Association of Maternal Age With Severe Maternal Morbidity and Mortality in Canada

Aoyama, Kazuyoshi; Pinto, Ruxandra; Ray, Joel G.; Hill, Andrea; Scales, Damon C.; Lapinsky, Stephen E.; Hladunewich, Michelle A.; Seaward, Gareth; Fowler, Robert

doi:10.1001/jamanetworkopen.2019.9875

Cited by 68 publications

(66 citation statements)

References 43 publications

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“…With regards to obstetric outcomes after oocyte cryopreservation for age-related fertility loss, it has been shown that there are risks of due to older age at pregnancy, which increase after the age of 45 ( Aoyama et al , 2019 ). More research is needed on the number of women who return to use their frozen oocytes, pregnancy complications, and live birth rates in these women.…”

Section: Resultsmentioning

confidence: 99%

ESHRE guideline: female fertility preservation†

Anderson

Amant

Braat

et al. 2020

Human Reproduction Open

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STUDY QUESTION What is the recommended management for women and transgender men with regards to fertility preservation (FP), based on the best available evidence in the literature? SUMMARY ANSWER The ESHRE Guideline on Female Fertility Preservation makes 78 recommendations on organization of care, information provision and support, pre-FP assessment, FP interventions and after treatment care. Ongoing developments in FP are also discussed. WHAT IS KNOWN ALREADY The field of FP has grown hugely in the last two decades, driven by the increasing recognition of the importance of potential loss of fertility as a significant effect of the treatment of cancer and other serious diseases, and the development of the enabling technologies of oocyte vitrification and ovarian tissue cryopreservation (OTC) for subsequent autografting. This has led to the widespread, though uneven, provision of FP for young women. STUDY DESIGN, SIZE, DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 November 2019 and written in English were included in the review. PARTICIPANTS/MATERIALS, SETTING, METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help providers meet a growing demand for FP options by diverse groups of patients, including those diagnosed with cancer undergoing gonadotoxic treatments, with benign diseases undergoing gonadotoxic treatments or those with a genetic condition predisposing to premature ovarian insufficiency, transgender men (assigned female at birth), and women requesting oocyte cryopreservation for age-related fertility loss. The guideline makes 78 recommendations on information provision and support, pre-FP assessment, FP interventions and after treatment care, including 50 evidence-based recommendations—of which 31 were formulated as strong recommendations and 19 as weak—25 good practice points and 3 research only recommendations. Of the evidence-based recommendations, 1 was supported by high-quality evidence, 3 by moderate-quality evidence, 17 by low-quality evidence and 29 by very low-quality evidence. To support future research in the field of female FP, a list of research recommendations is provided. LIMITATIONS, REASONS FOR CAUTION Most interventions included are not well studied in FP patients. As some interventions, e.g. oocyte and embryo cryopreservation, are well established for treatment of ...

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Section: Resultsmentioning

confidence: 99%

ESHRE guideline: female fertility preservation†

Anderson

Amant

Braat

et al. 2020

Human Reproduction Open

391

345

View full text Add to dashboard Cite

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“…There are approximately 300,000 maternal deaths in the world annually [1], and in a recent population-based study, we have highlighted 18 episodes of severe maternal morbidity (i.e., a potentially life-threatening condition) per 1000 deliveries in Canada, increasing 1.3% annually for the last one decade [2]. However, severe maternal morbidity can often be anticipated according to known maternal risk factors, and outcomes possibly improved with early recognition and timely supportive acute and intensive care [3–8].…”

Section: Introductionmentioning

confidence: 99%

Variability in intensive care unit admission among pregnant and postpartum women in Canada: a nationwide population-based observational study

et al. 2019

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BackgroundPregnancy-related critical illness results in approximately 300,000 deaths globally each year. The objective was to describe the variation in ICU admission and the contribution of patient- and hospital-based factors in ICU admission among acute care hospitals for pregnant and postpartum women in Canada.MethodsA nationwide cohort study between 2004 and 2015, comprising all pregnant or postpartum women admitted to Canadian hospitals. The primary outcome was ICU admission. Secondary outcomes were severe maternal morbidity (a potentially life-threatening condition) and maternal death (during and within 6 weeks after pregnancy). The proportion of total variability in ICU admission rates due to the differences among hospitals was described using the median odds ratio from multi-level logistic regression models, adjusting for individual hospital clusters.ResultsThere were 3,157,248 identifiable pregnancies among women admitted to 342 Canadian hospitals. The overall ICU admission rate was 3.2 per 1000 pregnancies. The rate of severe maternal morbidity was 15.8 per 1000 pregnancies, of which 10% of women were admitted to an ICU. The most common severe maternal morbidity events included postpartum hemorrhage (n = 16,364, 0.52%) and sepsis (n = 11,557, 0.37%). Of the 195 maternal deaths (6.2 per 100,000 pregnancies), only 130 (67%) were admitted to ICUs. Patients dying in hospital, without admission to ICU, included those with cardiovascular compromise, hemorrhage, and sepsis. For 2 pregnant women with similar characteristics at different hospitals, the average (median) odds of being admitted to ICU was 1.92 in 1 hospital compared to another. Hospitals admitting the fewest number of pregnant patients had the highest incidence of severe maternal morbidity and mortality. Patient-level factors associated with ICU admission were maternal comorbidity index (OR 1.88 per 1 unit increase, 95%CI 1.86–1.99), urban residence (OR 1.09, 95%CI 1.02–1.16), and residing at the lowest income quintile (OR 1.44, 95%CI 1.34–1.55).ConclusionsMost women who experience severe maternal morbidity are not admitted to an ICU. There exists a wide hospital-level variability in ICU admission, with patients living in urban locations and patients of lowest income levels most likely to be admitted to ICU. Cardiovascular compromise, hemorrhage, and sepsis represent an opportunity for improved patient care and outcomes.

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“…10,11 Although our data did not reveal an association between maternal age and admission, there is literature indicating higher levels of maternal morbidity associated with extremes of maternal age at delivery, notably age 40 years or older in population-based studies. 12 Readmission is only one surrogate of maternal morbidity and the low proportion of our patient sample meeting this age requirement limits our ability to draw further conclusions. Further, we are not alone in recognizing the increasing maternal morbidity risk to African American women delivering in the United States.…”

Section: Discussionmentioning

confidence: 99%

Timing of Emergency Postpartum Hospital Visits in the Fourth Trimester

et al. 2020

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Objective The concept of the “fourth trimester” emphasizes the importance of individualized postpartum follow-up. Women seek care for urgent issues during this critical time period. Our objective was to evaluate trends in presenting complaints and admissions in an emergency setting over the first 42 days following delivery. Study Design Postpartum hospital encounters within 42 days of delivery at our institution from 2015 to 2019 were studied. Demographic information, delivery route, and emergent hospital encounter details were obtained from the electronic medical record. The postpartum encounters were analyzed by week of presentation. Statistical analysis included Student's t-test and Mantel–Haenszel test with p <0.05 considered significant. Results Of the 8,589 deliveries, 491 (5.7%) were complicated by an emergent hospital presentation within 42 days of delivery resulting in 576 hospital encounters. 35.9% of these visits occurred in the first week and 75.5% occurred within the first 3 weeks. Women presenting to the hospital were more commonly African American, higher body mass index, and delivered via cesarean. The most common chief complaints were fever, headache, abdominal pain, vaginal bleeding, hypertension, and wound concerns with temporal trends noted. 72% of admissions occur within 14 days of delivery and drop dramatically thereafter (p = 0.001). The most common admission diagnoses were hypertension/preeclampsia with severe features, vaginal bleeding/delayed postpartum hemorrhage, and wound infection. Conclusion We observed important trends in presenting complaints and admission diagnoses of emergency postpartum visits in the first 42 days. The majority of hospital visits and admissions occur within the first 2 weeks postpartum. Understanding maternal conditions and reasons for accessing care through an emergency setting allows for tailoring of routine postpartum follow-up. Key Points

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Association of Maternal Age With Severe Maternal Morbidity and Mortality in Canada

Cited by 68 publications

References 43 publications

ESHRE guideline: female fertility preservation†

ESHRE guideline: female fertility preservation†

Variability in intensive care unit admission among pregnant and postpartum women in Canada: a nationwide population-based observational study

Timing of Emergency Postpartum Hospital Visits in the Fourth Trimester

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