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Objective. This study examined hospitalisations and associated in-patient costs for babies during the first year of life following spontaneous labour, compared with labour induction or prelabour Caesarean section, at each gestational age. Methods. Birth data for singleton liveborn babies from 33 weeks gestation in New South Wales from 2005 to 2014 were linked to hospital and death data. Generalised linear models were used to examine the association between the type of labour and the length of hospitalisations and hospital costs. Results. From 2005 to 2014, 598 640 women gave birth to 1 187 451 liveborn singleton babies. The mean total length of hospitalisations and costs of hospitalisations for babies in the first year of life decreased significantly as week of gestational age increased to 39 weeks, then plateaued. Overall, the total length of hospitalisations and hospital costs were significantly (P, 0.001) lower for babies born after spontaneous labour (5.6 days and A$8405 respectively) than for babies born following labour induction (6.1 days and A$9452 respectively) or prelabour Caesarean section (8.2 days and A$12 320 respectively). Conclusions. Babies born following spontaneous labour spend less time in hospital and have lower hospital costs than those born following labour induction or prelabour Caesarean section. Hospitalisations and costs decrease with each week of gestational age until 39 weeks. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests that the trend toward early planned births observed among singletons may be evident among twin pregnancies. Aims: To describe trends in gestational age at birth, pregnancy characteristics, neonatal morbidity and mortality among twin pregnancies. Materials and Methods: Population‐based data linkage study of twin births of ≥30 weeks of gestation without a major congenital anomaly born in 2003–2014 in New South Wales (NSW), Australia. Linked pregnancy and birth, hospital and mortality data were used. Generalised linear regression was used to assess linear trends. Risk difference (RD) and 95% confidence intervals were estimated. Results: Among 28 076 eligible twin births (14 038 pregnancies), 49% of births occurred prior to 37 weeks and 69% of births were planned (pre‐labour caesarean or induction of labour). There were increases over time in the proportion of twin births at preterm gestations (30–34 weeks (RD 2.1, 95% CI 0.1, 4.0), 35–36 weeks (RD 7.5, 95% CI 5.4, 9.7)) and in the rates of planned births (pre‐labour caesarean (RD 6.4, 95% CI 4.0, 8.8), induction (RD 4.6, 95% CI 2.6, 6.6)). There was no significant change in stillbirth or neonatal death rates, but there was an increase in neonatal morbidity over the study period. Concurrently, there were increases in the prevalence of gestational diabetes; and decreases in pregnancy hypertension, assisted reproductive technology use, small‐for‐gestational age and birthweight discordance. Conclusions: Gestational age at birth among twin births is decreasing and birth intervention is increasing. There are increasing rates of neonatal morbidity, but no overall change in perinatal mortality. [ABSTRACT FROM AUTHOR]

Background: Research suggests that in Australia, maternal region of birth is a risk factor for stillbirth. Aims: We aimed to examine the relationship between stillbirth and maternal region of birth in New South Wales (NSW), Australia from 2004 to 2015. Methods: Adjusted logistic regression was used to determine odds of stillbirth by maternal region of birth, compared with Australian or New Zealand‐born (AUS/NZ‐born) women. Intervention rates (induction or pre‐labour caesarean) by maternal region of birth, over time, were also examined. Interaction terms were used to assess change in relative odds of stillbirth, over two time periods (2004–2011 and 2012–2015). Results: There were 944 457 singleton births ≥24 weeks gestation that met the study inclusion criteria and 3221 of these were stillbirths, giving a stillbirth rate of 3.4 per 1000 births. After adjustment for confounders, South Asian (adjusted odds ratio (aOR) 1.42, 95% CI 1.24–1.62), Oceanian (aOR 1.45, 95% CI 1.17–1.80) and African (aOR 1.46, 96% CI 1.19–1.80) born women had significantly higher odds of stillbirth that AUS/NZ‐born women. Intervention rates increased from the earlier to the later time period by 13.1% across the study population, but the increase was larger in African and South Asian‐born women (18.1% and 19.6% respectively) than AUS/NZ‐born women (11.2%). There was a significant interaction between ethnicity and time period for South Asian‐born women in the all‐births model, with their stillbirth rates becoming closer to AUS/NZ‐born women in the later period. Conclusion: South Asian, African and Oceanian maternal region of birth are independent risk factors for stillbirth in NSW. [ABSTRACT FROM AUTHOR]

Previous studies have reported inconsistent associations between maternal serum ferritin concentrations and the risk of spontaneous preterm birth (sPTB). The aim of the present study was to examine the association between Fe biomarkers, including serum ferritin concentrations, and the risk of total ( < 37 weeks), early ( < 34 weeks) and moderate-to-late (34–36 weeks) sPTB. The study cohort included 2254 women with singleton pregnancies attending first-trimester screening in New South Wales, Australia. sPTB included births following spontaneous labour or preterm premature rupture of the membranes. Serum collected at a mean gestational age of 12·0 (sd 0·9) weeks was analysed for Fe biomarkers, including serum ferritin and soluble transferrin receptor (sTfR), and the inflammatory biomarker C-reactive protein. Multivariate logistic regression analysis evaluated the association between low and high Fe levels and sPTB. Women with elevated serum ferritin concentrations were more likely to be older, nulliparous or have gestational diabetes. The multivariate analysis found increased odds of sPTB for women with elevated ferritin levels defined as >75th percentile ( ≥ 43 μg/l) (OR 1·49, 95 % CI 1·06, 2·10) and >90th percentile ( ≥ 68 μg/l) (OR 1·92, 95 % CI 1·25, 2·96). Increased odds of early and moderate-to-late sPTB were associated with ferritin levels >90th percentile (OR 2·50, 95 % CI 1·32, 4·73) and >75th percentile (OR 1·56, 95 % CI 1·03, 2·37), respectively. No association was found between the risk of sPTB and elevated sTfR levels or Fe deficiency. In conclusion, elevated maternal serum ferritin levels in early pregnancy are associated with an increased risk of sPTB from 34 weeks of gestation. The usefulness of early pregnancy ferritin levels in identifying women at risk of sPTB warrants further investigation. [ABSTRACT FROM PUBLISHER]

Objective. The aim of this study was to determine 1) if repeat lumbar transforaminal epidural steroid injections (TFESIs) resulted in recovery of pain relief, which has waned since an index injection, and 2) if cumulative benefit could be achieved by repeat injections within 3 months of the index injection. Design. Retrospective observational study with statistical modeling of the response to repeat TFESI. Setting. Academic radiology practice. Patients. Two thousand eighty-seven single-level TFESIs were performed for radicular pain on 933 subjects. Subjects received repeat TFESIs >2 weeks and <1 year from the index injection. Methods. Hierarchical linear modeling was performed to evaluate changes in continuous and categorical pain relief outcomes after repeat TFESI. Subgroup analyses were performed on patients with <3 months duration of pain (acute pain), patients receiving repeat injections within 3 months (clustered injections), and in patients with both acute pain and clustered injections. Results. Repeat TFESIs achieved pain relief in both continuous and categorical outcomes. Relative to the index injection, there was a minimal but statistically significant decrease in pain relief in modeled continuous outcome measures with subsequent injections. Acute pain patients recovered all prior benefit with a statistically significant cumulative benefit. Patients receiving clustered injections achieved statistically significant cumulative benefit, of greater magnitude in acute pain patients. Conclusion. Repeat TFESI may be performed for recurrence of radicular pain with the expectation of recovery of most or all previously achieved benefit; acute pain patients will likely recover all prior benefit. Repeat TFESIs within 3 months of the index injection can provide cumulative benefit. [ABSTRACT FROM AUTHOR]

Objective To assess whether computed tomography( CT)-guided injections of local anesthetic and corticosteroid into chronic lumbar pars interarticularis defects may identify and provide benefit to a cohort of patients where the pars defects act as a primary axial pain generator. Design Retrospective practice audit. Setting Single academic radiology pain management practice. Patients 59 consecutive patients undergoing CT-guided injections of lumbar pars defects. Methods Patients were assessed with a pain numerical rating scale ( NRS, 0-10) and Roland- Morris disability questionnaire ( R- M) prior to injection and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief response was defined as either ≥50% reduction in NRS or pain 0/10; functional response was defined as ≥40% reduction in R- M score. Continuous outcomes (mean NRS, R- M scores) were assessed for significant change following injection. Results For categorical outcomes, 37.9% of patients were responders at 2 months' follow-up; 20.7 % had complete relief of index pain. For functional recovery, 34.5% were responders at 2 months. Using continuous outcomes, mean NRS was 5.4 ± 2.1 prior to injection and 3.6 ± 2.6 at 2 months ( P < 0.0001). Mean R- M score was 11.7 ± 6.0 prior to injection and 9.0 ± 5.4 at 2 months ( P = 0.001). There were no complications. Conclusions This practice audit suggests that in patients with axial low back pain and chronic pars defects, the pars defects may be implicated as the primary axial pain generator in a small subgroup of patients. Local deposition of corticosteroids into the pars defect may provide significant pain relief in one out of three patients, and complete relief in one out of five patients. This data suggest there may be benefit to pursuing randomized controlled trials of pars injections comparing steroid injection with placebo. [ABSTRACT FROM AUTHOR]

Background: Low serum 25-hydroxyvitamin D [25(OH)D] concentrations during pregnancy have been associated with adverse pregnancy outcomes in a few studies but not in other studies. Objectives: We assessed the serum 25(OH)D concentration at 10-14 wk of pregnancy and its association with adverse pregnancy outcomes and examined the predictive accuracy. Design: In this nested case-control study, we measured serum 25(OH)D in 5109 women with singleton pregnancies who were attending first-trimester screening in New South Wales, Australia. Multivariate logistic regression was conducted to examine the association between low 25(OH)D concentrations and adverse pregnancy outcomes (small for gestational age, preterm birth, preeclampsia, gestational diabetes, miscarriage, and stillbirth). The predictive accuracy of models was assessed. Results: The median (IQR) 25(OH)D concentration for the total population was 56.4 nmol/L (43.3-69.8 nmol/L). Serum 25(OH)D concentrations showed significant variation by parity, smoking, weight, season of sampling, country of birth, and socioeconomic status. After adjustment for maternal and clinical risk factors, low 25(OH)D concentrations were not associated with most adverse pregnancy outcomes. The area under the receiver operating characteristic curve (AUC) and likelihood ratio for a composite of severe adverse pregnancy outcomes of 25(OH)D concentrations <25 nmol/L were 0.51 and 1.44, respectively, and, for risk factors alone, were 0.64 and 2.87, respectively. The addition of 25(OH)D information to maternal and clinical risk factors did not improve the ability to predict severe adverse pregnancy outcomes (AUC: 0.64; likelihood ratio: 2.32; P = 0.39). Conclusion: Low 25(OH)D serum concentrations in the first trimester of pregnancy are not associated with adverse pregnancy outcomes and do not predict complications any better than routinely assessed clinical and maternal risk-factor information. [ABSTRACT FROM AUTHOR]

Objective To assess whether a nonparticulate steroid (dexamethasone, 10 mg) is less clinically effective than the particulate steroids (triamcinolone, 80 mg; betamethasone, 12 mg) in lumbar transforaminal epidural steroid injections ( TFESIs) in subjects with radicular pain with or without radiculopathy. Design Retrospective observational study with noninferiority analysis of dexamethasone relative to particulate steroids. Setting Single academic radiology pain management practice. Subjects Three thousand six hundred forty-five lumbar TFESIs at the L4-5, L5- S1, or S1 neural foramina, performed on 2,634 subjects. Methods/Outcome Measures Subjects were assessed with a pain numerical rating scale ( NRS, 0-10) and Roland- Morris disability questionnaire ( R- M) prior to TFESI, and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R- M score. Noninferiority analysis was performed with δ = −10% as the limit of noninferiority. Continuous outcomes (mean NRS, R- M scores) were analyzed for noninferiority with difference bounds of 0.3 for NRS scores and 1.0 for R- M scores. Results With categorical outcomes, dexamethasone was demonstrated to be noninferior to the particulate steroids in pain relief and functional improvement at 2 months. Using continuous outcomes, dexamethasone was demonstrated to be superior to the particulate steroids in both pain relief and functional improvement at 2 months. Conclusion This retrospective observational study reveals no evidence that dexamethasone is less effective than particulate steroids in lumbar TFESIs performed for radicular pain with or without radiculopathy. [ABSTRACT FROM AUTHOR]

Objectives. To assess the clinical effectiveness of single lumbar transforaminal epidural steroid injections ( TFESIs) in subjects with radicular pain with or without radiculopathy. Design. Retrospective observational series. Setting. Single academic radiology pain management practice. Subjects. Two thousand twenty-four subjects undergoing single lumbar TFESIs at the L4-5, L5- S1, or S1 neural foramina. Methods / Outcome Measures. Subjects were assessed with a pain numerical rating scale ( NRS, 0-10) and Roland-Morris disability questionnaire ( R-M, 23-point Deyo modification) prior to TFESI and at 2 weeks and 2 months follow-up. Successful pain relief (responders) was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R-M score. Results. There were statistically significant ( P < 0.0001) reductions in mean NRS and R-M scores at 2 weeks and 2 months postinjection. For NRS, 40.9% were responders at 2 weeks and 45.6% at 2 months. For R-M, 31.9% were responders at 2 weeks and 41.3% at 2 months. The proportion of responders for NRS and R-M was higher when there was <3 months of pain (odds ratio 2-month NRS = 2.42 [95% confidence interval: 1.82, 3.24], odds ratio 2-month R-M = 2.61 [1.96, 3.48]). For subjects with <3 months of pain, the proportion of responders was 62.4% (56.5, 68.3%) for NRS and 59.3% (53.3, 65.3%) for R-M scores. Conclusions. This retrospective observational study suggests TFESIs are clinically effective in the treatment of lumbar radicular pain. Subjects with a shorter duration of pain are more likely to achieve a successful outcome. [ABSTRACT FROM AUTHOR]

Background Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries ( OASIS). To date, little investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates. Aims To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 - 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates. Methods Using two linked population-based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively. Results The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth ( aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates. Conclusion In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS. [ABSTRACT FROM AUTHOR]

Aim To determine the trends in oxytocin use at a population level within New South Wales and to assess the maternal and neonatal morbidities associated with the use of oxytocin. Methods Trends in oxytocin use were assessed for women in NSW who were nulliparas at term with a singleton, cephalic fetus between 1998 and 2008. Maternal and neonatal morbidities were assessed in 2007-2008 using linked hospital and birth data with regression analysis. Oxytocin was also assessed by indication for use being either induction or augmentation of labour. Results The overall use of oxytocin increased from 10 291 (36.5%) of births in 1998 to 14 440 (45.4%) of births in 2008 ( P < 0.0001) with the increase entirely because of the increased use for induction of labour. The use of oxytocin was associated with an increase in regional analgesia (65 to 22%), instrumental delivery (21 to 18%) and caesarean section (29 to 14%) as compared to women who did not receive oxytocin in labour. Oxytocin was also associated with an increase in severe maternal adjusted odds ratios (( aOR) 1.48, 95% CI 1.30-1.68) and neonatal morbidity ( aOR 1.29, 95% CI 1.17-1.41). This increase in morbidity was maintained when both augmentation and induction were assessed separately. Conclusion Oxytocin has an important role in the management of labour. However, its use should be carefully monitored with standardised treatment regimes to minimise maternal and neonatal morbidity. [ABSTRACT FROM AUTHOR]

Aim: To determine induction trends and delivery, maternal and neonatal health outcomes by gestational age following induction at term for women having a first baby. Methods: Linked birth and hospital data were used to examine the rates of adverse maternal and neonatal health outcomes for the period 2001-2007, among the 212 389 nullipara with singleton cephalic-presenting fetuses delivering between 370 and 416 weeks of gestation. Rates of caesarean delivery, neonatal transfers and overall severe neonatal and maternal adverse outcomes were determined by gestational age. Results: Between 1990 and 2008, nulliparous term inductions as a proportion of all births increased from 5518 (6.8%) to 11 166 (12.5%). More than 60% of these inductions are performed before 41 weeks. Among induced nullipara, 30.4% delivered by caesarean section. Adverse neonatal outcomes and transfer rates were lowest at 39-40 weeks (overall 2.1 and 0.5%, respectively), regardless of labour onset. Maternal morbidity increased at 40 weeks (from 1.1 to 1.3%) for women in spontaneous labour, was relatively stable in those undergoing induction of labour between 37 and 40 weeks (1.8%) and decreased with gestational age until 40 weeks in those undergoing a prelabour caesarean delivery (from 3.1 to 0.8%). Conclusion: NSW has high rates of both induction and caesarean section following induction. This study highlights the changes to clinical practice that may help reduce the rate of caesarean births in nullipara. [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]

Objective: To describe the use of episiotomy among Vietnamese-born women in Australia, including risk factors for, and pregnancy outcomes associated with, episiotomy.Methods: This population-based, retrospective cohort study included data on 598 305 singleton, term (i.e. ? 37 weeks' gestation) and vertex-presenting vaginal births between 2001 and 2010. Data were obtained from linked, validated, population-level birth and hospitalization data sets. Contingency tables and multivariate analysis were used to compare risk factors and pregnancy outcomes in women who did or did not have an episiotomy.Findings: The episiotomy rate in 12 208 Vietnamese-born women was 29.9%, compared with 15.1% in Australian-born women. Among Vietnamese-born women, those who had an episiotomy were significantly more likely than those who did not to be primiparous, give birth in a private hospital, have induced labour or undergo instrumental delivery. In these women, having an episiotomy was associated with postpartum haemorrhage (adjusted odds ratio, aOR: 1.26; 95% confidence interval, CI: 1.08-1.46) and postnatal hospitalization for more than 4 days (aOR: 1.14; 95% CI: 1.00-1.29). Among multiparous women only, episiotomy was positively associated with a third- or fourth-degree perineal tear (aOR: 2.00; 95% CI: 1.31-3.06); in contrast, among primiparous women the association was negative (aOR: 0.47; 95% CI: 0.37-0.60).Conclusion: Episiotomy was performed in far fewer Vietnamese-born women giving birth in Australia than in Viet Nam, where more than 85% undergo the procedure, and was not associated with adverse outcomes. A lower episiotomy rate should be achievable in Viet Nam. [ABSTRACT FROM AUTHOR]