Lesley Regan

Maternal obesity and pregnancy outcome: a study of 287 213 pregnancies in London

OBJECTIVE: To examine the maternal and foetal risks of adverse pregnancy outcome in relation to maternal obesity, expressed as body mass index (BMI, kg/m2) in a large unselected geographical population.DESIGN: Retrospective analysis of data from a validated maternity database system which includes all but one of the maternity units in the North West Thames Region. A comparison of pregnancy outcomes was made on the basis of maternal BMI at booking.SUBJECTS: A total of 287u2005213 completed singleton pregnancies were studied including 176 923 (61.6%) normal weight (BMI 20–24.9), 79 014 (27.5%) moderately obese (BMI 25–29.9) and 31 276 (10.9%) very obese (BMI≥30) women.MEASUREMENTS: Ante-natal complications, intervention in labour, maternal morbidity and neonatal outcome were examined and data presented as raw frequencies and adjusted odds ratios with 99% confidence intervals following logistic regression analysis to account for confounding variables.RESULTS: Compared to women with normal BMI, the following outcomes were significantly more common in obese pregnant women (odds ratio (99% confidence interval) for BMI 25–30 and BMI≥30 respectively): gestational diabetes mellitus (1.68 (1.53–1.84), 3.6 (3.25–3.98)); proteinuric pre-eclampsia (1.44 (1.28–1.62), 2.14 (1.85–2.47)); induction of labour (2.14 (1.85–2.47), 1.70 (1.64–1.76)); delivery by emergency caesarian section (1.30 (1.25–1.34), 1.83 (1.74–1.93)); postpartum haemorrhage (1.16 (1.12–1.21), 1.39 (1.32–1.46)); genital tract infection (1.24 (1.09–1.41), 1.30 (1.07–1.56)); urinary tract infection (1.17 (1.04–1.33), 1.39 (1.18–1.63)); wound infection (1.27 (1.09–1.48), 2.24 (1.91–2.64)); birthweight above the 90th centile (1.57 (1.50–1.64), 2.36 (2.23–2.50)), and intrauterine death (1.10 (0.94–1.28), 1.40 (1.14–1.71)). However, delivery before 32 weeks gestation (0.73 (0.65–0.82), 0.81 (0.69–0.95)) and breastfeeding at discharge (0.86 (0.84–0.88), 0.58 (0.56–0.60)) were significantly less likely in the overweight groups. In all cases, increasing maternal BMI was associated with increased magnitude of risk.CONCLUSION: Maternal obesity carries significant risks for the mother and foetus. The risk increases with the degree of obesity and persists after accounting for other confounding demographic factors. The basis of many of the complications is likely to be related to the altered metabolic state associated with morbid obesity.

Obstetric risks of Pregnancy in women less than 18 years old

Objective To quantify the age-related risks of adverse outcome during pregnancy in women less than 18 years old. Methods We analyzed data from 341,708 completed singleton pregnancies in the North West Thames region between 1988 and 1997. Pregnancy outcomes were compared by age at delivery in women less than 18 years old (n = 5246) and 18–34 years old (n = 336,462); women 35 years old or older (n = 48,658) were excluded. Data are presented as percentages of women less than 18 and 18–34-year-old women, with adjusted odds ratios (OR) and 99% confidence intervals (CI). Results Pregnancy in women less than 18 years old was associated with increased risk of preterm labor before 32 weeks gestation (OR 1.41, CI 1.02, 1.90), maternal anemia (OR 1.82, CI 1.63, 2.03), chest infection (OR 2.70, CI 1.21, 6.70), and urinary tract infection (OR 1.60, CI 1.11, 2.31), but less obstetric intervention. Operative vaginal delivery (OR 0.46, CI 0.41, 0.56), elective cesarean (OR 0.47, CI 0.35, 0.65), or emergency cesarean (OR 0.45, CI 0.38, 0.53) were all less likely in women aged less than 18 years. Women less than 18 years old were no more likely to have stillbirths (OR 0.75, CI 0.42, 1.34) or small-for-gestational-age infants (OR 0.95, CI 0.82, 1.09) than women aged 18–34 years. Conclusion Pregnant women less than 18 years old were more likely to deliver preterm than older women. In most other respects they have less maternal and perinatal morbidity and were more likely to have normal vaginal deliveries.

Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening.

OBJECTIVE To determine reproductive outcomes in women with congenital uterine anomalies detected incidentally by three‐dimensional ultrasound. METHODS We studied 1089 women with no history of infertility or recurrent miscarriage who were seen for a transvaginal ultrasound scan. They were screened for uterine abnormalities using three‐dimensional ultrasound. We determined prevalence of miscarriage and preterm labor in women with normal and abnormal uterine morphology. RESULTS We found that 983 women had a normally shaped uterine cavity, 72 an arcuate, 29 a subseptate, and five a bicornuate uterus. Women with a subseptate uterus had a significantly higher proportion of first‐trimester loss (Z = 4.68, P < .01) compared with women with a normal uterus. Women with an arcuate uterus had a significantly greater proportion of second‐trimester loss (Z = 5.76, P < .01) and preterm labor (Z = 4.1, P < .01). There were no other significant differences in pregnancy outcomes between women with normal and abnormal uterine morphology. CONCLUSION This study shows the potential value of three‐dimensional ultrasound and confirmed that women with congenital uterine anomalies were more likely to have adverse pregnancy outcomes than women with a normal uterus.

Is maternal underweight really a risk factor for adverse pregnancy outcome? A population-based study in London

Objective To determine the maternal and fetal risk of adverse outcome during pregnancy in relation to low maternal body mass index in an unselected population.

Recurrent miscarriage: pathophysiology and outcome

Purpose of review This article reviews new concepts in the aetiology of recurrent miscarriage, presents new outcome data and evaluates new modalities of treatment for unexplained recurrent miscarriage. Recent findings Preimplantation genetic diagnosis has been considered an option for couples who have structural chromosomal abnormalities or unexplained recurrent miscarriage. The association between thrombophilias and adverse pregnancy outcome is further reviewed. In relation to this, there is increasing support for the use of thromboprophylaxis in improving pregnancy outcome in women with inherited thrombophilias. Nonrandomized studies have shown that the reduction in insulin levels with metformin in insulin-resistant individuals may reduce miscarriage risk by restoring normal haemostasis and improving the endometrial milieu. With respect to immunological concepts there is now evidence to suggest that, in addition to a suppression of maternal cell-mediated immunity, some elements of the innate immune system are activated in successful pregnancies. Summary With the exception of aspirin and heparin for the prevention of recurrent miscarriage in women with the antiphospholipid syndrome, no other suggested therapies for this heterogeneous group of patients have been evaluated in randomized controlled trials. These include thromboprophylaxis for inherited thrombophilias and use of insulin sensitizers in women with insulin resistance and/or polycystic ovarian syndrome. The role of the innate immune system in pregnancy was recently highlighted, and use of nonspecific therapies to suppress the maternal immune response to pregnancy should be reassessed.

Pregnancy outcome is not affected by antiphospholipid antibody status in women referred for in vitro fertilization

OBJECTIVEnTo determine the prevalence of antiphospholipid (aPL) and anti-beta 2 glycoprotein I (anti-beta2-GPI) antibodies in women referred for IVF and to prospectively evaluate the effect of these antibodies on IVF outcome.nnnDESIGNnProspective observational study.nnnSETTINGnA university hospital and IVF unit.nnnPATIENT(S)nThree hundred eighty consecutive women referred for IVF.nnnINTERVENTION(S)nBlood samples taken before commencement of IVF cycles were tested for the presence of aPL (lupus anticoagulant [LA], anticardiolipin [aCL], and antiphosphatidyl serine antibodies [aPS]) and anti-beta2-GPI antibodies.nnnMAIN OUTCOME MEASURE(S)nAntibody prevalence, pregnancy rates, and live birth rates.nnnRESULT(S)nOf the total 380 women, 89 tested persistently positive for aPL (23.4%). None of 176 women tested for IgG aPS antibodies had a positive titer. Only 3.3% (11 of 329) tested positive for anti-beta2-GPI antibodies. Pregnancy rate, live birth rate, gestational age at delivery, and birth weight were not affected by aPL status.nnnCONCLUSION(S)nAlthough women referred for IVF have a high prevalence of aPL, these antibodies do not affect the outcome of treatment. Screening women undergoing IVF for aPL is not justified.

Uterine artery Doppler in predicting pregnancy outcome in women with antiphospholipid syndrome.

OBJECTIVE To assess midtrimester uterine artery Doppler in the prediction of preeclampsia and small for gestational age (SGA) infants in women with primary antiphospholipid syndrome. METHODS One hundred seventy pregnant women with histories of recurrent miscarriage in association with antiphospholipid antibodies (32 lupus anticoagulant positive, 47 IgG anticardiolipin positive, 78 IgM anticardiolipin positive, and 13 lupus anticoagulant and anticardiolipin antibodies positive) treated with low‐dose aspirin and heparin were recruited prospectively. Doppler assessment of the uterine arteries (presence or absence of notches and pulsatility index) were performed at 16–18 and 22–24 weeks. The main outcome measures were the delivery of a SGA infant and the development of preeclampsia. RESULTS There were 164 live births and six midtrimester losses. The prevalence of preeclampsia and SGA was similar at 10%. In predicting preeclampsia or SGA, uterine artery pulsatility index at either interval was of no value, and the diagnostic accuracy of the Doppler was limited to bilateral uterine artery notches at 22–24 weeks in the subgroup of women with positive lupus anticoagulant. In this subgroup, bilateral uterine artery notches at 22–24 weeks in predicting preeclampsia generated a high likelihood ratio for positive test (12.8, 95% confidence interval 2.2, 75), sensitivity (75%), specificity (94%), positive (75%) and negative (94%) predictive value. In predicting SGA, the corresponding figures were respectively 13.6 (95% confidence interval 1.9, 96), 80%, 94%, 80%, 94%. Uterine artery Doppler was of limited value in pregnancies associated with anticardiolipin antibodies in isolation. CONCLUSION In pregnancies associated with lupus anticoagulant, uterine artery Doppler at 22–24 weeks is a useful screening test in predicting preeclampsia and SGA infants.

Dynamic imaging of the pelvic floor using an open‐configuration magnetic resonance scanner

The aims of this study were to develop a noninvasive, erect, gravity‐dependent method for assessing movements of the female pelvic floor, to describe the range of movements in pelvic floor ascent and descent in asymptomatic and symptomatic women, and to quantify any differences. A total of 102 women, 28–86 years of age, 35 symptomatic and 67 asymptomatic, were included in the study. They were scanned in a sitting position in an open scanner with good vertical access using fast‐gradient echo sequences fast spoiled grass (FSPGR). Measurements of the bladder base, uterocervical junction, and anorectal junction were taken in the sagittal plane. The levator ani (LA) muscle insertion was assessed in the coronal plane with the patients at rest, during maximal strain, and during maximum contraction of the pelvic floor. Premenopausal multiparous women have a significantly lower bladder base (8/0 mm above the baseline; P value = 0.009) and uterocervical junction (15.5/3.5 mm; P value = 0.03) at rest than nulliparous women, and this becomes more apparent on straining. Parity confers a more significant effect on the position and function of the pelvic floor than menopausal status. All pelvic organs are lower at rest and on straining in women with defecation difficulties (0/–24 mm; P value = 0.001). These differences are also seen when comparing women with and without urinary incontinence. Dynamic seated magnetic resonance imaging (MRI) shows that all the pelvic organs are lower at rest and on straining in multiparous women and in those with urinary incontinence than in a group of asymptomatic nulliparous volunteers. This difference is also seen in the position of the bladder base and anorectal junction during pelvic floor contraction. These findings suggest general pelvic floor weakness in women who present with symptoms in one compartment and indicate the need for evaluation of the entire pelvic floor particularly prior to surgery. J. Magn. Reson. Imaging 2001;13:923–929.

Magnetic resonance-guided percutaneous laser ablation of uterine fibroids

Laser ablation of uterine fibroids using a percutaneous approach under local anesthetic in an open magnetic resonance (MR) scanner was performed in 12 symptomatic women awaiting hysterectomy. Accurate laser fiber placement was assisted by the use of an MR needle tracking system, as well as laser heat dissipation monitored during treatment by a real‐time imaging processor. This day case procedure was well tolerated by all women, with eight women subsequently declining their planned surgery. Follow‐up measurements of treated fibroid volume by MRI demonstrated a mean decrease of 37.5% at 3 months. This novel minimally invasive approach offers an alternative to surgery for women with fibroids, but longer follow‐up is required to ascertain maximal fibroid shrinkage and to compare outcome with traditional surgery. J. Magn. Reson. Imaging 2000;12:565–570.

Histological chorioamnionitis in relation to clinical presentation at 14-40 weeks of gestation.

This study examines the prevalence of histological inflammation of the fetal membranes according to gestational age and mode of clinical presentation in a series of 179 consecutive placentas evaluated in a single centre. The frequency of histological inflammation between clinical groups was compared and relation between the prevalence of inflammation and gestational age examined using regression analysis. One hundred and seventy-nine placentas were examined. Histological inflammation was present in 65 (38%) cases including 37/52 (71%) pregnancies presenting with spontaneous preterm labour and delivery (PTL), 23/36 (64%) with preterm prelabour rupture of membranes (PPROM), 1/20 (5%) with vaginal bleeding but no contractions (PVB), 1/13 (8%) with intrauterine death but no labour (IUD), 1/28 (4%) with iatrogenic delivery, 0/4 with termination of pregnancy and 2/20 (10%) delivering spontaneously at term. The prevalence of histological inflammation was significantly higher in those with PTL or PPROM compared to the other groups ( P <0·0001). The frequency of histological inflammation was associated with gestational age ( F =57·2, P <0·0001, R =0·91), with a peak prevalence (>90%) at 20-24 weeks gestation.This study examines the prevalence of histological inflammation of the fetal membranes according to gestational age and mode of clinical presentation in a series of 179 consecutive placentas evaluated in a single centre. The frequency of histological inflammation between clinical groups was compared and relation between the prevalence of inflammation and gestational age examined using regression analysis. One hundred and seventy-nine placentas were examined. Histological inflammation was present in 65 (38%) cases including 37/52 (71%) pregnancies presenting with spontaneous preterm labour and delivery (PTL), 23/36 (64%) with preterm prelabour rupture of membranes (PPROM), 1/20 (5%) with vaginal bleeding but no contractions (PVB), 1/13 (8%) with intrauterine death but no labour (IUD), 1/28 (4%) with iatrogenic delivery, 0/4 with termination of pregnancy and 2/20 (10%) delivering spontaneously at term. The prevalence of histological inflammation was significantly higher in those with PTL or PPROM compared to the other groups (P<0.0001). The frequency of histological inflammation was associated with gestational age (F=57.2, P<0.0001, R=0.91), with a peak prevalence (>90%) at 20-24 weeks gestation.