A Bayesian model to estimate the cutoff value of TSH for management of preterm birth.

BACKGROUND: Determining a thyroid hormone cutoff value in pregnancy is challenging issue and several approaches have been introduced to optimize a utility function. We aimed to estimate the cutoff value of TSH using Bayesian method for prediction of preterm-birth. METHODS: This study was a secondary-analysis of the population-based data collected prospectively within the framework of the Tehran Thyroid and Pregnancy Study. A total of 1,538 pregnant women attending prenatal clinics. RESULTS: Using Bayesian method resulted a TSH-cutoff of (3.97mIU/L,95%CI:3.95-4.00) for distinguishing pregnant women at risk of preterm-birth. The cutoff was associated with acceptable positive predictive and negative predictive values (0.84,95% CI:0.80-0.88) and 0.92 (95%CI: 0.91-0.94), respectively). In women who were negative for thyroid peroxides antibody (TPOAb) with sufficient urinary iodine concentration (UIC), the TSH cutoff of 3.92 mIU/L(95%CI:3.70-4) had the highest predictive value; whereas in TPOAb positive women with insufficient UIC, the cutoff of 4.0 mIU/L(95%:CI 3.94-4) could better predict preterm birth. Cutoffs estimated in this study are close to the revised TSH value of 4.0mIU/L which is currently recommended by the American Thyroid Association. CONCLUSION: Regardless of TPOAb status or iodine insufficiency, risk of preterm labor is increased in pregnant women with TSH value of > 3.92 mIU/L; these women may benefit from Levothyroxine (LT4) therapy for preventing preterm birth.

Shoulder dystocia: A panic station or an opportunity for post-traumatic growth?

BACKGROUND: Traumatic births are considered as challenging events in the professional life of midwives. Negative emotional and psychological consequences of these births on midwives are well-established. However, evidence suggests that in the aftermath of challenging events, such as birth traumas, positive outcomes may emerge as well. Based on the literature, shoulder dystocia (SD) is known as one of the most traumatic birth experiences for midwives. In this study we aimed to explore the impact of experiencing SD complicated births on clinical practice of midwives. METHODS: A qualitative descriptive study was undertaken. Midwives who had an experience of at least one case of SD were invited to the study through the Australian College of Midwives. In-depth interviews were conducted with 25 midwives. Data were analysed using an inductive thematic approach. RESULTS: Three themes were identified 1) Putting on a brave face 2) Towards the growth zone 3) I am resilient enough to recover, because of …. Experience of SD was described as a dreadful event in midwives' career. However, on reflection, this experience was considered as a benefit which developed midwives' clinical expertise and contributed to their professional empowerment. Having faith in birth normality, support from workplace, seniority/ years of experience and self-confidence were among the factors which helped midwives in overcoming the stress after SD. CONCLUSION: There needs to be greater awareness about the consequences of traumatic births such as SD for midwives. Collegial support has a critical role in helping midwives to have a positive outlook on their traumatic experience and to ease their pathway of professional growth.

Catastrophic thinking: Is it the legacy of traumatic births? Midwives' experiences of shoulder dystocia complicated births.

BACKGROUND: Shoulder dystocia (SD) is considered one of the most traumatic birth experiences not only for women, but for clinicians involved as well. Adverse effects of birth trauma on the emotions and psyche of midwives have been well established. AIM: To explore the impact of SD, as a birth trauma, on midwives' orientation towards normal births and on their clinical practice and the factors which may deteriorate or improve the experience of SD. METHODS: In a qualitative descriptive study design, 25 in-depth interviews were undertaken with Australian midwives who had experienced at least one case of SD. Data were analysed thematically. FINDINGS: A total of four themes emerged: 1) an unforgettable birth; a wake-up call, 2) from passion to caution, 3) factors worsening the experience, and 4) factors soothing the experience. Fear, anxiety and doubt about their professional competence were the most common feelings experienced by midwives after SD. For many, the first exposure to SD left them contemplating their previous attitude towards normal birth. Disturbed orientation of normal birth shifted midwives towards hypervigilance in practice. Not having effective relationships with women and receiving poor support from colleagues were perceived to worsen the traumatic experience, whereas working in a midwifery continuity of care model and the sense of being appreciated improved midwives' experience after the trauma. CONCLUSION: Shoulder dystocia is a birth emergency that midwives will inevitably experience. Involvement in such births can potentially direct midwives towards a 'worst case scenario' mentality and affect the way they provide care for women in future.

Scoping review of the impact of birth trauma on clinical decisions of midwives.

OBJECTIVE: The psychological and emotional impact of a traumatic birth experience on clinicians is well-established. It is also known that emotions can generally influence decisions. However, it is not clear whether experiencing a birth trauma can affect the professional behaviour and decision-making of clinicians. This study explores the impact of birth trauma on clinical decision-making of midwives. DATA SOURCES: Four databases (Medline, Scopus, CINAHL and ProQuest) were searched to identify English language studies published from 1990 to 2018. Due to the lack of studies with specific focus on clinical decision-making after birth trauma, we defined two main domains for our literature search. To be included, studies had to focus on either traumatic birth experience or clinical decision-making in midwifery. The findings of the two domains were then integrated. STUDY SELECTION: Of a total 2104 studies identified, 70 received full-text screening with 40 included in the review. Twenty-two articles were about traumatic birth events and 18 examined decision-making in midwifery. DATA EXTRACTION: Information were extracted on each article's purpose, study design, data collection, participants, definitions of birth trauma and the context in which clinical decisions were made. RESULTS: Thematic analysis was conducted. The impact of birth trauma on midwives could be categorized into the following themes: psychological issues; professional concerns; changes in practice and positive impact. Review of literature indicated that clinical decision-making could be influenced through all these themes. CONCLUSION: Decision-making can be impacted by the midwife's affective state related to previous experience of birth trauma. The continuum of impact may vary from increased defensiveness to increased personal and professional growth. Being aware of this impact can help midwives to better manage their emotions while making decision after traumatic birth experiences.

Reproductive Assessment: Findings from 20 Years of the Tehran Lipid and Glucose Study.

CONTEXT: Reproductive domains of the Tehran lipid and glucose study (TLGS) are unique in that they provide reliable information on reproduction of an urban population of West Asia. The aim of this review is to present the most important reproductive findings of TLGS. EVIDENCE ACQUISITION: This review is summarizing all articles published in the context of reproductive aspects of TLGS results over the 20-year follow-up. A comprehensive databases search was conducted in PubMed (including Medline), Web of Science and Scopus for retrieving articles on the reproductive histories in context of the TLGS. RESULTS: The mean (SD) age at menarche and menopause was 13 (1.2) and 49.6 (4.5) years respectively. While pills were the most commonly used modern methods at the initiation of TLGS, the prevalence of condoms rose sharply and significantly over the follow up duration. Among women with history of gestational diabetes, the risk of diabetes and dyslipidemia progression were 2.44 and 1.2 fold higher than others. Prevalences of PCOS and idiopathic hirsutism among reproductive age participants of TLGS were 8.5% (95% CI: 6.8% - 10.2%) and 13.0% (95% CI: 10.9% - 15.1%), respectively. Trend of cardio-metabolic risk factors among women with PCOS showed that there were no statistically significant differences between mean changes of each cardio metabolic variables between PCOS and healthy women; PCOS status also significantly associated with increased hazard of diabetes and prediabetes among women aged younger than 40 years (HR: 4.9; 95% CI: 2.5 - 9.3, P value < 0.001)) and (HR: 1.7; 95% CI: 1.1 - 2.6), P value < 0.005), respectively. CONCLUSIONS: The population based nature of TLGS provides a unique opportunity for valid assessment of reproductive issues, the results of which could provide new information for modification of existing guidelines.

Validation of Billewicz Scoring System for Detection of Overt Hypothyroidism During Pregnancy.

BACKGROUND: Currently, various clinical and laboratory diagnostic methods are used to detect overt hypothyroidism during pregnancy. The Billewicz scoring index, as a clinical scale for detection of hypothyroidism, has been applied in general populations; however, its application during pregnancy remains a controversial subject of ongoing research. OBJECTIVES: The purpose of this study was to evaluate the diagnostic value of Billewicz scoring index for overt hypothyroidism in a general population of Iranian pregnant women. METHODS: This study was conducted on 1843 pregnant women. A comprehensive questionnaire, including Billewicz scoring items, was completed, and relevant clinical examinations were performed. The participants underwent serum measurements of thyroxine (T4), thyroid hormone uptake, thyroid-stimulating hormone (TSH), and thyroid peroxidase antibody (TPOAb). Using the receiver operating characteristic (ROC) curve analysis, the optimal sensitivity and specificity were determined as values with maximum yields on the Youden and Rsquo's Index (sensitivity + specificity-1). RESULTS: The prevalence of overt hypothyroidism and subclinical hypothyroidism was 3.3% and 28.6%, respectively. Overall, 3.6%, 18.9%, and 50% of euthyroid, subclinical hypothyroid, and overt hypothyroid women were TPOAb-positive, respectively. The mean Billewicz scores of euthyroid, overt hypothyroid, and subclinical hypothyroid women were -41.16 (11.16), -17.11 (13.63), and -40.1 (11.2), respectively. Based on the Billewicz scale, at least one sign of hypothyroidism was reported in 38.84% (n, 491) of euthyroid women. Scores ≤ -26.5 (sensitivity, 100%; specificity, 90.82%) were considered as the optimal scores for predicting overt hypothyroidism (Ldquo, Norisk, and Rsquo). CONCLUSIONS: The Billewicz clinical scoring system, as a reliable and inexpensive clinical tool, used along with laboratory measurements, can help screen overt hypothyroidism during pregnancy, primarily in low-resource settings.

Shoulder dystocia and range of head-body delivery interval (HBDI): The association between prolonged HBDI and neonatal outcomes: Protocol for a systematic review.

OBJECTIVE: Shoulder dystocia (SD) is an obstetric emergency which if not carefully diagnosed and managed, can contribute to lifelong neonatal morbidities. Despite current guidelines on the definition of SD (impaction of the fetal shoulder behind the maternal symphysis pubis and need for ancillary manoeuvres or head-body delivery interval (HBDI) >60 s) its accurate diagnosis requires clinical expertise as well as overall consideration of feto-maternal condition. Based on the literature available, our study aims to determine (1) the range of HBDI as an indicator of SD and (2) the neonatal complications occurring following prolonged HBDI in normal or SD-complicated births. STUDY DESIGN: A comprehensive literature search will be conducted in the following databases MEDLINE, CINAHL and Scopus (Elsevier) as well as international obstetric guidelines to find English language published data since 1970 that evaluate HBDI, prolonged HBDI and associated neonatal outcomes. Retrospective/prospective observational studies and randomized controlled trials will be recruited. As heterogeneity in definitions of SD among studies is expected, we will categorize our results according to the following two definitions: 1-Bony obstruction of fetal shoulder behind the maternal symphysis pubis or less commonly, posterior shoulder on sacral promontory and need for ancillary manoeuvres or 2- Head-body delivery interval (HBDI)> 60 s). Two reviewers will independently identify eligible studies, assess risk of bias and extract data based on predefined checklists. Outcomes of interest will be the HBDI in normal and SD-complicated births and associated neonatal consequences. DISCUSSION: Findings of this systematic review will provide reliable information regarding (1) the interval between birth of the head and birth of the shoulders and (2) neonatal outcomes attributed to either true SD or prolonged HBDI. Our findings will add to the knowledge of whether prolonged HBDI is an appropriate definition for SD and whether/what level of prolongation of HBDI results in adverse neonatal outcomes. This increased understanding will better inform the clinical practice of midwives and obstetricians.

Effectiveness of Prenatal Vitamin D Deficiency Screening and Treatment Program: A Stratified Randomized Field Trial.

Context: Despite evidence on the association between hypovitaminosis D and adverse pregnancy outcomes and the positive impact of vitamin D supplementation, no evidence exists supporting a universal screening program in pregnancy as part of routine prenatal care. Objective: We sought to determine the effectiveness of a prenatal screening program on optimizing 25-hydroxyvitamin D [25(OH)D] levels and preventing pregnancy complications. Also, to identify a safe regimen, we compared several regimens in a subgroup of vitamin D-deficient pregnant women. Design: Two cities of Masjed-Soleyman and Shushtar from Khuzestan province, Iran, were selected as the screening and nonscreening arms, respectively. Within the screening arm, a randomized controlled trial was conducted on 800 pregnant women. Setting: Health centers of Masjed-Soleyman and Shushtar cities. Patients or Participants: Pregnant women aged 18 to 40 years. Intervention: Women with moderate [25(OH)D, 10 to 20 ng/mL] and severe [25(OH)D, <10 ng/mL] deficiency were randomly divided into four subgroups and received vitamin D3 (D3) until delivery. Main Outcome Measure: Maternal concentration of 25(OH)D at delivery and rate of pregnancy complications. Results: After supplementation, only 2% of the women in the nonscreening site met the sufficiency level (>20 ng/mL) vs 53% of the women in the screening site. Adverse pregnancy outcomes, including preeclampsia, gestational diabetes mellitus, and preterm delivery, were decreased by 60%, 50%, and 40%, respectively, in the screening site. A D3 injection in addition to monthly 50,000 IU maintenance therapy contributed the most to achievement of sufficient levels at delivery. Conclusions: A prenatal vitamin D screening and treatment program is an effective approach in detecting deficient women, improving 25(OH)D levels, and decreasing pregnancy adverse outcomes.

Audit of Intrapartum Care Based on the National Guideline for Midwifery and Birth Services.

Providing high-quality maternity care is a worldwide health concern that necessitates regular assessment of intrapartum practice. In an observational study, we aimed to audit intrapartum care based on the National Guideline for Midwifery and Birth Services. Using quota sampling, a total of 200 pregnant women, admitted for normal vaginal delivery, were recruited from four educational hospitals in Tehran, Iran. An observational checklist was developed based on the national guideline to assess the quality of provided care. Content and face validity of the tool were checked and confirmed. Reliability of the observational checklist and questionnaire was confirmed using concurrent observation (intrarater reliability; r = .93) and test-retest ( r = .9) methods, respectively. We found that the compatibility of intrapartum care and the national guideline in different domains were as follows: history taking 88.3%, vital sign measurement 64.6%, performing Leopold's maneuver 38.5%, initial assessment 83.4%, labor care 22.5%, using pain relief methods 63.5%, labor progress assessment 71.5%, process of delivery 89.5%, and postpartum management 89.5%. The findings indicate that additional attention and monitoring are required to align current intrapartum care practices with the national guidelines.

Establishment of trimester-specific reference range for thyroid hormones during pregnancy.

OBJECTIVE: Physiological gestational changes are associated with alterations in thyroid function which require different biochemical interpretation from that of non-pregnant women and necessitate established pregnancy-specific reference ranges. We aimed to identify the trimester-specific ranges of thyroid markers in a healthy population of pregnant Iranian women. METHODS: In this self-sequential study, data were extracted from The Tehran Thyroid and Pregnancy Study; a total of 314 women were tested during the 1st, 2nd and 3rd trimesters for serum levels of thyrotropin (TSH), thyroxine (T4), free thyroxine index (FT4I) and thyroid peroxidase antibody (TPOAb). Trimester-specific reference intervals for TSH, T4 and FT4I and first trimester reference range for TPOAb were estimated. The normal and modulus exponential-normal models were fitted by maximum likelihood using STATA software. The 2.5th and 97.5th percentiles of thyroid parameters were determined and used as reference intervals. RESULTS: Mean±SD age of participants was 26.8±5.2years. Estimated reference intervals for TSH, T4 and FT4I in the 1st, 2nd and 3rd trimesters corresponding to the 2.5th and 97.5th percentiles were 0.14-6.14, 0.43-4.64, 0.63-3.9µIU/ml; 78.01-215.19, 93.23-243.87, 89.61-211.37nmol/L; and 1.73-4.53, 1.96-5.64, 1.72-4.30, respectively. Reference interval for TPOAb in the 1st trimester was 1.40-38.02IU/mL. Median of TSH was low in the 1st trimester, and gradually increased until 2nd trimester, followed by a slight decrease onward. A decreasing trend in TSH levels was observed in higher centiles with advancing gestational age. CONCLUSION: This study provides trimester-specific reference ranges for some common thyroid markers among healthy Iranian women in an iodine sufficient area, to prevent biochemical misinterpretations during pregnancy.

Effects of Levothyroxine on Pregnant Women With Subclinical Hypothyroidism, Negative for Thyroid Peroxidase Antibodies.

Context: Currently, there is no consensus on universal thyroid screening and levothyroxine (LT4) treatment of pregnant women with subclinical hypothyroidism (SCH) who are negative for thyroid peroxidase antibody (TPOAb-). Objective: We aimed to evaluate the benefits of LT4 treatment on pregnancy outcomes in SCH-TPOAb- women. Design: This study was conducted within the framework of the Tehran Thyroid and Pregnancy Study. A single-blind randomized clinical trial was undertaken in pregnant women who were SCH-TPOAb-. Setting: Prenatal care centers of the Shahid Beheshti University of Medical Sciences. Patients: Using the thyrotropin (TSH) cut point of 2.5 mIU/L, 366 SCH-TPOAb- and 1092 euthyroid TPOAb- women were recruited. Intervention: SCH-TPOAb- women were randomly assigned to two groups: group A (n = 183) who were treated with LT4 and group B (n = 183) who received no treatment. A total of 1,028 euthyroid TPOAb- women served as the control group (group C). Main Outcome Measure: The primary outcome was the rate of preterm delivery. Results: Using the TSH cutoff of 2.5 mIU/L, no significant difference in preterm delivery was observed between groups A and B [relative risk (RR): 0.86; 95% confidence interval (CI): 0.47 to 1.55; P = 0.61]. However, log-binomial model analysis based on a cut point of 4.0 mIU/L demonstrated a significantly lower rate of preterm delivery in LT4-treated women compared with those who received no treatment (RR: 0.38; 95% CI: 0.15 to 0.98; P = 0.04). Conclusions: Despite no beneficial effect of LT4 therapy in reducing preterm delivery in SCH-TPOAb- women with a TSH cut point of 2.5 to 4 mIU/L, LT4 could precisely decrease this complication using the newly recommended cutoff ≥4.0 mIU/L.

Dyslipidemia incidence and the trend of lipid parameters changes in women with history of gestational diabetes: a 15-year follow-up study.

PURPOSE: Evidence shows that patients with gestational diabetes mellitus (GDM) may exhibit features of dyslipidemic phenotype later in life. We aimed to examine and compare dyslipidemia incidence rate and the trend of lipid changes over a 15-years follow-up between the women with the history of GDM and their healthy peers. METHODS: This longitudinal study included 289 patients with GDM and 1183 women without GDM, aged 20-50 years. Pooled logistic regression model was utilized to estimate odds ratio of dyslipidemia. The generalized estimating equation was used to evaluate the trend of lipid parameters changes over time. RESULTS: Person-time dyslipidemia incidence rate in women with previous GDM was 0.067 (CI: 0.038, 0.096) with a median progression time of 2.13 years and for those without GDM was 0.059 (CI: 0.046, 0.072) with the median time of 2.31 years ([Formula: see text] = 0.214). The generalized estimating equation (GEE) analysis revealed no significant difference in trend changes of lipid profiles between two groups. CONCLUSIONS: Lipid disorder after GDM might be more influenced by other variables (BMI, anthropometric features, and smoking/lifestyle habits) rather than by the GDM status alone. Lipid profile changes of GDM women do not become significantly worse than their non-GDM counterparts, as time progresses.

Serum variations of anti-mullerian hormone and total testosterone with aging in healthy adult Iranian men: A population-based study.

BACKGROUND: Literature proves anti-mullerian hormone (AMH) and total testosterone (TT) as two important reproductive hormones in male development, however evidence regarding age variations of these hormones is lacking. AIMS: To estimate the normal serum AMH values and to assess the age-specific TT levels in men aged 30-70, we conducted the present population-based study. METHODS: A total of 831 healthy eligible men, aged 30-70 years, were recruited from Tehran Lipid and Glucose study cohort. Centiles for AMH were estimated according to the exponential normal 3-parameter model. The parametric method of Royston available in general software was applied for the first time to estimate the age-specific AMH and TT percentiles of 5th, 10th, 25th, 50th, 75th, 90th and 95th. RESULTS: Mean AMH level was 6.93, ranging from 0.1 to 40.1 ng/ml. Serum AMH concentrations followed a steady reduction with increasing age. Mean TT level was 4.8, ranging from 0.44 to 11.4 ng/ml. DISCUSSION: A measurable serum concentrations of AMH in healthy males throughout lifespan with variations, based on age, confirming a slight age-related AMH decline. Fractional polynomial (FP) regression models revealed that the mean and standard deviation (SD) of the TT were not associated with age, so the percentiles estimated were not age-specific. CONCLUSION: We presented a nomogram of age-specific AMH values in a healthy cohort of Iranian men. This finding might have clinical importance in dealing hormonal disorders in men.

Diabetes incidence and influencing factors in women with and without gestational diabetes mellitus: A 15year population-based follow-up cohort study.

AIM: Very few extensive follow-up investigations evaluating patients with history of gestational diabetes mellitus (GDM) have been documented. We conducted this longitudinal study to estimate the incidence of diabetes and its predictors in women with and without GDM. METHOD: A total of 2458 eligible women, aged 20-50years (476 with GDM and 1982 without GDM) were selected from among participants of the Tehran Lipid and Glucose study, based on the World Health Organization definition for GDM screening. Pooled logistic regression was used to assess the association between time-dependent covariates and diabetes. RESULTS: The incidence rate of diagnosed diabetes was 9/1000 for women with GDM and 4/1000 for their counterparts, without GDM. Kaplan-Meier curve indicated a significantly shorter median time for developing diabetes in women with a history of GDM (6.95years [IQ: 4.22-10.71]), compared to their healthy peers (8.45years [IQ: 5.08-10.89]). BMI and previous family history of diabetes were found as major risk factors for future diabetes in women with GDM. CONCLUSION: The results presented here lead to better identification and selection of at-risk women with prior GDM history.

Role of androgen ratios in the prediction of the metabolic phenotype in polycystic ovary syndrome.

OBJECTIVE: To identify the androgen ratio that best predicts insulin resistance and metabolic syndrome among women with polycystic ovary syndrome (PCOS). METHODS: Data for 180 women with PCOS and 180 healthy controls were extracted from two previous studies in Iran (conducted during 2008-2010 and 2011-2013). The diagnosis of PCOS was based on the Rotterdam criteria. The serum concentration of different androgens was measured. Receiver operating characteristic curve analysis was used to assess the ability of various androgen ratios to predict insulin resistance and metabolic syndrome. RESULTS: Among women with PCOS, the testosterone-to-androstenedione ratio was the best predictor of insulin resistance (sensitivity 0.83, specificity 0.42) and metabolic syndrome (sensitivity 0.85, specificity 0.70). Among healthy controls, the ratio of free androgen index to testosterone was the best predictor of insulin resistance (sensitivity 0.84, specificity 0.33) and metabolic syndrome (sensitivity 0.91, specificity 0.17). CONCLUSION: The prediction of insulin resistance and metabolic syndrome among women with PCOS was best accomplished with the testosterone-to-androstenedione ratio.

Low birth weight may increase body fat mass in adult women with polycystic ovarian syndrome.

BACKGROUND: Women engaged with polycystic ovarian syndrome (PCOS), as the commonest endocrine disorder, are known to have a specific type of adiposity. Birth weight is among different contributors reported to be responsible for this diversity. OBJECTIVE: We aimed to compare the relation between birth weight and body fat mass (BFM)/ body lean mass (BLM) in PCOS and their age and body mass index (BMI) matched normal controls. MATERIALS AND METHODS: In this case-control study, a total number of 70 reproductive aged women, diagnosed with PCOS and 70 age- BMI matched healthy women without hirsutism and/or ovulatory dysfunction were recruited., control group had no polycystic ovaries in ultrasonographic scans. A detailed history of birth weight was taken and was divided into the following categories: <2,500 (low birth weight, LBW) and 2,500-4,000 (normal birth weight; NBW). RESULTS: Results showed that LBW prevalence was higher in women with PCOS than in controls (19.3% (27) vs. 15.7% (22)). Also body fat and lean mass (BFM, BLM) have increased in adult women with PCOS who were born underweight compared to their normal (19.8±9.05 vs. 12.9±4.5, p=0.001 and 48.9±6.9 vs. 43.2±5.8, p=0.004 respectively). CONCLUSION: Fetal birth weight influences on the adulthood obesity, BFM and BLM. This impact is different among women with and without PCOS.