Maternal racial origin and adverse pregnancy outcome: a cohort study

Examining the Magnitude of Maternal Ethnic and Socioeconomic Inequalities on Foetal Growth Restriction and Preterm Birth: A Cohort Study Set in North West England

OBJECTIVE

To calculate population attributable fractions (PAFs) for the effect of ethnicity and deprivation on foetal growth restriction (FGR) and preterm birth (PTB). PAF estimates the risk reduction of FGR and PTB if ethnic and socioeconomic inequalities did not exist.

DESIGN

A retrospective cohort study using routinely recorded electronic health records, 2016-2021, Manchester, UK.

METHODS

Women with singleton pregnancies greater than 22 weeks' gestation. Logistic regression models were fitted to explore the association between maternal self-reported ethnicity, or deprivation (index of multiple deprivation) on the odds of developing foetal growth restriction (FGR) and preterm birth (PTB). PAFs were estimated from (un)adjusted logistic regression models.

MAIN OUTCOME MEASURES

The PAF of FGR and PTB cases associated with ethnicity and deprivation.

RESULTS

A total of 48,930 pregnancies were included in the analysis with FGR and PTB rates of 8.5% and 6.9%, respectively. Forty-five percent were from ethnic minority backgrounds with 33% living in the most deprived postcode wards. In adjusted models, 22.8% (95% CI 19.6-25.9%) of FGR cases were attributable to ethnicity (using White British/Irish as comparison group). There was no effect of ethnicity on the PAF of PTB cases. In comparison to women living in the least deprived tertile of our population, 9.1% (95% CI 4.6-13.5%) of FGR cases and 11.2% (95% CI 6.2-15.9%) of PTB cases were attributable to deprivation.

CONCLUSIONS

In our population, there is a disparity in pregnancy outcomes for women of ethnic minorities and those living in deprived areas. Targeted interventions such as antenatal caseload models and improved screening in high-risk women could contribute to the efforts to reduce maternal and perinatal morbidity in the UK.

Association between Apolipoprotein L1 genetic variants and risk of preeclampsia and preterm birth among U.S. Black women

Background

Preeclampsia and preterm birth disproportionally affects Black women, but the current understanding of genetic predisposition to preeclampsia and preterm birth is rudimentary. It has been hypothesized that carriers of high-risk genetic variants in the apolipoprotein L1 gene (APOL1) may have an increased risk of preeclampsia and preterm birth. These genetic variants are found only among individuals of recent African ancestry. Previous studies have been small and have yielded inconsistent results.

Objective

To examine whether APOL1 genetic variants are associated with risk of preeclampsia or preterm birth.

Study design

We conducted a retrospective case-control study of 6616 Black women from the Black Women's Health Study, a cohort of self-identified Black women in the U.S. Genotype data on APOL1 risk alleles for this case control study were obtained through new genotyping and existing genetic data from a prior case control study of breast cancer using the Illumina Infinium Global Diversity Array or Multi Ethnic Genotyping Array. Primary analyses evaluated risk based on a recessive model, comparing women who carried two APOL1 risk alleles to women who carried zero or one risk allele. We used multivariable logistic regression models to examine associations among 1473 participants with a history of preeclampsia (cases) and 5143 parous women who had not experienced preeclampsia (controls), and among 1296 participants who had a history of preterm birth and 5320 without such history.

Results

The odds ratio (OR) of preeclampsia for two APOL1 risk alleles vs. zero or one risk allele was 0.99 (95 % confidence interval (CI): 0.74, 1.32) after adjustment for principal components, genotype platform, and age in 1995. For preterm birth, the comparable multivariable OR was 1.04 (95 % CI: 0.86, 1.25).

Conclusions

This large prospective study from a general population of Black women found no evidence of an association of APOL1 genotype with risk of either preeclampsia or preterm birth.

Association of genetic ancestry with pre-eclampsia in multi-ethnic cohorts of pregnant women

OBJECTIVES

Maternal self-reported ethnicity is recognised as a risk factor for pre-eclampsia in clinical screening tools and models. This study investigated whether ethnicity is acting as a proxy for genetic variants in this context.

STUDY DESIGN

A total of 436 women from multi-ethnic backgrounds recruited to two UK observational pregnancy hypertension cohort studies were genotyped. Genetically-computed individual ancestry estimates were calculated for each individual through comparison to the multi-ethnic 1000 Genomes reference panel genotypes. Regression models for pre-eclampsia using clinical risk factors including self-reported ethnicity with and without ancestry estimates were built and compared using Likelihood Ratio Tests (LRT).

MAIN OUTCOME MEASURES

Pre-eclampsia (early- and late-onset).

RESULTS

In these multi-ethnic cohorts (mean age 34.9 years; 41.3 % White, 34.2 % Black, 13.1 % Asian ethnic backgrounds; 82.6 % chronic hypertension), discrepancies between self-reported ethnicity and genetically-computed individual ancestry estimates were present in all ethnic groups, particularly minority groups. Genetically-computed pan-African ancestry percentage was associated with early-onset (< 34 weeks) pre-eclampsia in adjusted models (aOR 100 % vs 0 % African ancestry: 3.81, 95 % CI 1.04-14.14, p-value 0.044) independently of self-reported ethnicity and established clinical risk factors. Addition of genetically-computed African ancestry to a clinical risk factor model including self-reported ethnicity, improved model fit (Likelihood ratio test p-value 0.023).

CONCLUSIONS

Self-reported maternal ethnicity is an imperfect proxy for genetically-computed individual ancestry estimates, particularly in ethnic minority groups. Genetically-computed African ancestry percentage was associated with early-onset pre-eclampsia independently of self-reported maternal ethnicity. Well-powered studies in multi-ethnic cohorts are required to delineate the genetic contribution to pre-eclampsia.

Antenatal screening - The roles of medical and family history, routine tests, and examination findings

Routine antenatal care includes history, examination, and several standard laboratory tests. Other than the original objectives, the generated data is seldom utilised for screening for adverse obstetric and perinatal outcomes. Although new approaches and sophisticated tests improve prediction of complications such as pre-eclampsia, these may not be available globally. Maternal age, race/ethnicity, anthropometry, and method of conception can influence the occurrence of pregnancy complications. The importance of medical and obstetric history is well documented but often ignored. Routine test results including blood picture, hepatitis B and rubella serology, and sexually transmitted diseases, have additional health implications. The awareness of, and the ability to utilise, available antenatal data and tests in obstetric management will enhance individualised obstetric risk assessment thus facilitating the targeting of high-risk gravidae for further management, including the use of specific and technology-driven tests where available, and close monitoring and treatment, in a cost-effective manner.

Pharmacotherapeutic options for the treatment of hypertension in pregnancy

INTRODUCTION

Hypertensive disorders of pregnancy affect approximately one in 10 pregnancies and are associated with increased risk of adverse fetal, neonatal and maternal outcomes. There is strong evidence that effective treatment of hypertension (blood pressure ≥ 140/90 mmHg), and enhanced monitoring throughout pregnancy reduces these risks.

AREAS COVERED

This article provides a contemporaneous review of treatment of hypertension in pregnancy with antihypertensive agents. We completed a systematic search and review of all meta-analyses and systematic reviews of studies comparing antihypertensives for treatment of pregnancy hypertension in the last five years. We provide a clinically focused summary of when to treat hypertension in pregnancy and which antihypertensive agents can be offered. Special scenarios reviewed include treatment-resistant hypertension and pre-pregnancy antihypertensive optimization.

EXPERT OPINION

Several antihypertensives are considered safe and are known to be effective for treatment of hypertension in pregnancy. Given the current uncertainty as to which antihypertensive(s) are superior for treatment of hypertension in pregnancy, women should be counselled and offered a range of antihypertensive options in keeping with evidence on clinical effectiveness, local context and availability of antihypertensive(s), potential side effect profile, and women's preference. Further research is required to help guide clinical decision making, and move toward personalized treatment.

Preeclampsia and eclampsia: Enhanced detection and treatment for morbidity reduction

Preeclampsia is a life-threatening complication that develops in 2-8% of pregnancies. It is characterized by elevated blood pressure after 20 weeks of gestation and may progress to multiorgan dysfunction, leading to severe maternal and fetal morbidity and mortality. The only definitive treatment is delivery, and efforts are focused on early risk prediction, surveillance, and severity mitigation. Anesthesiologists, as part of the interdisciplinary team, should evaluate patients early in labor in order to optimize cardiovascular, pulmonary, and coagulation status. Neuraxial techniques are safe in the absence of coagulopathy and aid avoidance of general anesthesia, which is associated with high risk in these patients. This review aims to provide anaesthesiologists with a comprehensive update on the latest strategies and evidence-based practices for managing preeclampsia, with an emphasis on perioperative care.

Stillbirth: we can do better

Stillbirth is far too common, occurring in millions of pregnancies per year globally. The rate of stillbirth (defined as death of a fetus prior to birth at 20 weeks' gestation or more) in the United States is 5.73 per 1000. This is approximately 1 in 175 pregnancies accounting for about 21,000 stillbirths per year. Although rates are much higher in low-income countries, the stillbirth rate in the United States is much higher than most high resource countries. Moreover, there are substantial disparities in stillbirth, with rates twice as high for non-Hispanic Black and Native Hawaiian or Other Pacific Islanders compared to non-Hispanic Whites. There is considerable opportunity for reduction in stillbirths, even in high resource countries such as the United States. In this article, we review the epidemiology, risk factors, causes, evaluation, medical and emotional management, and prevention of stillbirth. We focus on novel data regarding genetic etiologies, placental assessment, risk stratification, and prevention.

A Scoping Review of Risk Factors of Hypertensive Disorders of Pregnancy in Black Women Living in High-Income Countries: An Intersectional Approach

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are maternity-related increases in blood pressure (eg, gestational hypertension, preeclampsia, and eclampsia). Compared with women of other races in high-income countries, Black women have a comparatively higher risk of an HDP. Intersectionality helps to provide a deeper understanding of the multifactorial identities that affect health outcomes in this high-risk population.

OBJECTIVE

In this review, we sought to explore the literature on HDP risk factors in Black women living in high-income countries and to assess the interaction of these risk factors using the conceptual framework of intersectionality.

METHODS

We conducted this review using the Arksey and O'Malley methodology with enhancements from Levac and colleagues. Published articles in English on HDP risk factors with a sample of not less than 10% of Black women in high-income countries were included. Six databases, theses, and dissertations were searched from January 2000 to July 2021. A thematic analysis was used to summarize the results.

RESULTS

A final total of 36 studies were included from the 15 480 studies retrieved; 4 key themes of HDP risks were identified: (1) biological; (2) individual traditional; (3) race and ethnicity, geographical location, and immigration status; and (4) gender related. These intersectional HDP risk factors intersect to increase the risk of HDP among Black women living in high-income countries.

CONCLUSION

Upstream approaches are recommended to lower the risks of HDP in this population.

Causes of stillbirth in ethnically diverse women in a Perth metropolitan hospital: A retrospective study

BACKGROUND

Most published reports analysing the differences in causation of stillbirth between different ethnic groups focus on stillbirth risk factors, with a paucity of data comparing actual causes of stillbirth.

AIMS

To determine whether causes of stillbirth differ between Caucasian and non-Caucasian ethnic groups in an Australian context.

MATERIALS AND METHODS

Data from all stillbirths occurring at 20 or more completed weeks of gestation between 1 January 2010 and 31 December 2020 at a secondary level, outer metropolitan hospital, were analysed in this retrospective case series. Causes of stillbirth as determined by perinatal autopsy and placental histopathology were categorised using the Perinatal Society of Australia and New Zealand Perinatal Death Classification and compared between Caucasian and non-Caucasian groups.

RESULTS

Ninety-two stillbirths (0.7% of all births) were identified during the study period. A greater proportion of non-Caucasian women had small for gestation age placentas compared to Caucasian women (n = 22/43 (51%) vs n = 12/49 (24%); P = 0.025). A greater proportion of stillbirths were caused by hypoxic peripartum death in non-Caucasian than in Caucasian women (n = 4/43 (9%) vs n = 0/49 (0%); P = 0.044), and a greater prevalence of placental dysfunction was seen in the non-Caucasian cohort compared to Caucasian women (n = 14/43 (33%) vs n = 8/49 (16%); P = 0.057).

CONCLUSIONS

The differences observed in causes of stillbirth between Caucasian and non-Caucasian women are hypothesis generating and warrant further larger-scale, multi-centred studies using standardised definitions and classification systems to determine whether these differences persist in a more representative sample.

Risk factors for pre-eclampsia in clinical practice guidelines: Comparison with the evidence

OBJECTIVE

To compare pre-eclampsia risk factors identified by clinical practice guidelines (CPGs) with risk factors from hierarchical evidence review, to guide pre-eclampsia prevention.

DESIGN

Our search strategy provided hierarchical evidence of relationships between risk factors and pre-eclampsia using Medline (Ovid), searched from January 2010 to January 2021.

SETTING

Published studies and CPGs.

POPULATION

Pregnant women.

METHODS

We evaluated the strength of association and quality of evidence (GRADE). CPGs (n = 15) were taken from a previous systematic review.

MAIN OUTCOME MEASURE

Pre-eclampsia.

RESULTS

Of 78 pre-eclampsia risk factors, 13 (16.5%) arise only during pregnancy. Strength of association was usually 'probable' (n = 40, 51.3%) and the quality of evidence was low (n = 35, 44.9%). The 'major' and 'moderate' risk factors proposed by 8/15 CPGs were not well aligned with the evidence; of the ten 'major' risk factors (alone warranting aspirin prophylaxis), associations with pre-eclampsia were definite (n = 4), probable (n = 5) or possible (n = 1), based on moderate (n = 4), low (n = 5) or very low (n = 1) quality evidence. Obesity ('moderate' risk factor) was definitely associated with pre-eclampsia (high-quality evidence). The other ten 'moderate' risk factors had probable (n = 8), possible (n = 1) or no (n = 1) association with pre-eclampsia, based on evidence of moderate (n = 1), low (n = 5) or very low (n = 4) quality. Three risk factors not identified by the CPGs had probable associations (high quality): being overweight; 'prehypertension' at booking; and blood pressure of 130-139/80-89 mmHg in early pregnancy.

CONCLUSIONS

Pre-eclampsia risk factors in CPGs are poorly aligned with evidence, particularly for the strongest risk factor of obesity. There is a lack of distinction between risk factors identifiable in early pregnancy and those arising later. A refresh of the strategies advocated by CPGs is needed.

Usefulness of angiogenic factors in prenatal counseling of late-onset fetal growth-restricted and small-for-gestational-age gestations: a prospective observational study

OBJECTIVES

To create a predictive model including biomarkers and evaluate its ability to predict adverse perinatal outcomes in late-onset small fetuses, ultimately helping to provide individualized counseling at the time of diagnosis.

METHODS

This was a prospective observational study, including singleton pregnancies with an estimated fetal weight (EFW) below the 10th percentile, at a gestational age between 32 + 0 and 36 + 6 weeks of gestation (WG). Variables recorded at diagnosis to predict adverse pregnancy outcomes were: soluble fms-like tyrosine-kinase-1 to placental growth factor ratio (sFlt-1/PlGF), fetal Doppler (umbilical artery and middle cerebral artery), uterine artery pulsatility index (UtAPI), EFW percentile, gestational age, and the presence of maternal risk factors for placental insufficiency. Logistic regression models were developed for the prediction of three co-primary outcomes: composite adverse perinatal outcomes (APO), and the need for elective delivery before 35 or 37 WG.

RESULTS

Sixty (52.2%) fetal growth restricted (FGR) and 55 (47.8%) small for gestational age (SGA) were enrolled. Thirteen (11.3%) women needed elective delivery before 35 WG and 27 (23.5%) women before 37 WG. At least one APO occurred in 43 (37.4%) pregnancies. The best marker in univariate analyses was the sFlt-1/PlGF ratio [AUC = 0.932 (95% CI, 0.864-0.999)]. The multivariate model including sFlt-1/PlGF showed a better predictive performance for APO than the multivariate model without sFlt-1/PlGF (P < 0.024).

CONCLUSIONS

sFlt-1/PlGF is a good predictor of APO at the time of late-onset FGR/SGA diagnosis. Our predictive models may be useful to provide early individualized prenatal counseling in this group of women. Further studies are needed to validate these preliminary findings in a larger cohort.

Memantine for Refractory Obsessive-Compulsive Disorder: Protocol for a Pragmatic, Double-blind, Randomized, Parallel-Group, Placebo-Controlled, Monocenter Trial

BACKGROUND

Obsessive-compulsive disorder (OCD) is a psychiatric syndrome characterized by unwanted and repetitive thoughts and repeated ritualistic compulsions for decreasing distress. Symptoms can cause severe distress and functional impairment. OCD affects 2% to 3% of the population and is ranked within the 10 leading neuropsychiatric causes of disability. Cortico-striatal-thalamo-cortical circuitry dysfunction has been implicated in OCD, including altered brain activation and connectivity. Complex glutamatergic signaling dysregulation within cortico-striatal circuitry has been proposed in OCD. Data obtained by several studies indicate reduced glutamatergic concentrations in the anterior cingulate cortex, combined with overactive glutamatergic signaling in the striatum and orbitofrontal cortex. A growing number of randomized controlled trials have assessed the utility of different glutamate-modulating drugs as augmentation medications or monotherapies for OCD, including refractory OCD. However, there are relevant variations among studies in terms of patients' treatment resistance, comorbidity, age, and gender. At present, 4 randomized controlled trials are available on the efficacy of memantine as an augmentation medication for refractory OCD.

OBJECTIVE

Our study's main purpose is to conduct a double-blind, randomized, parallel-group, placebo-controlled, monocenter trial to assess the efficacy and safety of memantine as an augmentative agent to a selective serotonin reuptake inhibitor in the treatment of moderate to severe OCD. The study's second aim is to evaluate the effect of memantine on cognitive functions in patients with OCD. The third aim is to investigate if responses to memantine are modulated by variables such as gender, symptom subtypes, and the duration of untreated illness.

METHODS

Investigators intend to conduct a double-blind, randomized, parallel-group, placebo-controlled, monocenter trial to assess the efficacy and safety of memantine as an augmentative agent to a selective serotonin reuptake inhibitor in the treatment of patients affected by severe refractory OCD. Participants will be rated via the Yale-Brown Obsessive Compulsive Scale at baseline and at 2, 4, 6, 8, 10, and 12 months. During the screening period and T4 and T6 follow-up visits, all participants will undergo an extensive neuropsychological evaluation. The 52-week study duration will consist of 4 distinct periods, including memantine titration and follow-up periods.

RESULTS

Recruitment has not yet started. The study will be conducted from June 2023 to December 2024. Results are expected to be available in January 2025. Throughout the slow-titration period, we will observe the minimum effective dose of memantine, and the follow-up procedure will detail its residual efficacy after drug withdrawal.

CONCLUSIONS

The innovation of this research proposal is not limited to the evaluation of the efficacy and safety of memantine as an augmentation medication for OCD. We will also test if memantine acts as a pure antiobsessive medication or if memantine's ability to improve concentration and attention mimics an antiobsessive effect.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05015595; https://clinicaltrials.gov/ct2/show/NCT05015595.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/39223.

INCIDENCE, CAUSES, AND RISK FACTORS OF STILLBIRTH IN AN AMAZONIAN CONTEXT: SAINT LAURENT DU MARONI MATERNITY WARD 2016-2021

Objective

We aimed to describe the epidemiology of intrauterine fetal deaths in multiethnic western French Guiana and to assess its main causes and risk factors.

Study design

A retrospective descriptive study was conducted based on data from January 2016 to December 2021. All information on stillbirth with a gestational age ≥20 weeks in the Western French Guiana Hospital Center was extracted. Terminations of pregnancy were excluded. We focused on medical history, clinical investigation, biological findings, placental histology, and autopsy examination to elucidate the cause of death. We used the Initial Cause of Fetal Death (INCODE) classification system for assessment. Univariable and multivariable logistic regression analyses were performed.

Results

Overall, 331 fetuses in 318 stillbirth deliveries were reviewed and compared to live births that occurred during the same period. The rate of fetal death varied between 1.3 % and 2.1 %, with an average of 1.8 % over the 6-year period. Poor antenatal care (104/318, 32.7 %), obesity ≥30 kg/m² (88/318, 31.7 %), and preeclampsia (59/318, 18.5 %) were the main risk factors associated with fetal death in this group. Four hypertensive crises were reported. According to the INCODE classification, the main causes of fetal death were obstetric complications (112/331, 33.8 %), particularly intrapartum fetal death with labor-associated asphyxia under 26 weeks (64/112, 57.1 %), and placental abruption (29/112, 25.9 %). Maternal-fetal infections were common, particularly mosquito-borne diseases (e.g., Zika virus, dengue, and malaria), re-emerging infectious agents such as syphilis, and severe maternal infections (8/331, 2.4 %). 19.3 % of fetal deaths (64/331) remained unexplained.

Conclusion

Change in lifestyle as well as social deprivation and isolation adversely affect pregnancy in western French Guiana, in the context of a poor health care system that is similar to what is found in the Amazonian basin. Particular attention must be paid to emerging infectious agents in pregnant women and travelers returning from the Amazon region.

Perspectives on the Use of Placental Growth Factor (PlGF) in the Prediction and Diagnosis of Pre-Eclampsia: Recent Insights and Future Steps

Pre-eclampsia (PE) is a complex multisystem disease of pregnancy that is becoming increasingly recognized as a state of angiogenic imbalance characterized by low concentrations of placental growth factor (PlGF) and elevated soluble fms-like tyrosine kinase (sFlt-1). PlGF is a protein highly expressed by the placenta with vasculogenic and angiogenic properties, which has a central role in spiral artery remodeling and the development of a low-resistance placental capillary network. PlGF concentrations are significantly lower in women with preterm PE, and these reduced levels have been shown to precede the clinical onset of disease. Subsequently, the clinical utility of maternal serum PlGF has been extensively studied in singleton gestations from as early as 11 to 13 weeks' gestation, utilizing a validated multimarker prediction model, which performs superiorly to the National Institute for Health and Care Excellence (NICE) and American College of Obstetricians and Gynecologists (ACOG) guidelines in the detection of preterm PE. There is extensive research highlighting the role of PlGF-based testing utilizing commercially available assays in accelerating the diagnosis of PE in symptomatic women over 20 weeks' gestation and predicting time-to-delivery, allowing individualized risk stratification and appropriate antenatal surveillance to be determined. "Real-world" data has shown that interpretation of PlGF-based test results can aid clinicians in improving maternal outcomes and a growing body of evidence has implied a role for sFlt-1/PlGF in the prognostication of adverse pregnancy and perinatal events. Subsequently, PlGF-based testing is increasingly being implemented into obstetric practice and is advocated by NICE. This literature review aims to provide healthcare professionals with an understanding of the role of angiogenic biomarkers in PE and discuss the evidence for PlGF-based screening and triage. Prospective studies are warranted to explore if its implementation significantly improves perinatal outcomes, explore the value of repeat PlGF testing, and its use in multiple pregnancies.

Prediction of pre-eclampsia at St. Mary's hospital lacor, a low-resource setting in northern Uganda, a prospective cohort study

BACKGROUND

Pre-eclampsia is the second leading cause of maternal death in Uganda. However, mothers report to the hospitals late due to health care challenges. Therefore, we developed and validated the prediction models for prenatal screening for pre-eclampsia.

METHODS

This was a prospective cohort study at St. Mary's hospital lacor in Gulu city. We included 1,004 pregnant mothers screened at 16-24 weeks (using maternal history, physical examination, uterine artery Doppler indices, and blood tests), followed up, and delivered. We built models in RStudio. Because the incidence of pre-eclampsia was low (4.3%), we generated synthetic balanced data using the ROSE (Random Over and under Sampling Examples) package in RStudio by over-sampling pre-eclampsia and under-sampling non-preeclampsia. As a result, we got 383 (48.8%) and 399 (51.2%) for pre-eclampsia and non-preeclampsia, respectively. Finally, we evaluated the actual model performance against the ROSE-derived synthetic dataset using K-fold cross-validation in RStudio.

RESULTS

Maternal history of pre-eclampsia (adjusted odds ratio (aOR) = 32.75, 95% confidence intervals (CI) 6.59-182.05, p = 0.000), serum alkaline phosphatase(ALP) < 98 IU/L (aOR = 7.14, 95% CI 1.76-24.45, p = 0.003), diastolic hypertension ≥ 90 mmHg (aOR = 4.90, 95% CI 1.15-18.01, p = 0.022), bilateral end diastolic notch (aOR = 4.54, 95% CI 1.65-12.20, p = 0.003) and body mass index of ≥ 26.56 kg/m² (aOR = 3.86, 95% CI 1.25-14.15, p = 0.027) were independent risk factors for pre-eclampsia. Maternal age ≥ 35 years (aOR = 3.88, 95% CI 0.94-15.44, p = 0.056), nulliparity (aOR = 4.25, 95% CI 1.08-20.18, p = 0.051) and white blood cell count ≥ 11,000 (aOR = 8.43, 95% CI 0.92-70.62, p = 0.050) may be risk factors for pre-eclampsia, and lymphocyte count of 800 - 4000 cells/microliter (aOR = 0.29, 95% CI 0.08-1.22, p = 0.074) may be protective against pre-eclampsia. A combination of all the above variables predicted pre-eclampsia with 77.0% accuracy, 80.4% sensitivity, 73.6% specificity, and 84.9% area under the curve (AUC).

CONCLUSION

The predictors of pre-eclampsia were maternal age ≥ 35 years, nulliparity, maternal history of pre-eclampsia, body mass index, diastolic pressure, white blood cell count, lymphocyte count, serum ALP and end-diastolic notch of the uterine arteries. This prediction model can predict pre-eclampsia in prenatal clinics with 77% accuracy.

Ethnic differences in the impact of gestational diabetes on macrosomia

BACKGROUND

Previous studies reported an ethnic disparity in gestational diabetes mellitus-associated birth outcomes, with some suggesting that macrosomia increases to a lesser extent in groups at high risk, the opposite of the pattern observed by others. Our aim was to evaluate ethnic variation in the impact of gestational diabetes mellitus (GDM).

METHODS

A case-control study evaluating pregnancy outcomes was conducted in women with and without GDM from five ethnic groups. Data on GDM were collected between January 2004 and July 2017. Women giving birth between May 2013 and July 2017 in whom pre-existing diabetes had been ruled out served as controls. A multivariate logistic regression analysis was performed to determine factors independently associated with macrosomia.

RESULTS

Overall, 852 GDM women and 3,803 controls were included. In Caucasian and East-Asian women excessive gestational weight gain (OR 2.273, 95% CI 1.364-3.788 and OR 3.776, 95% CI 0.958-14.886) was an independent predictor of macrosomia. In Latin-American and Moroccan women, obesity (OR 1.774, 95% CI 1.219-2.581 and OR 1.656, 95% CI 1.054-2.601), GDM (OR 2.440; 95% CI 1.048-5.679 and OR 3.249, 95% CI 1.269-8.321) and gestational weight gain but only for Latin-American women (OR 2.365, 95% CI 1.039-5.384) were associated with macrosomia. In South-Central Asian women, only GDM was associated with macrosomia (OR 3.701, 95% CI 1.437-9.532).

CONCLUSIONS

GDM is an independent predictor of macrosomia in Latin-American, South-Central Asian and Moroccan women but not in Caucasian or East-Asian women in whom other factors play a more important role.

Development, validation and clinical utility of a risk prediction model for adverse pregnancy outcomes in women with gestational diabetes: The PeRSonal GDM model

BACKGROUND

The ability to calculate the absolute risk of adverse pregnancy outcomes for an individual woman with gestational diabetes mellitus (GDM) would allow preventative and therapeutic interventions to be delivered to women at high-risk, sparing women at low-risk from unnecessary care. We aimed to develop, validate and evaluate the clinical utility of a prediction model for adverse pregnancy outcomes in women with GDM.

METHODS

A prediction model development and validation study was conducted on data from a observational cohort. Participants included all women with GDM from three metropolitan tertiary teaching hospitals in Melbourne, Australia. The development cohort comprised those who delivered between 1 July 2017 to 30 June 2018 and the validation cohort those who delivered between 1 July 2018 to 31 December 2018. The main outcome was a composite of critically important maternal and perinatal complications (hypertensive disorders of pregnancy, large-for-gestational age neonate, neonatal hypoglycaemia requiring intravenous therapy, shoulder dystocia, perinatal death, neonatal bone fracture and nerve palsy). Model performance was measured in terms of discrimination and calibration and clinical utility evaluated using decision curve analysis.

FINDINGS

The final PeRSonal (Prediction for Risk Stratified care for women with GDM) model included body mass index, maternal age, fasting and 1-hour glucose values (75-g oral glucose tolerance test), gestational age at GDM diagnosis, Southern and Central Asian ethnicity, East Asian ethnicity, nulliparity, past delivery of an large-for-gestational age neonate, past pre-eclampsia, GWG until GDM diagnosis, and family history of diabetes. The composite adverse pregnancy outcome occurred in 27% (476/1747) of women in the development (1747 women) and in 26% (244/955) in the validation (955 women) cohorts. The model showed excellent calibration with slope of 0.99 (95% CI 0.75 to 1.23) and acceptable discrimination (c-statistic 0.68; 95% CI 0.64 to 0.72) when temporally validated. Decision curve analysis demonstrated that the model was useful across a range of predicted probability thresholds between 0.15 and 0.85 for adverse pregnancy outcomes compared to the alternatives of managing all women with GDM as if they will or will not have an adverse pregnancy outcome.

INTERPRETATION

The PeRSonal GDM model comprising of routinely available clinical data shows compelling performance, is transportable across time, and has clinical utility across a range of predicted probabilities. Further external validation of the model to a more disparate population is now needed to assess the generalisability to different centres, community based care and low resource settings, other healthcare systems and to different GDM diagnostic criteria.

FUNDING

This work is supported by the Mothers and Gestational Diabetes in Australia 2 NHMRC funded project #1170847.

Exploring the COVID-19 pandemic experience of maternity clinicians in a high migrant population and low COVID-19 prevalence country: A qualitative study

BACKGROUND

Australia experienced a low prevalence of COVID-19 in 2020 compared to many other countries. However, maternity care has been impacted with hospital policy driven changes in practice. Little qualitative research has investigated maternity clinicians' perception of the impact of COVID-19 in a high-migrant population.

AIM

To investigate maternity clinicians' perceptions of patient experience, service delivery and personal experience in a high-migrant population.

METHODS

We conducted semi-structured in-depth interviews with 14 maternity care clinicians in Sydney, New South Wales, Australia. Interviews were conducted from November to December 2020. A reflexive thematic approach was used for data analysis.

FINDINGS

A key theme in the data was 'COVID-19 related travel restrictions result in loss of valued family support for migrant families'. However, partners were often 'stepping-up' into the role of missing overseas relatives. The main theme in clinical care was a shift in healthcare delivery away from optimising patient care to a focus on preservation and safety of health staff.

DISCUSSION

Clinicians were of the view migrant women were deeply affected by the loss of traditional support. However, the benefit may be the potential for greater gender equity and bonding opportunities for partners. Conflict with professional beneficence principles and values may result in bending rules when a disconnect exists between relaxed community health orders and restrictive hospital protocols during different phases of a pandemic.

CONCLUSION

This research adds to the literature that migrant women require individualised culturally safe care because of the ongoing impact of loss of support during the COVID-19 pandemic.

Racial variations of adverse perinatal outcomes: A population-based retrospective cohort study in Ontario, Canada

Introduction

Racial differences in adverse maternal and birth outcomes have been studied in other countries, however, there are few studies specific to the Canadian population. In this study, we sought to examine the inequities in adverse perinatal outcomes between Black and White pregnant people in Ontario, Canada.

Methods

We conducted a population-based retrospective cohort study that included all Black and White pregnant people who attended prenatal screening and had a singleton birth in any Ontario hospital (April 1^st, 2012-March 31^st, 2019). Poisson regression with robust error variance models were used to estimate the adjusted relative risks of adverse perinatal outcomes for Black people compared with White people while adjusting for covariates.

Results

Among 412,120 eligible pregnant people, 10.1% were Black people and 89.9% were White people. Black people were at an increased risk of gestational diabetes mellitus, preeclampsia, placental abruption, preterm birth (<37, <34, <32 weeks), spontaneous preterm birth, all caesarean sections, emergency caesarean section, low birth weight (<2500g, <1500g), small-for-gestational-age (<10th percentile, <3^rd percentile) neonates, 5-minute Apgar score <4 and <7, neonatal intensive care unit admission, and hyperbilirubinemia requiring treatment but had lower risks of elective caesarean section, assisted vaginal delivery, episiotomy, 3rd and 4th degree perineal tears, macrosomia, large-for-gestational-age neonates, and arterial cord pH≤7.1, as compared with White people. No difference in risks of gestational hypertension and placenta previa were observed between Black and White people.

Conclusion

There are differences in several adverse perinatal outcomes between Black and White people within the Ontario health care system. Findings might have potential clinical and health policy implications, although more studies are needed to further understand the mechanisms.

Gestational Diabetes Mellitus Among Asians - A Systematic Review From a Population Health Perspective

Objective

Since Asians are particularly vulnerable to the risk of gestational diabetes mellitus (GDM), the lifecourse health implications of which are far beyond pregnancy, we aimed to summarize the literature to understand the research gaps on current GDM research among Asians.

Methods

We systematically searched the articles in PubMed, Web of Science, Embase, and Scopus by 30 June 2021 with keywords applied on three topics, namely "GDM prevalence in Asians", "GDM and maternal health outcomes in Asians", and "GDM and offspring health outcomes in Asians".

Results

We observed that Asian women (natives and immigrants) are at the highest risk of developing GDM and subsequent progression to type 2 diabetes among all populations. Children born to GDM-complicated pregnancies had a higher risk of macrosomia and congenital anomalies (i.e. heart, kidney and urinary tract) at birth and greater adiposity later in life.

Conclusion

This review summarized various determinants underlying the conversion between GDM and long-term health outcomes in Asian women, and it might shed light on efforts to prevent GDM and improve the lifecourse health in Asians from a public health perspective.

Systematic Review Registration

Prospero, CRD42021286075.

Maternal race and pre-eclampsia: Cohort study and systematic review with meta-analysis

OBJECTIVES

To examine the association between race and pre-eclampsia and gestational hypertension after adjustment for factors in maternal characteristics and medical history in a screening study from the Fetal Medicine Foundation (FMF) in England, and to perform a systematic review and meta-analysis of studies on pre-eclampsia.

DESIGN

Prospective observational study and systematic review with meta-analysis.

SETTING

Two UK maternity hospitals.

POPULATION

A total of 168 966 women with singleton pregnancies attending for routine ultrasound examination at 11-13 weeks of gestation without major abnormalities delivering at 24 weeks or more of gestation.

METHODS

Regression analysis examined the association between race and pre-eclampsia or gestational hypertension in the FMF data. Literature search to December 2021 was carried out to identify peer-reviewed publications on race and pre-eclampsia.

MAIN OUTCOME MEASURE

Relative risk of pre-eclampsia and gestational hypertension in women of black, South Asian and East Asian race by comparison to white women.

RESULTS

In black women, the respective risks of total-pre-eclampsia and preterm-pre-eclampsia were 2-fold and 2.5-fold higher, respectively, and risk of gestational hypertension was 25% higher; in South Asian women there was a 1.5-fold higher risk of preterm pre-eclampsia but not of total-pre-eclampsia and in East Asian women there was no statistically significant difference in risk of hypertensive disorders. The literature search identified 19 studies that provided data on several million pregnancies, but 17 were at moderate or high-risk of bias and only three provided risks adjusted for some maternal characteristics; consequently, these studies did not provide accurate contributions on different racial groups to the prediction of pre-eclampsia.

CONCLUSION

In women of black and South Asian origin the risk of pre-eclampsia, after adjustment for confounders, is higher than in white women.

Understanding ethnic inequalities in stillbirth rates: a UK population-based cohort study

OBJECTIVES

To investigate inequalities in stillbirth rates by ethnicity to facilitate development of initiatives to target those at highest risk.

DESIGN

Population-based perinatal mortality surveillance linked to national birth and death registration (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK).

SETTING

UK.

PARTICIPANTS

4 391 569 singleton births at ≥24⁺⁰ weeks gestation between 2014 and 2019.

MAIN OUTCOME MEASURES

Stillbirth rate difference per 1000 total births by ethnicity.

RESULTS

Adjusted absolute differences in stillbirth rates were higher for babies of black African (3.83, 95% CI 3.35 to 4.32), black Caribbean (3.60, 95% CI 2.65 to 4.55) and Pakistani (2.99, 95% CI 2.58 to 3.40) ethnicities compared with white ethnicities. Higher proportions of babies of Bangladeshi (42%), black African (39%), other black (39%) and black Caribbean (37%) ethnicities were from most deprived areas, which were associated with an additional risk of 1.50 stillbirths per 1000 births (95% CI 1.32 to 1.67). Exploring primary cause of death, higher stillbirth rates due to congenital anomalies were observed in babies of Pakistani, Bangladeshi and black African ethnicities (range 0.63-1.05 per 1000 births) and more placental causes in black ethnicities (range 1.97 to 2.24 per 1000 births). For the whole population, over 40% of stillbirths were of unknown cause; however, this was particularly high for babies of other Asian (60%), Bangladeshi (58%) and Indian (52%) ethnicities.

CONCLUSIONS

Stillbirth rates declined in the UK, but substantial excess risk of stillbirth persists among babies of black and Asian ethnicities. The combined disadvantage for black, Pakistani and Bangladeshi ethnicities who are more likely to live in most deprived areas is associated with considerably higher rates. Key causes of death were congenital anomalies and placental causes. Improved strategies for investigation of stillbirth causes are needed to reduce unexplained deaths so that interventions can be targeted to reduce stillbirths.

The predicted risk of adverse pregnancy outcomes as a result of treatment-associated obesity in a hypothetical population receiving tenofovir alafenamide/emtricitabine/dolutegravir, tenofovir disoproxil fumarate/emtricitabine/dolutegravir or tenofovir disoproxil fumarate/emtricitabine/efavirenz

OBJECTIVE

Integrase inhibitors, including dolutegravir (DTG), are associated with weight gain and obesity, especially when combined with tenofovir alafenamide (TAF). Obesity increases the risk of adverse pregnancy outcomes (APOs). This study aimed to predict the risk of APOs caused by treatment-associated obesity, using a hypothetical sample based on the ADVANCE trial.

DESIGN

Risk prediction.

METHODS

Firstly, a meta-analysis was performed to determine the relative risk (RR) for APOs in women with obese (≥30) versus normal prepregnancy BMIs (18.5-24.9). For the hypothetical sample, 3000 nonpregnant women with normal BMIs at Week 0 of treatment were evenly allocated across the following treatment arms: TAF/FTC+DTG, TDF/FTC+DTG, TDF/FTC/EFV. The treatment-associated obesity rates from ADVANCE were used to calculate the number of women with obese and normal BMIs expected at Week 96 in our sample. This was combined with the APO RRs to predict the number of women at risk of APOs, in each treatment arm, assuming they conceived at Week 96.

RESULTS

At Week 96, the percentage of women predicted to be obese was 14.1% with TAF/FTC+DTG, 7.9% with TDF/FTC+DTG and 1.5% with TDF/FTC/EFV. The RR in women with obese versus normal BMIs was significantly higher for most APOs. Therefore, the number of women at risk of APOs was higher with TAF/FTC+DTG than TDF/FTC+DTG and TDF/FTC/EFV. For example, 11/1000 additional gestational hypertension cases were predicted with TAF/FTC+DTG, 6/1000 with TDF/FTC+DTG and 1/1000 with TDF/FTC/EFV.

CONCLUSION

Treatment-associated obesity increased the APO risk in women. This risk is likely to increase, as preliminary data from ADVANCE demonstrates ongoing weight gain beyond Week 96.

Ethnic variation in causes of stillbirth in high income countries: A systematic review and meta-analysis

OBJECTIVE

Inequities in stillbirth rate according to ethnicity persist in high income nations. The objective of the present study is to investigate whether causes of stillbirth differ by ethnicity in high-income nations.

METHODS

The following databases were searched since their inception to 1 February 2021: Medline, Embase, Scopus, CINAHL, Cochrane Library, and Global Health. Cohort, cross-sectional, and retrospective studies were included. Causes of stillbirth were aligned to the International Classification of Disease 10 for Perinatal Mortality (ICD10-PM) and pooled estimates were derived by meta-analysis.

RESULTS

Fifteen reports from three countries (72 555 stillbirths) were included. Seven ethnic groups - "Caucasian" (n = 11 studies), "African" (n = 11 studies), "Hispanic" (n = 7 studies), "Indigenous Australian" (n = 4 studies), "Asian" (n = 2 studies), "South Asian" (n = 2 studies), and "American Indian" (n = 1 study) - were identified. There was an overall paucity of recent, high-quality data for many ethnicities. For those with the greatest amount of data - Caucasian, African, and Hispanic - no major differences in the causes of stillbirth were identified.

CONCLUSION

There is a paucity of high-quality information on causes of stillbirth for many ethnicities. Improving investigation and standardizing classification of stillbirths is needed to assess whether causes of stillbirth differ across more diverse ethnic groups.

Immigration and Adverse Pregnancy Outcomes in an Italian Free Care Hospital

Introduction

The ever-increasing wave of immigration in Italy has posed demanding challenges in the management of the new multiethnic obstetric population. The aim of this study was to compare pregnancy and perinatal outcomes between immigrants and the native population in an Italian public hospital.

Materials and Methods

Singleton pregnant women (≥ 24 weeks of gestation) who delivered during a 3-year period in an Italian free care hospital were included. Long-term (≥ 2 years of residence) immigrant patients were divided into 4 groups according to their ethnic origin: Europeans, Asians, Latin Americans, and Africans. Perinatal indicators of obstetric outcomes were collected and compared between immigrants and Italians.

Results

Of the 3556 patients included, 1092 were immigrants and 2464 Italians. The immigrant cohort experienced a higher rate of macrosomia (1.8% vs 0.6%; p = 0.001), very low birth weight (1.3% vs 0.6%; p = 0.048), very early preterm delivery (1.4% vs 0.4%; p = 0.048), and gestational diabetes mellitus (1.8% vs 0.5%; p = 003) compared with the native population. The overall rate of cesarean sections was greater among Italians (56% vs 45.8%; p < 0.001). Among ethnic groups, Europeans and Latin Americans reported a higher rate of preterm delivery (20.2% and 19%, respectively; p < 0.001). Latin Americans carried also a greater risk of fetal macrosomia (3.6%; p < 0.008), while the rate of very low birth weight was higher among Europeans and Africans (2% and 1.8%, respectively; p < 0.04).

Conclusion

Obstetricians should pay special attention to the potential disparities in pregnancy outcomes between immigrants and the native population. Future efforts should focus on reducing preterm delivery and glucose dysmetabolism among pregnant immigrants.

Differences in epidemiology of patients with preeclampsia between China and the US (Review)

Preeclampsia (PE) is a complex complication that occurs during pregnancy. Studies indicated that morbidity from PE exhibits marked variations among geographical areas. Disparities in the incidence of PE between China and the US may be due to differences in ethnicity and genetic susceptibility, maternal age, sexual culture, body mass index, diet, exercise, multiple pregnancies and educational background. These epidemiological differences may give rise to differences between the two countries in terms of diagnostic and therapeutic criteria for PE. PE may be largely attributed to susceptibility genes and lifestyles, such as diet, body mass index and cultural norms regarding sexual relationships. The epidemiologic differences of patients with PE between the two countries indicated that appropriate prevention plans for PE require to be developed according to local conditions.

Perinatales Outcome bei Frauen mit Gestationsdiabetes unter besonderer Berücksichtigung eines Migrationshintergrundes – Ergebnisse einer prospektiven Studie in Berlin

Hintergrund Etwa 25 % der Bevölkerung Deutschlands haben einen Migrationshintergrund (MH), der mit einem schlechteren perinatalen Outcome einhergehen kann. Der Gestationsdiabetes (GDM) gehört zu den häufigsten Schwangerschaftserkrankungen; von ihm sind Frauen mit MH in höherem Maße betroffen. Bisher liegen keine systematisch erhobenen Daten zur Betreuung von Migrantinnen mit GDM vor.

Fragestellung Ziel der Studie war es, Auswirkungen eines MH auf Schwangerschaften von Frauen mit GDM zu evaluieren: Haben Immigrantinnen und ihre Nachkommen ein schlechteres perinatales Outcome als Frauen ohne MH in den Parametern Geburtseinleitung, Sectio, Makrosomie, Apgar, Nabelschnur-pH-Wert, Verlegung auf eine neonatologische Intensivstation, Frühgeburt und prä-/postpartale Hb-Differenz? Beeinflusst ein MH außerdem den Zeitpunkt der ersten Schwangerenvorsorge sowie die Zahl der Vorsorgeuntersuchungen?

Methoden Datenerhebung an drei Berliner Geburtskliniken 2011/2012 unmittelbar in der Kreißsaalaufnahme über 12 Monate anhand standardisierter Interviews (Fragebogenset) in deutscher, türkischer und anderen Sprachen. Fragen zu soziodemografischen Aspekten, Schwangerenvorsorge sowie ggf. Migration und Akkulturation. Verknüpfung der Befragungsdaten mit Mutterpass- und klinischen Perinataldaten. Adjustierung für Alter, BMI, Parität und sozioökonomischen Status erfolgte in Regressionsmodellen.

Ergebnisse Die Daten von n = 2878 Frauen mit MH (GDM: 4,7 %) und n = 2785 Frauen ohne MH (GDM: 4,8 %) konnten verglichen werden. Eine multiple Regressionsanalyse zeigte keine Unterschiede in den Chancen der beiden Gruppen mit GDM hinsichtlich Sectio, Makrosomie, Apgar, Nabelschnur-pH-Werten, Verlegungen auf eine neonatologische Intensivstation sowie Zeitpunkt der ersten Schwangerenvorsorge ≥ 12 SSW und Zahl der Vorsorgeuntersuchungen < 10. Sowohl für Frauen mit GDM und MH (OR 1,57; 95 %-KI 1,08–2,27) als auch für solche mit GDM ohne MH (OR 1,47; 95 %-KI 1,01–2,14) bestand eine signifikant höhere Chance der Geburtseinleitung.

Schlussfolgerung Frauen mit GDM und MH zeigen ein ähnlich gutes Schwangerschaftsergebnis wie solche mit GDM und ohne MH, was auf eine hohe Qualität der peripartalen Betreuung und Versorgung hinweist. Im Vergleich zu Frauen ohne GDM wird bedingt durch diesen und den höheren BMI unabhängig vom MH vermehrt eingeleitet. Die Ergebnisse für Frauen mit GDM lassen unabhängig vom MH auf einen ähnlichen Standard der Inanspruchnahme von Vorsorgeuntersuchungen in der Schwangerschaft schließen.

Country of birth, educational level and other predictors of seeking care due to decreased fetal movements: an observational study in Sweden using data from a cluster-randomised controlled trial

OBJECTIVES

To identify predictors of seeking care for decreased fetal movements and assess whether care-seeking behaviour is influenced by Mindfetalness.

DESIGN

Observational study with data from a cluster-randomised controlled trial.

SETTING

67 maternity clinics and 6 obstetrical clinics in Sweden.

PARTICIPANTS

All pregnant women with a singleton pregnancy who contacted the obstetrical clinic due to decreased fetal movements from 32 weeks' gestation of 39 865 women.

METHODS

Data were collected from a cluster-randomised controlled trial where maternity clinics were randomised to Mindfetalness or routine care. Mindfetalness is a self-assessment method for women to use daily to become familiar with the unborn baby's fetal movement pattern.

OUTCOME MEASURES

Predictors for contacting healthcare due to decreased fetal movements.

RESULTS

Overall, 5.2% (n=2059) of women contacted healthcare due to decreased fetal movements, among which 1287 women (62.5%) were registered at a maternity clinic randomised to Mindfetalness and 772 women (37.5%) were randomised to routine care. Predictors for contacting healthcare due to decreased fetal movements were age, country of birth, educational level, parity, prolonged pregnancy and previous psychiatric care (p<0.001). The main differences were seen among women born in Africa as compared with Swedish-born women (2% vs 6%, relative risk (RR) 0.34, 95% CI 0.25 to 0.44) and among women with low educational level compared with women with university-level education (2% vs 5.4%, RR 0.36, 95% CI 0.19 to 0.62). Introducing Mindfetalness in maternity care increased the number of women seeking care due to decreased fetal movements overall.

CONCLUSION

Women with country of birth outside Sweden and low educational level sought care for decreased fetal movements to a lesser extent compared with women born in Sweden and those with university degrees. Future research could explore whether pregnancy outcomes can be improved by motivating women in these groups to contact healthcare if they feel a decreased strength or frequency of fetal movements.

TRIAL REGISTRATION NUMBER

NCT02865759.

The Fourth Trimester: Pregnancy as a Predictor of Cardiovascular Disease

Pregnancy identifies women who may be at a greater risk of cardiovascular disease (CVD), based on the development of adverse pregnancy outcomes (APOs), and may identify women who may benefit from atherosclerotic CVD (ASCVD) risk reduction efforts. APOs are common and although they are separate diagnoses, all these disorders seem to share an underlying pathogenesis. What is not clear is whether the APO itself initiates a pathway that results in CVD or whether the APO uncovers a woman's predisposition to CVD. Regardless, APOs have immediate risks to maternal and foetal health, in addition to longer-term CVD consequences. CVD risk assessment and stratification in women remains complex and, historically, has underestimated risk, especially in young women. Further research is needed into the role of ASCVD risk assessment and the effect of aggressive ASCVD risk modification on CVD outcomes in women with a history of APOs.

Why we succeed and fail in detecting fetal growth restriction: A population-based study

INTRODUCTION

The objective of this study was to explore the association between detection of fetal growth restriction and maternal-, healthcare provider- and organizational factors.

MATERIAL AND METHODS

A historical, observational, multicentre study. All women who gave birth to a child with a birthweight <2.3rd centile from 1 September 2012 to 31 August 2015 in Zealand, Denmark, were included. The population was identified through the Danish Fetal Medicine Database. Medical charts were reviewed to obtain data regarding maternal characteristics and information on the healthcare professionals. Date of authorization for the midwives and obstetricians involved was extracted from the Danish Health Authorization Registry. Multivariable Cox regression models were used to identify predictors of antenatal detection of fetal growth restriction, and analyses were adjusted for hospital, body mass index, parity, the presence of at least one risk factor and experience of the first midwife, number of midwife visits, number of visits to a doctor, the experience of the consultant midwife or the educational level of the doctor, the number of scans and gaps in continuity of midwife-care. Antenatal detection was defined as an ultrasound estimated fetal weight <2.3rd centile (corresponding to -2 standard deviations) prior to delivery.

RESULTS

Among 78 544 pregnancies, 3069 (3.9%) had a fetal growth restriction. Detection occurred in 31% of fetal growth-restricted pregnancies. Clinical experience (defined as years since graduation) of the first consultation midwife was positively associated with detection, with a hazard ratio [HR] of 1.15, 95% confidence interval [CI] 1.03-1.28), for every 10 years of additional experience. The hazard of detection increased with the number of midwife consultations (HR 1.15, 95% CI 1.05-1.26) and with multiparity (HR 1.28, 95% CI 1.03-1.58). After adjusting for all covariates, an unexplained difference between hospitals (P = .01) remained.

CONCLUSIONS

The low-risk nullipara may constitute an overlooked group of women at increased risk of antenatal non-detection of fetal growth restriction. Being screened by experienced midwives during early pregnancy and having access to multiple midwife consultations may improve future diagnosis.

Influence of maternal region of birth on neonatal outcomes of babies born small

AIM

To compare neonatal outcomes of small for gestational age (SGA) infants born to South Asian (SA)-born women and Australian/New Zealand (ANZ)-born women.

METHODS

Retrospective cohort study at a hospital network in Australia. Maternal and neonatal data were collected for infants born SGA between 2013 and 2017 to SA- or ANZ-born women. Rates of perinatal mortality and neonatal morbidities were analysed between groups.

RESULTS

A total of 1018 SA and 959 ANZ SGA infants were included. SA SGA babies were older (median [IQR] 39 [38-40] weeks) and heavier (2590 [2310-2780] grams) compared to ANZ SGA babies (38 [37-40] weeks and 2480 [2059-2740] grams; P < .001 for both). After adjustment for differences in demographics, SA SGA babies were 1.5 times more likely to develop hypothermia (CI: 1.16-1.88, P = .001), but 60% less likely to be born with a major congenital malformation (CI: 0.24-0.67, P = .001) and 36% less likely to need gavage feeding (CI: 0.43-0.93, P = .02) compared to ANZ SGA babies.

CONCLUSION

Small for gestational age babies of SA-born women have different neonatal outcomes as compared to those born to ANZ-born women. Further research into influence of maternal region of birth on placental function, organogenesis and body composition of SGA babies is warranted.

The predicted clinical workload associated with early post-term surveillance and inductions of labour in south Asian women in a non-tertiary hospital setting

BACKGROUND

Stillbirth increases steeply after 42 weeks gestation; hence, induction of labour (IOL) is recommended after 41 weeks. Recent Victorian data demonstrate that term stillbirth risk rises at an earlier gestation in south Asian mothers (SAM).

AIMS

To determine the impact on a non-tertiary hospital in Melbourne, Australia, if post-dates IOL were recommended one week earlier at 40 + 3 for SAM; and to calculate the proportion of infants with birthweight < 3rd centile that were undelivered by 40 weeks in SAM and non-SAM, as these cases may represent undetected fetal growth restriction.

MATERIALS AND METHODS

Singleton births ≥ 37 weeks during 2017-18 were extracted from the hospital Birthing Outcomes System. Obstetric and neonatal outcomes for pregnancies that birthed after spontaneous onset of labour or IOL were analysed according to gestation and country of birth.

RESULTS

There were 5408 births included, and 24.9% were born to SAM (n = 1345). SAM women had a higher rate of IOL ≥ 37 weeks compared with non-SAM women (42.5% vs 35.0%, P < 0.001). If all SAM accepted an offer of IOL at 40 + 3, there would be an additional 80 term inductions over two years. There was no significant difference in babies < 3rd centile undelivered by 40 weeks in SAM compared with non-SAM (29.6% vs 37.7%, P = 0.42).

CONCLUSIONS

Earlier IOL for post-term SAM would only modestly increase the demand on birthing services, due to pre-existing high rates of IOL. Our current practices appear to capture the majority at highest risk of stillbirth in our SAM population.

Effect of race on longitudinal central hemodynamics in pregnancy

OBJECTIVE

To compare central hemodynamics between white, black and Asian women in pregnancy.

METHODS

This was a prospective, longitudinal study of maternal central hemodynamics in white, black and Asian women with a singleton pregnancy, assessed using a bioreactance method at 11 + 0 to 13 + 6, 19 + 0 to 24 + 0, 30 + 0 to 34 + 0 and 35 + 0 to 37 + 0 weeks' gestation. At each visit, cardiac output (CO), stroke volume (SV), heart rate (HR), peripheral vascular resistance (PVR) and mean arterial pressure were recorded. Multilevel linear mixed-effects analysis was performed to compare the repeated measures of the cardiac variables between white, black and Asian women, controlling for maternal characteristics, medical history and medication use.

RESULTS

The study population included 1165 white, 247 black and 116 Asian women. CO increased with gestational age to a peak at 32 weeks and then decreased; the highest CO was observed in white women and the lowest in Asian women. SV initially increased after the first visit but subsequently declined with gestational age in white women, decreased with gestational age in black women and remained static in Asian women. In all three study groups, HR increased with gestational age until 32 weeks and then remained constant; HR was highest in black women and lowest in white women. PVR showed a reversed pattern to that of CO; the highest values were in Asian women and the lowest in white women. The least favorable hemodynamic profile, which was observed in black and Asian women, was reflected in higher rates of a small-for-gestational-age infant.

CONCLUSIONS

There are race-specific differences in maternal cardiac adaptation to pregnancy. White women have the most favorable cardiac adaptation by increasing SV and HR, achieving the highest CO and lowest PVR. In contrast, black and Asian women have lower CO and higher PVR than do white women, with CO increasing through a rise in HR due to declining or static SV. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Rates of stillbirth by maternal region of birth and gestational age in New South Wales, Australia 2004-2015

BACKGROUND

Research suggests that in Australia, maternal region of birth is a risk factor for stillbirth.

AIMS

We aimed to examine the relationship between stillbirth and maternal region of birth in New South Wales (NSW), Australia from 2004 to 2015.

METHODS

Adjusted logistic regression was used to determine odds of stillbirth by maternal region of birth, compared with Australian or New Zealand-born (AUS/NZ-born) women. Intervention rates (induction or pre-labour caesarean) by maternal region of birth, over time, were also examined. Interaction terms were used to assess change in relative odds of stillbirth, over two time periods (2004-2011 and 2012-2015).

RESULTS

There were 944 457 singleton births ≥24 weeks gestation that met the study inclusion criteria and 3221 of these were stillbirths, giving a stillbirth rate of 3.4 per 1000 births. After adjustment for confounders, South Asian (adjusted odds ratio (aOR) 1.42, 95% CI 1.24-1.62), Oceanian (aOR 1.45, 95% CI 1.17-1.80) and African (aOR 1.46, 96% CI 1.19-1.80) born women had significantly higher odds of stillbirth that AUS/NZ-born women. Intervention rates increased from the earlier to the later time period by 13.1% across the study population, but the increase was larger in African and South Asian-born women (18.1% and 19.6% respectively) than AUS/NZ-born women (11.2%). There was a significant interaction between ethnicity and time period for South Asian-born women in the all-births model, with their stillbirth rates becoming closer to AUS/NZ-born women in the later period.

CONCLUSION

South Asian, African and Oceanian maternal region of birth are independent risk factors for stillbirth in NSW.

Profile of severely growth-restricted births undelivered at 40 weeks in Western Australia

PURPOSE

To investigate the proportion of severely growth-restricted singleton births < 3rd percentile (proxy for severe fetal growth restriction; FGR) undelivered at 40 weeks (FGR_40), and compare maternal characteristics and outcomes of FGR_40 births and FGR births at 37-39 weeks' (FGR_37-39) to those not born small-for-gestational-age at term (Not SGA_37+).

METHODS

The annual rates of singleton FGR_40 births from 2006 to 2015 were calculated using data from linked Western Australian population health datasets. Using 2013-2015 data, maternal factors associated with FGR births were investigated using multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI) while relative risks (RR) of birth outcomes between each group were calculated using Poisson regression. Neonatal adverse outcomes were identified using a published composite indicator (diagnoses, procedures and other factors).

RESULTS

The rate of singleton FGR_40 births decreased by 23.0% between 2006 and 2015. Factors strongly associated with FGR_40 and FGR_37-39 births compared to Not SGA_37+ births included the mother being primiparous (ORs 3.13: 95% CI 2.59-3.79; 1.69, 95% CI 1.47, 1.94, respectively) and ante-natal smoking (ORs 2.55, 95% CI 1.97, 3.32; 4.48, 95% CI 3.74, 5.36, respectively). FGR_40 and FGR_37-39 infants were more likely to have a neonatal adverse outcome (RRs 1.70, 95% CI 1.41, 2.06 and 2.46 95% CI 2.18, 2.46, respectively) compared to Not SGA 37+ infants.

CONCLUSIONS

Higher levels of poor perinatal outcomes among FGR births highlight the importance of appropriate management including fetal growth monitoring. Regular population-level monitoring of FGR_40 rates may lead to reduced numbers of poor outcomes.

Could maternal ethnicity be a determinant of healthcare costs for birth assistance? Insights from a retrospective hospital-based study for the implementation of a woman-centered approach in obstetrics

Background: Current policy and service provision recommend a woman-centered approach to maternity care and the development of personalized models for clinical assistance. Ethnicity has been recognized as a determinant in the risk calculation of selected obstetric complications. Based on these assumptions, our aims were to describe the linkage between baseline characteristics and maternal ethnicity and to analyze the cost for the local healthcare system, distinguishing mode of delivery, absence or presence of complications at birth, and maternal stay duration for all ethnic groups.Methods: In a 5-year period (2012-16), all women admitted for delivery at the Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario "A Gemelli" IRCCS, Rome, Italy, were included in the analysis. Maternal demographics, adverse outcomes, and costs were evaluated. Economic calculations were performed by using the "diagnosis-related group" (DRG) approach.Results: A total of 18,093 patients were included in the analysis. An overall care expense of €42,663,481 was calculated. Caucasian was the main ethnicity (90.7%), with 9.3% minority groups. Vaginal delivery (VD) was the most common mode of delivery in all ethnic groups, with a global rate of 59.6%. The highest cesarean section (CS) rates were observed among Maghreb (51.5%) and Afro-Caribbean (47.8%) women. Minority groups had a doubled rate of complicated VD, primarily Afro-Caribbean women (69.9%), followed by Asian (64.1%), Maghreb (63.2%), and Latin American (62.7%) women. Afro-Caribbean women had the highest rate of complicated CS compared to the overall study population (37.6 versus 28.5%, p < .005).Conclusions: Minority groups have increased healthcare costs for birth assistance, mainly due to the higher rates of complications. In a prospective view, two strategies could be planned: first, calculating individualized risk to mitigate the clinical care charge, based on the ad hoc combination of ethnicity, mode of delivery, and obstetric complications; and second, endorsing the current financial return-on-investment opportunity tied to mitigating ethnic disparities in birth outcomes.

Placental lncRNA expression associated with placental cadmium concentrations and birth weight

Heavy metal exposures, such as cadmium, can have negative effects on infant birth weight (BW)-among other developmental outcomes-with placental dysfunction potentially playing a role in these effects. In this study, we examined how differential placental expression of long non-coding RNAs (lncRNAs) may be associated with cadmium levels in placenta and whether differences in the expression of those lncRNAs were associated with fetal growth. In the Rhode Island Child Health Study, we used data from Illumina HiSeq whole transcriptome RNA sequencing (n = 199) to examine association between lncRNA expression and measures of infant BW as well as placental cadmium concentrations controlled for appropriate covariates. Of the 1191 lncRNAs sequenced, 46 demonstrated associations (q < 0.05) with BW in models controlling for infant sex, maternal age, BMI, maternal education, and smoking during pregnancy. Furthermore, four of these transcripts were associated with placental cadmium concentrations, with MIR22HG and ERVH48-1 demonstrating increases in expression associated with increasing cadmium exposure and elevated odds of small for gestational age birth, while AC114763.2 and LINC02595 demonstrated reduced expression associated with cadmium, but elevated odds of large for gestational age birth with increasing expression. We identified relationships between lncRNA expression with both placental cadmium concentrations and BW. This study provides evidence that disrupted placental expression of lncRNAs may be a part of cadmium's mechanisms of reproductive toxicity.

Performance of Fetal Medicine Foundation Software for Pre-Eclampsia Prediction Upon Marker Customization: Cross-Sectional Study

Background

FMF2012 is an algorithm developed by the Fetal Medicine Foundation (FMF) to predict pre-eclampsia on the basis of maternal characteristics combined with biophysical and biochemical markers. Afro-Caribbean ethnicity is the second risk factor, in magnitude, found in populations tested by FMF, which was not confirmed in a Brazilian setting.

Objective

This study aimed to analyze the performance of pre-eclampsia prediction software by customization of maternal ethnicity.

Methods

This was a cross-sectional observational study, with secondary evaluation of data from FMF first trimester screening tests of singleton pregnancies. Risk scores were calculated from maternal characteristics and biophysical markers, and they were presented as the risk for early pre-eclampsia (PE34) and preterm pre-eclampsia (PE37). The following steps were followed: (1) identification of women characterized as black ethnicity; (2) calculation of early and preterm pre-eclampsia risk, reclassifying them as white, which generated a new score; (3) comparison of the proportions of women categorized as high risk between the original and new scores; (4) construction of the receiver operator characteristic curve; (5) calculation of the area under the curve, sensitivity, and false positive rate; and (6) comparison of the area under the curve, sensitivity, and false positive rate of the original with the new risk by chi-square test.

Results

A total of 1531 cases were included in the final sample, with 219 out of 1531 cases (14.30; 95% CI 12.5-16.0) and 182 out of 1531 cases (11.88%; 95% CI 10.3-13.5) classified as high risk for pre-eclampsia development, originally and after recalculating the new risk, respectively. The comparison of FMF2012 predictive model performance between the originally estimated risks and the estimated new risks showed that the difference was not significant for sensitivity and area under the curve, but it was significant for false positive rate.

Conclusions

We conclude that black ethnicity classification of Brazilian pregnant women by the FMF2012 algorithm increases the false positive rate. Suppressing ethnicity effect did not improve the test sensitivity. By modifying demographic characteristics, it is possible to improve some performance aspects of clinical prediction tests.

Ethnic differences in singleton preterm birth in England and Wales, 2006-12: Analysis of national routinely collected data

BACKGROUND

Data recorded at birth and death registration in England and Wales have been routinely linked with data recorded at birth notification since 2006. These provide scope for detailed analyses on ethnic differences in preterm birth (PTB).

OBJECTIVES

We aimed to investigate ethnic differences in PTB and degree of prematurity in England and Wales, taking into account maternal sociodemographic characteristics and to further explore the contribution of mother's country of birth to these ethnic differences in PTB.

METHODS

We analysed PTB and degree of prematurity by ethnic group, using routinely collected and linked data for all singleton live births in England and Wales, 2006-2012. Logistic regression was used to adjust for mother's age, marital status/registration type, area deprivation and mother's country of birth.

RESULTS

In the 4 634 932 births analysed, all minority ethnic groups except 'Other White' had significantly higher odds of PTB compared with White British babies (ORs between 1.04-1.25); highest odds were in Black Caribbean, Indian, Bangladeshi and Pakistani groups. Ethnic differences in PTB tended to be greater at earlier gestational ages. In all ethnic groups, odds of PTB were lower for babies whose mothers were born outside the UK.

CONCLUSIONS

In England and Wales, Black Caribbean, Indian, Bangladeshi, Pakistani and Black African babies all have significantly increased odds of being born preterm compared with White British babies. Bangladeshis apart, these groups are particularly at risk of extremely PTB. In all ethnic groups, the odds of PTB are lower for babies whose mothers were born outside the UK. These ethnic differences do not appear to be wholly explained by area deprivation or other sociodemographic characteristics.

Inequalities and stillbirth in the UK: a meta-narrative review

OBJECTIVE

To review what is known about the relationship between stillbirth and inequalities from different disciplinary perspectives to inform stillbirth prevention strategies.

DESIGN

Systematic review using the meta-narrative method.

SETTING

Studies undertaken in the UK.

DATA SOURCES

Scoping phase: experts in field, exploratory electronic searches and handsearching. Systematic searches phase: Nine databases with no geographical or date restrictions. Non-English language studies were excluded.

STUDY SELECTION

Any investigation of stillbirth and inequalities with a UK component.

DATA EXTRACTION AND SYNTHESIS

Three authors extracted data and assessed study quality. Data were summarised, tabulated and presented graphically before synthesis of the unfolding storyline by research tradition; and then of the commonalities, differences and interplays between narratives into resultant summary meta-themes.

RESULTS

Fifty-four sources from nine distinctive research traditions were included. The evidence of associations between social inequalities and stillbirth spanned 70 years. Across research traditions, there was recurrent evidence of the social gradient remaining constant or increasing, fuelling repeated calls for action (meta-theme 1: something must be done). There was less evidence of an effective response to these calls. Data pertaining to socioeconomic, area and ethnic disparities were routinely collected, but not consistently recorded, monitored or reported in relation to stillbirth (meta-theme 2: problems of precision). Many studies stressed the interplay of socioeconomic status, deprivation or ethnicity with aggregated factors including heritable, structural, environmental and lifestyle factors (meta-theme 3: moving from associations towards intersectionality and intervention(s)). No intervention studies were identified.

CONCLUSION

Research investigating inequalities and stillbirth in the UK is underdeveloped. This is despite repeated evidence of an association between stillbirth risk and poverty, and stillbirth risk, poverty and ethnicity. A specific research forum is required to lead the development of research and policy in this area, which can harness the multiple relevant research perspectives and address the intersections between different policy areas.

PROSPERO REGISTRATION NUMBER

CRD42017079228.

Diabetes distress is associated with adverse pregnancy outcomes in women with gestational diabetes: a prospective cohort study

BACKGROUND

Around 12% of pregnant women develop gestational diabetes mellitus (GDM), which is associated with increased health risks for both mother and child and pre- and postpartum depression. Little is known about the relationship of GDM with diabetes-specific emotional distress (diabetes distress). The aims of this study are to assess the prevalence of diabetes distress in GDM and its association with adverse pregnancy outcomes.

METHODS

A prospective cohort study was carried out in an Amsterdam based teaching hospital with an ethnic diverse population. Women diagnosed with GDM completed a set of questionnaires at three time points. Questionnaires consisted of Problem Areas in Diabetes Scale 5 (PAID-5) for diabetes distress (T0-T1), Patient Health Questionnaire 9 (PHQ-9) for depressive symptoms (T0-T2), and questions to assess adverse pregnancy outcomes (T2). Adverse pregnancy outcomes (collected via self-report and if feasible from the medical records) were defined as hypertension, pre-eclampsia, caesarean section, severe perineal tearing, postpartum hemorrhage, postpartum depression, shoulder dystocia, neonatal hospitalization, macrosomia, jaundice, hypoglycemia and other (among which low heart rate, fever, hypoxia). Adverse pregnancy outcomes were dichotomized into none and 1 or more. Additional information was collected from the medical charts. Missing data were imputed via predictive mean matching and a multivariable logistic regression analysis was performed with diabetes distress, depressive symptoms, socioeconomic status, parity and ethnicity as predictors and age, HbA1c, and BMI as covariates.

RESULTS

A total of 100 women were included, mean age 32.5 (4.1), mean BMI 26.7 (4.8), 71% were of non-Dutch ethnic background. Elevated diabetes distress (PAID score ≥ 8) was reported by 36% of the women. Multivariable logistic regression analyses revealed that both high diabetes distress (OR 4.70, p = .02) and parity (OR 0.21, p = .02) but not antepartum depressive symptoms were related to adverse pregnancy outcomes.

CONCLUSIONS

Diabetes distress is likely in women with GDM and our findings suggest an association between both diabetes distress, parity and adverse pregnancy outcomes in women with GDM. This warrants replication and further research into the underlying mechanisms explaining the impact of diabetes distress in GDM and potential interventions to reduce distress.

The Effect of Maternal Age at the First Childbirth on Gestational Age and Birth Weight: The Japan Environment and Children's Study (JECS)

BACKGROUND

In Japan, mean maternal age at first childbirth is increasing. The aim of this study was to investigate whether maternal age at the first childbirth is a risk factor for preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA).

METHODS

We used the results of Japan Environment and Children's Study (JECS) who gave birth in 2011-2014. Cases of primiparous singleton pregnancies where the subject was ≥20 years and delivered after 22 weeks were included. All subjects were categorized into five groups according to maternal age: 20-24, 25-29, 30-34, 35-39, and ≥40 years. Adjusted odds ratios (aORs) for PTB (before 37 and 34 weeks), LBW (<2,500 g and <1,500 g), and SGA were calculated using a logistic regression model, with the 20-24-year age group as reference.

RESULTS

We analyzed 38,412 singleton primiparous pregnancies. The aORs of all outcomes increased in parallel with each maternal age group >30 years. The aORs of PTB before 37 and 34 weeks, LBW <2,500 g, LBW <1,500 g, and SGA in the 30-34-year age group were 1.39 (95% confidence interval [CI], 1.16-1.67), 2.23 (95% CI, 1.45-3.41), 1.34 (95% CI, 1.18-1.53), 2.30 (95% CI, 1.35-3.94), and 1.24 (95% CI, 1.05-1.46), respectively.

CONCLUSION

The present study showed that higher maternal age (>30 years) at the first childbirth was an independent risk factor for PTB, LBW, and SGA.

The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention

Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.

Essential variables for reporting research studies on fetal growth restriction: a Delphi consensus

OBJECTIVE

To determine, by expert consensus using a Delphi procedure, a minimum reporting set of study variables for fetal growth restriction (FGR) research studies.

METHODS

A panel of experts, identified based on their publication record as lead or senior author of studies on FGR, was asked to select a set of essential reporting study parameters from a literature-based list of variables, utilizing the Delphi consensus methodology. Responses were collected in four consecutive rounds by online questionnaires presented to the panelists through a unique token-secured link for each round. The experts were asked to rate the importance of each parameter on a five-point Likert scale. Variables were selected in the three first rounds based on a 70% threshold for agreement on the Likert-scale scoring. In the final round, retained parameters were categorized as essential (to be reported in all FGR studies) or recommended (important but not mandatory).

RESULTS

Of the 100 invited experts, 87 agreed to participate and of these 62 (71%) completed all four rounds. Agreement was reached for 16 essential and 30 recommended parameters including maternal characteristics, prenatal investigations, prenatal management and pregnancy/neonatal outcomes. Essential parameters included hypertensive complication in the current pregnancy, smoking, parity, maternal age, fetal abdominal circumference, estimated fetal weight, umbilical artery Doppler (pulsatility index and end-diastolic flow), fetal middle cerebral artery Doppler, indications for intervention, pregnancy outcome (live birth, stillbirth or neonatal death), gestational age at delivery, birth weight, birth-weight centile, mode of delivery and 5-min Apgar score.

CONCLUSIONS

We present a list of essential and recommended parameters that characterize FGR independent of study hypotheses. Uniform reporting of these variables in prospective clinical research is expected to improve data quality, study consistency and ultimately our understanding of FGR. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Association of first-trimester HbA1c levels with adverse pregnancy outcomes in different ethnic groups

AIM

To determine, in a multi-ethnic cohort, the association of first-trimester HbA1c levels with the development of pregnancy complications.

METHODS

A prospective study between April 2013-October 2016. Participants were stratified in five ethnic groups. Women had an HbA1c measurement added to their first antenatal bloods. Primary outcome was macrosomia and secondary outcomes included preeclampsia and large-for-gestational age (LGA). A multivariate logistic regression analysis was performed to adjust for potential confounders in determining the association between different HbA1c cut-off points and obstetric outcomes on each ethnic group.

RESULTS

1,882 pregnancies were included. Analysis was limited to the three main ethnic groups: Caucasian (54.3%), South-Central Asian (19%) and Latin-American (12.2%). There was no association between HbA1c levels and obstetric outcomes among Caucasians. In Latin-Americans, an HbA1c ≥ 5.8% (40 mmol/mol) was associated with higher risk of macrosomia, whereas an HbA1c ≥ 5.9% (41 mmol/mol) was associated with LGA. In South-Central Asian, an HbA1c ≥ 5.7% (39 mmol/mol) was associated with increased risk of macrosomia and a continuous graded relationship between HbA1c levels and preeclampsia and LGA was detected starting at HbA1c levels of 5.4% (36 mmol/mol).

CONCLUSION

First-trimester HbA1c levels perform as a suitable predictor of pregnancy complications in South-Central Asian and Latin-American women whereas in Caucasian no significant associations were found.

Stillbirth in Western Australia, 2005-2013: the influence of maternal migration and ethnic origin

OBJECTIVE

To investigate prevalence rates and the risk of ante- and intrapartum stillbirth in Western Australia with respect to maternal country of birth and ethnic origin.

DESIGN, SETTING AND PARTICIPANTS

Whole population retrospective cohort analysis of de-identified, linked routinely collected birth, perinatal and mortality data for all births to non-Indigenous women in WA during 2005-2013.

MAIN OUTCOME MEASURES

Crude and adjusted odds ratios (aORs) with 95% confidence intervals were estimated by logistic regression and adjusted for confounding factors, for all stillbirths, antepartum stillbirths and intrapartum stillbirths, stratified by migrant status and ethnic background (white, Asian, Indian, African, Māori, other).

RESULTS

Women born overseas were more likely to have a stillbirth than Australian-born women (aOR, 1.26; 95% CI, 1.09-1.37). There was no significant difference for any type of stillbirth between Australian-born women of white and non-white backgrounds, but non-white migrant women were more likely than white migrants to have a stillbirth (OR, 1.42; 95% CI, 1.19-1.70). Compared with Australian-born women, migrants of Indian (aOR, 1.71; 95% CI, 1.17-2.47), African (aOR, 2.12; 95% CI, 1.46-3.08), and "other" ethnic origins (aOR, 1.43; 95% CI, 1.06-1.93) were more likely to have antepartum stillbirths; women of African (aOR, 5.08; 95% CI, 3.14-8.22) and "other" (aOR, 1.86; 95% CI, 1.15-3.00) background were more likely to have an intrapartum stillbirth.

CONCLUSIONS

Immigrants of African or Indian background appear to be at greater risk of ante- and intrapartum stillbirth in WA. Specific strategies are needed reduce the prevalence of stillbirth in these communities.

The Japan Environment and Children's Study (JECS) in Fukushima Prefecture: Pregnancy Outcome after the Great East Japan Earthquake

Japan Environment and Children's Study (JECS) is nationwide birth cohort study that was initiated in January 2011 to investigate the effect of environmental factors on children's health. Soon after the JECS started, the Great East Japan Earthquake occurred on March 11, 2011, with subsequent nuclear accident at the Fukushima Daiichi Nuclear Power Plant, causing catastrophic damage in Fukushima Prefecture. After the disaster, JECS was relaunched to cover all areas in Fukushima Prefecture due to public concern. In this study, we used the results of individuals enrolled in JECS, who gave birth during 2011-2014 in Fukushima Prefecture, to elucidate pregnancy outcomes in Fukushima Prefecture. The study consisted of 12,804 maternal outcomes. We thus found that the prevalence rates of preterm birth < 37 weeks, low birth weight (LBW) < 2,500 g, and LBW < 1,500 g were 5.6 %, 9.5%, and 0.8%, respectively; these rates are in accordance with the National Vital Statistics of 2014. The proportion of major anomaly among the newborns was 1.7%, the value of which was lower than other epidemiological studies. This study also found that severe obstetrics outcomes, such as hypertensive disorder of pregnancy and placental abruption, were most frequently seen among teenage mothers with low socioeconomic status. A prefecture-wide birth cohort study following a large-scale disaster may provide valuable information for obstetric care providers and residents to improve obstetric and perinatal care for pregnant women after a disaster.