ART Raises Risk for Severe Maternal Morbidity 1.8-Fold

Ricki Lewis, PhD

December 15, 2015

Singleton pregnancies conceived with assisted reproductive technology (ART) are at increased risk for severe maternal morbidity compared with singleton deliveries without ART, according to results of a study published online December 7 and in the January 2016 issue of Obstetrics & Gynecology.

Severe maternal morbidity refers to physical and psychological conditions that are caused or aggravated by pregnancy. They include gestational diabetes, hypertension, and placenta accreta. Severe maternal morbidity affects more than 60,000 women in the United States annually.

Because ART has been associated with gestational diabetes, hypertension, and placental abnormalities, Angela S. Martin, MD, from the Department of Gynecology and Obstetrics at Emory University, Atlanta, Georgia, and colleagues conducted a retrospective longitudinal cohort study to investigate whether ART increases risk for severe maternal morbidity.

The researchers analyzed de-identified data from health insurance claims for women older than 15 years who had hospital deliveries between January 1, 2008, and November 19, 2012. International Classification of Diseases, Ninth Revision, codes indicated vaginal or cesarean delivery, single or multiple birth, postpartum readmission (within 6 weeks of delivery), and follicle puncture for oocyte retrieval, intrauterine embryo transfer, or gamete, zygote, or embryo intrafallopian transfer since 45 weeks before delivery.

To minimize bias from effects of comorbidities, the researchers stratified participants by presence or absence of major comorbidities such as tobacco use and preexisting diabetes, renal disease, hypertension, cardiovascular disease, and obesity.

The investigators included 25 indicators of severe maternal morbidity plus one of three criteria: hospitalization of at least 3 days, discharge status as transferred, or death. They calculated the rates of having at least one severe maternal morbidity indicator or postpartum readmission for every 10,000 deliveries that used ART and 10,000 deliveries that did not for each year in the study period and all years combined.

Of 1,016,618 deliveries, 14,761 (1.5%) were pregnancies conceived with ART. Women who conceived with ART were older and more likely to be nulliparous than women who did not, and 29.8% of ART deliveries were multiple gestations compared with 2.2% for non-ART deliveries.

The most prevalent severe morbidity indicators for both ART and non-ART groups were blood transfusion, disseminated intravascular coagulation, and mechanical ventilation.

Every 10,000 singleton deliveries included 273 with severe maternal morbidity at delivery or postpartum that had used ART compared with 126 for non-ART deliveries (P < .001). Among ART singleton deliveries, the rate of severe maternal morbidity fell from 369 per 10,000 deliveries in 2008 to 219 per 10,000 deliveries in 2012 (P = .025). The investigators attribute the improvement to technological advances.

"ART singletons had significantly higher odds of severe maternal morbidity compared with non-ART singletons after controlling for age, parity, comorbid conditions, prior cesarean delivery, and year of delivery (adjusted [odds ratio,] 1.84, 95% [confidence interval,] 1.63–2.08)," the researchers write.

Severe maternal morbidity did not differ significantly for multiple gestations with (604/10,000) or without (539/10,000) ART (P = .089; adjusted odds ratio, 1.04; 95% confidence interval, 0.91 - 1.20). Postpartum readmissions did not differ significantly between the groups, nor did comorbidities. The researchers conclude that ART is a risk factor for singleton pregnancies.

Limitations of the study include reliance on an insurance database; use of International Classification of Diseases, Ninth Revision, codes instead of medical record reviews; and spontaneous conceptions that might have occurred during the period of attempting an ART.

The researchers have disclosed no relevant financial relationships.

Obstet Gynecol. 2016;127:59-66. Abstract

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