Association between interpregnancy interval and the risk of recurrent loss after a midtrimester loss.

STUDY QUESTION: After an initial midtrimester loss, is the interval to the next conception associated with the risk of a recurrent loss? SUMMARY ANSWER: Among women who had a pregnancy loss at 14-19 weeks gestation, conception at least 3 months after this initial loss was associated with a reduced risk of a recurrent loss. WHAT IS KNOWN ALREADY: A short interpregnancy interval (IPI) has been thought to increase risk but recent studies of pregnancy after a loss have found no effect; however, these studies have been based almost entirely on an initial first trimester (<14 weeks) loss. STUDY DESIGN, SIZE, DURATION: A retrospective cohort study drawing on over 997 000 linked birth and hospital records from New South Wales, Australia for 2003-2011. Index pregnancies were those of women who had a first recorded pregnancy loss of 14-23 weeks gestation (miscarriage, termination and perinatal death). The study population was 4290 women who conceived again within 2 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: The index loss was categorized by subgroups: 14-19 weeks gestation versus 20-23 weeks, and by whether spontaneous or a termination. The primary outcome was any loss or perinatal death before 24 weeks in the subsequent pregnancy. MAIN RESULTS AND THE ROLE OF CHANCE: After a 14-19 weeks index loss, an IPI of ≤3 months had an increased rate of recurrent loss compared with an IPI of >9-12 months: 21.9% versus 11.3% (adjusted relative risk (aRR) = 2.02, 95% CI 1.44-2.83). For women who had a spontaneous index loss of 20-23 weeks, there was no evidence that a short IPI increased or decreased the risk of recurrent loss. For any gestational age group of index losses, an IPI of >18-24 months increased the risk of a recurrent loss; the risk was highest after a 20-23 weeks index loss (aRR = 2.15, 95% CI 1.18-3.91). LIMITATIONS, REASONS FOR CAUTION: We do not know how many cycles were required to achieve conception. Pregnancies resulting in early first trimester losses are unlikely to have resulted in hospitalization so would not have been identified. WIDER IMPLICATIONS OF THE FINDINGS: The risk of recurrent loss after an initial midtrimester loss may differ from the risk after an initial first trimester loss. STUDY FUNDING/COMPETING INTERESTS: This work was supported by an Australian National Health and Medical Research Council (NHMRC) Centre for Research Excellence Grant (1001066). C.L.R. is supported by an NHMRC Senior Research Fellowship (#APP1021025). J.B.F. is supported by an ARC Future Fellowship (#120100069). The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Methods of classification for women undergoing induction of labour: a systematic review and novel classification system.

BACKGROUND: A lack of reproducible methods for classifying women having an induction of labour (IOL) has led to controversies regarding IOL and related maternal and perinatal health outcomes. OBJECTIVES: To evaluate articles that classify IOL and to develop a novel IOL classification system. SEARCH STRATEGY: Electronic searches using CINAHL, EMBASE, WEB of KNOWLEDGE, and reference lists. SELECTION CRITERIA: Two reviewers independently assessed studies that classified women having an IOL. DATA COLLECTION AND ANALYSIS: For the systematic review, data were extracted on study characteristics, quality, and results. Pre-specified criteria were used for evaluation. A multidisciplinary collaboration developed a new classification system using a clinically logical model and stakeholder feedback, demonstrating applicability in a population cohort of 909 702 maternities in New South Wales, Australia, over the period 2002-2011. MAIN RESULTS: All seven studies included in the systematic review categorised women according to the presence or absence of varying medical indications for IOL. Evaluation identified uncertainties or deficiencies across all studies, related to the criteria of total inclusivity, reproducibility, clinical utility, implementability, and data availability. A classification system of ten groups was developed based on parity, previous caesarean, gestational age, number, and presentation of the fetus. Nulliparous and parous women at full term were the largest groups (21.2 and 24.5%, respectively), and accounted for the highest proportion of all IOL (20.7 and 21.5%, respectively). AUTHOR'S CONCLUSIONS: Current methods of classifying women undertaking IOL based on medical indications are inadequate. We propose a classification system that has the attributes of simplicity and clarity, uses information that is readily and reliably collected, and enables the standard characterisation of populations of women having an IOL across and within jurisdictions.

Variation in hospital caesarean section rates and obstetric outcomes among nulliparae at term: a population-based cohort study.

OBJECTIVE: To explore the variation in hospital caesarean section (CS) rates for nulliparous women, to determine whether different case-mix, labour and delivery, and hospital factors can explain this variation and to examine the association between hospital CS rates and outcomes. DESIGN: Population-based cohort study. SETTING: New South Wales, 2009-2010. POPULATION: Nulliparous women with singleton cephalic live births at term. METHODS: Random effect multilevel logistic regression models using linked hospital discharge and birth data. MAIN OUTCOME MEASURES: Prelabour and intrapartum CS rates following spontaneous labour or labour induction; maternal and neonatal severe morbidity rates. RESULTS: Of 67 239 nulliparous women, 4902 (7.3%) had a prelabour CS, 39 049 (58.1%) laboured spontaneously, and 23 288 (34.6%) had labour induced. Overall, there were 18 875 (28.1%) CSs, with labour inductions twice as likely to result in an intrapartum CS compared with women with a spontaneous onset of labour (34.0% versus 15.5%). After adjusting for differences in case-mix, labour and delivery, and hospital factors, the overall variation in CS rates decreased by 78% for prelabour CSs, 52% for intrapartum CSs following spontaneous labour and 9% following labour induction. Adjusting for labour and delivery practices increased the unexplained variation in intrapartum CSs. The adjusted rates of severe maternal and neonatal morbidity were not significantly different across CS rate quintile groups, except for women in spontaneous labour, where the hospitals in the lowest CS quintile had the lowest neonatal morbidity rate. CONCLUSIONS: Differences in clinical practice were substantial contributors to variation in intrapartum CS rates. Our findings suggest that CS rates in some hospitals could be lowered without adversely affect pregnancy outcomes.

Premature ovarian failure: a review.

OBJECTIVES: To present an updated review on the etiology, consequences and management of premature ovarian failure. DESIGN: A search of the English language literature using the Cochrane Library database and Medline 1966-2006, with a hand search of the references. CONCLUSION: Premature ovarian failure is defined as the occurrence of amenorrhea, hypergonadotropinemia and estrogen deficiency in women under the age of 40 years, with the prevalence being 0.9-1.2%. In the majority of cases, the etiology is unknown, but known causes include chemotherapy, radiotherapy, surgery, genetic disorders, particularly involving the X chromosome, associations with autoimmune diseases, infections, smoking and other toxins. The three critical issues of management in these women are the effect of the diagnosis on the psychological health of the patient, the consequent infertility and the long- and short-term effects of estrogen deficiency arising from ovarian decline. Promising methods of screening for premature ovarian failure are being developed.