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Fetal Growth Restriction: A Comprehensive Review of Major Guidelines. 胎儿生长受限:主要指南的全面回顾。
IF 6.2 4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-11-01 DOI: 10.1097/OGX.0000000000001203
Sonia Giouleka, Ioannis Tsakiridis, Apostolos Mamopoulos, Ioannis Kalogiannidis, Apostolos Athanasiadis, Themistoklis Dagklis
<p><strong>Importance: </strong>Fetal growth restriction (FGR) is a common pregnancy complication and a significant contributor of fetal and neonatal morbidity and mortality, mainly due to the lack of effective screening, prevention, and management policies.</p><p><strong>Objective: </strong>The aim of this study was to review and compare the most recently published influential guidelines on the management of pregnancies complicated by FGR.</p><p><strong>Evidence acquisition: </strong>A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the International Society of Ultrasound in Obstetrics and Gynecology, the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada (SOGC), the Perinatal Society of Australia and New Zealand, the Royal College of Physicians of Ireland, the French College of Gynecologists and Obstetricians (FCGO), and the German Society of Gynecology and Obstetrics on FGR was carried out.</p><p><strong>Results: </strong>Several discrepancies were identified regarding the definition of FGR and small-for-gestational-age fetuses, the diagnostic criteria, and the need of testing for congenital infections. On the contrary, there is an overall agreement among the reviewed guidelines regarding the importance of early universal risk stratification for FGR to accordingly modify the surveillance protocols. Low-risk pregnancies should unanimously be evaluated by serial symphysis fundal height measurement, whereas the high-risk ones warrant increased sonographic surveillance. Following FGR diagnosis, all medical societies agree that umbilical artery Doppler assessment is required to further guide management, whereas amniotic fluid volume evaluation is also recommended by the ACOG, the SOGC, the Perinatal Society of Australia and New Zealand, the FCGO, and the German Society of Gynecology and Obstetrics. In case of early, severe FGR or FGR accompanied by structural abnormalities, the ACOG, the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the Royal College of Obstetricians and Gynecologists, the SOGC, and the FCGO support the performance of prenatal diagnostic testing. Consistent protocols also exist on the optimal timing and mode of delivery, the importance of continuous fetal heart rate monitoring during labor, and the need for histopathological examination of the placenta after delivery. On the other hand, guidelines concerning the frequency of fetal growth and Doppler velocimetry evaluation lack uniformity, although most of the reviewed medical societies recommend an average interval of 2 weeks, reduced to weekly or less when umbilical artery abnormalities are detected. Moreover, there is a discrepancy on the appropriate timing for corticosteroids and magnesium sulfate administration, as well as
重要性:胎儿生长受限(FGR)是一种常见的妊娠并发症,也是导致胎儿和新生儿发病和死亡的重要因素,这主要是由于缺乏有效的筛查、预防和管理政策:本研究的目的是回顾和比较最近发表的有关 FGR 并发症妊娠管理的有影响力的指南:此外,还与加拿大妇产科医师协会 (SOGC)、澳大利亚和新西兰围产协会、爱尔兰皇家内科医师学会、法国妇产科医师学院 (FCGO) 和德国妇产科学会就 FGR 进行了合作。结果:在 FGR 和小于妊娠年龄胎儿的定义、诊断标准以及是否需要进行先天性感染检测等方面发现了一些差异。与此相反,参阅的指南在 FGR 早期普遍风险分层的重要性方面达成了总体一致,从而相应地修改了监测方案。低风险妊娠应一致通过连续测量干骺端高度进行评估,而高风险妊娠则应加强超声监测。在确诊 FGR 后,所有医学会都认为需要进行脐动脉多普勒评估,以进一步指导管理,而羊水量评估也是 ACOG、SOGC、澳大利亚和新西兰围产学会、FCGO 和德国妇产科学会所推荐的。对于早期、严重的胎儿畸形或伴有结构异常的胎儿畸形,ACOG、母胎医学会、国际妇产科联盟、英国皇家妇产科学院、SOGC 和 FCGO 都支持进行产前诊断检测。在分娩的最佳时间和方式、分娩过程中持续监测胎儿心率的重要性以及分娩后胎盘组织病理学检查的必要性等方面也有一致的规范。另一方面,关于胎儿生长和多普勒速度测量评估频率的指南缺乏统一性,尽管大多数接受审查的医学会都建议平均间隔两周进行一次,如果发现脐动脉异常,则缩短至每周一次或更少。此外,在使用皮质类固醇和硫酸镁以及使用阿司匹林作为预防措施的适当时机上也存在分歧。戒烟、戒酒和戒毒是降低胎儿畸形发生率的预防措施:胎儿生长受限是一种与产前和产后诸多不良事件相关的临床实体,但目前除分娩外尚无确切的治疗方法。因此,制定统一的国际方案,对生长受限胎儿进行早期识别、充分监测和优化管理,对于安全指导临床实践,从而改善此类妊娠的围产期结局至关重要。
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引用次数: 0
The Exciting Potential for ChatGPT in Obstetrics and Gynecology ChatGPT在妇产科的激动人心的潜力
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/01.ogx.0000993696.39744.23
Amos Grünebaum, Joseph Chervenak, Susan L. Pollet, Adi Katz, Frank A. Chervenak
ABSTRACT In November 2022, AI Lab OpenAI launched the online chatbot ChatGPT (Chat Generative Pre-Trained Transformer), an accessible language model that uses the artificial intelligence (AI) branch of natural language processing (NLP) to answer prompts based on a library of 175 billion parameters from the “internet, books and other sources.” Because of its ability to answer clinical questions in plain English that can be understood by providers and patients alike, the potential for ChatGPT to be used as a clinical tool is obvious. Despite its impressive fund of source knowledge, these data are potentially biased and unreliable and may not reflect current stances. In addition, ChatGPT does not list sources for its information, and its current capability to answer clinical questions correctly is not well understood. This study aimed to assess answers given by ChatGPT in response to a spectrum of questions about obstetrics and gynecology including systems-level questions, ethical questions, and treatment-related decision making. A total of 14 questions were asked. The first question asked why US preterm birth rates are so high. The second question asked for a list of the most important interventions physicians can do to monitor, prevent, and treat premature births. The third question asked whether vaginal progesterone was effective and safe for preventing preterm birth in women with a short cervix in the midtrimester, and the fourth question asked the same question but in women with a history of preterm birth and no short cervix. The fifth question asked why maternal mortality rates in the United States are so high. The sixth question asked for a list of what obstetricians can do to prevent preeclampsia. The seventh question asked about the safety of hospital births when compared with planned home births in the United States. The eighth question asked whether it is ethically acceptable for an obstetrician to provide emergency cesarean delivery without a woman's informed consent to save the fetus or the mother. The ninth question asked how obstetricians should screen for domestic abuse and intimate partner violence in pregnancy. The 10th question asked if women should freeze their eggs and at what age. The 11th question asked about the risks and benefits of menopause hormone replacement therapy. The 12th question asked how abortion bans in the United States affect women's health and lives. The 13th question asked whether complex hyperplasia atypia surgery should be performed only by a gynecologist-oncologist. The final question asked whether we should continue using the term “pregnant woman” versus alternative including “pregnant person.” Overall, ChatGPT provided nuanced and informed answers to question on virtually any topic in obstetrics and gynecology, but occasionally revealed an apparent lack of insight into the questions being asked. ChatGPT can provide preliminary information about a wide range of topics and can be valuable to both providers
2022年11月,人工智能实验室OpenAI推出了在线聊天机器人ChatGPT(聊天生成预训练转换器),这是一种可访问的语言模型,它使用自然语言处理(NLP)的人工智能(AI)分支来回答基于“互联网,书籍和其他来源”的1750亿个参数库的提示。由于ChatGPT能够用简单易懂的英语回答临床问题,提供者和患者都能理解,因此ChatGPT作为临床工具的潜力是显而易见的。尽管这些数据的来源知识丰富,但可能存在偏见和不可靠,可能无法反映当前的立场。此外,ChatGPT没有列出其信息来源,其目前正确回答临床问题的能力尚不清楚。本研究旨在评估ChatGPT对一系列关于妇产科的问题的回答,包括系统级问题、伦理问题和与治疗相关的决策。总共问了14个问题。第一个问题是为什么美国的早产率如此之高。第二个问题要求医生列出最重要的干预措施,以监测、预防和治疗早产。第三个问题是阴道黄体酮对于预防中期短宫颈的妇女早产是否有效和安全,第四个问题是同样的问题,但对于有早产史但没有短宫颈的妇女。第五个问题是为什么美国的产妇死亡率如此之高。第六个问题是产科医生可以做些什么来预防先兆子痫。第七个问题是关于在美国将医院分娩与计划在家分娩进行比较的安全性。第八个问题是产科医生在没有得到妇女知情同意的情况下为挽救胎儿或母亲而提供紧急剖宫产在道德上是否可以接受。第九个问题是产科医生应如何筛查怀孕期间的家庭暴力和亲密伴侣暴力。第10个问题是女性是否应该冷冻卵子,以及在什么年龄冷冻。第11个问题是关于更年期激素替代疗法的风险和益处。第12个问题问及美国的堕胎禁令如何影响妇女的健康和生活。第13个问题是复杂增生异型手术是否只能由妇科肿瘤科医生进行。最后一个问题是,我们是否应该继续使用“孕妇”这个词,而不是包括“孕妇”在内的替代词。总的来说,ChatGPT提供了细致入微和知情的答案,几乎任何话题的产科和妇科的问题,但偶尔暴露出明显缺乏洞察力的问题被问到。ChatGPT可以提供关于广泛主题的初步信息,对提供者和患者都很有价值,并且随着训练数据的更新和模型从用户提示中学习,ChatGPT将继续改进。
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引用次数: 0
Heparin for Women With Recurrent Miscarriage and Inherited Thrombophilia (ALIFE2): An International Open-Label, Randomized Controlled Trial 肝素治疗复发性流产和遗传性血栓形成(ALIFE2):一项国际开放标签随机对照试验
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/ogx.0000000000001209
Siobhan Quenby, Katie Booth, Louise Hiller, Arri Coomarasamy, Paulien G. de Jong, Eva N. Hamulyák, Luuk J. Scheres, Thijs F. van Haaps, Lauren Ewington, Shreeya Tewary, Mariëtte Goddijn, Saskia Middeldorp
ABSTRACT Thrombophilia has been implicated in the cause of recurrent miscarriage, which affects approximately 3% of couples trying to conceive. International professional guidelines recommend heparin anticoagulation for antiphospholipid syndrome, an acquired thrombophilia responsible for approximately 15% of recurrent miscarriage, but not for other inherited thrombophilias due to an absence of evidence. Many clinicians prescribe heparin to women with recurrent miscarriage and inherited thrombophilia despite the professional recommendations. This international, open-label, randomized controlled trial aimed to compare the effect of low-molecular weight heparin (LMWH) and standard pregnancy surveillance on livebirth rates in women with recurrent miscarriage and inherited thrombophilia. Women aged 18–42 years with recurrent miscarriages who were attempting to conceive or less than 7 weeks pregnant and had an inherited thrombophilia were recruited across 40 hospitals in 5 countries. Women were randomly assigned to LMWH or no LMWH in a 1:1 ratio. Women randomized to LMWH self-administered it once a day subcutaneously, beginning as soon as possible after a positive pregnancy test and before 7 weeks of gestation and continuing throughout pregnancy. The primary study outcome was livebirth after 24 weeks of gestation. Livebirth was compared across randomized treatment groups using an χ 2 test with continuity correction, then a sensitivity analysis with logistic regression to adjust for stratification factors. A total of 326 women were randomized between August 2012 and January 2021. Of these, 164 were randomized to LMWH plus standard care and 162 to standard care alone. In the standard care group, 30 patients ultimately received LMWH for thromboprophylaxis per professional treatment guidelines. The mean age of participants was 33 years, and the median number of miscarriages before randomization was 3 (interquartile range, 2–4), with two thirds of patients having a history of 3 or more miscarriages. The most common thrombophilia diagnoses were heterozygosity for factor V Leiden, prothrombin G20210A mutation, and protein S deficiency. The livebirth rate was 72% (116/162) in the LMWH group, and 71% (112/158) in the standard care group, and no statistical significant was detected between the groups even after adjustment (odds ratio, 1.08; 95% confidence interval, 0.65–1.78; P = 0.77). No differences in adverse pregnancy outcomes or complications were observed between the groups. Easy bruising was reported by 45% (73) women in the LMWH group and 10% (16) in the standard care group. This randomized controlled trial demonstrates that although LMWH is safe in women with recurrent pregnancy loss and inherited thrombophilia, it does not result in an increased live birth rate compared with standard pregnancy surveillance.
血栓病与复发性流产有关,约有3%的夫妇试图怀孕。国际专业指南推荐使用肝素抗凝治疗抗磷脂综合征,抗磷脂综合征是一种获得性血栓性疾病,约占复发性流产的15%,但由于缺乏证据,不建议用于其他遗传性血栓性疾病。许多临床医生不顾专业建议,给反复流产和遗传性血栓形成的妇女开肝素。这项国际、开放标签、随机对照试验旨在比较低分子肝素(LMWH)和标准妊娠监测对复发性流产和遗传性血栓形成妇女的活产率的影响。在5个国家的40家医院招募了年龄在18-42岁、有复发性流产、试图怀孕或怀孕少于7周且患有遗传性血栓形成症的妇女。女性按1:1的比例随机分配低分子肝素组和非低分子肝素组。随机分配到低分子肝素组的妇女在妊娠试验阳性后和妊娠7周之前尽快开始,并持续整个妊娠期间,每天皮下给药一次。主要研究结果是妊娠24周后的活产。采用连续性校正的χ 2检验比较各随机治疗组的活产,然后采用logistic回归进行敏感性分析以调整分层因素。在2012年8月至2021年1月期间,共有326名女性被随机分配。其中,164例随机分配到低分子肝素加标准治疗组,162例随机分配到单独标准治疗组。在标准治疗组,根据专业治疗指南,30名患者最终接受低分子肝素预防血栓。参与者的平均年龄为33岁,随机分组前流产的中位数为3次(四分位数范围为2-4),其中三分之二的患者有3次或以上的流产史。最常见的血栓病诊断为Leiden因子V杂合性、凝血酶原G20210A突变和蛋白S缺乏。低分子肝素组的活产率为72%(116/162),标准护理组的活产率为71%(112/158),调整后两组间差异无统计学意义(优势比1.08;95%置信区间为0.65-1.78;P = 0.77)。在不良妊娠结局或并发症方面,两组间无差异。低分子肝素组中有45%(73)的妇女易出现瘀伤,标准护理组中有10%(16)的妇女易出现瘀伤。这项随机对照试验表明,尽管低分子肝素对复发性妊娠丢失和遗传性血栓形成的妇女是安全的,但与标准妊娠监测相比,它不会导致活产率增加。
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引用次数: 0
Low-Dose Aspirin for the Prevention of Superimposed Preeclampsia in Women With Chronic Hypertension: A Systematic Review and Meta-analysis 低剂量阿司匹林预防慢性高血压女性合并子痫前期:一项系统综述和荟萃分析
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/01.ogx.0000993664.57399.b2
Eleanor M. F. Richards, Veronica Giorgione, Oliver Stevens, Basky Thilaganathan
ABSTRACT Women with chronic hypertension are at increased risk for the development of preeclampsia during pregnancy. Low-dose aspirin treatment has been studied in the context of preeclampsia prevention, but there have been conflicting results among different populations. Some reasons for this are heterogeneous treatment regimens including timing, dosage, and even target outcomes. Among populations where there are limited data on the effect of low-dose aspirin on preeclampsia are women with chronic hypertension. This study is a systematic review and meta-analysis designed to analyze the use of low-dose aspirin during pregnancy and to assess whether the treatment reduces the risk of superimposed preeclampsia in women with chronic hypertension. It also aimed to secondarily assess related outcomes such as small for gestational age (SGA), preterm birth, and perinatal mortality. Systematic searches and assessment isolated 9 articles for final analysis. Six of these were randomized controlled trials, and 3 were retrospective cohort studies. Four studies focused on populations of only women with chronic hypertension, and the others included women with several different risk factors for preeclampsia. The retrospective studies and one of the randomized controlled trials compared aspirin treatment with no treatment, and the others compared with a placebo group; all studies used a dose of aspirin between 60 and 150 mg daily. No studies were excluded from the analysis based on risk of bias, as none were determined to be “critical” or “high” risk, although risk of bias was determined to be a contributing factor to low-quality data. Final analysis included a pooled sample size of 1078 individuals with chronic hypertension on low-dose aspirin, compared with 1072 women with chronic hypertension in control groups. This analysis did not find a decreased odds of superimposed preeclampsia in either randomized controlled trials (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.55–1.25) or observational studies (OR, 1.21; 95% CI, 0.78–1.87). No significant differences were found with aspirin treatment, possibly due to risk of bias, heterogeneity, and imprecision. These findings held true when analyzed based on the timing of aspirin treatment induction (before or after 20 weeks' gestation), still finding no difference in the rate of superimposed preeclampsia. Low-dose aspirin treatment did reduce the odds of preterm birth according to a pooled analysis of 2 randomized controlled trials (OR, 0.62; 95% CI, 0.45–0.89). However, neither SGA nor perinatal mortality was shown to be significantly different in a pooled analysis of the studies that reported this outcome. Although these findings did not show statistical significance in reduction of preeclampsia in women with chronic hypertension due to aspirin treatment, the data are suggestive of benefit; many individuals in each study were lost to follow-up, and thus, the results of the analysis are different than they m
患有慢性高血压的女性在怀孕期间发生子痫前期的风险增加。低剂量阿司匹林治疗已经在预防子痫前期的背景下进行了研究,但在不同的人群中有相互矛盾的结果。造成这种情况的一些原因是治疗方案的不均匀,包括时间、剂量,甚至目标结果。在低剂量阿司匹林对子痫前期影响的数据有限的人群中,有慢性高血压的妇女。本研究是一项系统综述和荟萃分析,旨在分析妊娠期间低剂量阿司匹林的使用情况,并评估该治疗是否能降低慢性高血压妇女合并先兆子痫的风险。它还旨在次要评估相关结果,如小于胎龄(SGA)、早产和围产期死亡率。系统检索和评估分离出9篇文章进行最终分析。其中6项为随机对照试验,3项为回顾性队列研究。四项研究只关注患有慢性高血压的女性人群,其他研究包括患有子痫前期几种不同风险因素的女性。回顾性研究和一项随机对照试验将阿司匹林治疗组与不治疗组进行了比较,其他研究将安慰剂组与安慰剂组进行了比较;所有研究使用的阿司匹林剂量在每天60到150毫克之间。没有研究被排除在基于偏倚风险的分析之外,因为没有研究被确定为“关键”或“高”风险,尽管偏倚风险被确定为低质量数据的一个促成因素。最终分析包括1078名服用低剂量阿司匹林的慢性高血压患者,与对照组的1072名女性慢性高血压患者进行比较。该分析未发现两项随机对照试验中合并先兆子痫的几率降低(比值比[OR], 0.83;95%可信区间[CI], 0.55-1.25)或观察性研究(or, 1.21;95% ci, 0.78-1.87)。阿司匹林治疗组未发现显著差异,可能是由于存在偏倚、异质性和不精确的风险。当基于阿司匹林治疗诱导的时间(妊娠20周之前或之后)进行分析时,这些发现是正确的,仍然没有发现叠加先兆子痫发生率的差异。根据两项随机对照试验的汇总分析,低剂量阿司匹林治疗确实降低了早产的几率(OR, 0.62;95% ci, 0.45-0.89)。然而,在对报道这一结果的研究的汇总分析中,SGA和围产期死亡率均未显示出显著差异。虽然这些发现在阿司匹林治疗导致的慢性高血压妇女子痫前期减少方面没有统计学意义,但这些数据表明是有益的;每项研究中都有许多个体在随访中丢失,因此,分析的结果与保留更大的情况下可能出现的结果不同。观察性研究的结果表明,低剂量阿司匹林治疗可能在统计学上增加合并先兆子痫的可能性,但这些结果存在高度的不确定性。它们增加了先前关于这一主题的相互矛盾的发现;需要更多的研究,以更大和更少的异质样本来澄清这种联系。这项研究的结果与之前的研究结果相矛盾,之前的研究包括了具有各种子痫前期风险因素的个体,但与之前的研究一致,仅包括慢性高血压患者。由于异质性和偏倚,本研究受到证据质量的限制,但应促进对慢性高血压人群低剂量阿司匹林治疗的进一步研究。
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引用次数: 1
Effectiveness and Safety of Prenatal Valacyclovir for Congenital Cytomegalovirus Infection: Systematic Review and Meta-analysis 产前缬昔洛韦治疗先天性巨细胞病毒感染的有效性和安全性:系统评价和荟萃分析
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/ogx.0000000000001212
F. D'Antonio, D. Marinceu, S. Prasad, A. Khalil
ABSTRACT One of the most common causes of infection-related fetal malformations is congenital cytomegalovirus (CMV), which affects approximately 0.5% to 2% of newborns. Several approaches have been investigated for screening, prevention, and treatment; one drug that shows activity against CMV is valacyclovir, and prenatal administration of this drug has been investigated in the context of preventing fetal disorders due to CMV. Although studies and clinical trials have been done regarding the safety and effectiveness of valacyclovir, clinical attitudes regarding universal CMV screening and prenatal valacyclovir treatment have yet to change. This article is a systematic review and meta-analysis of the safety and effectiveness of prenatal valacyclovir in CMV-infected pregnancies. Inclusion criteria included pregnancies with CMV infection diagnosed through serology, with a primary outcome of incidence of congenital CMV confirmed by polymerase chain reaction from amniocentesis. Secondary outcomes included symptomatic infection (rash, jaundice, microcephaly, seizures, hepatosplenomegaly, hearing loss, visual loss, retinitis, and central nervous system anomalies), asymptomatic infection, perinatal death, pregnancy termination, fetal anomaly, or severe symptoms. Adverse events related to the administration of valacyclovir were also recorded. Because relatively few studies were available for inclusion, the authors were unable to assess publication bias, but other risk of bias was assessed using standard tools. Final analysis included 8 studies and 620 pregnant women with CMV in 2 randomized controlled trials and 6 observational studies. One randomized controlled trial focused on valacyclovir treatment for CMV infection acquired in early pregnancy, and the other assessed valacyclovir treatment between 34 and 38 weeks' gestation to reduce risk of CMV within 1 year of delivery. The latter of the 2 studies was not included in pooled data synthesis because of inclusion criteria differences. Three studies focused on valacyclovir treatment for confirmed maternal CMV infection; pooled data analysis showed that valacyclovir-treated pregnancies had lower risk of congenital CMV (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.21–0.64; P < 0.001). When contracted in the first trimester, risk of vertical transmission was lower in those who were treated with valacyclovir (OR, 0.34; 95% CI, 0.15–0.74; P = 0.001); however, there was no effect observed in those with CMV in the periconceptual period. Analysis additionally showed that prenatal valacyclovir treatment was more likely to result in asymptomatic children (OR, 2.98; 95% CI, 1.18–7.55; P = 0.021), but no other significant perinatal differences were observed. These results show that treatment of CMV with prenatal valacyclovir reduces the risk of congenital CMV and its associated complications. Limitations of this analysis include the heterogeneity of inclusion and measurement criteria, as well as small sampl
感染相关胎儿畸形的最常见原因之一是先天性巨细胞病毒(CMV),影响约0.5%至2%的新生儿。已经研究了几种筛查、预防和治疗方法;一种显示抗巨细胞病毒活性的药物是valacyclovir,产前给药这种药物已经在预防巨细胞病毒引起的胎儿疾病的背景下进行了研究。尽管关于valacyclovir安全性和有效性的研究和临床试验已经完成,但临床对通用巨细胞病毒筛查和产前valacyclovir治疗的态度尚未改变。这篇文章是一个系统的回顾和荟萃分析的安全性和有效性产前缬昔洛韦在巨细胞病毒感染的妊娠。纳入标准包括通过血清学诊断为巨细胞病毒感染的妊娠,主要结局是羊膜穿刺术的聚合酶链反应证实先天性巨细胞病毒的发病率。次要结局包括症状性感染(皮疹、黄疸、小头畸形、癫痫发作、肝脾肿大、听力丧失、视力丧失、视网膜炎和中枢神经系统异常)、无症状感染、围产期死亡、终止妊娠、胎儿异常或严重症状。与服用伐昔洛韦有关的不良事件也被记录下来。由于可纳入的研究相对较少,作者无法评估发表偏倚,但使用标准工具评估了其他偏倚风险。最终分析包括8项研究和620名巨细胞病毒孕妇,其中2项随机对照试验和6项观察性研究。一项随机对照试验侧重于valacyclovir治疗妊娠早期获得的巨细胞病毒感染,另一项试验评估valacyclovir治疗妊娠34至38周之间以降低分娩后1年内巨细胞病毒的风险。由于纳入标准不同,后一项研究未纳入汇总数据综合。三项研究聚焦于伐昔洛韦治疗确诊的母体巨细胞病毒感染;综合数据分析显示,服用伐昔洛韦的孕妇发生先天性巨细胞病毒的风险较低(优势比[OR], 0.37;95%置信区间[CI], 0.21-0.64;P & lt;0.001)。当在妊娠早期感染时,接受伐昔洛韦治疗的患者垂直传播的风险较低(OR, 0.34;95% ci, 0.15-0.74;P = 0.001);然而,在围孕期的巨细胞病毒患者中没有观察到任何影响。分析还显示,产前使用伐昔洛韦治疗更有可能导致无症状儿童(OR, 2.98;95% ci, 1.18-7.55;P = 0.021),但其他围产儿差异无统计学意义。这些结果表明,产前使用伐昔洛韦治疗巨细胞病毒可降低先天性巨细胞病毒及其相关并发症的风险。该分析的局限性包括纳入和测量标准的异质性,以及评估围产期结局的小样本。与该药物相关的风险很小,并且在患者停用valacyclovir后不良事件得到解决。这一发现与先前的研究一致,表明了valacyclovir的益处。进一步的研究应该评估与valacyclovir治疗相关的围产期结局,以及valacyclovir在继发性感染和原发性感染中的作用。特别是,应该实施更大规模的随机对照试验,以确定伐昔洛韦治疗与胎儿结构异常、症状性感染和神经认知障碍风险的关系。
{"title":"Effectiveness and Safety of Prenatal Valacyclovir for Congenital Cytomegalovirus Infection: Systematic Review and Meta-analysis","authors":"F. D'Antonio, D. Marinceu, S. Prasad, A. Khalil","doi":"10.1097/ogx.0000000000001212","DOIUrl":"https://doi.org/10.1097/ogx.0000000000001212","url":null,"abstract":"ABSTRACT One of the most common causes of infection-related fetal malformations is congenital cytomegalovirus (CMV), which affects approximately 0.5% to 2% of newborns. Several approaches have been investigated for screening, prevention, and treatment; one drug that shows activity against CMV is valacyclovir, and prenatal administration of this drug has been investigated in the context of preventing fetal disorders due to CMV. Although studies and clinical trials have been done regarding the safety and effectiveness of valacyclovir, clinical attitudes regarding universal CMV screening and prenatal valacyclovir treatment have yet to change. This article is a systematic review and meta-analysis of the safety and effectiveness of prenatal valacyclovir in CMV-infected pregnancies. Inclusion criteria included pregnancies with CMV infection diagnosed through serology, with a primary outcome of incidence of congenital CMV confirmed by polymerase chain reaction from amniocentesis. Secondary outcomes included symptomatic infection (rash, jaundice, microcephaly, seizures, hepatosplenomegaly, hearing loss, visual loss, retinitis, and central nervous system anomalies), asymptomatic infection, perinatal death, pregnancy termination, fetal anomaly, or severe symptoms. Adverse events related to the administration of valacyclovir were also recorded. Because relatively few studies were available for inclusion, the authors were unable to assess publication bias, but other risk of bias was assessed using standard tools. Final analysis included 8 studies and 620 pregnant women with CMV in 2 randomized controlled trials and 6 observational studies. One randomized controlled trial focused on valacyclovir treatment for CMV infection acquired in early pregnancy, and the other assessed valacyclovir treatment between 34 and 38 weeks' gestation to reduce risk of CMV within 1 year of delivery. The latter of the 2 studies was not included in pooled data synthesis because of inclusion criteria differences. Three studies focused on valacyclovir treatment for confirmed maternal CMV infection; pooled data analysis showed that valacyclovir-treated pregnancies had lower risk of congenital CMV (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.21–0.64; P &lt; 0.001). When contracted in the first trimester, risk of vertical transmission was lower in those who were treated with valacyclovir (OR, 0.34; 95% CI, 0.15–0.74; P = 0.001); however, there was no effect observed in those with CMV in the periconceptual period. Analysis additionally showed that prenatal valacyclovir treatment was more likely to result in asymptomatic children (OR, 2.98; 95% CI, 1.18–7.55; P = 0.021), but no other significant perinatal differences were observed. These results show that treatment of CMV with prenatal valacyclovir reduces the risk of congenital CMV and its associated complications. Limitations of this analysis include the heterogeneity of inclusion and measurement criteria, as well as small sampl","PeriodicalId":19409,"journal":{"name":"Obstetrical & Gynecological Survey","volume":"33 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135963374","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
The Cell-Free DNA Virome of 108,349 Dutch Pregnant Women 108349名荷兰孕妇的无细胞DNA病毒组
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/01.ogx.0000993668.06748.a3
Jasper Linthorst, Moezammin M. M. Baksi, Matthijs R. A. Welkers, Erik A. Sistermans
ABSTRACT Pregnancy increases the body's vulnerability to infectious disease, and current guidelines during pregnancy include minimizing possible exposure to viral infection. In cases where viral infection does occur, these can cause mild to severe complications in both mother and fetus; many viruses that result in such complications are DNA viruses. Current diagnosis technology for DNA viruses relies largely on polymerase chain reaction (PCR), which is very sensitive but generally targeted at a specific virus and so tends to not be very comprehensive. In addition, this testing is normally performed only on those who are at high risk or expressing symptoms. To more fully understand the effect and prevalence of DNA viruses in pregnancy, this study used noninvasive prenatal testing (NIPT) that captures cell-free DNA (cfDNA) to examine the DNA virome in pregnant women between 2017 and 2020. Data included deidentified NIPT results for 108,349 individuals, and DNA sequences were used to screen for 224 DNA viruses. Viruses that were genetically similar were differentiated based on taxonomy through a meticulous decision tree to avoid generalized errors in categorizing them. The most commonly detected virus was parvovirus B19, occurring in approximately 1 in 3000 cfDNA reads. High viral loads were also observed for hepatitis B, Bocaparvovirus , papillomavirus, adenovirus, adeno-associated virus, Epstein-Barr virus (EBV)/herpesvirus 4, cytomegalovirus (CMV), herpesvirus 6, and torque teno virus. A cross-examination of demographic and pregnancy factors revealed many associations, most of which remained significant after adjustments for multiple comparisons. Available characteristics included maternal age, body mass index (BMI), gestational age, fetal fraction, and the number of sequenced reads with the presence of viral DNA in the samples. Detection of viral DNA was associated with lower BMI, along with a lower concentration of cfDNA and a higher fetal fraction. When individual viruses were analyzed, CMV had the most significant relationship with gestational age and maternal age. Results additionally showed that low fetal fraction was associated with lower detection of viral DNA for specific viruses. These results show that it is feasible to detect viral DNA in NIPT samples. If viral DNA can be detected, there is potential to diagnose infection and to possibly prevent complications due to the virus. Current clinical practice does not use NIPT as a diagnostic tool for viral infection, but there is potential for this in the future. Further research should focus on clinical utility, sensitivity, specificity, and accuracy, as well as the relationship of viral DNA with low fetal fraction.
怀孕增加了身体对传染病的易感性,目前的怀孕指南包括尽量减少可能的病毒感染。在确实发生病毒感染的情况下,这些可能会导致母亲和胎儿出现轻微到严重的并发症;许多导致这种并发症的病毒是DNA病毒。目前的DNA病毒诊断技术主要依赖于聚合酶链反应(PCR),该技术非常敏感,但通常针对特定的病毒,因此往往不是很全面。此外,这种检测通常只对那些有高风险或有症状的人进行。为了更充分地了解DNA病毒在怀孕期间的影响和流行程度,本研究使用了无细胞DNA (cfDNA)的无创产前检测(NIPT)来检测2017年至2020年间孕妇的DNA病毒组。数据包括108,349人的NIPT鉴定结果,DNA序列用于筛选224种DNA病毒。通过精细决策树的分类方法,对基因相似的病毒进行分类,避免了分类的泛化错误。最常检测到的病毒是细小病毒B19,大约在3000个cfDNA读数中出现1个。乙型肝炎病毒、bocaparvov病毒、乳头瘤病毒、腺病毒、腺相关病毒、eb病毒/疱疹病毒4、巨细胞病毒(CMV)、疱疹病毒6和torque teno病毒的病毒载量也很高。人口统计学和妊娠因素的交叉检查揭示了许多关联,其中大多数在多次比较调整后仍然显着。可用的特征包括母亲年龄、体重指数(BMI)、胎龄、胎儿分数以及样本中存在病毒DNA的测序读数。病毒DNA的检测与较低的BMI、较低的cfDNA浓度和较高的胎儿分数相关。当对单个病毒进行分析时,巨细胞病毒与胎龄和母亲年龄的关系最为显著。结果还表明,低胎儿分数与特定病毒的低病毒DNA检测相关。这些结果表明,在NIPT样品中检测病毒DNA是可行的。如果能检测到病毒DNA,就有可能诊断感染,并可能预防由病毒引起的并发症。目前的临床实践并没有使用NIPT作为病毒感染的诊断工具,但在未来有这种潜力。进一步的研究应侧重于临床应用、敏感性、特异性和准确性,以及病毒DNA与低胎儿分数的关系。
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引用次数: 0
Nicotine Use During Pregnancy: Cessation and Treatment Strategies 怀孕期间使用尼古丁:戒烟和治疗策略
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/ogx.0000000000001191
Avan Shirwani, Jeffrey A. Kuller, Sarah K. Dotters-Katz, Kateena Addae-Konadu
ABSTRACT The use of tobacco and nicotine products during pregnancy is known to increase the risk of adverse effects on the fetus. Increased education and research have resulted in greater rates of smoking cessation during pregnancy, with a decline from 13.2% of pregnant individuals smoking in 2006 to 7.2% in 2016. However, smoking while pregnant still proves to be a prevalent issue that is associated with numerous adverse outcomes, including low birth weight, preterm birth, and developmental delays. Smoking cessation before or during pregnancy can help mitigate these effects, but the appropriate treatment can be challenging to ascertain. Accordingly, clinicians should look to provide individualized care composed of behavioral counseling in conjunction with pharmacotherapies when indicated, combined with ongoing support and education. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After completing this activity, the learner should be better able to identify the pathophysiologic effects of smoking during pregnancy and the different forms of nicotine use; describe the maternal risk of smoking, along with its neonatal and childhood effects; and explain the potential screening and treatment strategies for smoking cessation during pregnancy.
怀孕期间使用烟草和尼古丁产品会增加胎儿不良反应的风险。教育和研究的增加导致怀孕期间戒烟率上升,从2006年的13.2%下降到2016年的7.2%。然而,怀孕期间吸烟仍然是一个普遍存在的问题,它与许多不良后果有关,包括低出生体重、早产和发育迟缓。在怀孕前或怀孕期间戒烟可以帮助减轻这些影响,但适当的治疗方法可能很难确定。因此,临床医生应该寻求提供个性化的护理,包括行为咨询和药物治疗,并结合持续的支持和教育。目标受众:妇产科医生、家庭医生。学习目标完成本活动后,学习者应能更好地识别怀孕期间吸烟的病理生理影响和不同形式的尼古丁使用;描述母亲吸烟的风险及其对新生儿和儿童的影响;并解释怀孕期间戒烟的潜在筛查和治疗策略。
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引用次数: 0
CME PROGRAM EXAM AND ANSWER SHEET 继续教育课程考试及答题卡
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/ogx.0000000000001221
Obstetrical & Gynecological Survey 78(10):p 620-622, October 2023. | DOI: 10.1097/OGX.0000000000001221
妇产科调查78(10):p 620-622, 2023年10月。| doi: 10.1097/ ogx.0000000000001221
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引用次数: 0
Tranexamic Acid to Prevent Obstetrical Hemorrhage After Cesarean Delivery 氨甲环酸预防剖宫产后产科出血
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/01.ogx.0000993672.66513.1f
L. D. Pacheco, R. G. Clifton, G. R. Saade, S. J. Weiner, S. Parry, J. M. Thorp, M. Longo, A. Salazar, W. Dalton, A. T. N. Tita, C. Gyamfi-Bannerman, S. P. Chauhan, T. D. Metz, K. Rood, D. J. Rouse, J. L. Bailit, W. A. Grobman, H. N. Simhan, G. A. Macones
ABSTRACT Previous research has presented convincing evidence that the administration of tranexamic acid (TXA) after cesarean delivery can reduce the incidence of postpartum hemorrhage (PPH) and the associated mortality and morbidity. Although there have been several significant studies on this topic, they are limited by small sample sizes, which make the studies difficult to generalize and limit their statistical power. This study aimed to address that gap and assess clinical outcomes related to the administration of TXA in a large sample. This was a multicenter, double-blind, randomized controlled trial including 31 hospitals participating in the Maternal-Fetal Medicine Units Network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Eligibility criteria included scheduled or unscheduled cesarean delivery of a singleton or twin gestation. Exclusion criteria included maternal age younger than 18 years, blood transfusion before randomization, plan for transfusion after randomization, contraindications to TXA, patient decision not to use blood products, or administration of antifibrolytic agents or uterotonic agents other than oxytocin. The primary outcome was maternal death or blood transfusion before hospital discharge or 7 days after delivery, whichever came first. Secondary outcomes included intraoperative blood loss of more than 1 L and treatments or interventions in response to bleeding or related complications within 7 days of delivery, as well as infectious complications within 6 weeks of delivery. Final analyses included 11,000 patients, with 5529 in the TXA group and 5471 in the placebo group. Baseline characteristics were not significantly different between groups, and no center-dependent differences were observed. The primary outcome was observed in 3.6% of patients in the TXA group and 4.3% of patients in the placebo group (adjusted relative risk, 0.89; P = 0.19). Intraoperative blood loss of more than 1 L was recorded in 7.3% and 8.0% in the tranexamic and placebo groups, respectively (relative risk, 0.90; 95% CI, 0.79–1.05). Treatments and interventions in response to bleeding occurred in 16.1% of individuals in the TXA group and 18.0% of those in the placebo group (relative risk, 0.90; 95% CI, 0.82–0.97). Infectious complications were reported in 3.2% and 2.5% in the TXA and placebo groups, respectively (relative risk, 1.28; 95% CI, 1.02–1.61). Sensitivity analysis showed similar results to initial analysis, and no significant differences were seen between groups in major safety outcomes. This analysis indicates that the administration of TXA during cesarean delivery did not lower the risk of maternal death or blood transfusion. These results are in direct contradiction to previous research showing that TXA is effective at reducing these outcomes. This trial was stronger than any previous studies in sample size and careful randomization ensuring equal representation of scheduled and unscheduled c
既往研究已提供令人信服的证据,表明剖宫产后给予氨甲环酸(TXA)可降低产后出血(PPH)的发生率及相关的死亡率和发病率。虽然已经有一些关于这一主题的重要研究,但它们受到样本量小的限制,这使得研究难以推广,限制了它们的统计能力。本研究旨在解决这一差距,并在大样本中评估与TXA管理相关的临床结果。这是一项多中心、双盲、随机对照试验,包括31家医院参与了尤尼斯肯尼迪施赖弗国家儿童健康和人类发展研究所的母胎医学单位网络。入选标准包括单胎或双胎妊娠的预定或非预定剖宫产。排除标准包括母亲年龄小于18岁,随机化前输血,随机化后输血计划,TXA禁忌症,患者决定不使用血液制品,或使用除催产素以外的抗纤溶药物或子宫舒张药物。主要结局为产妇死亡或出院前输血或分娩后7天输血,以先发生者为准。次要结局包括术中出血量大于1l,分娩7天内出血或相关并发症的治疗或干预措施,以及分娩6周内的感染性并发症。最终的分析包括11000例患者,其中5529例为TXA组,5471例为安慰剂组。各组间基线特征无显著差异,无中心依赖性差异。TXA组3.6%的患者和安慰剂组4.3%的患者观察到主要结局(校正相对风险,0.89;P = 0.19)。氨甲环组和安慰剂组术中出血量大于1l的比例分别为7.3%和8.0%(相对危险度为0.90;95% ci, 0.79-1.05)。在TXA组中,16.1%的个体对出血进行了治疗和干预,而在安慰剂组中,这一比例为18.0%(相对风险,0.90;95% ci, 0.82-0.97)。TXA组和安慰剂组的感染并发症发生率分别为3.2%和2.5%(相对危险度为1.28;95% ci, 1.02-1.61)。敏感性分析结果与初始分析结果相似,各组间主要安全性结果无显著差异。这一分析表明,在剖宫产期间给予TXA并没有降低产妇死亡或输血的风险。这些结果与先前表明TXA能有效降低这些结果的研究结果直接矛盾。该试验在样本量和谨慎的随机化方面强于以往的任何研究,确保了计划和非计划剖宫产的平等代表性,这使得与以往研究的矛盾尤为重要。该试验的一些局限性包括给药时间和剂量的限制。与这两个变量相关的结果在很大程度上仍然未知。该试验还排除了血栓栓塞现象高风险的患者,TXA在这一人群中的作用尚不清楚。进一步的研究应该关注更多样化的人群,并了解随着时间和剂量的变化结果,这是本研究没有解决的问题。
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引用次数: 0
US Infant Pertussis Incidence Trends Before and After Implementation of the Maternal Tetanus, Diphtheria, and Pertussis Vaccine 美国婴儿百日咳发病率趋势前后实施产妇破伤风,白喉,百日咳疫苗
4区 医学 Q1 OBSTETRICS & GYNECOLOGY Pub Date : 2023-10-01 DOI: 10.1097/01.ogx.0000993680.79685.68
Tami H. Skoff, Li Deng, Catherine H. Bozio, Susan Hariri
ABSTRACT Many illnesses can become especially serious when contracted within the first year of life; pertussis remains quite deadly despite recent medical advances in disease prevention. Current guidance on vaccination in the United States includes 3 doses of the DTaP (diphtheria, tetanus toxoid, and acellular pertussis) vaccine beginning at 2 months of age, but this regimen leaves infants younger than that very vulnerable to illness. Research has shown both that vaccinating mothers with tetanus toxoid reduces tetanus, diphtheria, and pertussis (Tdap) between 27 and 36 weeks of gestation significantly reduces instances of pertussis in infants younger than 2 months, and that maternal vaccination rates have risen in the last few years. However, research is lacking in analyzing the relationship between vaccination rates in pregnant mothers and the burden of pertussis in infants in the United States. This study was designed to assess data from 2000 to 2019 and examine the association of Tdap vaccination during pregnancy with trends in infant pertussis. This analysis included data obtained from the National Notifiable Diseases Surveillance System between 2000 and 2019. This included a total of 57,460 cases of pertussis in infants younger than 1 year and a total of 19,322 cases in infants younger than 2 months. The rate of pertussis incidence for infants younger than 2 months in the time period before the implementation of prenatal Tdap was calculated to be 165.3 per 100,000 individuals, with no significant trend observed annually ( P = 0.28). After the implementation of routine maternal Tdap, incidence decreased to 80.9 per 100,000 infants between 2017 and 2019. Accounting for both time periods, the mean annual incidence was calculated as 121.8 per 100,000 infants younger than 2 months. Annual incidence also showed a significant decreasing trend in the period after implementation of maternal Tdap vaccination (slope: −14.53 per 100,000 infants per year; P = 0.001). The change in trends before and after this implementation was also significant ( P = 0.01). In a slightly older age group of 6 to 12 months of age, mean annual incidence of pertussis was 19.7 per 100,000 infants. In the time period before implementation of maternal Tdap, incidence among infants aged 6 to 12 months was consistently 4 to 12 times less than infants younger than 2 months and did not significantly change after the implementation of the maternal vaccine. Comparing the 2 age groups, there was no significant change in the difference in incidence between infants younger than 2 months and those between 6 and 12 months in the period before the maternal vaccine, and after its implementation, there was a significant decrease in the incidence difference between the 2 groups ( P < 0.001). These results suggest an association between the maternal Tdap vaccination and trends of pertussis incidence in infants younger than 2 months. This also indicates a possible reduction in disease burden at
许多疾病在生命的第一年感染时可能会变得特别严重;尽管最近在疾病预防方面取得了医学进步,百日咳仍然是相当致命的。美国目前的疫苗接种指南包括从2个月大开始接种3剂DTaP(白喉、破伤风类毒素和无细胞百日咳)疫苗,但这种方案使年龄小于2个月的婴儿非常容易患病。研究表明,为母亲接种破伤风类毒素疫苗可在妊娠27周至36周期间减少破伤风、白喉和百日咳(Tdap),显著减少2个月以下婴儿的百日咳病例,而且母亲疫苗接种率在过去几年中有所上升。然而,在美国,缺乏对孕妇疫苗接种率与婴儿百日咳负担之间关系的分析研究。本研究旨在评估2000年至2019年的数据,并检查怀孕期间接种百日咳疫苗与婴儿百日咳趋势的关系。该分析包括2000年至2019年期间从国家法定疾病监测系统获得的数据。其中包括1岁以下婴儿百日咳57,460例,2个月以下婴儿百日咳19,322例。在实施产前百日咳百日咳前,2个月以下婴儿百日咳发病率计算为每10万人165.3例,每年无显著趋势(P = 0.28)。在实施常规母亲百白破疫苗后,2017年至2019年期间,发病率降至每10万名婴儿80.9例。考虑到这两个时间段,计算出的年平均发病率为每10万名2个月以下婴儿121.8例。在实施母亲百白破疫苗接种后,年发病率也呈现显著下降趋势(斜率:- 14.53 / 10万婴儿/年;P = 0.001)。实施前后的趋势变化也很显著(P = 0.01)。在年龄稍大的6至12个月的年龄组中,百日咳的年平均发病率为每10万名婴儿19.7例。在实施母亲百白破疫苗之前,6至12个月婴儿的发病率始终比2个月以下婴儿低4至12倍,并且在实施母亲百白破疫苗后没有显着变化。两个年龄组比较,接种疫苗前2个月以下婴儿与6 ~ 12个月婴儿的发病率差异无显著变化,接种疫苗后两组发病率差异显著降低(P <0.001)。这些结果表明,母亲接种百日咳疫苗与2个月以下婴儿百日咳发病率趋势之间存在关联。这也表明,产妇在分娩前接种百白破疫苗可能会减少疾病负担。本研究的局限性包括个体母亲疫苗接种状况的有限可用性,以及无法确定是否有婴儿在2个月前接种过疫苗。进一步的研究应侧重于在后期接种百白破疫苗的背景下接种百白破疫苗的临床影响,并分析与两种疫苗接种相关的疾病趋势。还应审查临床指南,以确保公共卫生趋势和个人健康趋势相一致。
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引用次数: 0
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Obstetrical & Gynecological Survey
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