Objective: This study evaluates whether timing of amniotomy affects labor characteristics and maternal and neonatal outcomes in twin deliveries.
Methods: This retrospective study was conducted at a single academic medical center and included dichorionic diamniotic (DCDA) twin pregnancies with a normal anomaly scan and a vertex-presenting leading twin, delivered over a 7-year period. The cohort was divided into two groups: early amniotomy (performed at cervical dilation ≤3 cm) and late amniotomy (performed at >3 cm cervical dilation). Exclusion criteria included monochorionic twin pregnancies and planned elective cesarean deliveries. Maternal demographics, delivery characteristics, and neonatal outcomes were compared between groups.
Results: Of 51 592 deliveries, 1196 were twins; 565 DCDA pregnancies met the inclusion criteria (early n = 279; late n = 286). Groups were similar in age, body mass index (kg/m2), comorbidities, and gestation. Nulliparity and intrapartum cesarean rates were more common in the early amniotomy group (56.6% vs. 29.4%; P < 0.001, 24.4% vs. 9.8%; P < 0.001, respectively). Induction and augmentation rates, rupture-to-delivery interval, second stage duration, intrapartum fever, and meconium were similar. Neonatal outcomes, including birthweight, 5-min Apgar <7, neonatal intensive care unit admission, and composite morbidity were comparable. On adjusted analysis, early amniotomy (adjusted odds ratio [aOR] 1.84; 95% confidence interval 1.09-3.1), nulliparity (aOR 5.60; 3.17-9.87), and previous cesarean (aOR 3.94; 1.32-11.77) increased cesarean risk, whereas epidural was protective (aOR 0.40; 0.24-0.67).
Conclusion: In DCDA twin labor, early amniotomy (≤3 cm) is associated with increased intrapartum cesarean, despite similar durations of labor and neonatal outcomes. Amniotomy timing should be individualized, with caution against routine early rupture.
Objective: A single oral dose of azithromycin (AZM) given during labor to women planning a vaginal delivery reduced maternal infections including sepsis, with a stronger effect in sub-Saharan Africa than South Asia. Since maternal infection contributes to labor dysfunction and postpartum hemorrhage (PPH), we evaluated the effect of AZM on the risk of PPH and blood transfusion.
Methods: This was an unplanned secondary analysis of the Azithromycin Prevention in Labor Use Study (A-PLUS) randomized controlled trial at eight sites in seven low- and middle-income countries in sub-Saharan Africa, South Asia, and Latin America. The population consisted of pregnant women in labor at ≥28 weeks' gestation in health facilities randomized to either 2 g AZM or placebo. Based on an intent-to-treat analysis, the risk of PPH and blood transfusion was compared between AZM and placebo arms using Poisson regression adjusting for arm and site as fixed effects. The main outcome measures were (1) PPH (500 mL or greater) after delivery; and (2) postpartum blood transfusion after delivery.
Results: A total of 29 278 participants were randomized to APLUS; 14 590 to AZM and 14 688 to placebo. The risk of PPH did not significantly differ between AZM and placebo arms (1.4% in AZM; 1.6% in placebo; relative risk [RR] = 0.88; 95% confidence interval [CI]: 0.73, 1.07). The risk of blood transfusion also did not significantly differ between AZM and placebo arms (0.5% in AZM; 0.5% in placebo; RR = 0.90; 95% CI: 0.65, 1.25). There was also evidence indicating that the effect of AZM on the risk of blood transfusion, but not PPH, was beneficial in sub-Saharan Africa but not in South Asia (P value for two-way interaction = 0.002).
Conclusion: A single intrapartum oral dose of AZM did not significantly reduce the overall risk of PPH or blood transfusion.
Clinicaltrials: gov Identifier: NCT03871491.
Objective: The randomized trial of azithromycin to reduce maternal and neonatal sepsis (the A-PLUS Trial) found substantial reduction in maternal sepsis among women receiving azithromycin and substantial non-study antibiotic use. This secondary analysis explored the effect modification of non-study antibiotics on azithromycin versus placebo on maternal and newborn infection among A-PLUS participants.
Methods: Women ≥28 weeks gestation in labor and planning a vaginal delivery at a study hospital in seven low- and middle-income countries (Bangladesh, India [two sites], Pakistan, Guatemala, Kenya, Democratic Republic of Congo, and Zambia) were eligible for inclusion. Non-study antibiotic use was collected prospectively. We estimated the interaction of non-study antibiotics with azithromycin versus placebo on maternal and newborn sepsis.
Results: A total of 29 287 participants were randomized (14 590 to azithromycin; 14 688 to placebo). Maternal infection was reduced among the azithromycin group compared to placebo among those who did not receive non-study antibiotics, with estimated relative risk (RR) 0.58 (95% confidence interval [CI] 0.48, 0.70), and among those who received non-study antibiotics, with RR 0.80 (95% CI 0.70, 0.91). Similar results were observed for maternal sepsis. Neonatal infection was not significantly reduced in any group. These results were similar when stratified by African and Asian region but not statistically significant.
Conclusion: Our results suggest a benefit of azithromycin in reducing maternal infection or sepsis across all groups, with a larger reduction in risk among participants who had not received other antibiotics. Given the concerns of inappropriate use of antibiotics, further research is warranted to determine the most effective strategies of reducing risk of infection.
Objective: The aim of this study is to predict the severity of preeclampsia (PE) using the microvascular flow (MV-Flow) imaging technique, to examine the placental microvascular structure of PE patients, and to evaluate whether placental microvascular findings are associated with adverse outcomes in PE.
Methods: This study was designed as a single-center, prospective observational study including a total of 90 patients, comprising 30 cases of PE and 60 healthy pregnant women. Placental microvascularization was evaluated using MV-Flow imaging technology in both groups, and the vascular index (VImv) was automatically calculated for each patient. First, the perinatal outcomes of patients with PE and healthy controls were compared, followed by subgroup analyses comparing non-severe versus severe PE and early-onset (<34 weeks) versus late-onset (≥34 weeks) PE.
Results: In the preeclampsia group, placental VImv values were lower compared to the control group at all gestational ages (P < 0.001). There were more preterm births (P < 0.001) and more admissions to the neonatal intensive care unit in the preeclampsia group (P < 0.001). In the subgroup analysis, placental VIvm was found to be lower in severe PE patients (P = 0.012). Low placental VIvm values in patients with preeclampsia were associated with disease severity, preterm delivery, and neonatal intensive care unit admission.
Conclusion: By applying MV-Flow imaging technology in patients with PE, we demonstrated that in vivo placental vascularity was reduced compared to healthy pregnancies. The ease of clinical applicability and high efficiency of this ultrasound-based technology might provide preliminary insight into identifying patients at higher risk of severe disease and adverse perinatal outcomes in patients with preeclampsia.
Unsafe abortion remains a major public health and human rights challenge in Latin America, despite recent reforms that have expanded the legal grounds for abortion in several countries. A central reason for the persistent gap between law and access is the region's widespread reliance on physician-exclusive provider models, which structurally limit the availability of services, particularly in rural, Indigenous, and primary-care settings where specialists are scarce. Task sharing in abortion care should be understood not as a discretionary efficiency strategy, but as an essential component of States' obligations under legal rights to health care, equality, life, and scientific progress. A review of global evidence, a comparative analysis of legal and regulatory frameworks in 14 countries, and an in-depth examination of emerging reforms in Mexico, Colombia, Argentina, and Ecuador show that expanding provider eligibility is both clinically safe and normatively required. The conclusion outlines a regional reform agenda for aligning domestic regulations with World Health Organization standards.
Objective: To assess risk factors associated with persistent human papillomavirus (HPV) infection 6 months after loop electrosurgical excision procedure (LEEP) among Bhutanese women who tested HPV positive before LEEP at the National Referral Hospital of Bhutan.
Method: This was a retrospective study with review of patient records of women who tested HPV positive and underwent LEEP between January 1, 2022, and June 30, 2023. Sociodemographic and clinicopathologic factors were entered into EpiData and associations with HPV persistence were assessed using STATA.
Results: Among 132 women who tested HPV positive before LEEP, histologic diagnosis was normal in 32.6% (43), cervical intraepithelial neoplasia Grade 1 (CIN 1) in 19.7% (26), CIN 2 in 26.5% (35), CIN 3 in 18.9% (25), and adenocarcinoma in situ in 2.3% (3). HPV persistence 6 months after LEEP was 14.4% (19/132). Factors including age at the time of LEEP, age at marriage, educational status, number of sexual partners, use of oral contraceptive pill, colposcopy diagnosis, histology result, parity, and margin status were not associated with HPV persistence at 6 months.
Conclusion: This study provides baseline data on the proportion of HPV persistence at 6 months after LEEP in Bhutan. Ongoing follow up of patients after LEEP, including HPV typing and histology, would guide risk assessment for recurrent disease at the time of LEEP.
Objective: The causal relevance of thrombohemostatic factors and anticoagulant drug targets to miscarriage remains unclear. This study aims to systematically evaluate their potential causal effects on miscarriage phenotypes using Mendelian randomization (MR) analysis.
Methods: We conducted a multidimensional MR study leveraging summary-level genome-wide association study (GWAS) data from individuals of European ancestry to systematically evaluate the potential causal effects of 36 thrombohemostatic factors, long-term anticoagulant use, and genetic targets of aspirin and heparin on four miscarriage phenotypes, including sporadic, spontaneous, and recurrent miscarriage, as well as bleeding in early pregnancy. Analyses included linkage disequilibrium score regression for genetic correlation, two-sample MR for causal inference, drug target MR using cis-acting genetic variants, and summary-data-based MR. Sensitivity analyses addressed pleiotropy and heterogeneity, and multiple testing was rigorously controlled.
Results: No significant genetic correlation or causal association was found between thrombohemostatic factors or anticoagulant use and the risk of miscarriage after correction for multiple comparisons. Similarly, collective genetic proxies for aspirin and heparin targets showed no association with miscarriage risk. Notably, only genetically elevated expression of FGF2, a heparin target, was associated with an increased risk of spontaneous miscarriage (β = 0.277, P = 0.0017, FDR q = 0.015). Other nominal findings did not withstand correction for multiple testing. Sensitivity analyses affirmed the robustness of the primary results.
Conclusion: These findings do not support a causal role for thrombohemostatic factors or routine anticoagulant therapy in miscarriage prevention, underscoring the complexity of miscarriage etiology. Precision medicine approaches based on validated biomarkers might be necessary to identify women most likely to benefit from targeted interventions.
Objective: This study evaluates the effectiveness of targeted interventions implemented in Zambia from June 2023 to May 2024 in improving access to self-managed medical abortion (SMA) care, following the identification of barriers among providers and community through a baseline assessment and subsequent endline survey.
Methods: A pre- and post-survey using quantitative method focused on barriers for healthcare providers and community, including Access and Physical Environment; Guidelines and Documents; Equipment and Supplies; Provision and Staff Training; and Financial Aspects. Interventions included improving access, provider training, commodity strengthening, and community sensitization. Participants included healthcare providers, community members, and peer educators across 30 health facilities. STATA was used for descriptive analysis and McNemar's test.
Results: Our study revealed notable improvements in the provision of SMA services across the 30 participating facilities. Facilities offering SMA services increased from 25.3% at baseline to 44% at endline, while the proportion of facilities with adequate sticks of combipacks and misoprostol increased significantly. There was also a documented rise in hospital leadership support and a reduction in charges for SMA services. Access to telemedicine services also improved, increasing from 5.3% to 20.9%. Among community health volunteers, social acceptance of SMA care increased from 54.7% to 79.3%. There was also a greater preference for home administration of SMA medication and self-assessment of effectiveness. Facilities with trained community health volunteers delivering SMA education rose markedly from 25.3% to 93.1%.
Conclusion: The findings demonstrated significant improvements from baseline to endline, highlighting that SMA interventions were effective in improving access to safe abortion care in Zambia.
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