Susan Bewley

Incidence and predictors of severe obstetric morbidity: case-control study.

abstract Objective: To estimate the incidence and predictors of severe obstetric morbidity. Design: Development of definitions of severe obstetric morbidity by literature review. Case-control study from a defined delivery population with four randomly selected pregnant women as controls for every case. Setting: All 19 maternity units within the South East Thames region and six neighbouring hospitals caring for pregnant women from the region between 1 March 1997 and 28 February 1998. Participants: 48 865 women who delivered during the time frame. Results: There were 588 cases of severe obstetric morbidity giving an incidence of 12.0/1000 deliveries (95% confidence interval 11.2 to 13.2). During the study there were five maternal deaths attributed to conditions studied. Disease specific morbidities per 1000 deliveries were 6.7 (6.0 to 7.5) for severe haemorrhage, 3.9 (3.3 to 4.5) for severe pre-eclampsia, 0.2 (0.1 to 0.4) for eclampsia, 0.5 (0.3 to 0.8) for HELLP (Haemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, 0.4 (0.2 to 0.6) for severe sepsis, and 0.2 (0.1 to 0.4) for uterine rupture. Age over 34 years, non-white ethnic group, past or current hypertension, previous postpartum haemorrhage, delivery by emergency caesarean section, antenatal admission to hospital, multiple pregnancy, social exclusion, and taking iron or anti-depressants at antenatal booking were all independently associated with morbidity after adjustment. Conclusion: Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone. Most events are related to obstetric haemorrhage and severe pre-eclampsia. Caesarean section quadruples the risk of morbidity. Development and evaluation of ways of predicting and reducing risk are required with particular emphasis paid on the management of haemorrhage and pre-eclampsia. What is already known on this topic Maternal mortality is used internationally as a measure of the quality of obstetric intervention, although it is now rare in the developed world Hospital based series estimating the incidence of severe obstetric morbidity have used different definitions Estimated incidence of severe obstetric morbidity ranges from 0.05 to 1.09 What this study adds With clear definitions and population based estimates of some severe obstetric morbidities this study estimated the overall incidence of severe obstetric morbidity as 1.2 % of deliveries Two thirds of the cases are related to severe haemorrhage, one third to hypertensive disorders Risk factors for severe maternal morbidity include maternal age >34, social exclusion, non-white, hypertension, previous postpartum haemorrhage, induction of labour, and caesarean section

Doppler investigation of uteroplacental blood flow resistance in the second trimester: a screening study for pre‐eclampsia and intrauterine growth retardation

Objective— To assess the screening properties of a mid‐trimester uteroplacental Doppler scan in a normal unselected population.

DOMESTIC VIOLENCE: PREVALENCE IN PREGNANT WOMEN AND ASSOCIATIONS WITH PHYSICAL AND PSYCHOLOGICAL HEALTH

OBJECTIVES To examine the prevalence of domestic violence (DV) and its associations with obstetric complications and psychological health in women on antenatal and postnatal wards. STUDY DESIGN A cross-sectional survey conducted in an inner-London teaching hospital. Two hundred English-speaking women aged 16 and over, were interviewed between July 2001 and April 2002. The Abuse Assessment Screen was used to assess for experiences of DV. Depression was assessed using the Edinburgh Postnatal Depression Scale (EPDS). The analysis of predictors of obstetric complications grouped together those known to be associated with DV. RESULTS 23.5% of women had lifetime experience of DV, 3% during the current pregnancy. Women with a history of DV were significantly more likely to be single, separated or in non-cohabiting relationship and to have smoked in the year prior to and/or during pregnancy. Higher EPDS scores were significantly associated with DV, single, separated or non-cohabiting status, and obstetric complications. Both a history of DV and increased EPDS scores were significantly associated with obstetric complications after controlling for other known risk factors. CONCLUSIONS Domestic violence is regarded as an important risk marker for the development of obstetric complications and depressive symptomatology. This finding of itself justifies training and education of maternity health professionals to raise awareness.

Pregnancy outcome in different clinical phenotypes of antiphospholipid syndrome

Women with antiphospholipid syndrome (APS) may have diverse pregnancy outcomes. The objective of this study was to evaluate pregnancy outcome in women with APS according to their clinical phenotype, i.e. thrombotic and obstetric APS. Eighty-three pregnancies in 67 women with APS were included in the study, including 21 with recurrent miscarriage (Group 1), 21 with late fetal loss or early delivery due to placental dysfunction (Group 2) and 41 with thrombotic APS (Group 3). Group 3 had higher rates of preterm delivery (26.8% versus 4.7%, p = 0.05) than Group 1 and more small for gestational age (SGA) babies than Group 2 (39.5% versus 4.8%, p = 0.003). Group 2 had significantly longer gestations compared with their pretreatment pregnancies (38.4 [28.4—41.4] versus 24.0 [18—35] weeks, p < 0.0001) and 100% live birth rate after treatment with aspirin and low-molecular-weight heparin (LMWH). In conclusion, women with thrombotic APS (Group 3) have higher rates of pregnancy complications than those with obstetric APS (Groups 1 and 2). Treatment with aspirin and LMWH is associated with improved outcomes for women with previous late fetal loss or early delivery due to placental dysfunction (Group 2). Lupus (2010) 19, 58—64.

Domestic violence, lifetime trauma and psychological health of childbearing women

Objective  Although histories of abuse are associated with psychiatric illness in women, health professionals rarely enquire directly about such experiences. This study examined the association between physical and sexual violence and lifetime trauma and depressive and posttraumatic stress symptoms in women receiving maternity care.

Which career first

The most secure age for childbearing remains 20-35

II. The unfacts of ‘request’ caesarean section

The previous Confidential Enquiry for the UK did not attempt a case fatality rate for caesarean section, temporarily restricting the safety debate. When trying to isolate mortality due to elective caesarean section in previously healthy women, Lilford et al. found a 3.8 relative risk (elective vs vaginal delivery 23:6 deaths /100,000). This would equate to a maternal death rate of 1 in 4262 for mothers having elective caesarean section which seems high, particularly compared with unproven claims of avoidable intrapartum fetal death. A more recent study from The Netherlands found a similar relative risk of 3.25 (and a death rate of 13/100,000). Extrapolated estimates (Table 1) show that elective caesarean section death rates can be as much as two to eight times higher, and in the 1994–1996 Confidential Enquiry period would be at least three times higher, than vaginal delivery. Numerous studies have recorded the higher risk of caesarean section delivery, not all of which can be accounted for by the complications which necessitated the operation – . Proponents of caesarean section point out that the relative risk of elective caesarean section might fall further with increasing safety procedures (e.g. use of epidural anaesthesia, antibiotics, and thromboprophylaxis). However, we must use what figures we have, as vaginal delivery also becomes less mortal with the growing use of the same procedures in an increasingly healthy population. There are rare risks in multiple medical interventions, such as allergic anaphylaxis, which may become more significant in the future, and maternal mortality must be watched particularly in countries with the highest and rising caesarean section rates. Even if vaginal delivery is safer than elective caesarean section, the real risk–benefit calculation is between labour (which might end in an emergency caesarean section) and elective caesarean section, and thus becomes critically dependent on the emergency caesarean section rate. The only hard data on this comes from a meta-analysis of all the randomised breech trials which found an increased risk of maternal death or severe early morbidity (RR 1.29, 95% CI 1.03–1.61), and this despite a high emergency caesarean section rate of 45% in the labour arm. This increase of nearly 30% is likely to be an underestimate for cephalic presentation with its higher vaginal delivery rate. A laissezfaire attitude to elective caesarean section sends a mistaken signal to the public and professionals alike that all caesarean sections are safe and the request debate can be misinterpreted as such. A reduction in the threshold for emergency caesarean section increases the dangers for labouring women in this and future pregnancies as 67% of women will have further caesarean sections. A vicious cycle can result whereby high emergency caesarean section rates fuel further loss of confidence and raise caesarean section rates, making elective caesarean section relatively more attractive. Working towards optimum safety in childbirth must mean increasing the rate of uncomplicated vaginal delivery. As emergency caesarean section in labour is the worst mode of delivery in terms of maternal morbidity, concentrating on the quality of intrapartum care should be our priority. Surely the real obstetric debate today, with the highest intervention rates on record, is how to achieve this.

A Qualitative Exploration of the Nature of Domestic Violence in Pregnancy

This article presents a small, qualitative study of 16 women who had experienced domestic violence in the previous 12 months. The violence was perpetrated by a current or former partner in all but one case. Ten of the 16 women had experienced domestic violence during their recent pregnancy, of whom four women had also been assaulted in at least one previous pregnancy. Three women had been assaulted by their partners in a previous pregnancy but not during their recent pregnancy, and three had experienced domestic violence outside of pregnancy only. Some women reported increased feelings of insecurity, jealousy, and possessiveness in their partner during their pregnancy. Abuse within the relationship centered around the arrival and care of the new baby: financial worries, the womans lessening physical and emotional availability during pregnancy, the lack of practical and emotional support from the male partner, and doubts about paternity.

Postnatal morbidity after childbirth and severe obstetric morbidity

Objective To identify the impact of pregnancy and childbirth, and severe obstetric morbidity on outcome 6 to 12 months postpartum.

Pregnancy Outcomes in Systemic Lupus Erythematosus with and without Previous Nephritis

Objective. To compare rates and predictors of pregnancy complications in mothers with systemic lupus erythematosus (SLE) with and without previous nephritis (PN). Methods. Retrospective analysis of 107 pregnancies in 83 women with SLE diagnosed prepregnancy. Results. Mothers with PN had higher rates of preterm delivery (< 37/40, 30% vs 11%, p = 0.029) than those without PN. Women with PN had earlier onset of preeclampsia [median 34.5 weeks (IQR 32–37) vs 37.5 weeks (IQR 35–38, p = 0.047)] that was more frequently complicated by preterm delivery (p = 0.02). Risk factors for preeclampsia in women with PN include 10–13 weeks’ gestation diastolic blood pressure > 80 mmHg and proteinuria, and prepregnancy estimated glomerular filtration rate (eGFR) < 90 ml/min/1.73 m2. In women with PN, midtrimester uterine-artery-Doppler notching had low negative predictive value (47%). After 39 months followup, eGFR was stable in women with or without PN. Conclusion. In SLE, preterm deliveries are more frequent and preeclampsia occurs earlier in women with PN, but longterm eGFR is preserved.