Obstetrics and gynecology最新文献

The objectives of our study were to estimate trends in severe early pregnancy morbidity in pregnant individuals at less than 24 weeks of gestation at a referral center in an abortion-restricted environment and to assess differences after the Dobbs v. Jackson Women's Health Organization decision. We measured severe early pregnancy morbidity from January 2017 to December 2023 using billing codes, transfusion records, and intensive care transfers. We verified events and assessed preventability using chart review. We performed an interrupted time series analysis evaluating whether the level or slope of the severe early pregnancy morbidity rate varied with the Dobbs decision. We identified 407 severe early pregnancy morbidity events among 46,181 pregnancies. We noted no significant changes in the rate of total severe early pregnancy morbidity before and after the Dobbs decision, but we did note a significant level increase of 19 events per 100 total events (95% CI, 8.9-29.8) in the rate of preventable severe early pregnancy morbidity.

Objective: To describe demographic and clinical characteristics, preventability, Maternal Mortality Review Committee (MMRC)-determined contributing factors, and example recommendations for pregnancy-related deaths due to infection using data from MMRCs.

Methods: We used pregnancy-related death data from MMRCs in 29 states occurring during 2017-2019 with MMRC-determined underlying cause of death of infection. We describe the distribution of demographic and clinical characteristics, present the most frequent contributing factor classes, and provide example MMRC prevention recommendations.

Results: Ninety-one pregnancy-related infection deaths were identified, and MMRCs determined that 86.4% of deaths were preventable among 88 deaths for which MMRCs determined preventability. Most deaths occurred within 42 days of delivery (69.3%). Additional clinical information was available for many deaths. Group A streptococci were the most frequently identified pathogen (34.0%, 18/53) and genital tract was the most frequently identified source (47.9%, 35/73) of the infection. The most frequent health care encounter before death was hospitalization (50.7%, 36/71). More than half of decedents (69.1%, 47/68) had a health care encounter less than 7 days before death. The five most frequent contributing factor classes were clinical skill/quality of care (18.6%), delay (10.1%), knowledge (10.1%), lack of continuity of care (9.6%), and lack of access/financial resources (7.8%). The MMRC prevention recommendations occur at multiple levels, addressing frequent contributing factor classes.

Conclusion: Most pregnancy-related deaths due to infection are preventable. Example MMRC recommendations highlight prevention opportunities, including improving patient and clinician knowledge regarding clinical signs and symptoms of serious infections, implementing obstetric sepsis protocols, and enhancing care coordination within and across systems.

Objective: To identify determinants of selected pregnancy testing behaviors among pregnancy planners and to elucidate the relationship between pregnancy testing and detection.

Methods: In PRESTO (Pregnancy Study Online), a North American prepregnancy cohort study of pregnancy planners (2018-2024), participants reported day-specific information about pregnancy testing spanning 4 days before day of expected menstruation through 4 days after. We used generalized linear models to estimate the association between maternal attributes and pregnancy testing behavior, characterized as the timing of the first test and testing frequency. We used quantile regression to estimate the timing of pregnancy detection among participants who conceived by maternal characteristics and pregnancy testing behavior. We estimated the adjusted risk of having a negative test result and the probability of detecting a very early pregnancy loss by the timing of the pregnancy test.

Results: We analyzed data from 20,458 pregnancy tests across 6,569 unique participants. Of the participants, 40.7% of reported they engaged in very early testing, defined as testing more than 4 days before their expected period. We observed a range of pregnancy testing intensity, with some participants testing only once and others testing every day. Among participants who detected pregnancy, very early testers were more than 5 times more likely to have a negative test result before a positive test result than those who waited until the day of expected period to test (adjusted risk ratio [aRR[ 5.89; 95% CI, 4.73-7.33). Very early testers were more than 3 times more likely to have an initial positive test result followed by a negative test result, likely reflecting increased detection of very early pregnancy losses (aRR 3.80; 95% CI, 2.12-6.80).

Conclusion: Patterns in home pregnancy testing varied widely among pregnancy planners. Early initiation of pregnancy testing was associated with slightly earlier pregnancy detection, but also a marked increase in risk of negative test results and detection of very early pregnancy losses.

Objective: To evaluate the association between psychostimulant continuation, compared with discontinuation, and postpartum mental health outcomes in pregnant people with attention-deficit/hyperactivity disorder (ADHD) who had consistent psychostimulant prescriptions before pregnancy.

Methods: This was a retrospective cohort study that used the Merative MarketScan Commercial Claims Database (2011-2021). Included individuals were aged 13-50 years with singleton pregnancies, had delivered at or after 20 weeks of gestation, and had an ADHD diagnosis and psychostimulant adherence. Psychostimulant use during pregnancy was classified as no refills, the proportion of days covered below 80%, or the proportion of days covered at or above 80%. The primary outcomes were mental health events that occurred within 1 year postpartum, such as emergency department or inpatient mental health-related admissions, and new diagnoses of mood or anxiety disorders. Adjusted event rate ratios were estimated using Poisson regression, controlling for maternal age, gestational age at delivery, maternal comorbidities, and preexisting mental health diagnoses.

Results: Among 3,676 eligible patients, 1,521 (41.4%) had no psychostimulant prescriptions during pregnancy (discontinued), 1,899 (51.7%) had a proportion of days covered below 80%, and 256 (7.0%) maintained a proportion of days covered at or above 80%. Overall, 3.3% (95% CI, 2.7-4.0%) experienced postpartum mental health-related admissions and 16.2% (95% CI, 14.6-18.0%) received new postpartum mood or anxiety disorder diagnoses. Although unadjusted analyses suggested a higher incidence of postpartum mood or anxiety disorders among patients continuing psychostimulants than those who discontinued (19.3% vs 12.8%; rate ratio 1.46, 95% CI, 1.17-1.83), this association was no longer observed after controlling for confounders. In adjusted analyses, continuation of psychostimulants during pregnancy was not associated with differences in postpartum mental health-related admissions (rate ratio 1.01, 95% CI, 0.59-1.71) or new mood or anxiety disorder diagnoses (rate ratio 1.30, 95% CI, 0.97-1.74). Preexisting mental health diagnoses (rate ratio 2.60, 95% CI, 1.76-3.90) and medical comorbidities (rate ratio 1.98, 95% CI, 1.33-2.93) were the strongest predictors of postpartum admissions.

Conclusion: Among individuals with ADHD adherent to psychostimulants before pregnancy, the continuation of medication during pregnancy was not associated with adverse postpartum mental health outcomes when compared with discontinuation of medication.