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Al Khalaf SY, Heazell AEP, Kublickas M, Kublickiene K, Khashan AS. Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study. BJOG 2024; 131:1054-1061. [PMID: 38287170 DOI: 10.1111/1471-0528.17760] [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: 04/04/2023] [Revised: 12/19/2023] [Accepted: 12/30/2023] [Indexed: 01/31/2024]
Abstract
OBJECTIVES To investigate the risk of stillbirth in relation to (1) a previous caesarean delivery (CD) compared with those following a vaginal birth (VB); and (2) vaginal birth after caesarean (VBAC) compared with a repeat CD. DESIGN Population-based cohort study. SETTING The Swedish Medical Birth registry. POPULATION Women with their first and second singletons between 1982 and 2012. METHODS Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum). MAIN OUTCOME MEASURES Stillbirth (antepartum and intrapartum fetal death). RESULTS Of the 1 771 700 singleton births from 885 850 women, 117 114 (13.2%) women had a CD in the first pregnancy, and 51 755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR 1.37; 95% CI 1.23-1.52) in women with a previous CD compared with VB. The odds of intrapartum stillbirth were higher in the previous pre-labour CD group (aOR 2.72; 95% CI 1.51-4.91) and in the previous in-labour CD group (aOR 1.35; 95% CI 0.76-2.40), although not statistically significant in the latter case. No increased odds were found for intrapartum stillbirth in women who had VBAC (aOR 0.99; 95% CI 0.48-2.06) compared with women who had a repeat CD. CONCLUSIONS This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help healthcare providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.
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Affiliation(s)
| | - Alexander E P Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Medical and Health, University of Manchester, Manchester, UK
| | - Marius Kublickas
- Department of Obstetrics & Gynaecology, Unit of Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Karolina Kublickiene
- Department of Clinical Intervention, Science and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ali S Khashan
- School of Public Health, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
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2
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Jennewein L, Heemann R, Hoock SC, Hentrich AE, Eichbaum C, Feidicker S, Louwen F. Sonographic examination at the beginning of the second stage of labor predicts birth outcome in vaginally intended breech deliveries: a blinded prospective study. Arch Gynecol Obstet 2024; 309:1333-1340. [PMID: 36961567 PMCID: PMC10894138 DOI: 10.1007/s00404-023-07011-x] [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: 11/05/2022] [Accepted: 03/13/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE In order to spread competence in vaginal breech deliveries, it is necessary to develop new and easily applicable tools for birth progression and safety evaluation. Ultrasound is a useful and ubiquitously available tool with already documented value for birth progression observation. In deliveries out of breech presentation, an established ultrasound examination is missing. We determined the descent of the fetal buttocks in relation to the maternal pelvic inlet using intrapartum ultrasound. We evaluated these results in comparison to the clinical vaginal examination with the aim to establish an easily applicable method for birth outcome prediction. Therefore, we analyzed the predictive value of our examinations on birth outcome parameters, such as cesarean section rate, as well as fetal and maternal outcome parameters. METHODS We performed a prospective blinded study on 106 mothers with vaginally intended breech delivery. At beginning of stage two in labor, the descent of the fetal buttocks into the mother's pelvic inlet was detected with transabdominal ultrasound and vaginal examination by different observers. PRIMARY OUTCOME VARIABLE Cesarean section rate. Secondary outcome variables: rate of manual assistance in vaginal deliveries, birth duration, 5' APGAR score, umbilical arterial pH, maternal blood loss, and perineal injury. For non-parametric values, Wilcoxon's χ2 test was performed. In order to analyze the predictive value of our examination, lack-of-fit analysis was conducted. Reliability evaluation of the sonographic examination was done with a matched-pair analysis. RESULTS Women with positive intrapartum ultrasound breech engagement sign (+ IPUBES) had a significantly lower rate of cesarean section in comparison with those with negative IPUBES (5/67; 7.5% vs. 18/39; 46.2%; p < 0.0001). The area under the ROC curve for the prediction of CS for negative IPUBES was 0.765 with a sensitivity of 78.3% and a specificity of 74.7%. Sonographic examination showed an excellent reliability in a matched-pair analysis comparing vaginal and sonographic examinations with a mean difference of 0.012 (SD ± 0.027, 95% CI - 0.014 to 0.065). Mean birth duration was significantly longer in deliveries with negative IPUBES (533 min vs. 440 min; p = 0.0011). Fetal and maternal outcome parameters were not significantly different between deliveries with positive and negative IPUBES. CONCLUSIONS Sonographic evaluation of the fetal descent in relation to the mother's pelvic inlet screens reliably for emergency cesarean section. This newly presented method for birth progression observation might be a powerful tool for distribution of expertise in vaginal breech delivery and is able to give reference for clinical vaginal examination by obstetricians in training. TRAIL REGISTRY Clinical trial. Date of registration: 13.03.2019; Date of initial participant enrollment: 20.03.2019; DRKS00016885; https://www.drks.de ; German clinical trials register.
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Affiliation(s)
- Lukas Jennewein
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | - Ricarda Heemann
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Samira Catharina Hoock
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Anna Elisabeth Hentrich
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Christine Eichbaum
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Susanne Feidicker
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Frank Louwen
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
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Dimassi H, Alameddine M, Sabra N, El Arnaout N, Harb R, Hamadeh R, El Kak F, Shanaa A, Mossi MO, Saleh S, AlArab N. Maternal health outcomes in the context of fragility: a retrospective study from Lebanon. Confl Health 2023; 17:59. [PMID: 38093261 PMCID: PMC10720064 DOI: 10.1186/s13031-023-00558-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND AND AIMS The Lebanese healthcare system faces multiple challenges including limited capacities, shortage of skilled professionals, and inadequate supplies, in addition to hosting a significant number of refugees. While subsidized services are available for pregnant women, representing the majority of the refugee population in Lebanon, suboptimal access to antenatal care (ANC) and increased maternal mortality rates are still observed, especially among socioeconomically disadvantaged populations. This study aimed to review the maternal health outcomes of disadvantaged Lebanese and refugee pregnant women seeking ANC services at primary healthcare centers (PHCs) in Lebanon. METHODS A retrospective chart review was conducted at twenty PHCs in Lebanon, including Ministry of Public Health (MOPH) and United Nations Relief and Works Agency for Palestine refugees (UNRWA) facilities. Data was collected from medical charts of pregnant women who visited the centers between August 2018 and August 2020. Statistical analysis was performed to explore outcomes such as the number of ANC visits, delivery type, and onset of delivery, using bivariate and multivariable logistic regression models. RESULTS In the study, 3977 medical charts were analyzed. A multivariate logistic regression analysis, revealed that suboptimal ANC visits were more common in the Beqaa region and among women with current abortion or C-section. Syrians had reduced odds of C-sections, and Beqaa, Mount Lebanon, and South Lebanon regions had reduced odds of abortion. Suboptimal ANC visits and history of C-section increased the odds of C-section and abortion in the current pregnancy. As for preterm onset, the study showed an increased likelihood for it to occur when being Palestinian, having current C-section delivery, experiencing previous preterm onset, and enduring complications at the time of delivery. CONCLUSION This study suggests the need for low-cost interventions aiming at enhancing access to ANC services, especially among pregnant women in fragile settings.
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Affiliation(s)
- Hani Dimassi
- School of Pharmacy, Lebanese American University, Beirut, Lebanon
| | - Mohamad Alameddine
- College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Nadine Sabra
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Nour El Arnaout
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Ranime Harb
- School of Pharmacy, Lebanese American University, Beirut, Lebanon
| | | | - Faysal El Kak
- Faculty of Health Sciences, American University of Beirut (AUB), Beirut, Lebanon
- Department of Obstetrics Gynecology, American University of Beirut, Medical Center (AUB) Medical Center, Beirut, Lebanon
| | - Abed Shanaa
- United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), Beirut, Lebanon
| | | | - Shadi Saleh
- Global Health Institute, American University of Beirut, Beirut, Lebanon
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Natally AlArab
- Global Health Institute, American University of Beirut, Beirut, Lebanon.
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Dasgupta S, Dasgupta J. Development of a multivariate predictive nomogram among women with antepartum fetal death diagnosed at ≥ 34 weeks of gestation for outcome of TOLAC. Arch Gynecol Obstet 2023:10.1007/s00404-023-07264-6. [PMID: 37930360 DOI: 10.1007/s00404-023-07264-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The present study was planned to develop a nomogram that will give a priori estimate on the probability of vaginal birth from maternal features in women with antepartum fetal death diagnosed at ≥ 34 week's gestation and previous one low transverse cesarean section (LTCS). This will help to reduce maternal complications and increase confidence when planning a trial of labor after cesarean section (TOLAC). METHODS A prospective observational study was planned where participants underwent induction of labor with Foley's catheter (unless already in spontaneous labor) within 24 h of enrolment. Participants with absent or inadequate contractions, oxytocin infusion as an additional agent was used. Data was collected on maternal predelivery features. Outcome of participants was categorized into two classes-vaginal and cesarean delivery. Classifiers were trained with data on maternal features and the accuracy of predicting outcome class determined. The classifier with maximum accuracy was used to develop a nomogram. RESULT Three hundred and one women underwent treatment as per protocol. Two hundred and twenty women attained successful vaginal delivery and eighty-one women underwent caesarean section. Factors having a significant impact on outcome were maternal body mass index (BMI), bishop score, duration of augmentation, estimated foetal weight, interval from previous LTCS, admission to active labor interval, vaginal delivery after LTCS and gestational age. The Naïve -Bayes model gave the highest prediction accuracy (0.88). CONCLUSION Non-linear classifiers by using selective features could predict the outcome of TOLAC among women with intra-uterine fetal death attempting vaginal birth at or beyond 34 weeks gestation with high accuracy.
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Affiliation(s)
- Subhankar Dasgupta
- Department of Obstetrics and Gynecology, Rampurhat government medical college, New hospital road, Rampurhat, Birbhum, West Bengal, 731224, India.
- Department of Obstetrics and Gynecology, Chittaranjan Seva Sadan, College of Obstetrics, Gynecology and Child Health, Kolkata, India.
- Department of Obstetrics and Gynecology, Medical College, 88, College Street, College square, Kolkata, West Bengal, India, 700073.
| | - Jija Dasgupta
- Department of Obstetrics and Gynecology, Rampurhat government medical college, New hospital road, Rampurhat, Birbhum, West Bengal, 731224, India
- Department of Obstetrics and Gynecology, Chittaranjan Seva Sadan, College of Obstetrics, Gynecology and Child Health, Kolkata, India
- AILABS Adani Enterprises LTD, Kolkata, West Bengal, India
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5
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Gyaase D, Enuameh YA, Adjei BN, Gyaase S, Nakua EK, Kabanunye MM, Alhassan MM, Yakubu MS, Tetteh RJ, Newton S, Asante KP. Prevalence and determinants of caesarean section deliveries in the Kintampo Districts of Ghana. BMC Pregnancy Childbirth 2023; 23:286. [PMID: 37098478 PMCID: PMC10131307 DOI: 10.1186/s12884-023-05622-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 04/18/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Globally, the increasing rate of caesarean section (CS) delivery has become a major public health concern due to its cost, maternal, neonatal, and perinatal risks. In Ghana, the Family Health Division of the Ghana Health Service in 2016 opted to initiate a program to prevent the abuse of CS and identify the factors contributing to its increase in the country. This study aimed to determine the prevalence and factors influencing CS deliveries in the Kintampo Districts of Ghana. METHODS The current study used secondary data from the Every Newborn-International Network for the Demographic Evaluation of Populations and their Health (EN-INDEPTH) project in Kintampo, Ghana. The outcome variable for this study is CS delivery. The predictor variables were socio-demographic and obstetric factors. RESULTS The prevalence of CS delivery in the study area was 14.6%. Women with secondary education were 2.6 times more likely to give birth by CS than those with primary education. Unmarried women were about 2.5 times more likely to deliver by CS compared to those who were married. There was an increasing order of CS delivery among women in the wealthy quintiles from poorer to richest. The likelihood of women with gestational ages from 37 to 40 weeks to give birth by CS was about 58% less compared to those with less than 37 gestational weeks. Women who had 4-7 and 8 or more antenatal care (ANC) visits were 1.95 and 3.5 times more likely to deliver by CS compared to those who had less than 4 ANC visits. The odds of women who have had pregnancy loss before to deliver by CS was 68% higher compared to women who have not lost pregnancy before. CONCLUSIONS Caesarean section delivery prevalence in the study population was within the Ghana Health Service and World Health Organization ranges. In addition to known socio-demographic and obstetric factors, this study observed that a history of pregnancy loss increased the chances of a woman undergoing a CS. Policies should aim at addressing identified modifiable factors to stem the rise in CS deliveries.
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Affiliation(s)
- Daniel Gyaase
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Yeetey Akpe Enuameh
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo, Ghana.
| | - Benjamin Noble Adjei
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Stephaney Gyaase
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo, Ghana
| | - Emmanuel Kweku Nakua
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Moses Musah Kabanunye
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Mohammed Muhib Alhassan
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Mohammed Sheriff Yakubu
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Richard Joshua Tetteh
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo, Ghana
| | - Sam Newton
- Department of Global and International Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo, Ghana
- London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
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6
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Thisted DLA, Rasmussen SC, Krebs L. Outcome of subsequent pregnancies in women with complete uterine rupture: A population-based case-control study. Acta Obstet Gynecol Scand 2022; 101:506-513. [PMID: 35233771 DOI: 10.1111/aogs.14338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In the attempt of a trial of labor after a cesarean section approximately one in 200 women experience a complete uterine rupture. As a complete uterine rupture is associated with an adverse perinatal outcome, data regarding subsequent pregnancies are needed to provide proper care and guidance to women with a complete uterine rupture when informing them of future possibilities. The objective of this study was to investigate the fetal and maternal outcomes in subsequent pregnancies after a complete uterine rupture. MATERIAL AND METHODS Retrospective population-based case-control study. Denmark 1997-2017. A total of 175 women with complete uterine rupture during an attempted trial of labor after cesarean (TOLAC) at term (cases) and a corresponding group of 272 women with no uterine rupture during an attempted TOLAC at term (controls) were labeled as index deliveries. Index deliveries were included from January 1, 1997 to December 31, 2008. From the date of the index delivery to December 31, 2017 the information on subsequent pregnancies and deliveries, and on referral to hospital with any obstetric or gynecological diagnosis were retrieved from the Danish Medical Birth Registry and National Patient Registry. Main outcome measures were miscarriage, perinatal death, neonatal morbidity, preterm birth, and recurrence of uterine rupture. Outcome measures were compared between cases and controls. RESULTS After the index deliveries; there were 109 pregnancies and 70 deliveries after gestational age 22+0 weeks in the population of cases. In the population of controls, there were 183 pregnancies and 126 deliveries after 22+0 weeks. Cases had a significantly higher risk of miscarriage (odds ratio [OR] 3.99; 95% confidence interval [CI] 1.36-13.17). The incidence of uterine rupture was 8.6% among cases and 0.8% among controls (OR 11.7; 95% CI 1.36-543.1). Among cases, 98.6% had live-born infants, and none of these had severe neonatal morbidity. No significant association was found between previous complete uterine rupture and preterm delivery, placenta previa, hysterectomy in relation to subsequent births, diagnosis such as meno/metrorrhagia, dysmenorrhea, or procedures such as hysteroscopy or hysterectomy. CONCLUSIONS In pregnancies following complete uterine rupture continuing after 22+0 weeks, maternal and fetal outcomes are good when managed promptly with cesarean delivery.
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Affiliation(s)
- Dorthe Louise Ahrenkiel Thisted
- Department of Gynecology and Obstetrics, University of Copenhagen, Holbaek Hospital, Denmark.,Department of Gynecology and Obstetrics, Zealand University Hospital, Roskilde, Denmark
| | - Steen Christian Rasmussen
- Department of Gynecology and Obstetrics, University of Copenhagen, Amager Hvidovre Hospital, Hvidovre, Denmark
| | - Lone Krebs
- Department of Gynecology and Obstetrics, University of Copenhagen, Amager Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Toijonen A, Hinnenberg P, Gissler M, Heinonen S, Macharey G. Maternal and neonatal outcomes in the following delivery after previous preterm caesarean breech birth: a national cohort study. J OBSTET GYNAECOL 2021; 42:49-54. [PMID: 33938353 DOI: 10.1080/01443615.2021.1871888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The objective of this retrospective, nationwide Finnish population-based cohort study was to determine whether there is an association between preterm caesarean breech delivery in the first pregnancy and maternal and neonatal morbidity in the subsequent pregnancy and delivery. We identified all singleton preterm breech birth in Finland from 2000 to 2017 (n = 1259) and constructed a data set of the first two deliveries for these women. We compared outcomes of the following pregnancy and delivery among women with a previous preterm caesarean breech section with the outcomes of women with one previous vaginal preterm breech birth. p Value, odds ratio, and adjusted odds ratio were calculated. Neonates of women with a previous caesarean preterm breech delivery had an increased risk for arterial umbilical cord pH below seven (1.2% versus 0%; p value .024) and a higher rate of neonatal intensive care unit admission [22.9% versus 15% adjusted OR 1.57 (1.13-2.18); p value <.001]. The women with a previous caesarean section had a higher rate of uterine rupture (2.3% versus 0%; p value .001). They were also more likely in the subsequent pregnancy to have a planned caesarean section [19.9% versus 4% adjusted OR 8.55 (4.58-15.95), an emergency caesarean section [21.5% versus 9.7% adjusted OR 2.16 (1.28-2.18)], or an instrumental vaginal delivery [9.3% versus 3.8% adjusted OR 2.38 (1.08-5.23)].IMPACT STATEMENTWhat is already known on this subject? Vaginal birth after caesarean section is generally known to be associated with a higher risk of maternal and neonatal morbidity.What do the results of this study add? The following birth after previous caesarean preterm breech section is associated with a higher rate of uterine rupture and with a higher rate neonatal admission to the neonatal intensive care unit and more often an arterial umbilical cord pH below seven regardless of the mode of the following delivery, compared to women with a subsequent delivery after a previous vaginal preterm breech birth.What are the implications of these findings for clinical practice and/or further research? Our results must be considered when counselling patients regarding their first preterm breech delivery, as the selected method of delivery also affects the outcomes of subsequent pregnancies and deliveries.
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Affiliation(s)
- Anna Toijonen
- Department of Obstetrics and Gynaecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Pia Hinnenberg
- Department of Obstetrics and Gynaecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Mika Gissler
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynaecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Georg Macharey
- Department of Obstetrics and Gynaecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
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Townsend R, Sileo FG, Allotey J, Dodds J, Heazell A, Jorgensen L, Kim VB, Magee L, Mol B, Sandall J, Smith G, Thilaganathan B, von Dadelszen P, Thangaratinam S, Khalil A. Prediction of stillbirth: an umbrella review of evaluation of prognostic variables. BJOG 2020; 128:238-250. [PMID: 32931648 DOI: 10.1111/1471-0528.16510] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth. OBJECTIVES To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development. SEARCH STRATEGY MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019. SELECTION CRITERIA We included systematic reviews of association of individual variables with stillbirth without language restriction. DATA COLLECTION AND ANALYSIS Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded. RESULTS The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension. CONCLUSION We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias. TWEETABLE ABSTRACT Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.
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Affiliation(s)
- R Townsend
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - F G Sileo
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Allotey
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - J Dodds
- Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Centre for Women's Health, Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Heazell
- St Mary's Hospital, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK.,Faculty of Biology, Medicine and Health, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester, UK
| | | | - V B Kim
- The Robinson Institute, University of Adelaide, Adelaide, SA, Australia
| | - L Magee
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - B Mol
- Department of Obstetrics and Gynaecology, School of Medicine, Monash University, Melbourne, Vic., Australia
| | - J Sandall
- Health Service and Population Research Department, Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Women and Children's Health, Faculty of Life Sciences & Medicine, School of Life Course Sciences, King's College London, St Thomas' Hospital, London, UK
| | - Gcs Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK.,Department of Physiology, Development and Neuroscience, Centre for Trophoblast Research (CTR), University of Cambridge, Cambridge, UK
| | - B Thilaganathan
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - P von Dadelszen
- Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College London, London, UK
| | - S Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Pragmatic Clinical Trials Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Khalil
- Molecular and Clinical Sciences Research Institute, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
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9
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Halla M, Mayr H, Pruckner GJ, García-Gómez P. Cutting fertility? Effects of cesarean deliveries on subsequent fertility and maternal labor supply. JOURNAL OF HEALTH ECONOMICS 2020; 72:102325. [PMID: 32535109 DOI: 10.1016/j.jhealeco.2020.102325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 02/29/2020] [Accepted: 04/04/2020] [Indexed: 06/11/2023]
Abstract
Despite the growing incidence of cesarean deliveries (CDs), procedure costs and benefits continue to be controversially discussed. In this study, we identify the effects of CDs on subsequent fertility and maternal labor supply by exploiting the fact that obstetricians are less likely to undertake CDs on weekends and public holidays and have a greater incentive to perform them on Fridays and days preceding public holidays. To do so, we adopt high-quality administrative data from Austria. Women giving birth on different days of the week are pre-treatment observationally identical. Our instrumental variable estimates show that a non-planned CD at parity 0 decreases lifecycle fertility by almost 13.6%. This reduction in fertility translates into a temporary increase in maternal employment.
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Affiliation(s)
- Martin Halla
- Johannes Kepler University Linz, Austria; Christian Doppler Laboratory Aging, Health, and the Labor Market, Austria; IZA, Institute for the Study of Labor, Bonn, Germany; GÖG, Austrian Public Health Institute, Vienna, Austria.
| | | | - Gerald J Pruckner
- Johannes Kepler University Linz, Austria; Christian Doppler Laboratory Aging, Health, and the Labor Market, Austria
| | - Pilar García-Gómez
- Erasmus University Rotterdam, Netherlands; Tinbergen Institute, Netherlands
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10
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Oliveira-Brancati CIF, Ferrarese VCC, Costa AR, Fett-Conte AC. Birth defects in Brazil: Outcomes of a population-based study. Genet Mol Biol 2020; 43:e20180186. [PMID: 31429860 PMCID: PMC7198030 DOI: 10.1590/1678-4685-gmb-2018-0186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 02/02/2019] [Indexed: 01/23/2023] Open
Abstract
Birth defects (BDs) are functional and structural alterations in embryonic or fetal development. With an incidence of approximately 3-5%, BDs are a leading cause of infant mortality and lifelong disability. A population-based prospective case-control study was conducted for one year with 5204 infants, between March 1st, 2011 and February 29th, 2012 in the city of São José do Rio Preto, State of São Paulo, Brazil. The incidence of BDs was 3.2% [95% confidence interval (95%CI): 2.8-3.8%]. The most common congenital anomalies were heart diseases in isolation (11.2%; 95%CI: 7.3-16.9%) followed by Down syndrome (9.5%; 95%CI: 5.9-14.8%), neural tube defects (8.9%; 95%CI: 5.4-14.1), urinary tract anomalies (7.7%; 95%CI: 4.4-12.7%), and polydactyly (7.0%; 95%CI: 4.0-12.0%). The majority of mothers with Down syndrome babies had advanced age. Family members with the same BD, maternal alcohol consumption, gestational diabetes, and previous miscarriages were the most frequent risk factors. The results were similar to published data from other countries except for the incidence of Down syndrome, which was twice as high as reported by other authors and is probably due to the high sociocultural level of the region where the current study was performed, leading to pregnancies at older maternal age.
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Affiliation(s)
| | | | - Antonio Richieri Costa
- Universidade de São Paulo (USP), Hospital de Reabilitação de
Anomalias Craniofaciais, Bauru, SP, Brazil
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van den Tweel MM, Klijn NF, Diaz de Pool JDN, van der Westerlaken LAJ, Louwe LA. Previous caesarean section is associated with lower subsequent in vitro fertilization live birth rates. HUM FERTIL 2019; 25:93-98. [DOI: 10.1080/14647273.2019.1696990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Marjolein M. van den Tweel
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Obstetrics and Gynecology, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Nicole F. Klijn
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Juan D. N. Diaz de Pool
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Leoni A. Louwe
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
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12
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Barinov SV, Tirskaya YI, Shamina IV, Medyannikova IV, Kadcyna TV, Shkabarnya LL, Lazareva OV. The use of an osmotic dilator for induction of miscarriage in patients with the second trimester missed miscarriage. J Matern Fetal Neonatal Med 2019; 34:2778-2782. [PMID: 31570024 DOI: 10.1080/14767058.2019.1671331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM The aim of this study was to assess the outcomes of combined use of dilapan-S and pharmacological induction of miscarriage with mifepristone and misoprostol versus mifepristone and misoprostol only in patients with a second-trimester pregnancy loss. MATERIALS AND METHODS Our study included 74 patients with a second-trimester antenatal death who were randomized into two groups to receive pharmacological induction of miscarriage combined with intracervical insertion of dilapan-S (n = 37) or pharmacological induction of miscarriage only (n = 37). Efficacy endpoints included: blood loss volume, length of time between the procedure initiation and complete miscarriage, and the number of complications. RESULTS The use of dilapan-S together with mifepristone and misoprostol for induction of miscarriage in the second trimester in women with antenatal fetal death reduced the time from the start of the procedure to complete miscarriage by 1.98-fold. However, the use of dilapan-S did not significantly reduce the odds of such post-procedural complications as hematometra and retention of the products of conception in the uterus (p = .2501). CONCLUSIONS Combined management of antenatal pregnancy loss in the second trimester including intracervical insertion of dilapan-S and conventional induction with miscarriage may be considered a valuable clinical strategy. However, future studies should focus on ways to prevent postprocedural complications in this group of women.
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Affiliation(s)
- Sergey V Barinov
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | - Yuliya I Tirskaya
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | - Inna V Shamina
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | - Irina V Medyannikova
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | - Tatiana V Kadcyna
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
| | | | - Oksana V Lazareva
- 2nd Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russia
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Xia X, Zhou Z, Shen S, Lu J, Zhang L, Huang P, Yu J, Yang L, Wang P, Lam KBH, Jacobsson B, Mol BW, Xia H, Qiu X. Effect of a two-stage intervention package on the cesarean section rate in Guangzhou, China: A before-and-after study. PLoS Med 2019; 16:e1002846. [PMID: 31283770 PMCID: PMC6613675 DOI: 10.1371/journal.pmed.1002846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/31/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The cesarean section (CS) rate has risen globally during the last two decades. Effective and feasible strategies are needed to reduce it. The aim of this study was to assess the CS rate change after a two-stage intervention package that was designed to reduce the overall CS rate in Guangzhou, China. METHODS AND FINDINGS This intervention package was implemented by the Health Commission of Guangzhou Municipality in 2 stages (October 2010-September 2014 and October 2014-December 2016) and included programs for population health education, skills training for healthcare professionals, equipment and technical support for local healthcare facilities, and capacity building for the maternal near-miss care system. A retrospective repeated cross-sectional study was conducted to evaluate influences of the intervention on CS rates. A pre-intervention period from January 2008 to September 2010 served as the baseline. The primary outcome was the CS rate, and the secondary outcomes included maternal mortality ratio (MMR) and perinatal mortality rate (PMR), all obtained from the Guangzhou Perinatal Health Care and Delivery Surveillance System (GPHCDSS). The Cochran-Armitage test was used to examine the trends of the overall CS rate, MMR, and PMR across different stages. Segmented linear regression analysis was used to assess the change of the CS rate over the intervention period. A total of 1,921,932 records of births and 108 monthly CS rates from 2008 to 2016 were analyzed. The monthly CS rate declined across the intervention stages (Z = 75.067, p < 0.001), with an average rate of 42.4% at baseline, 39.8% at Stage 1, and 35.0% at Stage 2. The CS rate declined substantially among nulliparous women who delivered term singletons, with an accelerating decreasing trend observed across Stage 1 and Stage 2 (the difference in slopes: -0.09 [95% CI -0.16 to -0.02] between Stage 1 and baseline, p = 0.014; -0.11 [95% CI -0.20 to -0.02] between Stage 1 and Stage 2, p = 0.017). The CS rate in the remaining population increased during baseline and Stage 1 and subsequently decreased during Stage 2. The sensitivity analysis suggested no immediate impact of the universal two-child policy on the trend of the CS rate. The MMR (Z = -4.368, p < 0.001) and PMR (Z = -13.142, p < 0.001) declined by stage over the intervention period. One of the main limitations of the study is the lack of a parallel control group. Moreover, the influence of temporal changes in the study population on the CS rate was unknown. Given the observational nature of the present study, causality cannot be confirmed. CONCLUSIONS Apparent decline in the overall CS rate was observed in Guangzhou, China, after the implementation of a two-stage intervention package. The decline was most evident among nulliparous women who delivered term singletons. Despite some limitations for causal inference, Guangzhou's experience in controlling the CS rate by implementing composite interventions with public health education and perinatal healthcare service improvement could have implications for other similar areas with high rates of CS.
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Affiliation(s)
- Xiaoyan Xia
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zehong Zhou
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Songying Shen
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jinhua Lu
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lifang Zhang
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Peiyuan Huang
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jia Yu
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li Yang
- Guangzhou Women and Children’s Health Information Center, Guangzhou, China
| | - Ping Wang
- Guangzhou Women and Children’s Health Information Center, Guangzhou, China
| | - Kin-bong Hubert Lam
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Domain of Health Data and Digitalisation, Institute of Public Health, Oslo, Norway
| | - Ben Willem Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
- Department of Obstetrics and Gynecology, University of Birmingham, Birmingham, United Kingdom
| | - Huimin Xia
- Department of Neonatal Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- * E-mail: , (HX); , (XQ)
| | - Xiu Qiu
- Division of Birth Cohort Study, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Woman and Child Health Care, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Department of Obstetrics and Gynecology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- * E-mail: , (HX); , (XQ)
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14
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Magnus MC, Wilcox AJ, Morken NH, Weinberg CR, Håberg SE. Role of maternal age and pregnancy history in risk of miscarriage: prospective register based study. BMJ 2019; 364:l869. [PMID: 30894356 PMCID: PMC6425455 DOI: 10.1136/bmj.l869] [Citation(s) in RCA: 276] [Impact Index Per Article: 55.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To estimate the burden of miscarriage in the Norwegian population and to evaluate the associations with maternal age and pregnancy history. DESIGN Prospective register based study. SETTING Medical Birth Register of Norway, the Norwegian Patient Register, and the induced abortion register. PARTICIPANTS All Norwegian women that were pregnant between 2009-13. MAIN OUTCOME MEASURE Risk of miscarriage according to the woman's age and pregnancy history estimated by logistic regression. RESULTS There were 421 201 pregnancies during the study period. The risk of miscarriage was lowest in women aged 25-29 (10%), and rose rapidly after age 30, reaching 53% in women aged 45 and over. There was a strong recurrence risk of miscarriage, with age adjusted odds ratios of 1.54 (95% confidence interval 1.48 to 1.60) after one miscarriage, 2.21 (2.03 to 2.41) after two, and 3.97 (3.29 to 4.78) after three consecutive miscarriages. The risk of miscarriage was modestly increased if the previous birth ended in a preterm delivery (adjusted odds ratio 1.22, 95% confidence interval 1.12 to 1.29), stillbirth (1.30, 1.11 to 1.53), caesarean section (1.16, 1.12 to 1.21), or if the woman had gestational diabetes in the previous pregnancy (1.19, 1.05 to 1.36). The risk of miscarriage was slightly higher in women who themselves had been small for gestational age (1.08, 1.04 to 1.13). CONCLUSIONS The risk of miscarriage varies greatly with maternal age, shows a strong pattern of recurrence, and is also increased after some adverse pregnancy outcomes. Miscarriage and other pregnancy complications might share underlying causes, which could be biological conditions or unmeasured common risk factors.
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Affiliation(s)
- Maria C Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, PO Box 222 Skøyen, N-0213 Oslo, Norway
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Allen J Wilcox
- Centre for Fertility and Health, Norwegian Institute of Public Health, PO Box 222 Skøyen, N-0213 Oslo, Norway
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, USA
| | - Nils-Halvdan Morken
- Centre for Fertility and Health, Norwegian Institute of Public Health, PO Box 222 Skøyen, N-0213 Oslo, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Clarice R Weinberg
- Biostatistics and Computational Biology Branch, National Institute of Environmental Health Sciences, Durham, NC, USA
| | - Siri E Håberg
- Centre for Fertility and Health, Norwegian Institute of Public Health, PO Box 222 Skøyen, N-0213 Oslo, Norway
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15
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Zhou X, Yang X, Chen H, Fang X, Wang X. Obstetrical outcomes after vaginal repair of caesarean scar diverticula in reproductive-aged women. BMC Pregnancy Childbirth 2018; 18:407. [PMID: 30340551 PMCID: PMC6194597 DOI: 10.1186/s12884-018-2015-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 09/17/2018] [Indexed: 11/29/2022] Open
Abstract
Background Although vaginal repair has been conducted to manage caesarean scar diverticula, most studies evaluated only the gynaecological outcomes post-surgery, and their obstetrical outcomes were unknown. This study aimed to evaluate the obstetrical outcomes in vaginal repair-treated caesarean scar diverticula patients. Methods A series of 51 symptomatic women with caesarean scar defects or a thickness of the remaining muscular layer of less than 3 mm according to transvaginal ultrasound were included. We retrospectively evaluated the gynaecological and obstetrical outcomes after vaginal repair and histologically analysed the defect. Results Transvaginal ultrasound revealed that the thickness of the remaining muscular layer significantly increased from 2.24 ± 0.81 mm to 6.10 ± 1.43 mm 3 months after vaginal repair. The duration of menstruation significantly decreased from 14.29 ± 3.13 days to 8.31 ± 2.14 days post-vaginal repair. Notably, 26 of the 51 (50.98%) women who were followed for more than 15.04 months post-surgery achieved pregnancy. A total of 6 of the 26 pregnancies (23.08%) resulted in miscarriages, including 5 early miscarriages and 1 late miscarriage. Among the 20 women who achieved pregnancy without miscarriage, 18 had term deliveries, 2 had preterm birth, and none reported uterine rupture. Histological analysis was performed in all 51 cases. Muscle fibre density was significantly lower in the scar than in the myometrium adjacent to the scar and collagen expression was markedly increased in the scar tissue. Conclusion Satisfactory gynaecological and subsequent obstetrical outcomes can be achieved in vaginal repair-treated caesarean scar diverticula patients.
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Affiliation(s)
- Xingchen Zhou
- Department of Gynecology, Xinhua Hospital affiliated with Shanghai Jiaotong University, 1665 Kong Jiang Rd, Yang Pu District, Shanghai, 200092, China
| | - Xiaoqian Yang
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, Affiliated to Tongji University, Shanghai, China
| | - Huihui Chen
- Department of Gynecology, Xinhua Hospital affiliated with Shanghai Jiaotong University, 1665 Kong Jiang Rd, Yang Pu District, Shanghai, 200092, China
| | - Xuhong Fang
- Department of Gynecology, Xinhua Hospital affiliated with Shanghai Jiaotong University, 1665 Kong Jiang Rd, Yang Pu District, Shanghai, 200092, China.
| | - Xipeng Wang
- Department of Gynecology, Xinhua Hospital affiliated with Shanghai Jiaotong University, 1665 Kong Jiang Rd, Yang Pu District, Shanghai, 200092, China.
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Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, Gibbons D, Kelly NM, Kennedy HP, Kidanto H, Taylor P, Temmerman M. Short-term and long-term effects of caesarean section on the health of women and children. Lancet 2018; 392:1349-1357. [PMID: 30322585 DOI: 10.1016/s0140-6736(18)31930-5] [Citation(s) in RCA: 574] [Impact Index Per Article: 95.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/06/2018] [Accepted: 08/10/2018] [Indexed: 02/08/2023]
Abstract
A caesarean section (CS) can be a life-saving intervention when medically indicated, but this procedure can also lead to short-term and long-term health effects for women and children. Given the increasing use of CS, particularly without medical indication, an increased understanding of its health effects on women and children has become crucial, which we discuss in this Series paper. The prevalence of maternal mortality and maternal morbidity is higher after CS than after vaginal birth. CS is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose-response manner. There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology. Short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity. The persistence of these risks into later life is less well investigated, although an association between CS use and greater incidence of late childhood obesity and asthma are frequently reported. There are few studies that focus on the effects of CS on cognitive and educational outcomes. Understanding potential mechanisms that link CS with childhood outcomes, such as the role of the developing neonatal microbiome, has potential to inform novel strategies and research for optimising CS use and promote optimal physiological processes and development.
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Affiliation(s)
- Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, St Thomas' Hospital Campus, King's College London, London UK.
| | - Rachel M Tribe
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, St Thomas' Hospital Campus, King's College London, London UK
| | - Lisa Avery
- Department of Community Health Sciences, Centre for Global Public Health, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Glen Mola
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea; Department of Obstetrics and General Hospital, Port Moresby, Papua New Guinea
| | - Gerard Ha Visser
- International Federation of Gynecology and Obstetrics (FIGO), London, UK
| | - Caroline Se Homer
- Maternal and Child Health Programme, Burnet Institute, Melbourne, VIC, Australia
| | - Deena Gibbons
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London UK
| | - Niamh M Kelly
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, St Thomas' Hospital Campus, King's College London, London UK
| | | | | | - Paul Taylor
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, St Thomas' Hospital Campus, King's College London, London UK
| | - Marleen Temmerman
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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17
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Castillo MC, Vwalika B, Stoner MCD, Chi BH, Stringer JSA, Kasaro M, Kumwenda A, Stringer EM. Risk of stillbirth among Zambian women with a prior cesarean delivery. Int J Gynaecol Obstet 2018; 143:360-366. [PMID: 30207602 DOI: 10.1002/ijgo.12668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/16/2018] [Accepted: 09/10/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Cesarean delivery (CD) may be associated with stillbirth in future pregnancies. We investigated prior CD as a risk factor for stillbirth in Lusaka, Zambia. METHODS We conducted a retrospective cohort analysis of women with only one prior pregnancy who delivered between February 1, 2006, and May 31, 2013. We analysed data from the Zambia Electronic Perinatal System. Maternal and infant characteristics were analyzed for association with stillbirth using Pearson's χ2 test or the Wilcoxon rank-sum test. We calculated risk ratios for the relationship between stillbirth (antepartum vs intrapartum) and prior CD, with a log Poisson model to adjust for confounding. RESULTS Of 57 320 women in our cohort, 1933 (3.4%) reported a prior CD. There were 1012 (1.8%) stillbirths in the no prior CD group and 81 (4.2%) in the prior CD group (P<0.001). In multivariate models adjusting for stillbirth risk factors, prior CD was associated with antepartum (adjusted risk ratio 1.56, 95% confidence interval 1.08-2.24) and intrapartum (adjusted risk ratio 3.26, 95% confidence interval 2.40-4.42) stillbirth compared with no prior CD. The difference between groups was most apparent at 36-37 weeks' gestation (log-rank P<0.001). CONCLUSION Prior CD was associated with increased risk of stillbirth. Improved monitoring during labor and safe methods for induction are urgently needed in low-resource settings.
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Affiliation(s)
- Marcela C Castillo
- The University of Texas at Austin Dell Medical School, Austin, TX, USA.,University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Bellington Vwalika
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,University Teaching Hospital, Lusaka, Zambia.,University of Zambia School of Medicine, Lusaka, Zambia
| | - Marie C D Stoner
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Margaret Kasaro
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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18
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Joyce NM, Tully E, Kirkham C, Dicker P, Breathnach FM. Perinatal mortality or severe neonatal encephalopathy among normally formed singleton pregnancies according to obstetric risk status:" is low risk the new high risk?" A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2018; 228:71-75. [PMID: 29909266 DOI: 10.1016/j.ejogrb.2018.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 06/05/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the capacity of the current system of obstetric risk stratification at the outset of pregnancy to predict severe adverse perinatal outcome. STUDY DESIGN This retrospective cohort study of singleton pregnancies over a five year period (2009-2013) was performed at the Rotunda Hospital, Dublin, Ireland. High-risk or low-risk status was assigned retrospectively to a large consecutive cohort of women with a normally-formed singleton pregnancy on the basis of factors analyzed at the first prenatal hospital visit. The incidence of severe perinatal morbidity and mortality were compared between high- and low-risk groups to determine the predictive utility of risk stratification at the outset of pregnancy for severe perinatal morbidity. RESULTS During the study period, 41,044 patients registered for prenatal care. 25,702;(63%) were deemed low-risk and 15,342;(37%) high-risk. Low-risk women were statistically more likely to be nulliparous (p < 0.0001) and to have a spontaneous or operative vaginal delivery (p < 0.0001). High-risk women were more likely to be multiparous and to undergo Caesarean delivery (p < 0.0001). The perinatal mortality rate was 3.8 per-1000 in low-risk pregnancies and 6.1 per-1000 in the a priori high-risk group (p = 0.012). The incidence of severe neonatal encephalopathy (NNE) was 1.8 and 0.65 per-1000 in the low and high-risk groups respectively (p = 0.0025). CONCLUSION Where low-risk status is assigned at registration, neonatal encephalopathy is more prevalent. This data is relevant for the design of prenatal care models and demonstrates that assignment of low obstetric risk on the basis of maternal or pre-pregnancy factors alone may erroneously be interpreted as conferring low-risk status to the fetus.
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Affiliation(s)
- Niamh M Joyce
- RCSI Rotunda, Royal College of Surgeons in Ireland, RCSI Unit, Rotunda Hospital, Parnell Square, Dublin 1, Ireland.
| | - Elizabeth Tully
- RCSI Rotunda, Royal College of Surgeons in Ireland, RCSI Unit, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Colin Kirkham
- The Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Patrick Dicker
- RCSI Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Lower Mercer Street, Dublin 2, Ireland
| | - Fionnuala M Breathnach
- RCSI Rotunda, Royal College of Surgeons in Ireland, RCSI Unit, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
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19
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Idoko P, Anyanwu M. Outcome of caesarean section at the Edward Francis Small Teaching Hospital, Banjul The Gambia. Afr Health Sci 2018; 18:157-165. [PMID: 29977269 PMCID: PMC6016991 DOI: 10.4314/ahs.v18i1.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Caesarean section is a very important procedure to decrease maternal and perinatal morbidity and mortality. Anecdotal evidence suggests that more than half of all caesarean sections done in The Gambia are done at the Edward Francis Small Teaching Hospital. OBJECTIVE The aim of the study was to determine the caesarean section rate at the Edward Francis Small teaching Hospital. The study also aimed to determine the socio-demographic factors associated with caesarean section and maternal and fetal outcomes of caesarean section at the hospital. METHOD A retrospective review of all caesarean sections carried out at the Edward Francis Small Teaching Hospital from 1st January 2014 to 31st December 2014 was done. Data was extracted from patients' record. Descriptive statistics was done using Epi Info 7 statistical software. RESULTS The Caesarean section rate in the hospital is 24.0%. The commonest indications for caesarean section were previous caesarean section (20.6%) and cephalopelvic disproportion (20.2%). There were 21 maternal deaths (1.8%) and 71 fresh stillbirths (6.0%) in the study population. CONCLUSION About a quarter of all deliveries in the hospital were caesarean sections most of which were done as emergencies. The commonest indications for caesarean section were cephalopelvic disproportion and previous caesarean section.
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Affiliation(s)
- Patrick Idoko
- Edward Francis Small Teaching Hospital, Banjul The Gambia
- School of Medical and Allied Health Sciences, University of The Gambia
| | - Matthew Anyanwu
- Edward Francis Small Teaching Hospital, Banjul The Gambia
- School of Medical and Allied Health Sciences, University of The Gambia
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Alamo L, Vial Y, Denys A, Andreisek G, Meuwly JY, Schmidt S. MRI findings of complications related to previous uterine scars. Eur J Radiol Open 2018; 5:6-15. [PMID: 29387735 PMCID: PMC5790820 DOI: 10.1016/j.ejro.2018.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/28/2017] [Accepted: 01/04/2018] [Indexed: 01/23/2023] Open
Abstract
Although the World Health Organization suggests 10–15% as the adequate cesarean delivery rate to assure optimal prognosis for mother and children, cesarean rates have continuously increased worldwide over the last three decades, even in primiparous women. Moreover, uterine scars after myomectomies, complications of obstetrical interventions and more recently, after fetal surgery, are often observed. This review article describes the most commonly seen complications related to prior uterine scars and discusses their imaging findings, with emphasis on the increasing role of Magnetic Resonance Imaging for diagnosis.
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Affiliation(s)
- Leonor Alamo
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV) and University of Lausanne (UNIL) Rue du Bugnon, 46, 1011, Lausanne, Switzerland
| | - Yvan Vial
- Department of Gynecology and Obstetrics, University Hospital of Lausanne (CHUV) and University of Lausanne (UNIL), Rue du Bugnon, 46, 1011, Lausanne, Switzerland
| | - Alban Denys
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV) and University of Lausanne (UNIL) Rue du Bugnon, 46, 1011, Lausanne, Switzerland
| | - Gustav Andreisek
- Department of Diagnostic Radiology, Institute of Diagnostic and interventional Radiology, University Hospital of Zurich and University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Jean-Yves Meuwly
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV) and University of Lausanne (UNIL) Rue du Bugnon, 46, 1011, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV) and University of Lausanne (UNIL) Rue du Bugnon, 46, 1011, Lausanne, Switzerland
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Brierley-Jones L, Crawley R, Jones E, Gordon I, Knight J, Hinshaw K. Supporting parents through stillbirth: A qualitative study exploring the views of health professionals and health care staff in three hospitals in England. Eur J Obstet Gynecol Reprod Biol 2018; 222:45-51. [PMID: 29353132 DOI: 10.1016/j.ejogrb.2018.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To investigate the views of a range of hospital based health professionals and health care staff involved in the management of stillbirth. STUDY DESIGN A qualitative pilot study informed by grounded theory conducted in three hospital trusts in the North East of England. In total, 21 consultant obstetricians, 3 trainees (including 1 senior trainee), 29 midwives, 3 midwife sonographers and 4 chaplains took part in six focus groups and two semi-structured interviews. RESULTS Two different approaches in stillbirth management could be detected in our study. One approach emphasised the existing evidence-base and patient directed choice whilst the other emphasised tradition and profession-directed care. These differences were particularly apparent in choices over mode of delivery, and the location of women as well as the time interval between diagnosis of an IUD and delivery. The existence of these two approaches was underscored by a lack of high quality evidence. CONCLUSION Robust, high quality evidence is needed regarding the longer term psychological and emotional sequelae of different modes of delivery and varying time intervals and locations of women between diagnosis and delivery in stillbirth. If the competing discourses demonstrated here are found elsewhere then such need to be considered in any future policy development, evidence implementation and training programmes.
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Affiliation(s)
- Lyn Brierley-Jones
- Department of Sociology, Wentworth College, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - Rosalind Crawley
- School of Psychology, Faculty of Health Sciences and Well-being, Shackleton House, Sunderland, SR1 3SD, United Kingdom
| | - Emma Jones
- School of Psychology, Faculty of Health Sciences and Well-being, Shackleton House, Sunderland, SR1 3SD, United Kingdom
| | - Isabel Gordon
- Nursing, Health and Wellbeing, Sciences Complex, Wharncliffe Street, Sunderland, SR1 3SD, United Kingdom
| | - Joanne Knight
- Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, United Kingdom
| | - Kim Hinshaw
- Department of Obstetrics and Gynaecology, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, United Kingdom
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Cassidy PR. Care quality following intrauterine death in Spanish hospitals: results from an online survey. BMC Pregnancy Childbirth 2018; 18:22. [PMID: 29321000 PMCID: PMC5763533 DOI: 10.1186/s12884-017-1630-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 12/14/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The objective of the study was to evaluate practices in Spanish hospitals after intrauterine death in terms of medical/ technical care and bereavement support care. METHODS A cross-sectional descriptive study using an online self-completion questionnaire. The population was defined as women who had experienced an intrauterine fetal death between sixteen weeks and birth, either through spontaneous late miscarriage/stillbirth or termination of pregnancy for medical reasons. Respondents were recruited through an online advertisement on a stillbirth charity website and social media. The analysis used Pearson's chi-squared (p ≤ 0.05) test of independence to cross-analyse for associations between objective measures of care quality and independent variables. RESULTS Responses from 796 women were analysed. Half of the women (52.9%) had postmortem contact with their baby. 30.4% left the hospital with a least one linking object or a photograph. In 35.8% of cases parents weren't given any option to recover the body/remains. 22.9% of births ≥26 weeks gestation were by caesarean, with a significant (p < 0.001) difference between public hospitals (16.8%) and private hospitals (41.5%). 29.3% of respondents were not accompanied during the delivery. 48.0% of respondents recalled being administered sedatives at least once during the hospital stay. The autopsy rate in stillbirth cases (≥ 20 weeks) was 70.5% and 44.4% in cases of termination of pregnancy (all gestational ages). Consistent significant (p < 0.05) differences in care practices were found based on gestational age and type of hospital (public or private), but not to other variables related to socio-demographics, pregnancy history or details of the loss/death. Intrauterine deaths at earlier gestational ages received poorer quality care. CONCLUSIONS Supportive healthcare following intrauterine death is important to women's experiences in the hospital and beneficial to the grief process. Many care practices that are standard in other high-income countries are not routine in Spanish hospitals. Providing such care is a relatively new phenomenon in the Spanish health system, the results provide a quality benchmark and identify a number of areas where hospitals could make improvements to care practices that should have important psychosocial benefits for women and their families.
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Affiliation(s)
- Paul Richard Cassidy
- Universidad Complutense de Madrid, Facultad de Ciencia Política y Sociología, Somosaguas, Pozuelo de Alarcon, 28223, Madrid, Spain.
- Umamanita (Stillbirth Charity), C/ Hierbabuena 15, Esc B, 4 Izq, 28039, Madrid, Spain.
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Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med 2018; 15:e1002494. [PMID: 29360829 PMCID: PMC5779640 DOI: 10.1371/journal.pmed.1002494] [Citation(s) in RCA: 409] [Impact Index Per Article: 68.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/18/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The objective of this systematic review is to describe the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies. The primary maternal outcome was pelvic floor dysfunction, the primary baby outcome was asthma, and the primary subsequent pregnancy outcome was perinatal death. METHODS AND FINDINGS Medline, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were systematically searched for published studies in human subjects (last search 25 May 2017), supplemented by manual searches. Included studies were randomized controlled trials (RCTs) and large (more than 1,000 participants) prospective cohort studies with greater than or equal to one-year follow-up comparing outcomes of women delivering by cesarean delivery and by vaginal delivery. Two assessors screened 30,327 abstracts. Studies were graded for risk of bias by two assessors using the Scottish Intercollegiate Guideline Network (SIGN) Methodology Checklist and the Risk of Bias Assessment tool for Non-Randomized Studies. Results were pooled in fixed effects meta-analyses or in random effects models when significant heterogeneity was present (I2 ≥ 40%). One RCT and 79 cohort studies (all from high income countries) were included, involving 29,928,274 participants. Compared to vaginal delivery, cesarean delivery was associated with decreased risk of urinary incontinence, odds ratio (OR) 0.56 (95% CI 0.47 to 0.66; n = 58,900; 8 studies) and pelvic organ prolapse (OR 0.29, 0.17 to 0.51; n = 39,208; 2 studies). Children delivered by cesarean delivery had increased risk of asthma up to the age of 12 years (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity up to the age of 5 years (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Pregnancy after cesarean delivery was associated with increased risk of miscarriage (OR 1.17, 1.03 to 1.32; n = 151,412; 4 studies) and stillbirth (OR 1.27, 1.15 to 1.40; n = 703,562; 8 studies), but not perinatal mortality (OR 1.11, 0.89 to 1.39; n = 91,429; 2 studies). Pregnancy following cesarean delivery was associated with increased risk of placenta previa (OR 1.74, 1.62 to 1.87; n = 7,101,692; 10 studies), placenta accreta (OR 2.95, 1.32 to 6.60; n = 705,108; 3 studies), and placental abruption (OR 1.38, 1.27 to 1.49; n = 5,667,160; 6 studies). This is a comprehensive review adhering to a registered protocol, and guidelines for the Meta-analysis of Observational Studies in Epidemiology were followed, but it is based on predominantly observational data, and in some meta-analyses, between-study heterogeneity is high; therefore, causation cannot be inferred and the results should be interpreted with caution. CONCLUSIONS When compared with vaginal delivery, cesarean delivery is associated with a reduced rate of urinary incontinence and pelvic organ prolapse, but this should be weighed against the association with increased risks for fertility, future pregnancy, and long-term childhood outcomes. This information could be valuable in counselling women on mode of delivery.
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Affiliation(s)
- Oonagh E. Keag
- NHS Lothian Department of Obstetrics and Gynaecology, Simpson’s Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Jane E. Norman
- Tommy’s Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, University of Edinburgh Queen’s Medical Research Institute, Edinburgh, United Kingdom
| | - Sarah J. Stock
- Tommy’s Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, University of Edinburgh Queen’s Medical Research Institute, Edinburgh, United Kingdom
- School of Women’s and Infants’ Health, University of Western Australia, Crawley, Australia
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Cohain JS, Buxbaum RE, Mankuta D. Spontaneous first trimester miscarriage rates per woman among parous women with 1 or more pregnancies of 24 weeks or more. BMC Pregnancy Childbirth 2017; 17:437. [PMID: 29272996 PMCID: PMC5741961 DOI: 10.1186/s12884-017-1620-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 12/07/2017] [Indexed: 12/18/2022] Open
Abstract
Background The purpose of this study was to quantify spontaneous first trimester miscarriage rates per woman among parous women. A vast amount of data has accumulated regarding miscarriage rates per recognized pregnancy as well as about recurrent miscarriage. This is the second study of miscarriage rates per woman in a parous population and the first study of recurrent and non-recurrent, spontaneous first trimester miscarriage rates per woman in a large parous population. Methods Extraction of the following variables from all delivery room admissions from both Hadassah Medical Centers in Jerusalem Israel, 2004–2014: # of first trimester spontaneous miscarriages, # live births; # living children; age on admission, pre-pregnancy height and weight, any smoking this pregnancy, any alcohol or drug abuse this pregnancy, blood type, history of ectopic pregnancy, history of cesarean surgery (CS) and use of any fertility treatment(s). Results Among 53,479 different women admitted to labor and delivery ward, 43% of women reported having had 1 or more first trimester spontaneous miscarriages; 27% reported having had one, 10% two, 4% three, 1.3% four, 0.6% five and 0.05% reported having 6–16 spontaneous first trimester miscarriages. 18.5% had one or more first trimester miscarriages before their first live birth. Eighty-one percent of women with 11 or more living children experienced one or more first trimester miscarriages. First trimester miscarriage rates rose with increasing age, increasing parity, after previous ectopic pregnancy, after previous cesarean surgery, with any smoking during pregnancy and pre-pregnancy BMI ≥30. Conclusions Miscarriages are common among parous women; 43% of parous women report having experienced one or more first trimester spontaneous miscarriages, rising to 81% among women with 11 or more living children. One in every 17 parous women have three or more miscarriages. Depending on her health, nutrition and lifestyle choices, even a 39 year old parous woman with a history of 3 or more miscarriages has a good chance of carrying a future pregnancy to term but she should act expediently.
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Affiliation(s)
| | | | - David Mankuta
- Dept Obstetrics and Gynecology, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
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O'Neill SM, Kabir Z, McNamara G, Buckley CM. Comorbid depression and risk of lower extremity amputation in people with diabetes: systematic review and meta-analysis. BMJ Open Diabetes Res Care 2017; 5:e000366. [PMID: 28878931 PMCID: PMC5574442 DOI: 10.1136/bmjdrc-2016-000366] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/30/2017] [Accepted: 02/14/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare the risk of lower extremity amputation (LEA) in people with diabetes with and without comorbid depression. RESEARCH DESIGN AND METHODS A systematic review of the published literature was conducted. Six databases were searched including PubMed, CINAHL, EMBASE, Medline, the Cochrane Library and PsycARTICLES from inception to 22 June 2016, using a detailed search strategy and cross-checking of reference lists for potentially eligible studies published in English. No date restrictions were employed. All studies were reviewed independently for inclusion by two review authors. Data extraction was performed using a standardized data abstraction form, and study quality was assessed independently by two reviewers. A meta-analysis was performed reporting pooled hazard ratios (HRs) and 95% CIs in Review Manager software. RESULTS In total, seven studies were eligible for inclusion in the systematic review. Data on 767 997 patients from five studies were included in the meta-analysis. Pooled estimates across the studies were obtained using a random-effects model due to significant heterogeneity (I2=87%). People with diabetes and depression had an increased hazard of LEA (HR 1.76, 95% CI 1.19 to 2.60) compared to people with diabetes and no depression. CONCLUSIONS Based on the available evidence, comorbid depression appears to increase the risk of LEA in people with diabetes. Limited data were available, however, with significant heterogeneity between studies. Further research is needed to inform intervention and clinical practice development in the management of diabetes.
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Affiliation(s)
- Sinéad M O'Neill
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Zubair Kabir
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Grace McNamara
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Claire Mary Buckley
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
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Maaløe N, Housseine N, Bygbjerg IC, Meguid T, Khamis RS, Mohamed AG, Nielsen BB, van Roosmalen J. Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study. BMC Pregnancy Childbirth 2016; 16:351. [PMID: 27832753 PMCID: PMC5103376 DOI: 10.1186/s12884-016-1142-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/01/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital. METHODS A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249). RESULTS The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75-315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06-3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68-5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70-12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect. CONCLUSIONS Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities. TRIAL REGISTRATION This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Natasha Housseine
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353 Copenhagen K, Denmark
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health & Medical Sciences, State University of Zanzibar, P.O.Box:146, Zanzibar, Tanzania
| | | | | | - Birgitte Bruun Nielsen
- Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Jos van Roosmalen
- Athena Institute, VU University of Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands
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Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, Flenady V, Frøen JF, Qureshi ZU, Calderwood C, Shiekh S, Jassir FB, You D, McClure EM, Mathai M, Cousens S. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet 2016; 387:587-603. [PMID: 26794078 DOI: 10.1016/s0140-6736(15)00837-5] [Citation(s) in RCA: 957] [Impact Index Per Article: 119.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An estimated 2.6 million third trimester stillbirths occurred in 2015 (uncertainty range 2.4-3.0 million). The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030. 94 mainly high-income countries and upper middle-income countries have already met this target, although with noticeable disparities. At least 56 countries, particularly in Africa and in areas affected by conflict, will have to more than double present progress to reach this target. Most (98%) stillbirths are in low-income and middle-income countries. Improved care at birth is essential to prevent 1.3 million (uncertainty range 1.2-1.6 million) intrapartum stillbirths, end preventable maternal and neonatal deaths, and improve child development. Estimates for stillbirth causation are impeded by various classification systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7.4% of stillbirths. Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8.0% and syphilis 7.7%), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6.7%). Prolonged pregnancies contribute to 14.0% of stillbirths. Causal pathways for stillbirth frequently involve impaired placental function, either with fetal growth restriction or preterm labour, or both. Two-thirds of newborns have their births registered. However, less than 5% of neonatal deaths and even fewer stillbirths have death registration. Records and registrations of all births, stillbirths, neonatal, and maternal deaths in a health facility would substantially increase data availability. Improved data alone will not save lives but provide a way to target interventions to reach more than 7000 women every day worldwide who experience the reality of stillbirth.
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Affiliation(s)
- Joy E Lawn
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK; Saving Newborn Lives, Save the Children, Washington, DC, USA.
| | - Hannah Blencowe
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK; Saving Newborn Lives, Save the Children, Washington, DC, USA
| | - Peter Waiswa
- Maternal and Newborn Centre of Excellence, Makerere University and INDEPTH Maternal Newborn Working Group, School of Public Health, Kampala, Uganda
| | - Agbessi Amouzou
- Division of Data, Research, and Policy, United Nations Children's Fund, New York, NY, USA
| | - Colin Mathers
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | - Dan Hogan
- Department of Information, Evidence and Research, World Health Organization, Geneva, Switzerland
| | | | - J Frederik Frøen
- Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway; Center for Intervention Science for Maternal and Child Health, University of Bergen, Bergen, Norway
| | - Zeshan U Qureshi
- Institute of Global Health, University College London, London, UK
| | - Claire Calderwood
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Suhail Shiekh
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Fiorella Bianchi Jassir
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Danzhen You
- Division of Data, Research, and Policy, United Nations Children's Fund, New York, NY, USA
| | | | - Matthews Mathai
- Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Simon Cousens
- Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene & Tropical Medicine, London, UK
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Brüggmann D, Löhlein LK, Louwen F, Quarcoo D, Jaque J, Klingelhöfer D, Groneberg DA. Caesarean Section--A Density-Equalizing Mapping Study to Depict Its Global Research Architecture. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:14690-708. [PMID: 26593932 PMCID: PMC4661674 DOI: 10.3390/ijerph121114690] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/04/2015] [Accepted: 11/11/2015] [Indexed: 11/20/2022]
Abstract
Caesarean section (CS) is a common surgical procedure. Although it has been performed in a modern context for about 100 years, there is no concise analysis of the international architecture of caesarean section research output available so far. Therefore, the present study characterizes the global pattern of the related publications by using the NewQIS (New Quality and Quantity Indices in Science) platform, which combines scientometric methods with density equalizing mapping algorithms. The Web of Science was used as a database. 12,608 publications were identified that originated from 131 countries. The leading nations concerning research activity, overall citations and country-specific h-Index were the USA and the United Kingdom. Relation of the research activity to epidemiologic data indicated that Scandinavian countries including Sweden and Finland were leading the field, whereas, in relation to economic data, countries such as Israel and Ireland led. Semi-qualitative indices such as country-specific citation rates ranked Sweden, Norway and Finland in the top positions. International caesarean section research output continues to grow annually in an era where caesarean section rates increased dramatically over the past decades. With regard to increasing employment of scientometric indicators in performance assessment, these findings should provide useful information for those tasked with the improvement of scientific achievements.
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Affiliation(s)
- Dörthe Brüggmann
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, Los Angeles, CA 90033, USA.
- Department of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Theodor-Stern-Kai 7, Frankfurt 60590, Germany.
| | - Lena-Katharina Löhlein
- Department of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Theodor-Stern-Kai 7, Frankfurt 60590, Germany.
| | - Frank Louwen
- Department of Gynecology and Obstetrics, Goethe-University, Theodor-Stern-Kai 7, Frankfurt 60590, Germany.
| | - David Quarcoo
- Department of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Theodor-Stern-Kai 7, Frankfurt 60590, Germany.
| | - Jenny Jaque
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, Los Angeles, CA 90033, USA.
| | - Doris Klingelhöfer
- Department of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Theodor-Stern-Kai 7, Frankfurt 60590, Germany.
| | - David A Groneberg
- Department of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Theodor-Stern-Kai 7, Frankfurt 60590, Germany.
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Maternal caffeine intake during pregnancy and risk of pregnancy loss: a categorical and dose-response meta-analysis of prospective studies. Public Health Nutr 2015; 19:1233-44. [PMID: 26329421 DOI: 10.1017/s1368980015002463] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the association between maternal caffeine intake and risk of pregnancy loss using a systematic review and meta-analysis. DESIGN Categorical and dose-response meta-analysis of prospective studies. SETTING Relevant articles were identified by searching MEDLINE and SCOPUS databases through 30 January 2015. Two authors independently extracted information from eligible studies. Random-effects models were used to derive the summary relative risks (RR) and corresponding 95% CI for specific categories of caffeine consumption and for a continuous association using generalized least-squares trend estimation. SUBJECTS A total of 130 456 participants and 3429 cases in fourteen included studies. RESULTS Compared with the reference category with no or very low caffeine intake, the RR (95% CI) of pregnancy loss was 1·02 (0·85, 1·24; I(2)=28·3%) for low intake (50-149 mg/d), 1·16 (0·94, 1·41; I 2=49·6%) for moderate intake (150-349 mg/d), 1·40 (1·16, 1·68; I(2)=18·6%) for high intake (350-699 mg/d) and 1·72 (1·40, 2·13; I(2)=0·0%) for very high intake (≥ 700 mg/d). In the dose-response analysis, each 100 mg/d increment in maternal caffeine intake (~1 cup of coffee) was associated with 7% (95% CI 3%, 12%) higher risk of pregnancy loss. Our results may have been affected by publication bias, but the association remained significant for the subset of larger studies. Furthermore, adjustment for smoking and pregnancy symptoms may have been incomplete, potentially resulting in residual confounding. CONCLUSIONS Albeit inconclusive, higher maternal caffeine intake was associated with a higher risk of pregnancy loss and adherence to guidelines to avoid high caffeine intake during pregnancy appears prudent.
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Wood S, Ross S, Sauve R. Cesarean Section and Subsequent Stillbirth, Is Confounding by Indication Responsible for the Apparent Association? An Updated Cohort Analysis of a Large Perinatal Database. PLoS One 2015; 10:e0136272. [PMID: 26331274 PMCID: PMC4557984 DOI: 10.1371/journal.pone.0136272] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 08/05/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Several studies and a recent meta-analysis have suggested that previous Cesarean section may increase the risk of stillbirth in a subsequent pregnancy. Given the high rates of Cesarean section in contemporary obstetric practice, this is of considerable public health importance. We sought to evaluate the potential that this association is the result of residual confounding bias. METHODS A large perinatal database (Alberta Perinatal Health Project) was searched to identify a matched set of first and second births from the years 1992-2006. Data on pregnancy outcomes, demographics and potential confounding factors were obtained. RESULTS The cohort was comprised of 98538 matched first and second births. Multivariate analysis did not reveal an association between previous Cesarean section and stillbirth, OR = 1.38 (0.98, 1.93). Restricting the analysis to a low risk group further attenuated the association, OR = .99 (0.62, 1.52). Analysis of the risk by indication for Cesarean section found that the risk was not increased for previous dystocia, OR = .91 (0.53, 1.55) nor for breech presentation, OR = 1.06 (0.50, 2.28) but only for other indications including non reassuring fetal status and fetal distress, OR = 1.96 (1.29, 2.98). CONCLUSIONS The results of our cohort analysis suggest that previous Cesarean section does not cause an increased risk of stillbirth.
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Affiliation(s)
- Stephen Wood
- Department of Obstetrics & Gynecology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
| | - Sue Ross
- Department of Obstetrics & Gynecology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Reg Sauve
- Canada Department of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Abstract
OBJECTIVE This study aims to examine the risk for subsequent ectopic pregnancy in women with prior cesarean delivery. STUDY DESIGN Women with a history of at least one cesarean delivery in the state of Utah during 1996 to 2011 were identified and compared with women with vaginal delivery only. The primary outcome was subsequent ectopic pregnancy. Data were analyzed by multivariate logistic regression and stratified by first, second, or third live births. Model covariates included maternal age, ethnicity, marital status, education level, gravidity, and prior ectopic pregnancy. RESULTS Overall, 260,249 women with at least one live birth were identified. After exclusions, 255,082, 154,930, and 70,228 women had at least one, two, and three prior live births that lead to 531, 199, and 62 subsequent ectopic pregnancies, respectively. Women who had one prior cesarean delivery were not at increased risk for subsequent ectopic pregnancy in relation to women with no prior cesarean delivery. However, women with two of two, two of three, or three of three prior cesareans had increased risk for subsequent ectopic pregnancy with odds ratios (95% confidence interval) of 1.54 (1.06-2.22), 3.50 (1.49-8.24), and 1.99 (1.00-3.98), respectively. CONCLUSION History of two or three cesarean deliveries is associated with increased risk for subsequent ectopic pregnancy.
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Affiliation(s)
- Zachary S. Bowman
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Ken R. Smith
- Department of Population Sciences, Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
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Moraitis AA, Oliver-Williams C, Wood AM, Fleming M, Pell JP, Smith G. Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis. BJOG 2015; 122:1467-74. [PMID: 26033155 DOI: 10.1111/1471-0528.13461] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2015] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine whether caesarean delivery in the first pregnancy is a risk factor for unexplained antepartum stillbirth in a second pregnancy. DESIGN A population-based retrospective cohort study and meta-analysis. SETTING All maternity units in Scotland. PARTICIPANTS A cohort of 128 585 second births, 1999-2008. METHODS Time-to-event analysis and random-effects meta-analysis. MAIN OUTCOME MEASURE Risk of unexplained antepartum stillbirth in a second pregnancy. RESULTS There were 88 stillbirths among 23 688 women with a previous caesarean delivery (2.34 per 10 000 women per week) and 288 stillbirths in 104 897 women who had previously delivered vaginally (1.67 per 10 000 women per week, P = 0.002). When analysed by cause, women with a previous caesarean delivery had an increased risk of unexplained stillbirth (hazard ratio, HR 1.47; 95% confidence interval, 95% CI 1.12-1.94; P = 0.006) and, as previously observed, the excess risk was apparent from 34 weeks of gestation onwards. The risk did not differ in relation to the indication of the caesarean delivery, and was independent of maternal characteristics and previous obstetric complications. We identified three other comparable studies (two in North America and one in Europe), and meta-analysis of these studies showed a statistically significant association between previous caesarean delivery and the risk of antepartum stillbirth in the second pregnancy (pooled HR 1.40; 95% CI 1.10-1.77; P = 0.006). CONCLUSIONS Women who have had a previous caesarean delivery are at increased risk of unexplained stillbirth in the second pregnancy. TWEETABLE ABSTRACT Caesarean first delivery is associated with an increased risk of unexplained stillbirth in the next pregnancy.
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Affiliation(s)
- A A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK.,National Institute for Health Research (NIHR), Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - C Oliver-Williams
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - A M Wood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - M Fleming
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - J P Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Gcs Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK.,National Institute for Health Research (NIHR), Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
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Delnord M, Blondel B, Drewniak N, Klungsøyr K, Bolumar F, Mohangoo A, Gissler M, Szamotulska K, Lack N, Nijhuis J, Velebil P, Sakkeus L, Chalmers J, Zeitlin J. Varying gestational age patterns in cesarean delivery: an international comparison. BMC Pregnancy Childbirth 2014; 14:321. [PMID: 25217979 PMCID: PMC4177602 DOI: 10.1186/1471-2393-14-321] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 09/04/2014] [Indexed: 11/10/2022] Open
Abstract
Background While international variations in overall cesarean delivery rates are well documented, less information is available for clinical sub-groups. Cesarean data presented by subgroups can be used to evaluate uptake of cesarean reduction policies or to monitor delivery practices for high and low risk pregnancies based on new scientific evidence. We studied differences and patterns in cesarean delivery rates by multiplicity and gestational age in Europe and the United States. Methods This study used routine aggregate data from 17 European countries and the United States on the number of singleton and multiple live births with cesarean versus vaginal delivery by week of gestation in 2008. Overall and gestation-specific cesarean delivery rates were analyzed. We computed rate differences to compare mode of delivery (cesarean vs vaginal birth) between selected gestational age groups and studied associations between rates in these subgroups namely: very preterm (26–31 weeks GA), moderate preterm (32–36 weeks GA), near term (37–38 weeks GA), term (39–41 weeks GA) and post-term (42+ weeks GA) births, using Spearman’s rank tests. Results High variations in cesarean rates for singletons and multiples were observed everywhere. Rates for singletons varied from 15% in The Netherlands and Slovenia, to over 30% in the US and Germany. In singletons, rates were highest for very preterm births and declined to a nadir at 40 weeks of gestation, ranging from 8.0% in Sweden and Norway, to 22.5% in the US. These patterns differed across countries; the average rate difference between very preterm and term births was 43 percentage points, but ranged from 14% to 61%. High variations in rate differences were also observed for near term versus term births. For multiples, rates declined by gestational age in some countries, whereas in others rates were similar across all weeks of gestation. Countries’ overall cesarean rates were highly correlated with gestation-specific subgroup rates, except for very preterm births. Conclusions Gestational age patterns in cesarean delivery were heterogeneous across countries; these differences highlight areas where consensus on best practices is lacking and could be used in developing strategies to reduce cesareans.
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Affiliation(s)
- Marie Delnord
- INSERM UMR1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), DHU Risks in pregnancy, Paris Descartes University, Port Royal Maternity Unit, 53 Avenue de l'Observatoire, Paris, 75014, France.
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Khashan AS, Kenny LC, Lundholm C, Kearney PM, Gong T, Almqvist C. Mode of obstetrical delivery and type 1 diabetes: a sibling design study. Pediatrics 2014; 134:e806-13. [PMID: 25092933 DOI: 10.1542/peds.2014-0819] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We investigated the association between cesarean section (CS) and type 1 diabetes (T1D), and if the association remains after accounting for familial confounding by using a sibling-control design. METHODS We conducted a population-based cohort study of all singleton live births in Sweden between 1982 and 2009, followed by sibling-control analyses. T1D diagnoses were identified from the Swedish National Patient Register. Mode of delivery was categorized into unassisted vaginal delivery (reference group), instrumental vaginal delivery (IVD), emergency CS, and elective CS. The statistical analysis was conducted in 2 steps: firstly log-linear Poisson regression with aggregated person-years by using the full cohort; secondly, conditional logistic regression for sibling-control analyses. The sibling analysis included siblings who were discordant for both mode of delivery and T1D. RESULTS In the cohort analyses (N = 2 638 083), there was an increased risk of childhood T1D among children born by elective CS (adjusted relative risk [RR] = 1.15 [95% confidence interval: 1.06-1.25]) and IVD (RR=1.14 [1.06-1.23]) but not emergency CS (RR = 1.02 [0.95-1.11]) when compared with children born by unassisted vaginal birth. However, the effect of elective CS and IVD on childhood T1D almost disappeared and became nonsignificant in the sibling-control analyses. CONCLUSIONS The present findings suggest a small association between elective CS and IVD and T1D. The sibling-control results, however, suggest that these findings are not consistent with causal effects of mode of delivery on T1D and may be due to familial confounders such as genetic susceptibility and environmental factors.
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Affiliation(s)
- Ali S Khashan
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, University College Cork, Ireland;
| | - Louise C Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, University College Cork, Ireland
| | - Cecilia Lundholm
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; and
| | - Patricia M Kearney
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Tong Gong
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; and
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; and Astrid Lindgren Children's Hospital, Lung and Allergy Unit, Karolinska University Hospital, Stockholm, Sweden
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O'Neill SM, Agerbo E, Kenny LC, Henriksen TB, Kearney PM, Greene RA, Mortensen PB, Khashan AS. Cesarean section and rate of subsequent stillbirth, miscarriage, and ectopic pregnancy: a Danish register-based cohort study. PLoS Med 2014; 11:e1001670. [PMID: 24983970 PMCID: PMC4077571 DOI: 10.1371/journal.pmed.1001670] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 05/16/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND With cesarean section rates increasing worldwide, clarity regarding negative effects is essential. This study aimed to investigate the rate of subsequent stillbirth, miscarriage, and ectopic pregnancy following primary cesarean section, controlling for confounding by indication. METHODS AND FINDINGS We performed a population-based cohort study using Danish national registry data linking various registers. The cohort included primiparous women with a live birth between January 1, 1982, and December 31, 2010 (n = 832,996), with follow-up until the next event (stillbirth, miscarriage, or ectopic pregnancy) or censoring by live birth, death, emigration, or study end. Cox regression models for all types of cesarean sections, sub-group analyses by type of cesarean, and competing risks analyses for the causes of stillbirth were performed. An increased rate of stillbirth (hazard ratio [HR] 1.14, 95% CI 1.01, 1.28) was found in women with primary cesarean section compared to spontaneous vaginal delivery, giving a theoretical absolute risk increase (ARI) of 0.03% for stillbirth, and a number needed to harm (NNH) of 3,333 women. Analyses by type of cesarean section showed similarly increased rates for emergency (HR 1.15, 95% CI 1.01, 1.31) and elective cesarean (HR 1.11, 95% CI 0.91, 1.35), although not statistically significant in the latter case. An increased rate of ectopic pregnancy was found among women with primary cesarean overall (HR 1.09, 95% CI 1.04, 1.15) and by type (emergency cesarean, HR 1.09, 95% CI 1.03, 1.15, and elective cesarean, HR 1.12, 95% CI 1.03, 1.21), yielding an ARI of 0.1% and a NNH of 1,000 women for ectopic pregnancy. No increased rate of miscarriage was found among women with primary cesarean, with maternally requested cesarean section associated with a decreased rate of miscarriage (HR 0.72, 95% CI 0.60, 0.85). Limitations include incomplete data on maternal body mass index, maternal smoking, fertility treatment, causes of stillbirth, and maternally requested cesarean section, as well as lack of data on antepartum/intrapartum stillbirth and gestational age for stillbirth and miscarriage. CONCLUSIONS This study found that cesarean section is associated with a small increased rate of subsequent stillbirth and ectopic pregnancy. Underlying medical conditions, however, and confounding by indication for the primary cesarean delivery account for at least part of this increased rate. These findings will assist women and health-care providers to reach more informed decisions regarding mode of delivery. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Sinéad M. O'Neill
- National Perinatal Epidemiology Centre, Anu Research Centre, Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Esben Agerbo
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - Louise C. Kenny
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Tine B. Henriksen
- Perinatal Epidemiology Research Unit, Department of Paediatrics, Aarhus University Hospital, Skejby, Denmark
| | - Patricia M. Kearney
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Richard A. Greene
- National Perinatal Epidemiology Centre, Anu Research Centre, Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Preben Bo Mortensen
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
- Centre for Integrated Register-based Research, Aarhus University, Aarhus, Denmark
| | - Ali S. Khashan
- Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
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Flo K, Widnes C, Vårtun Å, Acharya G. Blood flow to the scarred gravid uterus at 22-24 weeks of gestation. BJOG 2013; 121:210-5. [DOI: 10.1111/1471-0528.12441] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 11/30/2022]
Affiliation(s)
- K Flo
- Women's Health and Perinatology Research Group; Department of Clinical Medicine; Faculty of Health Sciences; University of Tromsø; Tromsø Norway
- Department of Obstetrics and Gynaecology; University Hospital of North Norway; Tromsø Norway
| | - C Widnes
- Women's Health and Perinatology Research Group; Department of Clinical Medicine; Faculty of Health Sciences; University of Tromsø; Tromsø Norway
- Department of Obstetrics and Gynaecology; University Hospital of North Norway; Tromsø Norway
| | - Å Vårtun
- Women's Health and Perinatology Research Group; Department of Clinical Medicine; Faculty of Health Sciences; University of Tromsø; Tromsø Norway
- Department of Obstetrics and Gynaecology; University Hospital of North Norway; Tromsø Norway
| | - G Acharya
- Women's Health and Perinatology Research Group; Department of Clinical Medicine; Faculty of Health Sciences; University of Tromsø; Tromsø Norway
- Department of Obstetrics and Gynaecology; University Hospital of North Norway; Tromsø Norway
- Department of Clinical Sciences, Intervention and Technology; Karolinska Institute; Stockholm Sweden
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Koopmans L, Wilson T, Cacciatore J, Flenady V. Support for mothers, fathers and families after perinatal death. Cochrane Database Syst Rev 2013; 2013:CD000452. [PMID: 23784865 PMCID: PMC7086381 DOI: 10.1002/14651858.cd000452.pub3] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Provision of an empathetic, sensitive, caring environment and strategies to support mothers, fathers and their families experiencing perinatal death are now an accepted part of maternity services in many countries. Interventions such as psychological support or counselling, or both, have been suggested to improve outcomes for parents and families after perinatal death. OBJECTIVES To assess the effect of any form of intervention (i.e. medical, nursing, midwifery, social work, psychology, counselling or community-based) on parents and families who experience perinatal death. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and article bibliographies. SELECTION CRITERIA Randomised trials of any form of support aimed at encouraging acceptance of loss, bereavement counselling, or specialised psychotherapy or counselling for mothers, fathers and families experiencing perinatal death. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility of trials. MAIN RESULTS No trials were included. AUTHORS' CONCLUSIONS Primary healthcare interventions and a strong family and social support network are invaluable to parents and families around the time a baby dies. However, due to the lack of high-quality randomised trials conducted in this area, the true benefits of currently existing interventions aimed at providing support for mothers, fathers and families experiencing perinatal death is unclear. Further, the currently available evidence around the potential detrimental effects of some interventions (e.g. seeing and holding a deceased baby) remains inconclusive at this point in time. However, some well-designed descriptive studies have shown that, under the right circumstances and guided by compassionate, sensitive, experienced staff, parents' experiences of seeing and holding their deceased baby is often very positive. The sensitive nature of this topic and small sample sizes, make it difficult to develop rigorous clinical trials. Hence, other research designs may further inform practice in this area. Where justified, methodologically rigorous trials are needed. However, methodologically rigorous trials should be considered comparing different approaches to support.
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Affiliation(s)
- Laura Koopmans
- MaterMedical Research Institute,MaterHealth Services,Woolloongabba, Australia.
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