American journal of obstetrics and gynecology最新文献

Background: Bariatric surgery is internationally performed as a treatment option in obesity to achieve significant and sustained weight loss. There is an increasing number of women having pregnancies after bariatric surgery with mixed maternal and fetal outcomes, with a limited number of large, matched studies.

Objective: This study aimed to describe the type of pre-pregnancy bariatric surgery, to analyse maternal, pregnancy and offspring outcomes compared to matched women and to assess the impact of pre-pregnancy bariatric surgery on fetal growth, particularly proportions of small for gestational (SGA) and large for gestational age (LGA).

Study design: A statewide hospital and perinatal data register linked cross-sectional matched study was performed. In total, n=2,018 births in n=1,677 women with pre-pregnancy bariatric surgery were registered between 2013 and 2018, of those n=1,282 were included and analysed with 1:10 to age, parity, smoking status and Body Mass Index (BMI) matched women without bariatric surgery. The first singleton pregnancy following bariatric surgery for each woman was used for analysis. Pregnancy and neonatal outcomes from International Statistical Classification of Diseases Tenth revision codes (ICD-10AM) and neonatal birth records for outcomes of interest were analysed. Multivariable logistic regression was used to estimate the association between SGA and LGA and pre-pregnancy bariatric surgery.

Results: Of the n=1,282 women, 93% had undergone laparoscopic sleeve gastrectomy. Offspring had lower absolute birthweight (3223g ± 605g vs 3418g ± 595g; p<0.001), fewer LGA (8.6% vs 14.1%; p<0.001) and more SGA infants (10.7% vs 7.3%; p<0.001) than offspring born to matched women. Offspring were more likely to be born preterm (10.5% vs 7.8%; p=0.007) to mothers with pre-pregnancy bariatric surgery. Fewer women with previous bariatric surgery were diagnosed with GDM (15% vs 20%; p<0.001) or pregnancy induced hypertension (3.7% vs 5.4%; p=0.01). In the adjusted model, pre-pregnancy bariatric surgery was associated with a lower risk of LGA (OR 0.54, 95% CI 0.44-0.66) and higher risk of SGA (OR 1.78, 95% CI 1.46-2.17).

Conclusions: These data suggest that pre-pregnancy bariatric surgery was associated with a reduction in several obesity related pregnancy complications at the expense of more pre-term births and SGA offspring.

Background: The ophthalmic artery, which is the first branch of the internal carotid artery, has a Doppler velocity waveform with two systolic peaks. The ratio of the peak systolic velocity (PSV) of the second wave divided by that of the first wave, reflects increased peripheral resistance. Previous studies in the first, second and third trimesters of pregnancy have reported that in pregnancies that subsequently develop preeclampsia (PE) the PSV ratio is increased. Both PE and gestational diabetes mellitus (GDM) are associated with endothelial dysfunction and an increased risk of cardiovascular diseases during the first decade following pregnancy.

Objectives: To compare the ophthalmic artery PSV ratio at 11-13 weeks' gestation in women who subsequently develop GDM to unaffected pregnancies and those who develop PE.

Study design: This was a prospective observational study in women attending for a routine hospital visit at 11⁺⁰ - 13⁺⁶ weeks' gestation at King's College Hospital, London, UK. This visit included recording of maternal demographic characteristics and medical history, ultrasound examination for fetal anatomy and growth, assessment of flow velocity waveforms from the maternal ophthalmic arteries and calculation of the PSV ratio, and measurement of mean arterial pressure (MAP). Linear regression was performed for the prediction of ophthalmic artery PSV ratio, from maternal characteristics and MAP. The PSV ratio in the group with GDM was compared to that of PE and unaffected pregnancies.

Results: 3999 women were included in the study, including 375 (9.8%) who developed GDM and 101 (2.5%) who developed PE. In the GDM group, 161 (43.3%) were treated by diet alone, 130 (34,1%) were treated with metformin and 84 (22.6%) received insulin ± metformin. Significant prediction of PSV ratio was provided by development of PE, maternal age, body mass index, MAP, first degree family history of diabetes mellitus, family history of PE, Asian ethnicity, and smoking. There was no significant contribution from GDM. In women who developed GDM requiring insulin treatment, ophthalmic artery PSV ratio (0.67 ± 0.09) was higher (p <0.001) than in unaffected pregnancies (0.63 ± 0.10), but it was not significantly different from that in the PE group (0.69 ± 0.10; p=0.90).

Conclusions: In women who develop severe GDM, requiring insulin treatment, there is evidence of increased peripheral resistance which is apparent from the first-trimester of pregnancy.

Background: The rising trend in maternal mortality over the past three decades sets the United States (U.S.) apart from all other high-income countries. Multidisciplinary state and city Maternal Mortality Review Committees (MMRCs) conduct comprehensive reviews of maternal deaths, including assessments of preventability and contributing factors.

Objective(s): Assess preventability of and contributing factors to maternal mortality in the U.S.

Study design: This study is a secondary analysis of cross-sectional, population-based data from the most recent, publicly available MMRC data from 40 state and 2 cities in the U.S. Preventability was analyzed among all deaths during pregnancy or within one year postpartum from any cause (pregnancy-associated deaths, PAD) and deaths during pregnancy or within one year postpartum from causes related to pregnancy or its management, but not from accidental causes (pregnancy-related deaths, PRD). We also explored preventability by cause-of-death and contributing factors grouped as community, patient-family, provider, facility, and health system factors.

Results: Of deaths that occurred after 2010, between 53%-93.8% of PADs and 45%-100% of PRDs were deemed preventable across the 42 states and cities. Across the ten states reporting PRD preventability by cause-of-death, MMRCs deemed preventable >90% of deaths from preeclampsia-eclampsia and mental health conditions, >80% of deaths from hemorrhage and cardiovascular conditions, about 70% of deaths from infection and thrombotic embolism, and about 40% of deaths from amniotic fluid embolism and stroke. A total of 3,345 contributing factors were described in MMRC reports from 14 states in relation to 739 PRDs. While collectively patient-family and provider factors were most frequently noted as contributing to PRDs, the contribution of such factors varied between 6%-56% and 18%-42.3%, respectively, across the states. Based on data from 20 MMRCs with available information, racism or discrimination were noted in relation to 37.7% of PRDs.

Conclusions: A large proportion of PADs and PRDs in the U.S. are preventable. However, likely due to differences in MMRC membership, available data, and judgement employed to determine preventability, wide variation exists in the proportion of deaths deemed preventable and factors identified as contributing to such deaths across states. There is need to reevaluate the definitions, structure, and outputs for maternal death preventability assessments currently employed by a majority MMRCs to adequately inform state and national programming and policies.