Cross-sectional study examining factors impacting on uptake of postpartum type 2 diabetes screening among women diagnosed with hyperglycaemia in pregnancy.

AIMS: Early postpartum glucose screening of women with hyperglycaemia in pregnancy (HIP) can identify women who have the highest risk of developing impaired glucose tolerance and T2DM. This study examines the association between demographics, events during pregnancy, socioeconomic status and postpartum T2DM screening. METHODS: Using the French National Health Data System, this cross-sectional study included all deliveries where the mother had HIP in France in 2015, (n = 76,862). The odds ratio (OR) for attending postpartum screening was calculated via multi-level logistic regression. RESULTS: T2DM screening uptake at six months postpartum was 42·9% [95 % Confidence Interval: 42·6-43·3]. Several characteristics were associated with lower uptake: living in the most deprived area(OR = 0·78[0·74-0·83]); being < 25 years-old (reference age group 25-29;≤17: 0.53 [0·31-0·90];18-24: 0.73[0·69-0·78]); smoking (0·65[0·62-0·68]); obesity (0·93[0·89-0·97]); caesarean delivery (0·95[0·92-0·99]). Factors associated with higher uptake included primiparity (1·30[1·26-1·34]); having followed the French recommendations for HIP screening (1·24[1·20-1·28]); insulin prescription (1·75[1·69-1·81]) and pre-eclampsia (1·30[1·19-1·42]). p < 0.01 is justified due to sample size. CONCLUSION: Improving identification of factors affecting postpartum T2DM screening uptake, such as demographics, socioeconomic context and events during pregnancy, may lead to development of target interventions to aide adherence to screening regime and thereby diagnosis of women with prediabetes or diabetes, for whom secondary and tertiary prevention is crucial.

Maternal and neonatal outcomes according to the timing of diagnosis of hyperglycaemia in pregnancy: a nationwide cross-sectional study of 695,912 deliveries in France in 2018.

AIMS/HYPOTHESIS: We aimed to assess maternal-fetal outcomes according to various subtypes of hyperglycaemia in pregnancy. METHODS: We used data from the French National Health Data System (Système National des Données de Santé), which links individual data from the hospital discharge database and the French National Health Insurance information system. We included all deliveries after 22 gestational weeks (GW) in women without pre-existing diabetes recorded in 2018. Women with hyperglycaemia were classified as having overt diabetes in pregnancy or gestational diabetes mellitus (GDM), then categorised into three subgroups according to their gestational age at the time of GDM diagnosis: before 22 GW (GDM<22); between 22 and 30 GW (GDM22-30); and after 30 GW (GDM>30). Adjusted prevalence ratios (95% CI) for the outcomes were estimated after adjusting for maternal age, gestational age and socioeconomic status. Due to the multiple tests, we considered an association to be statistically significant according to the Holm-Bonferroni procedure. To take into account the potential immortal time bias, we performed analyses on deliveries at ≥31 GW and deliveries at ≥37 GW. RESULTS: The study population of 695,912 women who gave birth in 2018 included 84,705 women (12.2%) with hyperglycaemia in pregnancy: overt diabetes in pregnancy, 0.4%; GDM<22, 36.8%; GDM22-30, 52.4%; and GDM>30, 10.4%. The following outcomes were statistically significant after Holm-Bonferroni adjustment for deliveries at ≥31 GW using GDM22-30 as the reference. Caesarean sections (1.54 [1.39, 1.72]), large-for-gestational-age (LGA) infants (2.00 [1.72, 2.32]), Erb's palsy or clavicle fracture (6.38 [2.42, 16.8]), preterm birth (1.84 [1.41, 2.40]) and neonatal hypoglycaemia (1.98 [1.39, 2.83]) were more frequent in women with overt diabetes. Similarly, LGA infants (1.10 [1.06, 1.14]) and Erb's palsy or clavicle fracture (1.55 [1.22, 1.99]) were more frequent in GDM<22. LGA infants (1.44 [1.37, 1.52]) were more frequent in GDM>30. Finally, women without hyperglycaemia in pregnancy were less likely to have preeclampsia or eclampsia (0.74 [0.69, 0.79]), Caesarean section (0.80 [0.79, 0.82]), pregnancy and postpartum haemorrhage (0.93 [0.89, 0.96]), LGA neonate (0.67 [0.65, 0.69]), premature neonate (0.80 [0.77, 0.83]) and neonate with neonatal hypoglycaemia (0.73 [0.66, 0.82]). Overall, the results were similar for deliveries at ≥37 GW. Although the estimation of the adjusted prevalence ratio of perinatal death was five times higher (5.06 [1.87, 13.7]) for women with overt diabetes, this result was non-significant after Holm-Bonferroni adjustment. CONCLUSIONS/INTERPRETATION: Compared with GDM22-30, overt diabetes, GDM<22 and, to a lesser extent, GDM>30 were associated with poorer maternal-fetal outcomes.

Measuring severe neonatal morbidity using hospital discharge data in France.

BACKGROUND: Measuring infant health at birth is key for surveillance and research in obstetrics and neonatology, but there is no international consensus on morbidity indicators. The Neonatal Adverse Outcome Indicator (NAOI) is a composite indicator, developed in Australia, which measures the burden of severe neonatal morbidity using hospital discharge data. OBJECTIVE: To evaluate the applicability of the NAOI in France for surveillance and research. METHODS: We constituted a cohort of live births ≥24 weeks' gestational age in Metropolitan France from 2014 to 2015 using hospital discharge, insurance claims and cause of death data. Outlier hospitals were identified using funnel plots of standardised morbidity ratios (SMR), and their coding patterns were assessed. We compared the NAOI and its component codes with published Australian and English data and estimated unadjusted and adjusted risk ratios for known risk factors for neonatal morbidity. RESULTS: We included 1,459,123 births (511 hospitals). Twenty-eight hospitals had SMR above funnel plot control limits. Newborns with NAOI morbidities in these hospitals had lower mortality and shorter stays than in other hospitals. Amongst within-limit hospitals, NAOI prevalence was 4.8%, comparable to Australia (4.6%) and England (5.4%). Most individual components had a similar prevalence, with the exception of respiratory support, intravenous fluid procedures and infection. NAOI was lowest at 39 weeks (2.2%) with higher risks for maternal age ≥40 (relative risk [RR] 1.47, 95% confidence interval [CI] 1.42, 1.51), state medical insurance (RR 1.60, 95% CI 1.52, 1.68), male sex (RR 1.21, 95% CI 1.19, 1.23) and birthweight <3rd percentile (RR 4.60, 95% CI 4.51, 4.69). CONCLUSIONS: The NAOI provides valuable information on population prevalence of severe neonatal morbidity and its risk factors. Whilst the prevalence was similar in high-income countries with comparable neonatal mortality levels, ensuring valid comparisons between countries and hospitals will require further work to harmonize coding procedures, especially for infection and respiratory morbidity.

Composite neonatal morbidity indicators using hospital discharge data: A systematic review.

BACKGROUND: Neonatal morbidity is associated with lifelong impairments, but the absence of a consensual definition and the need for large data sets limit research. OBJECTIVES: To inform initiatives to define standard outcomes for research, we reviewed composite neonatal morbidity indicators derived from routine hospital discharge data. DATA SOURCES: PubMed (updated on October 12, 2018). The search algorithm was based on three components: "morbidity," "neonatal," and "hospital discharge data." STUDY SELECTION AND DATA EXTRACTION: Studies investigating neonatal morbidity using a composite indicator based on hospital discharge data were included. Indicators defined for specific conditions (eg congenital anomalies, maternal addictions) were excluded. The target population, objectives, component morbidities, diagnosis and procedure codes, validation methods, and prevalence of morbidity were extracted. SYNTHESIS: For each study, we assessed construct validity by describing the methods used to select the indicator components and evaluated whether the authors assessed internal and external validity. We also calculated confidence intervals for the prevalence of the morbidity composite. RESULTS: Seventeen studies fulfilled inclusion criteria. Indicators targeted all (n = 4), low-/moderate-risk (n = 9), and very preterm (VPT, n = 4) infants. Components were similar for VPT infants, but domains and diagnosis codes within domains varied widely for all and low-/moderate-risk infants. Component selection was described for 8/17 indicators and some form of validation reported for 12/17. Neonatal morbidity prevalence ranged from 4.6% to 9.0% of all infants, 0.4% to 8.0% of low-/moderate-risk infants, and 17.8% to 61.0% of VPT infants. CONCLUSIONS: Multiple neonatal morbidity indicators based on hospital discharge data have been used for research, but their heterogeneity limits comparisons between studies. Standard neonatal outcome measures are needed for benchmarking and synthesis of research results.

The Impact of Severe Maternal Morbidity on Very Preterm Infant Outcomes.

OBJECTIVE: To estimate the prevalence of severe maternal morbidity among very preterm births and determine its association with very preterm infant mortality and morbidity. STUDY DESIGN: This study used New York City Vital Statistics birth and death records linked with maternal and newborn discharge abstract data for live births between 2010 and 2014. We included 6901 infants without congenital anomalies born between 240/7 and 326/7 weeks of gestation. Severe maternal morbidity was identified as life-threatening conditions or life-saving procedures. Outcomes were first-year infant mortality, severe neonatal morbidity (bronchopulmonary dysplasia, severe necrotizing enterocolitis, stage 3-5 retinopathy of prematurity, and intraventricular hemorrhage grades 3-4), and a combined outcome of death or morbidity. RESULTS: Twelve percent of very preterm live-born infants had a mother with severe maternal morbidity. Maternal and pregnancy characteristics associated with occurrence of severe maternal morbidity were multiparity, being non-Hispanic black, and preexisting health conditions, but gestational age and the percentage small for gestational age did not differ. Infants whose mothers experienced severe maternal morbidity had higher first-year mortality, 11.2% vs 7.7% without severe maternal morbidity, yielding a relative risk of 1.39 (95% CI: 1.14-1.70) after adjustment for maternal characteristics, preexisting comorbidities, pregnancy complications, and hospital factors. Severe neonatal morbidity was not associated with severe maternal morbidity. CONCLUSIONS: Severe maternal morbidity is an independent risk factor for mortality in the first year of life among very preterm infants after consideration of other maternal and pregnancy risk factors.

Preterm birth and selection in utero among males following the November 2015 Paris attacks.

BACKGROUND: On 13 November 2015, coordinated terrorist attacks swept through Paris. This large stressor, like earlier terrorist attacks in the USA, may have perturbed the health of pregnant women. We test whether the attacks preceded an increase in the risk of preterm parturition among live-born males as well as excess male loss in utero. We focused on males on the basis of previous findings of elevated male frailty following population stressors. METHODS: We examined live births in the Paris region (n = 1 049 057) over 70 months, from January 2011 to October 2016. Interrupted time-series methods identified and removed serial correlation in the monthly risk of preterm birth; these methods employed non-linear least-squares estimation. We also repeated analyses using month of conception, and performed sensitivity tests among females as well as among male births outside Paris. RESULTS: Males exhibited an elevated incidence of preterm birth in November 2015 and January 2016 [risk difference for November 2015 = 0.006, 95% confidence interval (CI): 0.0002-0.012; risk difference for January 2016 = 0.010, 95% CI: 0.004-0.016], which equates to an 11% increase in the count of preterm births. Females, as well as males born outside Paris, showed no change in preterm delivery. The sex ratio also fell below expected values in December 2015, January 2016 and February 2016. CONCLUSIONS: Among males, more preterm births, but fewer live births, occurred after the November 2015 Paris attacks. Future examinations of perinatal health responses to unexpected stressors may benefit from sex-specific analyses.

Are Meteorological Conditions within the First Trimester of Pregnancy Associated with the Risk of Severe Pre-Eclampsia?

BACKGROUND: Severe pre-eclampsia (SPE) is the second cause of maternal death in developed countries. The literature suggests different risk factors for early- and late-onset pre-eclampsia. SPE is usually related to the early-onset type. Pre-eclampsia rate exhibits seasonal variation. However, the weather-SPE association is still unknown. We examined the associations between maternal exposure to meteorological parameters after conception and SPE. METHODS: From 2008 to 2011, all deliveries of women living in the Yvelines area, France, have been prospectively registered. Meteorological measurements from weather stations scattered inside Yvelines were averaged on two exposure windows: early-pregnancy (30 days after conception) and first-trimester (90 days after conception). The relationship between SPE and season of conception was also examined. Hierarchical complementary log-log regression models were used to estimate the weather-SPE association. RESULTS: SPE was diagnosed in 526 (0.8%) out of 63,633 singleton pregnancies. Increasing temperature or sunshine across both windows was associated with increased SPE risk. Early-pregnancy minimum temperature showed the strongest effect with adjusted odds ratio (OR) per 1 degree Celsius: 1.03 [95% confidence interval (CI) 1.01, 1.04]. The risk of SPE was higher when conception was in summer as compared to winter (OR 1.53, 95% CI 1.27, 1.85). Effect estimates showed only small variations in sensitivity analyses. CONCLUSIONS: Our findings of a weather impact during early pregnancy on SPE may provide a new clue for understanding the causes of pre-eclampsia. Further investigation into the biologic mechanisms for this finding is required.