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Importance: Women who experience severe maternal morbidity (SMM) might have lasting health issues, and the association of SMM with the probability of future reproductive intentions is unknown., Objective: To examine the association between SMM in a first birth and the probability of a subsequent birth., Design, Setting, and Participants: Retrospective, population-based cohort study conducted among 1 046 974 women in Sweden who had their first birth between 1999 and 2021., Exposure: Overall SMM and SMM subtypes were identified among all deliveries at 22 weeks of gestation or later (including complications within 42 days of delivery) from the Swedish Medical Birth Register and National Patient Register., Main Outcomes and Measures: All women with a recorded first delivery were followed up from 43 days postpartum until the first day of the last menstrual period of the second pregnancy that resulted in a birth (stillbirth or live birth) or until death, emigration, or end of follow-up on December 31, 2021. Multivariable Cox proportional hazards regression was used to estimate associations between SMM and time to subsequent birth with adjusted hazard ratios (aHRs). Sibling analysis was performed to evaluate potential genetic and familial confounding., Results: A total of 36 790 women (3.5%) experienced an SMM condition in their first birth. Women with any SMM had a lower incidence rate of subsequent birth compared with those without SMM in their first delivery (136.6 vs 182.4 per 1000 person-years), with an aHR of 0.88 (95% CI, 0.87-0.89). The probability of subsequent birth was substantially lower among women with severe uterine rupture (aHR, 0.48; 95% CI, 0.27-0.85), cardiac complications (aHR, 0.49; 95% CI, 0.41-0.58), cerebrovascular accident (aHR, 0.60; 95% CI, 0.50-0.73), and severe mental health conditions (aHR, 0.48; 95% CI, 0.44-0.53) in their first birth. The associations were not influenced by familial confounding as indicated by sibling analyses., Conclusions and Relevance: Our findings suggest that women who experience SMM in their first birth are less likely to have a subsequent birth. Adequate reproductive counseling and enhancing antenatal care are crucial for women with a history of SMM.

Objective: To quantify temporal trends and regional variation in severe maternal morbidity (SMM) in Sweden., Design: Cohort study., Population: Live birth and stillbirth deliveries in Sweden, 1999-2019., Methods: Types and subtypes of SMM were identified, based on a standard list (modified for Swedish clinical setting after considering the frequency and validity of each indicator) using diagnoses and procedure codes, among all deliveries at ≥22 weeks of gestation (including complications within 42 days of delivery). Contrasts between regions were quantified using rate ratios (RRs) and 95% confidence intervals (95% CIs). Temporal changes in SMM types and subtypes were described., Main Outcome Measures: Types and subtypes of SMM., Results: There were 59 789 SMM cases among 2 212 576 deliveries, corresponding to 270.2 (95% CI 268.1-272.4) per 10 000 deliveries. Composite SMM rates increased from 236.6 per 10 000 deliveries in 1999 to 307.3 per 10 000 deliveries in 2006, before declining to 253.8 per 10 000 deliveries in 2019. Changes in composite SMM corresponded with temporal changes in severe haemorrhage rates, which increased from 94.9 per 10 000 deliveries in 1999 to 169.3 per 10 000 deliveries in 2006, before declining to 111.2 per 10 000 deliveries in 2019. Severe pre-eclampsia, eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (103.8 per 10 000 deliveries), severe haemorrhage (133.7 per 10 000 deliveries), sepsis, embolism, disseminated intravascular coagulation, shock and severe mental health disorders were the most common SMM types. Rates of embolism, disseminated intravascular coagulation and shock, acute renal failure, cardiac complications, sepsis and assisted ventilation increased, whereas rates of surgical complications, severe uterine rupture and anaesthesia complications declined., Conclusions: The observed spatiotemporal variations in composite SMM and SMM types provide substantive insights and highlight regional priorities for improving maternal health., (© 2023 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Importance: Adverse pregnancy outcomes are recognized risk enhancers for cardiovascular disease, but the prevalence of subclinical coronary atherosclerosis after these conditions is unknown., Objective: To assess associations between history of adverse pregnancy outcomes and coronary artery disease assessed by coronary computed tomography angiography screening., Design, Setting, and Participants: Cross-sectional study of a population-based cohort of women in Sweden (n = 10 528) with 1 or more deliveries in 1973 or later, ascertained via the Swedish National Medical Birth Register, who subsequently participated in the Swedish Cardiopulmonary Bioimage Study at age 50 to 65 (median, 57.3) years in 2013-2018. Delivery data were prospectively collected., Exposures: Adverse pregnancy outcomes, including preeclampsia, gestational hypertension, preterm delivery, small-for-gestational-age infant, and gestational diabetes. The reference category included women with no history of these exposures., Main Outcomes and Measures: Coronary computed tomography angiography indexes, including any coronary atherosclerosis, significant stenosis, noncalcified plaque, segment involvement score of 4 or greater, and coronary artery calcium score greater than 100., Results: A median 29.6 (IQR, 25.0-34.9) years after first registered delivery, 18.9% of women had a history of adverse pregnancy outcomes, with specific pregnancy histories ranging from 1.4% (gestational diabetes) to 9.5% (preterm delivery). The prevalence of any coronary atherosclerosis in women with a history of any adverse pregnancy outcome was 32.1% (95% CI, 30.0%-34.2%), which was significantly higher (prevalence difference, 3.8% [95% CI, 1.6%-6.1%]; prevalence ratio, 1.14 [95% CI, 1.06-1.22]) compared with reference women. History of gestational hypertension and preeclampsia were both significantly associated with higher and similar prevalence of all outcome indexes. For preeclampsia, the highest prevalence difference was observed for any coronary atherosclerosis (prevalence difference, 8.0% [95% CI, 3.7%-12.3%]; prevalence ratio, 1.28 [95% CI, 1.14-1.45]), and the highest prevalence ratio was observed for significant stenosis (prevalence difference, 3.1% [95% CI, 1.1%-5.1%]; prevalence ratio, 2.46 [95% CI, 1.65-3.67]). In adjusted models, odds ratios for preeclampsia ranged from 1.31 (95% CI, 1.07-1.61) for any coronary atherosclerosis to 2.21 (95% CI, 1.42-3.44) for significant stenosis. Similar associations were observed for history of preeclampsia or gestational hypertension among women with low predicted cardiovascular risk., Conclusions and Relevance: Among Swedish women undergoing coronary computed tomography angiography screening, there was a statistically significant association between history of adverse pregnancy outcomes and image-identified coronary artery disease, including among women estimated to be at low cardiovascular disease risk. Further research is needed to understand the clinical importance of these associations.

Context: There are scarce data on the management of chronic hypoparathyroidism (hypoPT) in pregnant women., Objective: The aim of this study was to evaluate pregnancy outcome and total number of births in maternal chronic hypoPT., Methods: The Swedish National Patient Register, The Swedish Prescribed Drug Register, Swedish Medical Birth Register, and the Total Population Register were used to identify 97 women with chronic hypoPT and 1030 age-matched controls who delivered 139 and 1577 singleton infants, respectively, following diagnosis between 1997 and 2017., Results: Women in the chronic hypoPT group had more frequent diabetes (DM) and chronic kidney disease (CKD) compared with the control group (P = 0.043 and P < 0.001, respectively). After adjusting for DM, CKD, maternal age at delivery, and calendar year of delivery, chronic hypoPT cases were associated with increased risk of induction of labor (OR, 1.82; 95% CI, 1.13-2.94) and birth of infants with lower birth weight (β-coefficient -188 g; 95% CI, -312.2 to -63.8) compared with controls. No difference was found in infant length, small for gestational age, or head circumference after adjustments. Mean gestational age at delivery after controlling for DM, CKD, and pre-eclampsia was not significantly younger (P = 0.119). There was no difference in congenital malformations or perinatal death and no difference in the total number of infants born between groups (P = 0.518)., Conclusion: The majority of women with chronic hypoPT had normal pregnancy outcomes, and the overall risks appear low. Maternal chronic hypoPT is, however, associated with higher risk of induction of labor and slightly lower infant birth weight., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

To evaluate associations between early-pregnancy body mass index (BMI) and active first stage labour duration, accounting for possible interaction with maternal age, we conducted a cohort study of women with spontaneous onset of labour allocated to Robson group 1. Quantile regression analysis was performed to estimate first stage labour duration between BMI categories in two maternal age subgroups (more and less than 30 years). Results show that obesity (BMI > 30) among younger women (< 30 years) increased the median labour duration of first stage by 30 min compared with normal weight women (BMI < 25), and time difference estimated at the 90th quantile was more than 1 h. Active first stage labour time differences between obese and normal weight women was modified by maternal age. In conclusion: (a) obesity is associated with longer duration of first stage of labour, and (b) maternal age is an effect modifier for this association. This novel finding of an effect modification between BMI and maternal age contributes to the body of evidence that supports a more individualized approach when describing labour duration.

Objective: To investigate whether maternal overweight and obesity increased the risk of fetal acidosis measured in umbilical cord arterial blood after delivery., Study Design: Population-based cohort study of 84,785 term (≥37 weeks) infants. Logistic regression was used to estimate risks of fetal acidosis in umbilical cord arterial blood. Fetal acidosis was defined as pH <7.10 or as pH <1st percentile on a normal reference curve., Result: Risks of fetal acidosis increased, regardless of definition, with maternal overweight and obesity severity. Compared to normal weight (BMI 18.5-<25), the odds ratios (95% confidence interval) for pH <7.10 were 1.35 (1.23-1.47) for overweight (BMI 25-<30), 1.46 (1.27-1.69) for mild obesity (BMI 30-<35), and 1.75 (1.42-2.15) for severe obesity (BMI ≥35). The association for obesity was attenuated in analyses restricted to non-instrumental vaginal deliveries., Conclusion: Maternal overweight and obesity increased the risk of fetal acidosis. More complicated deliveries in obese women may partially explain this association.

Objective: The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period. Design: A population‐based cohort study. Setting: Regions of Stockholm and Gotland, Sweden, 2008–2020. Population: A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups. Methods: The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed. Main outcome measures: Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures. Results: The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46–1.84) in primiparous women, 2.43 (95% CI 1.98–2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65–3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage. Conclusions: Increasing active first stage duration is associated with maternal complications in the early postpartum period. [ABSTRACT FROM AUTHOR]

Objective: To quantify temporal trends and regional variation in severe maternal morbidity (SMM) in Sweden. Design: Cohort study. Population: Live birth and stillbirth deliveries in Sweden, 1999–2019. Methods: Types and subtypes of SMM were identified, based on a standard list (modified for Swedish clinical setting after considering the frequency and validity of each indicator) using diagnoses and procedure codes, among all deliveries at ≥22 weeks of gestation (including complications within 42 days of delivery). Contrasts between regions were quantified using rate ratios (RRs) and 95% confidence intervals (95% CIs). Temporal changes in SMM types and subtypes were described. Main outcome measures: Types and subtypes of SMM. Results: There were 59 789 SMM cases among 2 212 576 deliveries, corresponding to 270.2 (95% CI 268.1–272.4) per 10 000 deliveries. Composite SMM rates increased from 236.6 per 10 000 deliveries in 1999 to 307.3 per 10 000 deliveries in 2006, before declining to 253.8 per 10 000 deliveries in 2019. Changes in composite SMM corresponded with temporal changes in severe haemorrhage rates, which increased from 94.9 per 10 000 deliveries in 1999 to 169.3 per 10 000 deliveries in 2006, before declining to 111.2 per 10 000 deliveries in 2019. Severe pre‐eclampsia, eclampsia and HELLP (haemolysis, elevated liver enzymes and low platelet count) syndrome (103.8 per 10 000 deliveries), severe haemorrhage (133.7 per 10 000 deliveries), sepsis, embolism, disseminated intravascular coagulation, shock and severe mental health disorders were the most common SMM types. Rates of embolism, disseminated intravascular coagulation and shock, acute renal failure, cardiac complications, sepsis and assisted ventilation increased, whereas rates of surgical complications, severe uterine rupture and anaesthesia complications declined. Conclusions: The observed spatiotemporal variations in composite SMM and SMM types provide substantive insights and highlight regional priorities for improving maternal health. [ABSTRACT FROM AUTHOR]