Pregnancy in women with hemoglobinopathy has been associated with an increased risk of adverse pregnancy outcomes. We conducted a historical cohort study using Discharge Abstract Database for the fiscal year 1991-1992 through 2007-2008. We estimated the frequency of pregnant women with hemoglobinopathy and examined their associations with adverse pregnancy outcomes. Women with sickle cell disease are more likely to develop pre-eclampsia and preterm labor, and to undergo cesarean delivery than women with nutritional deficiency anemia, suggesting that there are other mechanisms beyond anemia that may be responsible for an increased risk of adverse pregnancy outcomes. The data suggested a synergistic effect of hemoglobinopathy and pre-eclampsia on preterm labor and cesarean delivery. Prediction models for pre-eclampsia, preterm labor and cesarean delivery were created and internally validated for women with hemoglobinopathy, with satisfactory discrimination and calibration.

For most of the 20th century, the saying “once a cesarean, always a cesarean” was a rule in the United States. Today, the National Institutes of Health (NIH) opposes the dictum and urges women to consider trial of labor after cesarean (TOLAC). However, the factors that lead to a successful outcome remain unclear, as research continues to be conducted in hopes of creating a predictive model for vaginal birth after cesarean (VBAC) success. The NIH’s request for more research in this area of obstetrics led to this retrospective cohort study of all TOLACs at Marin General Hospital (MGH) from 2000-2013. All labor trials were studied for patient demographics, details of labor, maternal and neonatal morbidities, insurance, and provider type. After confirming the quality of the data, verifying inclusion criteria and ignoring cases with missing data, a data set of 745 TOLACs with 13 explanatory variables of interest was prepared. A forward stepwise (Likelihood Ratio) binary logistic regression was run in IBM® SPSS® Statistics in order to create a model that could determine which variables were most predictive of delivery outcome in TOLAC patients. Ultimately, seven variables were predictive and were included in the model. Of the seven, the most predictive variable in determining VBAC success was provider type. The model concluded that a woman’s odds of having a successful VBAC were almost four times greater if she began her delivery with a certified nurse midwife, than if she began her deliver with a physician (odds ratio 0.27, 95% CI 0.17-0.44; < 0.01). The results from this study mimic the results of other models, and introduce labor support as a key factor in predicting VBAC success.

Pregnancy in women with hemoglobinopathy has been associated with an increased risk of adverse pregnancy outcomes. We conducted a historical cohort study using Discharge Abstract Database for the fiscal year 1991-1992 through 2007-2008. We estimated the frequency of pregnant women with hemoglobinopathy and examined their associations with adverse pregnancy outcomes. Women with sickle cell disease are more likely to develop pre-eclampsia and preterm labor, and to undergo cesarean delivery than women with nutritional deficiency anemia, suggesting that there are other mechanisms beyond anemia that may be responsible for an increased risk of adverse pregnancy outcomes. The data suggested a synergistic effect of hemoglobinopathy and pre-eclampsia on preterm labor and cesarean delivery. Prediction models for pre-eclampsia, preterm labor and cesarean delivery were created and internally validated for women with hemoglobinopathy, with satisfactory discrimination and calibration.

Pregnancy in women with hemoglobinopathy has been associated with an increased risk of adverse pregnancy outcomes. We conducted a historical cohort study using Discharge Abstract Database for the fiscal year 1991-1992 through 2007-2008. We estimated the frequency of pregnant women with hemoglobinopathy and examined their associations with adverse pregnancy outcomes. Women with sickle cell disease are more likely to develop pre-eclampsia and preterm labor, and to undergo cesarean delivery than women with nutritional deficiency anemia, suggesting that there are other mechanisms beyond anemia that may be responsible for an increased risk of adverse pregnancy outcomes. The data suggested a synergistic effect of hemoglobinopathy and pre-eclampsia on preterm labor and cesarean delivery. Prediction models for pre-eclampsia, preterm labor and cesarean delivery were created and internally validated for women with hemoglobinopathy, with satisfactory discrimination and calibration.

Background: Current cesarean delivery (CD) rates in many industrialized countries are well above the recommended rates. Objective: The overall goal of this thesis was to identify sources for unnecessary CD. Specific objectives were to: 1) analyze the leading indications for CD and their associations with neonatal outcomes; 2) compare adverse birth outcomes between elective primary cesarean delivery (EPCD) and trial of labor after vaginal birth (TOLAV), and between elective repeat cesarean delivery (ERCD) and trial of labor after cesarean birth (TOLAC); and 3) assess the cost-effectiveness of ERCD and TOLAC. Methods: A retrospective cohort study was conducted. Leading indications for CD were analyzed and risks of neonatal outcomes between “soft” indications and “hard” indications were compared first, using 2006 to 2013 Better Outcomes and Registry Network Ontario data. A pair of analyses: comparing risks of adverse birth outcomes between EPCD and TOLAV and between ERCD and TOLAC, were then conducted using United States 2005 to 2010 birth registration data. Analysis were performed using logistic regression and propensity score matching models. Finally, a cost-effectiveness analysis between ERCD and TOLAC was performed. Results: The single largest contributor for overall CD was ERCD (34.3%) and for primary CD was dystocia (31.9%) in Ontario. Compared with infants of mothers with CD for “hard” indications, the risks of Apgar score <7 at 5 minutes for infants of mothers with CD for non-reassuring-fetal-status was increased, while the risks of Apgar score <7 at 5 minutes and neonatal death for infants of mothers with ERCD and dystocia were decreased. Compared with infants of mothers who underwent TOLAV, infants of mothers who underwent EPCD were more likely to require antibiotics and ventilation support, but less likely to have birth injury. On the other hand, compared with infants of mothers who underwent TOLAC, infants of mothers who underwent ERCD were less likely to require antibiotics and ventilation support. ERCD was similar to the TOLAC birth option in terms of cost effectiveness. Conclusions: Tight up criteria for “soft” indications such as labor dystocia could result in substantial reduction in CD without harming the infants.

Les taux de césarienne sont en constante croissance dans le monde. Ces dernières années, on assiste à une augmentation sans cesse des taux hospitaliers d’accouchement par césarienne dans les pays à faible ressource malgré les recommandations de l’Organisation mondiale de la santé de ne pas dépasser 10 à 15 %. En Afrique au sud du Sahara, en particulier au Sénégal et au Mali, des politiques de subvention de la césarienne ont été introduites à l’échelle nationale à partir de 2005. Ces mesures ont contribué à l’augmentation de l’utilisation des services de maternité et des taux de césarienne. Si l’accessibilité financière à la césarienne a été améliorée substantiellement, la qualité n’a pas toujours suivi. Or, une augmentation trop importante des taux de césarienne peut avoir des effets négatifs sur la santé maternelle et périnatale. Par exemple, l’augmentation des taux institutionnels de césarienne au dessus de 10% en Amérique latine était associée à une augmentation de la mortalité maternelle et périnatale hospitalière. Trois ans après la mise en œuvre des politiques d’exemption des césariennes, le Programme Gesta international (PGI) a été mis en œuvre pour améliorer la qualité des soins obstétricaux dans 23 hôpitaux de référence au Sénégal et au Mali. Ce programme se basait sur l’audit clinque et la formation médicale continue du personnel sur les pratiques optimales en matière de soins intrapartum. Un essai contrôlé randomisé en grappe (essai QUARITE) a été mise en œuvre en 2007-2011 pour tester l’effet du PGI sur la mortalité maternelle hospitalière au Sénégal et au Mali. Initialement prévu pour améliorer la qualité des soins intra-partum, je me suis posé la question de l’efficacité de ce programme sur la pratique et les résultats de la césarienne. Les résultats de notre étude montrent que le PGI a permis de réduire l’évolution des taux de césarienne institutionnels dans les hôpitaux du groupe d’intervention comparativement à l’évolution dans le groupe contrôle. Par ailleurs, nous avons trouvé que le PGI a été plus efficace, en terme de réduction de la mortalité maternelle, parmi les femmes césarisées que parmi celles qui ont accouché par voie vaginale. Nous avons donc recommandé que des programmes d’amélioration de la qualité des soins soient mis en œuvre pour accompagner les politiques de subvention en cours dans la plupart des pays en Afrique au sud du Sahara et limiter ainsi l’utilisation excessive des césariennes dans ces pays. / Cesarean rates are rising steadily worldwide. In recent years, there has been an increasing cesarean rates in low-resource countries despite the World Health Organization recommended to not exceed 10-15%. In Senegal and Mali free cesarean policies were implemented nationally since 2005 and have contributed to increase the access to cesarean section. Access to cesarean deliveries has been improved substantially but quality of care has not always followed. However, excessive increase in cesarean section rates can have negative impacts on maternal and perinatal health. In Latin America, Asia, and Africa, several studies have shown an intrinsic risk of maternal and neonatal mortality associated with cesareans regardless of the initial health status of the mother or fetus. For example, the increase in hospital-based cesarean rates above 10% in Latin America was associated with an increase risk of maternal and perinatal mortality.Three years after the implementation of cesarean sections free policies, The Advances in Labour and Risk Management (ALARM) international program was implemented to improve the quality of obstetric care in 23 referral hospitals in Senegal and Mali. This program was based on maternal death review and staff training on best practices for intrapartum care. A randomized controlled cluster trial (QUARITE trial) was implemented in 2007-2011 to assess the effectiveness of the ALARM international program on in-hospital maternal mortality in Senegal and Mali. Initially planned to improve quality of Emergency Obstetric and Neonatal Care (EmONC), we assumed that this program was also effective on the quality of cesarean delivery.Results showed that the ALARM international program slowed down the trends of hospital-based cesarean rates in the 23 participating centers of the intervention group compared to the changes observed in the control group. Furthermore, we found that the program was more effective on maternal mortality among women who delivered by cesarean section than among women who delivered vaginally. We recommend that quality improvement strategies should support free cesarean policies to limit the excessive use of cesarean delivery.

Background: Cesarean delivery rates have been increasing since 1996, and Cesarean delivery is now the most common major operative procedure performed in the United States. Identifying risk factors for wound complications following Cesarean delivery is necessary to prevent unnecessary maternal morbidity. Methods: A case-control study was carried out and data was collected via a medical record review for patients undergoing a Cesarean delivery at the UIHC between 10/1/2011 and 12/31/2012. Results: Several modifiable risk factors were identified, and models based on patient and surgical factors performed better than the current standard NHSN risk index model. Conclusion: More robust prediction models can be created using patient and surgical factors.

The overutilization of cesarean deliveries is a major public health issue in the United States (U.S.). The rates of cesarean deliveries have increased substantially from the mid 1990s. Low-risk, defined as nulliparous, term, singleton, vertex (NTSV) pregnancies with no medical indication of need, and elective cesarean deliveries have been implicated as drivers of these increases. Elective cesarean deliveries are NTSV cesarean deliveries in which no trial of labor was attempted. There is a lack of clear rationale as to the noted increases in cesarean delivery rates as the evidence shows that these procedures provide no additional health benefits to mothers or infants. In fact, excessive use of cesarean sections has been associated with poorer health outcomes and quality of care, and higher health care expenditures. The purpose of this dissertation is to examine the current variation in NTSV and elective cesarean deliveries in the U.S., and further to examine the extent to which national trends are mirrored in Appalachia, a region disproportionately burdened by lack of health care resources and poor health outcomes. A repeated cross-sectional analysis of the prevalence of NTSV and elective cesarean deliveries in the U.S. between 2016 and 2020 was conducted using individual-level vital records data. Differences were examined by rurality and Appalachian designation. Logistic regression and marginal analyses were used to examine changes in the prevalence of these outcomes over time while adjusting for additional pertinent covariates. Approximately 25% of NTSV births are delivered via cesarean section, and 37% of those NTSV cesarean deliveries are elective. No practically significant differences in the prevalence of NTSV cesarean deliveries were noted based on rurality or Appalachian designation. However, there were significant variations in the prevalence of elective cesarean deliveries by geography. Rates of elective cesarean deliveries were significantly lower in rural communities compared to metropolitan, or urban, communities. Non-Appalachia had predominantly higher prevalence of elective cesarean deliveries compared to the Appalachian sub-regions. The findings of this dissertation suggest that while variations in health outcomes may be driven by geographic designations, variations in health services utilization are likely driven by other factors, such as institutional and provider characteristics.

Submitted by Natalie Mendes (nataliermendes@gmail.com) on 2015-07-22T01:07:26Z No. of bitstreams: 1 Dissertacao versao final PPGSC.pdf: 1143429 bytes, checksum: 4001d67efdeaf38f6d494a206cf29031 (MD5) / Made available in DSpace on 2015-07-22T01:07:26Z (GMT). No. of bitstreams: 1 Dissertacao versao final PPGSC.pdf: 1143429 bytes, checksum: 4001d67efdeaf38f6d494a206cf29031 (MD5) Previous issue date: 2013-04-24 / Cohort study follow 672 couple of mothers and children since birth to 72 months of life. The objectives was identify economic, genetic and environment risk factors that are associated with overweight and obesity children at six years old. The research included all the children that birth in each from 10 hospitals of the city at 2004 year. The maternal hospital was visited a long period of two consecutive months, accord draw. Stander Inquiries was done after signing an informed consent. The classification to nutrition child was determinate from z-score of BMI graphics, have defined overweight/obesity that BMI ? +1 z-score. Stratified hierarchical statistical analysis, qui-quadratic test, p value, was considered significant values equivalent or minor of 5% with confidence interval (CI) of 95%. Logistic multivariate regression followed hierarchical levels. Overweight and obesity prevalence was 15,6% and 12,9% respective. The regress logistic analyses evidenced factors associated with final predictor maternal obesity for breastfeeding group. Children not breastfeeding had predictors as maternal obesity, father obesity, mother instruction level and cesarean delivery at the end of analysis. This study confirms the interaction of several factors to overweight and obesity, with genetics and environments factors. Early factors in the life were strongly with obesity than the neonatal predictors. There is important in the prevention of the obesity, modifier risk factors like breastfeeding practice and natural delivery. More research needs to investigate the association between cesarean delivery and excess BMI. / Estudo de coorte de nascidos vivos o qual pesquisou 672 duplas de m?es e filhos do nascimento aos 72 meses de vida. O objetivo ? identificar fatores socioecon?micos, gen?ticos e ambientais que est?o associados ao excesso de peso em crian?as aos seis anos de idade. Trata-se de um estudo prospectivo onde foram inclu?dos na pesquisa todas as crian?as que nasceram em cada uma das 10 maternidades do munic?pio no ano de 2004. As unidades foram visitadas por per?odo de dois meses consecutivos, conforme sorteio. Foram aplicados question?rios padronizados ap?s assinatura de Termo de Consentimento Livre e Esclarecido. Avaliado o estado nutricional da crian?a conforme o escore-z das curvas de IMC para idade, sendo considerado como sobrepeso/obesidade o IMC igual ou superior ao desvio padr?o +1. Foi realizado an?lise hierarquizada estratificada, teste do qui-quadrado (x?) com c?lculo do p valor, sendo considerados como significantes valores iguais ou menores a 5% com Intervalo de Confian?a (IC) de 95%. A regress?o log?stica multivariada seguiu o modelo conceitual te?rico em n?veis hier?rquicos. As preval?ncias de sobrepeso e obesidade foram de 15,6% e 12,9%, respectivamente. A an?lise de regress?o log?stica evidenciou como fatores associados ao desfecho a obesidade materna como preditor de risco para as crian?as amamentadas. No estrato de crian?as n?o amamentadas permaneceram no modelo as vari?veis obesidade materna, obesidade paterna, escolaridade das m?e e a via de parto ces?reo. O estudo corrobora a multifatoriedade do excesso de peso corporal com a participa??o de fatores gen?ticos e ambientais. Os fatores relativos a fases precoces da vida estiveram mais fortemente associados com a obesidade do que os preditores p?s neonatais. ? preciso valorizar, na preven??o da obesidade, os fatores de risco modific?veis como a pr?tica do aleitamento materno e a via de parto vaginal. S?o necess?rios mais estudos para elucidar a associa??o entre o parto ces?reo e obesidade.

Introducción. La pandemia por coronavirus 2019 (COVID-19) se ha extendido en más de 100 países. La información específica sobre su comportamiento en el embarazo y parto sigue siendo limitada. Objetivo. Describir las características materno perinatales de pacientes gestantes con COVID-19 en un hospital terciario. Métodos. Estudio descriptivo. Se seleccionó todas las gestantes hospitalizadas por el servicio de emergencia de gineco-obstetricia entre el 24 de marzo y el 07 de mayo del 2020 y que tuvieron diagnóstico de infección por SARS-CoV-2, mediante la prueba rápida o la prueba RT-PCR. Se revisó la historia clínica y registros hospitalarios buscando variables sociodemográficas, antecedentes, manifestaciones clínicas, serología materna, complicaciones obstétricas, vía de parto y aspectos perinatales. Resultados. Se encontró 41 casos de pacientes con diagnóstico de SARS-CoV-2. Un 9,2% tuvo resultado de prueba rápida positiva, Los síntomas más comunes fueron tos en 84,6%, fiebre en 76,9% y dolor de garganta en 61,5%. Un 68.2% estuvo asintomática, 19,5% tuvo enfermedad leve y 7,3% moderada. Dos casos de neumonía severa requirieron ventilación no invasiva. No se registró muerte materna. 21,7% de los partos fue vía vaginal y 78,3% por cesárea. Hubo un caso de neonato por parto vaginal con PCR positivo al octavo día de vida. Conclusiones. Hubo un alto porcentaje de pacientes gestantes PCR positivas asintomáticas. Es necesario implementar el tamizaje universal en parturientas en el protocolo de flujo de gestantes en cada institución. / Introduction: The pandemic of coronavirus disease 2019 (COVID-19) has spread to more than 100 countries. Specific information about its behavior in pregnancy is still limited. Objective: To describe the maternal and perinatal characteristics of pregnant patients infected with COVID-19 and their newborns in a tertiary referral hospital. Methods: Descriptive study. Subjects were all pregnant patients admitted to the OB/ GYN Emergency Department of the Edgardo Rebagliati Martins National Hospital from March 24 to May 7, 2020, who were diagnosed with SARS-CoV-2 infection by rapid test or by RT-PCR test. Medical and hospital records were reviewed to retrieve sociodemographic data, patient’s history, clinical manifestations, maternal serology, obstetric complications, delivery mode and perinatal aspects. Results: 41 patients diagnosed with SARS-CoV-2 were identified. 9.2% of all admissions had a positive rapid test. The most common symptoms were cough in 84.6%, fever in 76.9% and sore throat in 61.5%. 68.2% of the patients were asymptomatic, 19.5% had mild illness and 7.3 %, moderate. 2 cases progressed to severe pneumonia requiring non-invasive ventilation. No maternal deaths were recorded. 21.7% were vaginal deliveries, while 78.3% were C-sections. One baby born in a vaginal delivery had a positive PCR result on day 8. Conclusions: A large percentage of asymptomatic pregnant patients had a positive PCR test. Implementing universal screening among patients in l flow protocol is necessary for all institutions.