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Ata B, Mathyk B, Telek S, Kalafat E. Walking on thin endometrium. Curr Opin Obstet Gynecol 2024; 36:186-191. [PMID: 38572695 DOI: 10.1097/gco.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Endometrial thickness has been regarded a predictor of success in assisted reproductive technology cycles and it seems a common practice to cancel embryo transfer when it is below a cut-off. However, various cut-offs have been proposed without a causal relationship between endometrial thickness and embryo implantation being established, casting doubt on the current dogma. RECENT FINDINGS Methodological limitations of the available studies on endometrial thickness are increasingly recognized and better designed studies do not demonstrate a cut-off value which requires cancelling an embryo transfer. SUMMARY Endometrium is important for implantation and a healthy pregnancy; however, ultrasound measured thickness does not seem to be a good marker of endometrial function.
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Affiliation(s)
- Baris Ata
- ART Fertility Clinics, Dubai, United Arab Emirates
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkiye
| | - Begum Mathyk
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Savci Telek
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Erkan Kalafat
- ART Fertility Clinics, Dubai, United Arab Emirates
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkiye
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Kalafat E, Talay ZG, Demirci O, Ayaz R, Çelik E, Can F. Neutralizing antibody levels and cellular immune response against Omicron variant in pregnant women vaccinated with mRNA and inactivated SARS-CoV-2 vaccines. Ultrasound Obstet Gynecol 2024; 63:699-700. [PMID: 38011582 DOI: 10.1002/uog.27542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/08/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023]
Affiliation(s)
- E Kalafat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Koç University, Istanbul, Turkey
| | - Z Gülçe Talay
- Department of Clinical Microbiology, Faculty of Medicine, Koç University, Istanbul, Turkey
| | - O Demirci
- Department of Obstetrics and Gynecology, Zeynep Kamil Women's and Children's Diseases Training and Research Hospital, Istanbul, Turkey
| | - R Ayaz
- Department of Obstetrics and Gynecology, Faculty of Medicine, Medeniyet University, Istanbul, Turkey
| | - E Çelik
- Department of Obstetrics and Gynecology, Faculty of Medicine, Koç University, Istanbul, Turkey
| | - F Can
- Department of Clinical Microbiology, Faculty of Medicine, Koç University, Istanbul, Turkey
- Koç University İşbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey
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Palmrich P, Kalafat E, Pateisky P, Schirwani-Hartl N, Haberl C, Herrmann C, Khalil A, Binder J. Prognostic value of angiogenic markers in pregnancy with fetal growth restriction. Ultrasound Obstet Gynecol 2024; 63:619-626. [PMID: 37774098 DOI: 10.1002/uog.27509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE Pregnancies with fetal growth restriction (FGR) are at increased risk for pre-eclampsia. Angiogenic markers including soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) are altered in pregnancies complicated by FGR, but their utility for predicting pre-eclampsia in growth-restricted pregnancies is uncertain. This study aimed to evaluate the prognostic value of angiogenic markers for predicting the development of pre-eclampsia in pregnancies with FGR and suspected pre-eclampsia. METHODS This was a retrospective study of singleton pregnancies with FGR, defined according to Delphi consensus criteria, which underwent sampling of sFlt-1 and PlGF for suspicion of pre-eclampsia at the Medical University of Vienna, Vienna, Austria, between 2013 and 2020. Women with an established diagnosis of pre-eclampsia at sampling were excluded. Cox regression analysis and logistic regression analysis were performed to evaluate the association of angiogenic markers with the development of pre-eclampsia at various timepoints. RESULTS In this cohort of 93 women, pre-eclampsia was diagnosed in 14 (15.1%) women within 1 week after sampling, 21 (22.6%) within 2 weeks after sampling and 38 (40.9%) at any time after assessment. The sFlt-1/PlGF ratio consistently showed a stronger association with the development of pre-eclampsia compared to sFlt-1 or PlGF alone (pre-eclampsia within 1 week: area under the receiver-operating-characteristics curve, 0.87 vs 0.82 vs 0.72). Models including the sFlt-1/PlGF ratio were associated more strongly with pre-eclampsia hazard compared to models including sFlt-1 or PlGF alone (concordance index, 0.790 vs 0.759 vs 0.755). The risk classification capability of the sFlt-1/PlGF ratio decreased after the 2-week timepoint. The established cut-off value for the sFlt-1/PlGF ratio of < 38 was effective for ruling out pre-eclampsia within 2 weeks, with a negative predictive value of 0.933 and sensitivity of 0.952. CONCLUSIONS Use of the sFlt-1/PlGF ratio is preferrable to the use of PlGF alone for the prediction of pre-eclampsia in pregnancies with FGR. Established cut-offs for ruling out the development of pre-eclampsia in the short term seem to be effective in these patients. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- P Palmrich
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
| | - P Pateisky
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - N Schirwani-Hartl
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - C Haberl
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - C Herrmann
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - J Binder
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
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Martínez-Varea A, Prasad S, Domenech J, Kalafat E, Morales-Roselló J, Khalil A. Association of fetal growth restriction and stillbirth in twin compared with singleton pregnancies. Ultrasound Obstet Gynecol 2024. [PMID: 38642338 DOI: 10.1002/uog.27661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 03/02/2024] [Accepted: 03/18/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVE Twin pregnancies are at an increased risk of stillbirth compared to singletons. Fetal growth restriction (FGR) is a leading cause of perinatal mortality and morbidity, in both singleton and multiple pregnancies. Whether the contribution of FGR to stillbirth in twin pregnancies differs from that in singletons is yet to be determined. The main aim of this study was to determine the association between FGR and stillbirth in twin compared to singleton pregnancies. The secondary objectives include an assessment of the contribution of FGR to stillbirths, stratified by gestational age at delivery. Furthermore, we aimed to compare the association between FGR and stillbirth in twin pregnancies using the twin-specific versus singleton birthweight charts, stratified by chorionicity. METHODS This was a cross-sectional study including pregnancies receiving obstetric care and birth at St George's Hospital, London. The exclusion criteria included triplet and higher order pregnancies, those resulting in miscarriage or livebirths at or prior to 23+6 weeks, or had a termination of pregnancy, or with missing data on the gestational age at birth. FGR and small for gestational age (SGA) were defined as birthweight <5th and <10th centile, respectively. While standard logistic regression was used for singleton pregnancies, the association of FGR and SGA designation with stillbirth in twin pregnancies was investigated with mixed-effects logistic regression models. For twin pregnancies, intercepts were allowed to vary for twin pairs to account for inter-twin dependency. Analyses were stratified by gestational age at delivery and chorionicity. RESULTS The study included 95,342 singleton and 3,576 twin pregnancies. There were 494 (0.52%) stillbirths in singleton and 41 (1.15%) stillbirths in twin pregnancies (17 dichorionic and 24 monochorionic). FGR and SGA were significantly associated with stillbirth in singleton pregnancies, across all gestational ages at delivery (before 32 weeks- SGA: OR 2.36; 95% CI 1.78-3.13, p<0.001 and FGR: OR 2.67; 95% CI 2.02- 3.55, p<0.001; between 32-36 weeks- SGA: OR 2.70; 95% CI 1.71-4.31, p<0.001 and FGR: OR 2.82; 95% CI 1.78- 4.47, p<0.001; above 36 weeks- SGA: OR 3.85; 95% CI 2.83 - 5.21, p<0.001 and FGR: OR 4.43; 95% CI 3.16 - 6.12, p<0.001) A greater proportion of fetuses from twin pregnancies were diagnosed as SGA and FGR when singleton compared to the twin-specific chart was used (48.43% vs. 9.12%, and 36.73% vs. 6.23%, respectively). When stratified by gestational age at delivery, both SGA and FGR determined by the twin-specific charts were associated with significantly increased odds of having a stillbirth for those delivered before 32 weeks (SGA: OR 3.87; 95% CI 1.56-9.50, p=0.003 and FGR: OR 5.26; 95% CI 2.11-13.01, p<0.001), those delivered between 32-36 weeks (SGA: OR 6.67; 95% CI 2.11-20.41, p=0.001 and FGR: OR 9.54; 95% CI 3.01-29.40, p<0.001) and those delivered beyond 36 weeks (SGA: OR 12.68 95% CI 2.47-58,15, p=0.001 and FGR: OR 23.84; 95% CI 4.62-110.25, p<0.001), whereas the association of stillbirth with either SGA or FGR was inconsistent when analysed using singleton charts (before 32 weeks- SGA: p=0.014 and FGR: p=0.005; between 32-36 weeks- SGA: p=0.036 and FGR: p=0.008; above 36 weeks- SGA: p=0.080 and FGR: p=0.063). For dichorionic twins delivered before 32 weeks, the odds of an SGA or FGR fetus having a stillbirth was increased when analysed using twin-specific charts. In contrast, monochorionic twins delivered before 32 weeks showed lower and non-significant associations with stillbirth for both SGA and FGR cases using either twin-specific or singleton charts. In dichorionic twin pregnancies delivered between 32-36 weeks, the OR for stillbirth of SGA using twin birthweight chart was 6.70 (95% CI 0.80-56.46, p=0.059), and using singleton chart was 0.92 (95% CI 0.11-7.71, p=0.934) and statistically non-significant. Similarly, the OR for stillbirth of FGR using twin birthweight chart and singleton chart was 9.59 (95% CI 1.14-81.06, p=0.025), and 1.40 (95% CI 0.17-11.76, p=0.735), respectively. On the other hand, in monochorionic twin pregnancies delivered between 32-36 weeks, the OR for stillbirth of SGA and FGR using twin birthweight chart was 9.37 (95% CI 2.20- 37.72, p=0.001), and 13.55 (95% CI 3.12 - 55.94 p < 0.001) respectively. CONCLUSIONS Our study demonstrates a significant association between SGA, particularly for FGR, with increased odds of stillbirths in singleton pregnancies across all gestational ages. For twin pregnancies, when twin-specific charts were used, SGA and in particular FGR were associated with a significantly increased risk of stillbirth, across all gestational ages at delivery. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- A Martínez-Varea
- Department of Obstetrics and Gynaecology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - S Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J Domenech
- Department of Economics and Social Sciences, Universitat Politecnica de Valencia, Valencia, Spain
| | - E Kalafat
- Department of Obstetrics and Gynecology, Koc University Hospital, Istanbul, Turkey
| | - J Morales-Roselló
- Department of Obstetrics and Gynaecology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Twin and Multiple Pregnancy Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, Liverpool, UK
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Yaghi O, Prasad S, Boorman H, Kalafat E, Khalil A. Is micronized vaginal progesterone effective for the prevention of preeclampsia in twin pregnancies? Am J Obstet Gynecol 2024:S0002-9378(24)00519-2. [PMID: 38621482 DOI: 10.1016/j.ajog.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/12/2024] [Accepted: 04/03/2024] [Indexed: 04/17/2024]
Affiliation(s)
- Odai Yaghi
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, St. George's University Hospital, University of London, London, England, UK
| | - Smriti Prasad
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, St. George's University Hospital, University of London, London, England, UK
| | - Holly Boorman
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, St. George's University Hospital, University of London, London, England, UK
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University Hospital, Istanbul, Turkey
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, St. George's University Hospital, University of London, London, England, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom; Twin and Multiple Pregnancy Centre for Research and Clinical Excellence, St George's University Hospital, St George's University of London, London, UK; Fetal Medicine Unit, Liverpool Women's Hospital, Liverpool, United Kingdom.
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Lawrenz B, Kalafat E, Ata B, Del Gallego R, Melado L, Elkhatib I, Fatemi H. The combination of dydrogesterone and micronized vaginal progesterone can render serum progesterone level measurements on the day of embryo transfer and rescue attempts unnecessary in an HRT FET cycle. J Assist Reprod Genet 2024; 41:885-892. [PMID: 38372882 PMCID: PMC11052972 DOI: 10.1007/s10815-024-03049-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/30/2024] [Indexed: 02/20/2024] Open
Abstract
PURPOSE To evaluate the role of serum progesterone (P4) on the day of embryo transfer (ET) when dydrogesterone (DYD) and micronized vaginal progesterone (MVP) are combined as luteal phase support (LPS) in a hormone replacement therapy (HRT) frozen ET (FET) cycles. METHODS Retrospective study, including single euploid HRT FET cycles with DYD and MVP as LPS and P4 measurement on ET day. Initially, patients with P4 levels < 10 ng/ml increased MVP to 400 mg/day; this "rescue" was abandoned later. RESULTS 560 cycles of 507 couples were included. In 275 women, serum P4 level was < 10 ng/ml on the ET day. Among those with low P4 levels, MVP dose remained unchanged in 65 women (11.6%) and was increased in 210 women (37.5%). Women with P4 levels ≥ 10 ng/ml continued LPS without modification. Overall pregnancy rates in these groups were 61.5% (40/65), 54.8% (115/210), and 48.4% (138/285), respectively (p = n.s.). Association of serum P4 levels with ongoing pregnancy rates was analyzed in women without any additional MVP regardless of serum P4 levels (n = 350); multivariable analysis (adjusted for age, BMI, embryo quality (EQ)) did not show a significant association of serum P4 levels with OPR (OR 0.96, 95% CI 0.90-1.02; p = 0.185). Using inverse probability treatment weights, regression analysis in the weighted sample showed no significant association between P4 treatment groups and OP. Compared to fair EQ, the transfer of good EQ increased (OR 1.61, 95% CI 1.22-2.15; p = 0.001) and the transfer of a poor EQ decreased the odds of OP (OR 0.73, 95% CI 0.55-0.97; p = 0.029). CONCLUSION In HRT FET cycle, using LPS with 300 mg/day MVP and 30 mg/day DYD, it appears that serum P4 measurement and increase of MVP in patients with P4 < 10 ng/ml are not necessary.
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Affiliation(s)
- B Lawrenz
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE.
- Department of Reproductive Medicine, UZ Gent, Gent, Belgium.
| | - E Kalafat
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
- Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
| | - B Ata
- Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
- ART Fertility Clinic, Jumeirah St-Umm Suqeim-Umm Suqeim 3, Dubai, UAE
| | - R Del Gallego
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
| | - L Melado
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
| | - I Elkhatib
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
- School of Biosciences, University of Kent, Canterbury, UK
| | - H Fatemi
- ART Fertility Clinic, Royal Marina Village, B22-23, POB: 60202, Abu Dhabi, UAE
- ART Fertility Clinic, Jumeirah St-Umm Suqeim-Umm Suqeim 3, Dubai, UAE
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Del Gallego R, Lawrenz B, Ata B, Kalafat E, Melado L, Elkhatib I, Fatemi H. Association of 'normal' early follicular FSH concentrations with unexpected poor or suboptimal response when ovarian reserve markers are reassuring: a retrospective cohort study. Reprod Biomed Online 2024; 48:103701. [PMID: 38309124 DOI: 10.1016/j.rbmo.2023.103701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/06/2023] [Accepted: 11/06/2023] [Indexed: 02/05/2024]
Abstract
RESEARCH QUESTION Are basal FSH measurements, when elevated within its normal range, useful for assessing overall ovarian response and predicting unexpected poor or suboptimal ovarian response? DESIGN Retrospective cohort study of ovarian stimulation cycles. RESULTS A total of 1058 ovarian stimulation cycles (891 first, 167 repeated) were included. Anti-Müllerian hormone (AMH) values were categorized into four (0 to ≤0.6, >0.6 to ≤1.2, >1.2 to ≤3.0, >3.0 to ≤6.25 ng/ml) and basal FSH levels into four groups (<25th percentile: >3.5 to 6.1 IU/ml; 25-75th percentile: >6.1 to ≤8.5 IU/ml; >75-90th percentile: >8.5 to ≤9.9 IU/ml; >90th percentile: >9.9 to ≤12.5 IU/ml). Including only first cycles, a significant independent effect of basal FSH on retrieved cumulus-oocyte complex (COC) count was seen for all basal FSH categories (>90th, >75 to ≤90th, >25 to ≤75th compared with ≤25th percentile, P < 0.001, P = 0.001 and P = 0.007, respectively), when adjusted for age, body mass index (BMI), AMH, antral follicle count (AFC), starting dose and gonadotrophin type. Including only first cycles, patients aged 35 years or older with AFC of 5 or above and AMH 1.2 ng/ml or above, showed significantly higher odds of unexpected poor or suboptimal response if they had higher basal FSH values. Most prominently in the above 90th percentile group (OR 8.64, 95% CI 2.84 to 28.47 compared with <25th percentile) but lower categories (>25th to ≤75th percentile: OR 3.04, 95% CI 1.42 t 6.99; >75th to ≤90th percentile: OR 3.47, 95% CI 1.28 to 9.83 compared with ≤25th percentile) also showed a significant association after adjusting for age, AMH, BMI, AFC, dose, and gonadotrophin type. In patients with a second cycle, an increase in FSH levels in the second round compared with the first was associated with fewer retrieved COCs (estimate: -0.44, 95% CI -0.44 to -0.05, P = 0.027). This effect was adjusted for changes in age, FSH, AFC, starting dose, stimulation duration and change in medication type. CONCLUSIONS Basal FSH is independently associated with overall ovarian response. Moreover, it is associated with unexpected poor or suboptimal response in patients, who would fulfill POSEIDON group 2 criteria after oocyte retrieval.
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Affiliation(s)
| | - Barbara Lawrenz
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE; Department of Reproductive Medicine UZ Ghent, Belgium.
| | - Baris Ata
- ART Fertility Clinic, Jumeirah St - Umm Suqeim - Umm Suqeim 3 - Dubai, UAE; Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
| | - Erkan Kalafat
- ART Fertility Clinic, Jumeirah St - Umm Suqeim - Umm Suqeim 3 - Dubai, UAE; Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
| | - Laura Melado
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE
| | - Ibrahim Elkhatib
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE; School of Biosciences, University of Kent, Canterbury, UK
| | - Human Fatemi
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE; ART Fertility Clinic, Jumeirah St - Umm Suqeim - Umm Suqeim 3 - Dubai, UAE
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Barros FC, Gunier RB, Rego A, Sentilhes L, Rauch S, Gandino S, Teji JS, Thornton JG, Kachikis AB, Nieto R, Craik R, Cavoretto PI, Winsey A, Roggero P, Rodriguez GB, Savasi V, Kalafat E, Giuliani F, Fabre M, Benski AC, Coronado-Zarco IA, Livio S, Ostrovska A, Maiz N, Castedo Camacho FR, Peterson A, Deruelle P, Giudice C, Casale RA, Salomon LJ, Soto Conti CP, Prefumo F, Mohamed Elbayoumy EZ, Vale M, Hernández V, Chandler K, Risso M, Marler E, Cáceres DM, Crespo GA, Ernawati E, Lipschuetz M, Ariff S, Takahashi K, Vecchiarelli C, Hubka T, Ikenoue S, Tavchioska G, Bako B, Ayede AI, Eskenazi B, Bhutta ZA, Kennedy SH, Papageorghiou AT, Villar J. Maternal vaccination against COVID-19 and neonatal outcomes during Omicron: INTERCOVID-2022 study. Am J Obstet Gynecol 2024:S0002-9378(24)00078-4. [PMID: 38367758 DOI: 10.1016/j.ajog.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND In early 2023, when Omicron was the variant of concern, we showed that vaccinating pregnant women decreased the risk for severe COVID-19-related complications and maternal morbidity and mortality. OBJECTIVE This study aimed to analyze the impact of COVID-19 during pregnancy on newborns and the effects of maternal COVID-19 vaccination on neonatal outcomes when Omicron was the variant of concern. STUDY DESIGN INTERCOVID-2022 was a large, prospective, observational study, conducted in 40 hospitals across 18 countries, from November 27, 2021 (the day after the World Health Organization declared Omicron the variant of concern) to June 30, 2022, to assess the effect of COVID-19 in pregnancy on maternal and neonatal outcomes and to assess vaccine effectiveness. Women diagnosed with laboratory-confirmed COVID-19 during pregnancy were compared with 2 nondiagnosed, unmatched women recruited concomitantly and consecutively during pregnancy or at delivery. Mother-newborn dyads were followed until hospital discharge. The primary outcomes were a neonatal positive test for COVID-19, severe neonatal morbidity index, severe perinatal morbidity and mortality index, preterm birth, neonatal death, referral to neonatal intensive care unit, and diseases during the neonatal period. Vaccine effectiveness was estimated with adjustment for maternal risk profile. RESULTS We enrolled 4707 neonates born to 1577 (33.5%) mothers diagnosed with COVID-19 and 3130 (66.5%) nondiagnosed mothers. Among the diagnosed mothers, 642 (40.7%) were not vaccinated, 147 (9.3%) were partially vaccinated, 551 (34.9%) were completely vaccinated, and 237 (15.0%) also had a booster vaccine. Neonates of booster-vaccinated mothers had less than half (relative risk, 0.46; 95% confidence interval, 0.23-0.91) the risk of being diagnosed with COVID-19 when compared with those of unvaccinated mothers; they also had the lowest rates of preterm birth, medically indicated preterm birth, respiratory distress syndrome, and number of days in the neonatal intensive care unit. Newborns of unvaccinated mothers had double the risk for neonatal death (relative risk, 2.06; 95% confidence interval, 1.06-4.00) when compared with those of nondiagnosed mothers. Vaccination was not associated with any congenital malformations. Although all vaccines provided protection against neonatal test positivity, newborns of booster-vaccinated mothers had the highest vaccine effectiveness (64%; 95% confidence interval, 10%-86%). Vaccine effectiveness was not as high for messenger RNA vaccines only. Vaccine effectiveness against moderate or severe neonatal outcomes was much lower, namely 13% in the booster-vaccinated group (all vaccines) and 25% and 28% in the completely and booster-vaccinated groups, respectively (messenger RNA vaccines only). Vaccines were fairly effective in protecting neonates when given to pregnant women ≤100 days (14 weeks) before birth; thereafter, the risk increased and was much higher after 200 days (29 weeks). Finally, none of the neonatal practices studied, including skin-to-skin contact and direct breastfeeding, increased the risk for infecting newborns. CONCLUSION When Omicron was the variant of concern, newborns of unvaccinated mothers had an increased risk for neonatal death. Neonates of vaccinated mothers had a decreased risk for preterm birth and adverse neonatal outcomes. Because the protective effect of COVID-19 vaccination decreases with time, to ensure that newborns are maximally protected against COVID-19, mothers should receive a vaccine or booster dose no more than 14 weeks before the expected date of delivery.
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Affiliation(s)
- Fernando C Barros
- Post Graduate Program in Health in the Life Cycle, Universidade Católica de Pelotas, Pelotas, Brazil
| | - Robert B Gunier
- School of Public Health, University of California, Berkeley, CA
| | - Albertina Rego
- Departamento de Pediatria, Faculdade Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Stephen Rauch
- School of Public Health, University of California, Berkeley, CA
| | - Serena Gandino
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom; Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Jagjit S Teji
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jim G Thornton
- University of Nottingham Medical School, Nottingham, United Kingdom
| | - Alisa B Kachikis
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Ricardo Nieto
- Division Neonatología, Hospital Materno Infantil Ramón Sarda, Buenos Aires, Argentina
| | - Rachel Craik
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Paolo I Cavoretto
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Hospital and University, Milan, Italy
| | - Adele Winsey
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Paola Roggero
- Department of Woman, Child and Neonate, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriel B Rodriguez
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Valeria Savasi
- Unit of Obstetrics and Gynecology, L- Sacco Hospital ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biological and Clinical Sciences, University of Milan, Milan, Italy
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University Hospital, Istanbul, Turkey
| | - Francesca Giuliani
- Neonatal Special Care Unit, Regina Margherita Children's Hospital, Turin, Italy
| | - Marta Fabre
- Instituto de Investigación Sanitario de Aragón (IIS Aragon), Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | | | | | - Stefania Livio
- Hospital Buzzi, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Adela Ostrovska
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Nerea Maiz
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron, Barcelona Hospital Campus, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | | | - Philippe Deruelle
- Department of Obstetrics and Gynecology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Carolina Giudice
- Servicio de Neonatologia, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Roberto A Casale
- Maternal and Child Department, Hospital Nacional Profesor Alejandro Posadas, Buenos Aires, Argentina
| | | | | | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Marynéa Vale
- Hospital Universitário da Universidade Federal do Maranhão, São Luís, Brazil
| | | | | | - Milagros Risso
- Servicio de Neonatología del Departamento Materno Infantil, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Emily Marler
- St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | | | | | - Ernawati Ernawati
- Medical Faculty Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Michal Lipschuetz
- Obstetrics and Gynecology Division, Hadassah Medical Center Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shabina Ariff
- Department of Paediatrics & Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Ken Takahashi
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | | | - Teresa Hubka
- AMITA Health Resurrection Medical Center, Chicago, IL
| | - Satoru Ikenoue
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | | | - Babagana Bako
- Department of Obstetrics and Gynaecology, College of Medical Sciences, Gombe State University, Gombe, Nigeria
| | | | - Brenda Eskenazi
- School of Public Health, University of California, Berkeley, CA
| | - Zulfiqar A Bhutta
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Stephen H Kennedy
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom; Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Aris T Papageorghiou
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom; Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom; St George's University Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Jose Villar
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom; Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
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Lawrenz B, Kalafat E, Ata B, Melado L, Del Gallego R, Elkhatib I, Fatemi H. Do women with severely diminished ovarian reserve undergoing modified natural cycles benefit from earlier trigger at smaller follicle size? Ultrasound Obstet Gynecol 2024. [PMID: 38348612 DOI: 10.1002/uog.27611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE Would trigger and oocyte collection at smaller follicle sizes decrease the risk of premature ovulation while maintaining the reproductive potential of oocytes in women with severely diminished ovarian reserve in modified natural cycle IVF? METHODS Retrospective cohort study including women who had at least one unsuccessful cycle (due to no response) of conventional ovarian stimulation with a high dosage of gonadotropins and subsequently underwent a modified natural cycle with a solitary growing follicle (i.e., only one follicle above >10mm at the time of trigger). The association between follicle size at trigger and various cycle outcomes was tested with regression analyses. RESULTS A total of 160 cycles from 110 patients were included in the analysis. Oocyte pick-up (OPU) was performed in 153 cycles, 7 cycles were canceled due to premature ovulation. Patients who received their trigger shot at smaller follicle sizes (≤15mm) had significantly lower premature ovulation and thus higher OPU rates (98.3% vs. 94.0%, adjusted OR: 8.55, 95% CI: 1.30 - 172.2, P=0.048) compared to those who received it at larger follicle sizes (>15mm). In the multivariable analyses, smaller follicle sizes at trigger (>10 to ≤13mm, >13 to ≤15mm, >15mm to ≤17mm) were not significantly associated with a lower rate of cumulus-oocyte-complex (COC), metaphase II oocytes (MIIs), or blastulation compared to the >17mm group. In sensitivity analyses including the first cycle of each couple, the maturity rate among those with a COC retrieval was highest in follicle sizes >15 to ≤17mm (92.3%) and >13 to ≤15mm (91.7%), followed by >10 to ≤13mm (85.7%) and lowest in the >17mm group (58.8%). Five euploid blastocysts developed from 48 fertilized MIIs during the study period with follicle sizes at trigger 12mm (3), 14 mm (1), and 16mm (1). Four were transferred resulting in two live births, both developing from follicles with a size at trigger of 12mm. CONCLUSION The ideal follicle size for triggering oocyte maturation may be smaller in women with severely diminished ovarian reserve managed on a modified natural cycle compared to conventional cut-offs. The risk of OPU cancellation was higher in women triggered above 15 mm, and the yield of mature oocytes was not adversely affected in women triggered at >13 to ≤15mm compared to >15mm to ≤17mm. Waiting for follicles to reach sizes above 17mm may be detrimental to achieving optimal outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- B Lawrenz
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE
- Department of Reproductive Medicine, UZ Ghent, Ghent, Belgium
| | - E Kalafat
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE
- Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
| | - B Ata
- ART Fertility Clinic, Jumeirah St - Umm Suqeim - Umm Suqeim 3, Dubai, UAE
- Faculty of Medicine, Department of Obstetrics & Gynecology, Koc University, Istanbul, Turkey
| | - L Melado
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE
| | - R Del Gallego
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE
| | - I Elkhatib
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE
- School of Biosciences, University of Kent, Canterbury, UK
| | - H Fatemi
- ART Fertility Clinic, Royal Marina Village, B22-23, Abu Dhabi, UAE
- ART Fertility Clinic, Jumeirah St - Umm Suqeim - Umm Suqeim 3, Dubai, UAE
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Ata B, Kalafat E. Response to: Cumulative live birth rate following progestin-primed ovarian stimulation: controversial results with own and donated oocytes. Reprod Biomed Online 2024:103860. [PMID: 38365564 DOI: 10.1016/j.rbmo.2024.103860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Baris Ata
- ART Fertility Clinics, Dubai, United Arab Emirates; Dept. of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkiye.
| | - Erkan Kalafat
- ART Fertility Clinics, Dubai, United Arab Emirates; Dept. of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkiye
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Ata B, Kalafat E. Progestin-primed ovarian stimulation: for whom, when and how? Reprod Biomed Online 2024; 48:103639. [PMID: 38159467 DOI: 10.1016/j.rbmo.2023.103639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/10/2023] [Accepted: 10/18/2023] [Indexed: 01/03/2024]
Abstract
Progestin-primed ovarian stimulation (PPOS) is being increasingly used for ovarian stimulation in assisted reproductive technology. Different progestins have been used with similar success. The available studies suggest a similar response to ovarian stimulation with gonadotrophin-releasing hormone (GnRH) analogues. Any differences in the duration of stimulation or gonadotrophin consumption are minor and clinically insignificant. PPOS has the advantage of oral administration and lower medication costs than GnRH analogues. As such it is clearly more cost-effective for fertility preservation and planned freeze-all cycles, but when fresh embryo transfer is intended PPOS can be less cost-effective depending on the local direct and indirect costs of the additional initial frozen embryo transfer cycle. Oocytes collected in PPOS cycles have similar developmental potential, including blastocyst euploidy rates. Frozen embryo transfer outcomes of PPOS and GnRH analogue cycles seem to be similar in terms of both ongoing pregnancy/live birth rates and obstetric and perinatal outcomes. While some studies have reported lower cumulative live birth rates with PPOS, they have methodological issues, including arbitrary definitions of the cumulative live birth rate. PPOS has been used in all patient types (except progesterone receptor-positive breast cancer patients) with consistent results and seems a patient friendly and cost-effective choice if a fresh embryo transfer is not intended.
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Affiliation(s)
- Baris Ata
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey; ART Fertility Clinics, Dubai, United Arab Emirates.
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey; ART Fertility Clinics, Dubai, United Arab Emirates
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Ata B, Cakar A, Türkgeldi E, Yildiz S, Keles İ, Kalafat E. Should the trigger to oocyte retrieval interval be different in progestin-primed ovarian stimulation cycles? Reprod Biomed Online 2024; 48:103626. [PMID: 38160486 DOI: 10.1016/j.rbmo.2023.103626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 01/03/2024]
Abstract
RESEARCH QUESTION Does the trigger to oocyte retrieval interval (TORI) affect oocyte maturation rates differently in progestin-primed ovarian stimulation (PPOS) and gonadotrophin-releasing hormone (GnRH) antagonist cycles? DESIGN This was a retrospective cohort study. The interaction between the stimulation protocol and TORI was assessed in a linear mixed effects multivariable regression analysis with oocyte maturation rate as the dependent variable, and stimulation protocol (GnRH antagonist or PPOS), age (continuous), gonadotrophin type (FSH or human menopausal gonadotrophin), trigger (human chorionic gonadotrophin [HCG] or GnRH agonist), TORI (continuous) and days of stimulation (continuous) as the independent variables. Oocyte maturation rate was defined as number of metaphase II oocytes/number of cumulus-oocyte complexes retrieved. The maturation rate was calculated per cycle and treated as a continuous variable. RESULTS A total of 473 GnRH antagonist and 205 PPOS cycles (121 conventional PPOS and 84 flexible PPOS) were analysed. The median (quartiles) female age was 36 (32-40) years. Of these cycles, 493 were triggered with HCG and 185 with a GnRH agonist. The TORI ranged between 33.6 and 39.1 h, with a median (quartiles) of 36.2 (36-36.4) hours. Maturation rates were similar between fixed PPOS, flexible PPOS and antagonist cycles (median 80%, 75% and 75%, respectively, P = 0.15). There was no significant interaction between the stimulation protocols and TORI for oocyte maturation. CONCLUSIONS PPOS cycles do not seem to require a longer TORI than GnRH antagonist cycles.
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Affiliation(s)
- Baris Ata
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey; ART Fertility Clinics, Dubai, United Arab Emirates; Assisted Reproduction Unit, Koc University Hospital, Istanbul, Turkey.
| | - Aysu Cakar
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
| | - Engin Türkgeldi
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey; Assisted Reproduction Unit, Koc University Hospital, Istanbul, Turkey
| | - Sule Yildiz
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey; Assisted Reproduction Unit, Koc University Hospital, Istanbul, Turkey
| | - İpek Keles
- Assisted Reproduction Unit, Koc University Hospital, Istanbul, Turkey
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey; ART Fertility Clinics, Dubai, United Arab Emirates; Assisted Reproduction Unit, Koc University Hospital, Istanbul, Turkey
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Kalafat E, Liu B, Barratt I, Bhate R, Papageorghiou A, Khalil A. Risk factors associated with stillbirth and adverse perinatal outcomes in dichorionic twin pregnancies complicated by selective fetal growth restriction: a cohort study. BJOG 2024; 131:189-198. [PMID: 37308720 DOI: 10.1111/1471-0528.17564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 03/18/2023] [Accepted: 05/18/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The main aim of this study was to investigate the perinatal outcomes of dichorionic twin pregnancies complicated by selective fetal growth restriction (sFGR). DESIGN Retrospective cohort study. SETTING Tertiary reference centre. POPULATION Dichorionic twin pregnancies complicated by sFGR between 2000 and 2019 in St George's University Hospital. METHODS Regression analyses were performed using generalised linear models and mixed-effects generalised linear models where appropriate to account for pregnancy level dependency in variables. Time to event analyses were performed with mixed-effects Cox regression models. MAIN OUTCOME MEASURES Stillbirth, neonatal death or neonatal unit admission with morbidity in one or both twins. RESULTS A total of 102 (of 2431 dichorionic twin pregnancies) pregnancies complicated by sFGR were included in the study. The Cochrane-Armitage test revealed a significant trend for increased adverse perinatal outcome rates with more severe forms of umbilical artery flow impedance, i.e. reversed, absent, positive with resistant flow and positive flow without resistance. A multivariable model including maternal and conception characteristics had poor predictive accuracy for stillbirth (area under the curve: 0.68, 95% confidence interval [CI] 0.55-0.81) and composite adverse perinatal outcomes (area under the curve: 0.58, 95% CI 0.47-0.70). When umbilical artery Doppler parameters were added to the models, the area under the curve values improved to 0.95 (95% CI 0.89-0.99) and 0.83 (95% CI 0.73-0.92) for stillbirth and composite adverse perinatal outcomes, respectively. CONCLUSION In dichorionic twin pregnancies complicated by sFGR, the umbilical artery Z-scores were associated with both intrauterine death and adverse perinatal outcomes.
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Affiliation(s)
- Erkan Kalafat
- Department of Obstetrics and Gynaecology, School of Medicine, Koc University, Istanbul, Turkey
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
| | - Becky Liu
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
| | - Imogen Barratt
- Fetal Medicine Unit, St George's University Hospitals, London, UK
| | - Rohan Bhate
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
| | | | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals, London, UK
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Binder J, Palmrich P, Kalafat E, Haberl C, Schirwani N, Pateisky P, Khalil A. Longitudinal assessment of angiogenic markers in prediction of adverse outcome in women with confirmed pre-eclampsia. Ultrasound Obstet Gynecol 2023; 62:843-851. [PMID: 37265117 DOI: 10.1002/uog.26276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Angiogenic marker assessment, such as the ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF), is known to be a useful tool in the prediction of pre-eclampsia (PE). However, evidence from surveillance strategies in pregnancies with a PE diagnosis is lacking. Therefore, we aimed to assess the predictive performance of longitudinal maternal serum angiogenic marker assessment for both maternal and perinatal adverse outcomes when compared to standard laboratory parameters in pregnancies with confirmed PE. METHODS This was a retrospective analysis of prospectively collected data from January 2013 to December 2020 at the Medical University of Vienna. The inclusion criteria were singleton pregnancy with confirmed PE and post-diagnosis maternal serum angiogenic marker assessment at a minimum of two timepoints. The primary outcome was the predictive performance of longitudinal sFlt-1 and PlGF assessment for adverse maternal and perinatal outcomes compared to conventional laboratory monitoring at the same time in pregnancies with confirmed PE. Composite adverse maternal outcome included intensive care unit admission, pulmonary edema, eclampsia and/or death. Composite adverse perinatal outcome included stillbirth, neonatal death, placental abruption, neonatal intensive care unit admission, intraventricular hemorrhage, necrotizing enterocolitis, respiratory distress syndrome and/or mechanical ventilator support. RESULTS In total, 885 post-diagnosis sFlt-1/PlGF ratio measurements were obtained from 323 pregnant women with confirmed PE. For composite adverse maternal outcome, the highest standalone predictive accuracy was obtained using maternal serum sFlt-1/PlGF ratio (area under the receiver-operating-characteristics curve (AUC), 0.72 (95% CI, 0.62-0.81)), creatinine (AUC, 0.71 (95% CI, 0.62-0.81)) and lactate dehydrogenase (LDH) levels (AUC, 0.73 (95% CI, 0.65-0.81)). Maternal platelet levels (AUC, 0.65 (95% CI, 0.55-0.74)), serum alanine aminotransferase (ALT) (AUC, 0.59 (95% CI, 0.49-0.69)) and aspartate aminotransferase (AST) (AUC, 0.61 (95% CI, 0.51-0.71) levels had poor standalone predictive accuracy. The best prediction model consisted of a combination of maternal serum LDH, creatinine levels and sFlt-1/PlGF ratio, which had an AUC of 0.77 (95% CI, 0.68-0.85), significantly higher than sFlt-1/PlGF ratio alone (P = 0.037). For composite adverse perinatal outcome, the highest standalone predictive accuracy was obtained using maternal serum sFlt-1/PlGF ratio (AUC, 0.82 (95% CI, 0.75-0.89)) and creatinine (AUC, 0.74 (95% CI, 0.67-0.80)) levels, sFlt-1/PlGF ratio being superior to creatinine alone (P < 0.001). Maternal serum LDH levels (AUC, 0.65 (95% CI, 0.53-0.74)), platelet count (AUC, 0.57 (95% CI, 0.44-0.67)), ALT (AUC, 0.58 (95% CI, 0.48-0.67)) and AST (AUC, 0.58 (95% CI, 0.48-0.67)) levels had poor standalone predictive accuracy. No combination of biomarkers was superior to maternal serum sFlt-1/PlGF ratio alone for prediction of composite adverse perinatal outcome (P > 0.05 for all). CONCLUSIONS In pregnancies with confirmed PE, longitudinal maternal serum angiogenic marker assessment is a good predictor of adverse maternal and perinatal outcomes and superior to some conventional laboratory parameters. Further studies should focus on optimal surveillance following diagnosis of PE. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Binder
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Palmrich
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
| | - C Haberl
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - N Schirwani
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Pateisky
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Horgan R, Sinkovskaya E, Saade G, Kalafat E, Rice MM, Heeze A, Abuhamad A. Longitudinal assessment of spiral and uterine arteries in normal pregnancy using novel ultrasound tool. Ultrasound Obstet Gynecol 2023; 62:860-866. [PMID: 37470712 PMCID: PMC10801897 DOI: 10.1002/uog.26312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/09/2023] [Accepted: 06/22/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVES To use superb microvascular imaging (SMI) to evaluate longitudinally spiral artery (SA) and uterine artery (UtA) vascular adaptation in normal human pregnancy, and to develop reference ranges for use at various gestational ages throughout pregnancy. METHODS The data for this study were obtained from the National Institutes of Health (NIH)-funded Human Placenta Project. Women aged 18-35 years, with a body mass index < 30 kg/m2 , without comorbidities, with a singleton gestation conceived spontaneously, and gestational age at or less than 13 + 6 weeks were eligible for inclusion. The current analysis was restricted to uncomplicated pregnancies carried to term. Exclusion criteria included maternal or neonatal complications, fetal or umbilical cord anomalies, abnormal placental implantation or delivery < 37 weeks. Women who fulfilled the inclusion criteria formed the reference population of the Human Placenta Project study. Each participant underwent eight ultrasound examinations during pregnancy. The pulsatility index (PI) of both the left and right UtA were obtained twice for each artery and the presence or absence of a notch was noted. Using SMI technology, the total number of SA imaged was recorded in a sagittal placental section at the level of cord insertion. The PI and peak systolic velocity (PSV) were also measured in a total of six SA, including two in the central portion of the placenta, two peripherally towards the uterine fundal portion, and two peripherally towards the lower uterine segment. RESULTS A total of 90 women fulfilled the study criteria. Maternal UtA-PI decreased throughout the first half of pregnancy from a mean ± SD of 1.39 ± 0.50 at 12-13 weeks' gestation to 0.88 ± 0.24 at 20-21 weeks' gestation. The mean number of SA visualized in a sagittal plane of the placenta increased from 8.83 ± 2.37 in the first trimester to 16.99 ± 3.31 in the late-third trimester. The mean SA-PI was 0.57 ± 0.12 in the first trimester and decreased progressively during the second trimester, reaching a nadir of 0.40 ± 0.10 at 24-25 weeks, and remaining constant until the end of pregnancy. SA-PSV was highest in early pregnancy with a mean of 57.16 ± 14.84 cm/s at 12-13 weeks' gestation, declined to a mean of 49.38 ± 17.88 cm/s at 20-21 weeks' gestation and continued to trend downward for the remainder of pregnancy, reaching a nadir of 34.50 ± 15.08 cm/s at 36-37 weeks' gestation. A statistically significant correlation was noted between SA-PI and UtA-PI (r = 0.5633; P < 0.001). Multilevel regression models with natural cubic splines were used to create reference ranges of SA-PSV and SA-PI for given gestational ages. CONCLUSION From early gestation, we have demonstrated the ability to image and quantify SA blood flow in normal pregnancy, and have developed reference ranges for use at various gestational ages throughout pregnancy. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Horgan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - E Sinkovskaya
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - G Saade
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - E Kalafat
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
| | - M M Rice
- George Washington University Biostatistics Center, Milken Institute School of Public Health, Washington, DC, USA
| | - A Heeze
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - A Abuhamad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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Turkgeldi E, Yildiz S, Kalafat E, Keles I, Ata B, Bozdag G. Can endometrial compaction predict live birth rates in assisted reproductive technology cycles? A systematic review and meta-analysis. J Assist Reprod Genet 2023; 40:2513-2522. [PMID: 37726586 PMCID: PMC10643758 DOI: 10.1007/s10815-023-02942-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
PURPOSE Endometrial compaction (EC) is defined as the difference in endometrial thickness from the end of the follicular phase to the day of embryo transfer (ET). We aimed to determine the role of EC in predicting assisted reproductive technology (ART) success by conducting a meta-analysis of studies reporting the association between EC and clinical outcomes of ART. METHODS MEDLINE via PubMed, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from the date of inception to May 19, 2023. The primary outcome was live birth rate (LBR) per ET. Secondary outcomes were live birth or ongoing pregnancy per ET, ongoing pregnancy per ET, clinical pregnancy per ET, and miscarriage per clinical pregnancy. RESULTS Fifteen studies were included. When data from all studies reporting live birth were pooled, overall LBR rates were comparable in cycles showing EC or not [RR = 0.97, 95%CI = 0.92 to 1.02; 10 studies, 11,710 transfer cycles]. In a subgroup of studies that included euploid ET cycles, a similar LBR for patients with and without EC was noted [RR = 0.99, 95%CI = 0.86 to 1.13, 4 studies, 1172 cycles]. The miscarriage rate did not seem to be affected by the presence or absence of EC [RR = 1.06, 95%CI = 0.90 to 1.24; 12 studies]. CONCLUSION The predictive value of EC in determining LBR is limited, and assessment of EC may no longer be necessary, given these findings. TRIAL REGISTRATION PROSPERO CRD42023410389.
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Affiliation(s)
- E Turkgeldi
- Department of Obstetrics and Gynaecology, Koc University, Istanbul, Turkey.
| | - S Yildiz
- Department of Obstetrics and Gynaecology, Koc University, Istanbul, Turkey
| | - E Kalafat
- Department of Obstetrics and Gynaecology, Koc University, Istanbul, Turkey
| | - I Keles
- Koc University Hospital, Assisted Reproduction Unit, Istanbul, Turkey
| | - B Ata
- Department of Obstetrics and Gynaecology, Koc University, Istanbul, Turkey
- ART Fertility Center, Dubai, UAE
| | - G Bozdag
- Department of Obstetrics and Gynaecology, Koc University, Istanbul, Turkey
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Prasad S, Di Fabrizio C, Eltaweel N, Kalafat E, Khalil A. First-trimester choroid-plexus-to-lateral-ventricle disproportion and prediction of subsequent ventriculomegaly. Ultrasound Obstet Gynecol 2023; 62:234-240. [PMID: 36864532 DOI: 10.1002/uog.26189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/29/2023] [Accepted: 02/17/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE Ventriculomegaly can be associated with long-term neurodevelopmental impairment. Prenatal diagnosis of ventriculomegaly is most commonly made at the routine second-trimester anomaly scan. The value of first-trimester ultrasound has expanded to early diagnosis and screening of fetal abnormalities. The objective of this study was to assess the predictive accuracy of first-trimester choroid-plexus-to-lateral-ventricle-or-head ratios for development of ventriculomegaly at a later gestational age. METHODS This was a case-control study of fetuses with isolated ventriculomegaly diagnosed after 16 weeks' gestation and a control group of normal fetuses (without ventriculomegaly). The exclusion criteria included aneuploidy, genetic syndrome and/or other brain abnormality. Stored two-dimensional first-trimester ultrasound images were analyzed blindly offline and fetal biometry was performed in the axial view of the fetal head. The ratios of choroid plexus area (PA) to lateral ventricular area (VA), choroid plexus length (PL) to lateral ventricular length (VL), choroid plexus diameter (PD) to lateral ventricular diameter (VD) and PA to biparietal diameter (BPD) were measured at 11 + 0 to 13 + 6 weeks' gestation. Intra- and interobserver variability of measurement of these fetal head biometric parameters at 11 + 0 to 13 + 6 weeks' gestation were assessed in 20 normal fetuses using intraclass correlation coefficients with 95% CI. The accuracy of first-trimester biometric measurements for prediction of ventriculomegaly was assessed using the area under the receiver-operating-characteristics curves (AUC). RESULTS The analysis included 683 singleton pregnancies, of which 102 fetuses were diagnosed with ventriculomegaly. Ventriculomegaly was mild in 86 (84.3%) cases and severe in the other 16 (15.7%). All first-trimester fetal choroid-plexus-to-lateral-ventricle/head ratios were significantly lower in cases with ventriculomegaly compared with controls (P < 0.001), with good inter- and intraobserver agreement (≥ 0.95) for the majority of the fetal head biometric parameters assessed. On adjusting for crown-rump length, optimism-adjusted AUC values obtained after cross-validation showed that both PL/VL ratio (AUC, 0.87 (95% CI, 0.73-0.98)) and PA/VA ratio (AUC, 0.90 (95% CI, 0.82-0.98)) had good predictive accuracy for severe ventriculomegaly. The PA/BPD ratio (AUC, 0.73 (95% CI, 0.54-0.90)) had modest predictive ability, which was significantly lower compared with that of the PA/VA ratio and PL/VL ratio (P = 0.003 and P = 0.001, respectively). The predictive accuracy of PD/VD ratio was low with an AUC of 0.65 (95% CI, 0.47-0.84). Optimism-adjusted AUC values obtained after cross-validation showed that PA/VA ratio offered the highest predictive accuracy for mild ventriculomegaly with an AUC of 0.84 (95% CI, 0.79-0.89), followed by PL/VL ratio (AUC, 0.82 (95% CI, 0.76-0.88)), PA/BPD ratio (AUC, 0.76 (95% CI, 0.69-0.82)) and PD/VD ratio (AUC, 0.75 (95% CI, 0.67-0.81)). Calibration plots showed that both PA/VA and PL/VL ratios had good calibration. CONCLUSION First-trimester prediction of ventriculomegaly using ratios of fetal choroid plexus to lateral ventricle/head appears promising. Future prospective studies are needed to validate the predictive accuracy of these ultrasound markers as a screening tool for ventriculomegaly. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - C Di Fabrizio
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - N Eltaweel
- Department of Obstetrics and Gynaecology, University Hospital of Coventry and Warwickshire, Coventry, UK
| | - E Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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18
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Ata B, Liñán A, Kalafat E, Ruíz F, Melado L, Bayram A, Elkhatib I, Lawrenz B, Fatemi HM. Effect of the endometrial thickness on the live birth rate: insights from 959 single euploid frozen embryo transfers without a cutoff for thickness. Fertil Steril 2023; 120:91-98. [PMID: 36870593 DOI: 10.1016/j.fertnstert.2023.02.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE To investigate whether endometrial thickness (ET) independently affects the live birth rate (LBR) after embryo transfer. DESIGN Retrospective study. SETTING Private assisted reproductive technology center. PATIENT(S) A total of 959 single euploid frozen embryo transfers. INTERVENTION(S) Vitrified euploid blastocyst transfer. MAIN OUTCOME MEASURE(S) Live birth rate per embryo transfer. RESULT(S) The conditional density plots did not demonstrate either a linear relationship between the ET and LBR or a threshold below which the LBR decreased perceivably. Receiver operating characteristic curve analyses did not suggest a predictive value of the ET for the LBR. The area under the curve values were 0.55, 0.54, and 0.54 in the overall, programmed, and natural cycle transfers, respectively. Logistic regression analyses with age, embryo quality, day of trophectoderm biopsy, body mass index, and ET did not suggest an independent effect of the ET on the LBR. CONCLUSION(S) We did not identify a threshold of the ET that either precluded live birth or under which the LBR decreases perceivably. Common practice of cancelling embryo transfers when the ET is <7 mm may not be justified. Prospective studies, in which the management of the transfer cycle would not be altered by ET, would provide higher-quality evidence on the subject.
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Affiliation(s)
- Baris Ata
- ART Fertility Clinics, Dubai, United Arab Emirates; Department of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkish Republic.
| | | | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkish Republic; Middle East Technical University, Ankara
| | - Francisco Ruíz
- ART Fertility Clinics, Muscat, Oman; ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | - Laura Melado
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | - Asina Bayram
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates
| | | | - Barbara Lawrenz
- ART Fertility Clinics, Abu Dhabi, United Arab Emirates; Women's University Hospital Tübingen, Tübingen, Germany
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Palmrich P, Haase N, Sugulle M, Kalafat E, Khalil A, Binder J. Maternal haemodynamics in Hypertensive Disorders of Pregnancy under antihypertensive therapy (HyperDiP): study protocol for a prospective observational case-control study. BMJ Open 2023; 13:e065444. [PMID: 37263704 DOI: 10.1136/bmjopen-2022-065444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) are associated with a high incidence of maternal and perinatal morbidity and mortality. HDP, in particular pre-eclampsia, have been determined as risk factors for future cardiovascular disease. Recently, the common hypothesis of pre-eclampsia being a placental disorder was challenged as numerous studies show evidence for short-term and long-term cardiovascular changes in pregnancies affected by HDP, suggesting a cardiovascular origin of the disease. Despite new insights into the pathophysiology of HDP, concepts of therapy remain unchanged and evidence for improved maternal and neonatal outcome by using antihypertensive agents is lacking. METHODS AND ANALYSIS A prospective observational case-control study, including 100 women with HDP and 100 healthy controls, which will assess maternal haemodynamics using the USCOM 1A Monitor and Arteriograph along with cardiovascular markers (soluble fms-like kinase 1/placental-like growth factor, N-terminal pro-B type natriuretic peptide) in women with HDP under antihypertensive therapy, including a follow-up at 3 months and 1 year post partum, will be conducted over a 50-month period in Vienna. A prospective, longitudinal study of cardiovascular surrogate markers conducted in Oslo will serve as a comparative cohort for the Vienna cohort of haemodynamic parameters in pregnancy including a longer follow-up period of up to 3 years post partum. Each site will provide a dataset of a patient group and a control group and will be assessed for the outcome categories USCOM 1A measurements, Arteriograph measurements and Angiogenic marker measurements. To estimate the effect of antihypertensive therapy on outcome parameters, ORs with 95% CIs will be computed. Longitudinal changes of outcome parameters will be compared between normotensive and hypertensive pregnancies using mixed-effects models. ETHICS AND DISSEMINATION Ethical approval has been granted to all participating centres. Results will be published in international peer-reviewed journals and will be presented at national and international conferences.
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Affiliation(s)
- Pilar Palmrich
- Division of Obstetrics and Feto-Maternal Medicine, Hospital of the Medical University of Vienna, Vienna, Austria
| | - Nadine Haase
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin, Berlin, Germany
- Max-Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, Experimental and Clinical Research Center, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Meryam Sugulle
- Division of Gynecology and Obstetrics, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University Hospital, Istanbul, Turkey
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK
| | - Julia Binder
- Division of Obstetrics and Feto-Maternal Medicine, Hospital of the Medical University of Vienna, Vienna, Austria
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Lawrenz B, Ata B, Kalafat E, Melado L, ElKhatib I, Del Gallego R, Fatemi H. Are systemic progesterone levels in true natural cycle euploid frozen embryo transfers with luteal phase support predictive for ongoing pregnancy rates? Hum Reprod 2023:7169440. [PMID: 37196321 DOI: 10.1093/humrep/dead104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
STUDY QUESTION Are serum progesterone (P4) levels on the embryo transfer (ET) day predictive of ongoing pregnancy (OP) following a single euploid blastocyst transfer in a natural cycle (NC) when luteal phase support is routinely given? SUMMARY ANSWER In single euploid frozen ETs in NC, P4 levels on ET day are not predictive for OP, when luteal phase support (LPS) is routinely added after the ET. WHAT IS KNOWN ALREADY In an NC frozen embryo transfer (FET), P4 produced by the corpus luteum initiates secretory transformation of the endometrium and maintains pregnancy after implantation. There are ongoing controversies on the existence of a P4 cutoff level on the ET day, being predictive for the chance of OP as well as of the possible role of additional LPS after ET. Previous studies in NC FET cycles, evaluating and identifying P4 cutoff levels did not exclude embryo aneuploidy as a possible reason for failure. STUDY DESIGN, SIZE, DURATION This retrospective study analyzed single, euploid FET in NC, conducted in a tertiary referral IVF centre between September 2019 and June 2022, for which measurement of P4 on the day of ET and the treatment outcomes were available. Patients were only included once into the analysis. Outcome was defined as OP (ongoing clinical pregnancy with heartbeat, >12 weeks) or no-OP (not pregnant, biochemical pregnancy, early miscarriage). PARTICIPANTS/MATERIALS, SETTING, METHODS Patients with an ovulatory cycle and a single euploid blastocyst in an NC FET cycle were included. Cycles were monitored by ultrasound and repeated measurement of serum LH, estradiol, and P4. LH surge was identified when a rise of 180% above the previous level occurred and P4 levels of ≥1.0 ng/ml were regarded as confirmation of ovulation. The ET was scheduled on the fifth day after P4 rise and vaginal micronized P4 was started on the day of ET after P4 measurement. MAIN RESULTS AND THE ROLE OF CHANCE Of 266 patients included, 159 (59.8%) patients had an OP. There was no significant difference between the OP- and no-OP-groups for age, BMI, and day of embryo biopsy/cryopreservation (Day 5 versus Day 6). Furthermore, P4 levels were not different between the groups of patients with OP (P4: 14.8 ng/ml (IQR: 12.0-18.5 ng/ml)) versus no-OP (P4: 16.0 ng/ml (IQR: 11.6-18.9 ng/ml)) (P = 0.483), and no differences between both groups, when P4 levels were stratified into categories of P4 levels of >5 to ≤10, >10 to ≤15, >15 to ≤20, and >20 ng/ml (P = 0.341). However, both groups were significantly different for the embryo quality (EQ), defined by inner cell mass/trophectoderm, as well as when stratified into three EQ groups (good, fair, and poor) (P = 0.001 and 0.002, respectively). Stratified EQ groups remained the only significant parameter influencing OP in the uni- and multivariate analyses (P = 0.002 and P = 0.004, respectively), including age, BMI, and P4 levels (each in categories) and embryo cryopreservation day. Receiver operator characteristic curve for the prediction of an OP revealed an AUC of 0.648 when age, BMI and EQ groups were included into the model. The inclusion of P4 measurement on ET day into the model did not add any benefit for OP prediction (AUC = 0.665). LIMITATIONS, REASONS FOR CAUTION The retrospective design is a limitation. WIDER IMPLICATIONS OF THE FINDINGS Monitoring serum P4 levels can be abandoned in NC FET cycles with routine LPS as they do not seem to be predictive of live birth. STUDY FUNDING/COMPETING INTEREST(S) No external funding was used for this study. The authors state that they do not have any conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- B Lawrenz
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - B Ata
- ART Fertility Clinic, Dubai, United Arab Emirates
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University, Istanbul, Turkey
| | - E Kalafat
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University, Istanbul, Turkey
| | - L Melado
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - I ElKhatib
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - R Del Gallego
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
| | - H Fatemi
- ART Fertility Clinic, Abu Dhabi, United Arab Emirates
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21
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Knights S, Prasad S, Kalafat E, Dadali A, Sizer P, Harlow F, Khalil A. Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study. PLoS Med 2023; 20:e1004192. [PMID: 37023211 PMCID: PMC10079042 DOI: 10.1371/journal.pmed.1004192] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 02/07/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes. METHODS AND FINDINGS This was a retrospective multicentre cohort study where we included data from St. George's (SGH) and Norfolk and Norwich University Hospitals (NNUH). Pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH). Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned cesarean section for breech presentation were excluded. Undiagnosed breech presentation was defined as follows: (a) women presenting in labour or with ruptured membranes at term subsequently discovered to have a breech presentation; and (b) women attending for induction of labour at term found to have a breech presentation before induction. The primary outcome was the proportion of all term breech presentations that were undiagnosed. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE), and perinatal mortality (including stillbirths and early neonatal deaths). We employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood). The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models. All analyses were conducted using R for Statistical Software (v.4.2.0). Before and after the implementation of routine third trimester scan or POCUS, there were 16,777 and 7,351 births in SGH and 5,119 and 4,575 in NNUH, respectively. The rate of breech presentation in labour was consistent across all groups (3% to 4%). In the SGH cohort, the percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before (years 2016 to 2020) and 2.8% (7/251) after (year 2020 to 2021) the implementation of universal screening (p < 0.001). Similarly, in the NNUH cohort, the percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before (year 2015) and 3.5% (5/142) after (year 2020 to 2021) the implementation of universal POCUS screening (p < 0.001). Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9%. Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9%. There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). We do not have reliable data on number of facility-based ultrasound scans via the standard antenatal referral pathway or external cephalic versions (ECVs) performed during the study period. CONCLUSIONS In our study, we observed that both a policy of routine facility-based third trimester ultrasound or POCUS are associated with a reduction in the proportion of term breech presentations that were undiagnosed, with an improvement in neonatal outcomes. The findings from our study support the policy of third trimester ultrasound scan for fetal presentation. Future studies should focus on exploring the cost-effectiveness of POCUS for fetal presentation.
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Affiliation(s)
- Samantha Knights
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Smriti Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Erkan Kalafat
- Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey
- Department of Obstetrics and Gynaecology, Koc University, School of Medicine, Istanbul, Turkey
| | - Anahita Dadali
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Pam Sizer
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Francoise Harlow
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
- Fetal Medicine Unit, Liverpool Women's Hospital, Liverpool, United Kingdom
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Smith ER, Oakley E, Grandner GW, Rukundo G, Farooq F, Ferguson K, Baumann S, Adams Waldorf KM, Afshar Y, Ahlberg M, Ahmadzia H, Akelo V, Aldrovandi G, Bevilacqua E, Bracero N, Brandt JS, Broutet N, Carrillo J, Conry J, Cosmi E, Crispi F, Crovetto F, Del Mar Gil M, Delgado-López C, Divakar H, Driscoll AJ, Favre G, Fernandez Buhigas I, Flaherman V, Gale C, Godwin CL, Gottlieb S, Gratacós E, He S, Hernandez O, Jones S, Joshi S, Kalafat E, Khagayi S, Knight M, Kotloff KL, Lanzone A, Laurita Longo V, Le Doare K, Lees C, Litman E, Lokken EM, Madhi SA, Magee LA, Martinez-Portilla RJ, Metz TD, Miller ES, Money D, Moungmaithong S, Mullins E, Nachega JB, Nunes MC, Onyango D, Panchaud A, Poon LC, Raiten D, Regan L, Sahota D, Sakowicz A, Sanin-Blair J, Stephansson O, Temmerman M, Thorson A, Thwin SS, Tippett Barr BA, Tolosa JE, Tug N, Valencia-Prado M, Visentin S, von Dadelszen P, Whitehead C, Wood M, Yang H, Zavala R, Tielsch JM. Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: a sequential, prospective meta-analysis. Am J Obstet Gynecol 2023; 228:161-177. [PMID: 36027953 PMCID: PMC9398561 DOI: 10.1016/j.ajog.2022.08.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/04/2022] [Accepted: 08/07/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE This sequential, prospective meta-analysis sought to identify risk factors among pregnant and postpartum women with COVID-19 for adverse outcomes related to disease severity, maternal morbidities, neonatal mortality and morbidity, and adverse birth outcomes. DATA SOURCES We prospectively invited study investigators to join the sequential, prospective meta-analysis via professional research networks beginning in March 2020. STUDY ELIGIBILITY CRITERIA Eligible studies included those recruiting at least 25 consecutive cases of COVID-19 in pregnancy within a defined catchment area. METHODS We included individual patient data from 21 participating studies. Data quality was assessed, and harmonized variables for risk factors and outcomes were constructed. Duplicate cases were removed. Pooled estimates for the absolute and relative risk of adverse outcomes comparing those with and without each risk factor were generated using a 2-stage meta-analysis. RESULTS We collected data from 33 countries and territories, including 21,977 cases of SARS-CoV-2 infection in pregnancy or postpartum. We found that women with comorbidities (preexisting diabetes mellitus, hypertension, cardiovascular disease) vs those without were at higher risk for COVID-19 severity and adverse pregnancy outcomes (fetal death, preterm birth, low birthweight). Participants with COVID-19 and HIV were 1.74 times (95% confidence interval, 1.12-2.71) more likely to be admitted to the intensive care unit. Pregnant women who were underweight before pregnancy were at higher risk of intensive care unit admission (relative risk, 5.53; 95% confidence interval, 2.27-13.44), ventilation (relative risk, 9.36; 95% confidence interval, 3.87-22.63), and pregnancy-related death (relative risk, 14.10; 95% confidence interval, 2.83-70.36). Prepregnancy obesity was also a risk factor for severe COVID-19 outcomes including intensive care unit admission (relative risk, 1.81; 95% confidence interval, 1.26-2.60), ventilation (relative risk, 2.05; 95% confidence interval, 1.20-3.51), any critical care (relative risk, 1.89; 95% confidence interval, 1.28-2.77), and pneumonia (relative risk, 1.66; 95% confidence interval, 1.18-2.33). Anemic pregnant women with COVID-19 also had increased risk of intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.25-2.11) and death (relative risk, 2.36; 95% confidence interval, 1.15-4.81). CONCLUSION We found that pregnant women with comorbidities including diabetes mellitus, hypertension, and cardiovascular disease were at increased risk for severe COVID-19-related outcomes, maternal morbidities, and adverse birth outcomes. We also identified several less commonly known risk factors, including HIV infection, prepregnancy underweight, and anemia. Although pregnant women are already considered a high-risk population, special priority for prevention and treatment should be given to pregnant women with these additional risk factors.
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Affiliation(s)
- Emily R Smith
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC.
| | - Erin Oakley
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Gargi Wable Grandner
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Gordon Rukundo
- PeriCOVID (PREPARE)-Uganda Team, Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Fouzia Farooq
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Kacey Ferguson
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Sasha Baumann
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Kristina Maria Adams Waldorf
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA; Department of Global Health, University of Washington, Seattle, WA
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Mia Ahlberg
- Division of Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Homa Ahmadzia
- Division of Maternal-Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Victor Akelo
- Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Grace Aldrovandi
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
| | - Elisa Bevilacqua
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Nabal Bracero
- Department of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, San Juan, PR; Puerto Rico Obstetrics and Gynecology (PROGyn)
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Natalie Broutet
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Jorge Carrillo
- Departamento de Obstetricia y Ginecologia, Clinica Alemana de Santiago, Facultad de Medicina Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Jeanne Conry
- International Federation of Gynecology and Obstetrics, London, United Kingdom
| | - Erich Cosmi
- Department of Women's and Children's Health, Obstetrics and Gynecology Clinic, University of Padua, Padua, Italy
| | - Fatima Crispi
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu Barcelona and Hospital Clínic de Barcelona, Universitat de Barcelona, and Center for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - Francesca Crovetto
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu Barcelona and Hospital Clínic de Barcelona, Universitat de Barcelona, and Center for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - Maria Del Mar Gil
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain; School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Camille Delgado-López
- Surveillance for Emerging Threats to Mothers and Babies, Puerto Rico Department of Health, San Juan, PR
| | - Hema Divakar
- Asian Research & Training Institute for Skill Transfer, Bengaluru, India
| | - Amanda J Driscoll
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD
| | - Guillaume Favre
- Materno-fetal and Obstetrics Research Unit, Département Femme-Mère-Enfant, Lausanne University Hospital, Lausanne, Switzerland
| | - Irene Fernandez Buhigas
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain; School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Valerie Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Christopher Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Christine L Godwin
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Sami Gottlieb
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Eduard Gratacós
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu Barcelona and Hospital Clínic de Barcelona, Universitat de Barcelona, and Center for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - Siran He
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Olivia Hernandez
- Gynecology and Obstetrics, Félix Bulnes Hospital and RedSalud Clinic, Santiago, Chile
| | - Stephanie Jones
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit and Department of Science and Technology/National Research Foundation, South African Research Chair Initiative in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheetal Joshi
- Asian Research & Training Institute for Skill Transfer, Bengaluru, India
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koç University, Istanbul, Turkey
| | - Sammy Khagayi
- Kenya Medical Research Institute-Centre for Global Health Research, Kisumu, Kenya
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD
| | - Antonio Lanzone
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy; Catholic University of Sacred Heart, Rome, Italy
| | - Valentina Laurita Longo
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy; Catholic University of Sacred Heart, Rome, Italy
| | - Kirsty Le Doare
- PeriCOVID (PREPARE)-Uganda Team, Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda; Medical Research Council /Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda; Paediatric Infectious Disease Research Group, St George's University of London, London, United Kingdom
| | - Christoph Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Ethan Litman
- Division of Maternal-Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Erica M Lokken
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA; Department of Global Health, University of Washington, Seattle, WA
| | - Shabir A Madhi
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit and Department of Science and Technology/National Research Foundation, South African Research Chair Initiative in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Institute of Women and Children's Health, King's College Hospital, London, United Kingdom
| | | | - Torri D Metz
- Division of Maternal-Fetal Medicine, The University of Utah Health, Salt Lake City, UT
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Deborah Money
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, Canada
| | - Sakita Moungmaithong
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong
| | - Edward Mullins
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; George Institute for Global Health, London, United Kingdom
| | - Jean B Nachega
- Department of Epidemiology and Center for Global Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Marta C Nunes
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit and Department of Science and Technology/National Research Foundation, South African Research Chair Initiative in Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Alice Panchaud
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland; Service of Pharmacy, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong
| | - Daniel Raiten
- Pediatric Growth and Nutrition Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Lesley Regan
- International Federation of Gynecology and Obstetrics, Imperial College London, London, United Kingdom
| | - Daljit Sahota
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong
| | - Allie Sakowicz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jose Sanin-Blair
- Maternal-Fetal Unit, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Olof Stephansson
- Division of Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Anna Thorson
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Soe Soe Thwin
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Beth A Tippett Barr
- Centers for Disease Control and Prevention, Kisumu, Kenya; Nyanja Health Research Institute, Salima, Malawi
| | - Jorge E Tolosa
- Maternal-Fetal Unit, Universidad Pontificia Bolivariana, Medellín, Colombia; Department of Obstetrics and Gynecology, Maternal Fetal Medicine, Oregon Health & Science University, Portland, OR; Department of Obstetrics and Gynecology, Maternal Fetal Medicine, St. Luke's University Health Network, Bethlehem, PA
| | - Niyazi Tug
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Miguel Valencia-Prado
- Division of Children with Special Medical Needs, Puerto Rico Department of Health, San Juan, PR
| | - Silvia Visentin
- Department of Women's and Children's Health, Obstetrics and Gynecology Clinic, University of Padua, Padua, Italy
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Global Health Institute, King's College London, London, United Kingdom
| | - Clare Whitehead
- Department of Maternal Fetal Medicine, University of Melbourne, Royal Women's Hospital, Melbourne, Australia
| | - Mollie Wood
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Rebecca Zavala
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - James M Tielsch
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC
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23
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Smith ER, Oakley E, Grandner GW, Ferguson K, Farooq F, Afshar Y, Ahlberg M, Ahmadzia H, Akelo V, Aldrovandi G, Tippett Barr BA, Bevilacqua E, Brandt JS, Broutet N, Fernández Buhigas I, Carrillo J, Clifton R, Conry J, Cosmi E, Crispi F, Crovetto F, Delgado-López C, Divakar H, Driscoll AJ, Favre G, Flaherman VJ, Gale C, Gil MM, Gottlieb SL, Gratacós E, Hernandez O, Jones S, Kalafat E, Khagayi S, Knight M, Kotloff K, Lanzone A, Le Doare K, Lees C, Litman E, Lokken EM, Laurita Longo V, Madhi SA, Magee LA, Martinez-Portilla RJ, McClure EM, Metz TD, Miller ES, Money D, Moungmaithong S, Mullins E, Nachega JB, Nunes MC, Onyango D, Panchaud A, Poon LC, Raiten D, Regan L, Rukundo G, Sahota D, Sakowicz A, Sanin-Blair J, Söderling J, Stephansson O, Temmerman M, Thorson A, Tolosa JE, Townson J, Valencia-Prado M, Visentin S, von Dadelszen P, Adams Waldorf K, Whitehead C, Yassa M, Tielsch JM. Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis. BMJ Glob Health 2023; 8:e009495. [PMID: 36646475 PMCID: PMC9895919 DOI: 10.1136/bmjgh-2022-009495] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/24/2022] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. METHODS We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. RESULTS We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection-as compared with uninfected pregnant women-were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. CONCLUSIONS This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol.
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Affiliation(s)
- Emily R Smith
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Erin Oakley
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Gargi Wable Grandner
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Kacey Ferguson
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Fouzia Farooq
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Mia Ahlberg
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden
| | - Homa Ahmadzia
- Division of Maternal-Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Victor Akelo
- Office of the Director, US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Grace Aldrovandi
- Department of Pediatrics, University of California Los Angeles, Los Angeles, California, USA
| | - Beth A Tippett Barr
- Office of the Director, US Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Elisa Bevilacqua
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Roma, Italy
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Nathalie Broutet
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | | | - Jorge Carrillo
- Departamento de Obstetricia y Ginecologia, Universidad del Desarrollo Facultad de Medicina Clinica Alemana, Santiago, Chile
| | - Rebecca Clifton
- The Biostatistics Center, The George Washington University Milken Institute School of Public Health, Rockville, Maryland, USA
| | - Jeanne Conry
- International Federation of Gynecology and Obstetrics, London, UK
| | - Erich Cosmi
- Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Fatima Crispi
- Department of Maternal-Fetal Medicine, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francesca Crovetto
- Department of Maternal-Fetal Medicine, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Camille Delgado-López
- Surveillance for Emerging Threats to Mothers and Babies, Puerto Rico Department of Health, San Juan, Puerto Rico
| | - Hema Divakar
- Asian Research and Training Institute for Skill Transfer (ARTIST), Bengaluru, India
| | - Amanda J Driscoll
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Guillaume Favre
- Materno-Fetal and Obstetrics Research Unit, Department ‘Femme-Mère-Enfant’, Lausanne University Hospital, Lausanne, Switzerland
| | - Valerie J Flaherman
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Imperial College London Faculty of Medicine, London, UK
| | - Maria M Gil
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain
| | - Sami L Gottlieb
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Eduard Gratacós
- Department of Maternal-Fetal Medicine, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Sant Joan de Déu and Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Olivia Hernandez
- Gynecology and Obstetrics, Felix Bulnes Hospital and RedSalud Clinic, Santiago, Chile
| | - Stephanie Jones
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkey
| | - Sammy Khagayi
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Marian Knight
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Karen Kotloff
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Antonio Lanzone
- Department of Women and Child Health, Women Health Area, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Roma, Italy
| | - Kirsty Le Doare
- Uganda Virus Institute and the London School of Hygiene & Tropical Medicine, Entebbe, Uganda,Pediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Christoph Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Ethan Litman
- Division of Maternal-Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Erica M Lokken
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Valentina Laurita Longo
- Institute of Obstetrics and Gynecology Clinic, Catholic University of Sacred Heart, Rome, Italy
| | - Shabir A Madhi
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Laura A Magee
- Department of Women and Children’s Health, School of Life Course and Population Sciences, King's College London, London, UK
| | | | | | - Tori D Metz
- Departments of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake, Utah, USA
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Deborah Money
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sakita Moungmaithong
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Edward Mullins
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Jean B Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Marta C Nunes
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | | | - Alice Panchaud
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Daniel Raiten
- Pediatric Growth and Nutrition Branch, National Institute of Health, Bethesda, Maryland, USA
| | - Lesley Regan
- International Federation of Gynecology and Obstetrics, London, UK
| | - Gordon Rukundo
- Uganda Virus Institute and the London School of Hygiene & Tropical Medicine, Entebbe, Uganda
| | - Daljit Sahota
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Allie Sakowicz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jose Sanin-Blair
- Universidad Pontificia Bolivariana, Medellin, Antioquia, Colombia
| | - Jonas Söderling
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden
| | - Olof Stephansson
- Department of Medicine, Solna, Clinical Epidemiology Division, Karolinska Institute, Stockholm, Sweden
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Anna Thorson
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Jorge E Tolosa
- Department of Obstetrics and Gynecology, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Julia Townson
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Miguel Valencia-Prado
- Children with Special Medical Needs Division, Puerto Rico Department of Health, San Juan, Puerto Rico
| | - Silvia Visentin
- Department of Women's and Children's Health, University of Padua, Padova, Italy
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Kristina Adams Waldorf
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Clare Whitehead
- Department of Maternal-Fetal Medicine, The Royal Women's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Murat Yassa
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Jim M Tielsch
- Department of Global Health, The George Washington University Milken Institute School of Public Health, Washington, DC, USA
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24
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Blakeway H, Amin‐Chowdhury Z, Prasad S, Kalafat E, Ismail M, Abdallah FN, Rezvani A, Amirthalingam G, Brown K, Le Doare K, Heath PT, Ladhani SN, Khalil A. Evaluation of immunogenicity and reactogenicity of COVID-19 vaccines in pregnant women. Ultrasound Obstet Gynecol 2022; 60:673-680. [PMID: 36318630 PMCID: PMC9538835 DOI: 10.1002/uog.26050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 07/22/2022] [Accepted: 07/29/2022] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy is associated with increased risk of adverse maternal and perinatal outcomes. Vaccines are highly effective at preventing severe coronavirus disease 2019 (COVID-19), but there are limited data on COVID-19 vaccines in pregnancy. This study aimed to investigate the reactogenicity and immunogenicity of COVID-19 vaccines in pregnant women when administered according to the 12-week-interval dosing schedule recommended in the UK. METHODS This was a cohort study of pregnant women receiving COVID-19 vaccination between April and September 2021. The outcomes were immunogenicity and reactogenicity after COVID-19 vaccination. Pregnant women were recruited by phone, e-mail and/or text and were vaccinated according to vaccine availability at their local vaccination center. For immunogenicity assessment, blood samples were taken at specific timepoints after each dose to evaluate nucleocapsid protein (N) and spike protein (S) antibody titers. The comparator group comprised non-pregnant female healthcare workers in the same age group who were vaccinated as part of the national immunization program in a contemporaneous longitudinal cohort study. Longitudinal changes in serum antibody titers and association with pregnancy status were assessed using a two-step regression approach. Reactogenicity assessment in pregnant women was undertaken using an online questionnaire. The comparator group comprised non-pregnant women aged 18-49 years who had received two vaccine doses in primary care. The association of pregnancy status with reactogenicity was assessed using logistic regression analysis. RESULTS Overall, 67 pregnant women, of whom 66 had received a mRNA vaccine, and 79 non-pregnant women, of whom 50 had received a mRNA vaccine, were included in the immunogenicity study. Most (61.2%) pregnant women received their first vaccine dose in the third trimester, while 3.0% received it in the first trimester and 35.8% in the second trimester. SARS-CoV-2 S-antibody geometric mean concentrations after mRNA vaccination were not significantly different at 2-6 weeks after the first dose but were significantly lower at 2-6 weeks after the second dose in infection-naïve pregnant compared with non-pregnant women. In pregnant women, prior infection was associated with higher antibody levels at 2-6 weeks after the second vaccine dose. Reactogenicity analysis included 108 pregnant women and 116 non-pregnant women. After the first dose, tiredness and chills were reported less commonly in pregnant compared with non-pregnant women (P = 0.043 and P = 0.029, respectively). After the second dose, feeling generally unwell was reported less commonly (P = 0.046) in pregnant compared with non-pregnant women. CONCLUSIONS Using an extended 12-week interval between vaccine doses, antibody responses after two doses of mRNA COVID-19 vaccine were found to be lower in pregnant compared with non-pregnant women. Strong antibody responses were achieved after one dose in previously infected women, regardless of pregnancy status. Pregnant women reported fewer adverse events after both the first and second dose of vaccine. These findings should now be addressed in larger controlled studies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H. Blakeway
- Fetal Medicine Unit, St George's Hospital, St George's University of LondonLondonUK
| | - Z. Amin‐Chowdhury
- Immunisation and Vaccine Preventable Diseases DivisionUK Health Security Agency (previously known as Public Health England)LondonUK
| | - S. Prasad
- Fetal Medicine Unit, St George's Hospital, St George's University of LondonLondonUK
| | - E. Kalafat
- Koc University, School of Medicine, Department of Obstetrics and GynecologyIstanbulTurkey
- Department of Statistics, Faculty of Arts and SciencesMiddle East Technical UniversityAnkaraTurkey
| | - M. Ismail
- Fetal Medicine Unit, St George's Hospital, St George's University of LondonLondonUK
| | - F. N. Abdallah
- Fetal Medicine Unit, St George's Hospital, St George's University of LondonLondonUK
| | - A. Rezvani
- Fetal Medicine Unit, St George's Hospital, St George's University of LondonLondonUK
| | - G. Amirthalingam
- Immunisation and Vaccine Preventable Diseases DivisionUK Health Security Agency (previously known as Public Health England)LondonUK
| | - K. Brown
- Immunisation and Vaccine Preventable Diseases DivisionUK Health Security Agency (previously known as Public Health England)LondonUK
| | - K. Le Doare
- Centre for Neonatal and Paediatric Infection and Vaccine Institute, Institute of Infection and Immunity, St George's University of LondonLondonUK
| | - P. T. Heath
- Centre for Neonatal and Paediatric Infection and Vaccine Institute, Institute of Infection and Immunity, St George's University of LondonLondonUK
| | - S. N. Ladhani
- Immunisation and Vaccine Preventable Diseases DivisionUK Health Security Agency (previously known as Public Health England)LondonUK
- Centre for Neonatal and Paediatric Infection and Vaccine Institute, Institute of Infection and Immunity, St George's University of LondonLondonUK
| | - A. Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of LondonLondonUK
- Vascular Biology Research CentreMolecular and Clinical Sciences Research Institute, St George's University of LondonLondonUK
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Kalafat E, Keles I, Turkgeldi E, Yildiz S, Bozdag G, Ata B. CLINICAL FACTORS ASSOCIATED WITH SUBOPTIMAL BLASTULATION RATE IN ICSI CYCLES: A PARAMETRIC MODELING APPROACH. Fertil Steril 2022. [DOI: 10.1016/j.fertnstert.2022.08.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kalafat E, Bekir Telek SB, Gurbuz Z, Ata B. ORAL GONADOTROPIN-RELEASING HORMONE ANTAGONISTS IN THE TREATMENT OF ENDOMETRIOSIS: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS OF EFFICACY PARAMETERS AND ADVERSE EFFECTS. Fertil Steril 2022. [DOI: 10.1016/j.fertnstert.2022.08.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Despite a recent endorsement from official and professional bodies unequivocally recommending COVID-19 vaccination, vaccine hesitancy among pregnant people remains high. The accumulated evidence demonstrates that pregnant people are a special risk group for COVID-19, with an increased risk of intensive care unit admission, extracorporeal membranous oxygenation requirement, preterm birth, and perinatal death. These risks are further increased with some variants of concern, and vaccination of pregnant people reduces the COVID-19-related increase in maternal or fetal morbidity. Data from more than 180,000 vaccinated persons show that immunization against COVID-19 with an mRNA vaccine is safe for pregnant people. Many observational studies comparing perinatal outcomes between vaccinated and unvaccinated pregnant people have had reassuring findings and did not demonstrate harmful effects on pregnancy or the newborn. Immunization with mRNA vaccines does not increase the risk of miscarriage, preterm delivery, low birthweight, maternal or neonatal intensive care unit admission, fetal death, fetal abnormality, or pulmonary embolism. Moreover, observational data corroborate the findings of randomized trials that mRNA vaccination is highly effective at preventing severe SARS-CoV-2 infection in pregnant people, emphasizing that the potential maternal and fetal benefits of vaccination greatly outweigh the potential risks of vaccination. Ensuring pregnant people have unrestricted access to COVID-19 vaccination should be a priority in every country worldwide.
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Affiliation(s)
- Erkan Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
| | - Paul Heath
- Pediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London, England, United Kingdom
| | - Smriti Prasad
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, England, United Kingdom
| | - Pat O Brien
- Institute for Women's Health, University College London Hospitals, London, England, United Kingdom; Royal College of Obstetricians and Gynaecologists, London, England, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, England, United Kingdom; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University Hospitals NHS Foundation Trust, St George's University of London, London, England, United Kingdom; Liverpool Women's Hospital, Liverpool, United Kingdom.
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Birol Ilter P, Prasad S, Mutlu MA, Tekin AB, O'Brien P, von Dadelszen P, Magee LA, Tekin S, Tug N, Kalafat E, Khalil A. Maternal and perinatal outcomes of SARS-CoV-2 infection in unvaccinated pregnancies during Delta and Omicron waves. Ultrasound Obstet Gynecol 2022; 60:96-102. [PMID: 35441407 PMCID: PMC9111049 DOI: 10.1002/uog.24916] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/30/2022] [Accepted: 04/05/2022] [Indexed: 05/07/2023]
Abstract
OBJECTIVE There is little evidence related to the effects of the Omicron severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant on pregnancy outcomes, particularly in unvaccinated women. This study aimed to compare pregnancy outcomes of unvaccinated women infected with SARS-CoV-2 during the pre-Delta, Delta and Omicron waves. METHODS This was a retrospective cohort study conducted at two tertiary care facilities: Sancaktepe Training and Research Hospital, Istanbul, Turkey, and St George's University Hospitals NHS Foundation Trust, London, UK. Included were women who tested positive for SARS-CoV-2 by real-time reverse-transcription polymerase chain reaction (RT-PCR) during pregnancy, between 1 April 2020 and 14 February 2022. The cohort was divided into three periods according to the date of their positive RT-PCR test: (i) pre-Delta (1 April 2020 to 8 June 2021 in Turkey, and 1 April 2020 to 31 July 2021 in the UK), (ii) Delta (9 June 2021 to 27 December 2021 in Turkey, and 1 August 2021 to 27 December 2021 in the UK) and (iii) Omicron (after 27 December 2021 in both Turkey and the UK). Baseline data collected included maternal age, parity, body mass index, gestational age at diagnosis and comorbidities. The primary outcome was the need for oxygen supplementation, classified as oxygen support via nasal cannula or breather mask, non-invasive mechanical ventilation with continuous positive airway pressure (CPAP) or high-flow oxygen, mechanical ventilation with intubation, or extracorporeal membrane oxygenation (ECMO). Inferences were made after balancing of confounders, using an evolutionary search algorithm. Selected confounders were maternal age, body mass index and gestational age at diagnosis of infection. RESULTS During the study period, 1286 unvaccinated pregnant women with RT-PCR-proven SARS-CoV-2 infection were identified, comprising 870 cases during the pre-Delta period, 339 during the Delta wave and 77 during the Omicron wave. In the confounder-balanced cohort, infection during the Delta wave vs during the pre-Delta period was associated with increased need for nasal oxygen support (risk ratio (RR), 2.53 (95% CI, 1.75-3.65); P < 0.001), CPAP or high-flow oxygen (RR, 2.50 (95% CI, 1.37-4.56); P = 0.002), mechanical ventilation (RR, 4.20 (95% CI, 1.60-11.0); P = 0.003) and ECMO (RR, 11.0 (95% CI, 1.43-84.7); P = 0.021). The maternal mortality rate was 3.6-fold higher during the Delta wave compared to the pre-Delta period (5.3% vs 1.5%, P = 0.010). Infection during the Omicron wave was associated with a similar need for nasal oxygen support (RR, 0.62 (95% CI, 0.25-1.55); P = 0.251), CPAP or high-flow oxygen (RR, 1.07 (95% CI, 0.36-3.12); P = 0.906) and mechanical ventilation (RR, 0.44 (95% CI, 0.06-3.45); P = 0.438) with that in the pre-Delta period. The maternal mortality rate was similar during the Omicron wave and the pre-Delta period (1.3% vs 1.3%, P = 0.999). The need for nasal oxygen support during the Omicron wave was significantly lower compared to the Delta wave (RR, 0.26 (95% CI, 0.11-0.64); P = 0.003). Perinatal outcomes were available for a subset of the confounder-balanced cohort. Preterm birth before 34 weeks' gestation was significantly increased during the Delta wave compared with the pre-Delta period (15.4% vs 4.9%, P < 0.001). CONCLUSIONS Among unvaccinated pregnant women, SARS-CoV-2 infection during the Delta wave, in comparison to the pre-Delta period, was associated with increased requirement for oxygen support (including ECMO) and higher maternal mortality. Disease severity and pregnancy complications were similar between the Omicron wave and pre-Delta period. SARS-CoV-2 infection of unvaccinated pregnant women carries considerable risks of morbidity and mortality regardless of variant, and vaccination remains key. Miscommunication of the risks of Omicron infection may impact adversely vaccination uptake among pregnant women, who are at increased risk of complications related to SARS-CoV-2. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- P. Birol Ilter
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - S. Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation TrustUniversity of LondonLondonUK
| | - M. A. Mutlu
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - A. B. Tekin
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - P. O'Brien
- Royal College of Obstetricians and GynaecologistsLondonUK
- University College London Hospitals, Institute For Women's HealthLondonUK
| | - P. von Dadelszen
- Institute of Women and Children's Health, School of Life Course and Population SciencesKing's College LondonLondonUK
| | - L. A. Magee
- Institute of Women and Children's Health, School of Life Course and Population SciencesKing's College LondonLondonUK
| | - S. Tekin
- Department of Anesthesiology and Reanimation, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - N. Tug
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - E. Kalafat
- Department of Obstetrics and Gynecology, School of MedicineKoc UniversityIstanbulTurkey
- Department of Statistics, Faculty of Arts and SciencesMiddle East Technical UniversityAnkaraTurkey
| | - A. Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation TrustUniversity of LondonLondonUK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research InstituteSt George's University of LondonLondonUK
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Prasad S, Kalafat E, Blakeway H, Townsend R, O'Brien P, Morris E, Draycott T, Thangaratinam S, Le Doare K, Ladhani S, von Dadelszen P, Magee LA, Heath P, Khalil A. Systematic review and meta-analysis of the effectiveness and perinatal outcomes of COVID-19 vaccination in pregnancy. Nat Commun 2022; 13:2414. [PMID: 35538060 PMCID: PMC9090726 DOI: 10.1038/s41467-022-30052-w] [Citation(s) in RCA: 133] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022] Open
Abstract
Safety and effectiveness of COVID-19 vaccines during pregnancy is a particular concern affecting vaccination uptake by this vulnerable group. Here we evaluated evidence from 23 studies including 117,552 COVID-19 vaccinated pregnant people, almost exclusively with mRNA vaccines. We show that the effectiveness of mRNA vaccination against RT-PCR confirmed SARS-CoV-2 infection 7 days after second dose was 89·5% (95% CI 69·0-96·4%, 18,828 vaccinated pregnant people, I2 = 73·9%). The risk of stillbirth was significantly lower in the vaccinated cohort by 15% (pooled OR 0·85; 95% CI 0·73–0·99, 66,067 vaccinated vs. 424,624 unvaccinated, I2 = 93·9%). There was no evidence of a higher risk of adverse outcomes including miscarriage, earlier gestation at birth, placental abruption, pulmonary embolism, postpartum haemorrhage, maternal death, intensive care unit admission, lower birthweight Z-score, or neonatal intensive care unit admission (p > 0.05 for all). COVID-19 mRNA vaccination in pregnancy appears to be safe and is associated with a reduction in stillbirth. Pregnant women have been disproportionately under-vaccinated against COVID-19, partly because they were excluded from initial trials. This systematic review and meta-analysis supports efficacy of vaccination in pregnancy, and finds no evidence of adverse maternal or perinatal outcomes.
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Affiliation(s)
- Smriti Prasad
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
| | - Erkan Kalafat
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey.,Department of Obstetrics and Gynaecology, School of Medicine, Koc University, Istanbul, Turkey
| | - Helena Blakeway
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
| | - Rosemary Townsend
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Pat O'Brien
- The Royal College of Obstetricians and Gynaecologists, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Edward Morris
- The Royal College of Obstetricians and Gynaecologists, London, UK.,Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Tim Draycott
- The Royal College of Obstetricians and Gynaecologists, London, UK.,North Bristol NHS Trust Department of Women's Health, Westbury-on-Trym, Bristol, UK
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, UK
| | - Kirsty Le Doare
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London, UK
| | - Shamez Ladhani
- Immunisation and Countermeasures Division, Public Health England, England, UK.,British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, England, UK
| | - Peter von Dadelszen
- Institute of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Laura A Magee
- Institute of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Paul Heath
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK. .,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
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Birol Ilter P, Prasad S, Berkkan M, Mutlu MA, Tekin AB, Celik E, Ata B, Turgal M, Yildiz S, Turkgeldi E, O'Brien P, von Dadelszen P, Magee LA, Kalafat E, Tug N, Khalil A. Clinical severity of SARS-CoV-2 infection among vaccinated and unvaccinated pregnancies during the Omicron wave. Ultrasound Obstet Gynecol 2022; 59:560-562. [PMID: 35229932 PMCID: PMC9111183 DOI: 10.1002/uog.24893] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 05/05/2023]
Affiliation(s)
- P. Birol Ilter
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - S. Prasad
- Fetal Medicine UnitSt George's University Hospitals NHS Foundation Trust, University of LondonLondonUK
| | - M. Berkkan
- Department of Obstetrics and GynecologySchool of Medicine, Koc UniversityIstanbulTurkey
| | - M. A. Mutlu
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - A. B. Tekin
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - E. Celik
- Department of Obstetrics and GynecologySchool of Medicine, Koc UniversityIstanbulTurkey
| | - B. Ata
- Department of Obstetrics and GynecologySchool of Medicine, Koc UniversityIstanbulTurkey
| | - M. Turgal
- Department of Obstetrics and GynecologySchool of Medicine, Koc UniversityIstanbulTurkey
| | - S. Yildiz
- Department of Obstetrics and GynecologySchool of Medicine, Koc UniversityIstanbulTurkey
| | - E. Turkgeldi
- Department of Obstetrics and GynecologySchool of Medicine, Koc UniversityIstanbulTurkey
| | - P. O'Brien
- Royal College of Obstetricians and GynaecologistsLondonUK
- University College London Hospitals, Institute for Women's HealthLondonUK
| | - P. von Dadelszen
- Institute of Women and Children's HealthSchool of Life Course and Population Sciences, King's College LondonLondonUK
| | - L. A. Magee
- Institute of Women and Children's HealthSchool of Life Course and Population Sciences, King's College LondonLondonUK
| | - E. Kalafat
- Department of Obstetrics and GynecologySchool of Medicine, Koc UniversityIstanbulTurkey
- Department of Statistics, Faculty of Arts and SciencesMiddle East Technical UniversityAnkaraTurkey
| | - N. Tug
- Department of Obstetrics and Gynecology, Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research HospitalUniversity of Health SciencesIstanbulTurkey
| | - A. Khalil
- Fetal Medicine UnitSt George's University Hospitals NHS Foundation Trust, University of LondonLondonUK
- Twins Trust Centre for Research and Clinical ExcellenceSt George's University Hospitals NHS Foundation TrustLondonUK
- Vascular Biology Research CentreMolecular and Clinical Sciences Research Institute, St George's University of LondonLondonUK
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Affiliation(s)
- Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Paul Heath
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London SW17 0QT, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London SW17 0QT, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London SW17 0QT, UK.
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Kalafat E, Prasad S, Birol P, Tekin AB, Kunt A, Di Fabrizio C, Alatas C, Celik E, Bagci H, Binder J, Le Doare K, Magee LA, Mutlu MA, Yassa M, Tug N, Sahin O, Krokos P, O’brien P, von Dadelszen P, Palmrich P, Papaioannou G, Ayaz R, Ladhani SN, Kalantaridou S, Mihmanli V, Khalil A. An internally validated prediction model for critical COVID-19 infection and intensive care unit admission in symptomatic pregnant women. Am J Obstet Gynecol 2022; 226:403.e1-403.e13. [PMID: 34582796 PMCID: PMC8463298 DOI: 10.1016/j.ajog.2021.09.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/12/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022]
Abstract
Background Pregnant women are at an increased risk of mortality and morbidity owing to COVID-19. Many studies have reported on the association of COVID-19 with pregnancy-specific adverse outcomes, but prediction models utilizing large cohorts of pregnant women are still lacking for estimating the risk of maternal morbidity and other adverse events. Objective The main aim of this study was to develop a prediction model to quantify the risk of progression to critical COVID-19 and intensive care unit admission in pregnant women with symptomatic infection. Study Design This was a multicenter retrospective cohort study including 8 hospitals from 4 countries (the United Kingdom, Austria, Greece, and Turkey). The data extraction was from February 2020 until May 2021. Included were consecutive pregnant and early postpartum women (within 10 days of birth); reverse transcriptase polymerase chain reaction confirmed SARS-CoV-2 infection. The primary outcome was progression to critical illness requiring intensive care. The secondary outcomes included maternal death, preeclampsia, and stillbirth. The association between the primary outcome and 12 candidate predictors having a known association with severe COVID-19 in pregnancy was analyzed with log-binomial mixed-effects regression and reported as adjusted risk ratios. All the potential predictors were evaluated in 1 model and only the baseline factors in another. The predictive accuracy was assessed by the area under the receiver operating characteristic curves. Results Of the 793 pregnant women who were positive for SARS-CoV-2 and were symptomatic, 44 (5.5%) were admitted to intensive care, of whom 10 died (1.3%). The ‘mini-COvid Maternal Intensive Therapy’ model included the following demographic and clinical variables available at disease onset: maternal age (adjusted risk ratio, 1.45; 95% confidence interval, 1.07–1.95; P=.015); body mass index (adjusted risk ratio, 1.34; 95% confidence interval, 1.06–1.66; P=.010); and diagnosis in the third trimester of pregnancy (adjusted risk ratio, 3.64; 95% confidence interval, 1.78–8.46; P=.001). The optimism-adjusted area under the receiver operating characteristic curve was 0.73. The ‘full-COvid Maternal Intensive Therapy’ model included body mass index (adjusted risk ratio, 1.39; 95% confidence interval, 1.07–1.95; P=.015), lower respiratory symptoms (adjusted risk ratio, 5.11; 95% confidence interval, 1.81–21.4; P=.007), neutrophil to lymphocyte ratio (adjusted risk ratio, 1.62; 95% confidence interval, 1.36–1.89; P<.001); and serum C-reactive protein (adjusted risk ratio, 1.30; 95% confidence interval, 1.15–1.44; P<.001), with an optimism-adjusted area under the receiver operating characteristic curve of 0.85. Neither model showed signs of a poor fit. Categorization as high-risk by either model was associated with a shorter diagnosis to intensive care unit admission interval (log-rank test P<.001, both), higher maternal death (5.2% vs 0.2%; P<.001), and preeclampsia (5.7% vs 1.0%; P<.001). A spreadsheet calculator is available for risk estimation. Conclusion At presentation with symptomatic COVID-19, pregnant and recently postpartum women can be stratified into high- and low-risk for progression to critical disease, even where resources are limited. This can support the nature and place of care. These models also highlight the independent risk for severe disease associated with obesity and should further emphasize that even in the absence of other comorbidities, vaccination is particularly important for these women. Finally, the model also provides useful information for policy makers when prioritizing national vaccination programs to quickly protect those at the highest risk of critical and fatal COVID-19.
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Briffa C, Di Fabrizio C, Kalafat E, Giorgione V, Bhate R, Huddy C, Richards J, Shetty S, Khalil A. Adverse neonatal outcome in twin pregnancy complicated by small-for-gestational age: twin vs singleton reference charts. Ultrasound Obstet Gynecol 2022; 59:377-384. [PMID: 34405924 DOI: 10.1002/uog.23764] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The use of twin-specific vs singleton growth charts in the assessment of twin pregnancy has been controversial. The aim of this study was to assess whether a diagnosis of small-for-gestational age (SGA) made using twin-specific estimated-fetal-weight (EFW) and birth-weight (BW) charts is associated more strongly with adverse neonatal outcomes in twin pregnancies, compared with when the diagnosis is made using singleton charts. METHODS This was a cohort study of twin pregnancies delivered at St George's Hospital, London, between January 2007 and May 2020. Twin pregnancies complicated by intrauterine death of one or both twins, fetal aneuploidy or major abnormality, twin-twin transfusion syndrome or twin anemia-polycythemia sequence and those delivered before 32 weeks' gestation, were excluded. SGA was defined as EFW or BW below the 10th centile, and was assessed using both twin-specific and singleton EFW and BW charts. The main study outcome was composite adverse neonatal outcome. Mixed-effects logistic regression analysis with random pregnancy-level intercepts was used to test the association between SGA classified using the different charts and adverse neonatal outcome. RESULTS A total of 1329 twin pregnancies were identified, of which 913 (1826 infants) were included in the analysis. Of these pregnancies, 723 (79.2%) were dichorionic and 190 (20.8%) were monochorionic. Using the singleton charts, 33.3% and 35.7% of pregnancies were classified as SGA based on EFW and BW, respectively. The corresponding values were 5.9% and 5.6% when using the twin-specific charts. Classification as SGA based on EFW using the twin charts was associated significantly with composite adverse neonatal outcome (odds ratio (OR), 4.78 (95% CI, 1.47-14.7); P = 0.007), as compared with classification as appropriate-for-gestational age (AGA). However, classification as SGA based on EFW using the singleton standard was not associated significantly with composite adverse neonatal outcome (OR, 1.36 (95% CI, 0.63-2.88); P = 0.424). Classification as SGA based on EFW using twin-specific standards provided a significantly better model fit than did using the singleton standard (likelihood ratio test, P < 0.001). When twin-specific charts were used, classification as SGA based on BW was associated significantly with a 9.3 times increased odds of composite adverse neonatal outcome (OR, 9.27 (95% CI, 2.86-30.0); P < 0.001). Neonates classified as SGA according to the singleton BW standard but not according to the twin-specific BW standards had a significantly lower rate of composite adverse neonatal outcome than did AGA twins (OR, 0.24 (95% CI, 0.07-0.66); P = 0.009). CONCLUSIONS The singleton charts classified one-third of twins as SGA, both prenatally and postnatally. Infants classified as SGA according to the twin-specific charts, but not those classified as SGA according to the singleton charts, had a significantly increased risk of adverse neonatal outcome compared with infants classified as AGA. This study provides further evidence that twin-specific charts perform better than do singleton charts in the prediction of adverse neonatal outcome in twin pregnancies. The use of these charts may reduce misclassification of twins as SGA and improve identification of those that are truly growth restricted. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Briffa
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - C Di Fabrizio
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - E Kalafat
- Koc University, School of Medicine, Department of Obstetrics and Gynecology, Istanbul, Turkey
- Middle East Technical University, Faculty of Arts and Sciences, Department of Statistics, Ankara, Turkey
| | - V Giorgione
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - R Bhate
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - C Huddy
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Neonatal Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Richards
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Neonatal Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - S Shetty
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Neonatal Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Khalil
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Blakeway H, Prasad S, Kalafat E, Heath PT, Ladhani SN, Le Doare K, Magee LA, O’Brien P, Rezvani A, von Dadelszen P, Khalil A. COVID-19 vaccination during pregnancy: coverage and safety. Am J Obstet Gynecol 2022; 226:236.e1-236.e14. [PMID: 34389291 PMCID: PMC8352848 DOI: 10.1016/j.ajog.2021.08.007] [Citation(s) in RCA: 224] [Impact Index Per Article: 112.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 08/01/2021] [Indexed: 12/04/2022]
Abstract
Background Concerns have been raised regarding a potential surge of COVID-19 in pregnancy, secondary to the rising numbers of COVID-19 in the community, easing of societal restrictions, and vaccine hesitancy. Although COVID-19 vaccination is now offered to all pregnant women in the United Kingdom; limited data exist on its uptake and safety. Objective This study aimed to investigate the uptake and safety of COVID-19 vaccination among pregnant women. Study Design This was a cohort study of pregnant women who gave birth at St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom, between March 1, 2020, and July 4, 2021. The primary outcome was uptake of COVID-19 vaccination and its determinants. The secondary outcomes were perinatal safety outcomes. Data were collected on COVID-19 vaccination uptake, vaccination type, gestational age at vaccination, and maternal characteristics, including age, parity, ethnicity, index of multiple deprivation score, and comorbidities. Further data were collected on perinatal outcomes, including stillbirth (fetal death at ≥24 weeks’ gestation), preterm birth, fetal and congenital abnormalities, and intrapartum complications. Pregnancy and neonatal outcomes of women who received the vaccine were compared with that of a matched cohort of women with balanced propensity scores. Effect magnitudes of vaccination on perinatal outcomes were reported as mean differences or odds ratios with 95% confidence intervals. Factors associated with antenatal vaccination were assessed with logistic regression analysis. Results Data were available for 1328 pregnant women of whom 140 received at least 1 dose of the COVID-19 vaccine before giving birth and 1188 women who did not; 85.7% of those vaccinated received their vaccine in the third trimester of pregnancy and 14.3% in the second trimester of pregnancy. Of those vaccinated, 127 (90.7%) received a messenger RNA vaccine and 13 (9.3%) a viral vector vaccine. There was evidence of reduced vaccine uptake in younger women (P=.001), women with high levels of deprivation (ie, fifth quintile of the index of multiple deprivation; P=.008), and women of Afro-Caribbean or Asian ethnicity compared with women of White ethnicity (P<.001). Women with prepregnancy diabetes mellitus had increased vaccine uptake (P=.008). In the multivariable model the fifth deprivation quintile (most deprived) (adjusted odds ratio, 0.10; 95% confidence interval, 0.02–0.10; P=.003) and Afro-Caribbean ethnicity (adjusted odds ratio, 0.27; 95% confidence interval, 0.06–0.85; P=.044) were significantly associated with lower antenatal vaccine uptake, whereas prepregnancy diabetes mellitus was significantly associated with higher antenatal vaccine uptake (adjusted odds ratio, 10.5; 95% confidence interval, 1.74–83.2; P=.014). In a propensity score–matched cohort, the rates of adverse pregnancy outcomes of 133 women who received at least 1 dose of the COVID-19 vaccine in pregnancy were similar to that of unvaccinated pregnant women (P>.05 for all): stillbirth (0.0% vs 0.2%), fetal abnormalities (2.2% vs 2.5%), postpartum hemorrhage (9.8% vs 9.0%), cesarean delivery (30.8% vs 34.1%), small for gestational age (12.0% vs 12.8%), maternal high-dependency unit or intensive care admission (6.0% vs 4.0%), or neonatal intensive care unit admission (5.3% vs 5.0%). Intrapartum pyrexia (3.7% vs 1.0%; P=.046) was significantly increased but the borderline statistical significance was lost after excluding women with antenatal COVID-19 infection (P=.079). Mixed-effects Cox regression showed that vaccination was not significantly associated with birth at <40 weeks’ gestation (hazard ratio, 0.93; 95% confidence interval, 0.71–1.23; P=.624). Conclusion Of pregnant women eligible for COVID-19 vaccination, less than one-third accepted COVID-19 vaccination during pregnancy, and they experienced similar pregnancy outcomes with unvaccinated pregnant women. There was lower uptake among younger women, non-White ethnicity, and lower socioeconomic background. This study has contributed to the body of evidence that having COVID-19 vaccination in pregnancy does not alter perinatal outcomes. Clear communication to improve awareness among pregnant women and healthcare professionals on vaccine safety is needed, alongside strategies to address vaccine hesitancy. These strategies include postvaccination surveillance to gather further data on pregnancy outcomes, particularly after first-trimester vaccination, and long-term infant follow-up.
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Binder J, Kalafat E, Palmrich P, Pateisky P, Khalil A. Should angiogenic markers be included in diagnostic criteria of superimposed pre-eclampsia in women with chronic hypertension? Ultrasound Obstet Gynecol 2022; 59:192-201. [PMID: 34165863 DOI: 10.1002/uog.23711] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Although the most recent guidance from the International Society for the Study of Hypertension in Pregnancy (ISSHP) has highlighted the role of angiogenic marker assessment in the diagnosis of pre-eclampsia (PE) in women with chronic hypertension, the ISSHP has withheld recommending its implementation due to the limited available evidence in this group of women. Therefore, we aimed to investigate the value of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) assessment in women with chronic hypertension and suspected superimposed PE. METHODS This was a retrospective analysis of prospectively collected data recorded in an electronic database between January 2013 and October 2019. Women with chronic hypertension and singleton pregnancy who had suspected superimposed PE were included. Superimposed PE was suspected in women presenting with worsening hypertension, epigastric pain, new-onset edema, dyspnea or neurological symptoms. The exclusion criteria were delivery within 1 week after assessment for reasons other than PE, chronic kidney disease, history of cardiac disease, fetal aneuploidy, genetic syndrome or major structural anomaly and missing pregnancy outcome. Maternal serum angiogenic markers (sFlt-1, PlGF and sFlt-1/PlGF ratio) were measured. The primary outcome was the utility of angiogenic markers in the prediction of superimposed PE. Predictive accuracy was assessed for superimposed PE diagnosed at different timepoints, including within 1 week after assessment and any time before birth. The secondary outcome was comparison of adverse maternal and perinatal outcomes between women with superimposed PE diagnosed according to the traditional ISSHP criteria and those diagnosed according to extended criteria including angiogenic markers. The predictive accuracy of each angiogenic marker was assessed using receiver-operating-characteristics-curve analysis. Area under the curve (AUC) values were compared using De Long's test. A sensitivity analysis was planned for gestational age at assessment. The association of various variables with composite adverse maternal and perinatal outcomes was assessed using binomial regression. RESULTS The study included 142 pregnant women with chronic hypertension and suspected superimposed PE, of whom 25 (17.6%) developed PE within 1 week after assessment, 52 (36.6%) developed PE at any timepoint before birth and 90 (63.4%) delivered without PE. Maternal serum angiogenic imbalance was associated significantly with superimposed PE diagnosed according to the ISSHP criteria within 1 week or at any time after assessment (P < 0.001 for both). The predictive accuracy of maternal serum sFlt-1/PlGF ratio for superimposed PE diagnosed within 1 week after assessment was superior to that of maternal serum PlGF level (AUC, 0.91 vs 0.86; P = 0.032). The addition of angiogenic imbalance to the traditional ISSHP diagnostic criteria was associated with an increase in the detection rate (35.1% increase; 95% credible interval (CrI), 16.6-53.6%) and positive (9.6% increase; 95% CrI, 0.0-20.6%) and negative (3.1% increase; 95% CrI, 1.3-4.9%) predictive values for composite adverse maternal outcome, with high posterior probabilities of an increase in each predictive accuracy parameter (> 99.9%, 95.6% and > 99.9%, respectively), without a meaningful decrease in specificity. The addition of angiogenic imbalance improved the detection rate for composite adverse perinatal outcome (20.6% increase; 95% CrI, 0.0-42.2%), with a high posterior probability (96.9%). There was a corresponding drop in specificity (5.7% decrease; 95% CrI, -2.3% to 13.6%), with a posterior probability of 91.8%. CONCLUSIONS In women with chronic hypertension and suspected superimposed PE, addition of maternal serum angiogenic markers to the traditional diagnostic criteria for superimposed PE improved significantly the sensitivity for the prediction of both maternal and perinatal adverse outcomes. Implementation of angiogenic marker assessment in the evaluation of pregnant women with chronic hypertension should therefore be considered. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Binder
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kalafat
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
- Department of Obstetrics and Gynecology, Faculty of Medicine, Koc University, Istanbul, Turkey
| | - P Palmrich
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Pateisky
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Somigliana E, Busnelli A, Kalafat E, Viganò P, Ata B. Recurrent Implantation Failure: A plea for a widely adopted rational definition. Reprod Biomed Online 2022; 45:183-185. [DOI: 10.1016/j.rbmo.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
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Kalafat E, Turkgeldi E, Yıldız S, Dizdar M, Keles I, Ata B. Outcomes of a GnRH Agonist Trigger Following a GnRH Antagonist or Flexible Progestin-Primed Ovarian Stimulation Cycle. Front Endocrinol (Lausanne) 2022; 13:837880. [PMID: 35663329 PMCID: PMC9161281 DOI: 10.3389/fendo.2022.837880] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/31/2022] [Indexed: 11/29/2022] Open
Abstract
A suggested explanation for the pituitary-suppressive effects of progestin-primed ovarian stimulation cycles (PPOS) is pituitary luteinizing hormone (LH) depletion with progestin exposure during the follicular phase. The GnRH agonist (GnRHa) trigger releases endogenous LH from the pituitary, and if the LH depletion theory is correct, the response to the agonist trigger would be dampened in PPOS cycles. In this study, we compared the performance of the GnRHa trigger after PPOS and GnRH antagonist ovarian stimulation cycles. All women who underwent ovarian stimulation with the GnRH antagonist or flexible PPOS (fPPOS) and received a GnRH agonist trigger were eligible for inclusion. Outcomes included number of metaphase-II (MII) oocytes retrieved per cycle, rates of empty follicle syndrome, maturation, fertilization, blastulation, and cumulative clinical pregnancy per stimulation cycle. During the screening period, there were 166 antagonists and 58 fPPOS cycles triggered with a GnRH agonist. Groups were matched for potential confounders using propensity score matching. Progestin-downregulated cycles had 19% high mature oocyte yield (median: 14 vs. 19 MII oocytes, P = 0.03). Cumulative ongoing pregnancy or live birth rates were estimated after matching for transferred embryo count, and rates were similar between GnRH antagonist and fPPOS group (57.0% vs. 62.1%, P = 0.68). However, the number of remaining blastocysts was higher in the fPPOS group (median: 5.0 vs. 6.0, P < 0.001). LH levels were higher in fPPOS cycles compared to GnRH antagonist cycles up to the trigger day (P < 0.001). After the GnRHa trigger, fPPOS cycles were associated with a steeper LH surge compared with antagonist cycles (P = 0.02). Higher endogenous gonadotropin levels through the stimulation period and an LH surge of higher magnitude following a GnRHa trigger suggest a milder pituitary suppression by fPPOS, which needs to be confirmed in larger samples. It appears that progestins do not deplete pituitary LH reserves and a GnRHa trigger is usable after PPOS in women with high ovarian reserve.
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Affiliation(s)
- Erkan Kalafat
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
| | - Engin Turkgeldi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
| | - Sule Yıldız
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
| | - Merve Dizdar
- Department of Obstetrics and Gynecology, Umraniye Teaching and Research Hospital, Istanbul, Turkey
| | - Ipek Keles
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Ata
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey
- ART Fertility Clinics, Dubai, United Arab Emirates
- *Correspondence: Baris Ata,
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Magee LA, von Dadelszen P, Kalafat E, Duncan EL, O'Brien P, Morris E, Heath P, Khalil A. COVID-19 vaccination in pregnancy-number needed to vaccinate to avoid harm. Lancet Infect Dis 2021; 21:1627. [PMID: 34739865 PMCID: PMC8563006 DOI: 10.1016/s1473-3099(21)00691-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/23/2021] [Accepted: 10/25/2021] [Indexed: 10/26/2022]
Affiliation(s)
- Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Erkan Kalafat
- Middle East Technical University, Faculty of Arts and Sciences, Department of Statistics, Ankara, Turkey; Koc University, School of Medicine, Department of Obstetrics and Gynaecology, Istanbul, Turkey
| | - Emma L Duncan
- Department of Twin Research & Genetic Epidemiology, School of Life Course Sciences, King's College London, London, UK
| | - Pat O'Brien
- The Royal College of Obstetricians and Gynaecologists, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
| | - Edward Morris
- The Royal College of Obstetricians and Gynaecologists, London, UK; Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Paul Heath
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London SW17 0QT, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London SW17 0QT, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London SW17 0QT, UK.
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Sahin O, Yildirmak T, Karacalar S, Aydın E, Ciftci MA, Bagci H, Yildirim S, Emeklioglu C, Balci BG, Genc S, Cingillioglu B, Mihmanli V, Khalil A, Kalafat E. Short-term outcomes of pregnant women with convalescent COVID-19 and factors associated with false-negative polymerase chain reaction test: A prospective cohort study. Int J Clin Pract 2021; 75:e14670. [PMID: 34342119 PMCID: PMC8420588 DOI: 10.1111/ijcp.14670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 02/14/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
AIM To evaluate the clinical factors associated with false-negative RT-PCR results and to report the outcome of a cohort of pregnant women with COVID-19. METHODS This cohort study was conducted in a tertiary referral pandemic hospital and included 56 pregnant women. A study including pregnant women with either a laboratory or clinical diagnosis for COVID-19 were included in the study. The primary outcome was clinical factors associated with false-negative RT-PCR results defined as a positive immunoglobulin M assessed by rapid testing in clinically diagnosed patients. Clinical outcomes of laboratory diagnosed patients were also reported. RESULTS In total, 56 women with either RT-PCR or clinical COVID-19 diagnosis were included in the study. Forty-three women either had RT-PCR positivity or IgM positivity. The clinical outcome of these pregnancies was as follows: mean maternal age 27.7, immunoglobulin M positive patients 76.7%, RT-PCR positive patients 55.8%, maternal comorbidities 11.5%, complications in patients below 20 weeks 34.8%, complications in patients above 20 weeks 65.1%, elevated CRP 83.7%, lymphopenia 30.2%, time from hospital admission to final follow-up days 37 and stillbirth 8.3%. The proportion of women who tested positive for SARS-CoV-2 immunoglobulin M was 100% in the RT-PCR positive group and 56.5% in the clinical diagnosis group (P = .002). The symptom onset to RT-PCR testing interval longer than a week (risk ratio: 2.72, 95% CI: 1.14-5.40, P = .003) and presence of dyspnoea (risk ratio: 0.38, 95% CI: 0.14-0.89, P = .035) were associated with false-negative RT-PCR tests. The area under the curve of these parameters predicting false-negative RT-PCR was 0.73 (95% CI: 0.57-0.89). CONCLUSIONS Symptomatic women with a negative RT-PCR should not be dismissed as potential COVID-19 patients, especially in the presence of prolonged symptom onset-test interval and in women without dyspnoea.
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Affiliation(s)
- Orhan Sahin
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Taner Yildirmak
- Department of Infectious Diseases and Clinical MicrobiologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Serap Karacalar
- Department of Anesthesiology and ReanimationProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Emine Aydın
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Mehmet Ali Ciftci
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Helin Bagci
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Sukran Yildirim
- Department of NeonatologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Cagdas Emeklioglu
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Burcu Gulsah Balci
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Simten Genc
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Basak Cingillioglu
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Veli Mihmanli
- Department of Obstetrics and GynecologyProf. Dr. Cemil Tascioglu City HospitalIstanbulTurkey
| | - Asma Khalil
- Fetal Medicine UnitSt. George’s HospitalSt. George’s University of LondonUK
| | - Erkan Kalafat
- Department of Obstetrics and GynecologyFaculty of MedicineKoc UniversityIstanbulTurkey
- Department of StatisticsFaculty of Arts and SciencesMiddle East Technical UniversityAnkaraTurkey
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Kalafat E, Benlioğlu C, Gökçe A, Şükür YE, Özmen B, Sönmezer M, Atabekoğlu CS, Aytaç R, Berker B. Factors associated with livebirth in couples undergoing their first in vitro fertilization cycle: An internally validated prediction model. Turk J Obstet Gynecol 2021; 18:212-220. [PMID: 34580695 PMCID: PMC8480211 DOI: 10.4274/tjod.galenos.2021.71770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: The aim of the study is to create a new model to predict successful outcome in assisted reproductive techniques. Materials and Methods: A retrospective cohort study was conducted in tertiary fertility center between 2010 and 2017. Nulliparous women younger than 45 years-old undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) for the first time were included; frozen embryo transfers, canceled induction cycles, freeze-all cycles were excluded. Two prediction models were built using multivariate logistic regression with a subset of the dataset and then were internally validated using bootstrapping methods. Results: Four hundred eighty eight women were included with 136 (27.9%) live births. The basal model was built using variable age, antral follicle count (AFC), and basal luteinizing hormone (LH) levels. Age over 37 years [odds ratio (OR): 0.07, 95% confidence interval (CI): 0.00-0.36] and AFC below 5 (OR: 0.15, 95% CI: 0.02-0.53) was associated with poorer outcomes whereas an LH level above 6 mIU/mL (OR: 2.24, 95% CI: 1.27-3.94) was associated with better outcomes. Optimism adjusted area under the curve (AUC) of this model was 0.68 (95% CI: 0.62-0.74). Combined model in addition to basal model variables included the length of induction cycle, the endometrial thickness at the day of transfer, grade and count of the transferred embryo. Cycles lasting more than ten days (OR: 2.23, 95% CI: 1.17-4.42), an endometrial thickness greater than 9 mm (OR: 2.07, 95% CI: 1.00-4.53) were associated with better outcomes. Optimism adjusted AUC of this model was 0.76 (95% CI: 0.70-0.81). Calibration of both models was good according to Hosmer Lemeshow test (p=0.979 and p=0.848, respectively). Conclusion: This internally validated prediction model has good calibration and can be used predicting outcomes in first time IVF/ICSI cycles with modest sensitivity.
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Affiliation(s)
- Erkan Kalafat
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Can Benlioğlu
- Doğubeyazıt State Hospital, Ministry of Health, Ağrı, Turkey
| | - Ali Gökçe
- Yıldırım Beyazıt University, Yenimahalle Training and Research Hospital, Ankara, Turkey
| | - Yavuz Emre Şükür
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Batuhan Özmen
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Murat Sönmezer
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Cem Somer Atabekoğlu
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Ruşen Aytaç
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Bülent Berker
- Ankara University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
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Affiliation(s)
- Erkan Kalafat
- Koc University, School of Medicine, Department of Obstetrics and Gynaecology, Istanbul, Turkey
| | - Laura A Magee
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Peter von Dadelszen
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Pat O'Brien
- The Royal College of Obstetricians and Gynaecologists, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, Cranmer Terrace, London SW17 0RE, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK.
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Yildiz S, Turkgeldi E, Kalafat E, Keles I, Gokyer D, Ata B. Do live birth rate and obstetric outcomes vary between immediate and delayed embryo transfers following freeze-all cycles? J Gynecol Obstet Hum Reprod 2021; 50:102224. [PMID: 34506996 DOI: 10.1016/j.jogoh.2021.102224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/24/2021] [Accepted: 09/05/2021] [Indexed: 11/24/2022]
Abstract
RESEARCH QUESTION Do live birth rates (LBR), obstetric and perinatal outcomes vary between women who underwent frozen embryo transfer (ET) in the immediately subsequent menstrual cycle, and with those who underwent delayed frozen ET. DESIGN Retrospective cohort study (n = 198) consisting of 119 women who underwent immediate transfer within 30 days of oocyte retrieval (OR) and 79 women who underwent delayed transfer which was performed after >30 days following OR. Either flexible antagonist or flexible progestin-primed ovarian stimulation protocols were started after a baseline ultrasonography on the second or third day of menstrual cycle. Only freeze all cycles were included in the study and all transfers were with hormonal endometrial preparation. Main outcome measures were LBR, birth weight, gestational day at birth and pregnancy complications. RESULTS Peak estradiol level on trigger day (2746 vs 2081 pg/ml) and number of metaphase-two oocytes (13 vs 10) were significantly higher in the immediate transfer group. Clinical pregnancy rate per ET was similar between the groups (50.4% vs 44.3%). However, miscarriage rate per positive pregnancy was significantly higher (12.3% vs 31.1%) while LBR per ET was significantly lower (42.9% vs 26.6%) in the delayed transfer group. Median gestational age at delivery were 267.5 and 268 days in the immediate and delayed transfer groups. Median birthweight was significantly higher in the delayed transfer group (3520 vs 3195 g). Adjusted analyses also suggest similar LBR with immediate and delayed transfer. CONCLUSION(S) Frozen ET in the immediate menstrual cycle and delayed ET, after a freeze all strategy did not show significant difference in terms of LBR after adjustment. Obstetric and perinatal outcomes of frozen ET in the immediate menstrual cycle appear reassuring.
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Affiliation(s)
- Sule Yildiz
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koç University Hospital, Istanbul, Turkey
| | - Engin Turkgeldi
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koç University Hospital, Istanbul, Turkey
| | - Erkan Kalafat
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koç University Hospital, Istanbul, Turkey
| | - Ipek Keles
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koç University Hospital, Istanbul, Turkey
| | - Dilan Gokyer
- Koç University School of Medicine, Istanbul, Turkey
| | - Baris Ata
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Koç University Hospital, Istanbul, Turkey.
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Abstract
Background Women with chronic hypertension face a 5‐ to 6‐fold increased risk of developing preeclampsia compared with normotensive women. Angiogenic markers, especially soluble fms‐like kinase 1 (sFlt‐1) and placental growth factor (PlGF), were identified as clinically useful markers predicting the development of preeclampsia, but data on the prediction of superimposed preeclampsia are scarce. Therefore, we aimed to evaluate the predictive value of the sFlt‐1/PlGF ratio for delivery because of superimposed preeclampsia in women with chronic hypertension. Methods and Results This retrospective study included 142 women with chronic hypertension and suspected superimposed preeclampsia. Twenty‐seven women (19.0%) delivered because of maternal indications only, 17 women (12.0%) because of fetal indications primarily, and 98 women (69.0%) for other reasons. Women who both delivered because of maternal indications and for fetal indications had a significantly higher sFlt‐1/PlGF ratio (median 99.9 and 120.2 versus 7.3, respectively, P<0.001 for both) and lower PlGF levels (median 73.6 and 53.3 versus 320.0 pg/mL, respectively, P<0.001 for both) compared with women who delivered for other reasons. SFlt‐1/PlGF ratio and PlGF were strong predictors for delivery because of superimposed preeclampsia, whether for maternal or fetal indications (P<0.05). Half of women with angiogenic imbalance (sFlt‐1/PlGF ratio ≥85 or PlGF levels <100 pg/mL) delivered because of maternal or fetal indications within 1.6 weeks (95% CI, 1.0–2.4 weeks). Conclusions Angiogenic marker imbalance in women with suspected superimposed preeclampsia can predict delivery because of maternal and fetal indications related to superimposed preeclampsia and is associated with a significantly shorter time to delivery interval.
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Affiliation(s)
- Julia Binder
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Pilar Palmrich
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Erkan Kalafat
- Department of Statistics Faculty of Arts and Sciences Middle East Technical University Ankara Turkey.,Department of Obstetrics and Gynecology Faculty of Medicine Koc University Istanbul Turkey
| | - Petra Pateisky
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Ebru Öztürk
- Department of Biostatistics Faculty of Medicine Hacettepe University Ankara Turkey
| | - Johanna Mittelberger
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Asma Khalil
- Fetal Medicine Unit St George's Hospital St George's University of London London United Kingdom.,Vascular Biology Research Centre Molecular and Clinical Sciences Research Institute St George's University of London London United Kingdom
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Binder J, Kalafat E, Palmrich P, Pateisky P, Khalil A. Angiogenic markers and their longitudinal change for predicting adverse outcomes in pregnant women with chronic hypertension. Am J Obstet Gynecol 2021; 225:305.e1-305.e14. [PMID: 33812812 DOI: 10.1016/j.ajog.2021.03.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Women with chronic hypertension are at increased risk for adverse maternal and perinatal outcomes. Maternal serum angiogenic markers, such as soluble fms-like tyrosine kinase 1 and placental growth factor, can be used to triage women with suspected preeclampsia. However, data about these markers in pregnant women with chronic hypertension are scarce. OBJECTIVE We aimed to evaluate the predictive accuracy of maternal serum levels of soluble fms-like tyrosine kinase 1, placental growth factor, and their ratio for predicting adverse maternal and perinatal outcomes in women with chronic hypertension. STUDY DESIGN This was a retrospective analysis of prospectively collected data from January 2013 to October 2019 at the University of Vienna Hospital, Vienna, Austria. The inclusion criteria were pregnant women with chronic hypertension and suspected preeclampsia. The primary outcome of this study was the prognostic performance of angiogenic markers for the prediction of adverse maternal and perinatal outcomes in pregnant women with chronic hypertension. The accuracy of angiogenic markers for predicting adverse composite outcomes was assessed with a binomial logistic regression. The accuracy of each marker was assessed using receiver operating characteristics curves and area under the curve values. Area under the curve values were compared using De Long's test. RESULTS Of the 145 included women with chronic hypertension and suspected superimposed preeclampsia, 26 (17.9%) women developed complications (ie, composite adverse maternal or fetal outcomes) within 1 week of assessment (average gestational age at assessment, 29.9 weeks) and 35 (24.1%) developed complications at any time (average gestational age at assessment, 30.1 weeks). In women who developed complications at any time, the median maternal serum soluble fms-like tyrosine kinase-1 to placental growth factor ratio was 149.4 (interquartile range, 64.6-457.4) compared with 8.0 (interquartile range, 3.37-41.2) for women who did not develop complications (P<.001). The area under the curve values for the maternal serum soluble fms-like tyrosine kinase-1 to placental growth factor ratio Z-score (0.95; 95% confidence interval, 0.90-0.99) and placental growth factor level Z-score (0.94; 95% confidence interval, 0.88-0.99) for predicting complications within 1 week of assessment were very high. The area under the curve values for new-onset edema (0.61; 95% confidence interval, 0.52-0.70), proteinuria (0.62; 95% confidence interval, 0.52-0.71), high mean arterial pressure (0.52; 95% confidence interval, 0.50-0.54), and other symptoms of preeclampsia (0.57; 95% confidence interval, 0.49-0.65) were all significantly lower than for the angiogenic markers (P<.001 for all). Women who had an angiogenic imbalance and/or proteinuria had the highest rate of complications (28/57, 49.1%). The rate of complications in women with an angiogenic imbalance and/or proteinuria was significantly higher than in women with either proteinuria, other symptoms, or intrauterine growth restriction in the absence of an angiogenic imbalance (49.1% vs 16.7%; P=.039). The highest positive and negative predictive values for predicting adverse outcomes were demonstrated by an angiogenic imbalance and/or proteinuria criteria with a positive predictive value of 49.1% (95% confidence interval, 50.4%-57.9%) and a negative predictive value of 92% (95% confidence interval, 85.5%-95.8%). Longitudinal changes in measurements of the gestational age-corrected ratio of soluble fms-like tyrosine kinase-1 to placental growth factor up to the last measurement had a significantly higher area under the curve value than the last measurement alone (area under the curve, 0.95; 95% confidence interval, 0.92-0.99 vs 0.87; 95% confidence interval, 0.79-0.95; P=.024) CONCLUSION: Maternal serum angiogenic markers are superior to clinical assessment in predicting adverse maternal and perinatal outcomes in pregnant women with chronic hypertension. Repeated measurements of the ratio of soluble fms-like tyrosine kinase-1 to placental growth factor seems beneficial given the better predictive accuracy compared with a single measurement alone. The use of angiogenic makers should be implemented in clinical management guidelines for pregnant women with chronic hypertension.
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Yassa M, Kaya C, Kalafat E, Tekin AB, Karakas S, Mutlu MA, Birol P, Tug N. The Comparison of Transvaginal Natural Orifice Transluminal Endoscopic Surgery and Conventional Laparoscopy in Opportunistic Bilateral Salpingectomy for Permanent Female Sterilization. J Minim Invasive Gynecol 2021; 29:257-264.e1. [PMID: 34411729 DOI: 10.1016/j.jmig.2021.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 01/11/2023]
Abstract
STUDY OBJECTIVE To compare the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) approach with conventional laparoscopy (CL) in opportunistic bilateral salpingectomy (BS) alone for permanent female sterilization as an opportunistic cancer prevention strategy. DESIGN Prospective cohort study. SETTING Two-centered tertiary hospitals. PATIENTS Ninety-six women with a nonprolapsed uterus seeking definitive surgical permanent contraception. INTERVENTIONS Patients were scheduled for BS and assigned to a study arm in a 2:1 fashion (CL:vNOTES allocation ratio) concerning patient's choice. MEASUREMENTS AND MAIN RESULTS Patients were followed at their postoperative first week and first month. The visual analog score (VAS), Patient Global Impression of Improvement, and Female Sexual Function Index scales were used to assess the pain, patient satisfaction, and discomfort/pain after vaginal penetration, respectively. Patients who underwent to vNOTES had a significantly higher number of previous abdominal surgery (median difference, 1.97; 95% confidence interval [CI], 1.12-3.48; p = .016). Compared with CL, vNOTES was associated with lower 6-hour (rate ratio [RR], 0.63; 95% CI, 0.50-0.77) and 24-hour (RR, 0.33; 95% CI, 0.23-0.46) postoperative VAS scores and less amount of postoperative analgesics (RR, 0.54; 95% CI, 0.36-0.78). The slope of change in postoperative VAS scores was in a shorter time in the vNOTES group (RR, 0.47; 95% CI, 0.36-0.60). The rate of postoperative improvement was higher in the vNOTES group than the CL group at the postoperative first week (87.5% vs 68.2%, χ2 = 4.232, p = .032) and first month (96.9% vs 87.9%, χ2 = 2.091, p = .140). The rate of patients reporting postoperative decline in Female Sexual Function Index /pain scores (RR, 0.97; 95% CI, 0.47-1.96) was found to be similar in both of the study groups, and no postoperative complication was observed in either group. CONCLUSION Women seeking permanent sterilization and who underwent BS for ovarian cancer risk reduction purposes had higher satisfaction, less postoperative pain, lower analgesic requirement, and similar surgical outcomes in the vNOTES group than the CL group, even in patients with previous surgeries and a nonprolapsed uterus. vNOTES approach could be the preferred method for the opportunistic BS in female sterilization.
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Affiliation(s)
- Murat Yassa
- Department of Obstetrics and Gynecology, Sehit Prof Dr Ilhan Varank Sancaktepe Training and Research Hospital, University of Health Sciences (Drs. Yassa, Tekin, Mutlu, Birol, and Tug).
| | - Cihan Kaya
- Department of Obstetrics and Gynecology, Acibadem Bakirkoy Hospital, Acibadem Mehmet Ali Aydinlar University (Dr. Kaya)
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University (Dr. Kalafat)
| | - Arzu Bilge Tekin
- Department of Obstetrics and Gynecology, Sehit Prof Dr Ilhan Varank Sancaktepe Training and Research Hospital, University of Health Sciences (Drs. Yassa, Tekin, Mutlu, Birol, and Tug)
| | - Sema Karakas
- Department of Obstetrics and Gynecology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences (Dr. Karakas), Istanbul, Turkey
| | - Memis Ali Mutlu
- Department of Obstetrics and Gynecology, Sehit Prof Dr Ilhan Varank Sancaktepe Training and Research Hospital, University of Health Sciences (Drs. Yassa, Tekin, Mutlu, Birol, and Tug)
| | - Pinar Birol
- Department of Obstetrics and Gynecology, Sehit Prof Dr Ilhan Varank Sancaktepe Training and Research Hospital, University of Health Sciences (Drs. Yassa, Tekin, Mutlu, Birol, and Tug)
| | - Niyazi Tug
- Department of Obstetrics and Gynecology, Sehit Prof Dr Ilhan Varank Sancaktepe Training and Research Hospital, University of Health Sciences (Drs. Yassa, Tekin, Mutlu, Birol, and Tug)
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Yildiz S, Turkgeldi E, Kalafat E, Gokyer D, Keles I, Ata B. P–692 Are live birth rate and obstetric outcomes different between immediate and delayed embryo transfers following a freeze-all cycle? A retrospective study combined with a meta-analysis. Hum Reprod 2021. [DOI: 10.1093/humrep/deab130.691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Study question
Do livebirth rate (LBR), obstetric and perinatal outcomes vary between frozen embryo transfers (FET) in the first or subsequent menstrual cycles following a freeze-all approach?
Summary answer
Immediate FET has a higher LBR and similar perinatal outcomes than delayed FET. Quantitative synthesis of available literature shows an increased LBR with immediate transfer.
What is known already
Whether FET should be done in the first menstrual cycle following oocyte collection (OC) is controversial and the duration of a possible detrimental effect of supraphysiological sex steroid levels on pregnancy outcome is unknown. A multinational survey centers showed that, 61% of clinicians prefer to wait for a washout period before proceeding to FET, even after a failed fresh embryo transfer. Limited number of studies compared FET in the first menstrual cycle with delayed FET in a subsequent cycle with varying results. There is limited data on obstetric outcomes of pregnancies resulting from FET in the first menstrual cycle.
Study design, size, duration
198 women who underwent a freeze-all cycle followed by FET between July 2017 and June 2020 were included. 119 FET in the first menstrual cycle (<30 days from oocyte collection) and 79 FET in subsequent cycles (>30 days from oocyte collection) were retrospectively compared. MEDLINE was searched on 01 January 2021 using relevant keywords. Cohort studies comparing immediate versus delayed transfer following freeze all cycles were included and quantitative summary for LBR was obtained.
Participants/materials, setting, methods
Freeze-all was undertaken when (i) the woman is deemed to be at high risk for OHSS, (ii)serum progesterone level is > 1.5 ng/ml on the day of trigger, (iii)preimplantation genetic testing is planned, (iv)the woman will undergo surgery prior to ET, (v)couple preference.
Main results and the role of chance
Baseline characteristics were similar between the groups except for antral follicle count (22 vs 18, MD = 5, 95% CI = 0 to 8), and number of metaphase-two oocytes (13 vs 10, MD = 3, 95% CI = 1 to 6) all of which were significantly higher in the immediate transfer group. Clinical pregnancy rate (CPR) per ET was similar in two groups (50.4% vs 44.3%, RR = 1.14, 95% CI = 0.84 to 1.54). Miscarriage rate per pregnancy was significantly lower (12.3 vs 31.1, RR = 0.40, 95% CI = 0.19 to 0.84) and LBR per ET was significantly higher (42.9 vs 26.6, RR = 1.61, 95% CI = 1.06 to 2.46) in the immediate transfer group.
Median gestational age at delivery was similar (267.5 (262.5–273) vs 268 (260–271.5) days, MD = 1.00, 95% CI= –4.00 to 5.00). Median birthweight was significantly higher in the delayed transfer group (3520 vs 3195 grams, MD= –300, 95% CI= –660 to –20 grams). Birthweight percentile, height at birth and head circumference were similar between groups.
Literature search revealed 1712 studies from which nine were eligible for quantitative summary. Cumulative risk ratio showed a 10% increase in LBR with immediate transfer compared to delayed transfer (RR = 1.10, 95% CI = 1.01 – 1.20, I2=67%, 17369 embryo transfers).
Limitations, reasons for caution
Our study is limited by its retrospective design and relatively limited sample size for multivariate analyses. Yet, it is reassuring that the majority of our findings are consistent with previous publications.
Wider implications of the findings: The hypotheses generated by our retrospective findings, i.e., FET in the immediate menstrual cycle resembling fresh ETs with strong trends towards lower birthweight and lower incidence of preeclampsia is noteworthy for the design of future studies, and these outcomes should be followed and reported.
Trial registration number
None
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Affiliation(s)
- S Yildiz
- Koc University School of Medicine, Obstetrics and Gynecology, Istanbul, Turkey
| | - E Turkgeldi
- Koc University School of Medicine, Obstetrics and Gynecology, Istanbul, Turkey
| | - E Kalafat
- Koc University School of Medicine, Obstetrics and Gynecology, Istanbul, Turkey
| | - D Gokyer
- Koc University School of Medicine, Obstetrics and Gynecology, Istanbul, Turkey
| | - I Keles
- Koc University Hospital, Assisted Reproduction Unit, Istanbul, Turkey
| | - B Ata
- Koc University School of Medicine, Obstetrics and Gynecology, Istanbul, Turkey
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Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I, O'Brien P, Morris E, Draycott T, Thangaratinam S, Le Doare K, Ladhani S, von Dadelszen P, Magee LA, Khalil A. COVID-19 and maternal and perinatal outcomes - Authors' reply. Lancet Glob Health 2021; 9:e1066. [PMID: 34297960 PMCID: PMC8293946 DOI: 10.1016/s2214-109x(21)00293-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Barbara Chmielewska
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, St George's University of London, London SW17 0QT, UK
| | - Imogen Barratt
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, St George's University of London, London SW17 0QT, UK
| | - Rosemary Townsend
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, St George's University of London, London SW17 0QT, UK
| | - Erkan Kalafat
- Middle East Technical University, Faculty of Arts and Sciences, Department of Statistics, Ankara, Turkey; Koc University, School of Medicine, Department of Obstetrics and Gynaecology, Istanbul, Turkey
| | - Jan van der Meulen
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Pat O'Brien
- The Royal College of Obstetricians and Gynaecologists, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
| | - Edward Morris
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Tim Draycott
- The Royal College of Obstetricians and Gynaecologists, London, UK; North Bristol NHS Trust Department of Women's Health, Westbury on Trym, UK
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, UK
| | - Kirsty Le Doare
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London SW17 0QT, UK
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London SW17 0QT, UK; Immunisation and Countermeasures Division, Public Health England, London, UK; British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Laura A Magee
- British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, St George's University of London, London SW17 0QT, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London SW17 0QT, UK.
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Ata B, Kalafat E, Somigliana E. A new definition of recurrent implantation failure on the basis of anticipated blastocyst aneuploidy rates across female age. Fertil Steril 2021; 116:1320-1327. [PMID: 34332750 DOI: 10.1016/j.fertnstert.2021.06.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/04/2021] [Accepted: 06/24/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To present a definition of recurrent implantation failure that accounts for the effects of female age and anticipated blastocyst euploidy rates on cumulative implantation rates. DESIGN Mathematical modeling. SETTING Not applicable. PATIENT(S) Not applicable. INTERVENTION(S) Mathematical modeling of cumulative implantation probability on the basis of published blastocyst euploidy rates across categories of female age. MAIN OUTCOME MEASURE(S) The number of blastocysts required to achieve 95% cumulative implantation probability under the assumption of the absence of any other factor affecting implantation. RESULT(S) When the euploidy status of the transferred embryo is unknown (i.e., not subjected to preimplantation genetic testing for aneuploidies), our simulation shows that no age category reaches 95% cumulative probability of implantation of at least one embryo until after transfer of seven blastocysts. The number of blastocysts required to reach the same threshold is higher for older patients. For example, women older than 38 years require transfer of more than 10 untested blastocysts for the upper range of predictive probability to meet the threshold of 95%. On the other hand, if the implantation rate for a euploid blastocyst is assumed to be 55%, then 4 blastocysts are enough to reach a cumulative probability rate greater than 95%, regardless of age. CONCLUSION(S) The term "recurrent implantation failure" should be a functional term guiding further management. We suggest that recurrent implantation failure should not be called until implantation failure becomes reasonably likely to be caused by factors other than embryo aneuploidy, the leading cause of implantation failure. We propose a new definition that factors in anticipated blastocyst euploidy rates across categories of female age, euploid blastocyst implantation rate, and a specified threshold of cumulative probability of implantation.
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Affiliation(s)
- Baris Ata
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey.
| | - Erkan Kalafat
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey; Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
| | - Edgardo Somigliana
- Infertility Unit, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Università degli Studi di Milano, Milan, Italy
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Townsend R, Chmielewska B, Barratt I, Kalafat E, van der Meulen J, Gurol-Urganci I, O'Brien P, Morris E, Draycott T, Thangaratinam S, Doare KL, Ladhani S, Dadelszen PV, Magee LA, Khalil A. Global changes in maternity care provision during the COVID-19 pandemic: A systematic review and meta-analysis. EClinicalMedicine 2021; 37:100947. [PMID: 34195576 PMCID: PMC8233134 DOI: 10.1016/j.eclinm.2021.100947] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has had a profound impact on healthcare systems globally, with a worrying increase in adverse maternal and foetal outcomes. We aimed to assess the changes in maternity healthcare provision and healthcare-seeking by pregnant women during the COVID-19 pandemic. METHODS We performed a systematic review and meta-analysis of studies of the effects of the pandemic on provision of, access to and attendance at maternity services (CRD42020211753). We searched MEDLINE and Embase in accordance with PRISMA guidelines from January 1st, 2020 to April 17th 2021 for controlled observational studies and research letters reporting primary data comparing maternity healthcare-seeking and healthcare delivery during compared to before the COVID-19 pandemic. Case reports and series, systematic literature reviews, and pre-print studies were excluded. Meta-analysis was performed on comparable outcomes that were reported in two or more studies. Data were combined using random-effects meta-analysis, using risk ratios (RR) or incidence rate ratios (IRR) with 95% confidence intervals (CI). FINDINGS Of 4743 citations identified, 56 were included in the systematic review, and 21 in the meta-analysis. We identified a significant decrease in the number of antenatal clinic visits (IRR 0614, 95% CI 0486-0776, P<00001, I2=54.6%) and unscheduled care visits (IRR 0741, 95% CI 0602-0911, P = 00046, I2=00%) per week, and an increase in virtual or remote antenatal care (IRR 4656 95% CI 7762-2794, P<00001, I2=90.6%) and hospitalisation of unscheduled attendees (RR 1214, 95% CI 1118-1319, P<00001, I2=00%). There was a decrease in the use of GA for category 1 Caesarean sections (CS) (RR 0529, 95% CI 0407-0690, P<00001, I2=00%). There was no significant change in intrapartum epidural use (P = 00896) or the use of GA for elective CS (P = 079). INTERPRETATION Reduced maternity healthcare-seeking and healthcare provision during the COVID-19 pandemic has been global, and must be considered as potentially contributing to worsening of pregnancy outcomes observed during the pandemic.
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Affiliation(s)
- Rosemary Townsend
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom
| | - Barbara Chmielewska
- Fetal Medicine Unit, St George's Hospital, St George's University of London, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
| | - Imogen Barratt
- Fetal Medicine Unit, St George's Hospital, St George's University of London, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
| | - Erkan Kalafat
- Middle East Technical University, Faculty of Arts and Sciences, Department of Statistics, Ankara, Turkey
- Koc University, School of Medicine, Department of Obstetrics and Gynaecology, Istanbul, Turkey
| | - Jan van der Meulen
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Ipek Gurol-Urganci
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Pat O'Brien
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom
- The Royal College of Obstetricians and Gynaecologists, London, United Kingdom
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Edward Morris
- The Royal College of Obstetricians and Gynaecologists, London, United Kingdom
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, United Kingdom
| | - Tim Draycott
- The Royal College of Obstetricians and Gynaecologists, London, United Kingdom
- North Bristol NHS Trust Department of Women's Health, Westbury on Trym, United Kingdom
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, United Kingdom
| | - Kirsty Le Doare
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
- Immunisation and Countermeasures Division, Public Health England, United Kingdom
- British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Asma Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom
- Fetal Medicine Unit, St George's Hospital, St George's University of London, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
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Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I, O'Brien P, Morris E, Draycott T, Thangaratinam S, Le Doare K, Ladhani S, von Dadelszen P, Magee L, Khalil A. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis. Lancet Glob Health 2021; 9:e759-e772. [PMID: 33811827 PMCID: PMC8012052 DOI: 10.1016/s2214-109x(21)00079-6] [Citation(s) in RCA: 539] [Impact Index Per Article: 179.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The COVID-19 pandemic has had a profound impact on health-care systems and potentially on pregnancy outcomes, but no systematic synthesis of evidence of this effect has been undertaken. We aimed to assess the collective evidence on the effects on maternal, fetal, and neonatal outcomes of the pandemic. METHODS We did a systematic review and meta-analysis of studies on the effects of the pandemic on maternal, fetal, and neonatal outcomes. We searched MEDLINE and Embase in accordance with PRISMA guidelines, from Jan 1, 2020, to Jan 8, 2021, for case-control studies, cohort studies, and brief reports comparing maternal and perinatal mortality, maternal morbidity, pregnancy complications, and intrapartum and neonatal outcomes before and during the pandemic. We also planned to record any additional maternal and offspring outcomes identified. Studies of solely SARS-CoV-2-infected pregnant individuals, as well as case reports, studies without comparison groups, narrative or systematic literature reviews, preprints, and studies reporting on overlapping populations were excluded. Quantitative meta-analysis was done for an outcome when more than one study presented relevant data. Random-effects estimate of the pooled odds ratio (OR) of each outcome were generated with use of the Mantel-Haenszel method. This review was registered with PROSPERO (CRD42020211753). FINDINGS The search identified 3592 citations, of which 40 studies were included. We identified significant increases in stillbirth (pooled OR 1·28 [95% CI 1·07-1·54]; I2=63%; 12 studies, 168 295 pregnancies during and 198 993 before the pandemic) and maternal death (1·37 [1·22-1·53; I2=0%, two studies [both from low-income and middle-income countries], 1 237 018 and 2 224 859 pregnancies) during versus before the pandemic. Preterm births before 37 weeks' gestation were not significantly changed overall (0·94 [0·87-1·02]; I2=75%; 15 studies, 170 640 and 656 423 pregnancies) but were decreased in high-income countries (0·91 [0·84-0·99]; I2=63%; 12 studies, 159 987 and 635 118 pregnancies), where spontaneous preterm birth was also decreased (0·81 [0·67-0·97]; two studies, 4204 and 6818 pregnancies). Mean Edinburgh Postnatal Depression Scale scores were higher, indicating poorer mental health, during versus before the pandemic (pooled mean difference 0·42 [95% CI 0·02-0·81; three studies, 2330 and 6517 pregnancies). Surgically managed ectopic pregnancies were increased during the pandemic (OR 5·81 [2·16-15·6]; I2=26%; three studies, 37 and 272 pregnancies). No overall significant effects were identified for other outcomes included in the quantitative analysis: maternal gestational diabetes; hypertensive disorders of pregnancy; preterm birth before 34 weeks', 32 weeks', or 28 weeks' gestation; iatrogenic preterm birth; labour induction; modes of delivery (spontaneous vaginal delivery, caesarean section, or instrumental delivery); post-partum haemorrhage; neonatal death; low birthweight (<2500 g); neonatal intensive care unit admission; or Apgar score less than 7 at 5 min. INTERPRETATION Global maternal and fetal outcomes have worsened during the COVID-19 pandemic, with an increase in maternal deaths, stillbirth, ruptured ectopic pregnancies, and maternal depression. Some outcomes show considerable disparity between high-resource and low-resource settings. There is an urgent need to prioritise safe, accessible, and equitable maternity care within the strategic response to this pandemic and in future health crises. FUNDING None.
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Affiliation(s)
- Barbara Chmielewska
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, UK
| | - Imogen Barratt
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, UK
| | - Rosemary Townsend
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, UK
| | - Erkan Kalafat
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey; Department of Obstetrics and Gynaecology, School of Medicine, Koc University, Istanbul, Turkey
| | - Jan van der Meulen
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Service Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Pat O'Brien
- The Royal College of Obstetricians and Gynaecologists, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
| | - Edward Morris
- The Royal College of Obstetricians and Gynaecologists, London, UK; Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Tim Draycott
- The Royal College of Obstetricians and Gynaecologists, London, UK; North Bristol NHS Trust Department of Women's Health, Westbury on Trym, UK
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, UK
| | - Kirsty Le Doare
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, UK
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group and Vaccine Institute, Institute of Infection and Immunity, St George's University of London, UK; Immunisation and Countermeasures Division, Public Health England, London, UK; British Paediatric Surveillance Unit, Royal College of Paediatrics and Child Health, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Laura Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, UK.
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