Trends and outcomes of postpartum haemorrhage, 2003-2011

Background: While rates of postpartum haemorrhage (PPH) have continued to rise, it is not clear if the association with other morbidity and transfusion has changed over time. This study explores the recent trend in postpartum haemorrhage and risk factors for transfusion and other severe adverse maternal outcomes following postpartum haemorrhage, stratified by mode of delivery. Methods: Linked birth and hospital data were used to examine ICD-10AM coded PPH and outcomes in maternal birth admission records, 2003-2011 in hospitals in New South Wales (NSW), Australia (N= 818,965 singleton pregnancies). Trends were calculated on the whole population, and among subgroups, and tested using the Cochran Armitage test for trend. Logistic regression models were developed separately for vaginal and caesarean births, and for a maternal morbidity composite indicator (excluding transfusion) and red cell transfusion. Adjusted odds ratios (aOR) for yearly change and 95% confidence intervals (CI) are presented. Adjustment included maternal (eg. age, country of birth) and pregnancy factors (eg. parity, interventions, pregnancy complications). Results: Overall, there was a significant increase in the PPH rate, from 6.1% in 2003 to 8.3% in 2011 (p<0.0001). Having accounted for maternal and pregnancy factors, there was no significant increase in morbidity among women delivering vaginally with a PPH (aOR for yearly change 0.97 (0.94-1.00); p=0.36), and a slight decrease among women delivered by caesarean section (aOR 0.96 (0.92-0.99); p<0.01). There was a slight increase in transfusions for vaginal births (aOR 1.02 (1.00-1.03); p<0.01), however there was no significant trend amongst caesarean births (aOR 0.99 (0.97-1.01); p=0.30). Conclusions: PPH has become more frequent, however this has not been associated with increased maternal morbidity. This suggests that the increase in PPH may represent fewer severe haemorrhages, well-managed haemorrhage or better recording of PPH.NHMRC, AR

Methods of classification for women undergoing induction of labour: a systematic review and novel classification system

Background: The lack of reproducible methods for classifying women having an induction of labour (IOL) has led to controversies regarding the association of IOL and health outcomes for mother and baby. Objectives: To identify research papers that describe a methodology for classifying women having an IOL, and to evaluate the utility of these methods of classification for clinical, research and surveillance purposes. Search strategy: We conducted electronic searches in CINAHL, EMBASE and WEB of KNOWLEDGE from database inception until Oct 2013 and searched reference lists. Selection criteria: Two reviewers independently assessed eligibility. Studies had to describe a method for classifying women with an IOL using a minimum of two categories, regardless of whether or not this was the main purpose of the study. Data collection: Data were extracted on study characteristics, quality and results. Pre-specified criteria were used to evaluate the utility of these methods of classification for IOL. Main results: Seven studies met the inclusion criteria. All studies categorised women according to the presence or absence of a medical indication for IOL. Uncertainties and/or deficiencies were identified across all methods of classification related to the criteria of total inclusivity, reproducibility, clinical utility, implementability and data availability limiting their usefulness. Conclusion: Current methods of classifying women with an IOL are inadequate for clinical, research and surveillance purposes. Limitations with classification systems based on medical indications suggest that an alternative method of classification is required for women having IOL

Learning Practical Research Skills Using An Academic Paper Framework – An Innovative, Integrated Approach

Background: There is a pressing need for effective education to help develop basic research and publication skills among clinicians in low and middle-income countries (LMIC). Learning from experience is important for achieving understanding of concepts and acquisition of skills rather than simply recall of facts. Methods: An innovative research and academic writing skills course was run for 21 participants from two universities in the Philippines. The experientially-based workshop encouraged development of skills and understanding through active involvement. Interaction with tutors and other participants was integral to the process. The novel workshop design linked various phases of the research process to relevant sections of an academic paper, thus integrating activities usually regarded as separate.This paper outlines the structure of the workshop and reports its evaluation through pre- and post-workshop surveys and post-workshop focus groups. Results: Participants appreciated the integrated format of the workshop and felt more confident in their ability to plan, conduct and write up research. Conclusion: Explicitly linking elements of an academic journal article to the components of developing a research project was successful in promoting learning and understanding of the research process and increased confidence in academic writing in this context and is likely transferable to similar contexts. Keywords: Research skills, Writing skills, Integrated workshop, Learnin

Early onset preeclampsia: using population data to assess recurrence risk and adverse pregnancy outcomes

ABSTRACT Objective Use linked perinatal data to determine the subsequent pregnancy rate after a pregnancy with early onset preeclampsia and, among those who have a subsequent pregnancy, the risk of recurrence and adverse pregnancy outcomes. Approach Preeclampsia is a hypertensive disorder of pregnancy associated with adverse outcomes for the mother and baby. Although rare, when preeclampsia occurs before 34 weeks of gestation, the risk of adverse outcomes is markedly increased primarily due to prematurity. Despite the desire for another child, many women are anxious about becoming pregnant again because of concerns of recurrent complications in a next pregnancy but information for counselling is sparse. We undertook a population-based record linkage cohort study using longitudinally-linked birth and hospital records from New South Wales (Australia) to create medical and obstetric histories. The study population included nulliparous women with a singleton pregnancy and early onset preeclampsia who gave birth between 2001 and 2010 (the index pregnancy), with follow-up for a subsequent birth through 2012. Early onset preeclampsia was defined as a hospital record (antenatal and/or delivery hospitalisations) with a diagnosis of preeclampsia and delivery before 34 weeks gestation. Outcomes included subsequent pregnancy, and among women with a consecutive subsequent birth, the preeclampsia recurrence rate and adverse pregnancy outcome rates. Results Of 1473 (4.0/1000) nulliparous women who had early onset preeclampsia in the index pregnancy, 60% had evidence of any subsequent pregnancy compared to 66% for women without preeclampsia (P<0.001). Of 758 women with early onset preeclampsia and a subsequent singleton birth ≥20 weeks gestation, 256 (33.8%) had preeclampsia in the subsequent pregnancy but only 57 (7.5%) had recurrent early onset preeclampsia. Most women (717, 94.6%) progressed to a later gestational age in their subsequent pregnancy. The median overall increase in gestational age at delivery was 6 weeks (interquartile range [IQR] 4 to 8) and among the women with recurrent preeclampsia the median increase in gestation in the subsequent pregnancy was 5 weeks (IQR 2 to 7). Outcomes in the subsequent pregnancy included 4.2% postpartum haemorrhage, 3.4% severe maternal morbidity, 2.6% Apgar <7 at 5 minutes, 16.2% small-for gestational-age and 1.7% perinatal deaths. Conclusions Most women with early onset preeclampsia had good outcomes in their subsequent pregnancy. For rare conditions, linked population data with accurately recorded information can provide robust estimates of outcomes that can inform clinical counselling

Additional file 1: Table S1. of Trends and outcomes of postpartum haemorrhage, 2003-2011

Maternal and pregnancy characteristics of women with postpartum haemorrhage (PPH) with and without morbidity/transfusion, NSW, 2003-2011. (DOCX 15 kb

Differential placental gene expression in term pregnancies affected by fetal growth restriction and macrosomia

Introduction: Extremes of fetal growth are associated with increased perinatal mortality and morbidity and a higher prevalence of cardiovascular disease, obesity and diabetes in later life. We aimed to identify changes in placental gene expression in pregnancies with evidence of growth dysfunction and candidate genes that may be used to identify abnormal patterns of growth prior to delivery. Methods: Growth-restricted (n = 4), macrosomic (n = 6) and normal term (n = 5) placentas were selected from a banked series (n = 200) collected immediately after caesarean section. RNA was extracted prior to microarray analysis using Affymetrix HG-U219 arrays to determine variation in gene expression. Genes of interest were confirmed using qRT-PCR. Results: 338 genes in the growth-restricted and 41 genes in the macrosomic group were identified to be significantly dysregulated (>2-fold change; p < 0.05). CPXM2 and CLDN1 were upregulated and TXNDC5 and LRP2 downregulated in fetal growth restriction. In macrosomia, PHLDB2 and CLDN1 were upregulated and LEP and GCH1 were downregulated. Discussion: Dysfunctional growth is associated with differential placental gene expression and affects genes with a whole spectrum of developmental and cellular functions. Better elucidation of these pathways may allow the development of biomarkers to identify growth abnormalities and effective prenatal intervention

Dysregulation of Oxygen Sensing/Response Pathways in Pregnancies Complicated by Idiopathic Intrauterine Growth Restriction and Early-Onset Preeclampsia

Preeclampsia (PE) and intrauterine growth restriction (IUGR) are the leading causes of maternal and fetal morbidity/mortality. The central deficit in both conditions is impaired placentation due to poor trophoblast invasion, resulting in a hypoxic milieu in which oxidative stress contributes to the pathology. We examine the factors driving the hypoxic response in severely preterm PE (n = 19) and IUGR (n = 16) placentae compared to the spontaneous preterm (SPT) controls (n = 13) using immunoblotting, RT-PCR, immunohistochemistry, proximity ligation assays, and Co-IP. Both hypoxia-inducible factor (HIF)-1&alpha; and HIF-2&alpha; are increased at the protein level and functional in pathological placentae, as target genes prolyl hydroxylase domain (PHD)2, PHD3, and soluble fms-like tyrosine kinase-1 (sFlt-1) are increased. Accumulation of HIF-&alpha;-subunits occurs in the presence of accessory molecules required for their degradation (PHD1, PHD2, and PHD3 and the E3 ligase von Hippel&ndash;Lindau (VHL)), which were equally expressed or elevated in the placental lysates of PE and IUGR. However, complex formation between VHL and HIF-&alpha;-subunits is defective. This is associated with enhanced VHL/DJ1 complex formation in both PE and IUGR. In conclusion, we establish a significant mechanism driving the maladaptive responses to hypoxia in the placentae from severe PE and IUGR, which is central to the pathogenesis of both diseases

Trends in asthma self-management skills and inhaled corticosteroid use during pregnancy and postpartum from 2004 to 2017

Objective: Asthma exacerbations and medication non-adherence are significant clinical problems during pregnancy. While asthma self-management education is effective, the number of education sessions required to maximise asthma management knowledge and inhaler technique and whether improvements persist postpartum, are unknown. This paper describes how asthma knowledge, skills, and inhaled corticosteroid (ICS) use have changed over time. Methods: Data were obtained from 3 cohorts of pregnant women with asthma recruited in Newcastle, Australia between 2004 and 2017 (N = 895). Medication use, adherence, knowledge, and inhaler technique were compared between cohorts. Changes in self-management knowledge/skills and women's perception of medication risk to the fetus were assessed in 685 women with 5 assessments during pregnancy, and 95 women who had a postpartum assessment. Results: At study entry, 41%, 29%, and 38% of participants used ICS in the 2004, 2007, and 2013 cohorts, respectively (p = 0.017), with 40% non-adherence in each cohort. Self-management skills of pregnant women with asthma did not improve between 2004 and 2017 and possession of a written action plan remained low. Maximum improvements were reached by 3 sessions for medications knowledge and one session for inhaler technique, and were maintained postpartum. ICS adherence was maximally improved after one session, but not maintained postpartum. Perceived risk of asthma medications on the fetus was highest for corticosteroid-containing medication; and was significantly reduced following education. Conclusions: There was a high prevalence of non-adherence and poor self-management skills in all cohorts. More awareness of the importance of optimal asthma management during pregnancy is warranted, since no improvements were observed over the past decade.HLB is supported by an NHMRC Early Career Research Fellowship (APP1120070). PGG received a Practitioner Fellowship from the NHMRC. VEM received an Australian Research Training Fellowship (part-time, grant ID 455626, 2007–2012) and a Career Development Fellowship from the NHMRC (grant ID 1084816, since 2015)

Factors Associated with Asthma Exacerbations During Pregnancy

Background: Asthma exacerbations during pregnancy are associated with adverse pregnancy outcomes. Objective: The aim of this study was to establish factors associated with asthma exacerbations during pregnancy. Methods: We obtained data from three cohorts of pregnant women with asthma recruited in eastern Australia (2004-2019; n = 1461). Severe exacerbations were defined as episodes of asthma requiring hospitalization, an emergency department visit, or prescription of oral corticosteroids after enrollment. Baseline information on potential risk factors included demographic characteristics, asthma characteristics (eg, lung function, asthma triggers, asthma control, medication use), pregnancy factors (eg, fetal sex, parity, antenatal care type), and other maternal factors (body mass index, smoking status, mental health). Backward stepwise logistic regression and Akaike information criterion were used to determine the best-fitting model. Results: A total of 135 participants experienced a severe exacerbation during pregnancy (9.2%). Medium to high ICS dose was most strongly associated with severe asthma exacerbations (adjusted odds ratio = 3.20; 95% confidence interval, 1.85-5.53). Worse asthma control, possession of a written action plan, and a history of asthma exacerbations in the year preceding pregnancy were associated with an increased rate of exacerbations. Conclusions: Asthma exacerbations before pregnancy and more severe asthma at the beginning of pregnancy were associated with an increased rate of exacerbations during pregnancy. Despite Global Initiative for Asthma step 3 and 4 treatment and optimal management including a written asthma action plan, there is still a significant asthma burden in a group of women at high risk for severe exacerbations in pregnancy