Tag: obstetrics

Delta Variant Causes Pregnancy Complications

Source: Anna Hecker on Unsplash

Pregnant women have been a population of concern for physicians since the beginning of the COVID pandemic, and early on the frequency of caesarean delivery, preterm birth and pregnancy-related hypertension was reported to be increased in pregnant women who developed severe or critical illness from the novel coronavirus.

In May and June this year, there was a lull in COVID cases and hospitalisations, to the relief of physicians at the University of Alabama at Birmingham Hospital and their pregnant patients. However, the Delta variant soon caused a rise in cases, hospitalisations and deaths across the US state of Alabama. Along with this there was a seemingly higher number of pregnant patients with COVID in hospitals and intensive care units than in previous surges.

“We saw an alarming increase in pregnant patients hospitalised with the Delta variant in July and August,” said Akila Subramaniam, MD, associate professor in UAB’s Division of Maternal-Fetal Medicine. “Even more, many of our patients were delivering pre-term because of the effects of the virus on these women.”

Researchers tracked admission rates and maternal and neonatal outcomes of pregnant COVID patients at UAB Hospital from March 22, 2020, to Aug. 18, 2021. Outcomes were compared between pre-Delta and Delta groups, with preliminary findings seriousindicating  morbidity and adverse outcomes associated with the Delta variant and pregnancy.

Prior to the Delta variant, UAB Hospital saw the highest admission of pregnant women with active COVID in July 2020. A total of 28 pregnant patients were admitted that month, three of whom were admitted to the intensive care unit. In comparison, 39 pregnant patients, with 11 in ICU, were hospitalised in just the first 18 days of August.

“Pregnant women are a high-risk population with low-vaccination rates overall,” said Jodie Dionne, MD, associate director of UAB Global Health in the Center for Women’s Reproductive Health and associate professor in the Division of Infectious Diseases. “There is misinformation circulating that causes doubt in the vaccines or downplays the effect of the virus. This study highlights how dangerous contracting the virus, especially the Delta variant, can be for the mom and baby.”

From the study’s early findings, the UAB researchers emphasize recommendations from the Society of Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention to vaccinate pregnant patients to mitigate severe perinatal morbidity and mortality.

The findings were published in the journal of Obstetrics and Gynecology.

Source: University of Alabama at Birmingham

Black US Women at Increased Risk of Birth Complication

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Black US women are more likely than their white counterparts to experience a serious complication during labour or delivery, particularly due to systemic inflammation.

Systemic inflammation was one of four categories identified by the researchers when they looked for patterns in patients who experienced severe maternal morbidity (SMM) – an unexpected outcome of labour and delivery resulting in significant short- or long-term health consequences, including death. 

Women can experience multiple complications or events associated with SMM such as kidney failure and eclampsia. The study found these complications or events can occur within four categories: systemic inflammation (includes shock, abnormal blood clotting, adult respiratory distress syndrome [ARDS] and ventilation); cardiovascular events (includes kidney failure, eclampsia and cerebrovascular events such as aneurysm); admission to the intensive care unit; and haemorrhage leading to blood transfusion.

Black women were found to be at higher risk than white women in all four SMM categories, with the highest proportion experiencing SMM due to systemic inflammation.

“Previous studies have reported the higher the number of SMM complications or events a woman experiences, the higher the likelihood of death, but our study is the first to look at how these complications and events group together and their association with outcomes,” said lead author Andrea Ibarra, MD, MS, assistant professor of anesthesiology and perioperative medicine at the University of Pittsburgh School of Medicine. “We determined characteristics such as race, obesity and diabetes can identify which women are at higher risk of severe events, including death, in the various categories. That insight can spur efforts to develop new obstetric protocols and guidelines to improve care.”

Researchers reviewed records of 97 492 deliveries at one institution between 2008 and 2017 and determined that 2666 (2.7%) included an SMM event, with 49 women dying within a year of delivery. They found 44% of the deliveries associated with SMM were pre-term. Black women had higher rates of SMM (4.1%) than white women (2.4%).

Risk factors for all-category SMM included race, having pre-existing diabetes or having preeclampsia. Caesarean delivery was an additional risk factor for the haemorrhage category. Additional risk factors relating to women who fell in the systemic inflammation category were depression and social determinants, including low income or not graduating from high school.

“This research is crucial because most maternal morbidity is preventable,” said Dr Ibarra. “By identifying factors that put women at high risk of developing SMM complications or events, we can allocate more resources toward perinatal care.”

The findings were presented at the ANESTHESIOLOGY® 2021 annual meeting.

Source: American Society of Anesthesiologists

Minimal Risk Found for Home Birth With a Licensed Midwife

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Minimal Risk Found for Home Birth With a Licensed Midwife
In the US state of Washington, a planned home birth with a licensed midwife is just as safe as a birth at a licensed birth centre, according to researchers from the University of British Columbia and Bastyr University.

The research team of midwives, epidemiologists and obstetricians came to this conclusion after analysing outcomes of community births in Washington state between 2015 and 2020. The findings were reported in Obstetrics & Gynecology. A previous US study had shown that pregnancy outcomes with care provided by midwives had lower risks of caesarean and preterm birth than those with physician care.

The study analysed data from 10 609 home and birth centre births from midwives. Births met the professional association guidelines and were within regulatory standards. This included individuals with healthy pregnancies who were carrying to term with no history of caesarean delivery, and a foetus oriented for head-first birth.

“The birth setting had no association with increased risk for either parent or baby,” said lead author Elizabeth Nethery, PhD candidate at UBC. “Our findings show that when a state has systems to support the integration of community midwives into the healthcare system as Washington has done, birth centers and homes are both safe settings for birth.”

In the US, home birth is still controversial. The American College of Obstetricians and Gynecologists (ACOG) has stated that birth is safest at a hospital or an accredited birth centre, recommending against home birth because of countrywide studies that show higher rates of neonatal death among home births.

However, individual states have wide variations in licensing requirements, regulatory status and access to medications for midwives. These variations might contribute to differences in state level outcomes and reflected in national statistics.

Washington has worked to integrate midwifery into the healthcare system, with 3.5% of all births with midwives or at state-licensed birth centres. As a result, there is a low rate of 0.57 perinatal deaths per 1000 births, comparable to other countries where home birth is well-integrated into the health system and classed as low risk by ACOG.

“Washington provides a model for midwifery care and safe community birth that could be replicated throughout the U.S.,” said Nethery. “Currently, some U.S. states currently have no licensure available for community birth midwives at all, and this could be contributing to poorer birth outcomes in those states.”

Source: University of British Columbia

No COVID Impact on Increased Preterm Births or Stillbirths

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A study found no increases in preterm births or stillbirths during the first year of the COVID pandemic, which will help alleviate concerns around pregnancy and COVID. The large study of more than 2.4 million births in Ontario is published in CMAJ (Canadian Medical Association Journal).

Infection, inflammation, stress, medical or pregnancy-induced disorders, genetic predisposition, and environmental factors are risk factors for stillbirth and preterm birth, although in many instances the exact mechanism is not yet known.

During the COVID pandemic, reports emerged of declining rates of preterm births in countries such as the Netherlands, Ireland and the United States, while the United Kingdom, Italy, India while others reported increases in stillbirths and some variability in preterm birth rates. However, most studies were limited by their small size.

To identify a possible shift, the study researchers analysed Ontario births over an 18-year period and compared these trends in the prepandemic period (2002–2019) with the pandemic period (January to December 2020).

“We found no unusual changes in rates of preterm birth or stillbirth during the pandemic, which is reassuring,” said Dr Prakesh Shah, a paediatrician-in-chief at Sinai Health and professor at University of Toronto, Toronto, Ontario.

It is possible that measures related to the pandemic and compliance with them could affect preterm birth rates in different settings. Thus, the researchers examined birth outcomes in the public health units with higher SARS-CoV-2 positivity rates (Toronto, Peel Region, York Region and Ottawa), and also compared urban and rural births and those in neighbourhoods with different average income levels.

“In some areas and in certain people, the restrictions could be beneficial, and in other settings or individuals, restrictions could have the opposite effect,” said Dr Shah.  

International studies are now underway to help understand the impact of COVID on pregnancy and childbirth around the globe.

Source: EurekAlert!

Nearly Half of Female Surgeons Experience Pregnancy Complications

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Long hours and delaying pregnancy to after 35 increase complication risk for female surgeons’ pregnancies. Photo by JESHOOTS.COM on Unsplash

A survey of female surgeons found that 48 percent had experienced major pregnancy complications, with even higher risks for those with more operation hours per week in the last trimester of pregnancy.

Women are entering the surgical field in increasing numbers but they continue to face well-known challenges related to childbearing. Surveys have documented pregnancy-related stigma, unmodified work schedules, brief maternity leave options, and little support for childcare and lactation needs after delivery. Due to a lack of childcare options in developed countries, many female trainees delay pregnancy until after 35, already a risk factor for pregnancy complications, researchers from Brigham and Women’s Hospital and elsewhere surveyed 1175 surgeons and surgical trainees from across the US to study their or their partner’s pregnancy experiences. They found that 48 percent of surveyed female surgeons experienced major pregnancy complications, with those who operated 12-or-more hours per week during the last trimester of pregnancy at a higher risk compared to those who did not. Their findings are published in JAMA Surgery.

“The way female surgeons are having children today makes them inherently a high-risk pregnancy group,” said corresponding author Erika Rangel, MD, MS, of the Division of General and Gastrointestinal Surgery. “In addition to long working hours, giving birth after age 35 and multiple gestation which is associated with increased use of assisted reproductive technologies – is a risk factor for having major pregnancy complications, including preterm birth and conditions related to placental dysfunction.”

The researchers found that over half (57 percent) of female surgeons worked more than 60 hours per week during pregnancy. Over a third (37 percent) took more than six overnight calls. Of the 42 percent of women who experienced a miscarriage (a rate twice that of the general population) three-quarters took no leave afterwards.

“As a woman reaches her third trimester, she should not be in the operating room for more than 12 hours a week,” Dr Rangel said. “That workload should be offset by colleagues in a fair way so that it does not add to the already-existing stigma that people face in asking for help, which is unfortunately not a part of our surgical culture.”

Male and female surgeons were asked to respond to the survey, which had been developed with obstetricians and gynaecologists. Nonchildbearing surgeons answered questions regarding their partners’ pregnancies. The investigators found that, compared to female nonsurgeons, female surgeons were 1.7 times more likely to experience major pregnancy complications, along with greater risk of musculoskeletal disorders, non-elective caesarean delivery, and postpartum depression, which was reported by 11 percent of female surgeons.

“The data we have accumulated is useful because it helps institutions understand the need to invest in a top-down campaign to support pregnant surgeons and change the culture surrounding childbearing,” Dr Rangel said. “We need to start with policy changes at the level of residency programs, to make it easier and more acceptable for women to have children when it’s healthier, while also changing policies within surgical departments. It is a brief period of time that a woman is pregnant, but supporting them is an investment in a surgeon who will continue to practice for another 25 or 30 years.”

Source: Brigham and Women’s Hospital

Journal information: Rangel EL et al. “Incidence of Infertility and Pregnancy Complications in US Female Surgeons” JAMA Surgery DOI: 10.1001/jamasurg.2021.3301

WHO-recommended Pregnancy Gap Too Long for Some Countries

Researchers have found that a World Health Organization (WHO) recommendation to wait at least 24 months to conceive after a previous birth may be unnecessarily long for mothers in high-income countries.

Lead researcher Dr Gizachew Tessema from the Curtin School of Population Health said that since the WHO advice was based on limited evidence from resource-limited countries, it was necessary to check the recommendation in higher-income settings. The researchers’ findings were published in journal PLOS ONE.  

“We compared approximately 3 million births from 1.2 million women with at least three children and discovered the risk of adverse birth outcomes after an interpregnancy interval of less than six months was no greater than for those born after an 18-23 month interval,” Dr Tessema said.

“Given that the current recommendations on birth spacing is for a waiting time of at least 18 months to two years after livebirths, our findings are reassuring for families who conceive sooner than this.

“However, we found siblings born after a greater than 60-month interval had an increased risk of adverse birth outcomes.”

Dr Tessema said just as the current WHO recommendations are not age specific, the study’s results were not necessarily equally applicable to parents of all ages.

“Our next step with this research is to identify whether intervals between pregnancies affect the risk of adverse birth outcomes among women of different ages,” Dr Tessema said.

Dr Tessema is a perinatal and reproductive epidemiologist and conducted the study with senior author Professor Gavin Pereira, who are both from the Curtin School of Population Health and the new Curtin enAble Institute.

Source: Curtin University

Heart Health Strongly Linked to Pregnancy Outcomes

Photo by Anna Hecker on Unsplash
Photo by Anna Hecker on Unsplash

A strong and graded relationship between women’s heart health and pregnancy outcomes has been demonstrated by a study of more than 18 million pregnancies. 

Significant metabolic and haemodynamic changes occur to a woman’s body during pregnancy, some of which can later increase the risk of cardiovascular disease. Risk factors for cardiovascular disease also impact on pregnancy outcomes. The researchers examined the presence of four cardiovascular disease risk factors in women prior to pregnancy: unhealthy body weight, smoking, hypertension and diabetes. The risk of pregnancy complications – maternal intensive care unit (ICU) admission, preterm birth, low birthweight and foetal death – rose along with the number of pre-pregnancy cardiovascular risk factors.

“Individual cardiovascular risk factors, such as obesity and hypertension, present before pregnancy have been associated with poor outcomes for both mother and baby,” said study author Dr Sadiya Khan, Northwestern University Feinberg School of Medicine, Chicago, US. “Our study now shows a dose-dependent relationship between the number of risk factors and several complications. These data underscore that improving overall heart health before pregnancy needs to be a priority.”

The study, which was published in the European Journal of Preventive Cardiology, was a cross-sectional analysis of maternal and foetal data from the US National Center for Health Statistics (NCHS), which gathers information on all live births and foetal deaths after 20 weeks’ gestation. Individual-level data was pooled from births to women aged 15 to 44 years from 2014 to 2018. 

Information was collected on whether four cardiovascular risk factors were present before pregnancy: body mass index (BMI; under 18.5 kg/m2 or over 24.9 kg/m2), smoking, hypertension and diabetes. Women were categorised as having 0 to 4 risk factors. The researchers estimated the relative risks of maternal ICU admission, preterm birth (before 37 weeks), low birthweight (under 2500 g), and foetal death associated with risk factors compared with no risk factors (0). All analyses were adjusted for maternal age at delivery, race/ethnicity, education, receipt of prenatal care, parity, and birth plurality.

The analysis included a total of 18 646 512 pregnancies, with an average maternal age of 28.6 years. More than 60% of women had one or more pre-pregnancy cardiovascular risk factors, ranging from 52.5% with one risk factor and 0.02% with 4 risk factors.

Those with all four risk factors had an approximately 5.8-fold higher risk for ICU admission than those with none, 3.9-fold higher risk for preterm birth, 2.8-fold higher risk for low birthweight, and 8.7-fold higher risk for foetal death.

Graded associations were found between increasing numbers of pre-pregnancy risk factors and a higher odds of adverse outcomes. The risk ratio for maternal ICU admission compared to no risk factors was 1.12 for one risk factor, 1.86 for two risk factors, 4.24 for three risk factors, and 5.79 for four risk factors.

The analysis was repeated in women with their first pregnancy with consistent results. “We conducted this analysis since women with a complicated first pregnancy are more likely to have complications in subsequent pregnancies,” explained Dr Khan. “In addition, gestational weight gain can lead to a higher BMI going into the next pregnancy. We saw very similar results which strengthens the findings in the full cohort.”

She continued: “Levels of pre-pregnancy obesity and high blood pressure are rising and there are some indications that women are acquiring cardiovascular risk factors at earlier ages than before. In addition, pregnancies are occurring later in life, giving risk factors more time to accumulate. Taken together, this has created a perfect storm of more risk factors, earlier onset, and later pregnancies.”

Dr Khan concluded: “The findings argue for more comprehensive pre-pregnancy cardiovascular assessment rather than focussing on individual risk factors, such as BMI or blood pressure, in isolation. In reality not all pregnancies are planned, but ideally we would evaluate women well in advance of becoming pregnant so there is time to optimise their health. We also need to shift our focus towards prioritising and promoting women’s health as a society – so instead of just identifying hypertension, we prevent blood pressure from becoming elevated.”

Source: European Society of Cardiology (ESC)

Journal information: Wang, M.C., et al. (2021) Association of pre-pregnancy cardiovascular risk factor burden with adverse maternal and offspring outcomes. European Journal of Preventive Cardiology. doi.org/10.1093/eurjpc/zwab121.

In Utero or Neonatal Antibiotic Exposure Could Lead to Brain Disorders

Image by Ahmad Ardity from Pixabay
Image by Ahmad Ardity from Pixabay

According to a new study, antibiotic exposure early in life could alter human brain development in areas responsible for cognitive and emotional functions.

The study suggests that penicillin alters the body’s microbiome as well as gene expression, which allows cells to respond to its changing environment, in key areas of the developing brain. The findings, published in the journal iScience, suggest reducing widespread antibiotic use or using alternatives when possible to prevent neurodevelopment problems.
Penicillin and related medicines, such as ampicillin and amoxicillin, are the most widely used antibiotics in children worldwide. In the United States, the average child receives nearly three courses of antibiotics before age 2, and similar or greater exposure rates occur elsewhere.

“Our previous work has shown that exposing young animals to antibiotics changes their metabolism and immunity. The third important development in early life involves the brain. This study is preliminary but shows a correlation between altering the microbiome and  changes in the brain that should be further explored,” said lead author Martin Blaser, director of the Center for Advanced Biotechnology and Medicine at Rutgers.

In the study, mice were exposed to low-dose penicillin in utero or immediately after birth. Researchers found that, compared to the unexposed controls, mice given penicillin had large changes in their intestinal microbiota, with altered gene expression in the frontal cortex and amygdala. These two key brain areas are responsible for the development of memory as well as fear and stress responses.

Increasing evidence links conditions in the intestine to the brain in the ‘gut-brain axis‘. If this pathway is disturbed, it can lead to permanent altering of the brain’s structure and function and possibly lead to neuropsychiatric or neurodegenerative disorders in later childhood or adulthood.

“Early life is a critical period for neurodevelopment,” Blaser said. “In recent decades, there has been a rise in the incidence of childhood neurodevelopmental disorders, including autism spectrum disorder, attention deficit/hyperactivity disorder and learning disabilities. Although increased awareness and diagnosis are likely contributing factors, disruptions in cerebral gene expression early in development also could be responsible.”

Whether it is antibiotics directly affecting brain development or if molecules from the microbiome travelling to the brain, disturbing gene activity and causing cognitive deficits needs to be determined by future studies.

Source: Rutgers University-New Brunswick

‘Far Too Many Oocytes’ Being Extracted in IVF

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A study has suggested that IVF clinics in the UK may be retrieving “far too many oocytes” and that most of them “may never be used and are probably discarded”, a finding that may well represent global practice.

Studies indicate that the optimal and safe number of oocytes needed for achieving an ongoing pregnancy is between six and 15. However, the use of egg freezing (such as to preserve fertility to a later age, known as social egg freezing), frozen embryo replacement (FER) cycles and aggressive stimulation regimes has raised this number in order to boost success rates in older women and in poor responders who produce fewer eggs. What is not known is the impact of numbers of eggs retrieved and of over-stimulation practices on the health of patients, and on their emotional state and finances.

Details of the analysis were presented online at the virtual Annual Meeting of ESHRE by Dr Gulam Bahadur from North Middlesex University Hospital, London.

More than 1.625 million eggs in the UK were retrieved from 147,274 women between 2015 and 2018. Although an average of 11 eggs was collected per patient, 16% of cycles were associated with 16-49 oocytes retrieved (per cycle) and 58 women each had over 50 eggs collected in a single egg retrieval procedure.

“Our observations suggests that the high oocyte number per retrieval procedure needs re-evaluation,” said Dr Bahadur. “In particular, this needs to focus on the side effects, including ovarian hyperstimulation syndrome and procedure-related complications, and on the fate of unused frozen oocytes and the costs associated with freezing them.

“Patients should be advised that it’s better to collect fewer eggs leading to good quality embryos which may go to term and result in a healthy baby.”

This report is based on all UK IVF clinics and relates to non-donor fertility treatment carried out between 2015 and 2018 during which 172 341 fresh oocyte retrieval cycles took place. All outcomes and patterns remained uniform over the four years.

A substantial number (n = 10 148) of cycles did not yield any oocytes. Over half (53%) of all IVF cycles were in the desired egg yield range of 6-15. In addition, a quarter of cycles yielded 1-5 eggs; 14% produced 16-25; and a minority (2%) resulted in 26-49 oocytes. The authors point out that multiple birth rates increase significantly from 6-15 oocytes onwards, which increases the risk of birth complications and low birth weight.

A total of 931 265 embryos resulted from all eggs retrieved – a fertilisation rate of 57%. Of the embryos created, more than one in five (22% or 209,080) were transferred into the uterus, while a slightly higher proportion (24% or 219, 563) were frozen.

The fate of the unfertilised oocytes (43%) is unknown, though they are usually discarded. Most of the embryos not transferred (54%) will likely be discarded after patients have paid for several years of storage.

“This comes with a financial and emotional cost,” said Bahadur. “Patients build an attachment with this frozen material and there’s insufficient counselling to support them. They should be given more information about the implications of freezing eggs and embryos.”

Source: European Society of Human Reproduction and Embryology

Beneficial Microbiota can be Restored at Birth in C-section Babies

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Babies born by caesarean section lack the same healthy bacteria as those born vaginally, but a Rutgers-led study for the first time finds that these natural bacteria can be restored.

The human microbiota, consisting of trillions of bacteria, viruses, fungi and other microorganisms, live in and on our bodies, some potentially harmful while others provide benefits. During labour and birth, women naturally impart a small group of colonisers to their babies’ sterile bodies, which helps their immune system to develop. But antibiotics and C-sections disrupt this conferring of microbes and are related to increased risks of obesity (59% increase), asthma (21% increase) and metabolic diseases. ‘Vaginal seeding‘, where a baby delivered by C-section is swabbed with their mother’s vaginal fluids at birth, is becoming increasingly popular.

According to the World Health Organization, C-section is needed in about 15 percent of births to avoid risking the life of the mother or child. However, caesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America.

To see how well babies could be seeded with the mother’s microbiota after birth, the researchers followed 177 babies from four countries over the first year of their lives. Of these, 98 were born vaginally and 79 were born by C-section, 30 of which were swabbed with a maternal vaginal gauze right after birth.

Analysis showed that the microbiota of the C-section babies swabbed with their mother’s vaginal fluids was similar to that of vaginally born babies. Also, the mother’s vaginal microbiomes on the day of birth were similar to other areas of their bodies (gut, mouth and skin), indicating that maternal vaginal fluids help to colonise bacteria across their babies’ bodies.

This was the first large observational study to show that ‘vaginal seeding’ normalises the microbiome development during their first year of life. The next step would be conducting randomised clinical trials to determine if the microbiota normalisation translates into disease protection, the researchers said.

“Further research is needed to determine which bacteria protect against obesity, asthma and allergies, diseases with underlying inflammation,” said senior author Maria Gloria Dominguez Bello, a professor in the Department of Biochemistry and Microbiology in the School of Environmental and Biological Sciences at Rutgers University-New Brunswick. “Our results support the hypothesis that acquiring maternal vaginal microbes normalises microbiome development in the babies.”

Source: University News