Birth rate after major trauma in fertile-aged women: a nationwide population-based cohort study in Finland

Delivery mode and subsequent birth rate: A nationwide register-based analysis in Finland

OBJECTIVE

The study aimed to calculate the subsequent birth rate for different delivery modes, comparing them with spontaneous vaginal deliveries, using a comprehensive nationwide high-quality registry.

METHODS

Data from the National Medical Birth Register (MBR) were used to evaluate the birth rate after different delivery modes. All first deliveries for a mother during the years 2004 to 2016 were included. For these women, all second pregnancies from the MBR during the years 2004 to 2018 were retrieved and combined with the data of the first deliveries. A Cox regression model was used to evaluate the risk for the second pregnancy after giving birth the first time. The results were interpreted with adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

A total of 375 619 women with a first and second pregnancy leading to birth were included in this study. Of these, a total of 50 579 women underwent assisted vaginal delivery, 50 429 had an unplanned cesarean section (CS), 22 021 had elective CS, and 252 593 had spontaneous vaginal delivery as a mode of delivery in their first pregnancy. Women with assisted vaginal delivery (aHR, 1.23 [CI, 1.21-1.24]) and unplanned CS (aHR, 1.03 [CI, 1.02-1.05]) had higher birth rates after the first birth, and women with elective CS as a mode of delivery had lower birth rates (aHR, 0.86 [CI, 0.84-0.88]) when compared with women who had spontaneous vaginal delivery.

CONCLUSION

The findings of this study indicate that the CS operation itself is not the only cause of the observed lower birth rate; rather, there are underlying factors that have a greater impact on birth rates.

Effect of major trauma on the expected number of births in Finnish women: A nationwide population-based public data and register analysis

BACKGROUND

The effect of major trauma on subsequent fertility is poorly described. If women have lower fertility after trauma, they would have a lower risk of anti-D mediated hemolytic disease of the fetus and newborn in a future pregnancy following the transfusion of RhD-positive blood to RhD-negative women during their resuscitation.

STUDY DESIGN AND METHODS

Data was obtained from the Care Register for Health Care, National Medical Birth Register, and open access data from Statistic Finland to evaluate the effect of major trauma (traumatic brain injuries, spine, pelvic, hip/thigh fractures) on the age-specific number of births during years 1998-2018. The total number of births before a specific maternal age for different trauma populations was calculated and these were compared to the corresponding number of births in the general population.

RESULTS

There were 50,923 injured women in this study. All injured women, including when analyzed by the nature of their injury, demonstrated lower expected numbers of births starting at approximately 28 years of age compared to the general population of women in Finland. At age 49, the expected number of births in the general population was approximately 1.8, whereas for all injured women 0.6, women with TBIs and spine fractures 0.6, women with pelvic fractures 0.5, and women with hip or thigh fractures 0.3.

DISCUSSION

Injured women are predicted to have lower fertility rates compared to the general population of Finnish women. The lower fertility rate should be considered when planning a blood product resuscitation strategy for injured women.

Maternal and child life years gained by transfusing low titer group O whole blood in trauma: A computer simulation

BACKGROUND

Using low titer group O whole blood (LTOWB) is increasingly popular for resuscitating trauma patients. LTOWB is often RhD-positive, which might cause D-alloimmunization and hemolytic disease of the fetus and newborn (HDFN) if transfused to RhD-negative females of childbearing potential (FCP). This simulation determined the number of life years gained by the FCP and her future children if she was resuscitated with LTOWB compared with conventional component therapy (CCT).

METHODS

The model simulated 500,000 injured FCPs of each age between 0 and 49 years with LTOWB mortality relative reductions (MRRs) compared with components between 0.1% and 25%. For each surviving FCP, number of life years gained was calculated using her age at injury and average life expectancy for American women. The number of expected future pregnancies for FCPs that did not survive was also based on her age at injury; each future child was assigned the maximum lifespan unless they suffered perinatal mortality or serious neurological events from HDFN.

RESULTS

The LTOWB group with an MRR 25% compared with CCT had the largest total life years gained. The point of equivalence for RhD-positive LTOWB compared to CCT, where life years lost due to severe HDFN was equivalent to life years gained due to FCP survival/future childbearing, occurred at an MRR of approximately 0.1%.

CONCLUSION

In this model, RhD-positive LTOWB resulted in substantial gains in maternal and child life years compared with CCT. A >0.1% relative mortality reduction from LTOWB offset the life years lost to HDFN mortality and severe neurological events.

Not as "D"eadly as once thought - the risk of D-alloimmunization and hemolytic disease of the fetus and newborn following RhD-positive transfusion in trauma

The use of blood products to resuscitate injured and massively bleeding patients in the prehospital and early in-hospital phase of the resuscitation is increasing. Using group O red blood cells (RBC) and low titer group O whole blood (LTOWB) avoids an immediate hemolytic reaction from recipient's naturally occurring anti-A and - B, but choosing the RhD type for these products is more nuanced and requires the balancing of product availability and survival benefit against the risk of D-alloimmunization, especially in females of childbearing potential (FCP) due to the possible future occurrence of hemolytic disease of the fetus and newborn (HDFN). Recent models have estimated the risk of fetal/neonatal death from HDFN resulting from D-alloimmunization of an FCP during her trauma resuscitation at between 0-6.5% depending on her age at the time of the transfusion and other societal factors including trauma mortality, her age when she becomes pregnant, frequency of different RHD genotypes in the population, and the probability that the woman will have children with different fathers; this is counterbalanced by an approximately 24% risk of death from hemorrhagic shock. This review will discuss the different models of HDFN outcomes following RhD-positive transfusion as well as the results of recent surveys where the public was asked about their preferences for urgent transfusion in light of the risks of fetal/neonatal adverse events.

Previous traumatic brain injury is associated with an increased odds for gestational diabetes: a nationwide register-based cohort study in finland

AIMS

Despite recent findings that traumatic brain injury (TBI) is a possible risk factor for type 2 diabetes (DM2) and that a strong association exists between gestational diabetes (GDM) and the risk for the development of DM2, no previous studies have investigated the effects of TBI on the risk for the development of GDM. Therefore, this study aims to determine the possible association between a previous traumatic brain injury and later gestational diabetes.

METHODS

In this retrospective register-based cohort study, data from the National Medical Birth Register were combined with data from the Care Register for Health Care. Women who had sustained a TBI before pregnancy were included in the patient group. Women who had sustained previous fractures of the upper extremity, pelvis, or lower extremity were included in the control group. A logistic regression model was used to assess the risk for the development of GDM during pregnancy. Adjusted odds ratios (aOR) with 95% confidence intervals between the groups were compared. The model was adjusted by prepregnancy body mass index (BMI) and maternal age during pregnancy, the use of in vitro fertilization (IVF), maternal smoking status, and multiple pregnancies. The risk for the development of GDM during different periods following the injury (0-3 years, 3-6 years, 6-9 years, and 9+ years) was calculated.

RESULTS

In total, a 75 g 2-h oral glucose tolerance test (OGTT) was performed on 6802 pregnancies of women who had sustained a TBI and on 11 717 pregnancies of women who sustained fractures of the upper extremity, pelvis, or lower extremity. Of these, 1889 (27.8%) pregnancies were diagnosed with GDM in the patient group and 3117 (26.6%) in the control group. The total odds for GDM were higher after TBI compared to the other traumas (aOR 1.14, CI 1.06-1.22). The odds were highest at 9 + years after the injury (aOR 1.22, CI 1.07-1.39).

CONCLUSION

The total odds for the development of GDM after TBI were higher when compared to the control group. Based on our findings, more research on this topic is warranted. Moreover, a history of TBI should be considered a possible risk factor for the development of GDM.

The rates of vaginal births after cesarean section have increased during the last decades: a nationwide register-based cohort study in Finland

PURPOSE

Epidemiological studies assessing the effects of previous cesarean section (CS) on subsequent delivery mode using large nationwide study populations. This study aims to calculate the incidence rates of trial of labors after cesarean section (TOLACs) and evaluate the annual rates of vaginal births after cesarean section (VBAC) during the last decades in Finland.

METHODS

Data from the National Medical Birth Register (MBR) were used to evaluate incidence rates of VABC in the Finnish population (1998-2018). All nulliparous women having their first and second pregnancy during our study period, and with the mode of delivery identified in both of these pregnancies were included in this study. Absolute annual numbers and incidence rates for TOLACs, elective CS, and VBAC were calculated.

RESULTS

The absolute number of TOLACs had an increasing trend during our study period, increasing up to 2118 TOLACs in 2016. The incidence rates for elective CS after the first CS had a decreasing trend, decreasing from 45% in 1999, to 28% in 2018. The absolute number of VBACs had an increasing trend during our study period, peaking in 2016 (1466 VBACs). The rates for VBAC remained relatively constant, ranging between 38 and 52%, but a slightly increasing trend at the end of the study period was seen.

CONCLUSION

Despite the increasing annual total number of deliveries with CS in the first pregnancy, the absolute numbers and rates for VBACs have increased towards the end of the study period in Finland. The epidemiology of TOLACs and VBACs should be better studied around the world, as with the rapidly increasing rate of CSs, these events are becoming more common challenges in health care.

Multifetal gestations after traumatic brain injury: a nationwide register-based cohort study in Finland

BACKGROUND

There is a paucity of information regarding the association between traumatic brain injuries (TBIs) and subsequent multifetal gestations. Since TBIs are known to negatively affect the neuroendocrine system, we hypothesized that the functions of the whole reproductive system might be disturbed as a result. The aim of this study is to determine the association between previous TBIs and the risk of multifetal gestations using nationwide registers.

METHODS

In this retrospective register-based cohort study, data from the National Medical Birth Register (MBR) were combined with data from the Care Register for Health Care. All fertile-aged women (15-49 years) who had sustained a TBI before pregnancy were included in the patient group. Women with prior fractures of the upper extremity, pelvis, and lower extremity were included in the control group. A logistic regression model was used to assess the risk for multifetal gestation after TBI. Odds ratios (ORs) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs) between the groups were compared. The model was adjusted by maternal age and maternal BMI during pregnancy and previous births. The risk for multifetal gestations were evaluated during different periods following the injury (0-3 years, 3-6 years, 6-9 years, and 9 + years).

RESULTS

A total of 14 153 pregnancies occurred after the mother had sustained a TBI, and 23 216 pregnancies occurred after the mother had sustained fractures of the upper extremity, pelvis, or lower extremity. Of these, 201 (1.4%) women had multifetal gestations after TBI and 331 (1.4%) women had multifetal gestations after fractures of the upper extremity, pelvis, or lower extremity. Interestingly, the total odds of multifetal gestations were not higher after TBI when compared to fractures of the upper extremity, pelvis, and lower extremity (aOR 1.04, CI 0.86-1.24). The odds were highest at 6-9 years (aOR 1.54, 1.03-2.29) and lowest at 0-3 years (aOR 0.84, CI 0.59-1.18).

CONCLUSION

The risk for multifetal gestations after TBIs was not higher than after the other traumas included in this study. Our results provide good baseline information on the effects of TBIs on the risk for multifetal gestations, but further research is required on this topic.

Birth rate among women with fear of childbirth: a nationwide register-based cohort study in Finland

PURPOSE

The association between fear of childbirth (FOC) and subsequent birth rate is not well studied. The aim of this study is to evaluate the birth rate, and risk for second pregnancy ending in delivery among women with FOC compared to women without FOC in their first pregnancy.

METHODS

Data from the National Medical Birth Register were used to evaluate the birth rate after the first pregnancy in women with FOC. Cox regression model was used to evaluate the risk for the second pregnancy ending in delivery in women with FOC compared to reference individuals without FOC. The results were interpreted with adjusted hazard ratios (aHRs) and 95% confidence intervals (CI).

RESULTS

In total, 375,619 women were included in this study. Of these, 9660 (2.6%) had FOC in the first pregnancy (exposed group), and 365,959 (97.4%) had no FOC (non-exposed group). In the exposed group, 3600 (37.3%) women had second pregnancy ending in delivery during the study period, and 206,347 (56.4%) had the second pregnancy ending in delivery in the non-exposed group. The risk for the second pregnancy ending in delivery was lower among women with FOC (aHR 0.61, CI 0.59-0.63).

CONCLUSIONS

FOC complicates pregnancy and delivery and is strongly associated with lower likelihood to get pregnant again. Therefore, more research should be focused on the optimal prevention of FOC using a standardized procedure of care and treatment for women with FOC.

The rate of elective cesarean section after pelvic or hip fracture remains high even after the long-term follow-up: A nationwide register-based study in Finland

INTRODUCTION

There are only few studies on the effects of pelvic or hip fractures on subsequent delivery outcomes. The aim for this study is to evaluate in a nationwide sample whether the rate of elective CS and emergency CS would decrease during the time after maternal hip and pelvic fracture.

MATERIAL AND METHODS

In this nationwide registry-based study, data on all women aged 15-49 years with pelvic or hip fractures leading to hospitalization were retrieved from the Care Register for Health Care for the years 1998-2018. Wrist fractures were used as a control group. The data were linked with data from the National Birth Register, where each first pregnancy during the 14-year follow-up is collected. The delivery outcomes of these pregnancies were analyzed. The results were interpreted with odds ratios (OR), adjusted odds ratios (aOR), and 95 % confidence intervals (CI).

RESULTS

A total of 2878 women with pelvic fracture, 1330 women with hip fracture, and 29 580 with wrist fracture found in the Care Register for Health Care. Of these, a total of 586 (20.4 %) women gave birth during the following 14 years after pelvic fracture, 147 (11.0 %) women after hip fracture, and 5255 (17.7 %) women after wrist fracture. Women with pelvic fracture had higher odds for CS during each time period. The aOR for CS was 1.62 (CI 1.22-2.12) during first 5 years, 1.87 (CI 1.33-2.62) during years 5-10, and 1.97 (CI 1.11-3.41) during years 10-14. Women with hip fractures had notably higher odds for CS during first 5 years after fracture (aOR 1.64, CI 1.40-2.67).

CONCLUSIONS

The results of this study advocate that vaginal delivery is generally possible rather quickly after hip or pelvic fracture. Unplanned CS after hip fractures was more common at the beginning, but the exact reason for this remains unknown and further research should be made on this topic.