Obstetrics and gynecology最新文献

Objective: To aid in cancer control and prevention activities by developing, calibrating, and validating three distinct natural history simulation models of uterine cancer, a growing public health concern.

Methods: To perform comparative analyses, we developed two state-transition microsimulation models and a multistage clonal expansion model of uterine cancer. The models simulate uterine cancer incidence and mortality. All three models were calibrated to common data on the incidence of uterine cancer from the Surveillance, Epidemiology, and End Results (SEER) 18 database. Each model accounts for changing trends in hysterectomy and obesity over time and simulates incidence and mortality for endometrioid and nonendometrioid tumors and uterine sarcoma. After calibration, we projected the incidence and mortality of uterine cancer to 2050.

Results: The three uterine cancer models were well calibrated to population data and produced comparable results for projecting the burden of disease through 2050. Among non-Hispanic White women aged 40 years or older, the models project that by 2050 the incidence of uterine cancer will rise to 76.1-81.8 per 100,000 woman-years, up from 2018 SEER incidence of 60.0 per 100,000 woman-years. Among non-Hispanic Black women, new cases will rise to 90.3-107.2 per 100,000 woman-years, up from 2018 SEER incidence of 61.3 per 100,000 woman-years. Within these populations, incidence-based mortality will increase to 11.3-12.3 deaths per 100,000 woman-years for non-Hispanic White women and to 28.2-35.7 deaths per 100,000 woman-years for non-Hispanic Black women.

Conclusion: Three distinct mathematical simulation models of uterine cancer have been calibrated to observed population-based incidence and mortality. All three models project substantial and continued increases in the incidence and mortality of uterine cancer.

Objective: To develop twin-specific birth weight percentiles with corresponding singleton percentiles from the same population.

Methods: Using 5 years (2019-2023) of twin and singleton birth data from the U.S. National Vital Statistics System, we applied two established methods for generating centile curves: quantile regression and the lambda-mu-sigma (LMS) method. We created birth weight curves by gestational age and corresponding reference values for twins and singletons separately for girls and boys. We compared percentage classified under specific percentiles of birth weight between our curves and an existing reference previously developed for twins (Alexander), which had errors in last menstrual period gestational dating among fetuses born more than 30 years ago, and a separate reference developed for preterm neonates (Fenton).

Results: The quantile regression and LMS methods produced similar twin and singleton growth curves, classifying an almost identical proportion of neonates as less than the 3rd, 5th, or 10th percentile and more than the 90th, 95th, or 97th percentile. The Alexander twin reference classified fewer twin neonates than expected with birth weight below the 10th percentile (6.4%) or above the 90th percentile (6.6%). In contrast, the Fenton reference developed among primarily singletons for preterm neonates classified more twin neonates than expected with birth weight below the 10th percentile (18.7%) and fewer than expected for above the 90th percentile (1.4%).

Conclusion: In a modern cohort of neonates, our twin reference provides improved classification of birth weight percentiles over the existing Alexander reference and over the Fenton reference for preterm neonates. Our singleton reference is a useful addition for studies that examine birth weight centiles among both twins and singletons because it is derived from the same underlying population as the twin reference.

Immigrants face challenges in navigating complex policies that govern access to health care, shelter, food, and clean water, resulting in profound effects on health care outcomes, including increased risk of preterm births and decreased access to preventive health services. These disparities are further exacerbated when immigration policies result in mass detention, incarceration, and deportation, leading to profound trauma among undocumented immigrants and their communities. Obstetrician-gynecologists and other reproductive health care professionals should be prepared to practice immigration-informed care and ensure clinical spaces are welcoming to immigrants. Unless mandated by law, health care professionals should document only information related to a patient's migration history that is necessary for the ongoing clinical care. Health care institutions should provide robust guidance and support for health care personnel and patients faced with the continued complexities of the dynamic landscape of immigration policies. Obstetrician-gynecologists should advocate for the unique needs of patients who are immigrants to promote reproductive justice and health equity.

Objective: Evidence related to anemia in early pregnancy, and its resolution or persistence by late pregnancy, is limited. We evaluated pregnancy outcomes associated with anemia in early pregnancy and resolution compared with persistence in late pregnancy.

Methods: We used the Merative™ Marketscan ® Commercial Database of nationwide insurance claims (2018-2023) and included pregnant individuals without hereditary anemias. We used hemoglobin and hematocrit to identify anemia in early pregnancy (before 14 weeks of gestation) and late pregnancy (at or after 24 weeks of gestation). Pregnancy outcomes included preeclampsia, placenta previa, placental abruption, severe postpartum hemorrhage, blood products transfusion, cesarean birth, nontransfusion severe maternal morbidity (SMM), spontaneous preterm birth, medically indicated preterm birth, and small-for-gestational-age (SGA) birth weight. We used modified Poisson regression to estimate associations between: 1) anemia in early pregnancy and pregnancy outcomes; and 2) anemia resolution by late pregnancy and pregnancy outcomes, adjusting for confounders by inverse probability weighting.

Results: Among 73,586 individuals, 4.4% (95% CI, 4.3-4.6%) had anemia in early pregnancy. Early pregnancy anemia was associated with higher risk of each outcome assessed, with the exception of placenta previa, with the highest associated risk of blood products transfusion (2.4% vs 0.8%; adjusted risk ratio [aRR] 2.45; 95% CI, 1.91-3.13). Of those with early pregnancy anemia and laboratory values in late pregnancy (72.1%), 53.4% had persistent anemia and 46.6% had resolved anemia. Persistent anemia was associated with nontransfusion SMM (2.6% vs 1.1%, aRR 1.64; 95% CI, 1.13-2.37), blood products transfusion (2.9% vs 0.8%, aRR 2.60; 95% CI, 1.84-3.69), and SGA birth weight (8.5% vs 6.8%, aRR 1.23; 95% CI, 1.01-1.50), compared with those without anemia in the first trimester. The resolution of anemia by late pregnancy was not associated with nontransfusion SMM (1.6% vs 1.1%; aRR 1.07; 95% CI, 0.65-1.74) but was associated with blood products transfusion (1.6% vs 0.8%; aRR 1.64; 95% CI, 1.01-2.67) and SGA birth weight (10.0% vs 6.8%; aRR 1.38; 95% CI, 1.15-1.67) compared with those without anemia in the first trimester.

Conclusion: Anemia in the first trimester was associated with adverse maternal and neonatal outcomes. The resolution of anemia by late pregnancy eliminated the association with nontransfusion SMM but not other outcomes, emphasizing the importance of treating anemia in early pregnancy and before pregnancy.

Abstract: Stroke remains a rare but life-threatening complication of pregnancy, with significant implications for both maternal and fetal health. Current stroke prevention and treatment guidelines offer limited guidance for managing stroke in pregnant and postpartum patients. Despite advances in obstetric and neurological care, the diagnosis and management of pregnancy-associated stroke continue to be challenged by delayed recognition, a lack of tailored clinical guidelines, and persistent disparities in outcomes. This scientific statement represents a multidisciplinary effort to synthesize current knowledge of the risk factors and diverse causes of stroke in pregnancy and to offer consensus-driven suggestions for prevention, acute management, and postpartum recovery. Nearly half of all US pregnancy-associated stroke hospitalizations occur in the setting of hypertensive disorders. Primary stroke prevention strategies include risk factor modification, aggressive hypertension management and prompt treatment of severe hypertension in pregnancy and postpartum, and antithrombotic therapy in some high-risk groups. Secondary stroke prevention strategies in pregnancy depend on the mechanism of the prior stroke. Pregnancy should not delay evidence-based treatments for acute stroke. The use of telemedicine can facilitate early consultation with a vascular neurologist and a maternal-fetal medicine specialist in cases of acute pregnancy-related stroke, helping to guide initial decision-making. Computed tomography, computed tomography angiography, and magnetic resonance imaging without contrast are all safe neuroimaging modalities for rapid evaluation of pregnant patients with acute stroke symptoms. Acute stroke alone is not an indication for immediate delivery, and stabilization of the mother should come first. Vaginal delivery after stroke is preferred when feasible because it avoids the surgical risks and hemodynamic stress associated with cesarean delivery. Survivors of pregnancy-associated stroke face unique challenges such as caring for an infant and breastfeeding and require support from a multidisciplinary rehabilitation team. Continued research, including inclusive clinical trials, is urgently needed to refine stroke risk assessment, to expand treatment options, and to improve maternal outcomes.

Objective: To conduct a randomized controlled trial (RCT) to assess whether patient-led insulin titration (intervention) compared with clinician-led insulin titration (control) resulted in improved glycemic management and pregnancy outcomes for individuals with gestational diabetes mellitus (GDM).

Methods: EMPOWER (Patient Versus Provider-Led Titration of Insulin for Glycemic Control in Gestational Diabetes) was a single-center, nonblinded RCT among individuals with GDM requiring insulin between 20 and 32 weeks of gestation that was conducted from October 19, 2023, to January 10, 2025. Intervention participants self-titrated long-acting insulin, which was started at 10 units nightly and decreased or increased by 2 units per fasting glucose above or below 70 and 95 mg/dL, respectively, every day. Control participants started an insulin dose with weekly titration at the clinician's discretion. The primary outcome was mean fasting glucose in the 36th week or the week before delivery for preterm deliveries. Secondary outcomes included pregnancy outcomes and patient-reported measures. With 80% power, two-sided α of 0.05, and 5% loss-to-follow-up, 56 individuals needed to be randomized to demonstrate at least a 15% difference in mean fasting glucose. Analysis was by intention to treat.

Results: Of 89 individuals who were eligible during the study period, 56 consented and were randomized (29 intervention, 27 control). The median duration from starting insulin to delivery was 7.7 weeks. Patient-led insulin titration resulted in a similar mean fasting glucose before delivery compared with clinician-led titration (88.8 vs 90.3 mg/dL; β coefficient -1.50 mg/dL, 95% CI, -5.50 to 2.50) but resulted in more rapid achievement of fasting glucose below 95 mg/dL (mean 1.8 weeks vs 2.5 weeks; hazard ratio 1.48, 95% CI, 1.16 to 1.90). Patient-led titration was associated with a lower risk of macrosomia (6.9% vs 37.0%, relative risk 0.18, 95% CI, 0.04 to 0.84) and large-for-gestational-age (LGA) birth weight (3.3% vs 34.6%, relative risk 0.10, 95% CI, 0.08 to 0.12). Other pregnancy and patient-reported outcomes did not differ between the groups.

Conclusion: Patient-led insulin titration for GDM resulted in a similar mean fasting glucose compared with clinician-led insulin titration but was associated with more rapid achievement of glycemic control and a lower risk of macrosomia and LGA birth weight. These data support the need for larger patient-centered GDM treatment trials.

Clinical trial registration: ClinicalTrials.gov , NCT05922033.