Maternal death from stroke: a thirty year national retrospective review

Objective

In the United Kingdom (UK), the maternal mortality rate from stroke is reported at 0.3/100,000 deliveries, but only antenatal data have previously been reviewed. We hypothesise that the true rate is much higher due to a propensity for stroke occurring in the post-partum period, and that the rate will rise in parallel with trends of increasing maternal age and medical co-morbidities. Our objectives are to investigate the UK stroke mortality rate in pregnancy and the puerperium, and to examine temporal changes in fatal maternal strokes over a 30 year period.

Study design

Retrospective review of stroke-related maternal deaths reported to the UK confidential enquiries into maternal death between 1979 and 2008, encompassing 21,514,457 maternities. In accordance with the ICD.10 classification, cases were divided into direct or indirect deaths. Late and coincidental deaths were not included in analyses. Lessons from sub-standard care associated with maternal death from stroke were collated.

Results

In 1979–2008 there were 347 maternal deaths from stroke: 139 cases were direct deaths, i.e. the fatal stroke was a direct result of pregnancy. The incidence of fatal stroke is relatively constant at 1.61/100,000 maternities, with a 13.9% (95% CI 12.6–15.3) proportional mortality rate. Intracranial haemorrhage was the single greatest cause of maternal death from stroke.

Conclusion

This is the largest UK study examining the incidence of fatal maternal stroke in pregnancy and the puerperium. Our results highlight the high proportion of women who die from stroke in the puerperium. Sub-standard care featured especially in regard to management of dangerously high systolic blood pressure levels. These deaths highlight the importance of education in managing rapid-onset hypertension and superimposed coagulopathies.     

Risk factors of incomplete Apgar score and umbilical cord blood gas analysis: a retrospective observational study

Objective: To investigate whether incomplete umbilical cord blood gas (UCBG) analysis occurs more often than the incomplete reporting of the Apgar score, and risk factors associated with the incomplete values.

Methods: A total of 8824 infants born alive after 26 weeks’ gestation between January 2009 and April 2013 were included. We extracted data on five-minute Apgar score, UCBG analysis, gestational age, mode of delivery, time of delivery and multiple pregnancy. Univariate and multivariable logistic regression analyses were performed.

Results: Five-minute Apgar score was incomplete in 15 cases (0.2%) and UCBG analysis in 1960 cases (22.2%), p?<?0.05. Incomplete UCBG analysis was significantly more likely to occur in situations with Apgar score below seven (Odds ratio (OR) 1.68, 95% CI;1.29-2.19), gestational age between 26 to 27 6/7 and 28 to 31 6/7 weeks (OR 3.14, 95% CI; 2.13-4.62 and OR 1.91, 95% CI; 1.57-2.32), cesarean section (OR 1.31, 95% CI; 1.11-1.55), and multiple pregnancy (OR 2.02, 95% CI; 1.69-2.43). Deliveries during night time had a lower risk of incomplete UCBG analysis (OR 0.78, 95% CI; 0.69-0.88).

Conclusions: Measuring five-minute Apgar score generated less incomplete data compared with UCBG analysis. The risk factors associated with incomplete UCBG analysis were noted. Study outcomes with UCBG analysis as neonatal assessment tool should be interpreted with caution.     

The outcome of pregnancy with new onset proteinuria without hypertension: retrospective observational study

Objective: The aim of this study was to evaluate preeclampsia progression of isolated proteinuria and associations with pregnancy outcome.

Method: We performed a retrospective analysis in patients who were hospitalized for evaluation of new onset proteinuria without hypertension after 20 weeks of gestation between January 2012 and January 2014. One hundred fifty-seven patients who met the inclusion criteria were enrolled the study.

Results: After detection of new onset proteinuria, 53 of 157 (33.7%) patients developed preeclampsia and the incidence of gestational proteinuria was found to be 0.33%. Twenty-four hours urine proteinuria testing results were significantly higher in preeclampsia (PE) group compared with the gestational proteinuria (GP) group (p?<?0.01). Patients who developed preeclampsia delivered significantly earlier than the GP group (p?<?0.01). The weights of the infants born to mothers in the PE group were significantly lower than the other group (p?<?0.01).

Conclusion: The incidence of gestational proteinuria was lower than the previous studies. Preeclampsia developed in 33% of patients with new onset proteinuria in pregnancy. In patients who developed PE had significantly higher proteinuria, lower delivery time and birth weight in their infants. Therefore, patients with new onset proteinuria should be followed-up for preeclampsia development and associated morbidities.     

The relationship between FSH receptor polymorphism status and IVF cycle outcome: a retrospective observational study

Research questionWhat is the association between FSH receptor (FSHR) gene polymorphism at position 680 and live birth in women undergoing IVF and intracytoplasmic sperm injection (ICSI).DesignIn this retrospective cohort study, data were collected from the Electronic Patient Database of the VU University Medical Centre, Amsterdam, The Netherlands. Women undergoing their first IVF/ICSI cycle between January 2008 and March 2012, of whom the FSHR genotype was determined, were included. The main outcome was live birth rate. Secondary outcomes were ongoing pregnancy, total number of follicles, oocytes and embryos.ResultsThe FSHR genotype distribution was as follows: 334 women in the Asn/Asn group (28.2%), 617 in the Asn/Ser group (52.1%) and 234 in the Ser/Ser group (19.7%). Basal FSH concentration was highest in the Ser/Ser group (P = 0.006). The number of oocytes (P = 0.01) and number of embryos (P = 0.02) were lowest in the Ser/Ser group. The Asn/Asn group showed a significantly lower live birth rate. Live birth rates were 21.9% versus 31.1% and 27.6% (P = 0.009), for Asn/Asn, Asn/Ser and Ser/Ser, respectively. Logistic regression analysis, however, showed no significant difference on cumulative live birth rate between the three genotypes either unadjusted or when adjusted for age.ConclusionThe homozygous Ser/Ser genotype of FSHR polymorphism at position 680 is associated with a reduced ovarian response to ovarian stimulation in IVF/ICSI. No difference in cumulative live birth rate was found.     

Clinical outcomes of multifetal pregnancy reduction in trichorionic and dichorionic triplet pregnancies: A retrospective observational study

Objective

To observe the pregnancy and perinatal outcomes of trichorionic triplet (TCT) and dichorionic triplet (DCT) pregnancies with or without multifetal pregnancy reduction (MFPR).

A prospective observational study on tears during vaginal delivery: occurrences and risk factors

BACKGROUND: To ascertain the occurrence and distribution of various types of I-IV degree tears, during childbirth, and analyze risk factors for perineal II degree tears. MATERIALS AND METHODS: A total of 2883 consecutive vaginal deliveries, during 1995-97 at Sahlgrenska University Hospital in G?teborg Sweden, were included. All tears were classified according to an especially designed protocol, and risk factors for II degree tears were evaluated by use of univariate and logistic regression analysis. RESULTS: Only 6.6% of nulliparous parturients had no detectable tear as compared to 34.2% in parous women. Almost half of the women suffered from a II degree tear during birth, and a higher proportion of nulliparous (16.6%) than parous (9.4%) women had extensive perineal lacerations. In addition, nulliparous were more likely than parous parturients to be subjected to a perineotomy (18.1% versus 5.6%). Stepwise logistic regression analysis revealed that the following factors remained independently associated with II degree tear: slight perineal edema, high infant weight, excellent visualization of perineum, increasing age of the mother, excellent cooperation of the women, protracted second phase (> 60 min) and duration of second phase < 30 min. CONCLUSIONS: The majority of women (78%) undergoing childbirth had a tear and 47.1% suffered from perineal lacerations. Nulliparous women were more likely to have severe perineal lacerations or episiotomies. Similar risk factors were found for II degree tears as previously shown for III/IV degree tears.     

Anxiety and deterioration of quality of life factors associated with recurrent miscarriage in an observational study

Abstract Objective: Radical vaginal trachelectomy (RVT) as a fertility-preserving surgery in patients with early-stage cervical cancer is proven to be oncologically safe. After RVT, pregnancy rates vary between 40% and 80%. Outcome of infants is complicated by a preterm delivery rate of 30-50%. We investigated pregnancy and neonatal outcome after RVT. Methods: A total of 154 patients with cervical cancer underwent RVT between March 1995 and February 2008. Desire to conceive, pregnancy data, and neonatal outcome were prospectively recorded. Infants' data were pair-matched to data of a control group according to weeks of gestation. Bayley scales of infant development scores were recorded in the group of preterm-delivered infants. Results: Fifty-five women who underwent RVT gave birth to 58 children. Twenty-five (43%) pregnancies were complicated by preterm rupture of membranes. Thirty infants (52%) were born preterm, of with 17 (29%) were <32 gestational weeks (GW) and seven (12%) were <28 GW. There were significantly more premature rupture of membranes in pregnancies after RVT. Despite a higher occurrence of postnatal infections in newborns of mothers who underwent RVT, long-term outcomes are not affected negatively. Regarding overall morbidity, a trend to fewer postnatal complications, compared with the control group, was found. Conclusion: Postnatal morbidity in infants of women who underwent RVT, based on trend, is decreased compared with controls. Intense medical observation and treatment during pregnancy, birth, and neonatal period may explain this finding. Neonates in the RVT group have a non-significantly elevated risk for postnatal infections. They do not show an additional risk due to the maternal operation. Their long-term postnatal outcome is not affected negatively.     

Pelvic organ prolapse repair-relapse risk factors: A 10-year retrospective study

ObjectivesPelvic organ prolapse (POP) is a common problem among older female. The usual treatment for POP is surgery but there are high recurrence rates, with a 29% reoperation rate. This study aims to identify risk factors for both primary prolapse and recurrence after surgical treatment.MethodsRetrospectively assessment of clinical records of patients who underwent surgery for POP in a 10-year period. Statistical analysis was performed using the version 26.0 of Statistical Package for the Social Science (SPSS®) software.Results746 women entered our study. The population was predominantly post-menopausal, multiparous, and obese/overweight. The most affected compartment was the anterior. Almost 90% of the patient presented with major prolapse. Being overweight or obese, having apical compartment POP, major POP or all compartment POP were risk factors for recurrence with statistical significance. The recurrence rate was nearly one-third but the reoperation incidence was low, reaching less than 6%.ConclusionsPOP surgery has a high satisfaction rate. The only modifiable risk factor for recurrence is being overweight/obese and a nutritional plan should be considered before surgery so we can achieve the best possible results.     

Low bone mineral density may be associated with long-term risk of cancer in the middle-aged population: A retrospective observational study from a single center

Background

It is generally understood that cancer patients are at an increased risk for osteoporosis. Additionally, recent studies have suggested a shared pathophysiological mechanism between the development of cancer and osteoporosis. The purpose of this investigation was to investigate whether low bone mineral density is associated with cancer risk.

Identifying the associated factors with onset of preterm PROM compared with term PROM - A retrospective cross-sectional study

ObjectiveTo determine the risk factors associated with the preterm premature rupture of membranes (p-PROM).Materials and methodsThis retrospective cross-sectional study assessed 110 p-PROM cases from among 6642 deliveries at a Japanese perinatal medical center, from June 2016 to September 2018. The control group comprised 220 term PROM (t-PROM) cases. We excluded cases with artificial PROM or rupture of membranes after labor, those with multiple pregnancies, those with p-PROM at 36 weeks and those with t-PROM at 37 weeks. In order to compare p-PROM with t-PROM, univariate and multivariate analysis were performed using several clinical factors at the time of PROM onset.ResultsThe p-PROM group included 110 cases with 14–35 weeks PROM, and the t-PROM group included 220 cases with 38–41 weeks PROM. Eleven factors were identified as significant factors on the univariate analysis. A history of cervical conization (OR 37.5, 95% CI: 2.31–607.1), cervical length <25 mm at 28 weeks (OR 9.31, 95% CI: 1.76–49.3), negative Lactobacillus (OR 4.01, 95% CI: 1.18–13.7), and bleeding during the second trimester (OR 3.35, 95% CI: 1.18–9.53) were identified as significant factors by the multivariate analysis. Based on the risk factors identified during the multivariate analysis, we divided the 330 cases in the following three groups: 0 group (n = 244), 1 group (n = 60), and 2–4 group (n = 26). The ratio of p-PROM:t-PROM was calculated and compared for each group. The ratios were 21% (0 group), 57% (1 group), and 100% (2–4 group), indicating statistically significant differences between the groups (p < 0.001).ConclusionWe found that the following four factors were associated with p-PROM: history of cervical conization, cervical length <25 mm at 28 weeks, negative Lactobacillus, and bleeding during the second trimester. Our results suggest that we can identify patients who are at increased risk for p-PROM, based on these factors. Further research is necessary to determine the optimal treatment approach for these patients to prevent p-PROM.     

Kiwi omnicup handheld versus Mityvac M-style conventional vacuum system: a retrospective observational study

Introduction: To improve the choice of vacuum-assisted delivery (VAD) system, we compared the outcomes of Kiwi handheld system and Mityvac M-style conventional system (both use disposable plastic cups).

Materials and methods: Retrospective observational study with data collection from electronic medical records. The study was conducted at a tertiary medical center, with approximately 7000 deliveries annually. Categorical and continuous variables were analyzed using chi-square test and t-test, respectively. p value?Results: During a 10-month period, there were 507 (8.4%) attempted VADs, 36 failed (7.1%), and eight (1.5%) converted to cesarean section. Of these, 364 were Kiwi-assisted and 143 Mityvac-assisted. Background characteristics were similar. The handheld system had more failures overall (9.6 versus 0.7%), at OA (7.6 versus 0.9%), and non-OA positions (17.3% versus none), at +1 (13.25 versus 0.96%) and at +2/3 stations (6.1% versus none), than the conventional system did, respectively. There was a higher rate of early post-partum hemorrhage (15.3 versus 7.4%) in the conventional group. Both systems had similar rates of third/fourth degree perineal tears, shoulder dystocia and adverse neonatal outcomes.

Conclusions: Our results suggest more failures with Kiwi compared to Mityvac, overall and at any fetal position/station, without a significant difference in adverse outcome profile.     

Prevalence and risk factors associated with the patency of ductus arteriosus in premature neonates: a prospective observational study from Iran

Background: Patent ductus arteriosus (PDA) is a common problem in the preterm infants. The frequency of PDA varies with the time of study, and the characteristics of the population included in the trial.

Aims and objective: To determine the prevalence and prenatal risk factor associated with PDA.

Methods and material: This prospective cross-sectional observational study was carried out on neonates who had gestational age below 37 weeks during the period of February 2014 to September 2014. Echocardiography was done at 4–7 days of postnatal age. The association between prenatal risk factors of the infants and the PDA was studied.

Results: From a total population of 200 enrolled infants 22.5% had PDA. The mean gestational age and birth weight were 32.1?±?2.65 (weeks) and 1741?±?622.85 (g), respectively. Maternal antepartum hemorrhage, respiratory distress syndrome (RDS), need for surfactant, birth weights, female gender, gestational age, Apgar scores at 1 and 5?min of the infants were found to be associated with the prevalence of PDA.

Conclusion: Several prenatal factors make preterm newborns susceptible to PDA. These risk factors should be identified as soon as possible for early commencement of PDA management.     

Risk factors associated with coronary artery calcification in midlife women: a population-based study

Abstract

The aim of this study was to investigate the association between individual risk factors and coronary artery calcification (CAC), as a marker of subclinical cardiovascular disease, in a population-based nested cross-sectional study of midlife women. Anthropometric and metabolic data from 295 women from the South of Brazil were analyzed. Habitual physical activity was assessed by pedometer. CAC was assessed by a multi-detector computed tomography system. Average Agatston score was used to stratify participants as CAC?>?0 and CAC?=?0. Women with CAC?>?0 (34.7%) were older (58.7?±?5.4 vs. 56.3?±?5.2?years, p?<?.001) and had higher prevalence of central adiposity (71 vs. 59%, p?=?.04) and hypertension (71 vs. 52%, p?=?.002) than women in the CAC?=?0 group. Hormone therapy (HT) was more prevalent in the group with CAC?=?0 (19.7 vs. 9.8%, p?=?.029). The prevalence ratios for CAC?>?0 were 0.545 (95%CI:0.309–0.962, p?=?.036) for HT and 1.752 (95%CI:1.207–2.541, p?=?.003) for hypertension, after adjustment for age, educational level, smoking, alcohol intake, and physical activity. The present data in a population-based sample of midlife women indicate that hypertension and age were positively associated with higher risk for CAC?>?0 and HT was related with CAC?=?0.