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JMIR Bioinformatics and Biotechnology Feb 2024Current postpartum hemorrhage (PPH) risk stratification is based on traditional statistical models or expert opinion. Machine learning could optimize PPH prediction by...
BACKGROUND
Current postpartum hemorrhage (PPH) risk stratification is based on traditional statistical models or expert opinion. Machine learning could optimize PPH prediction by allowing for more complex modeling.
OBJECTIVE
We sought to improve PPH prediction and compare machine learning and traditional statistical methods.
METHODS
We developed models using the Consortium for Safe Labor data set (2002-2008) from 12 US hospitals. The primary outcome was a transfusion of blood products or PPH (estimated blood loss of ≥1000 mL). The secondary outcome was a transfusion of any blood product. Fifty antepartum and intrapartum characteristics and hospital characteristics were included. Logistic regression, support vector machines, multilayer perceptron, random forest, and gradient boosting (GB) were used to generate prediction models. The area under the receiver operating characteristic curve (ROC-AUC) and area under the precision/recall curve (PR-AUC) were used to compare performance.
RESULTS
Among 228,438 births, 5760 (3.1%) women had a postpartum hemorrhage, 5170 (2.8%) had a transfusion, and 10,344 (5.6%) met the criteria for the transfusion-PPH composite. Models predicting the transfusion-PPH composite using antepartum and intrapartum features had the best positive predictive values, with the GB machine learning model performing best overall (ROC-AUC=0.833, 95% CI 0.828-0.838; PR-AUC=0.210, 95% CI 0.201-0.220). The most predictive features in the GB model predicting the transfusion-PPH composite were the mode of delivery, oxytocin incremental dose for labor (mU/minute), intrapartum tocolytic use, presence of anesthesia nurse, and hospital type.
CONCLUSIONS
Machine learning offers higher discriminability than logistic regression in predicting PPH. The Consortium for Safe Labor data set may not be optimal for analyzing risk due to strong subgroup effects, which decreases accuracy and limits generalizability.
PubMed: 38935950
DOI: 10.2196/52059 -
Heart (British Cardiac Society) Sep 2021Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and... (Observational Study)
Observational Study
BACKGROUND/OBJECTIVES
Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan.
METHODS
We performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors.
RESULTS
We analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33±5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096).
CONCLUSIONS
Current antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy.
Topics: Adult; Chemoprevention; Drug Monitoring; Female; Fibrinolytic Agents; Fontan Procedure; Hemorrhage; Humans; International Cooperation; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Complications, Hematologic; Risk Adjustment; Thrombophilia; Thrombosis
PubMed: 33234672
DOI: 10.1136/heartjnl-2020-317397 -
Cureus May 2023Background Fetal death is the delivery of a fetus with no sign of life, as indicated by the absence of breathing, heartbeat, pulsation of the umbilical cord, or definite...
Background Fetal death is the delivery of a fetus with no sign of life, as indicated by the absence of breathing, heartbeat, pulsation of the umbilical cord, or definite movement of voluntary muscles. Nearly 2.6 million stillbirths are estimated to occur worldwide every year. Almost all of these (98%) stillbirths occur in low- and middle-income countries. About one-sixth of the stillbirths globally were recorded in India in 2019, making it the most burdened country in the world. In light of this, we conducted a study to identify the placental pathologies and maternal factors associated with stillbirth. Methodology A case-control study was conducted at the Department of Obstetrics & Gynecology, Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), from June 2022 to May 2023. Cases included pregnant women with a gestational age of 28 weeks or more who delivered a stillbirth infant at VIMSAR, and controls included gestational age-matched deliveries with live birth. Consent to participate in the study was obtained before enrolment. The final sample size was 79 cases and controls. The chi-square test was performed for bivariate analysis, and logistic regression was used for multivariate analysis. Results In our study, we found a significant association between maternal age of more than 30 years (odds ratio (OR) = 3.01, 95% confidence interval (CI) = 1.91-4.22, p = 0.012), maternal education (with up to the primary level or less: OR = 6.19, 95% CI = 2.92-7.87, p = 0.012), history of addiction (tobacco chewing: OR = 5.58, 95% CI = 3.71-7.11, p = 0.03), and the number of antenatal visits (no visit: OR = 6.87, 95% CI = 2.91-7.79, p = 0.019) with an increased risk of stillbirth. Among the obstetrical complications, pre-eclampsia/eclampsia (OR = 3.87, 95% CI = 1.98-5.11, p = 0.001), premature rupture of membranes (PROM)/preterm premature rupture of the membranes (PPROM) (OR = 2.49, 95% CI = 1.31-3.91, p = 0.03) and antepartum hemorrhage (APH) (OR = 2.66, 95% CI = 1.65-3.58, p = 0.02) were found to be significantly related with stillbirth. Among placental pathologies, uteroplacental vascular pathology (OR = 7.39, 95% CI = 3.01-8.97), acute chorioamnionitis (OR = 3.35, 95% CI = 2.11-5.21), chronic inflammation (OR = 2.33, 95% CI = 1.91 4.17), calcific changes (OR = 4.46, 95% CI = 2.56-6.01), and retroplacental clots (OR = 9.95, 95% CI = 4.39-11.71) were associated with stillbirth. Conclusions In our study, advanced maternal age, absence of antenatal visits, low level of education, tobacco addiction, pre-eclampsia/eclampsia, APH, and PROM in pregnancy were the major risk factors associated with stillbirth. Uteroplacental vascular pathology, chorioamnionitis, chronic inflammation, retroplacental hematoma, and calcific changes were the most significant placental lesions associated with stillbirth.
PubMed: 37351240
DOI: 10.7759/cureus.39339 -
BMC Pregnancy and Childbirth Oct 2023Routine health facility data provides the opportunity to monitor progress in quality and uptake of health care continuously. Our study aimed to assess the reliability...
Quality of reporting and trends of emergency obstetric and neonatal care indicators: an analysis from Tanzania district health information system data between 2016 and 2020.
BACKGROUND
Routine health facility data provides the opportunity to monitor progress in quality and uptake of health care continuously. Our study aimed to assess the reliability and usefulness of emergency obstetric care data including temporal and regional variations over the past five years in Tanzania Mainland.
METHODS
Data were compiled from the routine monthly district reports compiled as part of the health management information systems for 2016-2020. Key indicators for maternal and neonatal care coverage, emergency obstetric and neonatal complications, and interventions indicators were computed. Assessment on reliability and consistency of reports was conducted and compared with annual rates and proportions over time, across the 26 regions in of Tanzania Mainland and by institutional delivery coverage.
RESULTS
Facility reporting was near complete with 98% in 2018-2020. Estimated population coverage of institutional births increased by 10% points from 71.2% to 2016 to 81.7% in 2020 in Tanzania Mainland, driven by increased use of dispensaries and health centres compared to hospitals. This trend was more pronounced in regions with lower institutional birth rates. The Caesarean section rate remained stable at around 10% of institutional births. Trends in the occurrence of complications such as antepartum haemorrhage, premature rupture of membranes, pre-eclampsia, eclampsia or post-partum bleeding were consistent over time but at low levels (1% of institutional births). Prophylactic uterotonics were provided to nearly all births while curative uterotonics were reported to be used in less than 10% of post-partum bleeding and retained placenta cases.
CONCLUSION
Our results show a mixed picture in terms of usefulness of the District Health Information System(DHIS2) data. Key indicators of institutional delivery and Caesarean section rates were plausible and provide useful information on regional disparities and trends. However, obstetric complications and several interventions were underreported thus diminishing the usefulness of these data for monitoring. Further research is needed on why complications and interventions to address them are not documented reliably.
Topics: Infant, Newborn; Pregnancy; Humans; Female; Cesarean Section; Reproducibility of Results; Tanzania; Health Information Systems; Hospitals; Postpartum Hemorrhage; Delivery, Obstetric
PubMed: 37805475
DOI: 10.1186/s12884-023-06028-z -
Journal of Thrombosis and Haemostasis :... Jun 2008To study ante- and postnatal risk factors of venous thrombosis (VT) in pregnancy.
OBJECTIVE
To study ante- and postnatal risk factors of venous thrombosis (VT) in pregnancy.
METHODS
A hospital-based case-control study. Cases were women with objectively verified VT during pregnancy or postpartum. Two controls were selected for each case. Validated risk factors were analyzed using chi-square test and logistic regression.
RESULTS
In total 559 cases with no prior VT, 268 ante- and 291 postnatal cases were identified together with 1229 controls. Risk factors for antenatal VT were assisted reproduction technique (ART), antepartum immobilization, cigarette smoking, and slight weight gain (<7 kg). Conception after ART and multiple pregnancy had an additive effect, whereas antepartum immobilization and high body mass index (BMI) had a multiplicative effect on the risk for antepartum VT. No other interaction was found between risk factors for antepartum VT. Risk factors for postnatal VT were antepartum immobilization, cigarette smoking, intrauterine fetal growth restriction (IUGR), preeclampsia, emergency cesarean section, postpartum hemorrhage, infection, surgery, and age and parity. Antepartum immobilization, high BMI and reoperation on the indication of bleeding showed multiplicative effects on the risk of postnatal VT.
CONCLUSIONS
Ante- and postpartum risk factors differed markedly. More attention should be paid to pregnant women of high BMI who are immobilized.
Topics: Adolescent; Adult; Body Mass Index; Case-Control Studies; Female; Hospitals; Humans; Middle Aged; Postpartum Period; Pregnancy; Pregnancy Complications, Cardiovascular; Regression Analysis; Risk Factors; Treatment Outcome; Venous Thrombosis
PubMed: 18363820
DOI: 10.1111/j.1538-7836.2008.02961.x -
Journal of Multidisciplinary Healthcare 2021Antepartum hemorrhage is a very serious problem and contributes significantly to maternal and neonatal morbidity and mortality in developing countries including...
BACKGROUND
Antepartum hemorrhage is a very serious problem and contributes significantly to maternal and neonatal morbidity and mortality in developing countries including Ethiopia. Identification of risk factors of antepartum hemorrhage will help for prevention and control programs.
METHODS
An institutional-based case-control study was conducted from July 2013 to June 2016. A simple random sampling technique was employed, and 420 mothers' medical cards were reviewed using a pretested checklist. The data were entered in to EPI-info version 7 and then exported to SPSS version 20 for analysis, and all variables with a -value<0.2 at bivariate logistic regression analysis were considered as a candidate for multivariate logistic regression analysis, and those variables with a -value<0.05 in multiple logistic regression analysis were considered as significantly associated at 95% confidence interval.
RESULTS
Results of the multiple logistic regression showed that those mothers whose age was in the range of 35-44 years were significantly 4-times more likely to present with antepartum hemorrhage as compared to mothers in the age range of 15-24 years. Moreover, mothers who presented with a previous history of cesarean section were 4.7-times more likely to present with antepartum hemorrhage than those who had no previous history of cesarean section. Furthermore, women with a previous history of abortion were 2-times more likely to develop antepartum hemorrhage as compared to women who had no previous history of abortion.
CONCLUSION AND RECOMMENDATION
In this study, the factors found to be risk factors of antepartum hemorrhage were maternal age, previous history of cesarean section, and previous history of abortion. Strategies towards reduction of unwanted pregnancy to prevent abortion, pregnancy at advanced age, and to reduce the cesarean section rate should be emphasized.
PubMed: 33568914
DOI: 10.2147/JMDH.S269744 -
Journal of Obstetrics and Gynaecology... Mar 2015To evaluate the maternal and perinatal outcomes of pregnancies delivered at 23+0 to 23+6 weeks' gestation.
OBJECTIVE
To evaluate the maternal and perinatal outcomes of pregnancies delivered at 23+0 to 23+6 weeks' gestation.
METHODS
This prospective cohort study included women in the Canadian Perinatal Network who were admitted to one of 16 Canadian tertiary perinatal units between August 1, 2005, and March 31, 2011, and who delivered at 23+0 to 23+6 weeks' gestation. Women were included in the network if they were admitted with spontaneous preterm labour with contractions, a short cervix without contractions, prolapsing membranes with membranes at or beyond the external os or a dilated cervix, preterm premature rupture of membranes, intrauterine growth restriction, gestational hypertension, or antepartum hemorrhage. Maternal outcomes included Caesarean section, placental abruption, and serious complication. Perinatal outcomes were mortality and serious morbidity.
RESULTS
A total of 248 women and 287 infants were included in the study. The rate of Caesarean section was 10.5% (26/248) and 40.3% of women (100/248) had a serious complication, the most common being chorioamnionitis (38.6%), followed by blood transfusion (4.5%). Of infants with known outcomes, perinatal mortality was 89.9% (223/248) (stillbirth 23.3% [67/287] and neonatal death 62.9% [156/248]). Of live born neonates with known outcomes (n = 181), 38.1% (69/181) were admitted to NICU. Of those admitted to NICU, neonatal death occurred in 63.8% (44/69). Among survivors at discharge, the rate of severe brain injury was 44.0% (11/25), of retinopathy of prematurity 58.3% (14/24), and of any serious neonatal morbidity 100% (25/25). Two subgroup analyses were performed: in one, antepartum stillbirths were excluded, and in the other only centres that indicated they offered fetal monitoring at 23 weeks' gestation were included and antepartum stillbirths were excluded. In each of these, perinatal outcomes similar to the overall group were found.
CONCLUSION
Pregnant women delivering at 23 weeks' gestation are at risk of morbidity. Their infants have high rates of serious morbidity and mortality. Further research is needed to identify strategies and forms of management that not only increase perinatal survival but also reduce morbidities in these extremely low gestational age infants and reduce maternal morbidity.
Topics: Adult; Brain Diseases; Canada; Cesarean Section; Cohort Studies; Female; Gestational Age; Humans; Infant, Newborn; Infant, Premature; Infant, Premature, Diseases; Intensive Care, Neonatal; Morbidity; Perinatal Death; Perinatal Mortality; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Premature Birth; Prospective Studies; Retinopathy of Prematurity
PubMed: 26001868
DOI: 10.1016/S1701-2163(15)30307-8 -
Acta Obstetricia Et Gynecologica... Dec 2015Fatal antepartum fetomaternal hemorrhage is a relatively uncommon clinical presentation, though one that appears quickly and without warning. The pathophysiology of this...
INTRODUCTION
Fatal antepartum fetomaternal hemorrhage is a relatively uncommon clinical presentation, though one that appears quickly and without warning. The pathophysiology of this disease is unclear, and the incidence does not appear to be decreasing in line with overall antepartum mortality. This study was undertaken to analyse trends in antepartum fetal death from fetomaternal hemorrhage over a 25-year period in a single maternity hospital in Dublin, Ireland.
MATERIAL AND METHODS
A cross-sectional study of 192 132 nonanomalous infants weighing 500 g or more, delivered in a single tertiary-referral university institution between 1987 and 2011. Data was compared using Fisher's exact test, univariate analysis, and Cuzick's test for trend.
RESULTS
There was no decrease in the rate of fatal fetomaternal hemorrhage over the past 25 years (p = 0.29), despite a decline in overall antepartum deaths (p = 0.0049). Fetomaternal hemorrhage accounted for 4.1% (34/828) of antepartum stillbirths. A higher proportion of these stillbirths occurred at term gestations (74%; 25/34) compared with other causes (40%; 321/794; p = 0.0003). Female infants were statistically more likely to be involved than males [odds ratio (OR) 2.33, 95% confidence interval (CI) 1.08-5.47, p = 0.02). Multiple gestations were up to six times as likely to be affected as singleton pregnancies (OR 6.52, 95% CI 1.67-18.50, p = 0.005).
CONCLUSIONS
Over the past 25 years there has been no reduction in rates of fatal fetomaternal hemorrhage. Female infants and multiple gestations remain at higher risk of antepartum death from fatal fetomaternal hemorrhage.
Topics: Cross-Sectional Studies; Female; Fetomaternal Transfusion; Hemorrhage; Humans; Infant, Newborn; Ireland; Pregnancy; Risk Factors; Stillbirth
PubMed: 26332994
DOI: 10.1111/aogs.12762 -
The Journal of the American Board of... 2003Vasa previa is an uncommon obstetrical complication that poses a high risk of fetal demise if not recognized before rupture of membranes. It is vital that providers... (Review)
Review
INTRODUCTION
Vasa previa is an uncommon obstetrical complication that poses a high risk of fetal demise if not recognized before rupture of membranes. It is vital that providers recognize risk factors for vasa previa and diagnose this condition before the onset of labor so that fetal shock or demise is prevented.
METHODS
We report a patient with a bilobed placenta and perinatal hemorrhage caused by vasa previa that was not detected with antepartum ultrasound. A review of the literature published between January 1965 and August 2002 was conducted using a MEDLINE-assisted search using the key words "vasa previa," "bilobed placenta," and "succenturiate."
RESULTS
Risk factors for vasa previa have been identified. Advances in ultrasound have led to improved ability to diagnose this condition. Evaluation of patients in high-risk groups with transvaginal color flow Doppler ultrasound should be considered. The accuracy of this technique for diagnosing vasa previa is not known, nor is the true incidence of this condition. Antepartum diagnosis is associated with improved outcomes but does not eliminate morbidity and mortality.
CONCLUSIONS
A high index of suspicion for vasa previa at the time of amniotomy is required, because all cases cannot be diagnosed before the onset of labor.
Topics: Adult; Female; Fetal Death; Fetus; Gestational Age; Humans; Placenta; Placenta Diseases; Pregnancy; Risk Factors; Ultrasonography, Doppler, Color; Uterine Hemorrhage
PubMed: 14963081
DOI: 10.3122/jabfm.16.6.543 -
Cureus Sep 2023Adenomyosis is an ambiguous disorder causing a wide variety of implications from dysmenorrhea, heavy menstrual bleeding, and infertility to pregnancy complications....
Fertility and Obstetric Outcomes of Assisted Reproductive Technology (ART) in Women With Adenomyosis Following Gonadotropin-Releasing Hormone Agonist Therapy: A Single-Center Experience.
INTRODUCTION
Adenomyosis is an ambiguous disorder causing a wide variety of implications from dysmenorrhea, heavy menstrual bleeding, and infertility to pregnancy complications. Adenomyosis is associated with altered endocrine and inflammatory milieu, resulting in impaired implantation and reduced fertility potential. It is also associated with increased incidence of obstetric complications such as miscarriage, antepartum hemorrhage, placental mal-position, hypertensive disorders, small for gestational age-intrauterine growth restriction (SGA-IUGR), cesarean section, preterm labor, preterm premature rupture of membranes (PPROM), and neonatal intensive care unit (NICU) admissions.
OBJECTIVE
The aim of our study was to investigate the fertility and obstetric outcomes in women with adenomyosis treated with GnRH agonists compared to controls with normal uteri undergoing in-vitro fertilization (IVF) at our center, thereby establishing the role of gonadotropin-releasing hormone (GnRH) agonists in managing sub-fertile women with adenomyosis.
MATERIALS AND METHODS
We carried out a retrospective cohort study at our hospital to analyze the effects of adenomyosis on IVF and pregnancy outcomes. This study (n=83) involves women with adenomyosis between the ages of 21 and 37 years who were followed up at our center between 2013 and 2022. The controls (n=83) were selected from women who underwent IVF-intracytoplasmic sperm injection (IVF-ICSI) for tubal or mild male factor infertility with normal appearing uterus within the same time frame. Women with adenomyosis were given GnRH agonist as long/ultralong agonist protocol before controlled ovarian stimulation or as down-regulated frozen embryo transfer (FET). The length of suppression was between one and six months based on the size of the uterus and response to treatment. Fertility and obstetric outcomes were analyzed.
RESULTS
The implantation rates were found to be equivocal: 54.2% and 53% in the adenomyosis and control groups, respectively (p=0.208). The cumulative live birth rate was 50.6% and 48.2% in the study and control groups, respectively (p=0.341). The biochemical pregnancy rate and the first- and second-trimester miscarriage rates were not significantly different between the group with adenomyosis and the group with normal uterus. The incidence of preterm deliveries and antepartum hemorrhage was found to be significantly increased in the study group.
CONCLUSION
Medical management in women with adenomyosis optimizes the live birth rates giving results at par with the control population.
PubMed: 37809195
DOI: 10.7759/cureus.44691