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1.  Racial variation in the association between gestational age and perinatal mortality: prospective study 
BMJ : British Medical Journal  2007;334(7598):833.
Objectives To determine if the risks of perinatal mortality and antepartum stillbirth associated with post term birth increase earlier during pregnancy in South Asian and black women than in white women, and to investigate differences in the factors associated with antepartum stillbirth between the racial groups.
Design Prospective study using logistic regression analysis.
Setting 15 maternity units in northwest London from 1988 to 2000.
Participants 197 061 nulliparous women self reported as white, South Asian, or black, who delivered a single baby weighing at least 500 g at 24-43 completed weeks' gestation.
Main outcome measures Gestation specific perinatal mortality, antepartum stillbirth rates, and independent factors for antepartum stillbirth by racial groups.
Results The crude gestation specific perinatal mortality patterns for the three racial groups differed (P<0.001). The perinatal mortality rate among black women was lower than among white women before 32 weeks but was higher thereafter. Perinatal mortality was highest among South Asian women at all gestational ages and increased the fastest at term. After adjusting for the confounders of antepartum stillbirth (placental abruption, congenital abnormality, low birth weight, birth weight <10th centile, meconium passage, fever, maternal body mass index ≥30, and maternal age ≥30), the excess mortality among black women after 32 weeks was not significant. After adjusting for confounding, South Asian women still had a significantly higher risk of antepartum stillbirth (odds ratio 1.8, 95% confidence interval 1.2 to 2.7).
Conclusions The risk of perinatal mortality increased earlier in gestation among South Asian women than among white women. The most important factor associated with antepartum stillbirth among white women was placental abruption, but among South Asian and black women it was birth weight below 2000 g.
PMCID: PMC1853199  PMID: 17337455
2.  The impact of close surveillance on pregnancy outcome among women with a prior history of antepartum complications attributed to thrombosis: a cohort study 
There is limited evidence, so far, as to the optimal management of women with a prior obstetric history of antepartum complications attributed to thrombosis. We aimed to investigate the contribution of close antepartum surveillance on pregnancy outcome among women with prior antepartum complications attributed to thrombosis.
The study was conducted on all women who were delivered, conceived and delivered again between January 2000 and January 2006 at a university teaching hospital. Women included were managed in previous pregnancy at a low risk setting and had unpredicted antepartum complications occurring at a gestational age of 23 weeks or more. Antepartum complications considered were intrauterine fetal death, neonates who were small for gestational age, severe pre-eclampsia and placental abruption. All women were tested for the presence of thrombophilia after delivery. In the following pregnancy, only women found to have any thrombophilia (thrombophilic group) were treated with enoxaparin. Both the thrombophilic group and the non-thrombophilic group (tested negatively for thrombophilia) were managed and observed closely at our high-risk pregnancy clinic.
Ninety-seven women, who conceived at least once after the diagnosis of the relevant antepartum complications, were included in this study. Forty-nine had any thrombophilia and 48 tested negatively. Composite antepartum complications (all antepartum complications considered) were reduced significantly after close antepartum surveillance in both groups. Mean birth weight and mean gestational age improved significantly and were comparable between the groups.
Close antepartum surveillance may contribute to improvement in the perinatal outcomes of women with prior antepartum complications attributed to thrombosis.
PMCID: PMC2603012  PMID: 19025596
3.  First versus Second Trimester Ultrasound: The Effect on Pregnancy Dating and Perinatal Outcomes 
To examine the effect of first trimester obstetric ultrasound (OBUS) on the measurement of the effect of complications ascribed to postterm pregnancies.
Study Design
We conducted a retrospective cohort study of all term, singleton pregnancies delivered at our institution who had an OBUS at ≤24 weeks of gestation. Those women who underwent an OBUS at ≤12 weeks of gestation (OBUS12) were compared to those who had an OBUS at 13–24 weeks of gestation (OBUS13–24). The primary outcome measures were the rates of postterm pregnancies greater than 41 or 42 weeks’ gestation. Secondary outcomes were the differences between the postterm and term gestations in maternal and neonatal outcomes.
In the OBUS12 group, the rate of postterm pregnancy ≥42 weeks was lower (2.7%) as compared to the OBUS13–24 group (3.7%, p=0.022). With regards to reaching 41 weeks of gestation, the OBUS12 group was again lower (18.2%) as compared to the OBUS13–24 group (22.1%, p<0.001). There were also fewer postterm inductions at ≥42 weeks in the OBUS12 group (1.8%) as compared to the OBUS13–24 group (2.6%, p=0.017). When comparing perinatal outcomes between those women who reached 41 weeks of gestation and those prior to 41 weeks of gestation, the OBUS12 group demonstrated greater differences between these two groups.
Our findings suggest that earlier obstetric ultrasound, which leads to better pregnancy dating, reduces the rate of estimated postterm pregnancies. This may, in turn, reduce unnecessary intervention and lead to better identification of postterm pregnancies at greater risk of complications.
PMCID: PMC2603611  PMID: 18538160
pregnancy dating; ultrasound; complications of pregnancy; post-term; post-dates
4.  Risk factors for antepartum stillbirth and the influence of maternal age in New South Wales Australia: A population based study 
Maternal age is a known risk factor for stillbirth and delayed childbearing is a societal norm in developed country settings. The timing and reasons for age being a risk factor are less clear. This study aimed to document the gestational specific risk of maternal age throughout pregnancy and whether the underlying causes of stillbirth differ for older women.
Using linkage of state maternity and perinatal death data collections the authors assessed risk factors for antepartum stillbirth in New South Wales Australia for births between 2002 – 2006 (n = 327,690) using a Cox proportional hazards model. Gestational age specific risk was calculated for different maternal age groups. Deaths were classified according to the Perinatal Mortality Classifications of the Perinatal Society of Australia and New Zealand.
Maternal age was a significant independent risk factor for antepartum stillbirth (35 – 39 years HR 1.4 95% CI 1.12 – 1.75; ≥ 40 years HR 2.41 95% CI 1.8 – 3.23). Other significant risk factors were smoking HR 1.82 (95% CI 1.56 –2.12) nulliparity HR 1.23 (95% CI 1.08 – 1.40), pre-existing hypertension HR 2.77 (95% CI 1.94 – 3.97) and pre-existing diabetes HR 2.65 (95% CI 1.63 – 4.32). For women aged 40 or over the risk of antepartum stillbirth beyond 40 weeks was 1 in 455 ongoing pregnancies compared with 1 in 1177 ongoing pregnancies for those under 40. This risk was increased in nulliparous women to 1 in 247 ongoing pregnancies. Unexplained stillbirths were the most common classification for all women, stillbirths classified as perinatal infection were more common in the women aged 40 or above.
Women aged 35 or older in a first pregnancy should be counselled regarding stillbirth risk at the end of pregnancy to assist with informed decision making regarding delivery. For women aged 40 or older in their first pregnancy it would be reasonable to offer induction of labour by 40 weeks gestation.
PMCID: PMC3552834  PMID: 23324309
Stillbirth; Maternal age; Risk factors; Population-based; Data linkage
5.  A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes 
The New England journal of medicine  2009;361(14):1339-1348.
It is uncertain whether treatment of mild gestational diabetes mellitus improves pregnancy outcomes.
Women who were in the 24th to 31st week of gestation and who met the criteria for mild gestational diabetes mellitus (i.e., an abnormal result on an oral glucose-tolerance test but a fasting glucose level below 95 mg per deciliter [5.3 mmol per liter]) were randomly assigned to usual prenatal care (control group) or dietary intervention, self-monitoring of blood glucose, and insulin therapy, if necessary (treatment group). The primary outcome was a composite of stillbirth or perinatal death and neonatal complications, including hyperbilirubinemia, hypoglycemia, hyperinsulinemia, and birth trauma.
A total of 958 women were randomly assigned to a study group — 485 to the treatment group and 473 to the control group. We observed no significant difference between groups in the frequency of the composite outcome (32.4% and 37.0% in the treatment and control groups, respectively; P = 0.14). There were no perinatal deaths. However, there were significant reductions with treatment as compared with usual care in several prespecified secondary outcomes, including mean birth weight (3302 vs. 3408 g), neonatal fat mass (427 vs. 464 g), the frequency of large-for-gestational-age infants (7.1% vs. 14.5%), birth weight greater than 4000 g (5.9% vs. 14.3%), shoulder dystocia (1.5% vs. 4.0%), and cesarean delivery (26.9% vs. 33.8%). Treatment of gestational diabetes mellitus, as compared with usual care, was also associated with reduced rates of preeclampsia and gestational hypertension (combined rates for the two conditions, 8.6% vs. 13.6%; P = 0.01).
Although treatment of mild gestational diabetes mellitus did not significantly reduce the frequency of a composite outcome that included stillbirth or perinatal death and several neonatal complications, it did reduce the risks of fetal overgrowth, shoulder dystocia, cesarean delivery, and hypertensive disorders.
PMCID: PMC2804874  PMID: 19797280
6.  Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study 
Objective To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies.
Design Prospective cohort study.
Setting England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units.
Participants 64 538 eligible women with a singleton, term (≥37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded.
Main outcome measure A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units).
Results There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%).
Conclusions The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.
PMCID: PMC3223531  PMID: 22117057
7.  Use of ‘Mishri’ A Smokeless form of Tobacco During Pregnancy and its Perinatal Outcome 
Use of ‘Mishri’ (Tobacco containing teeth cleaning powder) is common in the central and southern part of India.
To study the effects of Mishri use on the fetus during pregnancy and the perinatal outcome, and stopping its use.
Materials and Methods:
All apparently healthy pregnant women were enrolled at 20 weeks of gestation from rural Maharashtra, India. Information related to use and giving up of Mishri, previous obstetrical history, current pregnancy, delivery and outcome during the perinatal period were recorded. Appropriate tests of significance were applied.
Out of 705 enrolled pregnant women, 218 (30.9%) were using Mishri. The proportion of women with complications during the previous perinatal period, complaints and complications during the current pregnancy/delivery and the number of stillbirths were significantly more among Mishri users. A relative risk of abnormal delivery was 2.7 for the users. In spite of counseling, 153 women never stopped the use of Mishri and gave birth to babies weighing on an average 169.9 gm less (statistically significant) than babies born from the group that never used it. Babies of 28.8% who stopped/reduced consumption of Mishri were significantly benefited.
The improvement seen in babies born to 28.8% mothers who stopped/reduced consumption of Mishri by 32 weeks during the current pregnancy is of paramount importance in the developing world for primary prevention of low birth weight.
PMCID: PMC2888344  PMID: 20606913
Smokeless Tobacco; perinatal outcome; Mishri – tobacco containing teeth cleaning powder; stopping consumption of tobacco
8.  Predisposing Individual Characteristics and Perinatal Outcomes of Women in the Tokyo Metropolitan Area Who Initiate Prenatal Care Late in Their Pregnancy: A Case-Control Study 
ISRN Obstetrics and Gynecology  2012;2012:945628.
Purpose. The purpose of this study was to investigate the individual characteristics and perinatal outcomes of women who initiate prenatal care late in their pregnancy in the Tokyo metropolitan area. Methods. Retrospective study. The study enrolled all women at our hospital who initiated prenatal care after 22 weeks of gestation (late attenders) and control women who initiated prenatal care prior to 11 weeks of gestation participated in the study at the National Center for Global Health and Medicine between January 1, 2007 and June 30, 2011. We compared the maternal characteristics and perinatal outcomes of late attenders with those of the control group. Results. A total of 121 late attenders and 1,787 controls were enrolled. Late attenders had a higher incidence of unmarried compared with the control group (P < 0.01). There were no differences in the incidence of preterm delivery and low birth weight; however, babies of the late attenders had a higher incidence of admission to the neonatal intensive care unit compared with the control group (P < 0.01). Conclusions. Our results indicate that there is a pressing need for further steps to promote the importance of receiving prenatal care during pregnancy.
PMCID: PMC3423917  PMID: 22928116
9.  Quality of obstetric care provided for Asian immigrants in Leicestershire. 
Between 1976 and 1981 some 939 perinatal deaths occurred to women living in Leicestershire, of which 128 (14%) were to Asian women. The qualifications of the general practitioners, the gestation at which women start antenatal care, and perinatal death were used as structural, process, and outcome measures for evaluating the services provided to Asian immigrants within this population. Perinatal deaths were divided into four groups: congenital malformation, macerated stillbirth, asphyxia in labour, and immaturity. Asian mothers had one and a half times the risk of perinatal mortality when social class, parity, height, legitimacy, and the general practitioner's qualifications were taken into account. Asian and non-Asian mothers with general practitioners who were not on the obstetric list had more than twice the risk of a perinatal death when a similar adjustment was made. Recommendations include priority allocation of community midwives to practitioners not on the obstetric list, the establishment of postgraduate courses for such doctors, and the continued evaluation of the effect of such proposals on perinatal mortality.
PMCID: PMC1546865  PMID: 6402175
10.  Socioeconomic status and perinatal outcomes in a setting with universal access to essential health care services 
The health care system in Canada provides essential health services to all women irrespective of socioeconomic status. Our objective was to determine whether perinatal and infant outcomes varied by family income and other socioeconomic factors in this setting.
We included all 92 914 women who delivered in Nova Scotia between 1988 and 1995 following a singleton pregnancy. Family income was obtained for 76 440 of these women through a confidential link to income tax records and was divided into 5 groups. Outcomes studied included pregnancy complications, preterm birth, small-for-gestational-age live birth, perinatal death, serious neonatal morbidity, postneonatal death and infant death. Logistic regression models were used to adjust for potential confounders.
Compared with women in the highest family income group, those in the lowest income group had significantly higher rates of gestational diabetes (crude rate ratio [RR] 1.44, 95% confidence interval [CI] 1.21–1.73), preterm birth (crude RR 1.20, 95% CI 1.06–1.35), small-for-gestational-age live birth (crude RR 1.81, 95% CI 1.66–1.97) and postneonatal death (crude RR 5.54, 95% CI 2.21–13.9). The opposite was true for rates of perinatal death (crude RR 0.74, 95% CI 0.56–0.96), and there was no significant difference between the 2 groups in the composite of perinatal death or serious neonatal morbidity (crude RR 1.01, 95% CI 0.82–1.24). Adjustment for behavioural and lifestyle factors accentuated or attenuated socioeconomic differences.
Lower family income is associated with increased rates of gestational diabetes, small-for-gestational-age live birth and postneonatal death despite health care services being widely available at no out-of-pocket expense.
PMCID: PMC1963370  PMID: 17846440
11.  Rates of stillbirth by gestational age and cause in Inuit and First Nations populations in Quebec 
Inuit and First Nations populations have higher rates of stillbirth than non-Aboriginal populations in Canada do, but little is known about the timing and cause of stillbirth in Aboriginal populations. We compared gestational age– and cause-specific stillbirth rates in Inuit and First Nations populations with the rates in the non-Aboriginal population in Quebec.
Data included singleton stillbirths and live births at 24 or more gestational weeks among Quebec residents from 1981 to 2009. We calculated odds ratios (ORs), rate differences and 95% confidence intervals (CIs) for the retrospective cohort of Inuit and First Nations births relative to non-Aboriginal births using fetuses at risk (i.e., ongoing pregnancies) as denominators and adjusting for maternal characteristics. The main outcomes were stillbirth by gestational age (24–27, 28–36, ≥ 37 wk) and cause of death.
Rates of stillbirth per 1000 births were greater among Inuit (6.8) and First Nations (5.7) than among non-Aboriginal (3.6) residents. Relative to the non-Aboriginal population, the risk of stillbirth was greater at term (≥ 37 wk) than before term for both Inuit (OR 3.1, 95% CI 1.9 to 4.8) and First Nations (OR 2.6, 95% CI 2.1 to 3.3) populations. Causes most strongly associated with stillbirth were poor fetal growth, placental disorders and congenital anomalies among the Inuit, and hypertension and diabetes among the First Nations residents.
Stillbirth rates in Aboriginal populations were particularly high at term gestation. Poor fetal growth, placental disorders and congenital anomalies were important causes of stillbirth among the Inuit, and diabetic and hypertensive complications were important causes in the First Nations population. Prevention may require improvements in pregnancy and obstetric care.
PMCID: PMC3612170  PMID: 23422443
12.  Does low maternal blood pressure during pregnancy increase the risk of perinatal death? 
Epidemiology (Cambridge, Mass.)  2007;18(5):619-622.
The reported association between low maximum diastolic blood pressure (DBP) during pregnancy and perinatal death (stillbirth and death in the first week combined) may result from failure to account for gestational length, a strong predictor of perinatal death.
We studied 41,089 singleton pregnancies from the U.S. Collaborative Perinatal Project (1955–1966).
The association between low maximum DBP and elevated risk of perinatal death disappeared after accounting for reverse causation related to gestational length. At any given gestational week, women whose offspring ultimately experienced perinatal death did not have significantly lower maximum DBP than women whose offspring survived the perinatal period. When accounting for DBP trend during pregnancy through gestational-age-specific DBP standardized score, we saw no association between a mean low score and perinatal death.
Low maximum maternal DBP during pregnancy was a post hoc correlate of perinatal death in these data, but not a risk factor.
PMCID: PMC2225167  PMID: 17879438
13.  Clinical Outcomes of Pregnancies Complicated by Mild Gestational Diabetes Mellitus Differ by Combinations of Abnormal Oral Glucose Tolerance Test Values 
Diabetes Care  2010;33(12):2524-2530.
To examine the association between levels of hyperglycemia, determined by each prenatal oral glucose tolerance test (OGTT) value (fasting, 1 and 2 h), and maternal and perinatal outcomes and to determine whether the risk for these outcomes differs for women whose value(s) equaled or exceeded the thresholds for gestational diabetes mellitus (GDM) established by the International Association of Diabetes in Pregnancy Study Groups (IADPSG).
This article discusses a retrospective study of 8,711 women, delivering at ≥20 weeks' gestation, who had a prenatal 2-h 75-g OGTT without a prior 50-g challenge and were not treated with insulin, glyburide, diet, and/or exercise during pregnancy. Associations between adverse outcomes and elevated OGTT values are reported.
After excluding treated women, 19.4% of the remaining women had IADPSG-defined GDM. Continuous fasting, 1- and 2-h OGTT measures, and GDM (yes/no) were significantly associated with most adverse outcomes. However, the magnitude and significance of risk for these outcomes differed by various combinations of abnormal glucose values. Women with normal fasting and elevated postload values were at higher risk for preterm delivery, gestational hypertension, and having an infant with hyperbilirubinema, whereas women with elevated fasting and normal postload values were at higher risk of having a large-for-gestational-age infant, compared with women without GDM.
Risks for different adverse outcomes vary depending on which single or combined IADPSG-defined OGTT thresholds are equaled or exceeded. Prospective studies are needed to determine whether changing pre- and postprandial glucose targets during pregnancy will more uniformly reduce adverse outcomes.
PMCID: PMC2992182  PMID: 20843973
14.  Mortality patterns among very preterm babies: a comparative analysis of two European regions in France and England 
To explore the differences in outcome of very preterm pregnancies between two geographically defined populations in Europe with similar socioeconomic characteristics and healthcare provision but different organisational arrangements for perinatal care.
Prospective cohort study.
Nord Pas‐de‐Calais (NPC), France, and Trent, UK.
All pregnancy outcomes 22+0 to 32+6 weeks' gestational age for resident mothers.
Outcome measures
Mortality patterns (antepartum death, intrapartum death, labour ward death and neonatal unit death) among very preterm babies were analysed by region. Multinomial logistic regression was used to model regional differences for a variety of pregnancy outcomes and to adjust for regional differences in the organisation of perinatal care.
Delivery of very preterm infants was significantly higher in Trent compared with NPC (1.9% v 1.5% of all births, respectively (p<0.001)). Stillbirth rate was significantly higher in NPC than in Trent (23.0%, 95% CI 20.0% to 26.5% v 14.4%, 95% CI 12.3% to 16.6%, respectively (p<0.001)) and survival to discharge was higher in Trent than in NPC (74.6%, 95% CI 71.9% to 77.1% v 66.7%, 95% CI 63.3% to 69.9%, respectively (p<0.001)). Probability of intrapartum and labour ward death in NPC was more than five times higher than Trent (relative risk 5.3, 95% CI 2.2 to 13.1 (p<0.001)).
The high rate of very preterm deliveries and the larger proportion of these infants recorded as live born in Trent appear to be the cause of the excess neonatal mortality seen in the routine statistics. Information about very preterm babies (not usually included in routine statistics) is vital to avoid inappropriate interpretation of international perinatal and infant data. This study highlights the importance of including deaths before transfer to neonatal care and emphasises the need to include the outcome of all pregnancies in a population in any comparative analysis.
PMCID: PMC2675356  PMID: 17213271
very preterm infant; international comparisons; antepartum stillbirth; intrapartum stillbirth; neonatal mortality
15.  Maternal blood pressure in pregnancy, birth weight, and perinatal mortality in first births: prospective study 
BMJ : British Medical Journal  2004;329(7478):1312.
Objective To investigate the relation of diastolic blood pressure in pregnancy with birth weight and perinatal mortality.
Design Prospective study.
Setting 15 maternity units in one London health region, 1988-2000.
Participants 210 814 first singleton births of babies weighing more than 200 g among mothers with no hypertension before 20 weeks' gestation and without proteinuria, delivering between 24 and 43 weeks' gestation.
Main outcome measures Birth weight and perinatal mortality.
Results The mean (SD) birth weight of babies born to mothers with no hypertension before 20 weeks' gestation or proteinuria was 3282 g (545 g) and there were 1335 perinatal deaths, compared with 94 perinatal deaths among women with proteinuria or a history of hypertension. Diastolic blood pressure at booking for antenatal checks was progressively higher from weeks 34 to 40 of gestation. The birth weight of babies being delivered after 34 weeks was highest for highest recorded maternal diastolic blood pressures of between 70 and 80 mm Hg and lower for blood pressures outside this range. Both low and high diastolic blood pressures were associated with statistically significantly higher perinatal mortality. Using a linear quadratic model, 94 of 825 (11.4%) perinatal deaths could be attributed to mothers having blood pressure differing from the optimal blood pressure (82.7 mm Hg) predicted by the fitted model. Most of these excess deaths occurred with blood pressures below the optimal value.
Conclusions Both low and high diastolic blood pressures in women during pregnancy are associated with small babies and high perinatal mortality.
PMCID: PMC534837  PMID: 15561733
16.  Maternal Body Mass Index and Pregnancy Outcome 
To evaluate the impact of the maternal body mass index on the pregnancy outcome.
Materials and Methods
Seven hundred eighty four women who had singleton pregnancies during a one year period, were categorized into 5 groups on the basis of their maternal Body Mass Index (BMI). The maternal and the neonatal outcome were noted in all the groups.
In the underweight group, the incidences of anaemia and growth retardation were more, while the overweight and the obese women had a higher risk for PIH, gestational diabetes and Large for gestational age (LGA). The groups 4 and 5 had higher incidences of LSCS, wound sepsis and neonatal ICU admissions. There was no significant increase in the perinatal mortality rate.
The health of women, throughout their childbearing ages, should be addressed, to improve their obstetrical and perinatal outcomes. Also, the high risk groups should be managed at tertiary centers.
PMCID: PMC3527788  PMID: 23285448
IUGR; BMI; Anaemia; PIH; Gestational diabetes
17.  The fetuses-at-risk approach: Clarification of semantic and conceptual misapprehension 
Although proponents of the fetuses-at-risk approach describe it as a causal model that resolves various conundrums, several areas of semantic and conceptual misapprehension remain. Differences in terminology include use of denominators such as 'ongoing pregnancies' and the need for an ad hoc 'correction factor' in order to calculate gestational age-specific rates. Further, there is conceptual disagreement regarding the proper candidates for neonatal death and related phenomena. Perhaps the most egregious misconception is the belief that rising rates of gestational age-specific perinatal mortality observed under the fetuses-at-risk model automatically imply the need for indiscriminate increases in iatrogenic preterm delivery.
The term 'fetuses at risk' addresses the plurality of candidates for stillbirth in a multi-fetal pregnancy, while the use of standard terminology such as 'cumulative incidence' and 'incidence density' harmonizes the language of perinatal epidemiology with that used in the general epidemiologic literature. On the conceptual side, it is necessary to integrate clinical insights regarding latent periods into models of neonatal morbidity and mortality. The contention that the fetuses-at-risk approach implies the need for indiscriminate iatrogenic preterm delivery is a non-sequitur (just as rising age-specific cancer death rates do not imply the need for routine chemotherapy and radiation for all middle aged people). Finally, the traditional and fetuses-at-risk models are better viewed in terms of function as prognostic (non-causal) and causal models, respectively.
A careful examination of terms and concepts helps situate the traditional perinatal and the fetuses-at-risk approaches within the broader context of non-causal and causal models within general epidemiology.
PMCID: PMC2292135  PMID: 18366767
18.  Rural obstetrics: a 5-year prospective study of the outcomes of all pregnancies in a remote northern community. 
OBJECTIVE: To determine whether a small, isolated hospital that has no facilities to perform cesarean section and handles fewer than 50 deliveries annually can provide acceptably safe obstetric and perinatal care. DESIGN: Cohort study. SETTING: Southern region of the Queen Charlotte Islands, BC, served by a 21-bed hospital and medical clinic in Queen Charlotte City. The hospital and clinic are staffed by five family practitioners without local obstetric, pediatric, anesthetic or surgical support. PATIENTS: All women beyond 20 weeks' gestation who gave birth from Jan. 1, 1984, to Dec. 31, 1988; 33% were primiparous and 20% native. Of the 286 women 192 (67%) delivered locally, 33 (12%) were transferred after admission because of antepartum or intrapartum complications, and 61 (21%) delivered elsewhere by choice or on their physician's recommendation. OUTCOME MEASURES: Perinatal mortality rate and adverse perinatal outcome (death, birth weight of less than 2500 g, neonatal transfer or Apgar score of less than 7 at 5 minutes). MAIN RESULTS: There were six perinatal deaths, for a perinatal mortality rate of 20.8 (95% confidence interval [CI] 4.4 to 37.2). The hospital-based rate of adverse perinatal outcome was 6.2% (12 of 193 newborns) (95% CI 2.8% to 9.6%). CONCLUSIONS: The perinatal mortality rate is not a meaningful way to assess small populations; about 85 years of data would be required to decrease the 95% CIs from within 16 to within 4. The rate of adverse perinatal outcome in our study was consistent with the rate in other studies. Collaboration of small, rural hospitals is required to increase cohort size so that the correlation between the currently accepted standard, the perinatal mortality rate, and other outcome measures can be determined.
PMCID: PMC1335411  PMID: 2009477
19.  Attitudes to viability of preterm infants and their effect on figures for perinatal mortality. 
BMJ : British Medical Journal  1990;300(6722):434-436.
OBJECTIVE--To examine how local attitudes to management of extreme preterm labour can influence data on perinatal mortality. DESIGN--One year prospective study in a geographically defined population. SETTING--The 17 perinatal units of Trent region. PATIENTS--All preterm infants of less than or equal to 32 weeks' gestation in the Trent region. INTERVENTIONS--Infants who had been considered viable at birth were referred for intensive care; those who had been considered non-viable received terminal care. MAIN OUTCOME MEASURES--Whether each infant was born alive, dead, or alive but considered non-viable. RESULTS--Large differences were observed among units in the rates of delivery of infants of less than or equal to 27 weeks' gestation (rates varied from 7.2 to 0 per 1000 births). These differences were not present in the data relating to infants of between 28 and 32 weeks' gestation. The variation seemed to result from different approaches to the management of extreme preterm labour--that is, whether management took place in a labour ward or a gynaecology ward. CONCLUSIONS--Place of delivery of premature babies (less than or equal to 27 weeks' gestation) may influence classification and hence figures for perinatal mortality. In addition, the fact that the onus of judgment regarding viability and classification is often placed on relatively junior staff might also affect the figures for perinatal mortality. The introduction of a standard recording system for all infants greater than 500 g would be advantageous.
PMCID: PMC1662236  PMID: 2107894
20.  The effect of hypertensive disorders in pregnancy on small for gestational age and stillbirth: a population based study 
Hypertensive disorders in pregnancy are leading causes of maternal, fetal and neonatal morbidity and mortality worldwide. However, studies attempting to quantify the effect of hypertension on adverse perinatal outcomes have been mostly conducted in tertiary centres. This population-based study explored the frequency of hypertensive disorders in pregnancy and the associated increase in small for gestational age (SGA) and stillbirth.
We used information on all pregnant women and births, in the Canadian province of Nova Scotia, between 1988 and 2000. Pregnancies were excluded if delivery occurred < 20 weeks, if birthweight was < 500 grams, if there was a high-order multiple pregnancy (greater than twin gestation), or a major fetal anomaly.
The study population included 135,466 pregnancies. Of these, 7.7% had mild pregnancy-induced hypertension (PIH), 1.3% had severe PIH, 0.2% had HELLP (hemolysis, elevated liver enzymes, low platelets), 0.02% had eclampsia, 0.6% had chronic hypertension, and 0.4% had chronic hypertension with superimposed PIH. Women with any hypertension in pregnancy were 1.6 (95% CI 1.5–1.6) times more likely to have a live birth with SGA and 1.4 (95% CI 1.1–1.8) times more likely to have a stillbirth as compared with normotensive women. Adjusted analyses showed that women with gestational hypertension without proteinuria (mild PIH) and with proteinuria (severe PIH, HELLP, or eclampsia) were more likely to have infants with SGA (RR 1.5, 95% CI 1.4–1.6 and RR 3.2, 95% CI 2.8–3.6, respectively). Women with pre-existing hypertension were also more likely to give birth to an infant with SGA (RR 2.5, 95% CI 2.2–3.0) or to have a stillbirth (RR 3.2, 95% CI 1.9–5.4).
This large, population-based study confirms and quantifies the magnitude of the excess risk of small for gestational age and stillbirth among births to women with hypertensive disease in pregnancy.
PMCID: PMC515178  PMID: 15298717
21.  Regional perinatal mortality differences in the Netherlands; care is the question 
BMC Public Health  2009;9:102.
Perinatal mortality is an important indicator of health. European comparisons of perinatal mortality show an unfavourable position for the Netherlands. Our objective was to study regional variation in perinatal mortality within the Netherlands and to identify possible explanatory factors for the found differences.
Our study population comprised of all singleton births (904,003) derived from the Netherlands Perinatal Registry for the period 2000–2004. Perinatal mortality including stillbirth from 22+0 weeks gestation and early neonatal death (0–6 days) was our main outcome measure. Differences in perinatal mortality were calculated between 4 distinct geographical regions North-East-South-West. We tried to explain regional differences by adjustment for the demographic factors maternal age, parity and ethnicity and by socio-economic status and urbanisation degree using logistic modelling. In addition, regional differences in mode of delivery and risk selection were analysed as health care factors. Finally, perinatal mortality was analysed among five distinct clinical risk groups based on the mediating risk factors gestational age and congenital anomalies.
Overall perinatal mortality was 10.1 per 1,000 total births over the period 2000–2004. Perinatal mortality was elevated in the northern region (11.2 per 1,000 total births). Perinatal mortality in the eastern, western and southern region was 10.2, 10.1 and 9.6 per 1,000 total births respectively. Adjustment for demographic factors increased the perinatal mortality risk in the northern region (odds ratio 1.20, 95% CI 1.12–1.28, compared to reference western region), subsequent adjustment for socio-economic status and urbanisation explained a small part of the elevated risk (odds ratio 1.11, 95% CI 1.03–1.20). Risk group analysis showed that regional differences were absent among very preterm births (22+0 – 25+6 weeks gestation) and most prominent among births from 32+0 gestation weeks onwards and among children with severe congenital anomalies. Among term births (≥ 37+0 weeks) regional mortality differences were largest for births in women transferred from low to high risk during delivery.
Regional differences in perinatal mortality exist in the Netherlands. These differences could not be explained by demographic or socio-economic factors, however clinical risk group analysis showed indications for a role of health care factors.
PMCID: PMC2674436  PMID: 19366460
22.  Collecting population-based perinatal data efficiently: the example of the Lebanese National Perinatal Survey 
We describe the methodology and the main results of the Lebanese perinatal health survey; the aim of the survey was to obtain a minimum data set on all births occurring during a short period of time. The survey was carried out during two consecutive weeks in fall 1999 and in spring 2000. All live births and stillbirths occurring during these periods in medical settings were recorded. The sample included 5231 women and 5333 newborns. Data were obtained from medical records and by interviewing the women in hospital after delivery. All maternity units and birth centers agreed to participate. Maternal characteristics, medical care during pregnancy and delivery, and pregnancy outcome were similar for the two study periods. However gestational age distribution differed between the two periods. In total, 9.0% of infants were born before 37 weeks of gestation and 7.0% weighed less than 2500 grams at birth. Wide regional variations were observed for many indicators of health, care and risk factors. For instance, the cesarean section rate varied from 16.2% in the North Region to 28.0% in Beirut. The survey protocol was successfully applied in Lebanon and may be useful in other countries that have a relatively well-developed health care system, but few sources of reliable population-based statistics on health and medical care. This type of survey may also be an appropriate instrument for collecting additional data for health policy evaluations.
PMCID: PMC2855854  PMID: 16911021
Adult; Birth Weight; Cesarean Section; Delivery, Obstetric; methods; Developing Countries; Educational Status; Female; Gestational Age; Health Care Surveys; methods; Home Childbirth; Humans; Infant, Newborn; Infant, Premature; Lebanon; epidemiology; Mothers; Parity; Perinatal Care; methods; Pregnancy; Pregnancy Outcome; Prenatal Care; methods; Risk Factors;  health survey ; prenatal care; delivery; pregnancy outcome; gestational age; birthweight; developing countries; Lebanon
23.  Risk of complications of pregnancy in women with type 1 diabetes: nationwide prospective study in the Netherlands 
BMJ : British Medical Journal  2004;328(7445):915.
Objective To investigate maternal, perinatal, and neonatal outcomes of pregnancies in women with type 1 diabetes in the Netherlands.
Design Nationwide prospective cohort study.
Setting All 118 hospitals in the Netherlands.
Participants 323 women with type 1 diabetes who became pregnant between 1 April 1999 and 1 April 2000.
Main outcome measures Maternal, perinatal, and neonatal outcomes of pregnancy.
Results 84% (n = 271) of the pregnancies were planned. Glycaemic control early in pregnancy was good in most women (HbA1c ≤ 7.0% in 75% (n = 212) of the population), and folic acid supplementation was adequate in 70% (n = 226). 314 pregnancies that went beyond 24 weeks' gestation resulted in 324 infants. The rates of pre-eclampsia (40; 12.7%), preterm delivery (101; 32.2%), caesarean section (139; 44.3%), maternal mortality (2; 0.6%), congenital malformations (29; 8.8%), perinatal mortality (9; 2.8%), and macrosomia (146; 45.1%) were considerably higher than in the general population. Neonatal morbidity (one or more complications) was extremely high (260; 80.2%). The incidence of major congenital malformations was significantly lower in planned pregnancies than in unplanned pregnancies (4.2% (n = 11) v 12.2% (n = 6); relative risk 0.34, 95% confidence interval 0.13 to 0.88).
Conclusion Despite a high frequency of planned pregnancies, resulting in overall good glycaemic control (early) in pregnancy and a high rate of adequate use of folic acid, maternal and perinatal complications were still increased in women with type 1 diabetes. Neonatal morbidity, especially hypoglycaemia, was also extremely high. Near optimal maternal glycaemic control (HbA1c ≤ 7.0%) apparently is not good enough.
PMCID: PMC390158  PMID: 15066886
24.  Screening in high-risk group of gestational diabetes mellitus with its maternal and fetal outcomes 
Gestational diabetes mellitus (GDM) is a metabolic disorder defined as glucose intolerance with the onset or first recognition during pregnancy. Women with GDM are at increased risk for adverse obstetric and perinatal outcome. The complications associated with GDM can be prevented by early recognition, intense monitoring and proper treatment.
The present study was done to screen the high-risk pregnancy group for GDM, to find the incidence of abnormal results on screening and to correlate the abnormal results with the maternal and fetal outcomes. The study was done in a tertiary care hospital and teaching institute. It was a prospective cohort study.
Materials and Methods:
Selective screening for GDM was done in 150 pregnant women with high-risk factors. Screening was done with 50 g glucose challenge test (GCT) after 18 weeks, and if GCT was negative then the test was repeated after 28 weeks of pregnancy. The patients who were having an abnormal GCT were subjected to 100 g oral glucose tolerance test (OGTT). All GDM patients were followed up and treated with diet and/or insulin therapy till delivery to know maternal and fetal outcomes. The period of study was from April 2008 to March 2009.
7.3% of study population was OGCT positive. 6% of the study population was OGTT positive. Age >25 years, obesity, family history of DM, and past history of GDM were the risk factors significantly associated with GDM. One newborn had hypoglycemia and one had hyperbilirubinemia. The fetal and maternal outcome in GDM patients was good in our study due to early diagnosis and intervention.
Women with GDM are at an increased risk for adverse obstetric and perinatal outcome. The increased morbidity in GDM is preventable by meticulous antenatal care.
PMCID: PMC3354928  PMID: 22701851
Hyperbilirubinemia; hypoglycemia; gestational diabetes mellitus; glucose challenge test; glucose tolerance test; obesity
25.  Aluminium sulphate in water in north Cornwall and outcome of pregnancy. 
BMJ : British Medical Journal  1991;302(6786):1175-1177.
OBJECTIVE--To determine whether the excess aluminum sulphate accidentally added to the local water supply in north Cornwall in July 1988 had an adverse effect on the outcome of pregnancies. DESIGN--Outcomes of all singleton pregnancies in the affected area at the time of the incident (n = 92) were compared with those in two control groups: pregnancies in this area completed before the incident (n = 68) and pregnancies in a neighbouring area (n = 193). SUBJECTS--Mothers in the three groups, among whom there were 13 miscarriages, five terminations of pregnancy, and 336 live births. MAIN OUTCOME MEASURES--Fetal and perinatal loss, birth weight, gestation, obstetric complications, neonatal condition, and congenital defects. RESULTS--Among 88 pregnancies in women exposed to excess aluminum sulphate there was no excess of perinatal deaths (n = 0), low birthweight (n = 3), preterm delivery (n = 4), or severe congenital malformations (n = 0). There was, however, an increased rate of talipes in exposed fetuses (four cases, one control; p = 0.01). CONCLUSIONS--Because of small numbers it is not possible to say that high doses of aluminum sulphate are safe in pregnancy, but there is no evidence from this study of major problems apparent at birth.
PMCID: PMC1669867  PMID: 2043811

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