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1.
BJOG ; 2020 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-32189413

RESUMO

OBJECTIVES: We assessed the incidence, risk factors and adverse birth outcomes associated with elevated liver enzymes and low platelets (HELLP) syndrome. DESIGN: A retrospective population-based cohort study. SETTING: Canada (excluding Quebec), 2012/13-2015/16. POPULATION: Mothers with a singleton hospital live birth or stillbirth at ≥24 weeks gestation (N=1,078,323). METHODS: HELLP syndrome was identified using ICD-10-CA diagnostic code from delivery hospitalization data. We used logistic regression to identify independent risk factors for HELLP syndrome by obtaining adjusted odds ratios (AOR) and 95% confidence intervals (CI), and to assess the associations with adverse outcomes. MAIN OUTCOME MEASURES: Adverse maternal (e.g., eclampsia) and fetal/neonatal outcomes (e.g., intraventricular hemorrhage, perinatal death). RESULTS: The incidence of HELLP syndrome was 2.5 per 1,000 singleton deliveries (n=2,663). Risk factors included: age ≥35 years, rural residence, nulliparity, parity ≥4, pre-pregnancy and gestational hypertension and diabetes, assisted reproduction, chronic cardiac conditions, systemic lupus erythematosus, obesity, chronic hepatic conditions, placental disorders (e.g., fetomaternal transfusion), and congenital anomalies; PROM and age <25 years were inversely associated with HELLP syndrome (p-values <0.05). Women with syndrome had a 10-fold higher maternal mortality (95% CI 1.6-84.3) and elevated severe maternal morbidity (9.6 vs. 121.7 per 1,000; AOR=12.5, 95% CI 11.1-14.1); and higher perinatal mortality (4.3 vs. 21.0 per 1,000; AOR=4.5, 95%CI 3.5-5.9) and perinatal mortality/severe neonatal morbidity (21.2 vs 202.4 per 1,000; AOR=10.7, 95% CI 9.7-11.8). CONCLUSION: HELLP syndrome is associated with specific pre-pregnancy and pregnancy risk factors, higher rates of maternal death, and substantially higher severe maternal morbidity, perinatal mortality and severe neonatal morbidity.

2.
CMAJ ; 192(8): E191-E192, 2020 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-32094271
3.
Obstet Gynecol ; 135(3): 730-731, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32080035
4.
Obstet Gynecol ; 135(3): 731-732, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32080037
5.
Acta Obstet Gynecol Scand ; 99(3): 341-349, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31654401

RESUMO

INTRODUCTION: Women with diabetes, and their infants, have an increased risk of adverse events due to excess fetal growth. Earlier delivery, when fetuses are smaller, may reduce these risks. This study aimed to evaluate the week-specific risks of maternal and neonatal morbidity/mortality to assist with obstetrical decision making. MATERIAL AND METHODS: In this population-based cohort study, women with type 1 diabetes (n = 5889), type 2 diabetes (n = 9422) and gestational diabetes (n = 138 917) and a comparison group without diabetes (n = 2 553 243) who delivered a singleton infant at ≥36 completed weeks of gestation between 2004 and 2014 were identified from the Canadian Institute of Health Information Discharge Abstract Database. Multivariate logistic regression was used to determine the week-specific rates of severe maternal and neonatal morbidity/mortality among women delivered iatrogenically vs those undergoing expectant management. RESULTS: For all women, the absolute risk of severe maternal morbidity/mortality was low, typically impacting less than 1% of women, and there was no significant difference in gestational age-specific severe maternal morbidity/mortality between iatrogenic delivery and expectant management among women with any form of diabetes. Among women with gestational diabetes, iatrogenic delivery was associated with an increased risk of neonatal morbidity/mortality compared with expectant management at 36 and 37 weeks' gestation (76.7 and 27.8 excess cases per 1000 deliveries, respectively) and a lower risk of neonatal morbidity/mortality at 38, 39 and 40 weeks' gestation (7.9, 27.3 and 15.9 fewer cases per 1000 deliveries, respectively). Increased risks of severe neonatal morbidity following iatrogenic delivery compared with expectant management were also observed for women with type 1 diabetes at 36 (98.3 excess cases per 1000 deliveries) and 37 weeks' gestation (44.5 excess cases per 1000 deliveries) and for women with type 2 diabetes at 36 weeks' gestation (77.9 excess cases per 1000 deliveries) weeks. CONCLUSIONS: The clinical decision regarding timing of delivery is complex and contingent on maternal-fetal wellbeing, including adequate glycemic control. This study suggests that delivery at 38, 39 or 40 weeks' gestation may optimize neonatal outcomes among women with diabetes.

6.
Obstet Gynecol ; 134(6): 1234-1244, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31764734

RESUMO

OBJECTIVE: To estimate the incidence of anemia in pregnancy and compare the maternal and perinatal outcomes of women with and without anemia. METHODS: We conducted a population-based retrospective cohort study on all pregnant women in British Columbia who had a live birth or stillbirth at or after 20 weeks of gestation between 2004 and 2016. Women were diagnosed with anemia based on two criteria: third-trimester hemoglobin value or a delivery admission diagnosis of anemia (made before delivery). Anemia was categorized into no anemia (hemoglobin 11 g/dL or greater), mild (9-10.9 g/dL), moderate (7-8.9 g/dL), severe (less than 7 g/dL), or anemia of unspecified severity (with diagnosis made before delivery). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% CIs expressing the association between anemia and maternal and perinatal outcomes. RESULTS: Of 515,270 women in the study population, 65,906 (12.8%) had anemia: 11.8%, 0.43%, and 0.02% had mild, moderate, and severe anemia, respectively, and 0.58% had anemia of unspecified severity. Anemic women had longer hospitalization duration and more antenatal admissions, and rates of preeclampsia, placenta previa and cesarean delivery were higher among women with anemia. The intrapartum-postpartum blood transfusion rate was 5.1 per 1,000 among women without anemia, and higher among women with anemia (aOR 2.45, 95% CI 1.74-3.45 for mild anemia; 21.3, 95% CI 12.2-37.3 for moderate anemia; not analyzable for severe anemia; and 48.3, 95% CI 6.60-353.9 for anemia of unspecified severity). Anemia was associated with preterm birth (mild anemia, aOR 1.09, 95% CI 1.05-1.12; moderate anemia, aOR 2.26, 95% CI 2.02-2.54; anemia of unspecified severity, aOR 2.27, 95% CI 2.06-2.50), small-for-gestational-age live birth, low 5-minute Apgar score, neonatal death, and perinatal death. CONCLUSION: Maternal anemia in pregnancy represents a common and potentially reversible risk factor associated with antepartum, intrapartum, and postpartum maternal morbidity and perinatal morbidity and mortality.

7.
Obstet Gynecol ; 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31698368

RESUMO

OBJECTIVE: To estimate the incidence of anemia in pregnancy and compare the maternal and perinatal outcomes of women with and without anemia. METHODS: We conducted a population-based retrospective cohort study on all pregnant women in British Columbia who had a live birth or stillbirth at or after 20 weeks of gestation between 2004 and 2016. Women were diagnosed with anemia based on two criteria: third-trimester hemoglobin value or a delivery admission diagnosis of anemia (made before delivery). Anemia was categorized into no anemia (hemoglobin 11 g/dL or greater), mild (9-10.9 g/dL), moderate (7-8.9 g/dL), severe (less than 7 g/dL), or anemia of unspecified severity (with diagnosis made before delivery). Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% CIs expressing the association between anemia and maternal and perinatal outcomes. RESULTS: Of 515,270 women in the study population, 65,906 (12.8%) had anemia: 11.8%, 0.43%, and 0.02% had mild, moderate, and severe anemia, respectively, and 0.58% had anemia of unspecified severity. Anemic women had longer hospitalization duration and more antenatal admissions, and rates of preeclampsia, placenta previa and cesarean delivery were higher among women with anemia. The intrapartum-postpartum blood transfusion rate was 5.1 per 1,000 among women without anemia, and higher among women with anemia (aOR 2.45, 95% CI 1.74-3.45 for mild anemia; 21.3, 95% CI 12.2-37.3 for moderate anemia; not analyzable for severe anemia; and 48.3, 95% CI 6.60-353.9 for anemia of unspecified severity). Anemia was associated with preterm birth (mild anemia, aOR 1.09, 95% CI 1.05-1.12; moderate anemia, aOR 2.26, 95% CI 2.02-2.54; anemia of unspecified severity, aOR 2.27, 95% CI 2.06-2.50), small-for-gestational-age live birth, low 5-minute Apgar score, neonatal death, and perinatal death. CONCLUSION: Maternal anemia in pregnancy represents a common and potentially reversible risk factor associated with antepartum, intrapartum, and postpartum maternal morbidity and perinatal morbidity and mortality.

8.
CMAJ ; 191(42): E1149-E1158, 2019 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-31636163

RESUMO

BACKGROUND: The rate of obstetric anal sphincter injury has increased in recent years, particularly among operative vaginal deliveries. We sought to characterize temporal trends in episiotomy use and to quantify the association between episiotomy and obstetric anal sphincter injury. METHODS: Using a population-based retrospective cohort study design of hospital data from 2004 to 2017, we studied all vaginal deliveries of singleton infants at term gestation in Canada (excluding Quebec). Rates of obstetric anal sphincter injury were contrasted between women who had an episiotomy and those who did not. Log-binomial regression was used to estimate the association between episiotomy and obstetric anal sphincter injury among women with spontaneous and operative vaginal deliveries after controlling for confounders. RESULTS: The study population included 2 570 847 deliveries. Episiotomy use declined significantly among operative vaginal deliveries (53.1% in 2004 to 43.2% in 2017, p < 0.0001) and spontaneous vaginal deliveries (13.5% in 2004 to 6.5% in 2017, p < 0.0001). Episiotomy was associated with higher rates of obstetric anal sphincter injury among spontaneous vaginal deliveries (4.8 with episiotomy v. 2.4% without; adjusted rate ratio [RR] 2.06, 95% confidence interval [CI] 2.00-2.11) and this association remained after stratification by parity and obstetric history. In contrast, episiotomy was associated with lower rates of obstetric anal sphincter injury among forceps deliveries in nulliparous women (adjusted RR 0.63, 95% CI 0.61-0.66), and women with vaginal birth after cesarean (adjusted RR 0.71, 95% CI 0.60-0.85), but not among parous women without a previous cesarean (adjusted RR 1.16, 95% CI 1.00-1.34). INTERPRETATION: Episiotomy use has declined in Canada for all vaginal deliveries. The protective association between episiotomy and obstetric anal sphincter injury among women who gave birth by operative vaginal delivery (especially forceps) warrants reconsideration of clinical practice among nulliparous women and those attempting vaginal birth after cesarean.

9.
Hypertension ; 74(5): 1089-1095, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31495278

RESUMO

We estimated changes in the prevalence of chronic hypertension among pregnant women and evaluated the extent to which changes in obesity and smoking were associated with these trends. We designed a population-based cross-sectional analysis of over 151 million women with delivery-related hospitalizations in the United States, 1970 to 2010. Maternal age, year of delivery (period), and maternal year of birth (birth cohort), as well as race, were examined as risk factors for chronic hypertension. Prevalence rates and rate ratios with 95% CIs of chronic hypertension in relation to age, period, and birth cohort were derived through age-period-cohort models. We also examined how changes in obesity and smoking rates influenced age-period-cohort effects. The overall prevalence of chronic hypertension was 0.63%, with black women (1.24%) having more than a 2-fold higher rate than white women (0.53%; rate ratio, 2.31; 95% CI, 2.30-2.32). In the age-period-cohort analysis, the rate of chronic hypertension increased sharply with advancing age and period from 0.11% in 1970 to 1.52% in 2010 (rate ratio, 13.41; 95% CI, 13.22-13.61). The rate of hypertension increased, on average, by 6% (95% CI, 5-6) per year, with the increase being slightly higher among white (7%; 95% CI, 6%-7%) than black (4%; 95% CI, 3%-4%) women. Adjustments for changes in rates of obesity and smoking were not associated with age and period effects. We observed a substantial increase in chronic hypertension rates by age and period and an over 2-fold race disparity in chronic hypertension rates.


Assuntos
Afro-Americanos/estatística & dados numéricos , Hipertensão Induzida pela Gravidez/diagnóstico , Hipertensão Induzida pela Gravidez/epidemiologia , Idade Materna , Obesidade/complicações , Fumar/efeitos adversos , Adolescente , Adulto , Fatores Etários , Doença Crônica , Estudos Transversais , Bases de Dados Factuais , Progressão da Doença , Feminino , Humanos , Hipertensão Induzida pela Gravidez/tratamento farmacológico , Pessoa de Meia-Idade , Gravidez , Prevalência , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Estados Unidos , Adulto Jovem
10.
Artigo em Inglês | MEDLINE | ID: mdl-31407359

RESUMO

BACKGROUND: There is no international consensus on the definition and components of severe maternal morbidity (SMM). OBJECTIVES: To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada. METHODS: Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality. RESULTS: There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4). CONCLUSIONS: The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.

11.
CMAJ ; 191(33): E922, 2019 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-31427359
12.
BMJ Open ; 9(5): e027655, 2019 05 09.
Artigo em Inglês | MEDLINE | ID: mdl-31072859

RESUMO

OBJECTIVES: We investigated the associations between Apgar scores at 1 and 5 min, across the entire range of score values, and child developmental health at 5 years of age. SETTING: British Columbia, Canada PARTICIPANTS: All singleton term infants without major congenital anomalies born between 1993 and 2009, who had a developmental assessment in kindergarten between 1999 and 2014. MAIN OUTCOMES AND MEASURES: Developmental vulnerability on one or more domains of the Early Development Instrument and special needs requirements. Adjusted rate ratios (aRRs) and 95% CIs were estimated using log-linear regression. RESULTS: Of the 150 081 children in the study, 45 334 (30.2%) were developmentally vulnerable and 3644 (2.5%) had special needs. There was an increasing trend in developmental vulnerability and special needs with decreasing 1 min and 5 min Apgar scores. Compared with children with an Apgar score of 10 at 5 min, the aRR for developmental vulnerability increased steadily with decreasing Apgar score from 1.02 (95% CI 1.00 to 1.04) for an Apgar score of 9 to 1.57 (95% CI 1.03 to 2.39) for an Apgar score of 2. Among children with 1 min Apgar scores in the 7-10 range, changes in Apgar scores between 1 and 5 min were associated with significant differences in developmental vulnerability. Compared with children who had an Apgar score of 9 at 1 min and 10 at 5 min, children with an Apgar score of 9 at both 1 and 5 min had higher rates of developmental vulnerability (aRR 1.03, 95% CI 1.01 to 1.05). Compared with infants with an Apgar of 10 at both 1 and 5 min, infants with a 1 min score of 10 and a 5 min score of <10 had higher rates of developmental vulnerability (aRR 1.53, 95% CI 1.08 to 2.17). CONCLUSION: Risks of adverse developmental health and having special needs at 5 years of age are inversely associated with 1 min and 5 min Apgar scores across their entire range.

13.
J Obstet Gynaecol Can ; 41(11): 1589-1598.e16, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31060985

RESUMO

OBJECTIVE: This study sought to quantify temporal trends and provincial and territorial variations in severe maternal morbidity (SMM) in Canada. METHODS: The study used data on all hospital deliveries in Canada (excluding Québec) from 2003 to 2016 to examine temporal trends and from 2012 to 2016 to study regional variations. SMM was identified using diagnosis and intervention codes. Contrasts among periods and regions were quantified using rate ratios (RRs) and 95% confidence intervals (CIs). Temporal changes were also assessed using chi-square tests for trend (Canadian Task Force Classification II-1). RESULTS: The study population included 3 882 790 deliveries between 2003 and 2016 and 1 418 545 deliveries between 2012 and 2016. Severe hemorrhage rates increased from 44.8 in 2003 to 62.4 per 10 000 deliveries in 2012 (P for trend <0.0001) and then declined to 41.8 per 10 000 deliveries in 2016 (P for trend <0.0001). Maternal intensive care unit admission and sepsis rates decreased between 2003 and 2016, whereas rates of stroke, severe uterine rupture, hysterectomy, obstetric embolism, shock, and assisted ventilation increased. Rates of composite SMM in 2012-2016 were higher in Newfoundland and Labrador (RR 1.15; 95% CI 1.04-1.26), Nova Scotia (RR 1.11; 95% CI 1.03-1.19), New Brunswick (RR1.22; 95% CI 1.13-1.32), Manitoba (RR 1.09; 95% CI 1.03-1.15), Saskatchewan (RR 1.15; 95% CI 1.09-1.22), the Yukon (RR 1.74; 95% CI 1.35-2.25), and Nunavut (RR 1.76; 95% CI 1.46-2.11) compared with the rest of Canada, whereas rates were lower in Alberta and British Columbia. CONCLUSION: This surveillance report helps inform clinical practice and public health policy for improving maternal health in Canada.

14.
BMJ ; 365: l1656, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-31064770

RESUMO

OBJECTIVE: To investigate associations between Apgar scores of 7, 8, and 9 (versus 10) at 1, 5, and 10 minutes, and neonatal mortality and morbidity. DESIGN: Population based cohort study. SETTING: Sweden. PARTICIPANTS: 1 551 436 non-malformed live singleton infants, born at term (≥37 weeks' gestation) between 1999 and 2016, with Apgar scores of ≥7 at 1, 5, and 10 minutes. EXPOSURES: Infants with Apgar scores of 7, 8, and 9 at 1, 5, and 10 minutes were compared with those with an Apgar score of 10 at 1, 5, and 10 minutes, respectively. MAIN OUTCOME MEASURES: Neonatal mortality and morbidity, including neonatal infections, asphyxia related complications, respiratory distress, and neonatal hypoglycaemia. Adjusted odds ratios (aOR), adjusted rate differences (aRD), and 95% confidence intervals were estimated. RESULTS: Compared with infants with an Apgar score of 10, aORs for neonatal mortality, neonatal infections, asphyxia related complications, respiratory distress, and neonatal hypoglycaemia were higher among infants with lower Apgar scores, especially at 5 and 10 minutes. For example, the aORs for respiratory distress for an Apgar score of 9 versus 10 were 2.0 (95% confidence interval 1.9 to 2.1) at 1 minute, 5.2 (5.1 to 5.4) at 5 minutes, and 12.4 (12.0 to 12.9) at 10 minutes. Compared with an Apgar score of 10 at 10 minutes, the aRD for respiratory distress was 9.5% (95% confidence interval 9.2% to 9.9%) for an Apgar score of 9 at 10 minutes, and 41.9% (37.7% to 46.4%) for an Apgar score of 7 at 10 minutes. A reduction in Apgar score from 10 at 5 minutes to 9 at 10 minutes was also associated with higher odds of neonatal morbidity, compared with a stable Apgar score of 10 at 5 and 10 minutes. CONCLUSIONS: In term non-malformed infants with Apgar scores within the normal range (7 to 10), risks of neonatal mortality and morbidity are higher among infants with lower Apgar score values, and also among those experiencing a reduction in score from 5 minutes to 10 minutes (compared with infants with stable Apgar scores of 10).


Assuntos
Índice de Apgar , Mortalidade Infantil , Doenças do Recém-Nascido/mortalidade , Mães/estatística & dados numéricos , Adulto , Índice de Massa Corporal , Escolaridade , Feminino , Inquéritos Epidemiológicos , Humanos , Lactente , Mortalidade Infantil/tendências , Recém-Nascido , Masculino , Idade Materna , Razão de Chances , Gravidez , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Suécia/epidemiologia , Nascimento a Termo , Fatores de Tempo , Adulto Jovem
15.
J Obstet Gynaecol Can ; 41(4): 466-472, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30885297

RESUMO

OBJECTIVE: Placenta accreta syndromes are well-recognized risk factors for severe postpartum hemorrhage and are associated with significant maternal morbidity. Internal iliac artery balloon tamponade is an adjunctive procedure used to reduce blood loss at the time of Caesarean hysterectomy with variable results in the reported literature. This study investigated the outcomes of preoperative balloon tamponade at the largest tertiary referral centre for placenta accreta in British Columbia. METHODS: Women treated with Caesarean hysterectomy for histologically confirmed placenta accreta from 2003 to 2015 were identified through medical records. A retrospective cohort study was performed after categorizing patients by receipt of internal iliac artery balloon tamponade. Statistically significant differences in clinical variables were assessed using Fisher exact and Mann-Whitney tests. RESULTS: The study population included 24 women. There was no significant difference in the primary outcomes of estimated blood loss or number of units of blood products transfused. Among emergency cases (n = 16), there was a significant reduction in the total number of blood products transfused (3.5 units vs. 15 units, P = 0.04). Operative (P = 0.003) and anaesthetic (P = 0.0001) times were longer among those women undergoing balloon tamponade. There were no differences in intensive care unit admission, length of stay, disseminated intravascular coagulation, or operative morbidity. CONCLUSION: Internal iliac artery balloon tamponade decreases blood transfusion requirements among women requiring emergency Caesarean hysterectomy for placenta accreta. Balloon insertion in the operating room may be an important factor in ensuring efficacy of this procedure. Further studies are required to clarify the potential benefits of balloon tamponade in the elective setting.

16.
Paediatr Perinat Epidemiol ; 33(2): 145-153, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30920008

RESUMO

BACKGROUND: We sought to assess the recent trend in NTD prevalence at birth in the post-folic acid food fortification era and to identify the maternal risk factors associated with that trend. METHODS: We carried out a population-based study of all livebirths and stillbirths (including late pregnancy terminations) delivered in hospitals in Canada (excluding Quebec) from 2004 to 2015 (n = 3 439 330). We examined NTD birth prevalence by year, multiple pregnancy, maternal age, parity, pregestational diabetes, chronic illness, and problematic substance use. Poisson regression was used to quantify the association between spina bifida and cranial defects and maternal characteristics and other risk factors. RESULTS: We identified 1517 non-chromosomal NTDs, yielding a birth prevalence of 4.4 per 10 000 total births. NTD prevalence rose from 3.6 in 2004 to 4.6 per 10 000 in 2015 (Ptrend  = 0.03). Among NTD subtypes, only spina bifida showed a temporal increase (Ptrend  = 0.03). Birth prevalence of spina bifida was higher among younger mothers, those with type 2 diabetes (rate ratio (RR) 3.74, 95% confidence interval (CI) 2.21, 6.35), chronic illness (RR 3.16, 95% CI 1.97, 5.07), and problematic substance use (RR 1.88, 95% CI 1.31, 2.71). Adjusting for risk factors attenuated the significant temporal trend in spina bifida (unadjusted average annual prevalence ratio (aAAPR) 1.016, 95% CI 1.001, 1.032; adjusted AAPR 1.014, 95% CI 0.998, 1.029). CONCLUSIONS: Increases in the frequency of maternal risk factors such as pregestational diabetes mellitus, substance use, and chronic illness may be partly responsible for the recent rise in NTDs, particularly spina bifida.


Assuntos
Diabetes Mellitus Tipo 2/complicações , Ácido Fólico/uso terapêutico , Mães , Defeitos do Tubo Neural/epidemiologia , Gravidez em Diabéticas/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/complicações , Adulto , Canadá/epidemiologia , Diabetes Mellitus Tipo 2/fisiopatologia , Feminino , Humanos , Recém-Nascido , Idade Materna , Defeitos do Tubo Neural/etiologia , Vigilância da População , Gravidez , Gravidez em Diabéticas/fisiopatologia , Prevalência , Fatores de Risco , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto Jovem
17.
Paediatr Perinat Epidemiol ; 33(2): 116-118, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30920009
19.
CMAJ ; 191(5): E118-E127, 2019 02 04.
Artigo em Inglês | MEDLINE | ID: mdl-30718336

RESUMO

BACKGROUND: The extent to which infertility treatment predicts severe maternal morbidity is not well known. We examined the association between infertility treatment and severe maternal morbidity in pregnancy and the postpartum period. METHODS: We conducted a cohort study using population-based registries from Ontario between 2006 and 2012. Pregnancies achieved using infertility treatment (ovulation induction, intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection) were compared with unassisted pregnancies using propensity score matching, based on demographic, reproductive and obstetric factors. The primary outcome was a validated composite of severe maternal morbidity or maternal death from 20 weeks' gestation to 42 days postpartum. We also calculated the odds ratio of a woman having 1, 2, or 3 or more severe maternal morbidity indicators in relation to invasive (e.g., in vitro fertilization) or noninvasive (e.g., intrauterine insemination) infertility treatment. RESULTS: We matched 11 546 infertility treatment pregnancies with 47 553 untreated pregnancies. Severe maternal morbidity or maternal death occurred in 356 infertility-treated pregnancies (30.8 per 1000 deliveries) versus 1054 untreated pregnancies (22.2 per 1000 deliveries); relative risk 1.39 (95% confidence interval [CI] 1.23-1.56). The likelihood of a woman having 3 or more severe maternal morbidity indicators was increased in women who received invasive infertility treatment (odds ratio [OR] 2.28, 95% CI 1.56-3.33) but not in those who received noninvasive infertility treatment (OR 0.99, 95% CI 0.57-1.72). INTERPRETATION: Women who undergo infertility treatment, particularly in vitro fertilization, are at somewhat higher risk of severe maternal morbidity or death. Efforts are needed to identify patient- and treatment-specific predictors of severe maternal morbidity that may influence the type of treatment a woman is offered.


Assuntos
Fertilização In Vitro , Infertilidade/terapia , Morbidade/tendências , Complicações na Gravidez/epidemiologia , Adulto , Estudos de Coortes , Feminino , Fertilização In Vitro/efeitos adversos , Humanos , Infertilidade/complicações , Idade Materna , Mortalidade Materna/tendências , Estudos Observacionais como Assunto , Razão de Chances , Ontário/epidemiologia , Período Pós-Parto , Gravidez , Complicações na Gravidez/etiologia , Pontuação de Propensão , Medição de Risco
20.
Paediatr Perinat Epidemiol ; 33(2): 101-112, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30671994

RESUMO

BACKGROUND: There is a need to reconcile the opposing perspectives of the births-based and fetuses-at-risk models of perinatal mortality and to formulate a coherent and unified perinatal theory. METHODS: Information on births in the United States from 2004 to 2015 was used to calculate gestational age-specific perinatal death rates for low- and high-risk cohorts. Cubic splines were fitted to the fetuses-at-risk birth and perinatal death rates, and first and second derivatives were estimated. Births-based perinatal death rates, and fetuses-at-risk birth and perinatal death rates and their derivatives, were examined to identify potential inter-relationships. RESULTS: The rate of change in the birth rate dictated the pattern of births-based perinatal death rates in a triphasic manner: increases in the first derivative of the birth rate at early gestation corresponded with exponential declines in perinatal death rates, the peak in the first derivative presaged the nadir in perinatal death rates, and late gestation declines in the first derivative coincided with an upturn in perinatal death rates. Late gestation increases in the first derivative of the fetuses-at-risk perinatal death rate matched the upturn in births-based perinatal death rates. Differences in birth rate acceleration/deceleration among low- and high-risk cohorts resulted in intersecting perinatal mortality curves. CONCLUSION: The first derivative of the birth rate links a cohort's fetuses-at-risk perinatal death rate to its births-based perinatal death rate, and cohort-specific differences in birth rate acceleration/deceleration are responsible for the intersecting perinatal mortality curves paradox. This mechanistic explanation unifies extant models of perinatal mortality and provides diverse insights.


Assuntos
Coeficiente de Natalidade/tendências , Morte Perinatal , Mortalidade Perinatal/tendências , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Estudos Longitudinais , Gravidez , Natimorto , Análise de Sobrevida , Estados Unidos/epidemiologia
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