Mairead Black

Obstetric outcomes subsequent to intrauterine death in the first pregnancy.

Objective  To compare obstetric outcomes in the pregnancy subsequent to intrauterine death with that following live birth in first pregnancy.

Planned Cesarean Delivery at Term and Adverse Outcomes in Childhood Health

IMPORTANCE Planned cesarean delivery comprises a significant proportion of births globally, with combined rates of planned and unscheduled cesarean delivery in a number of regions approaching 50%. Observational studies have shown that offspring born by cesarean delivery are at increased risk of ill health in childhood, but these studies have been unable to adjust for some key confounding variables. Additionally, risk of death beyond the neonatal period has not yet been reported for offspring born by planned cesarean delivery. OBJECTIVE To investigate the relationship between planned cesarean delivery and offspring health problems or death in childhood. DESIGN, SETTING, AND PARTICIPANTS Population-based data-linkage study of 321,287 term singleton first-born offspring born in Scotland, United Kingdom, between 1993 and 2007, with follow-up until February 2015. EXPOSURES Offspring born by planned cesarean delivery in a first pregnancy were compared with offspring born by unscheduled cesarean delivery and with offspring delivered vaginally. MAIN OUTCOMES AND MEASURES The primary outcome was asthma requiring hospital admission; secondary outcomes were salbutamol inhaler prescription at age 5 years, obesity at age 5 years, inflammatory bowel disease, type 1 diabetes, cancer, and death. RESULTS Compared with offspring born by unscheduled cesarean delivery (n = 56,015 [17.4%]), those born by planned cesarean delivery (12,355 [3.8%]) were at no significantly different risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, obesity at age 5 years, inflammatory bowel disease, cancer, or death but were at increased risk of type 1 diabetes (0.66% vs 0.44%; difference, 0.22% [95% CI, 0.13%-0.31%]; adjusted hazard ratio [HR], 1.35 [95% CI, 1.05-1.75]). In comparison with children born vaginally (n = 252,917 [78.7%]), offspring born by planned cesarean delivery were at increased risk of asthma requiring hospital admission (3.73% vs 3.41%; difference, 0.32% [95% CI, 0.21%-0.42%]; adjusted HR, 1.22 [95% CI, 1.11-1.34]), salbutamol inhaler prescription at age 5 years (10.34% vs 9.62%; difference, 0.72% [95% CI, 0.36%-1.07%]; adjusted HR, 1.13 [95% CI, 1.01-1.26]), and death (0.40% vs 0.32%; difference, 0.08% [95% CI, 0.02%-1.00%]; adjusted HR, 1.41 [95% CI, 1.05-1.90]), whereas there were no significant differences in risk of obesity at age 5 years, inflammatory bowel disease, type 1 diabetes, or cancer. CONCLUSIONS AND RELEVANCE Among offspring of women with first births in Scotland between 1993 and 2007, planned cesarean delivery compared with vaginal delivery (but not compared with unscheduled cesarean delivery) was associated with a small absolute increased risk of asthma requiring hospital admission, salbutamol inhaler prescription at age 5 years, and all-cause death by age 21 years. Further investigation is needed to understand whether the observed associations are causal.

Epidemiology of multiple pregnancy and the effect of assisted conception

Multiple pregnancy is one of the greatest perinatal challenges facing clinicians today. In a society of rising expectations among fertility and maternity service users, the potential for adverse outcomes associated with multiple pregnancy is a source of concern. This article examines the impact of assisted conception on the incidence of multiple pregnancies and associated complications. It explores some of the reasons for the strong association between assisted reproductive technology and multiple pregnancies and suggests possible ways of addressing this continuing problem.

Planned Repeat Cesarean Section at Term and Adverse Childhood Health Outcomes: A Record-Linkage Study.

Background Global cesarean section (CS) rates range from 1% to 52%, with a previous CS being the commonest indication. Labour following a previous CS carries risk of scar rupture, with potential for offspring hypoxic brain injury, leading to high rates of repeat elective CS. However, the effect of delivery by CS on long-term outcomes in children is unclear. Increasing evidence suggests that in avoiding exposure to maternal bowel flora during labour or vaginal birth, offspring delivered by CS may be adversely affected in terms of energy uptake from the gut and immune development, increasing obesity and asthma risks, respectively. This study aimed to address the evidence gap on long-term childhood outcomes following repeat CS by comparing adverse childhood health outcomes after (1) planned repeat CS and (2) unscheduled repeat CS with those that follow vaginal birth after CS (VBAC). Methods and Findings A data-linkage cohort study was performed. All second-born, term, singleton offspring delivered between 1 January 1993 and 31 December 2007 in Scotland, UK, to women with a history of CS (n = 40,145) were followed up until 31 January 2015. Outcomes assessed included obesity at age 5 y, hospitalisation with asthma, learning disability, cerebral palsy, and death. Cox regression and binary logistic regression were used as appropriate to compare outcomes following planned repeat CS (n = 17,919) and unscheduled repeat CS (n = 8,847) with those following VBAC (n = 13,379). Risk of hospitalisation with asthma was greater following both unscheduled repeat CS (3.7% versus 3.3%, adjusted hazard ratio [HR] 1.18, 95% CI 1.05–1.33) and planned repeat CS (3.6% versus 3.3%, adjusted HR 1.24, 95% CI 1.09–1.42) compared with VBAC. Learning disability and death were more common following unscheduled repeat CS compared with VBAC (3.7% versus 2.3%, adjusted odds ratio 1.64, 95% CI 1.17–2.29, and 0.5% versus 0.4%, adjusted HR 1.50, 95% CI 1.00–2.25, respectively). Risk of obesity at age 5 y and risk of cerebral palsy were similar between planned repeat CS or unscheduled repeat CS and VBAC. Study limitations include the risk that women undergoing an unscheduled CS had intended to have a planned CS, and lack of data on indication for CS, which may confound the findings. Conclusions Birth by repeat CS, whether planned or unscheduled, was associated with an increased risk of hospitalisation with asthma but no difference in risk of obesity at age 5 y. Greater risk of death and learning disability following unscheduled repeat CS compared to VBAC may reflect complications during labour. Further research, including meta-analyses of studies of rarer outcomes (e.g., cerebral palsy), are needed to confirm whether such risks are similar between delivery groups.

Outcomes of pregnancy in women using illegal drugs and in women who smoke cigarettes

To compare obstetric outcomes in women using illegal drugs with women who smoke cigarettes.

Mode of Delivery and Risk of Inflammatory Bowel Disease in the Offspring: Systematic Review and Meta-analysis of Observational Studies

Background:The incidence of inflammatory bowel disease (IBD) is increasing worldwide; however, pathogenesis is not fully understood. The global cesarean section (CS) rate is also rising, and evidence suggests that mode of delivery may influence colonization of the offspring gut microbiota, predisposing offspring to IBD. This study aimed to investigate the relationship between mode of delivery and risk of IBD. Methods:The electronic databases, Embase, CINAHL, and Medline (1948 to present) were searched, reference lists were checked, and no restrictions were assigned. Full texts of potentially relevant articles were evaluated, and included articles were assessed for quality. Raw data were used to calculate unadjusted odds ratios reflecting the risk of developing IBD in those delivered by cesarean. A meta-analysis was performed using RevMan 5 software to obtain a pooled measure of effect. Sensitivity analyses were performed to identify results according to specific study designs. Results:Seven eligible studies were included; 4 were retrospective cohort design and 3 were case-control studies. The total number of children born by CS in the meta-analysis was 1354, and 11,355 were delivered vaginally. The proportion of IBD in the CS group was 0.249% compared with 0.322% in the vaginal delivery group. The pooled odds ratio of developing IBD when delivered by CS was 1.00 (95% confidence interval, 0.75–1.33). Conclusions:This analysis observed no significant difference in risk of IBD in offspring delivered by CS compared with those born vaginally.

Qualitative website analysis of information on birth after caesarean section

BackgroundThe United Kingdom (UK) caesarean section (CS) rate is largely determined by reluctance to augment trial of labour and vaginal birth. Choice between repeat CS and attempting vaginal birth after CS (VBAC) in the next pregnancy is challenging, with neither offering clear safety advantages. Women may access online information during the decision-making process. Such information is known to vary in its support for either mode of birth when assessed quantitatively. Therefore, we sought to explore qualitatively, the content and presentation of web-based health care information on birth after caesarean section (CS) in order to identify the dominant messages being conveyed.MethodsThe search engine Google™ was used to conduct an internet search using terms relating to birth after CS. The ten most frequently returned websites meeting relevant purposive sampling criteria were analysed. Sampling criteria were based upon funding source, authorship and intended audience. Images and written textual content together with presence of links to additional media or external web content were analysed using descriptive and thematic analyses respectively.ResultsTen websites were analysed: five funded by Government bodies or professional membership; one via charitable donations, and four funded commercially. All sites compared the advantages and disadvantages of both repeat CS and VBAC. Commercially funded websites favoured a question and answer format alongside images, ‘pop-ups’, social media forum links and hyperlinks to third-party sites. The relationship between the parent sites and those being linked to may not be readily apparent to users, risking perception of endorsement of either VBAC or repeat CS whether intended or otherwise. Websites affiliated with Government or health services presented referenced clinical information in a factual manner with podcasts of real life experiences. Many imply greater support for VBAC than repeat CS although this was predominantly conveyed through subtle use of words rather than overt messages, with the exception of the latter being apparent in one site.ConclusionsWebsites providing information on birth after CS appear to vary in nature of content according to their funding source. The most user-friendly, balanced and informative websites appear to be those funded by government agencies.

Cesarean section in China, Taiwan, and Hong Kong : A safe choice for women and clinicians?

Mairead Black and Sohinee Bhattacharya discuss research findings on preferences for cesarean delivery in Asian settings and share their Perspective on facilitating woman-centered birth choices in China following the end of the one-child policy.

Intervention thresholds and cesarean section rates: A time‐trends analysis

To improve understanding of rising cesarean section (CS) rates in the UK, this study assessed the relation between clinician thresholds for performing CS for delayed labor progress or suspected fetal distress and corresponding CS rates in Aberdeen, UK.

Maternal Obesity and the Risk of Stillbirth

Abstract Obese women are more likely to experience stillbirth than those of normal weight and the risk increases with the degree of obesity. The association between the two is potentially confounded by a number of medical and social factors. Gestational diabetes, hypertensive disorders, placental dysfunction, metabolic syndrome, previous history of pregnancy loss, fetal abnormalities, suboptimal antenatal screening, and post maturity are direct risk factors for stillbirth which are related to obesity. Factors such as age, nulliparity, and social class are strongly related to both obesity and stillbirth and it is not always possible to confidently demonstrate an independent causal relationship between obesity and late pregnancy loss in their presence. Data from a single cohort study that adjusted for maternal age, smoking, alcohol, caffeine intake, height, parity, offspring gender, education, working, and cohabitation status suggest a higher unexplained stillbirth rate in nonhypertensive, nondiabetic obese women. Strategies for the prevention of stillbirth are the focus of much ongoing research. There is little evidence to support the use of fetal movement counting, Doppler studies, and fetal cardiotocography. Primary prevention of maternal obesity and encouraging women not to delay pregnancy have been suggested. Secondary prevention including weight management in pregnancy, risk scoring systems to highlight pregnancies at high risk for stillbirth, and additional surveillance have all been suggested, but the evidence base underpinning these is far from robust. Raising the profile of adverse effects of maternal obesity on pregnancy outcomes including stillbirth is of vital importance to improving future maternal and offspring health.