Introduction: Hypertensive disorders of pregnancy are associated with significant cardiac remodeling and diastolic dysfunction during pregnancy and are important contributors to maternal morbidity and mortality. Whether acute adverse maternal outcomes during hypertensive disorders of pregnancy are associated with abnormal left ventricular geometry and function has not been widely studied.
Material and methods: A prospective observational study was conducted on 255 women with hypertensive disorders of pregnancy who underwent transthoracic echocardiography during the peripartum period. Maternal echocardiographic parameters, including left ventricular morphology and function, were analyzed to determine their association with composite adverse maternal outcomes by univariate and multivariate analyses. The composite adverse maternal outcome was defined as at least one of the following: admission to a high dependency unit (an intermediate-care ward, providing enhanced cardiac monitoring), acute renal injury, adverse cardiopulmonary events, stroke, and disseminated intravascular coagulation.
Results: Adverse maternal outcomes occurred in 68 (26.7%) participants. Women with adverse outcomes had significantly higher left atrial volume index (28.8 [23.4-32.3] mL/m2 vs. 26.6 [22.2-30.9] mL/m2, p = 0.045) and E/e' ratio (7.8 [6.6-9.2] vs. 7.0 [5.9-8.1], p = 0.002) compared to those without complications. Other diastolic indices, namely, mitral inflow E/A and tissue-Doppler e' velocities at the lateral and septal mitral annulus, showed no statistically significant between-group. In multivariable analysis, both left atrial volume index and E/e' ratio remained independently associated with adverse maternal outcomes after adjusting for maternal factors and clinical variables. Right ventricular indices, such as tricuspid annular plane systolic excursion and systolic velocity S', were independently associated with adverse maternal outcomes, while fractional area change remained unchanged, indicating hyperkinetic circulatory adaptation rather than enhanced intrinsic right systolic function.
Conclusions: Cardiac abnormalities, particularly in left ventricular diastolic function and in right ventricular function, are more common in women with adverse maternal outcomes in hypertensive disorders of pregnancy than in hypertensive women without adverse maternal outcomes. Further studies are needed to determine whether these echocardiographic abnormalities could help identify women at increased risk of complications.
An increased incidence of endometrial cancer has been noted, especially in premenopausal women in countries with rapid socioeconomic transition. In one of the largest patient cohorts of women ≤50 years, with manually validated register data, we aim to examine the pattern of disease of endometrial cancer and to evaluate the prognosis according to tumor and patient characteristics, focusing on body mass index.
This is a nationwide population-based study on women ≤50 years with endometrial cancer, 2010–2021, using data from Swedish registries complemented by the reviewing of medical records. Overall survival and disease-free survival were calculated by the Kaplan–Meier method and the log-rank test. Multivariable regression analyses were performed.
Of the total endometrial cancer cohort, 797 (5%) patients were ≤50 years of age (the PremEnCa cohort) with 0.9% under 40 years of age. Women ≤50 years of age had a higher prevalence of stage IA and endometrioid histology than older women. Among women ≤50 years of age, 46% met the criteria for obesity. No associations between socioeconomic factors and stage at diagnosis were found. Notably, women with lower Body Mass Index <20, had a higher proportion of non-endometrioid histology and higher stage of disease at the time of diagnosis. Median follow-up time was 4.2 (IOR 1.9–5.4) years. The recurrence rate was 6.1% in the PremEnCa cohort during the follow-up period, and the 5-year overall survival was 94.6% (95% CI: 92.6–96.0) for endometrioid and 68.5% (95% CI: 51.1–80.8) for non-endometrioid endometrial cancer. Only 36 of the 74 deaths were caused by endometrial cancer. In adjusted analyses for disease-free survival, non-endometrioid histology and International Federation of Gynecology and Obstetrics (FIGO) stage were associated with worse prognosis.
Endometrial cancer in premenopausal women is very rare and is associated with an excellent prognosis. Histology and FIGO stage were the strongest prognostic factors. Half of the deaths were due to other causes, which emphasizes the importance of focusing on general health aspects in this young endometrial cancer population.
Survival and healthcare for patients with congenital heart disease have improved, and the number of pregnancies among women of childbearing age with congenital heart disease has increased. Our aim was to investigate obstetric outcomes in a large retrospective, national registry study of women with congenital heart disease compared to controls.
The study included women over 18 years of age from the Swedish Registry of Congenital Heart Disease. Each case was matched with 10 controls from Statistics Sweden, based on the mother's birth year and birth county and all were subsequently linked to the Swedish Medical Birth Register. We included 7998 pregnancies in women with congenital heart disease and 84 799 in controls during 1973–2020.
The mean age at delivery for women with congenital heart disease and controls was 28.7 (±5.0) and 28.7 (±5.1) years, respectively. Women with congenital heart disease smoked less, had a shorter gestation and a higher incidence of delivery by Cesarean section compared to controls. The likelihood of Cesarean section was increased in women with congenital heart disease compared to controls: odds ratio 1.45 (95% confidence interval (CI) 1.37–1.54). Compared to controls, women with congenital heart disease had an increased likelihood of giving birth to small-for-gestational-age neonates: odds ratio 1.40 (95% CI 1.23–1.58). The association regarding small-for-gestational-age remained after adjusting for body mass index, age, smoking, comorbid diseases and preeclampsia. Women with congenital heart disease had an increased likelihood of prematurity compared to controls: odds ratio 1.47 (95% CI 1.35–1.59). The likelihood of Cesarean section, small-for-gestational-age neonates and prematurity was higher in women with severe congenital heart disease than mild/moderate congenital heart disease, both compared to controls.
In this large national case–control study in women with congenital heart disease, we showed an increased likelihood of giving birth prematurely by Cesarean section, and having a small-for-gestational-age neonate compared to matched controls. The likelihood seems even higher in women with severe congenital heart disease. Further research is needed to explore the underlying reasons for the high rates of Cesarean section in women with congenital heart disease.
Introduction: Ovarian stimulation can cause supraphysiological estradiol levels and adverse effects on endometrial receptivity. Since patients could undergo cleavage or blastocyst stage embryo transfer, the threshold value of peak estradiol level for each transfer stage that impacts the pregnancy outcomes of fresh versus frozen embryo transfer remains unclear. This work aims at answering the following questions: what is the threshold of peak estradiol level that modifies the difference in pregnancy outcomes between fresh and frozen embryo transfer and whether the threshold value varies with the stage of embryo transferred?
Material and methods: A secondary analysis of data from four multicenter randomized trials with similar design comparing the rate of live birth between fresh and frozen embryo transfer in a total of 6153 patients. Peak serum estradiol level was measured on the day of hCG administration. Live birth rate is the primary outcome.
Results: Multivariable regression modeling showed an interaction between the stage of embryo transferred and the intervention (frozen vs fresh embryo transfer) on the live birth rate (p = 0.016). In the cleavage-stage embryo transfer group, frozen embryo transfer resulted in a higher rate of live birth when peak estradiol level >3900 pg/mL (55.4% vs 44.9%; OR, 1.57; 95% CI, 1.24-1.99) and a similar live birth rate (OR, 1.10; 95% CI, 0.93-1.31) when peak estradiol level was 1600-3900 pg/mL. However, in the blastocyst transfer group, frozen embryo transfers yielded a higher live birth rate when peak estradiol level >2000 pg/mL (54.3% vs 37.7%; OR, 2.00; 95% CI, 1.59-2.51).
Conclusions: A freeze-all strategy may result in a higher rate of live birth when the peak estradiol level >3900 pg/mL for cleavage-stage embryo transfer and when the peak estradiol level >2000 pg/mL for blastocyst transfer.
Unidentified small for gestational age (SGA) pregnancies have an increased risk for stillbirth. The risk of stillbirth is increased in women born abroad or with low socioeconomic status (SES). The aim of this study was to evaluate potential inequalities in antenatal screening and identification of SGA by examining whether a foreign background or indicators of low SES were associated with unidentified SGA.
This was a register-based cohort study of all pregnancies delivered in Stockholm in the year 2014 and 2017, including 5487 SGA pregnancies. Data from maternal medical records were linked to nationwide Swedish registers. Exposures were educational level, family income level, recent immigration, social security benefits, civil status, Swedish/foreign background, municipal affiliation, and country of birth. Outcome was unidentified SGA, defined as born SGA with no or normal growth scans performed at or after week 24 + 0 of pregnancy. We used unadjusted and adjusted logistic regression analyses to assess the associations between socioeconomic factors and unidentified SGA. Additionally, an intersectional regression analysis was performed to explore predefined combinations of the exposure factors.
Neither educational level, family income level, Swedish/foreign background, or any combination of these factors, nor recent immigration or civil status was associated with unidentified SGA in the adjusted model. Women receiving social security benefits had decreased odds of unidentified SGA, adjusted odds ratio 0.73, 95% confidence interval 0.55–0.97.
Foreign background or indicators of low SES were not positively associated with unidentified SGA. These findings suggest that antenatal screening and identification of SGA are provided on equal terms.
Pregnancies at very and extremely advanced maternal age (VAMA, 45–49 years and EAMA, ≥50 years) are increasingly common, particularly regarding the influence of assisted reproductive technology (ART), yet their obstetric and perinatal outcomes remain underexplored. This study aimed to investigate maternal and neonatal outcomes in singleton pregnancies among women aged ≥45 years, with a specific focus on ART conception and oocyte source.
This multicenter retrospective cohort study included women aged ≥45 years with singleton pregnancies delivered ≥22 weeks' gestation between 2016 and 2022 across five Italian academic hospitals. Pregnancies were categorized by mode of conception (spontaneous conception [SC] vs. ART), and ART pregnancies were further stratified by oocyte origin (homologous [ART-HO] vs. heterologous [ART-HE]). Multivariable logistic regression was used to evaluate associations between mode of conception and obstetric outcomes, adjusting for key confounders.
Among 557 included pregnancies, 495 (88.9%) involved women aged 45–49 years, and 62 (11.1%) women aged ≥50. Compared to SC, ART pregnancies were associated with higher adjusted odds of cesarean delivery (aOR 4.20, 95% CI 2.99–4.92; p < 0.001) and postpartum hemorrhage (aOR 2.72, 95% CI 1.75–4.23; p < 0.001). No significant differences in neonatal outcomes were observed. In the ART subgroup analysis, ART-HE was associated with increased odds of gestational diabetes (aOR 1.97, 95% CI 1.10–3.55; p = 0.024) and manual placental removal (aOR 10.45, 95% CI 1.23–88.46; p = 0.031) compared to ART-HO.
ART pregnancies in women ≥45 years are associated with increased maternal morbidity, particularly when involving heterologous oocytes. These findings underscored the need for tailored counseling and multidisciplinary perinatal care in this growing population.
Approximately 85% of women who undergo vaginal birth sustain childbirth-related perineal trauma. Worldwide, 21% of women give birth by cesarean section. These wounds therefore affect the vast majority of women after birth; however, there is a lack of validated tools to accurately identify women with abnormal wound healing in the postpartum period. Consequently, in clinical settings, validated wound-assessment tools are not generally used to assess wound healing in this population. We performed a scoping review to identify and characterize wound-assessment tools that have been used to determine the healing of childbirth-related wounds in existing research (to include women who experience perineal trauma or a cesarean section).
Medline, EMBASE, CINAHL, and Google Scholar were searched from inception to April 2024. Studies were included where wound-assessment tools were used to assess wound healing, after women had sustained either childbirth-related perineal trauma or a cesarean section, as an outcome of a primary research article. For studies that assessed wound healing in women with perineal trauma, this included all types of childbirth-related perineal trauma, sustained at spontaneous or assisted vaginal birth. Studies were eligible for inclusion where the wound-assessment tool was used at any time-point in the postpartum period.
There were 95 studies eligible for inclusion; 72 of which utilized wound-assessment tools for the assessment of healing after women sustained childbirth-related perineal trauma and 23 for women with cesarean section wounds. The REEDA tool (redness, oedema, ecchymosis, discharge, approximation) was used in 91 of the 95 studies, with the remainder using alternative wound-assessment tools, including the use of the ASEPSIS tool (additional treatment, serous discharge, erythema, purulent exudate, separation of deep tissues, isolation of bacteria, and length of inpatient stay).
There are limited wound-assessment tools to determine healing after women sustain childbirth-related wounds. The REEDA tool is the most commonly used in research settings. There is a clear need for the development of a clinically robust and inclusive wound- assessment tools, which comprehensively reflect the postpartum healing process among diverse populations.
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