International Journal of Gynecology & Obstetrics最新文献

Objective: To assess the occurrence of client financial insolvency, experiences of key healthcare stakeholders, and policy gaps on handling the situation during maternity services.

Methods: A qualitative study was conducted in North-Central Nigeria. Participants were key healthcare stakeholders including healthcare workers from private, primary, secondary, and tertiary facilities, healthcare administrators/facility-heads, program managers and policy makers at local and state government levels through In-depth and Key Informant interviews. Identified themes were occurrence, experiences of stakeholders, and prevention of client financial insolvency. Data were analyzed with the Nvivo statistical package.

Results: Participants confirmed the occurrence of client financial insolvency. Clients' inability to pay hospital bills was due to being indigent, awaiting support from relations, or clients who were uncommitted to the payment. Health facilities lack guiding policy documents; potential cases are referred from private to public or from primary to secondary/tertiary facilities. Methods of handling financial insolvency included healthcare worker-related (staff scavenging for needed consumables, fund-raising among facility staff), facility-related (revolving fund, medical social welfare, welfare committee, discharge with re-payment plan, fee-waiver), community-related (ward development committee, religious organizations/philanthropists) interventions, or hospital detention of insolvent clients. Although clients' bills did not increase during detention, many clients did not honor post-discharge re-payment agreements. Participants suggested a client-friendly billing system, early initiation of birth preparedness, partner involvement, and a rapid scale-up of health insurance for pregnant women to curb financial insolvency.

Conclusion: Tackling client financial insolvency requires policy documents, support to private facilities, effective debt-recovery mechanisms, and scale up of health insurance for pregnant women.

Objective: Sickle cell disease (SCD) is associated with complications during pregnancy and can negatively influence maternal outcomes. Our study aimed to determine the prevalence and predictors of maternal morbidity among participants enrolled in an eight-site SCD Implementation Consortium (SCDIC) registry.

Methods: We conducted a cross-sectional analysis of female registry participants, aged 15-45 years, with a confirmed diagnosis of SCD. Participants completed a survey of self-reported pregnancies and outcomes.

Results: Seven hundred and thirty-eight individuals had at least one pregnancy event, with 1076 live births. Twenty percent reported a pregnancy loss or fetal demise. Of the 1076 live births, 75% involved at least one complication. The most prevalent complications were pain crises (61.1%) and pregnancy requiring blood transfusion(s) (33.0%). Multiparous individuals with a prior occurrence of a complication in a previous pregnancy had higher odds of recurrence of the same complication in subsequent pregnancies (i.e., previous acute crisis was associated with subsequent acute pain events odds ratio [OR]: 3.13; 95% confidence interval [CI]: 2.06-4.76) and prior transfusion requiring another transfusion (OR: 3.22; 95% CI: 2.01-5.16).

Conclusion: Individuals reported a high prevalence of pregnancy loss and maternal complications. Our findings underscore the importance of preconception counseling and early initiation of perinatal care in SCD.

Background: Misoprostol is largely used in labor induction in cases of intrauterine fetal death. However, recent randomized clinical trials (RCTs) showed that the combination of mifepristone and misoprostol might have better effects than the use of misoprostol alone.

Objectives: To compare mifepristone and misoprostol lines of treatment.

Search strategy: Pubmed, Embase, Cochrane and Web of Science databases were systematically searched until April 9, 2024.

Selection criteria: The eligibility criteria were (1) RCT, (2) comparing misoprostol alone versus the combined treatment, (3) patients undergoing labor induction due to intrauterine fetal death and (4) reporting at least one relevant outcome.

Data collection and analysis: Data were examined using the Mantel-Haenszel method and 95% CIs. Heterogeneity was assessed using I² statics. R, version 4.2.3 was used for statistical analysis. The analyzed outcomes were delivery time interval, adverse effects (fever, vomiting, diarrhea and nausea) and the preinduction Bishop score. Other important outcomes, such as uterus rupture, could not be included due to lack of data from the included studies.

Main results: A total of seven RCTs comprising 599 patients with intrauterine fetal death were randomized to misoprostol or combined treatment to induce labor. Compared to the misoprostol only group, combined treatment presented lower delivery time interval (MD -6.86 h; 95% CI: -10.32 to -3.4; P = 0.0001; I² = 87%). However, in terms of adverse effects, the combined treatment group presented lower occurrence of fever (2.25% vs 12.12%; RR 0.26; 95% CI: 0.09-0.74; P = 0.01; I² = 0%) and vomiting (7.64% vs 14.45%; RR 0.54; 95% CI: 0.29-1.01; P = 0.05; I² = 0%). No statistically significant differences were observed when comparing the preinduction Bishop score of the two groups (MD -0.09; 95% CI: -0.28-0.10; P = 0.35; I² = 0%). Additionally, the mean of the preinduction Bishop score of the combined treatment was 2 versus 2.1 of the control group.

Conclusion: In this updated meta-analysis, consistent results suggest that the combined treatment is associated with more beneficial outcomes than the misoprostol alone treatment in patients undergoing labor induction in intrauterine fetal death.

Hyponatremia in labor and the postpartum period is generally underreported. In this study we aimed to identify attributable causes of severe hyponatremia in an obstetric population and define maternal outcomes. This was a retrospective cohort study, in a single center over a period of 10 years. The study setting was an NHS maternity trust serving a multi-ethnic population in southwest London. The hospital cared for 53 649 pregnant women in the study period. All patients with severe hyponatremia in labor and immediate postpartum period from January 2011 until December 2020 were identified from the laboratory database. Individual case notes were analyzed for fluid use, use and duration of oxytocin, medical conditions, and delivery details. Severe peripartum hyponatremia was identified in 77 patients. A total of 28% of those analyzed required ITU admission for electrolyte correction, of whom 6% presented with severe neurologic symptoms, making symptoms a poor marker of severity (P = 0.051). The main association was to oxytocin and intravenous fluid infusions (80% and 86%, respectively), only one-third of patients had pre-eclampsia. Other associated medical conditions did not appear to have a significant influence on disease course nor prognosis (P = 0.359). Hyponatremia during labor can have detrimental effect on maternal outcomes. Lower threshold for testing and diligent maintenance of fluid balance charts during labor can help with primary prevention.

Objective: To examine whether cervical ripening with a double balloon device for 6 h is as effective as 12 h in patients with a cervical length ≥ 30 mm measured on transvaginal ultrasound before induction of labor, and to determine whether patients with a long cervix need to have the balloon placed for a longer time.

Methods: This is a secondary analysis of data from a randomized controlled trial that compared maternal and neonatal outcomes between women undergoing cervical ripening with a double balloon device for 6 h (study group) versus 12 h (control group). In this secondary analysis, we included only patients who had cervical length ≥ 30 mm measured on transvaginal ultrasound on admission. Our primary outcome was a Bishop score change after removal of the device. Secondary outcomes included insertion to delivery interval, mode of delivery, and oxytocin infusion duration.

Results: Sixty-seven women met the inclusion criteria and were included in the analysis: 33 in the 6-h group and 34 in the 12-h group. Maternal characteristics were similar between both groups. Bishop score difference between the preinsertion and the postremoval scores were similar in the two groups (2.67 ± 1.8 vs. 2.53 ± 1.69, P = 0.76), while insertion to delivery time was 10 h shorter in the 6-h group (20.95 vs. 31.21, P = 0.02; mean difference, -10.26 [95% CI, -19.0 to -1.51]). The other secondary outcomes remained similar in both groups.

Conclusion: In women undergoing induction of labor who have a cervical length ≥ 30 mm measured on admission transvaginal ultrasound, removing a double balloon device after 6 h achieved similar Bishop score changes as removal after 12 h, but significantly reduced the time to delivery. REGISTRATION AT CLINICAL TRIALS: https://classic.

Clinicaltrials: gov/ct2/show/NCT03045939.

Background: The effectiveness and safety of laparoscopic pectopexy (LP) in the treatment of female pelvic organ prolapse (POP) have recently gained significant interest.

Objective: This study aimed to compare the outcomes and effectiveness of LP and laparoscopic sacrocolpopexy (LSC).

Search strategy: A comprehensive literature search was conducted across multiple databases, including PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, Clinical Trials, and CNKI. No language restrictions were applied in the search. The search encompassed the entire period from the inception of the respective databases to April 2023.

Selection criteria and data collection: All randomized controlled trials and comparative studies were included. A cumulative analysis was conducted on 10 studies, accounting for 15% of the overall research pool. The sample sizes of these studies were 760. Two researchers independently evaluated the eligibility of the studies, collected the relevant data, and evaluated their potential bias.

Main results: Compared with LSC, the average operation time for LP in the simple surgery group was shorter (standardized mean difference [SMD] -2.14, 95% CI -2.68 to -1.60, P < 0.001). The average bleeding volume was lower (SMD -3.17, 95% CI -5.22 to -1.12, P = 0.002), the postoperative indwelling catheterization time was shorter (SMD -0.35, 95% CI -0.67 to -0.02, P = 0.040), and there were fewer total postoperative complications (odds ratio [OR] 0.53, 95% CI 0.30-0.94, P = 0.030). In terms of effectiveness, the LP group had fewer postoperative prolapse recurrences than the LSC group (OR 0.33, 95% CI 0.14-0.77, P = 0.010).

Conclusion: LP demonstrates a comparable surgical efficacy to LSC. However, the surgical safety of LP is significantly improved. These findings should be validated by including additional randomized controlled trials.

Objective: To compare conservative management and appendectomy for acute appendicitis during pregnancy by trimester.

Methods: This retrospective cohort study used data from a national inpatient database from July 2010 to March 2022. Pregnant women diagnosed with acute appendicitis were included. Multivariable analysis using generalized estimating equations was performed to compare outcomes between conservative management and appendectomy across trimesters. The main outcomes were preterm labor, preterm delivery, or abortion; antepartum hemorrhage; duration of hospitalization; and duration of antibiotic use.

Results: A total of 3158 individuals from 632 acute-care hospitals were eligible. The proportion of conservative management versus appendectomy by trimester were 507 (49.1%) versus 525 (50.9%) in the first, 690 (44.6%) versus 856 (55.4%) in the second, and 337 (58.1%) versus 243 (41.9%) in the third. In the second trimester, appendectomy was associated with a higher rate of preterm delivery, preterm labor, or abortion (odds ratio [OR], 2.91 [95% confidence interval (CI), 1.62-5.25]). Antepartum hemorrhage occurred more frequently for appendectomy in the first (OR, 2.12 [95% CI, 1.31-3.43]) and third (OR, 2.43 [95% CI, 1.79-3.31]) trimesters. Appendectomy was associated with a longer duration of hospitalization in the second (2.15 days; 95% CI, 1.14-3.17 days) and third (3.97 days; 95% CI, 2.22-5.71 days) trimesters. Antibiotic use duration was shorter for appendectomy in the first (-1.20 days [95% CI -1.51 to -0.90 days]) and second (-0.61 days [95% CI -0.90 to -0.32 days]) trimesters.

Conclusions: Clinical outcomes of acute appendicitis during pregnancy vary by trimester. Considering the appendectomy risks, conservative management may be viable depending on the clinical context and trimester.

Objective: Dyspareunia can severely impact the quality of life of patients with endometriosis. This symptom is often linked to a specific form of deep infiltrating endometriosis, such as rectovaginal septum endometriosis. Despite the radicality of surgery, persistence and recurrence of symptoms post-surgery are not uncommon. The aim of the present study was to determine whether adenomyosis contributes to the failure of surgical interventions for dyspareunia in these patients.

Methods: A retrospective single-cohort study was conducted at the at tertiary care gynecologic center of the University Federico II of Naples, using medical records from January 2020 to July 2023. The study included patients who underwent surgery for dyspareunia associated with rectovaginal endometriosis and had a definitive histologic diagnosis. Pain and sexual quality of life were assessed using the visual analog scale (VAS) and the sexual quality of life-female (SQoL-F) questionnaire, both before and 6 months after surgery. Patients with isolated rectovaginal endometriosis were compared to those with concurrent adenomyosis.

Results: A total of 94 patients were included: thirty-five in group A (endometriosis with adenomyosis) and 59 in group B (isolated rectovaginal endometriosis). Histology confirmed deep infiltrating endometriosis (DIE) in all patients. Clinical characteristics such as age, BMI, abnormal uterine bleeding, and infertility, showed no significant differences between the groups. Multiparity was more common in group A (20%) compared to group B (5.1%) (P < 0.001). Pain VAS scores decreased significantly in both groups: from 7.11 to 5.40 in group A and from 7.34 to 3.31 in group B (both P < 0.001). Sexual quality of life (SQoL) scores improved significantly: from 42 to 57 in group A and from 41 to 66 in group B (both P < 0.001). Patients in group B showed a more significant improvement. Adjusted linear regression showed no significant association between parity and the severity of dyspareunia or sexual quality of life.

Conclusion: Adenomyosis appears to reduce the effectiveness of surgical treatment for dyspareunia in patients with rectovaginal septum endometriosis. Comprehensive preoperative screening for adenomyosis is recommended to improve surgical outcomes and provide appropriate counseling. Future research should further explore the impact of adenomyosis on dyspareunia and the potential benefits of adjunctive medical therapies.

Lipschütz ulcer (LU) is a condition known for painful vulvar ulcers, typically affecting young women and often linked to infectious agents. Recent reports have indicated a potential connection between LU and COVID-19 vaccination, particularly after the second or booster doses. This study presents a case of LU following the first dose of tozinameran in a young woman who had a previous SARS-CoV-2 infection and investigates similar cases globally. An 18-year-old woman experienced vulvar pain and ulcers 2-days after her initial COVID-19 vaccine dose. After ruling out infections through serological tests, a diagnosis of LU was made, and her symptoms resolved after 10 days. A literature search and VigiBase® analysis revealed 11 cases of LU following COVID-19 vaccination, and 519 vulvovaginal ulcer cases associated with these vaccines were identified in Vigibase®, with a median onset of 2 days. Most LU cases occurred after the second dose or booster shots. The primary hypothesis for this association is a type 3 hypersensitivity reaction mediated by immune complexes, possibly triggered by prior exposure, as many cases occurred after the second dose. Interestingly, the presented case suggests that prior COVID-19 infection could serve as sensitization. In conclusion, this study highlights the potential occurrence of LU after the initial COVID-19 vaccine dose in young patients with prior COVID-19 infection. While the risk of recurrence after subsequent vaccinations or infections remains uncertain, the benefits of vaccination outweigh the risks. Clinicians and patients should be aware of this potential issue to make informed decisions regarding vaccination.