Gestational weight trajectory and risk of adverse pregnancy outcomes among women with gestational diabetes mellitus: A retrospective cohort study.

The aim of this study was to explore gestational weight gain (GWG) trajectories and their associations with adverse pregnancy outcomes. A retrospective cohort study including 11,064 women with gestational diabetes mellitus (GDM) was conducted between 2015 and 2019 in China. The latent class trajectory model was used to identify GWG trajectories, and logistic regression was performed to examine odds ratio (OR) of pregnancy outcomes. Three trajectories of GWG were identified in these 11,604 women with GDM. Trajectory 1: 64.02% of women had sustained moderate GWG throughout pregnancy; Trajectory 2: 17.75% of women showed a high initial GWG but followed by a low GWG from the third trimester until delivery; Trajectory 3: 18.23% had low initial GWG but followed by drastic GWG from the second trimester until delivery. Compared with pregnant women with Trajectory 1, women with Trajectory 2 had a higher risk of large for gestational age (adjusted odds ratio [AOR]: 1.29, 95% confidence interval [CI]: 1.12-1.48) but at a lower risk of having hypertensive disorders of pregnancy (AOR: 0.76, 95% CI: 0.57-0.96). Women in Trajectory 3 were more likely to develop small for gestational age (AOR: 2.12, 95% CI: 1.62-2.78), low birthweight (AOR: 1.49, 95% CI: 1.07-2.08), preterm birth (AOR: 1.28, 95% CI: 1.05-1.63), caesarean section (AOR: 1.26, 95% CI: 1.112-1.42) and hypertensive disorders of pregnancy (AOR: 2.24, 95% CI: 1.82-2.76). The association of GWG trajectory with adverse pregnancy outcomes differs across prepregnancy body mass index and GWG categories. Women with a slow initial GWG but followed by drastic GWG had higher risks of adverse pregnancy outcomes. Early clinical recognition of poor GWG trajectory will contribute to early intervention in high-risk groups to minimise adverse outcomes.

The possible impact of the universal two-child policy on pregnancy outcomes.

PURPOSE: The implementation of the universal two-child policy contributes to adverse pregnancy outcomes, but how the policy change leads to adverse pregnancy outcomes is not well elaborated. In this study, we aimed to compare maternal characteristics and complications, accessed the change in the proportion of maternal characteristics and maternal complications, and evaluated the mediation of maternal characteristics on maternal complications. METHODS: Demographic and clinical data of three-level sample facilities were extracted from China's National Maternity Near Miss Obstetrics Surveillance System from Jan 1, 2012 to May 31, 2021. The associations between the universal two-child policy and maternal risk factors, the universal two-child policy and maternal complications, and maternal risk factors and maternal complications were evaluated using multivariate logistic regression analyses, with odds ratios (ORs) and 95% confidence intervals (CIs). Mediation analysis was used to estimate the potential mediation effects on the associations between the policy and maternal complications. Population-attributable fractions (PAF) were conducted to quantify the maternal complications burden attributable to the implementation of the universal two-child policy. RESULTS: In the context of the universal two-child policy, the incidence of maternal near miss, antepartum or intrapartum complication, and post-partum complication increased at municipal- and county-level sample facilities. After adjusting for covariables, there were significant associations between the universal two-child policy and maternal risk factors (P < 0.001), the universal two-child policy and an increased risk of maternal complications (P < 0.001), and maternal risk factors and maternal complications(P < 0.001). The effects of the universal two-child policy on maternal near miss and medical disease were significantly mediated by maternal risk factors with mediation proportions of 19.77% and 4.07% at the municipal-level sample facility, and mediation proportions for 2.72% at the county-level sample facility on medical disease. The universal two-child policy contributed 19.34%, 5.82%, 8.29%, and 46.19% in the incidence of the maternal near miss, antepartum or intrapartum complication, post-partum complication, and medical disease at municipal-level sample facility, respectively. The corresponding PAF% at county-level sample facility was 40.49% for maternal near miss, 32.39% for the antepartum or intrapartum complication, 61.44% for post-partum complication, and 77.72% for medical disease. For provincial-level sample facility, the incidence of maternal near miss, antepartum or intrapartum complications, and medical diseases decreased (P < 0.05) and no statistically significant difference occurred in the incidence of post-partum complications. CONCLUSIONS: In the context of the universal two-child policy, the incidence of maternal near miss, antepartum or intrapartum complication, and post-partum complication increased at municipal- and county-level sample facility. Maternal risk factors may play a mediating role in the effect of policy change and maternal complications. Provincial hospitals have been able to improve the quality of perinatal health care and reduce adverse pregnancy outcomes by adjusting their obstetric service strategies in the context of the new birth policy.

Interactive effect of prepregnancy overweight/obesity and GDM history on prevalence of GDM in biparous women.

Background: Prepregnancy overweight/obesity (OWO) and gestational diabetes mellitus (GDM) history may increase the prevalence of GDM in parous women, but little is known about their potential combined effect on the prevalence of GDM in biparous women. Objective: This study aims to explore the interactive effect of prepregnancy overweight/obesity (OWO) and GDM history on the prevalence of GDM in biparous women. Methods: A retrospective study was conducted on 16,282 second-birth women who delivered a single neonate at ≧28 weeks of gestation twice. Logistic regression was used to assess the independent and multiplicative interactions of prepregnancy overweight/obesity (OWO) and GDM history on the risk of GDM in biparous women. Additive interactions were calculated using an Excel sheet that was made by Anderson to calculate relative excess risk. Results: A total of 14,998 participants were included in this study. Both prepregnancy OWO and GDM history were independently associated with an increased risk of GDM in biparous women (odds ratio (OR) = 19.225, 95% confidence interval (CI) = 17.106, 21.607 and OR = 6.826, 95% CI = 6.085, 7.656, respectively). The coexistence of prepregnancy OWO and GDM history was associated with GDM, with an adjusted OR of 1.754 (95% CI, 1.625, 1.909) compared to pregnant women without either condition. The additive interaction between prepregnancy OWO and GDM history was found to be not significant with regard to GDM in biparous women. Conclusions: Prepregnancy OWO and GDM history both increase the risk of GDM in biparous women and have multiplicative interactions but not additive interactions.

Clinical characteristics of mirror syndrome: a retrospective study of 16 cases.

The exact prevalence of mirror syndrome remains unclear, and the precise clinical features need to be disclosed. We retrospectively reviewed 85 cases of foetal hydrops from a total of 98,484 deliveries. Of these 16 showed mirror syndrome, while 69 did not. The incidence of mirror syndrome among all deliveries was 0.0162%, while that among patients with foetal hydrops was 23.2%. Maternal symptoms of mirror syndrome included anaemia (n = 15), hypertension (n = 7), proteinuria (n = 8), pulmonary oedema (n = 3), cardiac failure (n = 2) and HELLP syndrome (n = 2). Placental thickness, placental weight and amniotic fluid index were significantly different between the groups. In the mirror syndrome group, uric acid, lactate dehydrogenase, creatinine and D-dimer levels were significantly higher (p < .05), whereas haemoglobin, serum albumin levels, haematocrit value and platelet count were significantly lower (p < .05). Elevated uric acid, lactate dehydrogenase and D-dimer levels may be useful as predictors of mirror syndrome.Impact statementWhat is already known on this subject? As mirror syndrome is uncommon and under-diagnosed, its exact incidence is not yet clear, and most publications are case reports or reviews of case reports.What the results of this study add? The incidence of mirror syndrome among all deliveries was 0.0162%, while that among patients with foetal hydrops was 23.2%. Pregnant women who develop mirror syndrome may show severe complications of pregnancy. Attention should be paid to the further progress of the condition. Placental thickness, placental weight and amniotic fluid index were significantly different between those with mirror syndrome and those without. In the mirror syndrome group, the uric acid, lactate dehydrogenase, creatinine and D-dimer levels were significantly higher (p < .05), whereas haemoglobin level, haematocrit value, platelet count and serum albumin level were significantly lower (p < .05).What the implications are of these findings for clinical practice and/or further research? Mirror syndrome is not rare among patients with foetal hydrops. Elevated uric acid, lactate dehydrogenase and D-dimer levels may be useful as predictors of mirror syndrome.

Two-stage nomogram models in mid-gestation for predicting the risk of spontaneous preterm birth in twin pregnancy.

PURPOSE: This study aimed to develop two-stage nomogram models to predict individual risk of preterm birth at < 34 weeks of gestation in twin pregnancies by incorporating clinical characteristics at mid-gestation. METHODS: We used a case-control study design of women with twin pregnancies followed up in a tertiary medical centre from January 2018 to March 2019. Maternal demographic characteristics and transvaginal cervical length data were extracted. The nomogram models were constructed with independent variables determined by multivariate logistic regression analyses. The risk score was calculated based on the nomogram models. RESULTS: In total, 65 twin preterm birth cases (< 34 weeks) and 244 controls met the inclusion criteria. Based on univariate and multivariate logistic regression analyses, we built two-stage nomogram prediction models with satisfactory discrimination and calibration when applied to the validation sets (first-stage [22-24 weeks] prediction model, C-index: 0.805 and 0.870, respectively; second-stage [26-28 weeks] prediction model, C-index: 0.847 and 0.908, respectively). Restricted cubic splines graphically showed the risk of preterm birth among individuals with increased risk scores. Moreover, the decision curve analysis indicated that both prediction models show positive clinical benefit. CONCLUSION: We developed and validated two-stage nomogram models at mid-gestation to predict the individual probability of preterm birth at < 34 weeks in twin pregnancy.

Establishment of an antepartum predictive scoring model to identify candidates for vaginal birth after cesarean.

BACKGROUND: Evidence-based medicine has shown that successful vaginal birth after cesarean (VBAC) is associated with fewer complications than an elective repeat cesarean. Although spontaneous vaginal births and reductions in cesarean delivery (CD) rates have been advocated, the risk factors for VBAC complications remain unclear and failed trials of labor (TOL) can lead to adverse pregnancy outcomes. METHODS: To construct an antepartum predictive scoring model for VBAC. Retrospective analysis of charts from 1062 women who underwent TOL at no less than 28 gestational weeks with vertex singletons and no more than one prior CD. RESULTS: We constructed our scoring model based on the following variables: maternal age, previous vaginal delivery, interdelivery interval (time between prior cesarean and the following delivery), presence of prior cesarean TOL, dystocia as prior CD indication, intertuberous diameter, maternal predelivery body mass index, gestational age at delivery, estimated fetal weight, and hypertensive disorders. Previous vaginal delivery was the most influential variable. The nomogram showed an area under the curve of 77.7% (95% confidence interval, 73.8-81.5%; sensitivity, 78%; specificity, 70%; cut-off, 13 points). The Kappa value to judge the consistency of the results between the predictive model and the actual results was 0.71(95% confidence interval 0.65-0.77) indicating strong consistency. We used the cut-off to divide the VBAC women into two groups according to the success of the TOL. The maternal and neonatal outcomes such as labor time, number of deliveries by midwives, postpartum hemorrhage, uterine rupture, neonatal asphyxia, puerperal infection were significantly different between the two groups. CONCLUSIONS: Our predictive scoring model incorporates easily ascertainable variables and can be used to personalize antepartum counselling for successful TOLs after cesareans.

Prediction of vaginal birth after cesarean delivery in Southeast China: a retrospective cohort study.

BACKGROUND: We aimed to develop and validate a nomogram for effective prediction of vaginal birth after cesarean (VBAC) and guide future clinical application. METHODS: We retrospectively analyzed data from hospitalized pregnant women who underwent trial of labor after cesarean (TOLAC), at the Fujian Provincial Maternity and Children's Hospital, between October 2015 and October 2017. Briefly, we included singleton pregnant women, at a gestational age above 37 weeks who underwent a primary cesarean section, in the study. We then extracted their sociodemographic data and clinical characteristics, and randomly divided the samples into training and validation sets. We employed the least absolute shrinkage and selection operator (LASSO) regression to select variables and construct VBAC success rate in the training set. Thereafter, we validated the nomogram using the concordance index (C-index), decision curve analysis (DCA), and calibration curves. Finally, we adopted the Grobman's model to perform comparisons with published VBAC prediction models. RESULTS: Among the 708 pregnant women included according to inclusion criteria, 586 (82.77%) patients were successfully for VBAC. Multivariate logistic regression models revealed that maternal height (OR, 1.11; 95% CI, 1.04 to 1.19), maternal BMI at delivery (OR, 0.89; 95% CI, 0.79 to 1.00), fundal height (OR, 0.71; 95% CI, 0.58 to 0.88), cervix Bishop score (OR, 3.27; 95% CI, 2.49 to 4.45), maternal age at delivery (OR, 0.90; 95% CI, 0.82 to 0.98), gestational age (OR, 0.33; 95% CI, 0.17 to 0.62) and history of vaginal delivery (OR, 2.92; 95% CI, 1.42 to 6.48) were independently associated with successful VBAC. The constructed predictive model showed better discrimination than that from the Grobman's model in the validation series (c-index 0.906 VS 0.694, respectively). On the other hand, decision curve analysis revealed that the new model had better clinical net benefits than the Grobman's model. CONCLUSIONS: VBAC will aid in reducing the rate of cesarean sections in China. In clinical practice, the TOLAC prediction model will help improve VBAC's success rate, owing to its contribution to reducing secondary cesarean section.

Safety and feasibility of trial of labor in pregnant women with cesarean scar diverticulum.

OBJECTIVE: Literature on trial of labor after cesarean section (TOLAC) in women with isthmoceles is scarce because of complications associated with the procedure. This study investigated TOLAC's safety and feasibility in patients with isthmoceles. METHODS: The study group comprised 34 pregnant women with isthmoceles who vaginally delivered. The control group comprised 102 pregnant women without isthmoceles who vaginally delivered during the same period. Scar diverticula were measured using color Doppler ultrasonography; between-group delivery outcomes were compared. RESULTS: Of the study group patients, 27/34 had isthmoceles diagnosed by ultrasound before pregnancy. Nineteen (70.37%) of these patients had mild defects and eight (29.63%) had moderate defects. The scar diverticula's mean length, depth, and width were 1.05 ± 0.62, 0.54 ± 0.28, and 1.20 ± 0.70 cm, respectively. The residual muscle layer's mean thickness was 0.27 ± 0.07 cm. The mean diverticulum depth/residual muscular thickness ratio was 2.39 ± 2.58. The duration of the first stage of labor was significantly shorter and the neonatal weight was significantly lower in the study group than control group. CONCLUSION: Successful vaginal delivery is possible for women with mild and moderate isthmoceles. Further large-scale studies are needed to improve TOLAC's safety in pregnant women with isthmoceles.

Establishment and assessment of a nomogram for predicting adverse outcomes of preterm preeclampsia.

OBJECTIVE: This prospective study was designed to develop and internally validate an accurate prognostic nomogram model with which to predict the adverse outcomes of preterm preeclampsia. METHODS: Pregnant women with preeclampsia were divided into the adverse outcome group and the no adverse outcome group. The Kaplan-Meier method, univariate Cox regression analysis, and calculation of the concordance index (C-index) were applied to predictive evaluation of the nomogram. Calibration curves were drawn to test the nomogram prediction and actual observation of the adverse outcome rate. RESULTS: After 1000 internal validations of bootstrap resampling, the C-index of the nomogram for predicting adverse outcomes within 48 hours was 0.74 and the cut-off value was 0.53, with a sensitivity of 61.57% and a specificity of 76.93%. The C-index of the nomogram for predicting adverse outcomes within 7 days was 0.76 and the cut-off value was 0.37, with a sensitivity of 58.17% and a specificity of 84.82%. The calibration curves showed good concordance of incidence of adverse outcomes between nomogram prediction and actual observation. CONCLUSION: Cox regression has certain guiding significance in preventing and treating adverse outcomes, choosing the time of termination of pregnancy, and improving the prognosis of the mother and child.

Expression of ß-catenin in human trophoblast and its role in placenta accreta and placenta previa.

OBJECTIVES: To investigate the expression of ß-catenin in chorionic villi, and to explore its roles in placenta accreta and placenta previa. METHODS: We compared ß-catenin expression in the control group, placenta accreta group (lesion area and normal zones), and placenta previa group (placental central and placental edge zones) by immunohistochemistry, Western blotting, and RT-PCR techniques. RESULTS: Compared with the normal group, the placenta accreta group had a longer length of stay, greater bleeding volume, and lower newborn birth weight. Further, the expression of ß-catenin was lower in both placenta previa and placenta accreta groups than in the control group, as measured by immunohistochemistry. Compared with the control group, expression of ß-catenin was significantly lower in the placenta previa and placenta accreta groups by Western blotting and RT-PCR. Importantly, the level of placental ß-catenin was significantly different when compared between the lesion and normal zones of placenta. CONCLUSION: The expression of ß-catenin in placenta accreta might play an important role in the regulation of placental cell invasion; low expression of ß-catenin in placenta accreta might be responsible for excessive trophoblastic invasion.

Relationship Between Myo-Inositol Supplementary and Gestational Diabetes Mellitus: A Meta-Analysis.

To determine whether myo-inositol supplement will increase the action of endogenous insulin, which is mainly measured by markers of insulin resistance such as homeostasis model assessment of insulin resistance.PubMed, Cochrane Library, Embase, and web of science were comprehensively searched using "gestational diabetes mellitus" and "myo-inositol" to identify relevant studies. Both subject headings and free texts were adopted. The methodological quality of the included studies were assessed and pooled analyzed by the methods recommended by the Cochrane collaboration.A total of 5 trials containing 513 participants were included. There was a significant reduction in aspects of gestational diabetes incidence (risk ratio [RR], 0.29; 95% confidence interval (95% CI), 0.19-0.44), birth weight (mean difference [MD], -116.98; 95% CI, -208.87 to -25.09), fasting glucose oral glucose tolerance test (OGTT) (MD, -0.36; 95% CI, -0.51 to -0.21), 1-h glucose OGTT (MD, -0.63; 95% CI, -1.01 to -0.26), 2-h glucose OGTT (MD, -0.45; 95% CI, -0.75 to -0.16), and related complications (odds ratio [OR], 0.28; 95% CI 0.14-0.58).On the basis of current evidence, myo-inositol supplementation reduces the development of gestational diabetes mellitus (GDM), although this conclusion requires further evaluation in large-scale, multicenter, blinded randomized controlled trials.