Stephen J McCall

Who has a repeat abortion? Identifying women at risk of repeated terminations of pregnancy: analysis of routinely collected health care data

Background Repeat termination of pregnancy highlights the issues of unplanned pregnancies and effective post-termination contraceptive practices. Objective To examine the risk factors at the time of a first termination that are associated with subsequent repeat termination. Design Registry-based study. Setting Grampian region of Scotland, UK. Methods A retrospective study using data from the Termination of Pregnancy Database, NHS Grampian for the period 1997–2013. Associations between repeat termination and womens sociodemographic characteristics and contraceptive use were assessed using multivariable logistic regression models. Results This study showed that 23.4% of women who had an initial termination (n=13 621) underwent a repeat termination. Women who had repeat terminations were more likely to be aged under 20 years at their initial termination with an adjusted odds ratio (AOR) of 5.59 [95% confidence interval (CI) 4.17–7.49], to belong to the most deprived social quintile [AOR 1.23 (95% CI 1.05–1.43)], and to be more likely to have had two or more previous livebirths [AOR 1.51 (95% CI 1.12–2.02)] or miscarriages [AOR 1.40 (95% CI 1.02–1.92)]. The likelihood of having a repeat termination was increased in women who had a contraceptive implant as post-termination contraception [AOR 1.78 (95% CI 1.50–2.11)] compared to women who left with none or unknown methods following the first termination. In those who had repeat terminations, women who had an implant or Depo-Provera® were at increased odds of repeat termination in the 2–5 years interval compared to the 0–2 years after their initial termination. Conclusions Teenage pregnancy, social deprivation, two or more previous livebirths or miscarriages at the time of the initial termination were identified as risk factors for repeat terminations. Post-termination contraception with implants and Depo-Provera® were associated with repeat termination 2–5 years after the first termination.

Effectiveness of peri-abortion counselling in preventing subsequent unplanned pregnancy: a systematic review of randomised controlled trials.

Objective This systematic review and meta-analysis assessed whether enhanced peri-abortion contraceptive counselling had an effect on subsequent unplanned pregnancies and the uptake and continuation of contraceptive methods. Methods and materials A systematic review of English-language articles published prior to May 2014 was conducted, using MEDLINE, EMBASE and the Cochrane Library. Only randomised controlled trials (RCTs) involving enhanced pre- and post-abortion contraceptive counselling were included. The authors independently applied the inclusion and exclusion criteria to the identified records, and extracted data from each included paper using a predefined extraction form. Risk of bias was assessed using the Cochrane Collaborations tool. Meta-analyses were undertaken where appropriate and based on random effects models. Results Six RCTs met the inclusion criteria. Three RCTs investigated the effect of enhanced counselling on subsequent unplanned pregnancy. The results of the meta-analysis were non-significant [pooled odds ratio (OR) 0.47; 95% confidence interval (95% CI) 0.12–1.90]. Four RCTs reported results relating to the uptake of long-acting reversible contraception (LARC) and continuation of chosen method of contraception at 3 months. Findings were non-significant (pooled OR 1.07; 95% CI 0.20–5.69 and pooled OR 3.22; 95% CI 0.85–12.22, respectively). Conclusions This review found no evidence of effect resulting from enhanced peri-abortion contraceptive counselling on subsequent unplanned pregnancy rate or the uptake of LARC. However, these findings are limited by the small number of relevant studies available and the marked heterogeneity between published studies. Further, larger-scale RCTs should be undertaken to ensure that there is sufficient power to detect an effect.

Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke: Analysis of UK Regional Registry Data, Systematic Review, and Meta‐Analysis

Background The impact of hemoglobin levels and anemia on stroke mortality remains controversial. We aimed to systematically assess this association and quantify the evidence. Methods and Results We analyzed data from a cohort of 8013 stroke patients (mean±SD, 77.81±11.83 years) consecutively admitted over 11 years (January 2003 to May 2015) using a UK Regional Stroke Register. The impact of hemoglobin levels and anemia on mortality was assessed by sex‐specific values at different time points (7 and 14 days; 1, 3, and 6 months; 1 year) using multiple regression models controlling for confounders. Anemia was present in 24.5% of the cohort on admission and was associated with increased odds of mortality at most of the time points examined up to 1 year following stroke. The association was less consistent for men with hemorrhagic stroke. Elevated hemoglobin was also associated with increased mortality, mainly within the first month. We then conducted a systematic review using the Embase and Medline databases. Twenty studies met the inclusion criteria. When combined with the cohort from the current study, the pooled population had 29 943 patients with stroke. The evidence base was quantified in a meta‐analysis. Anemia on admission was found to be associated with an increased risk of mortality in both ischemic stroke (8 studies; odds ratio 1.97 [95% CI 1.57–2.47]) and hemorrhagic stroke (4 studies; odds ratio 1.46 [95% CI 1.23–1.74]). Conclusions Strong evidence suggests that patients with anemia have increased mortality with stroke. Targeted interventions in this patient population may improve outcomes and require further evaluation.

Evaluating the social determinants of teenage pregnancy: a temporal analysis using a UK obstetric database from 1950 to 2010

Background Teenage pregnancy is a known social problem which has been previously described using a number of deprivation measures. This study aimed to explore the temporal patterns of teenage pregnancy in Aberdeen, Scotland and to assess the discriminating ability of three measures of socioeconomic status. Methods This was a population-based study from 1950 to 2010, using data from the Aberdeen Maternity Neonatal Databank (AMND). The main outcome variable was conceptions occurring in women aged less than 20 years. This study used two area-based measures, the Scottish Index of Multiple Deprivation (SIMD) and the Carstairs index, and one individual-based measure the Social Class based on Occupation (SCO). These measures were compared for their association with teenage conceptions using logistic regression models. The models were used to determine receiver operating characteristic (ROC) curves showing the discriminating ability of the measures. Results There was an overall decline in teenage conceptions over the 60-year period, but an increase in the rate ratio for deprived areas. All the measures of socioeconomic status were highly associated with teenage pregnancy. The adjusted OR of SIMD and teenage conception was 5.72 (95% CI 4.62 to 7.09), which compared the most deprived decile with the least deprived decile. The use of ROC curves showed that socioeconomic measures performed better than chance at determining teenage conceptions (χ2=21.67, p≤0.0001). They further showed that the SIMD had the largest area under the curve (AUC) with a value of 0.81 (95% CI 0.80 to 0.82), followed by the Carstairs index with an AUC of 0.80 (95% CI 0.78 to 0.80), then by SCO with an AUC of 0.79 (95% CI 0.78 to 0.80). Conclusions Despite a slight decline in teenage pregnancies over the past decades, there is still an evident association between deprivation and teenage pregnancy. This study shows that all the measures of socioeconomic status were highly associated with teenage pregnancy, with the SIMD having the greatest discriminatory effect.

Factors associated with maternal mortality at advanced maternal age: a population‐based case–control study

This study aimed to examine the factors associated with maternal mortality among women aged ≥35 years.

The incidence, characteristics, management and outcomes of anaphylaxis in pregnancy: a population-based descriptive study

The aim of this study was to estimate the incidence of anaphylaxis in pregnancy and describe the management and outcomes in the UK.

The shock index predicts acute mortality outcomes in stroke

BACKGROUND Shock index (SI) (ratio between heart rate and systolic blood pressure) has been shown to be associated with poor mortality outcomes in trauma and pneumonia; however it has yet to be examined in stroke. We aimed to examine the relationship between SI and acute outcomes of inpatient, 3-day and 7-day mortality in stroke. Secondly, we aimed to compare SI and systolic blood pressure (SBP) alone in predicting above outcomes. METHODS Data from a multicentre prospective cohort study conducted between October 2009 and September 2012 in eight NHS trusts in East of England were analysed. The relationships between SI, SBP and study outcomes were assessed using multivariable logistic regression models using mid-quintile groups as the reference category. Receiver operating characteristic (ROC) curves assessed the discriminating ability between the SI and SBP models. RESULTS A total of 2121 stroke patients were included (47.4% men; mean age 77.10 (sd) 12.40) years. The lowest quintile of the SI, had an increased odds of 3-day and 7-day mortality, adjusted odds ratio (AOR) 2.45 (95% CI:1.16-5.17) and 1.88 (1.01-3.49), respectively. Patients with the highest quintile of SI also had increased odds of in-patient, 3-day and 7-day mortality, AORs 1.85 (1.17-2.92), 2.18 (1.03-4.63) and 2.45 (1.34-4.49), respectively. Similarly, SBP had a U-shape relationship with mortality. All measures had an ROC area under the curve >0.8 but there was no difference in the discriminating ability between SI and SBP. CONCLUSIONS SI at extremely high and low values appeared to predict stroke mortality and appears to be particularly useful in predicting very early (3-day) mortality.

Addition of sodium criterion to SOAR stroke score.

To examine the usefulness of including sodium (Na) levels as a criterion to the SOAR stroke score in predicting inpatient and 7‐day mortality in stroke.

Hyperglycaemia and the SOAR stroke score in predicting mortality

Background: We assessed the association between admission blood glucose levels and acute stroke mortality and examined whether there was any incremental value of adding glucose status to the validated acute stroke mortality predictor – the SOAR (stroke subtype, Oxford Community Stroke Project classification, age, and pre-stroke modified Rankin) score. Methods: Data from Norfolk and Norwich University Hospital stroke and Transient Ischaemic Attack register (2003–2013) and Anglia Stroke Clinical Network Evaluation Study (2009–2012) were analysed. Multivariable logistic regression analysis assessed the association between admission blood glucose levels with inpatient and 7-day mortality. The prognostic ability of the SOAR score was then compared with the SOAR with glucose score. Results: A total of 5575 acute stroke patients (ischaemic stroke: 89.2%) with mean age (standard deviation) of 76.97 ( ± 11.88 ) years were included. Both borderline hyperglycaemia (7.9–11.0 mmol/L) and hyperglycaemia (>11.0 mmol/L) when compared to normoglycaemia (4.0–7.8 mmol/L) were associated with both 7-day and inpatient mortality after controlling for sex, age, Oxford Community Stroke Project classification and pre-stroke modified Rankin score. Both the SOAR stroke score and SOAR-G score were good predictors of inpatient stroke mortality [area under the curve: 0.82 (95% confidence interval: 0.81–0.84) and 0.83 (95% confidence interval: 0.81–0.84)], respectively. These scores were also good at predicting outcomes in both patients with and without diabetes. Conclusion: High blood glucose levels at admission were associated with worse acute stroke mortality outcomes. The constituents of the SOAR stroke score were good at predicting mortality after stroke.

Authors’ reply re: The incidence, characteristics, management and outcomes of anaphylaxis in pregnancy: a population‐based descriptive study

of observational studies consistently showed that a low vitamin D level could increase the risk of developing GDM by 85%. Combined with the insightful conclusions from Corcoy et al., it would be ideal to conduct larger, multicentre, randomised controlled trails of sophisticated design to document the preventive effects of vitamin D supplementation on GDM, and to facilitate future policymaking.&