Context:
High serum levels of TSH have been associated with adverse pregnancy outcomes by some studies, and not by others.
Objective:
The aim of the study was to assess the association between high ...levels of TSH in the first trimester of pregnancy and adverse pregnancy outcomes; and to examine the predictive accuracy as a screening test.
Setting and Participants:
Serum levels of TSH were measured in a cohort of 2801 women with a singleton pregnancy attending first trimester Down syndrome screening. Information on maternal and infant outcomes was obtained through record linkage to population-based birth and hospital data. Association between high TSH (>95th and >97.5th centiles) multiple of the median levels, and risk of adverse pregnancy outcomes was evaluated using multivariable logistic regression, and the predictive accuracy of models was assessed.
Main Outcomes:
Rates of infants being small for gestational age (SGA), preterm birth, preeclampsia, miscarriage, and stillbirth were investigated.
Results:
High TSH multiple of the median levels were associated with SGA (<10th centile) adjusted odds ratio (aOR), 1.71; 95% confidence interval (CI), 0.99–2.94; preterm birth at less than 37 wk gestation (aOR, 2.59; 95% CI, 1.21–5.53); miscarriage (aOR, 3.66; 95% CI, 1.59–8.44); and a composite measure of any study outcome (aOR, 2.10; 95% CI, 1.23–3.59). The area under the receiver operator characteristic curves were 0.69 (95% CI, 0.65–0.73) for SGA; 0.56 (95% CI, 0.51–0.61) for preterm birth; 0.70 (95% CI, 0.61–0.79) for miscarriage; and 0.63 (95% CI, 0.60–0.65) for any adverse pregnancy outcome.
Conclusions:
High TSH serum levels during the first trimester of pregnancy were associated with adverse pregnancy outcomes; however, the predictive accuracy was poor. Screening for high TSH levels in the first trimester would be of no benefit to identify women at risk.
To examine the relationship between antenatal care, iron and folic acid supplementation and tetanus toxoid vaccination during pregnancy in Indonesia and the risk of early neonatal death (death in ...days 0-6 of life).
We analysed pooled data on neonatal survival in singleton infants born in the 5 years before each of the Indonesian demographic and health surveys of 1994, 1997 and 2002-2003. Only the most recently born infant of each mother was included. Multivariate Cox proportional hazards models were used to identify factors linked to early neonatal death.
Of the 40 576 infants included, 442 experienced early neonatal death. After adjustment, the risk of early neonatal death was significantly reduced for infants of mothers who received either any form of antenatal care (hazard ratio, HR: 0.48; 95% confidence interval, CI: 0.31-0.73), any quantity of iron and folic acid (HR: 0.53; 95% CI: 0.36-0.77) or >or= 2 tetanus toxoid injections (HR: 0.66; 95% CI: 0.48-0.92). When we analysed different combinations of these measures, iron and folic acid supplementation provided the main protective effect: early neonatal deaths were still significantly reduced among infants whose mothers received iron and folic acid supplements but no other form of antenatal care (HR: 0.10; 95% CI: 0.01-0.67), or the supplements but < 2 tetanus toxoid injections (HR: 0.46; 95% CI: 0.29-0.73). Subsequent analysis showed that 20% of early neonatal deaths in Indonesia could be attributed to a lack of iron and folic acid supplementation during pregnancy.
Iron and folic acid supplementation during pregnancy in Indonesia significantly reduced the risk of early neonatal death and could also do so in other low- and middle-income countries.
The aim was to develop a composite outcome indicator to identify infants with severe adverse outcomes in routinely collected population health datasets, and assess the indicator’s association with ...readmission and infant mortality rates. A comprehensive list of diagnoses and procedures indicative of serious neonatal morbidity was compiled based on literature review, validation studies and expert consultation. Relevant diagnoses and procedures indicative of severe morbidity that are reliably reported were analysed and reviewed, and the neonatal adverse outcome indicator (NAOI) was refined. Data were obtained from linked birth and hospital data for 516,843 liveborn infants ≥24 weeks gestation, in New South Wales, Australia from 2001 to 2006. Face validity of the indicator was examined by calculating the relative risks (and 95% CI) of hospital readmission or death in the first year of life of those infants identified by the NAOI. Overall 4.6% of all infants had one or more conditions included in the NAOI; 35.4% of preterm infants and 2.4% of term infants. Infants identified by the composite indicator were 10 times more likely to die in the first year of life and twice as likely to be readmitted to hospital in the first year of life compared to infants not identified by the NAOI. The NAOI can reliably identify infants with a severe adverse neonatal outcome and can be used to monitor trends, assess obstetric and neonatal interventions and the quality of perinatal care in a uniform and cost-effective way.
Photolabile nighttime radical reservoirs, such as nitrous acid (HONO) and nitryl chloride (ClNO2), contribute to the oxidizing potential of the atmosphere, particularly in early morning. We present ...the first vertically resolved measurements of ClNO2, together with vertically resolved measurements of HONO. These measurements were acquired during the California Nexus (CalNex) campaign in the Los Angeles basin in spring 2010. Average profiles of ClNO2 exhibited no significant dependence on height within the boundary layer and residual layer, although individual vertical profiles did show variability. By contrast, nitrous acid was strongly enhanced near the ground surface with much smaller concentrations aloft. These observations are consistent with a ClNO2 source from aerosol uptake of N2O5 throughout the boundary layer and a HONO source from dry deposition of NO2 to the ground surface and subsequent chemical conversion. At ground level, daytime radical formation calculated from nighttime-accumulated HONO and ClNO2 was approximately equal. Incorporating the different vertical distributions by integrating through the boundary and residual layers demonstrated that nighttime-accumulated ClNO2 produced nine times as many radicals as nighttime-accumulated HONO. A comprehensive radical budget at ground level demonstrated that nighttime radical reservoirs accounted for 8% of total radicals formed and that they were the dominant radical source between sunrise and 09:00 Pacific daylight time (PDT). These data show that vertical gradients of radical precursors should be taken into account in radical budgets, particularly with respect to HONO.
Abstract Objective To determine whether rates of obstetric anal sphincter injuries (OASIS) are continuing to increase and whether risk of OASIS according to mode of delivery is constant over time. ...Methods In a retrospective population-based study, data were obtained for vaginal singleton vertex deliveries at 37–41 weeks of pregnancy among primiparous women in New South Wales, Australia, between January 2001 and December 2011. Annual OASIS rates were determined among non-instrumental, forceps, and vacuum deliveries with and without episiotomy. Multivariable logistic regression was used to determine adjusted odds ratios for each delivery mode category by year. Trends in adjusted odds ratios over time for each delivery category were compared. Results OASIS occurred in 955 (4.1%) of 23 081 deliveries in 2001 and 1487 (5.9%) of 25 081 deliveries in 2011. After adjustment for known risk factors, the only delivery categories to show statistically significant increases in OASIS over the study period were non-instrumental deliveries without episiotomy (linear trend P < 0.001) and forceps deliveries with episiotomy (linear trend P = 0.004). Conclusion Overall, OASIS rates have continued to increase. Known risk factors do not fully explain the increase in OASIS rates in non-instrumental deliveries without an episiotomy and in forceps deliveries with an episiotomy.
Access to skilled birth attendants and emergency obstetric care are thought to prevent early neonatal deaths. This study aims to examine the association between the type of delivery attendant and ...place of delivery and early neonatal mortality in Indonesia. Four Indonesia Demographic and Health Surveys from 1994, 1997, 2002/2003 and 2007 were used, including survival information from 52 917 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey. Cox proportional hazards regression models were used to obtain the hazard ratio for univariable and multivariable analyses. Our study found no significant reduction in the risk of early neonatal death for home deliveries assisted by the trained attendants compared with those assisted by untrained attendants. In rural areas, the risk of early neonatal death was higher for home deliveries assisted by trained attendants than home deliveries assisted by untrained attendants. In urban areas, a protective role of institutional deliveries was found if mothers had delivery complications. However, an increased risk was associated with deliveries in public hospitals in rural areas. Infants of mothers attending antenatal care services were significantly protected against early neonatal deaths, irrespective of the urban or rural setting. An increased risk of early neonatal death was also associated with male infants, infants whose size at birth was smaller than average and/or infants reported to be born early. A reduced risk was observed amongst mothers with high levels of education. Continuous improvement in the skills and the quality of the village midwives might benefit maternal and newborn survival. Efforts to strengthen the referral system and to improve the quality of delivery and newborn care services in health facilities are important, particularly in public hospitals and in rural areas.
The presence and severity of pelvic inflammatory disease (PID) symptoms are thought to vary by microbiological etiology but there is limited empirical evidence. We sought to estimate and compare the ...rates of hospitalisation for PID temporally related to diagnoses of gonorrhoea and chlamydia.
All women, aged 15-45 years in the Australian state of New South Wales (NSW), with a diagnosis of chlamydia or gonorrhoea between 01/07/2000 and 31/12/2008 were followed by record linkage for up to one year after their chlamydia or gonorrhoea diagnosis for hospitalisations for PID. Standardised incidence ratios compared the incidence of PID hospitalisations to the age-equivalent NSW population.
A total of 38,193 women had a chlamydia diagnosis, of which 483 were hospitalised for PID; incidence rate (IR) 13.9 per 1000 person-years of follow-up (PYFU) (95%CI 12.6-15.1). In contrast, 1015 had a gonorrhoea diagnosis, of which 45 were hospitalised for PID (IR 50.8 per 1000 PYFU, 95%CI 36.0-65.6). The annual incidence of PID hospitalisation temporally related to a chlamydia or gonorrhoea diagnosis was 27.0 (95%CI 24.4-29.8) and 96.6 (95%CI 64.7-138.8) times greater, respectively, than the age-equivalent NSW female population. Younger age, socio-economic disadvantage, having a diagnosis prior to 2005 and having a prior birth were also associated with being hospitalised for PID.
Chlamydia and gonorrhoea are both associated with large increases in the risk of PID hospitalisation. Our data suggest the risk of PID hospitalisation is much higher for gonorrhoea than chlamydia; however, further research is needed to confirm this finding.
Episiotomy remains a routine procedure at childbirth in many South-East Asian countries but the reasons for this are unknown. The aim of this study was to determine the knowledge of, attitudes ...towards and experience of episiotomy use among clinicians in Viet Nam.
All obstetricians and midwives who provide delivery care at Hung Vuong Hospital were surveyed about their practice, knowledge and attitudes towards episiotomy use. Data were analysed using frequency tabulations and contingency table analysis.
148 (88%) clinicians completed the questionnaire. Fewer obstetricians (52.2%) than midwives (79.7%) thought the current episiotomy rate of 86% was about right (P < 0.01). Most obstetricians (82.6%) and midwives (98.7%) reported performing episiotomies on nulliparous women over 90% of the time. Among multipara, 24.6% of obstetricians reported performing episiotomy less than 60% of the time compared with only 3 (3.8%) midwives (P < 0.01). Aiming to reduce 3rd-4th degree perineal tears was the most commonly reported reason for performing an episiotomy by both obstetricians (76.8%) and midwives (82.3%), and lack of training in how to minimize tears and keep the perineum intact was the mostly commonly reported obstacle (obstetricians 56.5%, midwives 36.7% P = 0.02) to reducing the episiotomy rate.
Although several factors that may impede or facilitate episiotomy practice change were identified by our survey, training and confidence in normal vaginal birth without episiotomy is a priority.
To describe the use of episiotomy among Vietnamese-born women in Australia, including risk factors for, and pregnancy outcomes associated with, episiotomy.
This population-based, retrospective cohort ...study included data on 598 305 singleton, term (i.e. ≥ 37 weeks' gestation) and vertex-presenting vaginal births between 2001 and 2010. Data were obtained from linked, validated, population-level birth and hospitalization data sets. Contingency tables and multivariate analysis were used to compare risk factors and pregnancy outcomes in women who did or did not have an episiotomy.
The episiotomy rate in 12 208 Vietnamese-born women was 29.9%, compared with 15.1% in Australian-born women. Among Vietnamese-born women, those who had an episiotomy were significantly more likely than those who did not to be primiparous, give birth in a private hospital, have induced labour or undergo instrumental delivery. In these women, having an episiotomy was associated with postpartum haemorrhage (adjusted odds ratio, aOR: 1.26; 95% confidence interval, CI: 1.08-1.46) and postnatal hospitalization for more than 4 days (aOR: 1.14; 95% CI: 1.00-1.29). Among multiparous women only, episiotomy was positively associated with a third- or fourth-degree perineal tear (aOR: 2.00; 95% CI: 1.31-3.06); in contrast, among primiparous women the association was negative (aOR: 0.47; 95% CI: 0.37-0.60).
Episiotomy was performed in far fewer Vietnamese-born women giving birth in Australia than in Viet Nam, where more than 85% undergo the procedure, and was not associated with adverse outcomes. A lower episiotomy rate should be achievable in Viet Nam.
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