American Journal of Obstetrics & Gynecology Mfm最新文献

Background: Pregnancy complications have been recognized as a window to future health. Though cesarean delivery is common, it is unknown whether labor duration and mode of delivery are associated with maternal long-term mortality.

Objectives: To examine whether labor duration and mode of delivery were associated with all-cause and cause-specific mortality.

Study design: Participants were mothers from the multisite Collaborative Perinatal Project cohort (1959-1966; n=43646, limited to last Collaborative Perinatal Project delivery). We ascertained all-cause and specific causes of death as of 2016 via linkage to the National Death Index and Social Security Death Master File. Hazard ratios testing mode of delivery and labor duration were estimated using Cox proportional hazards models adjusted for demographic and clinical characteristics. We further stratified analyses by parity.

Results: Among participants with a recorded delivery mode, 5.9% (2486/42335) had a cesarean delivery. Participants who had a cesarean were older (26.9 versus 24.3 years), with higher BMI (24.0 versus 22.7 kg/m²), were less likely to be nulliparous (21% versus 30%), and more likely to have a household income of at least $6000 (22% versus 17%), to smoke ≥1 pack/day (18% versus 15%), to have diabetes mellitus (12% versus 1%) and to have a prior medical condition (47% versus 34%), compared to participants with a vaginal delivery. Delivery mode was similar by race/ethnicity, marital status, and education. Median labor duration was 395 minutes among participants who had an intrapartum cesarean delivery and 350 minutes among participants delivered vaginally. By 2016, 52.2% of participants with a cesarean delivery and 38.5% of participants with a vaginal delivery had died. Cesarean versus vaginal delivery was significantly associated with increased risk for all-cause mortality (hazard ratio = 1.16 (95% confidence interval: 1.09, 1.23); in nulliparas, hazard ratio = 1.27 (95% confidence interval: 1.09, 1.47); in multiparas, hazard ratio = 1.13 (95% confidence interval: 1.06, 1.21)) as well as increased risk of death from cardiovascular disease, diabetes, respiratory disease, infection, and kidney disease. Associations with death from cardiovascular disease, infection and kidney disease were stronger for multiparas than nulliparas, though the association with death from diabetes was stronger among nulliparas. Labor duration was not significantly related to overall mortality.

Conclusions: In a historic United States cohort with a low cesarean delivery rate, cesarean delivery was an indicator for subsequent increased mortality risk, particularly related to cardiovascular disease and diabetes. Future studies with long-term follow-up are warranted given the current high prevalence of cesarean delivery.

Objective: Hypertensive disorders are major causes of maternal and neonatal morbidity and mortality, affecting ∼10% pregnancies worldwide. Understanding the lived experience of women with hypertensive disorders during pregnancy is important to inform best practice and provide holistic care.

Data sources: Medline via Ovid, Embase via Ovid, CINAHL via Ebsco, PsycINFO via Ebsco, Scopus, Web of Science Core Collection, and ASSIA via ProQuest were searched between database inception and June 2024.

Study eligibility criteria: Studies containing qualitative components relating to direct lived experience of hypertensive disorders of pregnancy were included.

Study appraisal and synthesis methods: Quality assessment was performed using the Critical Appraisal Skills Programme checklist for qualitative research. Themes were labeled and organized into a framework using NVivo software.

Results: Eighteen studies were included in the meta-synthesis. Anxiety, stress, fear and panic emerged as the most common emotional experiences during hypertensive disorders of pregnancy. Loss of control was also mentioned frequently and consistently across studies (frequency effect size 38.9% and intensity effect size 15.3%). Emotional responses to physical symptoms or lack thereof, and feelings about the impact of the complicated pregnancy on family and community also emerged as central themes associated with hypertensive disorders of pregnancy.

Conclusion: A range of emotional experiences was captured across the studies included in our meta-synthesis, some of which were observed across global settings whereas others were context-dependent. Interventions and care pathways for pregnancies affected by hypertensive disorders should aim to support women through complex emotional experiences as well as reducing morbidity and mortality.

Background: Perinatal depression has been suggested to adversely impact child neurodevelopment. However, the complexity of the early childhood environment challenges conclusive findings.

Objective: To evaluate whether there is an association between perinatal depressive symptoms and child intelligence quotient (IQ) at 5 years of age.

Study design: Secondary analysis of an ancillary study to a multicenter randomized trial of thyroxine therapy for pregnant individuals with subclinical hypothyroidism. Dyads of infants and birthing parent, with completed Center for Epidemiological Studies-Depression (CES-D) screens during pregnancy and postpartum and child neurodevelopment testing completed at five years of age (n=209) were included. CES-D screening was performed at 11-20 weeks, 34-38 weeks, and one-year postpartum. Depressive symptoms were categorized as antenatal (i.e., a positive screen at any point during pregnancy) or postpartum. The primary outcome was child IQ score < 85 at 5 years of age using the Wechsler Preschool and Primary Scale of Intelligence III (WPPSI-III) Full Scale test. Secondary outcomes included other assessments of childhood neurodevelopment. Bivariable analyses and multivariable logistic regressions were utilized.

Results: Of the 209 birthing people included, 72 (34%) screened positive for depression during pregnancy and 32 (15%) screened positive one year postpartum. Children born to individuals with a positive antenatal depression screen had a higher odds of IQ <85 at 5 years of age compared with children born to individuals with a CES-D <16 (35% vs. 18 %, OR 2.4, 95% CI 1.2-4.7). Similar findings were seen for children born to individuals with a positive postpartum depression screen (47% vs. 21%, OR 3.3, 95% CI 1.5-7.3). These associations did not persist in multivariable analyses that controlled for social determinants of health and clinical characteristics (adjusted odd ratio (aOR) 1.4, 95% CI 0.7-3.1; aOR 2.1, 95% CI 0.9-5.1, for antenatal and postpartum depressive symptoms, respectively). Similar findings were observed for other adverse neurodevelopmental outcomes.

Conclusions: Having a positive perinatal depression screen was not associated with child cognitive outcomes after controlling for covariates including social determinants of health.

Background: Limited English proficiency is associated with worse health outcomes regardless of health literacy. Prior research suggests that using interpreter services for low English proficiency helps mitigate the language barrier, is associated with improved health outcomes, and patient satisfaction; however, obstetric and neonatal outcomes and pregnancy risks in this population are not well studied.

Objectives: The primary purpose of this study was to determine if low English proficiency is an independent risk factor for small for gestational age infants by utilizing interpreter use as a proxy for low English proficiency. Due to the known challenges in communication with a language barrier and discrimination against people whose first language is not English, we hypothesized that this could result in an increase in high risk conditions in pregnancy such as SGA. Our hypothesis was that the need for an interpreter would be associated with having small for gestational age infants.

Study design: We performed a retrospective cohort study at a single center using data between 1/1/2016 and 12/31/2021; we included singleton, live births ≥21 weeks gestation. We excluded multiple gestations, intrauterine fetal demise, and delivery <21 weeks. The primary outcome was rate of small for gestational age. Small for gestational age was defined as birthweight < 10^th percentile for gestational age using the 2018 Fenton newborn growth curve. Multivariable logistic regression was performed to control for confounding variables.

Results: Of the 26,260 patients included in the study, 71.3% were non-Hispanic White, 9.5% were Hispanic/Latino, and 7.9% were non-Hispanic Black. Overall, 1,662 (6.3%) patients utilized an interpreter. Over half (58.0%) of patients requesting interpreter services were Hispanic. In unadjusted analyses, the rate of small for gestational age was not different between patients who used interpreter services (n = 106, 6.4%) and those who did not (n = 1612, 6.6 %), p = 0.779. After adjusting for race/ethnicity, gravidity, gestational age, private insurance, diabetes, hypertension, and pre-pregnancy body mass index, the use of interpreter services was associated with decreased odds of small for gestational age (aOR 0.67, 95% CI 0.53 - 0.84).

Conclusions: Our findings suggest that use of an interpreter is associated with a lower incidence of small for gestational age when controlling for patient characteristics and social determinants of health. Additional research is required to explore this association, but our results indicate that recognizing demographic risk factors and providing patients with social resources such as access to interpreter services may positively impact obstetric and neonatal outcomes.