Obstetrics and gynecology最新文献

Objective: To evaluate the effect of a behavioral science-informed intervention designed to facilitate postpartum-to-primary care transitions on primary care visits and screenings within 1 year postpartum for individuals with chronic conditions or pregnancy conditions with long-term health risks.

Methods: This was a planned secondary analysis of a randomized controlled trial of a behavioral science-informed intervention designed to increase primary care practitioner (PCP) visits within 4 months postpartum compared with routine care. The intervention included default PCP visit scheduling with nudge reminders and use of tailored language. The primary outcome for this secondary analysis was attending an annual examination or health care maintenance visit with a PCP within 1 year postpartum. Visits with a PCP for any reason and receipt of screenings or services by a PCP (eg, weight, blood pressure, mood screening) were also compared. Outcomes were compared between groups with χ2 testing.

Results: All 353 participants were followed through 1 year after their due dates: 173 in the control group and 180 in the intervention group. More patients in the intervention group attended an annual examination with a PCP within 1 year compared with the control group (59.0% vs 39.3%, P<.001) and had a PCP visit for any reason (72.8% vs 61.3%, P=.02). A significantly higher rate of mental health disorder screening was observed in the intervention group (63.9% vs 55.5%, P=.046); significant differences in other screenings were not observed.

Conclusion: This relatively simple and low-cost intervention designed to facilitate transition from postpartum to primary care within the first 4 months demonstrated benefits for PCP engagement within the first year postpartum.

Clinical trial registration: ClinicalTrials.gov, NCT05543265.

Objective: To identify underlying causes, contributing factors, and quality-improvement opportunities of pregnancy-related hemorrhage deaths.

Methods: The California Pregnancy-Associated Mortality Review examined pregnancy-related hemorrhage deaths in California that occurred in 2014-2018. Data were abstracted from multiple sources (vital records, hospital encounter data, medical records, and coroner or autopsy reports). A multidisciplinary expert panel reviewed all case summaries. Data from reviews were aggregated to determine underlying causes of death, preventability, contributing factors, and quality-improvement opportunities at the patient, clinician, facility, and system levels.

Results: During the study period, there were 2,409,732 live births and 49 pregnancy-related hemorrhage deaths. Placenta accreta spectrum accounted for 16 (32.7%) of deaths; intra-abdominal bleeding and uterine atony each accounted for 10 deaths (20.4%). Compared with the California birth population, a significantly higher proportion of women who died were born in China (14.3% vs 3.9%); were 35 years of age or older (49.0% vs 21.9%); had two or more prior births (57.4% vs 29.1%); had cesarean deliveries (74.4% vs 31.8%); or delivered at hospitals with fewer than 1,200 births per year (33.3% vs 12.2%) (all P<.05). The committee determined that 63.3% of all hemorrhage deaths were highly preventable with substantial variation by cause. Clinician-, facility-, and system-level contributing factors were noted in 88.9% of cases and included delayed response or escalation (77.8%), delayed recognition (72.2%), and insufficient quantities of blood products used (52.8%). Corresponding quality-improvement opportunities included timely hemorrhage risk assessment; increased vigilance for identifying signs and symptoms of hemorrhage; escalation of care and aggressive management; preparation for hemorrhage complications and ongoing training for all hospitals, particularly low-resource facilities; and adherence to severe hemorrhage protocols.

Conclusion: Obstetric hemorrhage remains a leading cause of pregnancy-related mortality and has multiple causes with various levels of preventability. Optimizing system-based approaches for hemorrhage preparedness, detection, and clinical management is critical to reduce preventable deaths from hemorrhage, especially among patients who do not respond to first-line treatment.

Objective: To evaluate the association between previous non-cesarean uterine surgery and placenta accreta spectrum (PAS) in subsequent pregnancies.

Data sources: PubMed, EMBASE, the Cochrane Library, ClinicalTrials.gov, CNKI (China National Knowledge Infrastructure), and Wan-fang Database were searched from inception to April 2024, supplemented by manual searches.

Methods of study selection: Studies included prospective, retrospective cohort, case-control, and cross-sectional studies involving pregnant women diagnosed with PAS and reporting at least one risk factor associated with previous uterine surgery.

Tabulation, integration, and results: Two authors independently screened potentially eligible studies and extracted data. The quality of the studies was assessed with the Newcastle-Ottawa Scale. The pooled odds ratios (ORs), adjusted ORs, and their 95% CIs were estimated with fixed- or random-effects models if the heterogeneity (I2) was high. Sensitivity analyses were conducted to account for potential study bias. The main measures were myomectomy, uterine artery embolization, dilatation and curettage, hysteroscopic adhesiolysis, abortion, endometrial ablation, and operative hysteroscopy. A total of 38 studies involving 7,353,177 participants were included in the systematic review, with an overall prevalence of PAS of 0.16%, and 31 studies were included in the meta-analysis. Prior non-cesarean uterine surgeries were associated with PAS in subsequent pregnancy (pooled OR 2.29, 95% CI, 1.43-3.68). Distinct associations between specific uterine surgery and PAS included myomectomy (OR 2.29, 95% CI, 1.77-2.97), uterine artery embolization (OR 43.16, 95% CI, 20.50-90.88), dilatation and curettage (OR 2.28, 95% CI, 1.78-2.93), hysteroscopic adhesiolysis (OR 7.72, 95% CI, 4.10-14.53), abortion (OR 1.65, 95% CI, 1.43-1.92), endometrial ablation (OR 20.26, 95% CI, 17.15-23.93), and operative hysteroscopy (OR 3.10, 95% CI, 1.86-5.18).

Conclusion: Prior non-cesarean uterine surgery is associated with a significantly increased odds for development of PAS in subsequent pregnancy, and the risk varies depending on the types of uterine surgery.

Systematic review registration: PROSPERO: CRD42024552210.

Carpal tunnel syndrome (CTS) represents a constellation of symptoms that can occur as a result of compression of the median nerve as it traverses through a constrained space at the level of the wrist. It is the most common compressive mononeuropathy in the human body. Patients frequently present with similar history and physical examination findings, most commonly consisting of numbness of the hand that is worse at nighttime. Although CTS is one of the more common conditions seen by hand, orthopedic, or plastic surgeons, patients often first report symptoms to their primary or obstetric care clinician. In this review, we describe the pathophysiology of CTS in pregnant patients, summarize the best methods for diagnosing this condition, and review the recommended treatment options. This review provides a practical strategy that can be used by both primary care and obstetric care clinicians in diagnosing and treating pregnant patients with CTS.

Objective: To evaluate whether comorbidities (defined as both medical conditions and peripartum complications) are associated with inpatient postpartum permanent contraception by tubal surgery completion.

Methods: This is a secondary analysis of a multisite retrospective cohort study of patients who had documented plans for permanent contraception. Our primary outcome was inpatient completion of postpartum permanent contraception by tubal surgery. We used univariable and multivariable logistic regression analyses to examine associations between aggregate and individual comorbidities and the attainment of inpatient postpartum permanent contraception.

Results: In this study of 2,226 pregnant people, 53.4% of patients received postpartum permanent contraception by the time of hospital discharge, and 70.8% of patients had documented comorbidities. Although patients with medical conditions initially had lower odds of permanent contraception completion compared with those without any comorbidities (adjusted odds ratio [aOR] 0.77, 95% CI, 0.64-0.93), this association was no longer significant after adjusting for multiple comparisons (adjusted P=.06). This association also was not significant for patients with peripartum complications (aOR 0.86, 95% CI, 0.64-1.16, adjusted P=.42). Similarly, when individual comorbidities were assessed, patients with hypertension (aOR 0.80, 95% CI, 0.65-0.97, adjusted P=.06), mental health diagnoses (aOR 0.80, 95% CI, 0.66-0.96, adjusted P=.06), and elevated body mass index (BMI, 40 or higher) (aOR 0.77, 95% CI, 0.63-0.95, adjusted P=.06) had no significant differences in odds of immediate permanent contraception attainment after adjusting for multiple comparisons.

Conclusions: Though the balance of risks and benefits is imperative for surgical care, it is imperative that modifiable barriers to desired permanent contraception are mitigated. There were no statistically significant differences in inpatient postpartum permanent contraception attainment for patients with medical conditions in our study; however, further study is needed to better elucidate the complex relationships between medical comorbidities and contraception.

Little is known about the fetal-neonatal pharmacokinetics of maternally administered, weight-based vancomycin dosing for group B streptococcus (GBS) intrapartum antibiotic prophylaxis. Our objective was to quantify vancomycin concentrations in umbilical cord blood at birth after weight-based maternal intrapartum vancomycin administration and to assess cord blood vancomycin levels relative to the established GBS clinical minimum inhibitory concentration (MIC) breakpoint. Using a convenience sample of stored sera from our biorepository, we measured vancomycin levels in umbilical cord blood from 26 neonates after maternal intrapartum vancomycin exposure. Most neonates (24/26, 92.3%; 95% CI, 74.9-99.1%) had vancomycin cord blood levels above the MIC breakpoint (1 microgram/mL or higher) for GBS.

We examined the association between blood pressure (BP) in the early third trimester and hypertension 10-14 years after delivery per American College of Cardiology and American Heart Association recommendations. We conducted a secondary analysis using the prospective HAPO FUS (Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study) in patients without a chronic hypertension diagnosis. The exposure and outcome were systolic and diastolic BP measured in the early third trimester and 10-14 years after delivery, respectively. Among 4,697 participants in the HAPO FUS, at 10-14 years after delivery (median age 41.6 years), 8.3% had elevated BP, 14.1% had stage 1 hypertension, and 6.1% had stage 2 hypertension. Compared with normal BP, elevated BP in the early third trimester was associated with an increased risk of stage 1 hypertension (adjusted odds ratio [aOR] 2.76; 95% CI, 1.91-4.00) and stage 2 hypertension (aOR 3.76; 95% CI, 2.28-6.19). Stage 1 hypertension was associated with an increased risk of stage 2 hypertension (aOR 6.16; 4.24, 8.94). Pregnant individuals with high BP in the third trimester were at increased risk of developing hypertension 10-14 years after delivery.

Objective: To describe preterm birth frequency and newborn and infant outcomes overall and among preterm children in the MATISSE (Maternal Immunization Study for Safety and Efficacy) trial of maternal vaccination with bivalent respiratory syncytial virus (RSV) prefusion F protein-based vaccine (RSVpreF) to protect infants against severe RSV-associated illness.

Methods: MATISSE was a global, phase 3, randomized, double-blind trial. Pregnant individuals received single injections of RSVpreF or placebo. Adverse events of special interest, including preterm birth (gestational age less than 37 weeks) and low birth weight (2,500 g or less), were collected through 6 months after delivery (pregnant participants) and from birth through age 12 or 24 months (pediatric participants).

Results: Overall, 7,386 pregnant participants received RSVpreF (n=3,698) or placebo (n=3,688); 7,305 newborns and infants were included in the analysis. Most children in both groups were born full term (more than 93%) with normal birth weight (95% or higher). Newborn and infant outcomes, including rates of low birth weight and neonatal hospitalization, were favorable and comparable between groups. Preterm birth rates were 5.7% in the RSVpreF arm and 4.7% in the placebo arm (relative risk [RR] 1.20, 95% CI, 0.98-1.46); most were late preterm. Newborn and infant outcomes, including rates of low birth weight and neonatal hospitalization, were comparable between groups. Twenty-two newborn or infant deaths occurred during the study (RSVpreF n=8, placebo n=14). When stratified by income region, preterm birth rates in RSVpreF and placebo recipients were both 5.0% in high-income countries. Rates in non-high-income countries were 7.0% and 4.0% in the RSVpreF and placebo groups, respectively, and 8.3% and 4.0% in South Africa (RR 2.06, 95% CI, 1.21-3.51).

Conclusion: In this study of maternal RSVpreF vaccination, no clinically significant increase in adverse events of special interest, including preterm birth, low birth weight, or neonatal hospitalization, was observed among pregnant people in the overall analysis. In subgroup analysis of non-high-income countries, an elevated risk of preterm birth was observed. More research is needed to better ascertain preterm delivery risk factors, particularly aimed at minimizing disparities among geographic regions.

Funding source: This study was sponsored by Pfizer.

Clinical trial registration: ClinicalTrials.gov , NCT04424316.

Acetaminophen is a common over-the-counter medication that recently gained substantial media attention regarding its use by pregnant individuals. In this clinical perspective, we discuss the strengths and limitations of the published literature on the effect of maternal acetaminophen use in pregnancy on the child's risk of developing attention-deficit and hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Studies included were specifically selected on the basis of the quality and validity of ADHD or ASD outcome definitions. From a total of 56 identified studies, commentaries, and editorials of relevance, we critically reviewed nine studies with original data that satisfied our inclusion criteria and three meta-analyses. Most studies that have reported positive findings are difficult to interpret because they have important biases, notably a high degree of selection bias, variability in selection and adjustment for various potential confounders, and unmeasured familial confounding. When unobserved familial confounding through sibling analysis was controlled for, associations weakened substantially. This suggests that residual confounding from shared genetic and environmental factors may have caused an upward bias in the original observations. According to the current scientific evidence, in utero exposure to acetaminophen is unlikely to confer a clinically important increased risk of childhood ADHD or ASD. The current level of evidence does not warrant changes to clinical guidelines on the treatment of fever or pain in pregnancy. Prospective research designed to account for familial and psychosocial environmental factors related to both maternal use of acetaminophen and children's neurodevelopment should be undertaken.