Jeani Chang

Homicide: A Leading Cause of Injury Deaths Among Pregnant and Postpartum Women in the United States, 1991–1999

OBJECTIVES We identified risk factors for pregnancy-associated homicide (women who died as a result of homicide during or within 1 year of pregnancy) in the United States from 1991 to 1999. METHODS Pregnancy-associated homicides were analyzed with data from the Pregnancy Mortality Surveillance System at the Centers for Disease Control and Prevention. RESULTS Six hundred seventeen (8.4%) homicide deaths were reported to the Pregnancy Mortality Surveillance System. The pregnancy-associated homicide ratio was 1.7 per 100000 live births. Risk factors included age younger than 20 years, Black race, and late or no prenatal care. Firearms were the leading mechanism for homicide (56.6%). CONCLUSIONS Homicide is a leading cause of pregnancy-associated injury deaths.

Pregnancy-related mortality among women with multifetal pregnancies.

OBJECTIVE: To examine the relative risk of pregnancy-related mortality between multifetal pregnancies and singleton pregnancies. METHODS: We used data from the Centers for Disease Control and Prevention’s Pregnancy Mortality Surveillance System to examine singleton and multifetal pregnancy-related deaths among women with a live birth or fetal death from 1979–2000. The plurality-specific (singleton or multifetal) pregnancy-based mortality ratio was defined as the number of pregnancy-related deaths per 100,000 pregnancies with a live birth. We analyzed the risk of death due to pregnancy for singleton and multifetal pregnancies by age, race, education, marital status, and cause of death. RESULTS: Of 4,992 pregnancy-related deaths in 1979–2000, 4.2% (209 deaths) were among women with multifetal pregnancies. The risk of pregnancy death among women with twin and higher-order pregnancies was 3.6 times that of women with singleton pregnancies (20.8 compared with 5.8). The leading causes of death were similar for women with singleton pregnancies and women with multifetal pregnancies: embolism, hypertensive complications of pregnancy, hemorrhage, and infection. CONCLUSION: Women with multifetal pregnancies have a significantly higher risk of pregnancy-related death than their counterparts with singleton pregnancies; this holds true for all women regardless of age, race, marital status, and level of education. LEVEL OF EVIDENCE: II-2

Outcomes of in vitro fertilization with preimplantation genetic diagnosis: an analysis of the United States Assisted Reproductive Technology Surveillance Data, 2011–2012

OBJECTIVE To assess the characteristics of IVF cycles for which preimplantation genetic diagnosis (PGD) was used and to evaluate indications for PGD and treatment outcomes associated with this procedure as compared with cycles without PGD with the data from the U.S. National ART Surveillance System. DESIGN Retrospective cohort study. SETTING None. PATIENT(S) Fresh autologous cycles that involved transfer of at least one embryo at blastocyst when available. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) PGD indications and age-specific reproductive outcomes. RESULT(S) There were a total of 97,069 non-PGD cycles and 9,833 PGD cycles: 55.6% were performed for aneuploidy screening (PGD Aneuploidy), 29.1% for other reasons (PGD Other), and 15.3% for genetic testing (PGD Genetic). In comparison to non-PGD cycles, PGD Aneuploidy cycles showed a decreased odds of miscarriage among women 35-37 years (adjusted odds ratio [aOR] 0.62; 95% CI, 0.45-0.87) and women >37 years (aOR 0.55; 95% CI, 0.43-0.70); and an increased odds of clinical pregnancy (aOR 1.18; 95% CI, 1.05-1.34), live-birth delivery (aOR 1.43; 95% CI, 1.26-1.62), and multiple-birth delivery (aOR 1.98; 95% CI, 1.52-2.57) among women >37 years. CONCLUSION(S) Aneuploidy screening was the most common indication for PGD. Use of PGD was not observed to be associated with an increased odds of clinical pregnancy or live birth for women <35 years. PGD for aneuploidy was associated with a decreased odds of miscarriage for women >35 years, but an increased odds of a live-birth and a multiple live-birth delivery among women >37 years.

First trimester pregnancy loss after fresh and frozen in vitro fertilization cycles

OBJECTIVE To characterize risks for early pregnancy loss after fresh and frozen IVF cycles and to investigate whether risk is modified by infertility diagnoses or transfer of embryos in fresh versus frozen cycles. DESIGN Retrospective cohort study using data from the National Assisted Reproductive Technology (ART) Surveillance System. SETTING Fertility centers. PATIENT(S) Clinical pregnancies achieved with fresh and frozen IVF cycles between 2007 and 2012 (N = 249,630). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) First trimester pregnancy loss. RESULT(S) A diagnosis of uterine factor was associated with an increased risk of loss in women aged 40 years and younger (<30 years: adjusted risk ratio (aRR) = 1.24, 95% confidence interval (CI) 1.04-1.48; 30-34 years: aRR = 1.27, 95% CI 1.17-1.38; 35-37 years: aRR = 1.12, 95% CI 1.03-1.21; 38-40 years: aRR = 1.08, 95% CI 1.01-1.17). There was an increased risk of loss in women with diminished ovarian reserve aged 30-34 years (aRR = 1.08, 95% CI 1.01-1.15) and in women with ovulatory dysfunction younger than 35 years (<30 years: aRR = 1.12, 95% CI 1.05-1.19; 30-34 years: aRR = 1.07, 95% CI 1.02-1.13). There was an increased risk of loss after frozen ETs versus fresh among women younger than 38 years, but this remained significant in the subanalysis of similar quality embryos only in women younger than 30 years (aRR = 1.16, 95% CI 1.04-1.32). CONCLUSION(S) Uterine factor had the largest increased risk of loss among infertility diagnoses, although the magnitudes of all risks were small. When transferring embryos of similar quality, the risks of loss were similar between fresh and frozen cycles.

CHANG AND BERG RESPOND TO HORON

We appreciate Horon’s interest in pregnancy-associated mortality and her work in this important area of women’s health. For the years of our study, we requested reporting areas (health departments in the 50 states, the District of Columbia, and New York City) to send us deidentified death certificates and, for those deaths after a live birth or stillbirth, matching birth or fetal death certificates. We also asked for certificates for deaths that occurred during pregnancy or within 1 year after pregnancy. We have no choice but to rely on the methods used by each reporting area to determine whether a death (including a death because of homicide) is pregnancy-associated. As stated in our discussion, the cause of death on death certificates is the most common way of ascertaining pregnancy-associated deaths. Next is computerized linking of deaths among women of reproductive age with birth certificates and fetal death certificates; we believe this system is used in about half the reporting areas. Maryland is fortunate to be able to also use medical examiners reports to ascertain additional cases. We know our numbers underestimate the overall magnitude of pregnancy-associated mortality. However, to produce a national picture of the risk factors associated with death during or shortly after pregnancy, we used the only sources of information available on pregnancy-associated deaths. We hope that our article and Horon’s letter will encourage states to use multiple methods to identify pregnancy-associated deaths and to use the information to develop appropriate interventions for the period around pregnancy to prevent mortality from all causes.

Predictors of Perfect Implantation in Double Embryo Transfer With In Vitro Fertilization [157]

INTRODUCTION AND BACKGROUND: Approximately half of in vitro fertilization (IVF) cycles are double embryo transfers, often resulting in multiple gestations, which increases maternal and neonatal morbidity. We assessed trends and predictors of “perfect implantation” in double embryo transfer (both embryos implant) to further identify candidates for elective single embryo transfer. METHODS: We analyzed 1,793,067 fresh, autologous cycles reported to the National Assisted Reproductive Technology Surveillance System from 2000 to 2012. We calculated trends of perfect implantation in double embryo transfer, identified as cycles with number of hearts on 6-week ultrasonography equal to or greater than number of embryos transferred. Adjusted risk ratios (RRs) for perfect implantation were estimated using log binomial models, adjusted for demographic and clinical characteristics, after stratifying by prognosis. Favorable prognosis was defined as first-time IVF with supernumerary embryo(s). Average prognosis was defined as first-time IVF without supernumerary embryos, prior unsuccessful IVF with supernumerary embryo(s), prior IVF with previous birth(s) resulting from IVF, or natural conception. RESULTS: During 2000–2012, rates of perfect implantation with double embryo transfer increased from 13.4% to 18.1% (P for trend <.001). Perfect implantation was positively associated with blastocyst (compared with cleavage) transfer in favorable (adjusted RR 1.58 [1.51–1.65]) and average (adjusted RR 1.67 [1.60–1.75]) prognosis groups and negatively associated with age older than 35 years in both prognosis groups. For average prognosis patients, perfect implantation was associated with retrieving more than 10 oocytes (adjusted RR 1.22 [1.18–1.24]). CONCLUSION: Regardless of prognosis, patients who are younger than 35 years with blastocyst-stage embryos, and average prognosis patients from whom more than 10 oocytes are retrieved, may be good candidates for elective single embryo transfer, which would reduce multiple gestations and associated complications.

Pregnancy-related mortality among women with multifetal pregnancies

OBJECTIVE To examine the relative risk of pregnancy-related mortality between multifetal pregnancies and singleton pregnancies. METHODS We used data from the Centers for Disease Control and Preventions Pregnancy Mortality Surveillance System to examine singleton and multifetal pregnancy-related deaths among women with a live birth or fetal death from 1979-2000. The plurality-specific (singleton or multifetal) pregnancy-based mortality ratio was defined as the number of pregnancy-related deaths per 100,000 pregnancies with a live birth. We analyzed the risk of death due to pregnancy for singleton and multifetal pregnancies by age, race, education, marital status, and cause of death. RESULTS Of 4,992 pregnancy-related deaths in 1979-2000, 4.2% (209 deaths) were among women with multifetal pregnancies. The risk of pregnancy death among women with twin and higher-order pregnancies was 3.6 times that of women with singleton pregnancies (20.8 compared with 5.8). The leading causes of death were similar for women with singleton pregnancies and women with multifetal pregnancies: embolism, hypertensive complications of pregnancy, hemorrhage, and infection. CONCLUSION Women with multifetal pregnancies have a significantly higher risk of pregnancy-related death than their counterparts with singleton pregnancies; this holds true for all women regardless of age, race, marital status, and level of education. LEVEL OF EVIDENCE II-2.