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American Journal of Obstetrics and... May 2018Impaired placentation in the first 16 weeks of pregnancy is associated with increased risk of subsequent development of preeclampsia, birth of small-for-gestational-age... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE DATA
Impaired placentation in the first 16 weeks of pregnancy is associated with increased risk of subsequent development of preeclampsia, birth of small-for-gestational-age neonates, and placental abruption. Previous studies reported that prophylactic use of aspirin reduces the risk of preeclampsia and small-for-gestational-age neonates with no significant effect on placental abruption. However, meta-analyses of randomized controlled trials that examined the effect of aspirin in relation to gestational age at onset of therapy and dosage of the drug reported that significant reduction in the risk of preeclampsia and small-for-gestational-age neonates is achieved only if the onset of treatment is at ≤16 weeks of gestation and the daily dosage of the drug is ≥100 mg.
STUDY
We aimed to estimate the effect of aspirin on the risk of placental abruption or antepartum hemorrhage in relation to gestational age at onset of therapy and the dosage of the drug.
STUDY APPRAISAL AND SYNTHESIS METHODS
To perform a systematic review and meta-analysis of randomized controlled trials that evaluated the prophylactic effect of aspirin during pregnancy, we used PubMed, Cinhal, Embase, Web of Science and Cochrane library from 1985 to September 2017. Relative risks of placental abruption or antepartum hemorrhage with their 95% confidence intervals were calculated with the use of random effect models. Analyses were stratified according to daily dose of aspirin (<100 and ≥100 mg) and the gestational age at the onset of therapy (≤16 and >16 weeks of gestation) and compared with the use of subgroup difference analysis.
RESULTS
The entry criteria were fulfilled by 20 studies on a combined total of 12,585 participants. Aspirin at a dose of <100 mg per day had no impact on the risk of placental abruption or antepartum hemorrhage, irrespective of whether it was initiated at ≤16 weeks of gestation (relative risk, 1.11; 95% confidence interval, 0.52-2.36) or at >16 weeks of gestation (relative risk, 1.32; 95% confidence interval, 0.73-2.39). At ≥100 mg per day, aspirin was not associated with a significant change on the risk of placental abruption or antepartum hemorrhage, whether the treatment was initiated at ≤16 weeks of gestation (relative risk, 0.62, 95% confidence interval, 0.31-1.26), or at >16 weeks of gestation (relative risk, 2.08; 95% confidence interval, 0.86-5.06), but the difference between the subgroups was significant (P=.04).
CONCLUSION
Aspirin at a daily dose of ≥100 mg for prevention of preeclampsia that is initiated at ≤16 weeks of gestation, rather than >16 weeks, may decrease the risk of placental abruption or antepartum hemorrhage.
Topics: Abruptio Placentae; Aspirin; Female; Hemorrhage; Humans; Platelet Aggregation Inhibitors; Pre-Eclampsia; Pregnancy
PubMed: 29305829
DOI: 10.1016/j.ajog.2017.12.238 -
Medicine May 2017The aim of this meta-analysis was to investigate the prenatal, perinatal, and postnatal risk factors for children autism. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The aim of this meta-analysis was to investigate the prenatal, perinatal, and postnatal risk factors for children autism.
METHODS
PubMed, Embase, Web of Science were used to search for studies that examined the prenatal, perinatal, and postnatal risk factors for children autism. A fixed-effects model or random-effects model was used to pool the overall effect estimates.
RESULTS
Data from 37,634 autistic children and 12,081,416 nonautistic children enrolled in 17 studies were collated. During the prenatal period, the factors associated with autism risk were maternal and paternal age≥35 years, mother's and father's race: White and Asian, gestational hypertension, gestational diabetes, maternal and paternal education college graduate+, threatened abortion, and antepartum hemorrhage. During perinatal period, the factors associated with autism risk were caesarian delivery, gestational age≤36 weeks, parity≥4, spontaneous labor, induced labor, no labor, breech presentation, preeclampsia, and fetal distress. During the postnatal period, the factors associated with autism risk were low birth weight, postpartum hemorrhage, male gender, and brain anomaly. Parity≥4 and female were associated with a decreased risk of autism. In addition, exposure to cigarette smoking, urinary infection, mother's and father's race: Black and Hispanic, mother's country of birth outside Europe and North America, umbilical cord around neck, premature membrane rupture, 5-minutes Apgar score<7, and respiratory infection were not associated with increased risk of autism.
CONCLUSION
The present meta-analysis confirmed the relation between some prenatal, perinatal, and postnatal factors with autism. All these factors were examined individually, thus it was still unclear that whether these factors are causal or play a secondary role in the development of autism. Further studies are needed to verify our findings, and investigate the effects of multiple factors on autism, rather than the single factor.
Topics: Autistic Disorder; Female; Humans; Pregnancy; Pregnancy Complications; Risk Factors
PubMed: 28471964
DOI: 10.1097/MD.0000000000006696 -
BMJ (Clinical Research Ed.) Oct 2017To provide evidence to support updated guidelines for the management of pregnant women with hereditary thrombophilia in order to reduce the risk of a first venous... (Meta-Analysis)
Meta-Analysis Review
To provide evidence to support updated guidelines for the management of pregnant women with hereditary thrombophilia in order to reduce the risk of a first venous thromboembolism (VTE) in pregnancy. Systematic review and bayesian meta-analysis. Embase, Medline, Web of Science, Cochrane Library, and Google Scholar from inception through 14 November 2016. Observational studies that reported on pregnancies without the use of anticoagulants and the outcome of first VTE for women with thrombophilia were eligible for inclusion. VTE was considered established if it was confirmed by objective means, or when the patient had received a full course of a full dose anticoagulant treatment without objective testing. 36 studies were included in the meta-analysis. All thrombophilias increased the risk for pregnancy associated VTE (probabilities ≥91%). Regarding absolute risks of pregnancy associated VTE, high risk thrombophilias were antithrombin deficiency (antepartum: 7.3%, 95% credible interval 1.8% to 15.6%; post partum: 11.1%, 3.7% to 21.0%), protein C deficiency (antepartum: 3.2%, 0.6% to 8.2%; post partum: 5.4%, 0.9% to 13.8%), protein S deficiency (antepartum: 0.9%, 0.0% to 3.7%; post partum: 4.2%; 0.7% to 9.4%), and homozygous factor V Leiden (antepartum: 2.8%, 0.0% to 8.6%; post partum: 2.8%, 0.0% to 8.8%). Absolute combined antepartum and postpartum risks for women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutations, or compound heterozygous factor V Leiden and prothrombin G20210A mutations were all below 3%. Women with antithrombin, protein C, or protein S deficiency or with homozygous factor V Leiden should be considered for antepartum or postpartum thrombosis prophylaxis, or both. Women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutation, or compound heterozygous factor V Leiden and prothrombin G20210A mutation should generally not be prescribed thrombosis prophylaxis on the basis of thrombophilia and family history alone. These data should be considered in future guidelines on pregnancy associated VTE risk.
Topics: Bayes Theorem; Evidence-Based Medicine; Female; Humans; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications, Hematologic; Risk Factors; Thrombolytic Therapy; Thrombophilia; Venous Thrombosis
PubMed: 29074563
DOI: 10.1136/bmj.j4452 -
Blood Advances Nov 2018Venous thromboembolism (VTE) complicates ∼1.2 of every 1000 deliveries. Despite these low absolute risks, pregnancy-associated VTE is a leading cause of maternal...
BACKGROUND
Venous thromboembolism (VTE) complicates ∼1.2 of every 1000 deliveries. Despite these low absolute risks, pregnancy-associated VTE is a leading cause of maternal morbidity and mortality.
OBJECTIVE
These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and others in decisions about the prevention and management of pregnancy-associated VTE.
METHODS
ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.
RESULTS
The panel agreed on 31 recommendations related to the treatment of VTE and superficial vein thrombosis, diagnosis of VTE, and thrombosis prophylaxis.
CONCLUSIONS
There was a strong recommendation for low-molecular-weight heparin (LWMH) over unfractionated heparin for acute VTE. Most recommendations were conditional, including those for either twice-per-day or once-per-day LMWH dosing for the treatment of acute VTE and initial outpatient therapy over hospital admission with low-risk acute VTE, as well as against routine anti-factor Xa (FXa) monitoring to guide dosing with LMWH for VTE treatment. There was a strong recommendation (low certainty in evidence) for antepartum anticoagulant prophylaxis with a history of unprovoked or hormonally associated VTE and a conditional recommendation against antepartum anticoagulant prophylaxis with prior VTE associated with a resolved nonhormonal provoking risk factor.
Topics: Administration, Oral; Anticoagulants; Breast Feeding; Evidence-Based Medicine; Female; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Infant; Infant, Newborn; Pregnancy; Venous Thromboembolism
PubMed: 30482767
DOI: 10.1182/bloodadvances.2018024802 -
Lancet (London, England) Jan 2016Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Preterm pre-labour ruptured membranes close to term is associated with increased risk of neonatal infection, but immediate delivery is associated with risks of prematurity. The balance of risks is unclear. We aimed to establish whether immediate birth in singleton pregnancies with ruptured membranes close to term reduces neonatal infection without increasing other morbidity.
METHODS
The PPROMT trial was a multicentre randomised controlled trial done at 65 centres across 11 countries. Women aged over 16 years with singleton pregnancies and ruptured membranes before the onset of labour between 34 weeks and 36 weeks and 6 days weeks who had no signs of infection were included. Women were randomly assigned (1:1) by a computer-generated randomisation schedule with variable block sizes, stratified by centre, to immediate delivery or expectant management. The primary outcome was the incidence of neonatal sepsis. Secondary infant outcomes included a composite neonatal morbidity and mortality indicator (ie, sepsis, mechanical ventilation ≥24 h, stillbirth, or neonatal death); respiratory distress syndrome; any mechanical ventilation; and duration of stay in a neonatal intensive or special care unit. Secondary maternal outcomes included antepartum or intrapartum haemorrhage, intrapartum fever, postpartum treatment with antibiotics, and mode of delivery. Women and caregivers could not be masked, but those adjudicating on the primary outcome were masked to group allocation. Analyses were by intention to treat. This trial is registered with the International Clinical Trials Registry, number ISRCTN44485060.
FINDINGS
Between May 28, 2004, and June 30, 2013, 1839 women were recruited and randomly assigned: 924 to the immediate birth group and 915 to the expectant management group. One woman in the immediate birth group and three in the expectant group were excluded from the primary analyses. Neonatal sepsis occurred in 23 (2%) of 923 neonates whose mothers were assigned to immediate birth and 29 (3%) of 912 neonates of mothers assigned to expectant management (relative risk [RR] 0·8, 95% CI 0·5-1·3; p=0·37). The composite secondary outcome of neonatal morbidity and mortality occurred in 73 (8%) of 923 neonates of mothers assigned to immediate delivery and 61 (7%) of 911 neonates of mothers assigned to expectant management (RR 1·2, 95% CI 0·9-1·6; p=0·32). However, neonates born to mothers in the immediate delivery group had increased rates of respiratory distress (76 [8%] of 919 vs 47 [5%] of 910, RR 1·6, 95% CI 1·1-2·30; p=0·008) and any mechanical ventilation (114 [12%] of 923 vs 83 [9%] of 912, RR 1·4, 95% CI 1·0-1·8; p=0·02) and spent more time in intensive care (median 4·0 days [IQR 0·0-10·0] vs 2·0 days [0·0-7·0]; p<0·0001) compared with neonates born to mothers in the expectant management group. Compared with women assigned to the immediate delivery group, those assigned to the expectant management group had higher risks of antepartum or intrapartum haemorrhage (RR 0·6, 95% CI 0·4-0·9), intrapartum fever (0·4, 0·2-0·9), and use of postpartum antibiotics (0·8, 0·7-1·0), and longer hospital stay (p<0·0001), but a lower risk of caesarean delivery (RR 1·4, 95% CI 1·2-1·7).
INTERPRETATION
In the absence of overt signs of infection or fetal compromise, a policy of expectant management with appropriate surveillance of maternal and fetal wellbeing should be followed in pregnant women who present with ruptured membranes close to term.
FUNDING
Australian National Health and Medical Research Council, the Women's and Children's Hospital Foundation, and The University of Sydney.
Topics: Adolescent; Adult; Antibodies; Australia; Cesarean Section; Critical Care; Delivery, Obstetric; Female; Fetal Membranes, Premature Rupture; Fever; Humans; Infant; Infant Mortality; Infant, Newborn; Length of Stay; Postpartum Period; Pregnancy; Pregnancy Outcome; Premature Birth; Respiratory Distress Syndrome, Newborn; Risk; Sepsis; Term Birth; Uterine Hemorrhage; Young Adult
PubMed: 26564381
DOI: 10.1016/S0140-6736(15)00724-2 -
Medicina (Kaunas, Lithuania) Apr 2020: Risk factors for neonatal/maternal morbidity and mortality in placental abruption have been incompletely studied in the current literature. Most of the research...
: Risk factors for neonatal/maternal morbidity and mortality in placental abruption have been incompletely studied in the current literature. Most of the research overlooked the African American population as mostly Caucasian populations are selected. We aimed to find which risk factor influence the neonatal and maternal outcome in cases of placental abruption occurring in African American pregnant women in an inner-city urban setting. : We performed a retrospective cohort study at St. Joseph's Regional Medical Center, NJ United States of America (USA), between 1986 and 1996. Inclusion criteria were African American race, singleton pregnancy with gestational age over 20 weeks and placental abruption. Maternal age, gravidity, parity, gestational age at delivery/occurrence of placental abruption and mode of delivery were collected. Risk factors for placental abruption such as placenta previa, hypertensive disorders of pregnancy, cigarette smoking, crack/cocaine and alcohol use, mechanical trauma, preterm premature rupture of membranes (PPROM), and premature rupture of membranes (PROM) were recorded. Poor neonatal outcome was considered when anyone of the following occurred: 1st and 5th minute Apgar score lower than 7, intrauterine fetal demise (IUFD), perinatal death, and neonatal arterial umbilical cord pH less than 7.15. Poor maternal outcome was considered if any of the following presented at delivery: hemorrhagic shock, disseminated intravascular coagulation (DIC), hysterectomy, postpartum hemorrhage (PPH), maternal intensive care unit (ICU) admission, and maternal death. A population of 271 singleton African American pregnant women was included in the study. Lower gestational age at delivery and cesarean section were statistically significantly correlated with poor neonatal outcomes ( 0.018; < 0.001; 0.015) in the univariate analysis; only lower gestational age at delivery remained significant in the multivariate analysis ( < 0.001). Crack/cocaine use was statistically significantly associated with poor maternal outcome ( 0.033) in the univariate analysis, while in the multivariate analysis, hemolysis, elevated enzymes, low platelet (HELLP) syndrome, crack/cocaine use and previous cesarean section resulted significantly associated with poor maternal outcome ( 0.029, 0.017, 0.015, 0.047). PROM was associated with better neonatal outcome in the univariate analysis, and preeclampsia was associated with a better maternal outcome in the multivariate analysis. : Lower gestational age at delivery is the most important risk factor for poor neonatal outcome in African American women with placental abruption. Poor maternal outcome correlated with HELLP syndrome, crack/cocaine use and previous cesarean section. More research in this understudied population is needed to establish reliable risk factors and coordinate preventive interventions.
Topics: Abruptio Placentae; Adult; Black or African American; Area Under Curve; Cohort Studies; Female; Gestational Age; Humans; Infant; Infant Mortality; Infant, Newborn; Maternal Mortality; New Jersey; Pregnancy; ROC Curve; Retrospective Studies; Risk Factors
PubMed: 32295061
DOI: 10.3390/medicina56040174 -
British Journal of Anaesthesia Dec 2009Maternal haemorrhage is the leading cause of preventable maternal death worldwide and encompasses antepartum, intrapartum, and postpartum bleeding. This review... (Review)
Review
Maternal haemorrhage is the leading cause of preventable maternal death worldwide and encompasses antepartum, intrapartum, and postpartum bleeding. This review highlights factors that predispose to severe bleeding, its management, and the most recent treatment and guidelines. Advances in obstetric care have provided physicians with the diagnostic tools to detect, anticipate, and prevent severe life-threatening maternal haemorrhage in most patients who have had prenatal care. In an optimal setting, patients at high risk for haemorrhage are referred to tertiary care centres where multidisciplinary teams are prepared to care for and deal with known potential complications. However, even with the best prenatal care, unexpected haemorrhage occurs. The first step in management is stabilization of haemodynamic status, which involves securing large bore i.v. access, invasive monitoring, and aggressive fluid management and transfusion therapy. Care for the patient with maternal bleeding should follow an algorithm that goes through a rapid and successive sequence of medical and surgical approaches to stem bleeding and decrease morbidity and mortality. With the addition of potent uterotonic agents and the advent of minimally invasive interventional radiological techniques such as angiographic embolization and arterial ligation, definitive yet conservative management is now possible in an attempt to avoid hysterectomy in patients with severe peripartum bleeding. If these interventions are inadequate to control the bleeding, the decision to proceed to hysterectomy must be made expeditiously. Recombinant factor VIIa is a relatively new treatment that could prove useful for severe coagulopathy and intractable bleeding.
Topics: Factor VIIa; Female; Humans; Placenta Diseases; Postpartum Hemorrhage; Pregnancy; Pregnancy Complications; Recombinant Proteins; Risk Factors; Uterine Hemorrhage
PubMed: 20007990
DOI: 10.1093/bja/aep303 -
Journal of Family Medicine and Primary... Dec 2023Antepartum hemorrhage (APH) is one of the deadliest complications in obstetrics. It can complicate about 2-5% of pregnancies. It contributes significantly to maternal...
INTRODUCTION AND AIM
Antepartum hemorrhage (APH) is one of the deadliest complications in obstetrics. It can complicate about 2-5% of pregnancies. It contributes significantly to maternal and perinatal mortality and morbidity during pregnancy and childbearing worldwide. The aim of this study was to determine maternal and fetal outcomes in patients presenting with APH.
MATERIALS AND METHODS
This was a retrospective study. Pregnant women with >28 weeks gestation reporting to the Department of Obstetrics and Gynecology from May 2021 to April 2022 were included in the study. Ethical approval from the institutional ethical committee was taken.
RESULT
This study included 76 patients of APH. Most patients in the analysis were found to be second gravida (30%). Anemia was the most common associated morbidity (51.31%). 58% of these patients were of placenta previa, 14% were of abruption, and 10% were of accreta. Among all patients, 94.74% recovered well. 2.63% of cases could not be saved and resulted in maternal mortality. The proportions of babies alive, intra-uterine death (IUD), and intubated were 86.84%, 11.84%, and 1.32%, respectively. 17.1% of patients required a lifesaving cesarean hysterectomy.
CONCLUSION
APH is an obstetrical emergency that requires timely diagnosis and early intervention. Swift management is required to improve maternal and fetal outcomes.
PubMed: 38361908
DOI: 10.4103/jfmpc.jfmpc_692_23