【高血压英文ppt精品课件】 hyperfertility the paradox of plenty

1 Hyperfertility theParadoxofPlenty LouisKeith MD PhDProfessorEmeritus DepartmentofObstetricsandGynecology NorthwesternUniversity Chicago ILAdjunctProfessor DepartmentofMaternalandChildHealth SchoolofPublicHealth UniversityofAlabamaatBirmingham 2 BasicPremise Theeffectsofhyperfertilityonmothersarewellknown witnessShahJehan swifeTheeffectsofhyperfertilityonfetaloutcomesarenotwellknownorstudied 3 AgreedDefinitionsofParity Nullipara gravidaswithnopriorpregnancy 20weeksgestationPrimapara gravidaswith1priorpregnancy 20weeksgestation 4 VariableDefinitionsofParity Withnoriskthresholdforoutcomes MultiparaGrandMultipara GreatGrandMultipara GrandGrandMultipara ExtremeGrandMultipara Generallyatleast8priordeliveries Variablyusedforgreaterthan10priordeliveries 5 ReclassificationofParity theUABModel 6 ValueofUABParityClassification Permitscomparisonsacrossdiscreteclinicallyrelevantgroupsforassessmentofmaternalandfetaloutcomeparameters 7 LiteraturePriortotheUABHyperfertilityStudies 8 Frequencyof High 5 Parity 10studies 9nations 1954 2001 9 AdverseMaternalOutcomeswithMultiparity 37studies 17nations 1865 2004 UterineruptureChronicrenaldiseaseHypertensivediseasePlacentaprevia PreeclampsiaUterineinertiaAnemiaPPHAbrubtioDiabetes Variouslymentionedconditions 10 FactorsConfoundingRelationsBetweenHighParityandAdverseMaternalOutcomes Selectionbias i e lowSESMaternalageDiseaseaccumulationwithage 11 FetalOutcomesandMultiparity 38studies 13nations 1940 2004 StillbirthsPerinatalMortalityLowBirthweightPrematurity 12 TheGreatGrandMultipara 10priorlivebirths only11studies 6nations 1992 2002 7ofthesefromMiddleEastDefinitionsvaryVariablestudysizes 139 2709 ascertainmentbias Non adjustmentforconfounders methodologicalbias 13 TheUABHyperfertilityStudies ThankstoMuktarAliyu DPh UniversityofAlabamaatBirmingham 14 BasicHypothesesonHyperfertility 1 Babiesborntomotherswithparity 15aremorelikelytohaveadversefetaloutcomescomparedtowomenoflowerparity 2 Stillbirthratesaregreateramongmotherswithparity 15comparedtomotherswhoaremoderatelyfertile parity2 4 15 TheDatabase Combinednatalitydatafilesand fetaldeathfiles fromNCHS 1989 2000Singletonlivebirthsandfetaldeaths 20weeksGestationalagefromLMP DOBStillbirth SB IUFDat 20weeksTermSB 37completedgest wks PretermSB 37completedgest wks SGAstillbirth 10th tileofbirthweightforgest AgePretermSGAstillbirth 16 Methodology ExcludemultiplesRace ethnicity non Hispanicblacks non Hispanicwhites andHispanicsMaternalageadjustedbydirectmethodofstandardizationTestofhypothesistwo tailed typeIerrorat5 Logisticregressionusedwhereneeded 17 TheEvidence HyperfertilityandMaternalOutcomesHyperfertilityandFetalOutcomesHyperfertilityandStillbirths 18 TheSample 19 SociodemographiccharacteristicsofUSMothersbyFertilityStatus 1989 2000 20 TemporalTrendsinRatesofBirthbyFertilityStatus USA1989 2000 21 Asignificantpvaluemeansthatatleasttwoofthetestedgroupsaredifferent MaternalComplicationsbyFertilityStatus 1989 2000 22 InterimConclusions alldatanotpreviouslyshown Birthrateshavedeclinedoverthestudyperiodamongblacksaswellaswhites by10 and9 respectively BirthratesamongHispanicsincreasedby25 About75 ofHispanicbirthsoccuramongimmigrantsRacial ethnicdifferenceinfertilitymoderateformoderateleveloffertility andgreatestforveryhighfertilitystatus 23 TheEvidence HyperfertilityandMaternalOutcomesHyperfertilityandFetalOutcomesHyperfertilityandStillbirths 24 CrudeRatesforFetalOutcomesbyFertilityStatus 1989 2000 25 AORsforGrowthIndicesbyMaternalFertilityStatus 1989 2000 pfortrend 0 001 Adjustmentformaternalcomplicationswasperformedusingtheconfoundingeffectsofmaternaleducation maternalage maternalrace yearofbirth maritalstatus adequacyofprenatalcare andmaternalsmokingduringpregnancy 26 InterimConclusions IncreasingfertilityisariskfactorforLBW VLBW pretermandverypretermdeliveryinadose dependantfashionafter5deliveriesMacrosomicbabiesoccuringreaterthanexpectedincidenceamongwomenwithgreaterthan5birthsShortenedgestationratherthansizerestriction SGA isaffectedbyhyperfertility 27 TheEvidence HyperfertilityandMaternalOutcomesHyperfertilityandFetalOutcomesHyperfertilityandStillbirths 28 CrudeStillbirthRatesbyFertilityStatus 1989 2000 29 AORsforStillbirthbyFertilityStatus 1989 2000 Adjustedestimatesweregeneratedbytakingintoaccounttheconfoundingeffectsofmaternaleducation maternalage maternalrace yearofbirth maritalstatus adequacyofprenatalcare maternalsmokingduringpregnancyandselectedmaternalcomplications pfortrend 0 001 30 Type specificstillbirthratesbyfertilitystatus 1989 2000 31 Type specificstillbirthratesbyfertilitystatus 1989 2000 32 StillbirthRatesinTypeIVwithDoseEffect pfortrend 0 001 33 InterimConclusions Theriskofstillbirthincreasesincrementallywithascendingfertilityinhyperfertilewomen implyingadoseeffectrelationshipWomenwhoaremoderatelyfertile 2 4 havelowestriskandwomenwhoarehyperfertile 15 havehighestrisk 34 ExplanationforUABfindings MicronutrientdepletionhasneverbeenstudiedandcouldapplyinUS MaternalDepletionSyndrome usedincountrieswhereunder nutritioniscommon maynotapplyinUSUterineoverexhaustionmayleadtofetalunder nutritionviascartissueatpriorplacentalsitesMaternalageanddiseasestatemayaffectfetaloutcomesbutnotstudiedinhyperfertilewomen 35 Limitations NoaccesstoautopsydataorcauseofdeathNodataregardingbirthspacingNodataregardingdomesticactivitieswhichmayrelatetopretermlaborNodataonnegativehealthbehaviorsorpsychosocialstressorsNodataonreligiousinfluencesonfertility 36 Advantages Population baseddataminimizesbiasduetoselectionSamplesizesufficienttoprovideacceptablelevelofprecisioninestimatesThisdataimprovesunderstandingofthelinkbetweenextremefertilityandtheriskoffetaldemise 37 ApplicationsofUABHyperfertilityS