Maternal hypertension and survival in singletons and twins born at 23–29 weeks: not just one answer…

Gagliardi, Luigi; Basso, Olga

doi:10.1038/s41390-019-0337-4

Cited by 6 publications

(17 citation statements)

References 39 publications

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“…2 3 4 5 6 However, the results of the previous studies were not consistent largely due to the extent of preterm birth and intrauterine growth status of infants. 5 6 The early termination of pregnancy to rescue maternal symptoms of HDP has resulted in very preterm birth. On the other hand, the extension of the pregnancy period may cause fetal growth restriction (FGR) because maternal HDP often affects fetal growth, although the association between the severity of FGR and HDP is not conclusively established.…”

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confidence: 84%

“…1 As very preterm birth is linked to adverse outcomes of infants, the association between maternal HDP and neonatal mortality and morbidities in preterm infants has been examined. 2 3 4 5 6 However, the results of the previous studies were not consistent largely due to the extent of preterm birth and intrauterine growth status of infants. 5 6 The early termination of pregnancy to rescue maternal symptoms of HDP has resulted in very preterm birth.…”

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confidence: 84%

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A Retrospective Cohort Study on Mortality and Neurodevelopmental Outcomes of Preterm Very Low Birth Weight Infants Born to Mothers with Hypertensive Disorders of Pregnancy

et al. 2021

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Objective We examined the effects of maternal hypertensive disorders of pregnancy (HDP) on the mortality and neurodevelopmental outcomes in preterm very low birth weight (VLBW) infants (BW ≤1,500 g) based on their intrauterine growth status and gestational age (GA). Study Design We included singleton VLBW infants born at <32 weeks' gestation registered in the Neonatal Research Network Japan database. The composite outcomes including death, cerebral palsy (CP), and developmental delay (DD) at 3 years of age were retrospectively compared among three groups: appropriate for GA (AGA) infants of mothers with and without HDP (H-AGA and N-AGA) and small for GA (SGA) infants of mothers with HDP (H-SGA). The adjusted odds ratios (AOR) and 95% confidence intervals (CI) stratified by the groups of every two gestational weeks were calculated after adjusting for the center, year of birth, sex, maternal age, maternal diabetes, antenatal steroid use, clinical chorioamnionitis, premature rupture of membranes, non-life-threatening congenital anomalies, and GA. Results Of 19,323 eligible infants, outcomes were evaluated in 10,192 infants: 683 were H-AGA, 1,719 were H-SGA, and 7,790 were N-AGA. Between H-AGA and N-AGA, no significant difference was observed in the risk for death, CP, or DD in any GA groups. H-AGA had a lower risk for death, CP, or DD than H-SGA in the 24 to 25 weeks group (AOR: 0.434, 95% CI: 0.202–0.930). The odds for death, CP, or DD of H-SGA against N-AGA were found to be higher in the 24 to 25 weeks (AOR: 2.558, 95% CI: 1.558–3.272) and 26 to 27 weeks (AOR: 1.898, 95% CI: 1.427–2.526) groups, but lower in the 30 to 31 weeks group (AOR: 0.518, 95% CI: 0.335–0.800). Conclusion There was a lack of follow-up data; however, the outcomes of liveborn preterm VLBW infants of mothers with HDP depended on their intrauterine growth status and GA at birth. Key Points

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confidence: 84%

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confidence: 84%

A Retrospective Cohort Study on Mortality and Neurodevelopmental Outcomes of Preterm Very Low Birth Weight Infants Born to Mothers with Hypertensive Disorders of Pregnancy

et al. 2021

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“…However, even in preterm neonates <29 weeks' GA, less perinatal morbidity has been reported with exposure to maternal HTN. 15 16 In the AWAKEN cohort, the reduced odds of early AKI with any maternal HTN exposure was most prominent in the 22–to 28-week GA group, 30 while for late AKI it was noted in the ≥36-week GA group. 31 In stratifying the analysis by timing of AKI, maternal HTN was associated with a reduced odds of early but not late AKI.…”

Section: Resultsmentioning

confidence: 97%

Maternal Hypertension Disorders and Neonatal Acute Kidney Injury: Results from the AWAKEN Study

et al. 2022

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Objective: To examine the association between maternal hypertension (HTN) exposure and neonatal acute kidney injury (AKI). Study Design: Retrospective cohort study of 2162 neonates admitted to 24 NICUs. Neonates were classified into the following exposure groups: any maternal HTN, chronic maternal HTN, preeclampsia/eclampsia, both, or neither. Demographics, clinical characteristics, and AKI status were compared using chi-square and analysis of variance. General estimating logistic regression was used to estimate adjusted odds ratios and included a stratified analysis for site of delivery. Result: Neonates exposed to any maternal HTN disorder had a tendency towards less overall and early AKI. When stratified by inborn versus outborn, exposure to both maternal HTN disorders was associated with a significantly reduced odds of early AKI only in the inborn neonates. Conclusion: Exposure to maternal HTN, especially pre/eclampsia superimposed on chronic HTN, was associated with less likelihood of early AKI in the inborn group.

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“…Joseph has often referred to the intersection of mortality curves, which is “resolved” with the FAR approach, as a central weakness of the births‐based formulation . While the intersection of births‐based curves has been explained as being a consequence of inappropriately conditioning on gestational age at birth when it is a collider, there is no definite proof that this is the case. Conversely, the reasons why curves do not intersect with the FAR formulation are known: (i)FAR rates of postnatal outcomes are a composite of the probability of live birth at a given week and the probability of the outcome among live births at that week:

\frac{Y_{i}}{F_{i}} = \frac{L B_{i}}{F_{i}} \times \frac{Y_{i}}{L B_{i}}

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Section: B Beyond Crossing Curves: Reversals Under the Far Formulationmentioning

confidence: 99%

The fragile foundations of the extended fetuses‐at‐risk approach

Basso

2020

Paediatric Perinatal Epid

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Since Yudkin et al 1 demonstrated that fetuses alive at each week, rather than births, constitute the appropriate denominator for estimating gestational-age-specific risk of stillbirth, perinatal researchers have recognised that fetuses (or pregnancies) represent the population at risk of several outcomes, including birth, pregnancy complications, and labour induction. 2-4 Although Yudkin et al 1 identified live births as the appropriate denominator for predicting risk of neonatal death, the debate is ongoing on whether, in aetiologic research, rates of postnatal outcomes (those that can only be ascertained in a living child) should be based on live births or on fetuses. 2,[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Joseph, the main proponent of the latter approach, argues that the births-based model fosters several "conundrums" that would be resolved by extending the fetuses-atrisk (FAR) formulation to postnatal outcomes with a presumed prenatal origin. The three most frequently mentioned are the following: Abstract Background: Whether denominators for postnatal outcomes (ascertained after live birth) with a presumed prenatal origin should consist of fetuses or live births remains controversial. Proponents argue that the extended fetuses-at-risk (FAR) approach (a), provides a justification for medically indicated preterm delivery, (b), avoids paradoxical results, and (c), permits quantification of incidence of fetal-infant phenomena, such as "revealed" small for gestational age (SGA)-which, under FAR, rises with advancing gestation.Methods: This conceptual paper examines the validity of the above arguments. Results:As obstetricians induce babies early because of fetal (or maternal) compromise and despite the dangers posed by immaturity, there is no need to modify a paradigm that portrays preterm birth as a powerful risk factor. The FAR approach generally avoids "paradoxical" intersections because FAR rates of postnatal outcomes depend on the birth rate. However, this property, which causes rates of most postnatal outcomes to rise at term, can also lead to risk reversals and other misleading findings. The FAR formulation does not yield the incidence of postnatal conditions but, rather, the incidence of live birth (and survival to diagnosis) of babies with prevalent conditions (and, sometimes, future ones). Conclusions:The proposed arguments do not provide adequate support for extending the FAR approach to postnatal outcomes. As only live births can contribute to the numerator of rates, the usefulness and interpretability of FAR measures in this setting are limited. K E Y W O R D Sextended fetuses-at-risk approach, incidence, denominator, gestational-age-specific rates S U PP O RTI N G I N FO R M ATI O NAdditional supporting information may be found online in the Supporting Information section.How to cite this article: Basso O. The fragile foundations of the extended fetuses-at-risk approach. Paediatr. Perinat. Epidemiol.

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Maternal hypertension and survival in singletons and twins born at 23–29 weeks: not just one answer…

Cited by 6 publications

References 39 publications

A Retrospective Cohort Study on Mortality and Neurodevelopmental Outcomes of Preterm Very Low Birth Weight Infants Born to Mothers with Hypertensive Disorders of Pregnancy

A Retrospective Cohort Study on Mortality and Neurodevelopmental Outcomes of Preterm Very Low Birth Weight Infants Born to Mothers with Hypertensive Disorders of Pregnancy

Maternal Hypertension Disorders and Neonatal Acute Kidney Injury: Results from the AWAKEN Study

The fragile foundations of the extended fetuses‐at‐risk approach

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