ObjectiveThe objective of this study was to compare international trends in pre-eclampsia rates and in overall pregnancy hypertension rates (including gestational hypertension, pre-eclampsia and eclampsia).DesignPopulation data (from birth and/or hospital records) on all women giving birth were available from Australia (two states), Canada (Alberta), Denmark, Norway, Scotland, Sweden and the USA (Massachusetts) for a minimum of 6 years from 1997 to 2007. All countries used the 10th revision of the International Classification of Diseases, except Massachusetts which used the 9th revision. There were no major changes to the diagnostic criteria or methods of data collection in any country during the study period. Population characteristics as well as rates of pregnancy hypertension and pre-eclampsia were compared.ResultsAbsolute rates varied across the populations as follows: pregnancy hypertension (3.6% to 9.1%), pre-eclampsia (1.4% to 4.0%) and early-onset pre-eclampsia (0.3% to 0.7%). Pregnancy hypertension and/or pre-eclampsia rates declined over time in most populations. This was unexpected given that factors associated with pregnancy hypertension such as pre-pregnancy obesity and maternal age are generally increasing. However, there was also a downward shift in gestational age with fewer pregnancies reaching 40 weeks.ConclusionThe rate of pregnancy hypertension and pre-eclampsia decreased in northern Europe and Australia from 1997 to 2007, but increased in Massachusetts. The use of a different International Classification of Diseases coding version in Massachusetts may contribute to the difference in trend. Elective delivery prior to the due date is the most likely explanation for the decrease observed in Europe and Australia. Also, the use of interventions that reduce the risk of pregnancy hypertension and/or progression to pre-eclampsia (low-dose aspirin, calcium supplementation and early delivery for mild hypertension) may have contributed to the decline.

Objectives:To determine population-based rates and outcomes of hypertensive disorders in pregnancy. Design: Cross-sectional study using linked population databases. Setting and participants: All women, and their babies, discharged from hospital following birth in New South Wales, between 1 January 2000 and 31 December 2002. Main outcome measures: Rates of hypertensive disorders in pregnancy, maternal and infant morbidity and mortality, and level of hospital care for the birth admission. Results: 250 173 women and their 255 931 infants were included in the study. Overall, 24 517 women (9.8%) had a hypertensive disorder in pregnancy, including 1411 (0.6%) with chronic hypertension, 10 379 (4.2%) with pre-eclampsia, 731 (0.3%) with chronic hypertension with superimposed pre-eclampsia, and 10 864 (4.3%) with gestational hypertension. Women with, and infants exposed to, hypertension were more likely to suffer death or major morbidity than those without hypertension. Infants of mothers with hypertension were more likely to be to born preterm and small for gestational age. Just over half the women with major morbidity or mortality delivered in hospitals with a high level of medical care. In contrast, most infants with major morbidity or mortality were delivered in hospitals with neonatal intensive care units. Conclusions: Hypertension is a common complication of pregnancy, and adverse outcomes are increased among hypertensive women and their babies. Clinicians appear to be better at identifying and seeking an appropriate level of care for pregnancies where the infant is at risk of a poor outcome than when the mother is at risk. More specific antenatal indicators of poor maternal outcome would help guide the referral of MJA 2005; 182: 332-335 hypertensive women to higher levels of care.

BackgroundWhile rates of postpartum haemorrhage (PPH) have continued to rise, it is not clear if the association with other morbidity and transfusion has changed over time. This study explores the recent trend in postpartum haemorrhage and whether postpartum haemorrhage is associated with increased transfusions or adverse outcomes over time.MethodsLinked birth and hospital data were used to examine ICD-10 AM coded PPH and outcomes in maternal birth admission records, 2003-–2011 in hospitals in New South Wales (NSW), Australia (N = 818,965 pregnancies). Trends were calculated on the whole population, and among subgroups, and tested using the Cochran Armitage test for trend. Logistic regression models were developed separately for vaginal and caesarean births, and for a maternal morbidity composite indicator (excluding transfusion) and red cell transfusion. Adjusted odds ratios (aOR) for each year relative to 2003 and 95 % confidence intervals (CI) are presented with adjustment for maternal (eg. age, country of birth) and pregnancy factors (eg. parity, interventions, pregnancy complications).ResultsOverall, there was a significant increase in the PPH rate, from 6.1 % in 2003 to 8.3 % in 2011 (p < 0.0001). Crude rates of postpartum haemorrhage with transfusion increased from 0.75 % (n = 636) to 1.21 % (n = 1145) (p < 0.0001) while crude rates of postpartum haemorrhage with maternal morbidity increased from 0.18 % (n = 149) to 0.23 % (n = 221) (p = 0.02). Having accounted for maternal and pregnancy factors, there were significant overall decreases in the odds of morbidity among women with a PPH delivering vaginally (in 2006, 2007 and 2010, aORs were 0.70 (95 % CI 0.52, 0.96) 0.69 (0.51, 0.94) and 0.64 (0.47, 0.87) relative to 2003; p < 0.05), and no significant decrease among women delivered by caesarean section (aOR 0.87 (0.58, 1.29) in 2011; p = 0.37). Among women with a PPH delivering vaginally, there was a trend towards a non-linear increase in the adjusted odds of transfusion by birth year. Compared to women who had vaginal births with PPH in 2003, the adjusted odds for transfusion was between 1.1 and 1.2 fold higher for those with a PPH delivering vaginally in 2007, 2009, 2010 and 2011. However there was no significant trend amongst caesarean births (aOR 0.84 (0.66, 1.06) in 2011; p = 0.29).ConclusionsPPH has become more frequent, however this has not been associated with a clear pattern of increased severe maternal morbidity. This suggests that the increase in PPH may represent fewer severe haemorrhages, better management of severe haemorrhage or better recording of PPH. The increase in transfusions following vaginal births with PPH warrants further investigation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0788-5) contains supplementary material, which is available to authorized users.

Study Objectives: To examine the association between sleep apnea and pregnancy outcomes in a large population-based cohort. Methods: Population-based cohort study using linked birth and hospital records was conducted in New South Wales, Australia. Participants were all women who gave birth from 2002 to 2012 (n = 636,227). Sleep apnea in the year before pregnancy or during pregnancy was identified from hospital records. Outcomes of interest were gestational diabetes, pregnancy hypertension, planned delivery, caesarean section, preterm birth, perinatal death, 5-minute Apgar score, admission to neonatal intensive care or special care nursery, and infant size for gestational age. Maternal outcomes were identified using a combination of hospital and birth records. Infant outcomes came from the birth record. Modified Poisson regression models were used to examine associations between sleep apnea and each outcome taking into account maternal age, country of birth, socioeconomic disadvantage, smoking, obesity, parity, pre-existing diabetes and hypertension. Results: Sleep apnea was significantly associated with pregnancy hypertension (adjusted RR 1.43; 95% CI 1.18-1.73), planned delivery (1.15; 1.07-1.23), preterm birth (1.50; 1.21-1.84), 5-minute Apgar < 7 (1.60; 1.07-2.38), admission to neonatal intensive care/special care nursery (1.26; 1.11-1.44), largefor-gestational-age infants (1.27; 1.04-1.55) but not with gestational diabetes (1.09; 0.82-1.46), caesarean section (1.06; 0.96-1.17), perinatal death (1.73; 0.92-3.25), or small-for-gestational-age infants (0.81; 0.61-1.08). Conclusions: Sleep apnea is associated with higher rates of obstetric complications and intervention, as well as preterm delivery. Future research should examine if these are independent of obstetric history. Keywords: sleep-disordered breathing, pregnancy, gestational diabetes, pregnancy-induced hypertension, caesarean section, premature birth, small for gestational age, perinatal death, record linkage, cohort study Citation: Bin YS, Cistulli PA, Ford JB. Population-based study of sleep apnea in pregnancy and maternal and infant outcomes. J Clin Sleep Med 2016;12(6):871-877. I NTRO DUCTI O NSleep apnea is characterized by pauses in breathing during sleep causing intermittent blood oxygen desaturation and repeated awakening during the night. Snoring, daytime sleepiness and poor daytime function are the main symptoms. Sleep apnea is found disproportionately in men, those of late middle age, and those who are overweight/obese.1 More recently however, sleep apnea has been observed to occur commonly in pregnant women.2,3 While protected by their relative youth and gender, pregnant women are at increased risk for sleep apnea because of the weight gain and hormonal changes associated with pregnancy.4 Nasal congestion, narrowing of the upper airway, increased tongue size relative to the oral cavity, and enlarged neck circumference during pregnancy are all believed to be contributing factors. [5][6][7][8] In the general population, frank sleep apnea con...

Women with a history of prior invasive gynecologic procedures were more likely to develop abnormally invasive placenta. These insights may be used to inform management of pregnancies in women with a history of gynecologic procedures.

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Objective: Concern over rising caesarean rates has focused attention on initiatives to reverse this trend. We assessed variation in caesarean rates among hospitals to identify potential targets for intervention.Design, Setting and Participants: This is a population-based, record linkage study of 183,310 births in 81 hospitals in New South Wales, 2009-2010. The Robson classification was used to categorise births into 10 risk-based groups based on parity, plurality, labour onset, previous caesarean, fetal presentation and gestation. Multilevel logistic regression was used to examine variation in hospital caesarean rates within Robson groups, adjusted for differences in maternal age, country of birth, smoking, diabetes, hypertension and type of maternity care. The 20 th centile ("best practice" rate) of the risk-adjusted rates was used to quantify the potential impact on the overall caesarean rate of reducing practice variation. Main outcome measures: Hospital caesarean ratesResults: The overall caesarean rate was 30.9%, ranging from 11.8% to 47.4% among hospitals. Women with previous caesareans (36.4% of all caesareans) and nulliparous term births (induction or pre-labour caesarean 23.4%, spontaneous 11.1%) were the greatest contributors to the overall rate. After adjustment, marked unexplained variation in hospital caesarean rates persisted for: nulliparae at term, previous caesareans, multi-fetal pregnancies and preterm births. If variation in practice was reduced for these risk-based groups by achieving the "best practice" rate, this would lower the overall rate by 3.1%. Conclusion:Understanding hospital heterogeneity in performing caesarean sections and implementing evidence-based practices may result in improved maternity care. We have identified five risk-based groups as priority targets for reducing practice variation in caesarean rates.

A B S T R A C TObjective: to gain an understanding of how women conceptualise continuity of maternity care.Design: a qualitative study involving in-depth semi-structured interviews and thematic analysis.