Prenatal iodine supplementation and early childhood neurodevelopment: the PoppiE trial - study protocol for a multicentre randomised controlled trial.

INTRODUCTION: Observational studies suggest both low and high iodine intakes in pregnancy are associated with poorer neurodevelopmental outcomes in children. This raises concern that current universal iodine supplement recommendations for pregnant women in populations considered to be iodine sufficient may negatively impact child neurodevelopment. We aim to determine the effect of reducing iodine intake from supplements for women who have adequate iodine intake from food on the cognitive development of children at 24 months of age. METHODS AND ANALYSIS: A multicentre, randomised, controlled, clinician, researcher and participant blinded trial with two parallel groups. Using a hybrid decentralised clinical trial model, 754 women (377 per group) less than 13 weeks' gestation with an iodine intake of ≥165 µg/day from food will be randomised to receive either a low iodine (20 µg/day) multivitamin and mineral supplement or an identical supplement containing 200) µg/day (amount commonly used in prenatal supplements in Australia), from enrolment until delivery. The primary outcome is the developmental quotient of infants at 24 months of age assessed with the Cognitive Scale of the Bayley Scales of Infant Development, fourth edition. Secondary outcomes include infant language and motor development; behavioural and emotional development; maternal and infant clinical outcomes and health service utilisation of children. Cognitive scores will be compared between groups using linear regression, with adjustment for location of enrolment and the treatment effect described as a mean difference with 95% CI. ETHICS AND DISSEMINATION: Ethical approval has been granted from the Women's and Children's Health Network Research Ethics Committee (HREC/17/WCHN/187). The results of this trial will be presented at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04586348.

Asymptomatic bacteriuria in pregnancy.

BACKGROUND: Asymptomatic bacteriuria (ASB) is associated with adverse maternal and neonatal outcomes and is routinely screened for and treated in the first trimester. Prevalence of ASB in the second and third trimesters of pregnancy is unknown. AIMS: The aim is to determine the prevalence of ASB in the second and third trimesters of pregnancy. METHODS: Prospective cohort study of 150 pregnant women. Mid-stream urine samples were tested for ASB in the second (24-28+6 ) and third (32-36+6 ) trimesters. Women were assigned to one of two groups: (i) ASB in any trimester of pregnancy and (ii) no evidence of ASB in pregnancy. Maternal and neonatal outcomes were compared between groups. RESULTS: Among 143 women included in the study, the rate of ASB was 4.9% (2.1, 2.1 and 3.2% in the first, second and third trimesters, respectively). Of those with ASB, 14% had it in every trimester, whereas 43% had it on two or more samples. Of those with ASB in pregnancy, 43% were detected for the first time in the third trimester. Rates of maternal and neonatal outcomes were not statistically significantly different between the two groups. No women with ASB were induced for chorioamnionitis or growth restriction. CONCLUSION: The rate of ASB was highest in the third trimester of pregnancy, with rates of 2.1, 2.1 and 3.2% in the first, second and third trimesters, respectively. This study was underpowered to assess maternal and fetal outcomes. Although numbers were small, the absence of ASB in the first trimester was a poor predictor of ASB in the third trimester.

Trends in early gestation stillbirths and neonatal deaths in New South Wales, Australia 2002-2019.

BACKGROUND: Little research has focused on understanding trends in early gestation (20-27 weeks) stillbirths and neonatal deaths. AIMS: To examine trends in early gestation stillbirths and neonatal deaths in New South Wales (NSW), Australia. MATERIALS AND METHODS: Population-based cohort study of all births ≥20 weeks gestation among female NSW residents during 2002 to 2019, induced pregnancy terminations excluded. Stillbirth rates by gestational age and birth year were calculated per 1000 fetuses-at-risk (FAR). Neonatal death rates by gestational age and birth year were calculated per 1000 live births. Linear regression was used to examine trends in stillbirth and neonatal death rates among all, singleton and twin births. RESULTS: Declining trends in early gestation stillbirth and neonatal death rates were found. Stillbirth rates decreased from 1.9 and 0.9/1000 FAR in 2002 to 1.6 and 0.7 in 2019 for 20-23 and 24-27 week groups, respectively. Neonatal rates decreased from 940 and 315/1000 live births in 2002 to 925 and 189 in 2019 for the 20-23 and 24-27 week groups, respectively. Among singleton births, declining trends in stillbirth and neonatal death rates across all age groups were observed, except for 37-38 week stillbirths. No trends in twin stillbirth rates were found across gestational age groups, although a decreasing trend was observed for 20-23 week twin neonatal deaths. CONCLUSIONS: Trends in early gestation stillbirth and neonatal deaths have declined in recent decades in NSW but further efforts are needed to reduce both early and late gestation stillbirth rates among twin births.

Pregnancy outcomes in women with endometriosis and/or ART use: a population-based cohort study.

STUDY QUESTION: What is the association between endometriosis and adverse pregnancy outcomes with ART use and non-use? SUMMARY ANSWER: Endometriosis and ART use are both associated with increased risk of preterm birth, antepartum haemorrhage, placenta praevia and planned birth (caesarean delivery or induction of labour). WHAT IS KNOWN ALREADY: There are contradictory findings on the association between endometriosis and adverse pregnancy outcomes, and many large studies have not considered the effect of ART use. STUDY DESIGN, SIZE, DURATION: Population-based cohort study of 578 221 eligible pregnancies during 2006-2015, comparing pregnancy outcomes across four groups (No endo/no ART, No endo/ART, Endo/no ART and Endo/ART). PARTICIPANTS/MATERIALS, SETTING, METHODS: All female residents of New South Wales, Australia aged 15-45 years and their index singleton pregnancy of at least 20 weeks gestation or 400 g birthweight. Linked hospital, pregnancy/birth and mortality data were used. Modified Poisson regression with robust error variances was used to estimate adjusted risk ratios (aRRs) and 99% CIs, adjusting for sociodemographic and pregnancy factors. MAIN RESULTS AND THE ROLE OF CHANCE: Compared to women without endometriosis who had pregnancies without ART use, there was increased risk of preterm birth (<37 weeks) in all groups [No endo/ART (aRR 1.85, 99% CI 1.46-2.34), Endo/no ART (aRR 1.24, 99% CI 1.06-1.44), Endo/ART (aRR 1.93, 99% CI 1.11-3.35)] and antepartum haemorrhage [No endo/ART (aRR 1.99, 99% CI 1.39-2.85), Endo/no ART (aRR 1.31, 99% CI 1.03-1.67), Endo/ART (aRR 2.69, 99% CI 1.30-5.56)] among pregnancies affected by endometriosis or ART use, separately and together. There was increased risk of placenta praevia [No endo/ART (aRR 2.26, 99% CI 1.42-3.60), Endo/no ART (aRR 1.66, 99% CI 1.18-2.33)] and planned birth [No endo/ART (aRR 1.08, 99% CI 1.03-1.14), Endo/no ART (aRR 1.11, 99% CI 1.07-1.14)] among pregnancies with endometriosis or ART use, separately. There was increased risk of placental abruption [No endo/ART (aRR 2.36, 99% CI 1.12-4.98)], maternal morbidity [No endo/ART (aRR 1.67, 99% CI 1.07-2.62)] and low birthweight (<2500 g) [No endo/ART (aRR 1.45, 99% CI 1.09-1.93)] among pregnancies with ART use without endometriosis. There was decreased risk of having a large-for-gestational age infant [Endo/no ART (aRR 0.83, 99% CI 0.73-0.94)] among pregnancies with endometriosis without ART use. LIMITATIONS, REASONS FOR CAUTION: Endometriosis is often under-diagnosed and women with a history of hospital diagnosis of endometriosis may represent those with more symptomatic or severe disease. If the effects of endometriosis on pregnancy are greater for those with more severe disease, our results may over-estimate the effect of endometriosis on adverse pregnancy outcomes at a population level. We were unable to assess the effect of endometriosis stage or typology on the study outcomes. WIDER IMPLICATIONS OF THE FINDINGS: These results suggest that women with endometriosis including those who used ART to achieve pregnancy are a higher-risk obstetric group requiring appropriate surveillance and management during their pregnancy. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the Prevention Research Support Program, funded by the New South Wales Ministry of Health. The funder had no role in the design, data collection and analysis, interpretation of results, manuscript preparation or the decision to submit the manuscript for publication. The authors have no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Training in obstetric anal sphincter injuries in Australia and New Zealand: A survey of Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees.

BACKGROUND: Training in obstetric anal sphincter injuries (OASIS) in Australia and New Zealand relies upon consultant teaching and has not previously been assessed. AIMS: The aims of this study are to establish if training in OASIS is consistent and optimal in Australia and New Zealand and to evaluate trainee perspectives on supervision and teaching, along with confidence in repairing OASIS. MATERIALS AND METHODS: A descriptive cross-sectional study was performed. Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees were sent a 21-question survey. The survey was distributed to 725 trainees, and 132 trainees provided complete responses (18.2%). The main outcome measures were (i) comparison of confidence in performing a caesarean section versus OASIS repair and (ii) descriptive analysis of views towards training and suggestions for improvement. RESULTS: Trainees were significantly more confident in performing a caesarean section independently compared to OASIS repair (P < 0.05). This was the case for all year groups. Confidence increased with each year of training. Only 62% reported credentialing at their site. Whereas 50% reported training at the time of first unsupervised repair as good or excellent, 22.7% felt it was suboptimal and 2.3% unsatisfactory; 75.8% had attended a workshop; 38.6% requested mandatory workshops. Requests included that workshops be yearly, include video training and be required at consultant level. Trainees asked for supervision despite credentialing and for separate credentialing for 3A/B- and 3C/4th-degree tears. CONCLUSIONS: Trainees have increasing confidence in their ability to independently perform OASIS repairs throughout training. They requested that improvements be made to training and that there be an increase in structured teaching.

Maternal factors and risk of spontaneous preterm birth due to high ambient temperatures in New South Wales, Australia.

BACKGROUND: Exposure to high ambient temperatures has been shown to increase the risk of spontaneous preterm birth. Determining which maternal factors increase or decrease this risk will inform climate adaptation strategies. OBJECTIVES: This study aims to assess the risk of spontaneous preterm birth associated with exposure to ambient temperature and differences in this relationship between mothers with different health and demographic characteristics. METHODS: We used quasi-Poisson distributed lag non-linear models to estimate the effect of high temperature-measured as the 95th percentile of daily minimum, mean and maximum compared with the median-on risk of spontaneous preterm birth (23-36 weeks of gestation) in pregnant women in New South Wales, Australia. We estimated the cumulative lagged effects of daily temperature and analyses on population subgroups to assess increased or decreased vulnerability to this effect. RESULTS: Pregnant women (n = 916,678) exposed at the 95th percentile of daily mean temperatures (25ºC) had an increased risk of preterm birth (relative risk 1.14, 95% confidence interval 1.07, 1.21) compared with the median daily mean temperature (17℃). Similar effect sizes were seen for the 95th percentile of minimum and maximum daily temperatures compared with the median. This risk was slightly higher among women with diabetes, hypertension, chronic illness and women who smoked during pregnancy. CONCLUSIONS: Higher temperatures increase the risk of preterm birth and women with pre-existing health conditions and who smoke during pregnancy are potentially more vulnerable to these effects.

Benefits of not smoking during pregnancy for non-Aboriginal women and their babies in New South Wales, Australia: a record linkage study.

BACKGROUND: Smoking rates among pregnant women in New South Wales (NSW) have plateaued at 8-9%. To inform relevant smoking reduction efforts, we aimed to quantify the benefits of not smoking during pregnancy for non-Aboriginal NSW mothers and their babies. The benefits of not smoking during pregnancy for NSW Aboriginal mothers have previously been described. These data are important inputs in modelling health and economic impacts of smoking cessation interventions. METHODS: This population-based cohort study used linked-data from routinely collected data sets. Not smoking during pregnancy was the exposure of interest among all NSW non-Aboriginal women who became mothers of singleton babies in 2012-2016. Unadjusted and adjusted relative risks (aRR) were used to examine associations between not smoking during pregnancy and adverse outcomes including severe morbidity, inter-hospital transfer, perinatal death, preterm birth and small-for-gestational age. Population attributable fractions (PAFs) were calculated to quantify adverse perinatal outcomes avoided in the population if all mothers were non-smokers. RESULTS: Compared with babies born to mothers who smoked during pregnancy, babies born to non-smoking mothers had a lower risk of all adverse perinatal outcomes including perinatal death (aRR = 0.68, 95%CI 0.61-0.76), preterm birth (aRR = 0.58, 95%CI 0.56-0.61) and small-for-gestational age (aRR = 0.48, 95%CI 0.47-0.50). PAFs(%) were 3.9% for perinatal death, 5.6% for preterm birth and 7.3% for small-for-gestational-age. Compared with women who smoked during pregnancy (n = 36,518), those who did not smoke (n = 413,072) had a lower risk of suffering severe maternal morbidity (aRR = 0.87, 95%CI 0.81-0.93) and being transferred to another hospital (aRR = 0.92, 95%CI 0.86-0.99). CONCLUSIONS: Mothers who reported not smoking during pregnancy had a small reduction in their risk of morbidity and of being transferred to another hospital whilst their babies had substantially reduced risks of all adverse perinatal outcomes. Results have implications for clinician training, clinical care standards, and performance management.

Place of birth and outcomes associated with large volume transfusion: an observational study.

BACKGROUND: Guidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. However postpartum haemorrhage is often unexpected. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals. METHODS: The study population was women giving birth in public hospitals in New South Wales, Australia, between July 2006 and December 2010. Data were obtained from linked hospital, birth and blood bank databases. The exposure of interest was transfusion of four or more units of red cells during admission for delivery. Outcomes included maternal morbidity, length of stay, neonatal morbidity and need for other blood products or transfer to higher care. Multivariable regression models were developed to predict need of transfusion of ≥4 units of red cells using variables known early in pregnancy and those known by the birth admission. RESULTS: Data were available for 231,603 births, of which 4309 involved a blood transfusion, with 1011 (0.4%) receiving 4 or more units. Women giving birth in lower level and/or smaller hospitals were more likely to receive ≥4 units of red cells. Women receiving ≥4 units in tertiary settings were more likely to receive other blood products and have longer hospital stays, but morbidity, readmission and hysterectomy rates were similar. Although 46% of women had no identifiable risk factors early in pregnancy, 20% of transfusions of ≥4 units occurred within this group. By the birth admission 70% of women had at least one risk factor for requiring ≥4 units of red cells. CONCLUSIONS: Overall outcomes for women receiving ≥4 units of red cells were comparable between tertiary and non-tertiary facilities. This is important given the inability of known risk factors to predict many instances of postpartum haemorrhage.

Validation of anaemia, haemorrhage and blood disorder reporting in hospital data in New South Wales, Australia.

OBJECTIVE: Hospital data are a useful resource for studying pregnancy complications, including bleeding-related conditions, however, the reliability of these data is unclear. This study aims to examine reliability of reporting of bleeding-related conditions, including anaemia, obstetric haemorrhage and blood disorders, and procedures, such as blood transfusion and hysterectomy, in coded hospital records compared with obstetric data from two large tertiary hospitals in New South Wales. RESULTS: There were 36,051 births between 2011 and 2015 included in the analysis. Anaemia and blood disorders were poorly reported in the hospital data, with sensitivity ranging from 2.5% to 24.8% (positive predictive value (PPV) 12.0-82.6%). Reporting of postpartum haemorrhage, transfusion and hysterectomy showed high sensitivity (82.8-96.0%, PPV 78.0-89.6%) while moderate consistency with the obstetric data was observed for other types of obstetric haemorrhage (sensitivity: 41.9-65.1%, PPV: 50.0-56.8%) and placental complications (sensitivity: 68.2-81.3%, PPV: 20.3-72.3%). Our findings suggest that hospital data may be a reliable source of information on postpartum haemorrhage, transfusion and hysterectomy. However, they highlight the need for caution for studies of anaemia and blood disorders, given high rates of uncoded and 'false' cases, and suggest that other sources of data should be sought where possible.

Reporting of gestational diabetes and other maternal medical conditions: validation of routinely collected hospital data from New South Wales, Australia.

INTRODUCTION: Hospital datasets are a valuable resource for examining prevalence and outcomes of medical conditions during pregnancy. To enable effective research and health planning, it is important to determine whether variables are reliably captured. OBJECTIVE: To examine the reliability of reporting of gestational and pre-existing diabetes, hypertension, thyroid conditions, and morbid obesity in coded hospital records that inform the population-level New South Wales Admitted Patient Data Collection. METHODS: Coded hospital admission data from two large tertiary hospitals in New South Wales, from 2011 to 2015, were compared with obstetric data, collected by midwives at outpatient pregnancy booking and in hospital after birth, as the reference standard. Records were deterministically linked and sensitivity, specificity, positive predictive values and negative predictive values for the conditions of interest were obtained. RESULTS: There were 36,051 births included in the analysis. Sensitivity was high for gestational diabetes (83.6%, 95% CI 82.4-84.7%), pre-existing diabetes (88.2%, 95% CI 84.1-91.6%), and gestational hypertension (80.1%, 95% CI 78.2-81.9%), moderate for chronic hypertension (53.5%, 95% CI 47.8-59.1%), and low for thyroid conditions (12.9%, 95% CI 11.7-14.2%) and morbid obesity (9.8%, 95% CI 7.6-12.4%). Specificity was high for all conditions (≥97.8%, 95% CI 97.7-98.0) and positive predictive value ranged from 53.2% for chronic hypertension (95% CI 47.5-58.8%) to 92.7% for gestational diabetes (95% CI 91.8-93.5%). CONCLUSION: Our findings suggest that coded hospital data are a reliable source of information for gestational and pre-existing diabetes and gestational hypertension. Chronic hypertension is less consistently reported, which may be remedied by grouping hypertension types. Data on thyroid conditions and morbid obesity should be used with caution, and if possible, other sources of data for those conditions should be sought.

Protocol for probiotic therapy vs placebo for preterm prelabour rupture of membranes to prolong pregnancy duration (Pro-PPROM) trial.

BACKGROUND: Preterm prelabour rupture of membranes (PPROM) is a common preterm birth antecedent. Preterm infants experience increased adverse newborn outcome risks. Infection is a risk factor for early birth in PPROM. Current management is antibiotic therapy, antenatal corticosteroids and to plan delivery at 37 weeks gestation. The microbiota and probiotics are potentially protective and may improve outcomes. AIMS: The primary aim is to evaluate whether oral probiotic therapy (Lactobacillus fermentum CECT5716) administered during PPROM between 24 and 34 weeks gestation prolongs pregnancy duration. The secondary aim is to evaluate maternal and neonatal outcomes. MATERIALS AND METHODS: This is a pragmatic, multicentre, double-blind, placebo-controlled randomised controlled trial in Australia. The population will be women with a singleton pregnancy and PPROM less than 34 weeks gestation. The intervention will be an oral probiotic therapy compared with a placebo control. The primary outcome will be the proportion of women still pregnant at seven days following PPROM. One-to-one randomisation will occur within 24 h of PPROM. The trial is powered (80%, alpha = 0.05) to detect an absolute percentage increase in the primary outcome of 30%, (from expected rate of 20% up to 50%). DISCUSSION: This trial will provide evidence for the effectiveness of the probiotic in prolonging pregnancy duration. Findings will inform the feasibility of a larger trial to examine the effect of oral probiotics on clinically important maternal and neonatal outcomes in PPROM.

A study of pregnancy after endometrial ablation using linked population data.

INTRODUCTION: Endometrial ablation encapsulates a range of procedures undertaken to destroy the endometrial lining of the uterus as a treatment for heavy menstrual bleeding in women who no longer wish to bear children. Pregnancy following ablation, while unlikely, can occur and may carry higher rates of complications. The aim of this study was to identify factors associated with post-endometrial ablation pregnancy and to describe pregnancy and birth outcomes for post-endometrial ablation pregnancies. MATERIAL AND METHODS: This population-based data linkage study included all female residents of New South Wales, Australia, aged 15-50 years with a hospital admission between July 2001 to June 2014 who birthed between July 2001 and June 2015. Cox proportional hazard regression was used to estimate associations between women's characteristics and post-endometrial ablation pregnancy of at least 20 weeks' gestation. Descriptive statistics were used to characterize pregnancy and birth outcomes. RESULTS: Of 18 559 women with an endometrial ablation, 575 (3.1%) had a post-ablation pregnancy of at least 20 weeks' gestation. Nulliparity (adjusted hazard ratio [aHR] 12.2, 95% confidence interval [CI] 9.1-16.2), older age (35-39 years: aHR 0.39, 95% CI 0.29-0.51; 40-44 years: aHR 0.06, 95% CI 0.04-0.11), marital status (single: aHR 0.67, 95% CI 0.55-0.83; widowed/divorced/separated: aHR 0.58, 95% CI 0.36-0.94) and a diagnosis of heavy menstrual bleeding (aHR 0.09, 95% CI 0.07-0.13) were associated with post-ablation pregnancy. There were high rates of cesarean delivery (43%), preterm birth (13%), twin or higher order pregnancies (9%) and stillbirth (13.3/1000 births) among these post-ablation pregnancies. CONCLUSIONS: Nulliparity at the time of endometrial ablation is associated with increased risk of post-ablation pregnancy, highlighting the importance of careful discussion and consideration of treatment options for heavy menstrual bleeding.

Rates of neonatal morbidity by maternal region of birth and gestational age in New South Wales, Australia 2003-2016.

INTRODUCTION: Research suggests that neonatal morbidity differs by maternal region of birth at different gestational ages. This study aimed to determine the overall and gestation-specific risk of neonatal morbidity by maternal region of birth, after adjustment for maternal, infant and birth characteristics, for women giving birth in New South Wales, Australia, from 2003 to 2016. MATERIAL AND METHODS: The study utilized a retrospective cohort study design using linked births, hospital and deaths data. Modified Poisson regression was used to determine risk with 95% confidence intervals (95% CI) of neonatal morbidity by maternal region of birth, overall and at each gestational age, compared with Australian or New Zealand-born women giving birth at 39 weeks. RESULTS: There were 1 074 930 live singleton births ≥32 weeks' gestation that met the study inclusion criteria, and 44 394 of these were classified as morbid, giving a neonatal morbidity rate of 4.13 per 100 live births. The gestational age-specific neonatal morbidity rate declined from 32 weeks' gestation, reaching a minimum at 39 weeks in all maternal regions of birth. The unadjusted neonatal morbidity rate was highest in South Asian-born women at most gestations. Adjusted rates of neonatal morbidity between 32 and 44 weeks were significantly lower for babies born to East (adjusted relative risk [aRR] 0.65, 95% CI 0.62-0.68), South-east (aRR 0.76, 95% CI 0.73-0.79) and West Asian-born (aRR 0.93, 95% CI 0.88-0.98) mothers, and higher for babies of Oceanian-born (aRR 1.11, 95% CI 1.04-1.18) mothers, compared with Australian or New Zealand-born mothers. Babies of African, Oceanian, South Asian and West Asian-born women had a lower adjusted risk of neonatal morbidity than Australian or New Zealand-born women until 37 or 38 weeks' gestation, and thereafter an equal or higher risk in the term and post-term periods. CONCLUSIONS: Maternal region of birth is an independent risk factor for neonatal morbidity in New South Wales.

Is mode of first birth a risk factor for subsequent preterm birth?

BACKGROUND: Previous preterm birth is a strong predictor of subsequent preterm birth, but less is known about the causes of preterm birth following a full-term first pregnancy. Recent research has highlighted previous caesarean section as a potential risk factor. AIM: To examine the relationship between mode of first birth and the risk of subsequent preterm birth in New South Wales (NSW), Australia. MATERIALS AND METHODS: A population-based record-linkage study of NSW women who had a live singleton first birth at ≥37 weeks gestation, followed by a singleton second birth between 2005 and 2017. Relative risk (RR) and 95% CI of preterm birth in the subsequent pregnancy was calculated using modified Poisson regression, with mode of first birth as the exposure. Spontaneous preterm birth and preterm prelabour caesarean were secondary outcomes. RESULTS: Women who had either an intrapartum (RR: 1.26, 95% CI 1.19-1.32) or prelabour caesarean (RR: 1.26, 95% CI 1.18-1.35) first birth had a higher risk of subsequent preterm birth (any birth <37 weeks gestation), than those who birthed vaginally. Women who had a previous instrumental birth (RR: 0.85, 95% CI 0.79-0.91) or prelabour caesarean (RR: 0.74, 95% CI 0.67-0.82) had lower risks of subsequent spontaneous preterm birth. However, prior prelabour caesarean also greatly increased risk of subsequent preterm prelabour caesarean (RR: 5.25, 95% CI 4.65-5.93). CONCLUSIONS: The mode of first birth has differing effects on the risk of subsequent spontaneous preterm birth and preterm prelabour caesarean. Awareness of the risk of subsequent preterm birth following caesarean section may help inform clinical decisions around mode of first birth.

Intrapartum fetal blood sampling performed at early cervical dilatation and delivery outcomes.

BACKGROUND: Intrapartum fetal blood sampling (FBS) is a fetal well-being diagnostic test for cardiotocogram abnormalities. AIM: The aim of this study was to determine whether women who had their first FBS at <4 cm cervical dilation had an increased risk of operative delivery (caesarean section, instrumental delivery) compared to those women who had their first FBS ≥ 4 cm dilation. MATERIALS AND METHODS: Retrospective cohort study involving labouring women who underwent FBS in a tertiary centre between 2015 and 2017. Women who had their first FBS at <4 cm dilation were compared to those who had their first FBS at ≥4 cm. The primary outcome was operative delivery (caesarean, instrumental delivery); secondary outcomes were neonatal complications. Univariate logistic regression was used to assess the association between degree of cervical dilation at first FBS and study outcomes. RESULTS: Among 591 women, 39 (6.6%) had their first FBS at <4 cm cervical dilation. Women in the ≥4 cm group were less likely to have a total of ≥2 FBS (P = 0.003). There was no difference in the primary outcome between the two groups. Women who had the first FBS at <4 cm dilation were twice as likely to have a caesarean section delivery (odds ratio 2.06, 95% confidence interval 1.06-3.98), although 41% had a vaginal birth (instrumental and spontaneous). There were no differences in rates of resuscitation or admission to nursery between groups. CONCLUSION: Women who had their first FBS < 4cm cervical dilation were twice as likely to have a caesarean section compared to women who had their first FBS ≥ 4 cm. However, 41% had a vaginal birth, and there were no differences in fetal outcomes.

Outcomes of Subsequent Births After Placenta Accreta Spectrum.

OBJECTIVE: To investigate subsequent birth rates, maternal and neonatal outcomes for women with a history of placenta accreta spectrum (placenta accreta, increta, and percreta). METHODS: A population-based record linkage study of women who had a first, second, or third birth in New South Wales from 2003 to 2016 was conducted. Data were obtained from birth and hospital records and death registrations. Women with a history of placenta accreta spectrum were matched to women without, on propensity score and parity, to compare outcomes with women who had similar risk profiles. Modified Poisson regression models were used to calculate adjusted relative risk (aRR) for a range of maternal and neonatal outcomes. RESULTS: We identified recurrent placenta accreta spectrum in 27/570 (4.7%, 95% CI 3.0-6.5%) of second and 9/119 (7.6%, 95% CI 2.8-12.3%) of third pregnancies after placenta accreta spectrum in the preceding birth, with an overall recurrence rate of 38/689 (5.5%, 95% CI 3.9-7.5%, compared with the population prevalence of 25.5/10,000 births (95% CI 24.6-26.4). Subsequent births after placenta accreta spectrum had higher risk of postpartum hemorrhage (aRR 1.51, 95% CI 1.19-1.92), transfusion (aRR 2.13, 95% CI 1.17-3.90), cesarean delivery (aRR 1.19, 95% CI 1.02-1.37), manual removal of placenta (aRR 6.92, 95% CI 3.81-12.55), and preterm birth (aRR 1.43, 95% CI 1.03-1.98), with lower risk of small for gestational age (aRR 0.64, 95% CI 0.43-0.96), compared with similar-risk births. CONCLUSION: Women with a history of placenta accreta spectrum have increased risk of maternal morbidity, preterm birth, and placenta accreta spectrum in the subsequent pregnancy compared with similar-risk women with no previous placenta accreta spectrum, although the absolute risks are generally low. These findings may be used to inform counseling of women on the risks of future pregnancies.

Maternal and neonatal outcomes associated with restless legs syndrome in pregnancy: A systematic review.

Restless legs syndrome (RLS) affects one in five pregnant women. This review aims to synthesise evidence regarding gestational RLS and its consequences on pregnant women and neonates. Search of Embase, MEDLINE, PsycINFO, Maternity and Infant Care and Scopus was conducted in July 2018 using MeSH headings and keywords for 'restless legs syndrome' and 'pregnancy' or 'birth'. Our search identified 16 eligible studies from 12 countries published between 2004 and 2018 concerning gestational RLS and one or more maternal, delivery or neonatal outcomes. The most consistent associations were observed between gestational RLS and increased risks of gestational hypertension, pre-eclampsia, and peripartum depression. There were mixed findings for caesarean delivery, preterm birth and low birth weight, with the majority reporting no association with gestational RLS. Gestational RLS was not associated with postpartum haemorrhage, gestational diabetes, fetal distress, or low Apgar scores. Future research is needed to investigate whether effective treatment of RLS can mitigate these potential harms. Validated methods for diagnosing RLS in pregnancy would support research in this growing field.

Determining a strategy to reduce smoking in pregnancy.

BACKGROUND: Further efforts, informed by current data, are needed to reduce smoking during pregnancy. AIMS: To describe trends in smoking during pregnancy and identify regions most likely to benefit from targeted smoking cessation interventions, in New South Wales (NSW), Australia. MATERIALS AND METHODS: All women who gave birth in NSW between 1994 and 2016 were included. Smoking status was identified from the Perinatal Data Collection. For births between 2012 and 2016, women were grouped into Local Health District (LHD) of residence, and smoking rates calculated. The impacts of a hypothetical smoking cessation intervention in four LHDs with (i) high smoking rates and (ii) high numbers of smokers, were compared. RESULTS: The overall smoking rate during pregnancy decreased from 22.1% in 1994 to 8.3% in 2016. [Correction added on 13 August 2020, after first online publication: the overall smoking rate during pregnancy in 1994 has been corrected from 14.5% to 22.1%.]. The decrease was lowest among women living in the most socioeconomically disadvantaged areas (41%) and highest among those living in the most advantaged areas (83%). Between 2012 and 2016, over half the women who smoked during pregnancy lived in one of four LHDs. Only 1% of women reporting smoking during pregnancy resided in the LHD with the highest smoking rate (34.7%). A simulated intervention targeting only four regions showed greater effect on the statewide smoking rate when targeting LHDs with high numbers of smokers rather than high smoking rates. CONCLUSIONS: Despite decreases in rates of smoking during pregnancy, there was evidence of geographic clustering of smokers. The greatest reduction in overall smoking may come from interventions targeting the four LHDs with the highest number of smokers.

Hyperparathyroidism in pregnancy.

Hyperparathyroidism is a rare disease during pregnancy, which has increased risks, including miscarriage and fetal growth restriction. However, the diagnosis of hyperparathyroidism is frequently not recognised or delayed as symptoms are non-specific and calcium is not routinely measured. With a thorough medical history and clinical suspicion, early diagnosis and treatment can reduce the risk of some pregnancy complications. A 35-year-old woman presented at 13/40 with hyperemesis gravidarum. She had elevated serum calcium and a parathyroid lesion on ultrasound. She underwent a parathyroidectomy with rapid normalisation of her calcium. Histopathology confirmed a parafibromin-deficient parathyroid tumour, suggestive of hyperparathyroidism jaw tumour syndrome. At 30/40, she presented with pre-eclampsia (hypertension, hyper-reflexia, proteinuria and intrauterine growth restriction) and had a caesarean section at 30+1/40, delivering a male infant, 897 g (fifth percentile). She had a prior 12-month history of chronic constipation and nephrolithiasis but was not investigated further despite elevated calcium (2.82 mmol/L).