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Background Cervical cerclage is used in an attempt to reduce recurrence risk of preterm birth, but evidence for use is limited. Aims To compare pregnancy outcomes among women with a single previous midtrimester delivery when managed with or without a cervical cerclage. Materials and methods Population-based cohort study of all women in New South Wales, Australia with a singleton pregnancy ending in birth/miscarriage ≥14 and <28 weeks, between 2003 and 2011. Modified Poisson regression was used to compare outcomes in the next subsequent pregnancy, for women with a cerclage inserted <14 weeks, and those without cerclage. The primary outcome was gestational age <37 weeks at birth/miscarriage in the next pregnancy. Secondary outcomes included: maternal morbidity, preterm prelabour rupture of membranes ( PPROM), stillbirth/neonatal death and composite neonatal morbidity for liveborn infants ≥28 weeks. Adjusted risk ratios ( ARR) and 95% confidence intervals ( CI) were determined. Results Five thousand, six hundred and ninety-eight births/miscarriages were potential index deliveries. Of these, 2175 women had an eligible subsequent pregnancy: 108 received cerclage at <14 weeks gestation, 2067 did not. Women with cerclage were significantly more likely to deliver <37 weeks than those without (39.8% vs 19.3%, ARR 1.92, 95% CI 1.48-2.48), and had increased risks of PPROM ( ARR 4.38, 95% CI 2.62-7.32) and stillbirth/neonatal death ( ARR 2.20, 95% CI 1.02-4.73). Following cerclage, liveborn infants ≥28 weeks had double the risk of severe morbidity ( ARR 2.54, 95% CI 1.55-4.16). Conclusions In women with a single previous midtrimester delivery, cervical cerclage <14 weeks gestation in subsequent pregnancy was associated with worse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Background: Although infant and child mortality rates have decreased substantially worldwide over the past two decades, efforts continue in many nations to further these declines. The identification of pertinent perinatal factors that are associated with early childhood mortality would help with these efforts. We investigated the association of two crucial perinatal factors, gestational age and severe neonatal morbidity at birth, with mortality during infancy (29-364 days) and early childhood (1-5 years).Methods: The study population included all singleton livebirths, ≥32 weeks' gestation in New South Wales, Australia in 2001-11. Birth data were linked to hospitalisation morbidity data and deaths data (linked birth cohort n = 871 916), and multivariable Cox regression models were used to assess mortality.Results: The median follow-up time per child was 4.95 years (range 0.00-5.92 years; 3 614 738 total person-years), with 984 deaths observed. Gestational age was associated with increased mortality, and specifically from deaths attributable to infections, respiratory conditions, and injuries during infancy, but not during early childhood. Severe neonatal morbidity strongly mediated the effects of gestational age during infancy, but not during early childhood, and was associated with increased mortality from circulatory, nervous, and respiratory system causes.Conclusions: The direct effects of gestational age on mortality extended up to 1 year of age, whereas severe neonatal morbidity remained associated with heightened mortality into early childhood. Efforts to maximise the health and well-being of vulnerable infants, with emphasis on preventing infections and injuries, may help further reduce early childhood mortality. [ABSTRACT FROM AUTHOR]

Background: Acute gastroenteritis (AGE) is a leading cause of infectious morbidity in childhood. Clinical studies have implicated caesarean section, early birth and formula feeding in modifying normal gut microbiota development and immune system homeostasis in early life. Rates of early birth and cesarean delivery are also increasing worldwide. This study aimed to investigate the independent and combined associations of the mode and timing of birth and breastmilk feeding with AGE hospitalisations in early childhood.Methods: Population-based record-linkage study of 893,360 singleton livebirths of at least 33 weeks gestation without major congenital conditions born in hospital, New South Wales, Australia, 2001-2011. Using age at first AGE hospital admission, Cox-regression was used to estimate the associations for gestational age, vaginal birth or caesarean delivery by labour onset and formula-only feeding while adjusting for confounders.Results: There were 41,274 (4.6 %) children admitted to hospital at least once for AGE and the median age at first admission was 1.4 years. Risk of AGE admission increased with decreasing gestational age (37-38 weeks: 15 % increased risk, 33-36 weeks: 25 %), caesarean section (20 %), planned birth (17 %) and formula-only feeding (18 %). The rate of AGE admission was highest for children who were born preterm by modes of birth other than vaginal birth following the spontaneous onset of labour and who received formula-only at discharge from birth care (62-78 %).Conclusions: Vaginal birth following spontaneous onset of labour at 39+ weeks gestation with any breastfeeding minimised the risk of gastroenteritis hospitalisation in early childhood. Given increasing trends in early planned birth and caesarean section worldwide, these results provide important information about the impact obstetric interventions may have on the development of the infant gut microbiota and immunity. [ABSTRACT FROM AUTHOR]

Objective To examine pregnancy outcomes and pregnancy-related health service utilization among women with rare autoimmune diseases. Methods This population-based cohort study of an Australian obstetric population (2001-2011) used birth records linked to hospital records for identification of rare autoimmune diseases including systemic vasculitis, vasculitis limited to the skin, Sjögren's syndrome, systemic sclerosis, Behçet's disease, polymyositis/dermatomyositis, and other systemic involvement of connective tissue. We excluded births in women with systemic lupus erythematosus or rheumatoid arthritis as well as births occurring ≥6 months before the diagnosis of the rare autoimmune disease. Modified Poisson regression was used to compare study outcomes between women with autoimmune diseases and the general obstetric population. Results There were 991,701 births, including 409 births (0.04%) in 293 women with rare autoimmune diseases. Of the 409 births, 202 (49%) were delivered by cesarean section and 72 (18%) were preterm; these rates were significantly higher than those in the general obstetric population (28% and 7%, respectively). Compared to the general population, women with autoimmune diseases had higher rates of hypertensive disorders, antepartum hemorrhage, and severe maternal morbidity and required longer hospitalization at delivery, more hospital admissions, and tertiary obstetric care. Compared to other infants, those whose mothers had a rare autoimmune disease were at increased risk of admission to a neonatal intensive care unit, severe neonatal morbidity, and perinatal death. Conclusion While the majority of women with rare autoimmune diseases delivered healthy infants, they were at increased risk of having both maternal complications and adverse neonatal outcomes, suggesting that their pregnancies should be closely monitored. [ABSTRACT FROM AUTHOR]

Background There is controversy about the interaction between melanoma and pregnancy. There is a lack of Australian data on pregnancy outcomes associated with melanoma in pregnancy, despite Australia having the highest incidence of melanoma in the world. Aims Describe trends, maternal characteristics and pregnancy outcomes associated with pregnancy-associated melanoma in New South Wales. Materials and Methods Population-based cohort study of all births ( n = 1 309 501) of at least 20-week gestation or 400 g birthweight in New South Wales, 1994-2008. Logistic regression was used to analyse the association between melanoma in pregnancy and adverse birth outcomes. Results 577 pregnancy-associated melanomas were identified, including 195 diagnosed during pregnancy and 382 diagnosed within 12 months postpartum. The crude incidence of pregnancy-associated melanoma increased from 37.1 per 100 000 maternities in 1994 to 51.84 per 100 000 maternities in 2008. Adjusting for maternal age accounted for the trend in pregnancy-associated melanoma. Melanomas diagnosed in pregnancy were thicker (median = 0.75 mm) than melanomas diagnosed postpartum (median = 0.60 mm) ( P = 0.002). Pregnancy-associated melanoma was associated with the increased risk of large-for-gestational-age infant but not preterm birth, planned birth, caesarean section or stillbirth. Parity was inversely associated with pregnancy-associated melanoma, as women with three or more previous pregnancies had 0.59 times the odds of pregnancy-associated melanoma compared to nulliparous women (95% CI 0.42-0.84, P = 0.003). Conclusions The incidence of pregnancy-associated melanoma has increased with increasing maternal age. The observation of thicker melanomas in pregnancy and increased risk of large-for-gestational-age infants may suggest a role for growth-related pregnancy factors in pregnancy-associated melanoma. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine the association between early discharge from hospital after birth and readmission to hospital for jaundice among term infants, and among infants discharged early, to investigate the perinatal risk factors for readmission for jaundice. METHODS: Birth data for 781 074 term live-born infants born in New South Wales, Australia from 2001 to 2010 were linked to hospital admission data. Logistic regression models were used to investigate the association between postnatal length of stay (LOS), gestational age (GA), and readmission for jaundice in the first 14 days of life. Other significant perinatal risk factors associated with readmission for jaundice were examined for infants discharged in the first 2 days after birth. RESULTS: Eight per 1000 term infants were readmitted for jaundice. Infants born at 37 weeks' GA with an LOS at birth of 0 to 2 days were over 9 times (adjusted odds ratio [aOR] 9.43; 95% CI, 8.34-10.67) and at 38 weeks' GA were 4 times (aOR 4.05; 95% CI, 3.62-4.54) more likely to be readmitted for jaundice compared with infants born at 39 weeks' GA with an LOS of 3 to 4 days. Other significant risk factors for readmission for jaundice for infants discharged 0 to 2 days after birth included vaginal birth, born to mothers from an Asian country, born to first-time mothers, or being breastfed at discharge. CONCLUSIONS: This study can inform guidelines or policy about identifying infants at risk for readmission for jaundice and ensure that appropriate post-discharge follow-up is received. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To investigate the association of gestational age and mode of birth with early child development. METHODS: Population-based record linkage cohort study was conducted among 153 730 live-born infants of ≥32 weeks' gestation with developmental assessments at school age, in New South Wales, Australia, 2002 to 2007. Children were assessed in 5 domains: physical health and well-being, language and cognition, social competence, emotional maturity, and general knowledge and communication. Children scoring in the bottom 10% of national domains were considered developmentally vulnerable, and children developmentally vulnerable for ≥2 domains were classified as developmentally high risk (DHR), the primary outcome. Robust multivariable Poisson models were used to obtain individual and combined adjusted relative risks (aRRs) of gestational age and mode of birth for DHR children. RESULTS: Overall, 9.6% of children were DHR. The aRR (95% confidence interval) of being DHR increased with decreasing gestational age (referent: 40 weeks); 32 to 33 weeks 1.25 (1.08-1.44), 34 to 36 weeks 1.26 (1.18-1.34), 37 weeks 1.17 (1.10-1.25), 38 weeks 1.06 (1.01-1.10), 39 weeks 0.98 (0.94-1.02), ≥41 weeks 0.99 (0.94-1.03), and for labor induction or prelabor cesarean delivery (planned birth; referent: vaginal birth after spontaneous labor), 1.07 (1.04-1.11). The combined aRR for planned birth was 1.26 (1.18-1.34) at 37 weeks and 1.13 (1.08-1.19) at 38 weeks. CONCLUSIONS: Early (at <39 weeks) planned birth is associated with an elevated risk of poor child development at school age. The timing of planned birth is modifiable, and strategies to inform more judicious decision-making are needed to ensure optimal child health and development. [ABSTRACT FROM AUTHOR]

Background: Early-onset preeclampsia is associated with adverse maternal and perinatal outcomes. For women who consider another pregnancy after one complicated by early-onset preeclampsia, the likelihood of recurrence and the subsequent pregnancy outcome for themselves and their babies are pertinent considerations.Objectives: The purpose of this study was to determine the subsequent pregnancy rate after a nulliparous pregnancy that was complicated by early-onset preeclampsia and among those who have a subsequent pregnancy, the risk of recurrence by gestational week, and adverse pregnancy outcomes.Study Design: This was a population-based record linkage cohort study. The study population included nulliparous women with a singleton pregnancy and early-onset preeclampsia (<34 weeks gestation) who gave birth in New South Wales Australia from 2001-2010 (the index birth), with follow-up data for a subsequent birth through 2012. Early-onset in the index birth was further categorized as <28 vs 28-33 weeks gestation. Subsequent pregnancy outcomes that were assessed included the pregnancy rate, preeclampsia recurrence, and maternal and perinatal morbidity and mortality rates. The risk of preeclampsia necessitating delivery at each gestational week for women who were at risk was plotted, and the net gain or loss of gestational age when comparing the index with the subsequent pregnancy was calculated.Results: Among 361,031 nulliparous women with singleton pregnancies, 1473 (0.4%) had early-onset preeclampsia. Women with early-onset preeclampsia in their first pregnancy had a lower subsequent pregnancy rate (59.7%) than women without preeclampsia (67.7%). Of the 758 women with a subsequent singleton birth, 256 (33.8%) experienced preeclampsia in the next pregnancy; 57 women (7.5%) with recurrent early-onset preeclampsia were included. Cumulative rates of preeclampsia in the subsequent pregnancy were higher at every gestation from 23 weeks gestation when the index birth was <28 weeks compared with 28-33 weeks gestation. The cumulative rate and gestation-specific risk of recurrent preeclampsia rose most steeply at 32-38 weeks gestation. Most women (94.6%) progressed to a later gestational age in their subsequent pregnancy. The median overall increase in gestational age at delivery was 6 weeks (interquartile range, 4-8); among women with recurrent preeclampsia, the median increase was 5 weeks (interquartile range, 2-7). Women with index birth <28 weeks gestation compared with 28-33 weeks gestation were more likely to deliver preterm (38.8% vs 28.7%; relative risk, 1.35; 95% confidence interval, 1.04-1.75) and have a perinatal death (4.3% vs 1.2%; relative risk, 3.46; 95% confidence interval, 1.15-10.39) at the subsequent birth, but live born infants had similar rates of severe morbidity (17.1% vs 15.0%; relative risk, 1.14; 95% confidence interval, 0.73-1.79).Conclusion: Women with early-onset preeclampsia in a first pregnancy appear less likely than women without preeclampsia to have a subsequent pregnancy. Maternal and perinatal outcomes in the subsequent pregnancy are generally better than in the first; most women will not have recurrent preeclampsia, and those who do usually will give birth at a greater gestational age compared with their index birth. [ABSTRACT FROM AUTHOR]

Objective. To describe the rates of antenatal hospital admission during twin or higher order multifetal pregnancies, and the admission outcomes as discharge undelivered, transfer to higher care, or spontaneous or elective delivery. Methods. Cohort study using linked birth and hospital data. The cohort comprised women who gave birth to twins or higher order multiple infants of ≥ 24 weeks gestation in 2001--2008 and who were admitted to hospital in weeks 20--36 of the pregnancy. Results. In 63.4% of 10 779 twin pregnancies and 99.5% of 197 triplet and quadruplet pregnancies, the woman was admitted to hospital at least once in weeks 20--36 of the pregnancy, for a total 10 985 admissions. Almost half the admissions (46.3%) ended in discharge without delivery, 10.7% in transfer to higher care, 21.1% in spontaneous labour and birth, and 21.8% in elective delivery (induction or prelabour Caesarean section). The reason for admission was preterm labour in 34.2% of admissions. Conclusions. Hospital admission during pregnancy is common for women with multifetal pregnancies, with many of these admissions resulting in preterm birth. This is the first study to report the rate of pregnancy admissions for women with multifetal pregnancies, and provides a baseline for future studies of hospital use in this population. [ABSTRACT FROM AUTHOR]