RESUMEN
OBJECTIVES: With SARS-CoV-2 evolving, disease severity and presentation have changed due to changes in mechanisms of entry and effector site as well as due to effects of vaccination- and/or infection-acquired immunity. We re-assessed fetal lung pathology in pregnancies with uncomplicated SARS-CoV-2 infections during the late, omicron-dominated pandemic phase to inform disease understanding and pregnancy consultation. METHODS: In this case-control study, fetal lung volumes were assessed by fetal MRI in 24 pregnancies affected by mild maternal SARS-CoV-2 infection during the omicron-dominated pandemic phase with prevailing immunity through vaccination and/or prior SARS-CoV-2 infection. RESULTS: Fetal lung volumes (normalized to estimated fetal weight) in 24 pregnancies (GA 33.3 ± 3.8, 12 female fetuses) following mild, uncomplicated SARS-CoV-2 infection did not differ significantly from both, published reference values (96.3% ± 22.5% of 50th percentile reference values, p = 0.43), or fetal lung volumes of a site-specific, non-COVID control group (n = 15, 94.2% ± 18.5%, p = 0.76). Placental assessment revealed no group differences in thrombotic changes or placental heterogeneity (p > 0.05, respectively), and fetal lung volume did not correlate with placental heterogeneity when adjusting for gestational age at scan (p > 0.05). CONCLUSION: Assessment of fetal lung volume by MRI revealed unaffected lung growth in pregnancies affected by uncomplicated SARS-CoV-2 infection in the omicron-dominated pandemic phase in the presence of prevailing hybrid immunity. This finding contrasts sharply with the observed reduction in fetal lung volume following maternal alpha-variant infection in the pre-vaccination era and might reflect tropism- as well as immunity-related effects. KEY POINTS: Question: Is fetal lung development affected by mild maternal SARS-CoV-2 infection during the omicron-dominated phase of the pandemic? FINDINGS: Fetal lung volume in 24 affected pregnancies did not differ significantly from published reference values or fetal lung volumes in 15 site-specific, non-COVID-affected control pregnancies. CLINICAL RELEVANCE: Preserved fetal lung volume following mild maternal SARS-CoV-2 infection during the omicron-dominated phase contrasts with previous findings of reduced volume in unvaccinated pregnancies during the alpha-dominated pandemic phase. These observations might reflect tropism- as well as immunity-related effects.
RESUMEN
BACKGROUND: Compliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women's satisfaction with the services they receive. METHODS: Drawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women's overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women's satisfaction with delivery care services. RESULTS: Deliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the "functional referral system" performed highest (92.0%), while "competent, motivated human resources" performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels. CONCLUSIONS: Nepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.
Asunto(s)
Servicios de Salud Materna , Nivel de Atención , Femenino , Humanos , Embarazo , Parto Obstétrico , Instituciones de Salud , Nepal , Satisfacción Personal , Encuestas y Cuestionarios , Satisfacción del PacienteRESUMEN
BACKGROUND: Nepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved. METHODS: Cross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs. RESULTS: Despite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent. CONCLUSIONS: The slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased.
Asunto(s)
Muerte Materna , Recién Nacido , Femenino , Embarazo , Humanos , Nepal , Estudios Transversales , Instituciones de Salud , Parto ObstétricoRESUMEN
PURPOSE: After living with the COVID-19 pandemic for more than 2 years, the impact of lockdown measures on preterm birth rates is inconsistent according to data from different countries. In this study, rates of preterm-born infants during the time of COVID-19-related lockdowns were analyzed in a tertiary perinatal center at Munich University, Germany. METHODS: We analyzed the number of preterm births, infants, and stillbirths before 37 weeks of gestation during the German COVID-19 lockdown period compared to the same time periods in the years 2018 and 2019 combined. Additionally, we expanded the analysis to Pre- and Post-Lockdown Periods in 2020 compared to the respective control periods in the years 2018 and 2019. RESULTS: Our database shows a reduction in the rate of preterm infants during the COVID-19 lockdown period (18.6%) compared to the combined control periods in 2018 and 2019 (23.2%, p = 0.027). This was mainly based on a reduced rate of preterm multiples during the lockdown period (12.8% vs. 28.9%, p = 0.003) followed by a reversed effect showing a threefold rise in multiple births after the lockdown. In singletons, the rate of preterm births was not reduced during the lockdown. The rate of stillbirths was not affected by the lockdown measures as compared to the control period (0.9% vs. 0.7%, p = 0.750). CONCLUSION: During the COVID-19 pandemic lockdown period, we found a reduced rate of preterm-born infants compared to a combined control period in the years 2018 and 2019 in our large tertiary University Center in Germany. Due to the predominant reduction in preterm multiples, we postulate that less physical activity might have led to the protective effect by lockdown measures.
Asunto(s)
COVID-19 , Nacimiento Prematuro , Embarazo , Lactante , Femenino , Recién Nacido , Humanos , Recien Nacido Prematuro , Nacimiento Prematuro/epidemiología , COVID-19/epidemiología , COVID-19/prevención & control , Pandemias/prevención & control , Universidades , Control de Enfermedades Transmisibles , Mortinato/epidemiologíaRESUMEN
Expanding access to facility-based delivery services and improving the functionality of emergency obstetric and neonatal care (EmONC) are important strategies toward achieving a maternal mortality ratio of 70 deaths per 100,000 live births by 2030. In this study the researchers assess signal functions at designated facilities in Nepal, using Nepal Health Facility Survey data for 2015 and 2021. The functionality of basic and comprehensive EmONC sites was low, declining over the six-year period. Lack of progress may partly be attributed to the COVID-19 pandemic. Nepal needs to expand EmONC sites strategically, strengthen referral systems, improve service readiness, and periodically assess service quality.
RESUMEN
INTRODUCTION: SARS-CoV-2 is a viral disease with potentially devastating effects. Observational studies of pregnant women infected with SARS-CoV-2 report an increased risk for FGR. This study utilizes data from a prospective SARS-CoV-2 registry in pregnancy, investigating the progression of fetuses to fetal growth restriction (FGR) at birth following maternal SARS-CoV-2 and evaluating the hypothesis of whether the percentage of SGA at birth is increased after maternal SARS-CoV-2 taking into account the time interval between infection and birth. MATERIALS & METHODS: CRONOS is a prospective German registry enrolling pregnant women with confirmed SARS-CoV-2 infection during their pregnancy. SARS-CoV-2 symptoms, pregnancy- and delivery-specific information were recorded. The data evaluated in this study range from March 2020 until August 2021. Women with SARS-CoV-2 were divided into three groups according to the time of infection/symptoms to delivery: Group I<2 weeks, Group II 2-4 weeks, and Group III>4 weeks. FGR was defined as estimated and/or birth weight<10% ile, appropriate for gestational age (AGA) was within 10 and 90%ile, and large for gestational age (LGA) was defined as fetal or neonatal weight>90%ile. RESULTS: Data for a total of 2,650 SARS-CoV-2-positive pregnant women were available. The analysis was restricted to symptomatic cases that delivered after 24+0 weeks of gestation. Excluding those cases with missing values for estimated fetal weight at time of infection and/or birth weight centile, 900 datasets remained for analyses. Group I consisted of 551 women, Group II of 112 women, and Group III of 237 women. The percentage of changes from AGA to FGR did not differ between groups. However, there was a significantly higher rate of large for gestational age (LGA) newborns at the time of birth compared to the time of SARS-CoV-2 infection in Group III (p=0.0024), respectively. CONCLUSION: FGR rates did not differ between symptomatic COVID infections occurring within 2 weeks and>4 weeks before birth. On the contrary, it presented a significant increase in LGA pregnancies in Group III. However, in this study population, an increase in the percentage of LGA may be attributed to pandemic measures and a reduction in daily activity.
Asunto(s)
COVID-19 , SARS-CoV-2 , Embarazo , Femenino , Humanos , Recién Nacido , Peso al Nacer , Estudios Prospectivos , COVID-19/epidemiología , Desarrollo Fetal , Retardo del Crecimiento Fetal/diagnóstico , Retardo del Crecimiento Fetal/epidemiología , Edad GestacionalRESUMEN
BACKGROUND: Fetal growth restriction is strongly associated with impaired placentation and abnormal uteroplacental blood flow. Nitric oxide donors such as pentaerythritol tetranitrate are strong vasodilators and protect the endothelium. Recently, we demonstrated in a randomized controlled pilot study a 38% relative risk reduction for the development of fetal growth restriction or perinatal death following administration of pentaerythritol tetranitrate to pregnant women at risk, identified by impaired uterine perfusion at midgestation. Results of this monocenter study prompted the hypothesis that pentaerythritol tetranitrate might have an effect in pregnancies with compromised placental function as a secondary prophylaxis. OBJECTIVE: This study aimed to test the hypothesis that the nitric oxide donor pentaerythritol tetranitrate reduces fetal growth restriction and perinatal death in pregnant women with impaired placental perfusion at midgestation in a multicenter trial. STUDY DESIGN: In this multicenter, randomized, double-blind, placebo-controlled trial, 2 parallel groups of pregnant women presenting with a mean uterine artery pulsatility index >95th percentile at 19+0 to 22+6 weeks of gestation were randomized to 50-mg Pentalong or placebo twice daily. Participants were assigned to high- or low-risk groups according to their medical history before randomization was performed block-wise with a fixed block length stratified by center and risk group. The primary efficacy endpoint was the composite outcome of perinatal death or development of fetal growth restriction. Secondary endpoints were neonatal and maternal outcome parameters. RESULTS: Between August 2017 and March 2020, 317 participants were included in the study and 307 were analyzed. The cumulative incidence of the primary outcome was 41.1% in the pentaerythritol tetranitrate group and 45.5% in the placebo group (unadjusted relative risk, 0.90; 95% confidence interval, 0.69-1.17; adjusted relative risk, 0.90; 95% confidence interval, 0.69-1.17; P=.43). Secondary outcomes such as preterm birth (unadjusted relative risk, 0.73; 95% confidence interval, 0.56-0.94; adjusted relative risk, 0.73; 95% confidence interval, 0.56-0.94; P=.01) and pregnancy-induced hypertension (unadjusted relative risk, 0.65; 95% confidence interval, 0.46-0.93; adjusted relative risk, 0.65; 95% confidence interval, 0.46-0.92; P=0.01) were reduced. CONCLUSION: Our study failed to show an impact of pentaerythritol tetranitrate on the development of fetal growth restriction and perinatal death in pregnant women with impaired uterine perfusion at midgestation. Pentaerythritol tetranitrate significantly reduced secondary outcome parameters such as the incidence of preterm birth and pregnancy-induced hypertension in these pregnancies.
Asunto(s)
Hipertensión Inducida en el Embarazo , Tetranitrato de Pentaeritritol , Muerte Perinatal , Nacimiento Prematuro , Embarazo , Femenino , Recién Nacido , Humanos , Tetranitrato de Pentaeritritol/uso terapéutico , Retardo del Crecimiento Fetal/etiología , Placenta/irrigación sanguínea , Placentación , Perfusión/efectos adversosRESUMEN
BACKGROUND: Obesity in pregnancy and related early-life factors place the offspring at the highest risk of being overweight. Despite convincing evidence on these associations, there is an unmet public health need to identify "high-risk" offspring by predicting very early deviations in weight gain patterns as a subclinical stage towards overweight. However, data and methods for individual risk prediction are lacking. We aimed to identify those infants exposed to obesity in pregnancy at ages 3 months, 1 year, and 2 years who likely will follow a higher-than-normal body mass index (BMI) growth trajectory towards manifest overweight by developing an early-risk quantification system. METHODS: This study uses data from the prospective mother-child cohort study Programming of Enhanced Adiposity Risk in CHildhood-Early Screening (PEACHES) comprising 1671 mothers with pre-conception obesity and without (controls) and their offspring. Exposures were pre- and postnatal risks documented in patient-held maternal and child health records. The main outcome was a "higher-than-normal BMI growth pattern" preceding overweight, defined as BMI z-score >1 SD (i.e., World Health Organization [WHO] cut-off "at risk of overweight") at least twice during consecutive offspring growth periods between age 6 months and 5 years. The independent cohort PErinatal Prevention of Obesity (PEPO) comprising 11,730 mother-child pairs recruited close to school entry (around age 6 years) was available for data validation. Cluster analysis and sequential prediction modelling were performed. RESULTS: Data of 1557 PEACHES mother-child pairs and the validation cohort were analyzed comprising more than 50,000 offspring BMI measurements. More than 1-in-5 offspring exposed to obesity in pregnancy belonged to an upper BMI z-score cluster as a distinct pattern of BMI development (above the cut-off of 1 SD) from the first months of life onwards resulting in preschool overweight/obesity (age 5 years: odds ratio [OR] 16.13; 95% confidence interval [CI] 9.98-26.05). Contributing early-life factors including excessive weight gain (OR 2.08; 95% CI 1.25-3.45) and smoking (OR 1.94; 95% CI 1.27-2.95) in pregnancy were instrumental in predicting a "higher-than-normal BMI growth pattern" at age 3 months and re-evaluating the risk at ages 1 year and 2 years (area under the receiver operating characteristic [AUROC] 0.69-0.79, sensitivity 70.7-76.0%, specificity 64.7-78.1%). External validation of prediction models demonstrated adequate predictive performances. CONCLUSIONS: We devised a novel sequential strategy of individual prediction and re-evaluation of a higher-than-normal weight gain in "high-risk" infants well before developing overweight to guide decision-making. The strategy holds promise to elaborate interventions in an early preventive manner for integration in systems of well-child care.
Asunto(s)
Obesidad Materna , Obesidad Infantil , Índice de Masa Corporal , Niño , Preescolar , Estudios de Cohortes , Femenino , Humanos , Lactante , Estudios Longitudinales , Sobrepeso/epidemiología , Obesidad Infantil/diagnóstico , Obesidad Infantil/epidemiología , Obesidad Infantil/prevención & control , Embarazo , Estudios Prospectivos , Aumento de PesoRESUMEN
BACKGROUND: Disparities in the use of maternal, neonatal and child health (MNCH) services remain a concern in Low- and Middle-Income countries such as Nepal. Commonly observed disparities exist in education, income, ethnic groups, administrative regions and province-level in Nepal. In order to improve equitable outcomes for MNCH and to scale-up quality services, an Investment Case (IC) approach was lunched in the Asia Pacific region. The study assessed the impact of the IC intervention package in maternal and child health outcomes in Nepal. METHODS: The study used a quasi-experimental design extracting data from the Nepal Demographic Health Surveys - 2011 (pre-assessment) and 2016 (post-assessment) for 16 intervention and 24 control districts. A Difference in Difference (DiD) analysis was conducted to assess the impact of the intervention on maternal and child health outcomes. The linear regression method was used to calculate the DiD, adjusting for potential covariates. The final models were arrived by stepwise backward method including the confounding variables significant at p < 0.05. RESULTS: The results of the DiD analyses showed at least four antenatal care visits (ANC) decreased in the intervention area (DiD% = - 4.8), while the delivery conducted by skilled birth attendants increased (DiD% = 6.6) compared to control area. However, the adjusted regression coefficient showed that these differences were not significant, indicating a null effect of the intervention. Regarding the child health outcomes, children with underweight (DiD% = 6.3), and wasting (DiD% = 5.4) increased, and stunting (DiD% = - 6.3) decreased in the intervention area compared to control area. The adjusted regression coefficient showed that the difference was significant only for wasting (ß = 0.019, p = 0.002), indicating the prevalence of wasting increased in the intervention group compared to the control group. CONCLUSION: The IC approach implemented in Nepal did not show improvements in maternal and child health outcomes compared to control districts. The use of the IC approach to improve MCH in Nepal should be discussed and, if further used, the process of implementation should be strictly monitored and evaluated.
Asunto(s)
Servicios de Salud del Niño , Servicios de Salud Materna , Niño , Familia , Femenino , Humanos , Recién Nacido , Nepal/epidemiología , Embarazo , Atención PrenatalRESUMEN
OBJECTIVE: To evaluate delayed interval deliveries in multiple gestations in regard of delayed interval and neonatal survival and to provide a protocol. METHODS: Data of multiple pregnancies with delayed interval delivery at a tertiary maternity unit between 2002 and 2017 were collected. Contraindications for evaluation of a delay of the delivery of the remaining child were: severe maternal blood loss, poor maternal general condition, preeclampsia, placental abruption, fetal distress, serious congenital malformations of the remaining child, chorioamnionitis, and premature rupture of membranes of the second fetus. A total of 14 cases was included in this retrospective monocentric analysis. RESULTS: The cohort comprised nine twin and five triplet pregnancies. Mean gestational age at delivery of the first fetus was 21 + 6 and 26 + 0 of the retained fetus, respectively. The earliest delivery of the first fetus was at 15 + 2 weeks. The mean interval of the delay was 29.3 days (2-82 days). Mortality of the first fetuses was 53.3%, while it was 17.6% for the retained fetuses. Maternal outcome was good in general: two cases of major blood loss occurred with the necessity of a blood transfusion. CONCLUSION: Delayed interval delivery is a reasonable approach in cases of an imminent preterm birth in multiple gestations which can be performed with a good fetal outcome and limited maternal risks. The situation when this procedure may be an option always comes unexpected. Therefore, the team of perinatologists should keep it in mind as one potential therapeutic approach. In addition, a standard protocol for the procedure should be established in the perinatal center.
Asunto(s)
Parto Obstétrico/métodos , Adulto , Estudios de Cohortes , Femenino , Alemania , Edad Gestacional , Humanos , Recién Nacido , Embarazo , Nacimiento Prematuro , Atención Prenatal , Estudios Retrospectivos , Trillizos , Gemelos , Adulto JovenRESUMEN
BACKGROUND: Maternal pre-conception obesity is a strong risk factor for childhood overweight. However, prenatal mechanisms and their effects in susceptible gestational periods that contribute to this risk are not well understood. We aimed to assess the impact of late-pregnancy dysglycemia in obese pregnancies with negative testing for gestational diabetes mellitus (GDM) on long-term mother-child outcomes. METHODS AND FINDINGS: The prospective cohort study Programming of Enhanced Adiposity Risk in Childhood-Early Screening (PEACHES) (n = 1,671) enrolled obese and normal weight mothers from August 2010 to December 2015 with trimester-specific data on glucose metabolism including GDM status at the end of the second trimester and maternal glycated hemoglobin (HbA1c) at delivery as a marker for late-pregnancy dysglycemia (HbA1c ≥ 5.7% [39 mmol/mol]). We assessed offspring short- and long-term outcomes up to 4 years, and maternal glucose metabolism 3.5 years postpartum. Multivariable linear and log-binomial regression with effects presented as mean increments (Δ) or relative risks (RRs) with 95% confidence intervals (CIs) were used to examine the association between late-pregnancy dysglycemia and outcomes. Linear mixed-effects models were used to study the longitudinal development of offspring body mass index (BMI) z-scores. The contribution of late-pregnancy dysglycemia to the association between maternal pre-conception obesity and offspring BMI was estimated using mediation analysis. In all, 898 mother-child pairs were included in this unplanned interim analysis. Among obese mothers with negative testing for GDM (n = 448), those with late-pregnancy dysglycemia (n = 135, 30.1%) had higher proportions of excessive total gestational weight gain (GWG), excessive third-trimester GWG, and offspring with large-for-gestational-age birth weight than those without. Besides higher birth weight (Δ 192 g, 95% CI 100-284) and cord-blood C-peptide concentration (Δ 0.10 ng/ml, 95% CI 0.02-0.17), offspring of these women had greater weight gain during early childhood (Δ BMI z-score per year 0.18, 95% CI 0.06-0.30, n = 262) and higher BMI z-score at 4 years (Δ 0.58, 95% CI 0.18-0.99, n = 43) than offspring of the obese, GDM-negative mothers with normal HbA1c values at delivery. Late-pregnancy dysglycemia in GDM-negative mothers accounted for about one-quarter of the association of maternal obesity with offspring BMI at age 4 years (n = 151). In contrast, childhood BMI z-scores were not affected by a diagnosis of GDM in obese pregnancies (GDM-positive: 0.58, 95% CI 0.36-0.79, versus GDM-negative: 0.62, 95% CI 0.44-0.79). One mechanism triggering late-pregnancy dysglycemia in obese, GDM-negative mothers was related to excessive third-trimester weight gain (RR 1.72, 95% CI 1.12-2.65). Furthermore, in the maternal population, we found a 4-fold (RR 4.01, 95% CI 1.97-8.17) increased risk of future prediabetes or diabetes if obese, GDM-negative women had a high versus normal HbA1c at delivery (absolute risk: 43.2% versus 10.5%). There is a potential for misclassification bias as the predominantly used GDM test procedure changed over the enrollment period. Further studies are required to validate the findings and elucidate the possible third-trimester factors contributing to future mother-child health status. CONCLUSIONS: Findings from this interim analysis suggest that offspring of obese mothers treated because of a diagnosis of GDM appeared to have a better BMI outcome in childhood than those of obese mothers who-following negative GDM testing-remained untreated in the last trimester and developed dysglycemia. Late-pregnancy dysglycemia related to uncontrolled weight gain may contribute to the development of child overweight and maternal diabetes. Our data suggest that negative GDM testing in obese pregnancies is not an "all-clear signal" and should not lead to reduced attention and risk awareness of physicians and obese women. Effective strategies are needed to maintain third-trimester glycemic and weight gain control among otherwise healthy obese pregnant women.
Asunto(s)
Glucemia/metabolismo , Diabetes Mellitus Tipo 2/epidemiología , Hemoglobina Glucada/metabolismo , Obesidad/epidemiología , Estado Prediabético/epidemiología , Adulto , Peso al Nacer , Índice de Masa Corporal , Preescolar , Diabetes Gestacional/sangre , Diabetes Gestacional/tratamiento farmacológico , Diabetes Gestacional/epidemiología , Femenino , Macrosomía Fetal/epidemiología , Ganancia de Peso Gestacional , Humanos , Peso Corporal Ideal , Recién Nacido , Estudios Longitudinales , Masculino , Obesidad/sangre , Sobrepeso/epidemiología , Embarazo , Tercer Trimestre del Embarazo/sangre , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Intestinal parasitic infections (IPI) lead to significant morbidity and mortality in pediatric and adult populations worldwide. Intestinal parasitism during pregnancy is of interest as it may affect the health of pregnant women and their offspring. This study determined the prevalence of IPI in pregnant women living in substandard conditions in three urban districts of Bogotá, Colombia. Associations between prevalence and sociodemographic factors, housing, and living conditions were also evaluated. METHODS: In a cross-sectional and community-based study, pregnant women were recruited from three districts of Bogotá. A total of 550 participants answered a questionnaire; 331 of these also provided stool samples, with 233 providing one and 98 providing two stool samples. Questionnaire responses were associated with the presence of intestinal parasites, which was determined using a standard combined microscopy technique including direct wet mount and formol-ether concentration. Results were verified by supplementary examination of 48 stool samples by quantitative polymerase chain reaction (qPCR). RESULTS: Among pregnant women who lived in selected poor residential areas in Bogotá, the overall prevalence of intestinal parasitism was 41% with 9% polyparasitism. Pathogenic parasites were present in 1.2% of the 331 participants including Giardia lamblia and Ascaris lumbricoides. Higher prevalence was found for parasites with debated pathogenicity, including Blastocystis hominis (25%), Endolimax nana (15%), Entamoeba coli (8%), and Iodamoeba butschlii (2%). Entamoeba histolytica/dispar complex was also detected (1.5%). When comparing a subset of stool samples using the combined microscopy technique and qPCR, the latter detected a higher 58.3% overall IPI prevalence. Higher prevalence of infections by any intestinal parasite was found in participants who had never been dewormed (p = 0.01). Higher but not statistically significant associations were found between any parasite and women living with a partner, and intestinal polyparasitism and being from a minority group and not having a water sink. CONCLUSIONS: This first study of the prevalence of intestinal parasitism in Bogotá focused on pregnant women living in poverty, found a high prevalence of intestinal parasites of debated pathogenicity, and confirmed a low prevalence of pathogenic intestinal parasites. These results highlight the need for educational interventions to disrupt transmission routes for prevalent parasites.
Asunto(s)
Parasitosis Intestinales/epidemiología , Complicaciones Parasitarias del Embarazo/epidemiología , Características de la Residencia/estadística & datos numéricos , Adolescente , Adulto , Colombia/epidemiología , Estudios Transversales , Heces/parasitología , Femenino , Humanos , Pobreza , Embarazo , Prevalencia , Factores de Riesgo , Encuestas y Cuestionarios , Adulto JovenRESUMEN
BACKGROUND: Giving birth assisted by skilled care in a health facility plays a vital role in preventing maternal deaths. In Nepal, delivery services are free and a cash incentive is provided to women giving birth at a health facility. Nevertheless, about half of women still deliver at home. This study explores socio-cultural and health service-related barriers to and facilitators of institutional delivery. METHODS: Six village development committees in hill and plain areas were selected in Chitwan district. We conducted a total of 10 focus group discussions and 12 in-depth-interviews with relevant stakeholder groups, including mothers, husbands, mothers-in-law, traditional birth attendants, female community health volunteers, health service providers and district health managers. Data were analyzed inductively using thematic analysis. RESULTS: Three main themes played a role in deciding the place of delivery, i.e. socio-cultural norms and values; access to birthing facilities; and perceptions regarding the quality of health services. Factors encouraging an institutional delivery included complications during labour, supportive husbands and mothers-in-law, the availability of an ambulance, having birthing centres nearby, locally sufficient financial incentives and/or material incentives, the 24-h availability of midwives and friendly health service providers. Socio-cultural barriers to institutional deliveries were deeply held beliefs about childbirth being a normal life event, the wish to be cared for by family members, greater freedom of movement at home, a warm environment, the possibility to obtain appropriate "hot" foods, and shyness of young women and their position in the family hierarchy. Accessibility and quality of health services also presented barriers, including lack of road and transportation, insufficient financial incentives, poor infrastructure and equipment at birthing centres and the young age and perceived incompetence of midwives. CONCLUSION: Despite much progress in recent years, this study revealed some important barriers to the utilization of health services. It suggests that a combination of upgrading birthing centres and strengthening the competencies of health personnel while embracing and addressing deeply rooted family values and traditions can improve existing programmes and further increase institutional delivery rates.
Asunto(s)
Parto Obstétrico , Accesibilidad a los Servicios de Salud , Servicios de Salud Materna/estadística & datos numéricos , Calidad de la Atención de Salud , Población Rural , Adulto , Niño , Femenino , Humanos , Entrevistas como Asunto , Masculino , Partería , Nepal , Embarazo , Investigación Cualitativa , Adulto JovenRESUMEN
PURPOSE: The purpose of this study was to correlate MR pelvimetric pelvic inlet measurements with mode of delivery and neonatal outcome in patients with suspected fetopelvic disproportion or breech presentation. METHODS: For this retrospective monocentric study, 237 consecutive MR pelvimetry reports (1999-2016) of pregnant women due to either suspected fetopelvic disproportion, pelvic deformation after trauma, or persistent breech presentation were retrieved from the radiologic database and matched with corresponding information from the obstetric database. RESULTS: Of 223 included women, 95 (42.6%) underwent planned cesarean section (pCS) and 128 (57.4%) underwent a trial of vaginal labour (TOL), of whom 93 (72.7%) delivered vaginally. Vaginal delivery was successful in 45 out of 64 (70.3%) cephalic cases and in 48 out of 64 (75.0%) breech cases. We found statistically significant differences in conjugata vera obstetrica (CV) and diameter transversalis (DT) between the groups TOL and pCS (CV: 12.5 ± 1.0 vs 12.1 ± 1.2 cm, p value 0.001; DT: 13.3 ± 0.9 vs 12.7 ± 0.9 cm, p value <0.001, respectively). However, there was no significant difference between successful VD and cesarean section after TOL (CV: 12.5 ± 0.9 vs 12.3 ± 1.1 cm, p value 0.194; DT: 13.4 ± 0.9 vs 13.2 ± 0.9 cm, p value 0.358, respectively). CONCLUSIONS: In our cohort, MR pelvimetry was a useful tool for prepartal assessment of the female pelvis in the selection of TOL candidates. Yet, it does not seem to yield additional predictive value for women with a previous vaginal delivery.
Asunto(s)
Presentación de Nalgas/diagnóstico por imagen , Desproporción Cefalopelviana/diagnóstico por imagen , Parto Obstétrico/métodos , Imagen por Resonancia Magnética/métodos , Pelvimetría/métodos , Adulto , Femenino , Humanos , Embarazo , Pronóstico , Estudios RetrospectivosRESUMEN
OBJECTIVES: Gestational trophoblastic disease (GTD) involves a spectrum of abnormal proliferations arising from the placental villous trophoblast. Although the incidence is low, a biomarker with short serum half-life would be a major clinical advance to monitor surgical and medical treatment reducing the socioeconomic burden of multiple control visits as well as patient's anxiety. Placental growth hormone (hGH-V) plays an important role in the regulation of normal placental growth and has shown angiogenic effects. We aimed to determine by immunohistochemistry (IHC) whether hGH-V is expressed in GTD and whether it can be detected in the patient's blood for potential monitoring of surgical or medical treatment procedures. METHODS: Tissue and sera were collected from women undergoing treatment for GTD in a tertiary care university hospital. We evaluated partial and complete hydatidiform moles, invasive moles and choriocarcinoma, n=16. Trophoblast specimens were examined by a newly developed IHC set-up for hGH-V in addition to gross morphologic and histopathological examination. Serum samples were analyzed by a highly sensitive hGH-V specific immunoassay. RESULTS: hGH-V was localized in all entities of GTD to the syncytiotrophoblast by immunohistochemistry. Serum hGH-V was detected for the first time in GTD and was present in a high percentage of all analyzed entities. CONCLUSIONS: hGH-V can be detected in all entities of GTD by IHC as well as by serum analysis and may therefore serve as a novel biomarker for the disease. Its clinical utility in diagnosis of GTD and monitoring surgical or medical treatment needs to be determined in further studies.
Asunto(s)
Biomarcadores de Tumor/sangre , Enfermedad Trofoblástica Gestacional/metabolismo , Hormona de Crecimiento Humana/metabolismo , Hormonas Placentarias/sangre , Femenino , Enfermedad Trofoblástica Gestacional/sangre , Hormona de Crecimiento Humana/sangre , Humanos , Inmunohistoquímica , EmbarazoRESUMEN
BACKGROUND: Health facility delivery is considered a critical strategy to improve maternal health. The Government of Nepal is promoting institutional delivery through different incentive programmes and the establishment of birthing centres. This study aimed to identify the socio-demographic, socio-cultural, and health service-related factors influencing institutional delivery uptake in rural areas of Chitwan district, where high rates of institutional deliveries co-exist with a significant proportion of home deliveries. METHODS: This community-based cross-sectional study was conducted in six rural Village Development Committees of Chitwan district, which are characterised by relatively low institutional delivery rates and the availability of birthing centres. The study area represents both hilly and plain areas of Chitwan. A total of 673 mothers who had given birth during a one-year-period were interviewed using a structured questionnaire. Univariate and multivariable logistic regression analysis using stepwise backward elimination was performed to identify key factors affecting institutional delivery. RESULTS: Adjusting for all other factors in the final model, advantaged caste/ethnicity [aOR: 1.98; 95% CI: 1.15-3.42], support for institutional delivery by the husband [aOR: 19.85; 95% CI: 8.53-46.21], the decision on place of delivery taken jointly by women and family members [aOR: 5.43; 95% CI: 2.91-10.16] or by family members alone [aOR: 4.61; 95% CI: 2.56-8.28], birth preparations [aOR: 1.75; 95% CI: 1.04-2.92], complications during the most recent pregnancy/delivery [aOR: 2.88; 95% CI: 1.67-4.98], a perception that skilled health workers are always available [aOR: 2.70; 95% CI: 1.20-6.07] and a birthing facility located within one hour's travelling distance [aOR: 2.15; 95% CI: 1.26-3.69] significantly increased the likelihood of institutional delivery. On the other hand, not knowing about the adequacy of physical facilities significantly decreased the likelihood of institutional delivery [aOR: 0.14; 95% CI: 0.05-0.41]. CONCLUSION: With multiple incentives present, the decision to deliver in a health facility is affected by a complex interplay of socio-demographic, socio-cultural, and health service-related factors. Family decision-making roles and a husband's support for institutional delivery exert a particularly strong influence on the place of delivery, and this should be emphasized in the health policy as well as development and implementation of maternal health programmes in Nepal.
Asunto(s)
Centros de Asistencia al Embarazo y al Parto/estadística & datos numéricos , Características Culturales , Parto Obstétrico/estadística & datos numéricos , Parto Domiciliario/estadística & datos numéricos , Atención Prenatal , Adolescente , Adulto , Estudios Transversales , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Recién Nacido , Evaluación de Necesidades , Nepal/epidemiología , Aceptación de la Atención de Salud/psicología , Embarazo , Atención Prenatal/métodos , Atención Prenatal/psicología , Atención Prenatal/estadística & datos numéricos , Población Rural/estadística & datos numéricos , Factores Socioeconómicos , Población Urbana/estadística & datos numéricosRESUMEN
BACKGROUND: This is a follow-up study to the pentaerythrityl tetranitrate randomized controlled multicenter trial that reports neonatal outcome data of newborns admitted to neonatal intensive care units and outcome data of the offspring at 12 months of age. OBJECTIVE: We present data on adverse events reported during the study to document the safety of pentaerythrityl tetranitrate treatment during pregnancy. To further evaluate the effects of pentaerythrityl tetranitrate on neonatal and long-term outcomes, we present follow up data from of 240 children at 12 months of age, including information on height, weight, head circumference, developmental milestones, and the presence of chronic disease and of 144 newborns admitted to the neonatal intensive care unit during the trial. STUDY DESIGN: The pentaerythrityl tetranitrate trial was a randomized, double-blind, placebo-controlled study designed to assess the efficacy and safety of the nitric oxide-donor pentaerythrityl tetranitrate in the prevention of fetal growth restriction and perinatal death in pregnancies complicated by abnormal placental perfusion. RESULTS: Results at 12 months demonstrated that significantly more children were age appropriately developed without impairments in the pentaerythrityl tetranitrate group (P=.018). In addition, the presence of chronic disease was lower in the pentaerythrityl tetranitrate group (P=.041). Outcome data of the 144 newborns admitted to the neonatal intensive care unit did not reveal differences between the treatment and placebo groups. There were no differences in the number or nature of reported adverse events between the study groups. CONCLUSION: The analysis shows that study children born in the pentaerythrityl tetranitrate cohort have a clear advantage compared with the placebo group at the age of 12 months, as evidenced by the increased incidence of normal development without the presence of chronic disease. Although safety has been proven, further follow-up studies are necessary to justify pentaerythrityl tetranitrate treatment during pregnancies complicated by impaired uterine perfusion.
Asunto(s)
Retardo del Crecimiento Fetal , Tetranitrato de Pentaeritritol , Humanos , Femenino , Embarazo , Método Doble Ciego , Estudios de Seguimiento , Recién Nacido , Tetranitrato de Pentaeritritol/administración & dosificación , Tetranitrato de Pentaeritritol/efectos adversos , Tetranitrato de Pentaeritritol/farmacología , Lactante , Retardo del Crecimiento Fetal/epidemiología , Masculino , Muerte Perinatal/prevención & control , Unidades de Cuidado Intensivo Neonatal/estadística & datos numéricos , Circulación Placentaria/fisiologíaRESUMEN
BACKGROUND: Endometrial carcinomas are the most common female genital malignancies. They are very rare in pregnancy and worldwide less than 60 cases associated with pregnancy are published. No clear cell carcinoma has been described in a pregnancy with a live birth. CASE PRESENTATION: We present the course of a 43-year-old Uyghur female patient with the diagnosis of endometrial carcinoma with a deficiency in the DNA mismatch repair system in the pregnancy. The malignancy with clear cell histology was confirmed by biopsy following the delivery via caesarean section due to preterm birth of a fetus with sonographically suspected tetralogy of Fallot. Earlier whole exome sequencing after amniocentesis had shown a heterozygous mutation in the MSH2 gene, which was unlikely to be related to the fetal cardiac defect. The uterine mass was initially deemed an isthmocervical fibroid by ultrasound and was confirmed as stage II endometrial carcinoma. The patient was consequently treated with surgery, radiotherapy and chemotherapy. Six months after the adjuvant therapy, re-laparotomy was performed due to ileus symptoms and an ileum metastasis was found. The patient is currently undergoing immune checkpoint inhibitor therapy with pembrolizumab. CONCLUSION: Rare endometrial carcinoma should be included in the differential diagnosis of uterine masses in pregnant women with risk factors.
Asunto(s)
Neoplasias Endometriales , Nacimiento Prematuro , Neoplasias Uterinas , Recién Nacido , Embarazo , Femenino , Humanos , Adulto , Inestabilidad de Microsatélites , Cesárea , Neoplasias Endometriales/genética , Neoplasias Endometriales/terapia , Neoplasias Endometriales/patologíaRESUMEN
OBJECTIVE: To examine the effect of physical partner violence on pregnancy loss and unplanned pregnancy. DESIGN: Cross-sectional, self-reported questionnaire survey. SETTING: A maternity ward of a university hospital in Munich, Germany. SAMPLE: Women who gave birth within the previous seven days. METHODS: The effects of physical partner violence on pregnancy loss and unplanned pregnancy were estimated using descriptive statistics based on χ(2) tests, bivariate logistic regression and multivariate logistic regression. MAIN OUTCOME MEASURES: Physical partner violence was assessed using the Abuse Assessment Screen, information on pregnancy loss was derived from women's medical files and the assessment of pregnancy planning was based on women's self-reports. RESULTS: The survey had a response rate of 73%; 29% of the women experienced pregnancy loss, 13% reported that their last pregnancy was unplanned and 4% revealed physical violence by a current or previous partner. Physical partner violence was significantly associated with pregnancy loss (odds ratio 8.33, 95% confidence interval 2.01-34.59) and unplanned last pregnancy (odds ratio 5.03, 95% confidence interval 1.21-21.26), even after adjusting for other commonly known explanatory factors, such as number of children, women's age and women's and their partners' education level and employment, marital status, financial situation and support during pregnancy. CONCLUSIONS: Physical partner violence is an important factor in understanding pregnancy loss and unplanned pregnancy. Inquiring about the existence of intimate partner violence among these women might help to identify women in need of domestic violence services.
Asunto(s)
Aborto Espontáneo/etiología , Embarazo no Planeado , Maltrato Conyugal , Adulto , Distribución de Chi-Cuadrado , Estudios Transversales , Femenino , Humanos , Modelos Logísticos , Análisis Multivariante , Embarazo , Autoinforme , Maltrato Conyugal/estadística & datos numéricosRESUMEN
Purpose: To assess the percentage of missed developmental dysplasia of the hip, which escape the German criteria for newborn hip high-risk screening, we analyzed our data gained from the general neonatal sonographic hip screening performed at our department. The aim of the study was to determine the number of potentially belatedly treated developmental dysplasia of the hip. Methods: The data from 1145 standardized newborn hip ultrasound examinations according to the Graf technique were analyzed retrospectively comparing findings for general neonatal sonographic hip screening and high-risk screening subgroups. Results: We diagnosed developmental dysplasia of the hip in 18 of the 1145 newborns via ultrasound. A total of 10 out of 18 developmental dysplasia of the hip would have been missed by high-risk screening, which corresponds to a proportion of 55.6% false-negative results. The sensitivity of high-risk screening was only 44.4% and specificity, 78.3%. The positive predictive value was 3.2%. Family history as a screening criterion yielded false-negative results in 77.8% and false-positive results in 16.8%. In all, 83.3% of the children who were born with developmental dysplasia of the hip but not from breech position as a risk factor were false negative. The clinical examination was false negative in 88.9% and false positive in 0.6%. Conclusion: High-risk screening detected less than every second developmental dysplasia of the hip, rendering the first month as the most effective treatment window unavailable for inapparent dysplastic hips, potentially resulting in the need for more invasive treatment. Due to the high sensitivity of ultrasound in the detection of developmental dysplasia of the hip, we recommend to replace the current German high-risk screening guidelines with a general newborn screening for all neonates using Graf ultrasound in the first week of life. Level of evidence: Level II.