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Adams A, Dongarwar D, Shay L, Baroni M, Williams E, Ehieze P, Wilson R, Awoseyi A, Salihu HM. Social Determinants of Health and Risk of Stillbirth in the United States. Am J Perinatol 2024; 41:e477-e485. [PMID: 36055282 DOI: 10.1055/s-0042-1756141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Our aim was to evaluate the impact of social determinants of health (SDoH) risk factors on stillbirth among pregnancy-related hospitalizations in the United States. STUDY DESIGN We conducted a cross-sectional analysis of delivery-related hospital discharges using annualized data (2016-2017) from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. The International Classification of Diseases, 10th Revision ICD-10-CM codes were used to select women with singleton stillbirth. Z-codes were utilized to identify SDoH risk factors and their subtypes. The association between SDoH risk factors and stillbirth was assessed using survey logistic regression models. RESULTS We analyzed 8,148,646 hospitalizations, out of which 91,140 were related to stillbirth hospitalizations, yielding a stillbirth incidence of 1.1%. An increased incidence was observed for non-Hispanic (NH) Blacks (1.7%) when compared with NH Whites (1.0%). The incidence of stillbirth was greater in hospitalizations associated with SDoH risk factors compared with those without risk factors [2.0% vs. 1.1% (p <0.001)]. Among patients with SDoH risk factors, the rate of stillbirth was highest in those designated as NH other (3.0%). Mothers that presented with SDoH risk factors had a 60% greater risk of stillbirth compared with those without (odds ratio [OR] = 1.61 [95% confidence interval (CI) = 1.33-1.95], p < 0.001). The SDoH issues that showed the most significant risk for stillbirth were: occupational risk (OR = 7.05 [95% CI: 3.54-9.58], p < 0.001), upbringing (OR = 1.87 [95% CI: 1.23-2.82], p < 0.001), and primary support group and family (OR = 5.45 [95% 3.84-7.76], p < 0.001). CONCLUSION We found pregnancies bearing SDoH risk factors to be associated with a 60% elevated risk for stillbirth. Future studies should target a variety of risk reduction strategies aimed at modifiable SDoH risk factors that can be widely implemented at both the population health level as well as in the direct clinical setting. KEY POINTS · Health disparities exist in stillbirth rates, especially among NH Black women.. · Social determinants of health risk factors increase the risk of stillbirth.. · There is a need for further study on the impact of specific SDoH risk factors on stillbirth risk..
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Affiliation(s)
- April Adams
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
| | - Lena Shay
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Mariana Baroni
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
| | - Eunique Williams
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
| | - Priscilla Ehieze
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
| | - Rhanna Wilson
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
| | - Alexia Awoseyi
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
| | - Hamisu M Salihu
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
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Thadhani R, Cerdeira AS, Karumanchi SA. Translation of mechanistic advances in preeclampsia to the clinic: Long and winding road. FASEB J 2024; 38:e23441. [PMID: 38300220 DOI: 10.1096/fj.202301808r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/30/2023] [Accepted: 01/09/2024] [Indexed: 02/02/2024]
Abstract
As one of the leading causes of premature birth and maternal and infant mortality worldwide, preeclampsia remains a major unmet public health challenge. Preeclampsia and related hypertensive disorders of pregnancy are estimated to cause >75 000 maternal and 500 000 infant deaths globally each year. Because of rising rates of risk factors such as obesity, in vitro fertilization and advanced maternal age, the incidence of preeclampsia is going up with rates ranging from 5% to 10% of all pregnancies worldwide. A major discovery in the field was the realization that the clinical phenotypes related to preeclampsia, such as hypertension, proteinuria, and other adverse maternal/fetal events, are due to excess circulating soluble fms-like tyrosine kinase-1 (sFlt-1, also referred to as sVEGFR-1). sFlt-1 is an endogenous anti-angiogenic protein that is made by the placenta and acts by neutralizing the pro-angiogenic proteins vascular endothelial growth factor (VEGF) and placental growth factor (PlGF). During the last decade, this work has spawned a new era of molecular diagnostics for early detection of this condition. Antagonizing sFlt-1 either by reducing production or blocking its actions has shown salutary effects in animal models. Further, in early-stage human studies, the therapeutic removal of sFlt-1 from maternal circulation has shown promise in delaying disease progression and improving outcomes. Recently, the FDA approved the first molecular test for preterm preeclampsia (sFlt-1/PlGF ratio) for clinical use in the United States. Measuring serum sFlt-1/PlGF ratio in the acute hospital setting may aid short-term management, particularly regarding step-up or step-down of care, decision to transfer to settings better equipped to manage both the mother and the preterm neonate, appropriate timing of administration of steroids and magnesium sulfate, and in expectant management decisions. The test itself has the potential to save lives. Furthermore, the availability of a molecular test that correlates with adverse outcomes has set the stage for interventional clinical trials testing treatments for this disorder. In this review, we will discuss the role of circulating sFlt-1 and related factors in the pathogenesis of preeclampsia and specifically how this discovery is leading to concrete advances in the care of women with preeclampsia.
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Affiliation(s)
- Ravi Thadhani
- Woodruff Health Sciences Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ana Sofia Cerdeira
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford, UK
- Fetal Maternal Medicine Unit, Queen Charlotte's and Chelsea Hospital, London, UK
| | - S Ananth Karumanchi
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Thompson BB, Holzer PH, Kliman HJ. Placental Pathology Findings in Unexplained Pregnancy Losses. Reprod Sci 2024; 31:488-504. [PMID: 37725247 PMCID: PMC10827979 DOI: 10.1007/s43032-023-01344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023]
Abstract
There are approximately 5 million pregnancies per year in the USA, with 1 million ending in miscarriage (a loss occurring prior to 20 weeks of gestation) and over 20,000 ending in stillbirth at or beyond 20 weeks of gestation. As many as 50% of these losses are unexplained. Our objective was to evaluate the effect of expanding the placental pathology diagnostic categories to include the explicit categories of (1) dysmorphic chorionic villi and (2) small placenta in examining previously unexplained losses. Using a clinical database of 1256 previously unexplained losses at 6-43 weeks of gestation, the most prevalent abnormality associated with each loss was determined through examination of its placental pathology slides. Of 1256 cases analyzed from 922 patients, there were 878 (69.9%) miscarriages and 378 (30.1%) antepartum stillbirths. We determined the pathologic diagnoses for 1150/1256 (91.6%) of the entire series, 777/878 (88.5%) of the miscarriages (< 20 weeks' gestation), and 373/378 (98.7%) of the stillbirths (≥ 20 weeks' gestation). The most common pathologic feature observed in unexplained miscarriages was dysmorphic chorionic villi (757 cases; 86.2%), a marker associated with genetic abnormalities. The most common pathologic feature observed in unexplained stillbirths was a small placenta (128 cases; 33.9%). Our classification system reinforced the utility of placental examination for elucidating potential mechanisms behind pregnancy loss. The improved rate of diagnosis appeared to be the result of filling a gap in previous pregnancy loss classification systems via inclusion of the categories of dysmorphic chorionic villi and small placenta.
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Affiliation(s)
- Beatrix B Thompson
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
- Harvard Medical School, Boston, MA, USA
| | - Parker H Holzer
- Department of Statistics & Data Science, Yale University, New Haven, CT, USA
- Spiff Incorporated, Sandy, UT, USA
| | - Harvey J Kliman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA.
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Gandhi C, Page J. Stillbirth risk factors, causes and evaluation. Semin Perinatol 2024; 48:151867. [PMID: 38163743 DOI: 10.1016/j.semperi.2023.151867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Stillbirth impacts 5.73 per 1,000 births in the United States and this rate exceeds that of contemporary high-resource countries.1,2 Risk factors include both demographic and medical characteristics. There are also numerous pathophysiologic mechanisms that can lead to stillbirth. Unfortunately, these risk factors are fairly common, making stillbirth risk stratification and prevention challenging. This is due in part to a large number of unexplained stillbirths. In a large, multi-center study of stillbirths, approximately 24% of stillbirths remained unexplained following thorough, standardized evaluation.3 The number of unexplained stillbirths is unquestionably larger outside of a rigorous study protocol, but real-world data are lacking. This large proportion of unexplained stillbirth cases makes achieving further decreases in the stillbirth rate difficult given lack of understanding of underlying causes in this population. Cause of death identification can be improved with adoption of an evidence-based, comprehensive stillbirth evaluation.
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Affiliation(s)
- Christy Gandhi
- Columbia University Irving Medical Center, United States.
| | - Jessica Page
- Intermountain Health, University of Utah, United States
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Osborne B, Mitra S, Karol D, Azzi P, Ou K, Alibhai KM, Murphy MSQ, El-Chaâr D. Etiology of stillbirth in a tertiary care center: a retrospective cohort study assessing ultrasound, laboratory, and pathology investigations. J Matern Fetal Neonatal Med 2023; 36:2277131. [PMID: 37926910 DOI: 10.1080/14767058.2023.2277131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Canadian stillbirth data are limited, and a significant proportion of pregnancies resulting in stillbirth have no attributable cause. The objective of this study was to characterize stillbirth case investigations and management at a tertiary care hospital in Ontario, Canada. METHODS This was a retrospective chart review study of all cases of singleton stillbirth at The Ottawa Hospital between 1 January 2012 and 31 December 2017. Terminations and multiples stillbirths were excluded. Chart reviews were conducted to extract maternal sociodemographic, obstetrical, and fetal characteristics, including results from antenatal ultrasounds, autopsy, placenta pathology, and laboratory investigations. RESULTS A total of 155 eligible cases of stillbirth were identified, resulting in a 6-year stillbirth rate of 4.2 per 1000 total births. The median maternal age was 31.0 years (IQR: 29.0, 35.0) and the median gestational age at delivery was 28 weeks (IQR: 24, 35). A total of 9 (5.8%) pregnant individuals had a history of previous stillbirth. Of the 155 stillbirths, 35% underwent the full suite of post-loss laboratory, placental, and fetal autopsy investigations. 63.2% of cases had post-loss laboratory investigations completed. 76% and 71% of cases had fetal autopsy and placenta pathology evaluations completed, respectively. Antenatal characteristics associated with stillbirth included fetal anomalies/genetic markers (27.1%), umbilical cord and placental anomalies (24.5%), fetal growth abnormalities (27.7%), cervical/uterine abnormalities (11.6%), and amniotic fluid abnormalities (25.1%). The most common autopsy findings included evidence of infection (22.7%), fetal anomalies (12.6%), and fetal hypoxia (10%). The most common placental pathology findings included features of placental insufficiency (21.8%), retroplacental abnormalities (16.3%), and umbilical cord accident/infarct (15.4%). CONCLUSIONS Our findings demonstrate that as many as two-thirds of singleton stillbirth cases at our center did not receive the post-perinatal loss investigations recommended by clinical practice guidelines. More thorough collection of post-stillbirth data at all levels (institutional, provincial, national) is warranted to improve our understanding of stillbirth epidemiology, etiology, and management in Canada.
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Affiliation(s)
- Brenden Osborne
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Medicine, University of Galway, Galway, Ireland
| | - Sohini Mitra
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
| | - Dalia Karol
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
| | - Pierre Azzi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Kelsie Ou
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Kameela M Alibhai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Malia S Q Murphy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darine El-Chaâr
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Cersonsky TEK, Ayala NK, Pinar H, Dudley DJ, Saade GR, Silver RM, Lewkowitz AK. Identifying risk of stillbirth using machine learning. Am J Obstet Gynecol 2023; 229:327.e1-327.e16. [PMID: 37315754 PMCID: PMC10527568 DOI: 10.1016/j.ajog.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Previous predictive models using logistic regression for stillbirth do not leverage the advanced and nuanced techniques involved in sophisticated machine learning methods, such as modeling nonlinear relationships between outcomes. OBJECTIVE This study aimed to create and refine machine learning models for predicting stillbirth using data available before viability (22-24 weeks) and throughout pregnancy, as well as demographic, medical, and prenatal visit data, including ultrasound and fetal genetics. STUDY DESIGN This is a secondary analysis of the Stillbirth Collaborative Research Network, which included data from pregnancies resulting in stillborn and live-born infants delivered at 59 hospitals in 5 diverse regions across the United States from 2006 to 2009. The primary aim was the creation of a model for predicting stillbirth using data available before viability. Secondary aims included refining models with variables available throughout pregnancy and determining variable importance. RESULTS Among 3000 live births and 982 stillbirths, 101 variables of interest were identified. Of the models incorporating data available before viability, the random forests model had 85.1% accuracy (area under the curve) and high sensitivity (88.6%), specificity (85.3%), positive predictive value (85.3%), and negative predictive value (84.8%). A random forests model using data collected throughout pregnancy resulted in accuracy of 85.0%; this model had 92.2% sensitivity, 77.9% specificity, 84.7% positive predictive value, and 88.3% negative predictive value. Important variables in the previability model included previous stillbirth, minority race, gestational age at the earliest prenatal visit and ultrasound, and second-trimester serum screening. CONCLUSION Applying advanced machine learning techniques to a comprehensive database of stillbirths and live births with unique and clinically relevant variables resulted in an algorithm that could accurately identify 85% of pregnancies that would result in stillbirth, before they reached viability. Once validated in representative databases reflective of the US birthing population and then prospectively, these models may provide effective risk stratification and clinical decision-making support to better identify and monitor those at risk of stillbirth.
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Affiliation(s)
- Tess E K Cersonsky
- Department of Obstetrics & Gynecology, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI.
| | - Nina K Ayala
- Department of Obstetrics & Gynecology, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI
| | - Halit Pinar
- Department of Pathology, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI
| | - Donald J Dudley
- Department of Obstetrics & Gynecology, University of Virginia, Charlottesville, VA
| | - George R Saade
- Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Robert M Silver
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT
| | - Adam K Lewkowitz
- Department of Obstetrics & Gynecology, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence, RI
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Thompson RA, Thompson JMD, Wilson J, Cronin RS, Mitchell EA, Raynes-Greenow CH, Li M, Stacey T, Heazell AEP, O'Brien LM, McCowan LME, Anderson NH. Risk factors for late preterm and term stillbirth: A secondary analysis of an individual participant data meta-analysis. BJOG 2023. [PMID: 36852504 DOI: 10.1111/1471-0528.17444] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/14/2022] [Accepted: 01/09/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Identify independent and novel risk factors for late-preterm (28-36 weeks) and term (≥37 weeks) stillbirth and explore development of a risk-prediction model. DESIGN Secondary analysis of an Individual Participant Data (IPD) meta-analysis investigating modifiable stillbirth risk factors. SETTING An IPD database from five case-control studies in New Zealand, Australia, the UK and an international online study. POPULATION Women with late-stillbirth (cases, n = 851), and ongoing singleton pregnancies from 28 weeks' gestation (controls, n = 2257). METHODS Established and novel risk factors for late-preterm and term stillbirth underwent univariable and multivariable logistic regression modelling with multiple sensitivity analyses. Variables included maternal age, body mass index (BMI), parity, mental health, cigarette smoking, second-hand smoking, antenatal-care utilisation, and detailed fetal movement and sleep variables. MAIN OUTCOME MEASURES Independent risk factors with adjusted odds ratios (aOR) for late-preterm and term stillbirth. RESULTS After model building, 575 late-stillbirth cases and 1541 controls from three contributing case-control studies were included. Risk factor estimates from separate multivariable models of late-preterm and term stillbirth were compared. As these were similar, the final model combined all late-stillbirths. The single multivariable model confirmed established demographic risk factors, but additionally showed that fetal movement changes had both increased (decreased frequency) and reduced (hiccoughs, increasing strength, frequency or vigorous fetal movements) aOR of stillbirth. Poor antenatal-care utilisation increased risk while more-than-adequate care was protective. The area-under-the-curve was 0.84 (95% CI 0.82-0.86). CONCLUSIONS Similarities in risk factors for late-preterm and term stillbirth suggest the same approach for risk-assessment can be applied. Detailed fetal movement assessment and inclusion of antenatal-care utilisation could be valuable in late-stillbirth risk assessment.
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Affiliation(s)
- R A Thompson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - J M D Thompson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - J Wilson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - R S Cronin
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Women's Health Division, Counties Manukau Health, Auckland, New Zealand
| | - E A Mitchell
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - C H Raynes-Greenow
- Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - M Li
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
- Women's Health Division, Counties Manukau Health, Auckland, New Zealand
| | - T Stacey
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - A E P Heazell
- University of Manchester, Manchester, UK
- University of Michigan, Ann Arbor, Michigan, USA
| | - L M O'Brien
- University of Michigan, Ann Arbor, Michigan, USA
| | - L M E McCowan
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
| | - N H Anderson
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Science, The University of Auckland, Auckland, New Zealand
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Stepan H, Galindo A, Hund M, Schlembach D, Sillman J, Surbek D, Vatish M. Clinical utility of sFlt-1 and PlGF in screening, prediction, diagnosis and monitoring of pre-eclampsia and fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:168-180. [PMID: 35816445 DOI: 10.1002/uog.26032] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 05/27/2023]
Abstract
Pre-eclampsia (PE) is characterized by placental and maternal endothelial dysfunction, and associated with fetal growth restriction (FGR), placental abruption, preterm delivery and stillbirth. The angiogenic factors soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) are altered in pregnancies complicated by placenta-related disorders. In this Review, we summarize the existing knowledge, examining the performance of maternal PlGF, sFlt-1 and the sFlt-1/PlGF ratio for screening PE, predicting development of PE in the short term, diagnosing PE, monitoring established PE and predicting other placenta-related disorders in singleton pregnancy. We also discuss the performance of PlGF and the sFlt-1/PlGF ratio for predicting PE in twin pregnancy. For first-trimester screening in singleton pregnancy, a more accurate way of identifying high-risk women than current practice is to combine maternal PlGF levels with clinical risk factors and ultrasound markers. Later in pregnancy, the sFlt-1/PlGF ratio has advantages over PlGF because it has a higher pooled sensitivity and specificity for diagnosing and monitoring PE. It has clinical value because it can rule out the development of PE in the 1-4-week period after the test. Once a diagnosis of PE is established, repeat measurement of sFlt-1 and PlGF can help monitor progression of the condition and may inform clinical decision-making regarding the optimal time for delivery. The sFlt-1/PlGF ratio is useful for predicting FGR and preterm delivery, but the association between stillbirth and the angiogenic factors is unclear. The sFlt-1/PlGF ratio can be used to predict PE in twin pregnancy, although different sFlt-1/PlGF ratio cut-offs from those for singleton pregnancy should be applied for optimal performance. In summary, PlGF, sFlt-1 and the sFlt-1/PlGF ratio are useful for screening, diagnosing, predicting and monitoring placenta-related disorders in singleton and twin pregnancy. We propose that tests for these angiogenic factors are integrated more fully into clinical practice.© 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H Stepan
- University Hospital Leipzig, Leipzig, Germany
| | - A Galindo
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - M Hund
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | | | - J Sillman
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - D Surbek
- University Hospital, University of Bern, Bern, Switzerland
| | - M Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
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Escañuela Sánchez T, Matvienko‐Sikar K, Meaney S, O'Donoghue K. Exploring first-time mothers' experiences and knowledge about behavioural risk factors for stillbirth. Health Expect 2022; 26:329-342. [PMID: 36416378 PMCID: PMC9854314 DOI: 10.1111/hex.13662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Modifiable factors such as substance use, lack of attendance at antenatal care, overweight or obesity and sleeping position are associated with a higher risk of stillbirth. This qualitative study aimed to explore women's experiences of modifiable factors during pregnancy and their awareness of stillbirth. METHODS Purposive sampling was implemented by hospital staff in a large tertiary maternity hospital in Ireland between November 2020 and March 2021. Women were approached during their stay in the hospital and were invited to participate in a semistructured interview 3-5 months later. Eligible women were primiparous, >18 years of age and had an uncomplicated pregnancy and delivery. Eighteen women who consented to be followed up were interviewed at 3-5 months postpartum. Thematic analysis was used to analyse the data. RESULTS Four themes were identified: attitudes towards behaviour change, awareness regarding stillbirth and risk factors, the silence around stillbirth and risks, and attitudes towards receiving information about stillbirth. Women spoke about behaviour change in terms of outcomes, and most changes (e.g., ceasing alcohol consumption) were perceived as easy to manage. Awareness of stillbirth was limited among the women interviewed, and the association between risk behaviours and stillbirth was not known by any woman. Results suggest that there is a silence around stillbirth, including in antenatal care, which hinders information provision. However, most women highlighted the value of receiving information and extra education about modifiable risk factors and stillbirth. CONCLUSION There is a general lack of understanding of the link between behavioural risk factors and potential pregnancy outcomes such as stillbirth. Providing further information to women about stillbirth and providing additional support with behaviour change might contribute to enhancing preventive efforts. PATIENT OR PUBLIC CONTRIBUTION Patients were involved in this study by providing their experiences of antenatal care which were used as primary data.
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Affiliation(s)
- Tamara Escañuela Sánchez
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, Cork University Maternity HospitalUniversity College CorkCorkIreland,Infant CentreUniversity College CorkCorkIreland
| | | | - Sarah Meaney
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, Cork University Maternity HospitalUniversity College CorkCorkIreland,National Perinatal Epidemiology Centre (NPEC)University College CorkCorkIreland
| | - Keelin O'Donoghue
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, Cork University Maternity HospitalUniversity College CorkCorkIreland,Infant CentreUniversity College CorkCorkIreland
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Clinical Biochemical Indicators and Intestinal Microbiota Testing Reveal the Influence of Reproductive Age Extending from the Mother to the Offspring. Microbiol Spectr 2022; 10:e0107622. [PMID: 35993782 PMCID: PMC9602618 DOI: 10.1128/spectrum.01076-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Age is an important factor that determines the physiological functions of the human body, but the changes in maternal physiology, biochemistry, and intestinal flora related to reproductive age and their impact on offspring are not clear. Here, we tested and analyzed the clinical physiological and biochemical indicators and/or intestinal flora, matching the data of 252 parturients and their newborns. We found that 4 clinical indicators, including the white blood cell count and the absolute value of monocytes, were significantly related to the reproductive age (P < 0.05). The composition of the intestinal flora also varied with age, and the intestinal flora of advanced-age women (≥35 years old) was different from that of middle-aged women (>25 and <35 years old). We also found that changes in maternal clinical physiological and biochemical indicators related to reproductive age could reflect changes in the abundance of bacteria, such as Peptococcus and Vibrio, and changes in the intestinal flora spread to offspring. These results provide new evidence to explain the increased adverse pregnancy outcomes of mothers of inappropriate age, describe the increased health risks of newborns, help us examine the importance of age-appropriate birth from a broader perspective, and contribute to the discovery of mother-child bonds for a better understanding of healthy reproduction. IMPORTANCE In this study, we demonstrated that physiological indicators and the gut microbiome fluctuate drastically among parturients of different reproductive ages and that there is a significant correlation between the two changes. Mothers of different ages had different gut microbes, and the gut microbiota varied as the childbearing age became too high. Changes in the gut microbiome with maternal reproductive age affected the offspring, and the influence of reproductive age on the intestinal flora had a synergistic effect between mother and child that was revealed for the first time. The maternal childbearing age might affect the colonization of the offspring's initial flora. The results provide new evidence to explain the increased adverse pregnancy outcomes of mothers of inappropriate age, describe the increased health risks of newborns, and contribute to the discovery of mother-child bonds for a better understanding of healthy reproduction.
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11
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Goodarzi B, Seijmonsbergen‐Schermers A, van Rijn M, Shah N, Franx A, de Jonge A. Maternal characteristics as indications for routine induction of labor: A nationwide retrospective cohort study. Birth 2022; 49:569-581. [PMID: 35229355 PMCID: PMC9546001 DOI: 10.1111/birt.12628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/17/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Maternal characteristics, such as parity and age, are increasingly considered indications for routine induction of labor of otherwise healthy women to prevent fetal and neonatal mortality. To fully balance the risks and benefits of induction of labor, we examined the association of additional relevant maternal characteristics and gestational age with fetal and neonatal mortality. METHODS We conducted a nationwide retrospective cohort study among a healthy Dutch population consisting of all singleton pregnancies in midwife-led care after 37 weeks of gestation in the period 2000-2018. We examined the association of maternal ethnicity, age, parity, and socioeconomic status with fetal and neonatal mortality, stratified by gestational age. The association of single characteristics was examined using descriptive statistics, and univariable and multivariable logistics regression analyses. The associations of multiple characteristics were examined using inter-categorical analyses and using interaction terms in the multivariable logistic regression analyses. RESULTS The results showed that ethnicity, age, parity, socioeconomic status, and gestational age did not act as single determinant of fetal and neonatal mortality. The probability of fetal and neonatal mortality differed among subgroups of women depending on which determinants were considered and the number of determinants included. CONCLUSIONS Decision-making about induction of labor to prevent fetal and neonatal mortality based on a single determinant may lead to overuse or underuse of IOL. A value-based health care strategy, addressing social inequity, and investing in better screening and diagnostic methods that employ an individualized and multi-determinant approach may be more effective at preventing fetal and neonatal mortality.
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Affiliation(s)
- Bahareh Goodarzi
- Department of Midwifery ScienceAmsterdam Public HealthAmsterdam UMCVrije Universiteit AmsterdamAVAGAmsterdamthe Netherlands
| | - Anna Seijmonsbergen‐Schermers
- Department of Midwifery ScienceAmsterdam Public HealthAmsterdam UMCVrije Universiteit AmsterdamAVAGAmsterdamthe Netherlands
| | - Maaike van Rijn
- Department of Obstetrics and GynaecologyHaga ZiekenhuisThe HagueThe Netherlands
| | - Neel Shah
- Department of Obstetrics, Gynaecology and Reproductive BiologyHarvard Medical SchoolBostonMassachusettsUSA
| | - Arie Franx
- Department of Obstetrics and GynaecologyErasmus MCRotterdamthe Netherlands
| | - Ank de Jonge
- Department of Midwifery ScienceAmsterdam Reproduction and DevelopmentAmsterdam UMCVrije Universiteit AmsterdamAVAGAmsterdamthe Netherlands
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12
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Siassakos D, Bourne I, Sebire N, Kindinger L, Whitten SM, Battaglino C. Abnormal placental villous maturity and dysregulated glucose metabolism: implications for stillbirth prevention. J Perinat Med 2022; 50:763-768. [PMID: 35357795 DOI: 10.1515/jpm-2021-0579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 03/10/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES In the UK one in 250 pregnancies end in stillbirth. Abnormal placental villous maturation, commonly associated with gestational diabetes, is a risk factor for stillbirth. Histopathology reports of placental distal villous immaturity (DVI) are reported disproportionately in placentas from otherwise unexplained stillbirths in women without formal diagnosis of diabetes but with either clinical characteristics or risk factors for diabetes. This study aims to establish maternal factors associated with DVI in relation to stillbirth. METHODS Placental histopathology reports were reviewed for all pregnant women delivering at University College London Hospital between July 2018 to March 2020. Maternal characteristics and birth outcomes of those with DVI were compared to those with other placental lesions or abnormal villous maturation. RESULTS Of the 752 placental histopathology reports reviewed, 11 (1.5%) were reported as diagnostic of DVI. Eighty cases were sampled for clinical record analysis. All women with DVI had normal PAPP-A (>0.4 MoM), normal uterine artery Doppler studies (UtA-PI) and were normotensive throughout pregnancy. Nearly one in five babies (2/11, 18.5%) with DVI were stillborn and 70% had at least one high glucose test result in pregnancy despite no formal diagnosis of diabetes. CONCLUSIONS These findings suggest that the mechanism underlying stillbirth in DVI likely relates to glucose dysmetabolism, not sufficient for diagnosis using current criteria for gestational diabetes, resulting in placental dysfunction that is not identifiable before the third trimester. Relying on conventional diabetes tests, foetal macrosomia or growth restriction, may not identify all pregnancies at risk of adverse outcomes from glucose dysmetabolism.
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Affiliation(s)
- Dimitrios Siassakos
- Institute for Women's Health, University College London, London, UK.,University College London Hospital (UCLH), London, UK.,UCLH National Institute for Health Research Biomedical Research Centre, London, UK.,Wellcome/EPSRC Centre for Surgical and Interventional Sciences (WEISS), London, UK
| | - Isabella Bourne
- Institute for Women's Health, University College London, London, UK
| | - Neil Sebire
- Great Ormond Street Hospital Institute for Child Health, London, UK
| | | | - Sara Melissa Whitten
- Institute for Women's Health, University College London, London, UK.,University College London Hospital (UCLH), London, UK
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13
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Methodological approaches for assessing certainty of the evidence in umbrella reviews: A scoping review. PLoS One 2022; 17:e0269009. [PMID: 35675337 PMCID: PMC9176806 DOI: 10.1371/journal.pone.0269009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 05/12/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction The number of umbrella reviews (URs) that compiled systematic reviews and meta-analysis (SR-MAs) has increased dramatically over recent years. No formal guidance for assessing the certainty of evidence in URs of meta-analyses exists nowadays. URs of non-interventional studies help establish evidence linking exposure to certain health outcomes in a population. This study aims to identify and describe the methodological approaches for assessing the certainty of the evidence in published URs of non-interventions. Methods We searched from 3 databases including PubMed, Embase, and The Cochrane Library from May 2010 to September 2021. We included URs that included SR-MAs of studies with non-interventions. Two independent reviewers screened and extracted data. We compared URs characteristics stratified by publication year, journal ranking, journal impact factor using Chi-square test. Results Ninety-nine URs have been included. Most were SR-MAs of observational studies evaluating association of non-modifiable risk factors with some outcomes. Only half (56.6%) of the included URs assessed the certainty of the evidence. The most frequently used criteria is credibility assessment (80.4%), followed by GRADE approach (14.3%). URs published in journals with higher journal impact factor assessed certainty of evidence than URs published in lower impact group (77.1 versus 37.2% respectively, p < 0.05). However, criteria for credibility assessment used in four of the seven URs that were published in top ranking journals were slightly varied. Conclusions Half of URs of MAs of non-interventional studies have assessed the certainty of the evidence, in which criteria for credibility assessment was the commonly used method. Guidance and standards are required to ensure the methodological rigor and consistency of certainty of evidence assessment for URs.
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14
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Monari F, Spano' Bascio L, Banchelli F, Neri I, Bertucci E, Ferrari F, Menichini D, D'Amico R, Facchinetti F. First-trimester prediction model for placental vascular disorders: An observational prospective study. Pregnancy Hypertens 2022; 28:35-40. [PMID: 35168013 DOI: 10.1016/j.preghy.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 01/31/2022] [Accepted: 02/07/2022] [Indexed: 12/29/2022]
Abstract
This study aims to develop a multivariable predictive model for the risk of placental vascular complications (PVC), by using biochemical, biophysical, anamnestic and clinical maternal features available at the first trimester. PVC include gestational hypertension, preeclampsia, placenta abruption, intrauterine growth restriction (IUGR), and stillbirth. Prospective study that included all singleton pregnancies attending the first-trimester aneuploidy screening (11 +0-12 +6 weeks) at Obstetrics Unit of the University Hospital of Modena, in Northern Italy, between June 2018 and December 2019. In a total of 503 women included in the analysis, 40 patients were in the PVC group. The final prediction model for PVC included the following independent variables: pre-pregnancy BMI ≥ 30 (OR = 2.65, 95% CI = 1.04; 6.75, p = 0.0415), increasing values of mean arterial pressure (OR = 1.06, 95% CI = 1.02; 1.10, p = 0.0008), PAPP-A < 2.40465 U/L (OR = 0.43, 95% CI = 0.19; 0.96, p = 0.0388) and decreasing values of PlGf (MoM) (OR = 0.28, 95% CI = 0.10; 0.79, p = 0.0153). The area under the ROC curve was 79.4% indicating a satisfactory predictive accuracy. The best predictive cut-off for this score was equal to -2.562, which corresponds to a 7.2 % probability of having PVC. By using such a cut-off, the risk of PVC can be predicted in our sample with sensitivity equal to 82,4 % and specificity equal to 69,9 %. This model for early prediction of PVC is a promising tool to early identify women at greater risk for placenta vascular complications.
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Affiliation(s)
- Francesca Monari
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Modena, Italy.
| | - Ludovica Spano' Bascio
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Modena, Italy
| | - Federico Banchelli
- Department of Diagnostic, Clinical and Public Health Medicine, Statistics Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Isabella Neri
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Modena, Italy
| | - Emma Bertucci
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Modena, Italy
| | - Francesca Ferrari
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Modena, Italy
| | - Daniela Menichini
- International Doctorate School in Clinical and Experimental Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Italy
| | - Roberto D'Amico
- Department of Diagnostic, Clinical and Public Health Medicine, Statistics Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Modena, Italy
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15
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Muin DA, Pfeifer B, Helmer H, Oberaigner W, Leitner H, Kiss H, Neururer S. Universal gestational diabetes screening and antepartum stillbirth rates in Austria-A population-based study. Acta Obstet Gynecol Scand 2022; 101:396-404. [PMID: 35195277 PMCID: PMC9976563 DOI: 10.1111/aogs.14334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Occult or untreated gestational diabetes (GDM) is a well-known risk factor for adverse perinatal outcomes and may contribute to antepartum stillbirth. We assessed the impact of screening for GDM on the rate of antepartum stillbirths in non-anomalous pregnancies by conducting a population-based study in 974 889 women in Austria. MATERIAL AND METHODS Our database was derived from the Austrian Birth Registry. Inclusion criteria were singleton live births and antepartum stillbirths ≥24+0 gestational weeks, excluding fetal congenital malformations, terminations of pregnancy and women with pre-existing type 1 or 2 diabetes. Main outcome measures were (a) overall stillbirth rates and (b) stillbirth rates in women at high risk of GDM (i.e., women with a body mass index ≥30 kg/m2 , history of previous intrauterine fetal death, GDM, previous macrosomic offspring) before (2008-2010, "phase I") and after (2011-2019, "phase II") the national implementation of universal GDM screening with a 75 g oral glucose tolerance test in Austrian pregnant women by 2011. RESULTS In total, 940 373 pregnancies were included between 2008 and 2019, of which 2579 resulted in intrauterine fetal deaths at 33.51 ± 5.10 gestational weeks. After implementation of the GDM screening, a statistically significant reduction in antepartum stillbirth rates among non-anomalous singletons was observed only in women at high risk for GDM (4.10‰ [95% confidence interval (CI) 3.09-5.43] in phase I vs. 2.96‰ [95% CI 2.57-3.41] in phase II; p = 0.043) but not in the general population (2.76‰ [95% CI 2.55-2.99] in phase I vs. 2.74‰ [95% CI 2.62-2.86] in phase II; p = 0.845). The number needed to screen with the oral glucose tolerance test to subsequently prevent one case of (non-anomalous) intrauterine fetal death was 880 in the high-risk and 40 000 in the general population. CONCLUSIONS The implementation of a universal GDM screening program in Austria in 2011 has not led to any significant reduction in antenatal stillbirths among non-anomalous singletons in the general population. More international data are needed to strengthen our findings.
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Affiliation(s)
- Dana A. Muin
- Department of Obstetrics and Gynecology, Division of Fetomaternal MedicineMedical University of ViennaViennaAustria
| | - Bernhard Pfeifer
- Department of Clinical EpidemiologyTyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbHInnsbruckAustria
| | - Hanns Helmer
- Department of Obstetrics and Gynecology, Division of Fetomaternal MedicineMedical University of ViennaViennaAustria
| | - Wilhelm Oberaigner
- Research Unit for Diabetes Epidemiology, Institute for Public Health, Medical Decision Making and Health Technology AssessmentUMIT University for Health, Sciences, Medical Informatics and TechnologyHall in TirolAustria
| | - Hermann Leitner
- Department of Clinical EpidemiologyTyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbHInnsbruckAustria
| | - Herbert Kiss
- Department of Obstetrics and Gynecology, Division of Fetomaternal MedicineMedical University of ViennaViennaAustria
| | - Sabrina Neururer
- Department of Clinical EpidemiologyTyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbHInnsbruckAustria
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16
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Ali S, Kawooya MG, Byamugisha J, Kakibogo IM, Biira EA, Kagimu AN, Grobbee DE, Zakus D, Papageorghiou AT, Klipstein-Grobusch K, Rijken MJ. Middle cerebral arterial flow redistribution is an indicator for intrauterine fetal compromise in late pregnancy in low-resource settings: A prospective cohort study. BJOG 2022; 129:1712-1720. [PMID: 35118790 PMCID: PMC9545180 DOI: 10.1111/1471-0528.17115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/13/2022] [Accepted: 02/01/2022] [Indexed: 11/27/2022]
Abstract
Objective We aimed to determine the prevalence of abnormal umbilical artery (UA), uterine artery (UtA), middle cerebral artery (MCA) and cerebroplacental ratio (CPR) Doppler, and their relationship with adverse perinatal outcomes in women undergoing routine antenatal care in the third trimester. Design Prospective cohort. Setting Kagadi Hospital, Uganda. Population Non‐anomalous singleton pregnancies. Methods Women underwent an early dating ultrasound and a third‐trimester Doppler scan between 32 and 40 weeks of gestation, from 2018 to 2020. We handled missing data using multiple imputation and analysed the data using descriptive methods and a binary logistic regression model. Main outcome measures Composite adverse perinatal outcome (CAPO), perinatal death and stillbirth. Results We included 995 women. The mean gestational age at Doppler scan was 36.9 weeks (SD 1.02 weeks) and 88.9% of the women gave birth in a health facility. About 4.4% and 5.6% of the UA pulsatility index (PI) and UtA PI were above the 95th percentile, whereas 16.4% and 10.4% of the MCA PI and CPR were below the fifth percentile, respectively. Low CPR was strongly associated with stillbirth (OR 4.82, 95% CI 1.09–21.30). CPR and MCA PI below the fifth percentile were independently associated with CAPO; the association with MCA PI was stronger in small‐for‐gestational‐age neonates (OR 3.75, 95% CI 1.18–11.88). Conclusion In late gestation, abnormal UA PI was rare. Fetuses with cerebral blood flow redistribution were at increased risk of stillbirth and perinatal complications. Further studies examining the predictive accuracy and effectiveness of antenatal Doppler ultrasound screening in reducing the risk of perinatal deaths in low‐ and middle‐income countries are warranted. Tweetable abstract Blood flow redistribution to the fetal brain is strongly associated with stillbirths in low‐resource settings. Blood flow redistribution to the fetal brain is strongly associated with stillbirths in low‐resource settings. This article includes Author Insights, a video abstract available at https://vimeo.com/bjogabstracts/authorinsights17115.
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Affiliation(s)
- Sam Ali
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Michael G Kawooya
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Mengo Hospital, Kampala, Uganda
| | - Josaphat Byamugisha
- School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac M Kakibogo
- Antenatal and Maternity Unit, Kagadi Hospital, Kagadi District, Uganda
| | | | - Adia N Kagimu
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Mengo Hospital, Kampala, Uganda
| | - Diederick E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - David Zakus
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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17
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Allotey J, Whittle R, Snell KIE, Smuk M, Townsend R, von Dadelszen P, Heazell AEP, Magee L, Smith GCS, Sandall J, Thilaganathan B, Zamora J, Riley RD, Khalil A, Thangaratinam S. External validation of prognostic models to predict stillbirth using International Prediction of Pregnancy Complications (IPPIC) Network database: individual participant data meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:209-219. [PMID: 34405928 DOI: 10.1002/uog.23757] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/30/2021] [Accepted: 08/02/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Stillbirth is a potentially preventable complication of pregnancy. Identifying women at high risk of stillbirth can guide decisions on the need for closer surveillance and timing of delivery in order to prevent fetal death. Prognostic models have been developed to predict the risk of stillbirth, but none has yet been validated externally. In this study, we externally validated published prediction models for stillbirth using individual participant data (IPD) meta-analysis to assess their predictive performance. METHODS MEDLINE, EMBASE, DH-DATA and AMED databases were searched from inception to December 2020 to identify studies reporting stillbirth prediction models. Studies that developed or updated prediction models for stillbirth for use at any time during pregnancy were included. IPD from cohorts within the International Prediction of Pregnancy Complications (IPPIC) Network were used to validate externally the identified prediction models whose individual variables were available in the IPD. The risk of bias of the models and cohorts was assessed using the Prediction study Risk Of Bias ASsessment Tool (PROBAST). The discriminative performance of the models was evaluated using the C-statistic, and calibration was assessed using calibration plots, calibration slope and calibration-in-the-large. Performance measures were estimated separately in each cohort, as well as summarized across cohorts using random-effects meta-analysis. Clinical utility was assessed using net benefit. RESULTS Seventeen studies reporting the development of 40 prognostic models for stillbirth were identified. None of the models had been previously validated externally, and the full model equation was reported for only one-fifth (20%, 8/40) of the models. External validation was possible for three of these models, using IPD from 19 cohorts (491 201 pregnant women) within the IPPIC Network database. Based on evaluation of the model development studies, all three models had an overall high risk of bias, according to PROBAST. In the IPD meta-analysis, the models had summary C-statistics ranging from 0.53 to 0.65 and summary calibration slopes ranging from 0.40 to 0.88, with risk predictions that were generally too extreme compared with the observed risks. The models had little to no clinical utility, as assessed by net benefit. However, there remained uncertainty in the performance of some models due to small available sample sizes. CONCLUSIONS The three validated stillbirth prediction models showed generally poor and uncertain predictive performance in new data, with limited evidence to support their clinical application. The findings suggest methodological shortcomings in their development, including overfitting. Further research is needed to further validate these and other models, identify stronger prognostic factors and develop more robust prediction models. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Allotey
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - R Whittle
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - K I E Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - M Smuk
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK
| | - R Townsend
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - P von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - A E P Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - L Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - G C S Smith
- Department of Obstetrics and Gynaecology, NIHR Biomedical Research Centre, Cambridge University, Cambridge, UK
| | - J Sandall
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
- Health Service and Population Research Department, Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - J Zamora
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
- CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - R D Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - S Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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18
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Carroll A, Desforges M, Jones CJ, Heazell AE. Morphological and functional changes in placentas from prolonged pregnancies. Placenta 2022; 125:29-35. [DOI: 10.1016/j.placenta.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/23/2021] [Accepted: 01/10/2022] [Indexed: 11/27/2022]
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Nicolaides KH, Papastefanou I, Syngelaki A, Ashoor G, Akolekar R. Predictive performance for placental dysfunction related stillbirth of the competing risks model for small for gestational age fetuses. BJOG 2021; 129:1530-1537. [PMID: 34919332 DOI: 10.1111/1471-0528.17066] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/26/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES First, to examine the predictive performance for placental dysfunction related stillbirths of the competing risks model for small for gestational age (SGA) fetuses based on a combination of maternal risk factors, estimated fetal weight (EFW) and uterine artery pulsatility index (UtA-PI); and second, to compare the performance of this model to that of stillbirth-specific model utilizing the same biomarkers and to the Royal College of Obstetricians and Gynecologists (RCOG) guideline for the investigation and management of the SGA fetus. DESIGN Prospective observational study. SETTING Two UK maternity hospitals. POPULATION 131,514 women with singleton pregnancies attending for routine ultrasound examination at 19-24 weeks' gestation. METHODS The predictive performance for stillbirth achieved by three models was compared. Main outcome measure Placental dysfunction related stillbirth. RESULTS At 10% false positive rate, the competing risks model predicted 59%, 66% and 71% of placental dysfunction related stillbirths, at any gestation, at <37 weeks and at <32 weeks, respectively, which were similar to the respective figures of 62%, 70% and 73% for the stillbirth-specific model. At a screen positive rate of 21.8 %, as defined by the RCOG guideline, the competing risks model predicted 71%, 76% and 79% of placental dysfunction related stillbirths at any gestation, at <37 weeks and at <32 weeks, respectively, and the respective figures for the RCOG guideline were 40%, 44% and 42%. CONCLUSION The predictive performance for placental dysfunction related stillbirths by the competing risks model for SGA was similar to the stillbirth-specific model and superior to the RCOG guideline.
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Affiliation(s)
| | | | - Argyro Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Ghalia Ashoor
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Ranjit Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK.,Institute of Medical Sciences, Canterbury Christ Church University, Chatham, UK
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Abstract
PURPOSE OF REVIEW Stillbirth has a high global prevalence and has not improved despite other advances in maternal and perinatal outcomes in the last 20 years. The global applicability of research is challenged by the fact that most evidence originates from high-income countries, whereas the burden is greatest in low- and middle-income countries. Robust universally applicable evidence is therefore desired to address this problem. RECENT FINDINGS Good quality evidence has identified key risk factors for stillbirth. However, an effective universally applicable model is yet to be developed. Published prediction models lack internal or external validation, suffer from the risk of bias or cannot be applied to different populations. Term induction of labour suggests good clinical outcomes with no increase in obstetric interventions but must be considered within the context of the healthcare system's feasibility, cost-effectiveness and the experiences of women. SUMMARY The most realistic focus to reduce stillbirth is placental insufficiency. Globally, the greatest benefit will come from treating those with the highest risk of disease, such as those in low and middle-income countries. Further high-quality trials need to be conducted in these settings as a priority.
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von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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22
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Lin L, Lu C, Chen W, Li C, Guo VY. Parity and the risks of adverse birth outcomes: a retrospective study among Chinese. BMC Pregnancy Childbirth 2021; 21:257. [PMID: 33771125 PMCID: PMC8004392 DOI: 10.1186/s12884-021-03718-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background Nulliparity is considered to be a risk factor of preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA). With the new two-child policy launched in 2016, more Chinese women have delivered their 2nd baby. Yet few studies have assessed the impact of parity on adverse birth outcomes in China. This study aimed to examine the association between parity and risks of PTB, LBW and SGA in a Chinese population. The combined effects of maternal age and parity on adverse birth outcomes were also assessed. Methods This retrospective study included all non-malformed live births born during January 1, 2014 and December 31, 2018 in Chengdu, China. A total of 746,410 eligible live singletons with complete information were included in the analysis. Parity was classified into nulliparity (i.e. has never delivered a newborn before) and multiparity (i.e. has delivered at least one newborn before). Log-binomial regression analyses were applied to evaluate the association between parity and PTB, LBW and SGA. We further divided maternal age into different groups (< 25 years, 25–29 years, 30–34 years and ≥ 35 years) to assess the combined effects of maternal age and parity on adverse birth outcomes. Results Multiparity was associated with reduced risks of PTB (aRR = 0.91, 95% CI: 0.89–0.93), LBW (aRR = 0.74, 95% CI: 0.72–0.77) and SGA (aRR = 0.67, 95% CI: 0.66–0.69) compared with nulliparity. In each age group, we observed that multiparity was associated with lower risks of adverse birth outcomes. Compared to nulliparous women aged between 25 and 29 years, women aged ≥35 years had greater risks of PTB and LBW, regardless of their parity status. In contrast, multiparous women aged ≥35 years (aRR = 0.73, 95% CI: 0.70–0.77) and those aged < 25 years (aRR = 0.88, 95% CI: 0.84–0.93) were at lower risk of SGA compared with nulliparous women aged between 25 and 29 years. Conclusion Multiparity was associated with lower risks of all adverse birth outcomes. Special attention should be paid to nulliparous mothers and those with advanced age during antenatal care, in order to reduce the risks of adverse birth outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03718-4.
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Affiliation(s)
- Li Lin
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Ciyong Lu
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Weiqing Chen
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Chunrong Li
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, Sichuan, China.
| | - Vivian Yawei Guo
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.
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