Obstetrics and Gynaecology - Research Publications
Permanent URI for this collection
Search Results
1 - 10 of 11
-
ItemNo Preview AvailableMetformin in pregnancy and childhood neurodevelopmental outcomes: a systematic review and meta-analysis.(Elsevier BV, 2024-03-07)OBJECTIVE: This study aimed to examine the impact of maternal metformin use during pregnancy on offspring neurodevelopmental outcomes. DATA SOURCES: MEDLINE, Embase, and Web of Science (Core Collection) were searched from inception until July 1, 2023. STUDY ELIGIBILITY CRITERIA: Studies of women who received treatment with metformin at any stage of pregnancy for any indication with neurodevelopmental data available for their offspring were included. Studies without a control group were excluded. Randomized controlled trials, case-control, cohort, and cross-sectional studies were included in the review. METHODS: Studies were screened for inclusion and data were extracted independently by 2 reviewers. Risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale for nonrandomized studies, and the Risk of Bias 2 tool for randomized trials. RESULTS: A total of 7 studies met the inclusion criteria, including a combined cohort of 14,042 children with 7641 children who were exposed and followed for up to 14 years of age. Metformin use during pregnancy was not associated with neurodevelopmental delay in infancy (relative risk, 1.09; 95% confidence interval, 0.54-2.17; 3 studies; 9668 children) or at ages 3 to 5 years (relative risk, 0.90; 95% confidence interval, 0.56-1.45; 2 studies; 6118 children). When compared with unexposed peers, metformin use during pregnancy was not associated with altered motor scores (mean difference, 0.30; 95% confidence interval, -1.15 to 1.74; 3 studies; 714 children) or cognitive scores (mean difference, -0.45; 95% confidence interval, -1.45 to 0.55; 4 studies; 734 children). Studies that were included were of high quality and deemed to be at low risk of bias. CONCLUSION: In utero exposure to metformin does not seem to be associated with adverse neurodevelopmental outcomes in children up to the age of 14 years. These findings provide reassurance to clinicians and pregnant women considering metformin use during pregnancy.
-
ItemNo Preview AvailableTelehealth in antenatal care: recent insights and advances(BMC, 2023-08-30)BACKGROUND: For decades, antenatal care in high-resource settings has involved 12-14 face-to-face visits across pregnancy. The COVID-19 pandemic forced many care providers to rapidly embrace telehealth to reduce face-to-face visits. Here we review recent advances in telehealth used to provide antenatal care. MAIN BODY: We conducted a narrative review examining the impact of telehealth on obstetric care. Two broad types of telehealth are used in antenatal care. The first is real-time telehealth, where consultations are done virtually instead of face-to-face. The second is remote monitoring, where in-clinic physical examinations are replaced with at-home alternatives. These can include blood pressure monitoring, fetal heart rate monitoring, and emerging technologies such as tele-ultrasound. Large cohort studies conducted during the pandemic era have shown that telehealth appears not to have increased adverse clinical outcomes for mothers or babies. However, further studies may be required to confidently conclude rare outcomes are unchanged, such as maternal mortality, serious morbidity, or stillbirth. Health economic studies suggest telehealth has the potential to reduce the financial cost of care provision. Telehealth in antenatal care seems to be acceptable to both pregnant women and healthcare providers. CONCLUSION: Adoption of telehealth technologies may improve the antenatal care experience for women and reduce healthcare expenditure without adversely impacting health outcomes for the mother or baby. More studies are warranted to confirm telehealth does not alter the risk of rare outcomes such as maternal or neonatal mortality.
-
ItemNo Preview AvailableThe long-term risk of cardiovascular disease among women with a history of hypertensive disorders of pregnancy: a systematic review of clinical practice guidelines(BMC, 2023-09-09)BACKGROUND: The lifelong risks of cardiovascular disease following preeclampsia and gestational hypertension are well-established. However, it is unclear whether this evidence has been translated into clinical practice guidelines. Thus, this review aimed to assess the quality and content of Australian clinical practice guidelines regarding the risk of cardiovascular disease following gestational hypertension and preeclampsia. METHODS: We conducted a systematic search of MEDLINE (Ovid), EMBASE (Ovid), and CINAHL databases, as well as hospital, obstetric society, and medical college websites. Publications were included if: they were a clinical practice guideline; were published in the previous ten years; and included recommendations for the management of future cardiovascular disease risk following hypertensive disorders of pregnancy. Quality assessment was performed using Appraisal of Guidelines for Research and Evaluation Instrument Version Two (AGREE-II) and AGREE Recommendations Excellence Instrument (AGREE-REX). RESULTS: Eighteen guidelines were identified, and of these, less than half (n = 8) included recommendations for managing future cardiovascular risk following hypertensive disorders of pregnancy. Across these eight, four main counselling recommendations were found regarding (1) risk of future cardiovascular disease; (2) risk factor screening; (3) lifestyle interventions; and (4) prenatal counselling for future pregnancies. The quality and content of these recommendations varied significantly, and the majority of guidelines (87.5%) were assessed as low to moderate quality. CONCLUSIONS: There are limited Australian clinical practice guidelines providing appropriate advice regarding future risk of cardiovascular disease following hypertensive disorders of pregnancy. The quality and content of these guidelines varied significantly. These findings highlight the need for improved translation from evidence-based research to enhance clinical care and guidance.
-
ItemRisk of obstetric anal sphincter injury among women who birth vaginally after a prior caesarean section: A state-wide cohort study(WILEY, 2022-07)OBJECTIVE: Vaginal birth after caesarean (VBAC) has been suggested to be associated with an increased risk of obstetric anal sphincter injury (compared with primiparous women who birth vaginally). However, prior studies have been small or have used outdated methodology. We set out to validate whether the risk of obstetric anal sphincter injury among women having their first VBAC is greater than that among primiparous women having a vaginal birth. DESIGN: State-wide retrospective cohort study. SETTING: Victoria, Australia. POPULATION: All births (455 000) between 2009 and 2014. METHODS: The risk of severe perineal injury between the first vaginal birth and the first VBAC was compared, after adjustment for potential confounding variables. Covariates were examined using logistic regression for categorical data and the Wilcoxon rank-sum test for continuous data. Missing data were handled using multiple imputation; the analysis was performed using regression adjustment and stata 16 multiple imputation and suite of effects commands. RESULTS: Women having a VBAC (n = 5429) were significantly more likely than primiparous women (n = 123 353) to sustain a third- or fourth-degree tear during vaginal birth (7.1 versus 5.7%, p < 0.001). After adjustment for mode of birth, body mass index, maternal age, infant birthweight, episiotomy and epidural, there was a 21% increased risk of severe perineal injury (RR 1.21, 95% CI 1.07-1.38). CONCLUSIONS: Women having their first VBAC have a significantly increased risk of sustaining a third- or fourth-degree tear, compared with primiparous women having a vaginal birth. Patient counselling and professional guidelines should reflect this increased risk.
-
ItemNo Preview AvailableDevelopmental Outcomes for Children After Elective Birth at 39 Weeks' Gestation(AMER MEDICAL ASSOC, 2022-07)IMPORTANCE: Elective births at 39 weeks' gestation are increasing. While this option may improve maternal and perinatal outcomes compared with expectant management, longer-term childhood developmental outcomes are uncertain. OBJECTIVE: To investigate the association between elective birth at 39 weeks' gestation and the risk of childhood developmental vulnerability. DESIGN, SETTING, AND PARTICIPANTS: For this cohort study, 2 causal inference analyses were conducted using Australian statewide, population-based data. Perinatal data from births between January 1, 2005, and December 31, 2013, were linked to childhood developmental outcomes at age 4 to 6 years (assessed using multiple imputation via inverse probability-weighted regression adjustment). Data analyses were conducted between September 7 and November 9, 2021. EXPOSURES: Two exposure groups were considered: (1) elective birth between 39 weeks and 0 days' and 39 weeks and 6 days' gestation vs expectant management and (2) birth via induction of labor vs planned cesarean delivery among those born electively at 39 weeks' gestation. MAIN OUTCOMES AND MEASURES: Childhood developmental vulnerability at school entry, defined as scoring below the 10th percentile in at least 2 of 5 developmental domains (physical health and well-being, social competence, emotional maturity, school-based language and cognitive skills, and communication skills and general knowledge). RESULTS: Of 176 236 births with linked outcome data, 88 165 met the inclusion criteria. Among these, 15 927 (18.1%) were elective births at 39 weeks' gestation (induction of labor or planned cesarean delivery), and 72 238 (81.9%) were expectantly managed with subsequent birth between 40 and 43 weeks' gestation. Compared with expectant management, elective birth at 39 weeks' gestation was not associated with an altered risk of childhood global developmental vulnerability (adjusted relative risk [aRR], 1.03; 95% CI, 0.96-1.12) or with developmental vulnerability in any of the individual domains. In an analysis restricted to elective births at 39 weeks' gestation, induction of labor (n = 7928) compared with planned cesarean delivery (n = 7999) was not associated with childhood developmental vulnerability (aRR, 0.96; 95% CI, 0.82-1.12) or with vulnerability in any individual domains. CONCLUSIONS AND RELEVANCE: In this cohort study, elective birth at 39 weeks' gestation was not associated with childhood developmental vulnerability. For those born electively at 39 weeks' gestation, birth after induction of labor or by elective cesarean delivery had similar developmental outcomes.
-
ItemIncidence and causes of stillbirth in the only tertiary referral hospital in the Solomon Islands: a hospital-based retrospective cohort study(BMJ PUBLISHING GROUP, 2022-12)OBJECTIVES: Stillbirth is a major global health issue, which disproportionately affects families living in low-income and middle-income countries. The Solomon Islands is a Pacific nation with poor perinatal outcomes, however research investigating stillbirth is lacking. Thus, we aimed to investigate the incidence and cause of stillbirth occurring at the National Referral Hospital, Solomon Islands. DESIGN: We conducted a retrospective cohort study from January 2017 to December 2018. SETTING: At the only tertiary referral hospital in the Solomon Islands, on the main island of Guadalcanal. PARTICIPANTS: All births occurring in the hospital during the study period. OUTCOME MEASURES: Number of, causes and risk factors for stillbirths (fetal deaths before birth at ≥20 estimated gestational weeks, or ≥500 g in birth weight). RESULTS: Over 2 years 341 stillbirths and 11 056 total births were recorded, giving an institutional incidence of 31 stillbirths per 1000 births. Of the cases with a recorded cause of death, 72% were deemed preventable. Most stillbirths occurred antenatally and 62% at preterm gestations (<37 weeks). 59% had a birth weight below 2500 g and preventable maternal conditions were present in 42% of the cases. 46% of the cases were caused by an acute intrapartum event, and among these 92% did not receive intrapartum monitoring. CONCLUSIONS: Stillbirth affects 31 in every 1000 births at the National Referral Hospital in the Solomon Islands and many cases are preventable. Our findings highlight the urgent need for increased focus on perinatal deaths in the Solomon Islands with universal classification and targeted training, improved quality of obstetrical care and community awareness.
-
ItemNo Preview AvailablePatients' understanding of long-term cardiovascular risks and associated health-seeking behaviours after pre-eclampsia(BMJ PUBLISHING GROUP, 2023-03)OBJECTIVE: The lifelong risks of cardiovascular disease following hypertensive disorders of pregnancy are well described. Awareness of these risks and associated health-seeking behaviours among affected individuals remains unclear. We aimed to assess participants' knowledge of their cardiovascular disease risk and relevant health-seeking behaviours following a pregnancy affected by preeclampsia or gestational hypertension. METHODS: We undertook a single-site, cross-sectional cohort study. The target population included individuals who birthed at a large tertiary referral centre in Melbourne, Australia, between 2016 and 2020, and were diagnosed with gestational hypertension or pre-eclampsia. Participants completed a survey assessing pregnancy details, medical comorbidities, knowledge of future risks and health-seeking behaviours post-pregnancy. RESULTS: 1526 individuals met inclusion criteria and 438 (28.6%) completed the survey. Of these, 62.6% (n=237) were unaware of their increased risk of cardiovascular disease following a hypertensive disorder of pregnancy. Participants who reported awareness of their increased risk were more likely to have annual blood pressure monitoring (54.6% vs 38.1%, p<0.01), and at least one assessment of blood cholesterol (p<0.01), blood glucose (p=0.03) and renal function (p=0.01). Participants who were aware were more likely to be taking antihypertensive medication (24.5% vs 6.6%, p<0.01) since pregnancy, compared with those who were unaware. There were no differences between groups in diet, exercise or smoking habits. CONCLUSION: Among our study cohort, risk awareness was associated with increased health-seeking behaviours. Participants who were aware of their increased risk of cardiovascular disease were more likely to have regular cardiovascular risk factor assessments. They were also more likely to be taking antihypertensive medication.
-
ItemLow-Dose Aspirin for Preventing Birth of a Small-For-Gestational Age Neonate in a Subsequent Pregnancy(LIPPINCOTT WILLIAMS & WILKINS, 2022-04)OBJECTIVE: To estimate whether low-dose aspirin use is associated with an altered risk of delivering a small-for-gestational age (SGA) neonate among women with a history of having an SGA neonate in a prior pregnancy. METHODS: We performed a Swedish register-based cohort study including women in their second pregnancy who had a history of having an SGA neonate (birth weight less than the 10th percentile). The association between use of low-dose aspirin in subsequent pregnancy and birth of an SGA neonate or a severely SGA neonate (birth weight less than the third percentile) were estimated using inverse propensity-weighted estimation, accounting for potential confounders. RESULTS: Among 8,416 women who gave birth to an SGA neonate in their first pregnancy, 801 (9.5%) used low-dose aspirin during their second pregnancy. The incidence of SGA neonates was similar among women using low-dose aspirin (21.7%) and those who did not use aspirin (20.7%). Low-dose aspirin use in pregnancy was not associated with an altered risk of having an SGA neonate (adjusted relative risk [aRR] 0.86, 95% CI 0.67-1.10) or a severely SGA neonate (aRR 0.98, 95% CI 0.71-1.34). Given the strong association between preeclampsia and SGA, we performed subgroup analyses based on preeclampsia status. Among women who had an SGA neonate and co-existing preeclampsia in their first pregnancy, low-dose aspirin was not associated with an altered risk of having an SGA (aRR 0.83, 95% CI 0.63-1.10) or severely SGA (aRR 1.02, 95% CI 0.73-1.44) neonate. Additionally, no association was seen among women who developed preeclampsia in their second pregnancy. CONCLUSION: Among women with a history of having an SGA neonate, low-dose aspirin was not associated with a decreased risk of having an SGA or severely SGA neonate in subsequent pregnancy. These findings suggest that low-dose aspirin should not be used to prevent recurrent SGA.
-
ItemSevere maternal morbidity in the Asia Pacific: a systematic review and meta-analysis(ELSEVIER, 2021-09)BACKGROUND: Monitoring rates of severe maternal morbidity (such as eclampsia and uterine rupture) is useful to assess the quality of obstetric care, particularly in low and lower-middle-income countries (LMICs). METHODS: We undertook a systematic review characterising the proportion and causes of severe maternal morbidity in the Asia Pacific region. We searched Medline, Embase, Cochrane CENTRAL library and the World Health Organization Western Pacific Index database for studies in the Asia-Pacific reporting maternal morbidity/near miss using a predefined search strategy. We included cohort, case-control and cross-sectional studies published in English before September 2020. A meta-analysis was performed calculating the overall proportion of near miss events by sub-region, country, near miss definition, economic status, setting and cause using a random-effects model. FINDINGS: We identified 26,232 articles, screened 24,306 and retrieved 454 full text articles. Of these, 197 studies spanning 27 countries were included. 13 countries in the region were not represented. There were 30,183,608 pregnancies and 100,011 near misses included. The total proportion of near miss events was 4•4 (95% CI 4•3-4•5) per 1000 total births. The greatest proportion of near misses were found in the Western Pacific region (around Papua New Guinea) at 11•8 per 1000 births (95% CI 6•6-17•1; I2 96.05%). Low-income countries displayed the greatest proportion of near misses (13•4, 95% CI 6•0-20•7), followed by lower-middle income countries (11•1; 95% CI 10•4 - 11•9). High-income countries had the lowest proportion (2•2, 95% CI 2•1-2•3). Postpartum haemorrhage was the most common near miss event (5•9, 95% CI 4•5-7•2), followed by eclampsia (2•7, 95% CI 2•4 - 2•9). INTERPRETATION: There is a high burden of severe maternal morbidity in the Asia-Pacific. LMICs are disproportionately affected. Most of the common causes are preventable. This provides an opportunity to implement targeted interventions which could have major clinical impact.
-
ItemRisk of major labour-related complications for pregnancies progressing to 42 weeks or beyond(BMC, 2021-05-25)BACKGROUND: Post-term gestation beyond 41+6 completed weeks of gestation is known to be associated with a sharp increase in the risk of stillbirth and perinatal mortality. However, the risk of common adverse outcomes related to labour, such as shoulder dystocia and post-partum haemorrhage for those delivering at this advanced gestation, remains poorly characterised. The objective of this study was to examine the risk of adverse, labour-related outcomes for women progressing to 42 weeks gestation or beyond, compared with those giving birth at 39 completed weeks. METHODS: We performed a state-wide cohort study using routinely collected perinatal data in Australia. Comparing the two gestation cohorts, we examined the adjusted relative risk of clinically significant labour-related adverse outcomes, including macrosomia (≥ 4500 at birth), post-partum haemorrhage (≥1000 ml), shoulder dystocia, 3rd or 4th degree perineal tear and unplanned caesarean section. Parity, maternal age and mode of birth were adjusted for using logistic regression. RESULTS: The study cohort included 91,314 women who birthed at 39 completed weeks and 4317 at ≥42 completed weeks. Compared to 39 weeks gestation, those giving birth ≥42 weeks gestation had an adjusted relative risk (aRR) of 1.85 (95% CI 1.55-2.20) for post-partum haemorrhage following vaginal birth, 2.29 (95% CI 1.89-2.78) following instrumental birth and 1.44 (95% CI 1.17-1.78) following emergency caesarean section; 1.43 (95% CI 1.16-1.77) for shoulder dystocia (for non-macrosomic babies); and 1.22 (95% CI 1.03-1.45) for 3rd or 4th degree perineal tear (all women). The adjusted relative risk of giving birth to a macrosomic baby was 10.19 (95% CI 8.26-12.57) among nulliparous women and 4.71 (95% CI 3.90-5.68) among multiparous women. The risk of unplanned caesarean section was 1.96 (95% CI 1.86-2.06) following any labour and 1.47 (95% CI 1.38-1.56) following induction of labour. CONCLUSIONS: Giving birth at ≥42 weeks gestation may be an under-recognised risk factor for several important, labour-related adverse outcomes. Clinicians should be aware that labour at this advanced gestation incurs a higher risk of adverse outcomes. In addition to known perinatal risks, the risk of obstetric complications should be considered in the counselling of women labouring at post-term gestation.