changes in the course of otherwise normal pregnancy. Assessment of potential influence of periodontium pathology, and its severity, on the obstetrical complications. The authors have made literature search on the relation of active periodontitis and premature labor. MATERIALS AND METHODS: Study involved 120 randomized gravidae attending electively dental clinic for a routine control. INCLUSION CRITERIA: single pregnancy, no preterm delivery in a history, mother's age 18 to 35 years, gestational age 10 to 20 weeks based on a last menstrual period date--confirmed on ultrasound. Every patient underwent dental examination twice--at the inclusion date and 48 hours after delivery. Patients were divided into three groups. Group I (n = 25)--healthy patients. Group II (n = 61)--patients with mild or moderate periodontitis. Group III (n = 39) patients with a severe periodontitis. Progression of lesions was recognized if the post-delivery dental assessment revealed increase of the pockets depth higher than 2mm and in at least 4 places compared with the initial findings. RESULT: In the course of otherwise normal pregnancy women with signs of inflammation within periodontium revealed progression of this pathology proportional to its severity in early pregnancy. This increase was associated with 4-fold higher rate of preterm deliveries in Group II and 12-fold in Group III compared with healthy patients. CONCLUSION: Active and severe periodontitis should be regarded as independent and highly influential risk factor of the preterm delivery.