Obstetrics and gynecology最新文献

Objective: To compare odds of maternal morbidity by mode of becoming pregnant and type of medically assisted reproduction treatments: fertility-enhancing drugs, intrauterine insemination (IUI), and assisted reproductive technology (ART) with autologous or donor oocytes.

Methods: Birth certificates were used to study maternal morbidity among the birthing population in Utah between 2009 and 2017 (N=469,919 deliveries); 22,543 pregnancies occurred through medically assisted reproduction (4.8%). Maternal morbidity was identified as a binary variable, indicating the presence of any of the following: blood transfusion, unplanned operating room procedure, admission to intensive care unit, eclampsia, unplanned hysterectomy, and ruptured uterus. Using logistic regression, we assessed maternal morbidity among medically assisted reproduction pregnancies (overall and by type of treatment) compared with unassisted pregnancies in the overall sample before and after adjustment for individual sociodemographics (age at birth, family structure, level of education, Hispanic origin, parity), and pre-existing comorbidities (ie, chronic hypertension, heart disease, asthma), multifetal gestation, and obstetric comorbidities (ie, placenta previa, placental abruption, cesarean delivery).

Results: Individuals becoming pregnant through medically assisted reproduction had higher risk of maternal morbidity, with odds ratios (ORs) increasing as medically assisted reproduction treatments become more invasive. Associations were largely attenuated when accounting for multifetal gestation and further reduced after controlling for obstetric comorbidities. However, ART with autologous oocytes (OR 1.46, 95% CI, 1.20-1.78) maintained higher coefficients compared with unassisted pregnancies. In models including only singletons, after controlling for obstetric comorbidities, the OR differences in maternal morbidity between all medically assisted reproduction groups and unassisted pregnancies were no longer statistically significant.

Conclusion: More invasive medically assisted reproduction treatments (ART and IUI) are associated with higher odds of maternal morbidity, whereas less invasive treatments are not. This relationship is partially explained by higher prevalence of multifetal gestation and obstetric comorbidities in people undergoing more invasive treatment, but the persistent association suggests subfertility itself may contribute to maternal morbidity.

Objective: It remains unclear whether modifying laparoscopic radical hysterectomy to adopt tumor-free principles can improve oncologic outcomes in patients with early-stage cervical cancer.

Methods: We performed a single-center retrospective cohort study of 276 patients with early-stage cervical cancer who were treated between January 2017 and January 2023, including 151 patients who underwent laparoscopic radical hysterectomy that incorporated modified tumor-free techniques (MTF group) and 125 patients who underwent conventional laparoscopic radical hysterectomy with a uterine manipulator and unprotected intracorporeal colpotomy (non-MTF group). Oncologic outcomes and perioperative results were analyzed using inverse probability treatment weighting (IPTW).

Results: Patients in the MTF group had shorter length of hospital stay than those in the non-MTF group. However, there were no significant differences in operative time, decrease in hemoglobin, or complications. After a median follow-up of 36.0 months (range 15.3-62.0 months) for the MTF group and 66.8 months (range 3.0-82.5 months) for the non-MTF group, recurrence was observed in two (1.3%) and 16 (12.8%) of the patients, respectively. The 2-year disease-free survival (DFS) rates in the MTF group and non-MTF group were 99.3% and 91.9%, respectively. In the primary analysis limited to 2-year survival, the adjusted multivariate analysis showed that use of modified tumor-free techniques was an independent predictor of longer DFS (hazard ratio 0.10 95% CI, 0.01-0.77, P=.027). After IPTW, patients in the MTF group had a more favorable DFS than those in the non-MTF group (log-rank P=.031).

Conclusion: Laparoscopic radical hysterectomy that incorporates modified tumor-free techniques is a feasible treatment for patients with early-stage cervical cancer. Oncologic outcomes of individuals who underwent this procedure were more favorable than those of conventional laparoscopic radical hysterectomy.

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 evaluate the association between area poverty and adverse birth outcomes in the diverse birthing population of a large health system.

Methods: This was a retrospective cohort study using electronic health record and hospital administrative data for pregnant people at nine hospitals within a large health system in the Chicago metropolitan area from 2018 to 2023. Patient addresses were geocoded and categorized by Census tract area percent poor households. Unadjusted and adjusted Poisson regression models, controlling for individual-level risk factors, evaluated the independent association between area poverty and birth outcomes to determine the degree to which this association is attenuated by the inclusion of individual-level factors in the model.

Results: The study included 85,025 pregnant people. Area poverty was associated with sociodemographic factors, including young age, non-Hispanic Black race, Hispanic ethnicity, Medicaid insurance coverage, higher parity, and several comorbid conditions. Area poverty was associated with adverse birth outcomes and demonstrated a gradient effect with increasing area poverty in bivariable analyses. In unadjusted regression analyses, residence in areas with 5.0% or more poverty was associated with severe maternal morbidity, preterm birth, and low birth weight, and residence in areas with 8.0% or higher poverty was associated with neonatal intensive care unit admission. Although these associations persisted in multivariable analysis for severe maternal morbidity and neonatal intensive care unit admission, the associations with preterm birth and low birth weight persisted only for individuals residing in areas of 12.0% or higher poverty when controlling for individual-level risk factors.

Conclusion: Area poverty was associated with adverse birth outcomes in this birthing population even when controlling for individual-level risk factors, highlighting the need for system- and community-level quality-improvement interventions.

Objective: To investigate differences in health care utilization between immediate (within 10 minutes of placental delivery) and delayed (after 24 hours) intrauterine device (IUD) placement.

Methods: This retrospective cohort study was conducted with data from Kaiser Permanente Northern California from 2017 to 2019 and included patients with an IUD placed between 0 and 63 days postpartum. The primary outcome for health care utilization was the number of obstetrician-gynecologist (ob-gyn) or women's health office visits within 1 year. Secondary outcomes included formal imaging studies, surgical intervention, and hospitalizations related to IUD complications within 1 year. An additional secondary outcome was live births at 120 days and 1 year.

Results: Among 1,543 immediate and 10,332 delayed postpartum IUD placements, the number of visits to an ob-gyn or women's health office within 1 year was slightly increased with delayed placement (mean 2.30 vs 2.47, P<.001). Imaging was increased in the immediate compared with the delayed group (10.5% vs 4.1%, P<.001). Laparoscopy was decreased in the immediate compared with the delayed group (0.0% vs 0.4%, P=.005), with no significant difference in hysteroscopy (0.2% vs 0.1%, P=.413). Hospitalizations were rare and increased in the immediate group (0.4% vs 0.02%, P<.001). Lastly, there was no difference in repeat pregnancies between groups at 120 days (both 0.2%) or at 1 year (2.9% vs 2.5%, P=.342).

Conclusion: Compared with delayed placement, immediate postpartum IUD placement is not associated with increased office visits. Immediate placement is associated with an increase in imaging but a decrease in laparoscopic surgery to manage IUD-related complications. There was no difference in live birth rates at 6 months or 1 year between groups.

Objective: To assess the content validity of the classification of maternal level of care of the American Hospital Association Database for research use.

Methods: This was a secondary data analysis where we classified the maternal level of care in the 2018 American Hospital Association Database and linked this to birth hospitalizations from five states in the 2016 and 2017 State Inpatient Databases: Delaware, Florida, Kentucky, Maryland, and Washington. We compared maternal level of care classification with birth volume quartiles, hospital size quartiles, and teaching status to predict the birth hospital for women with high OCI (Obstetric Comorbidity Index) scores and hospital-to-hospital transfers. We calculated the odds of birth at the highest-level hospital, controlling for maternal race, rural residence, primary payer, and state.

Results: People with high OCI scores and hospital-to-hospital transfer had increased odds of birth at hospitals classified as maternal level III or IV, large hospitals, and teaching hospitals. The probability of birth at the highest-level hospital for people with high OCI scores was increased 4.9% for a level III or IV hospital, 2.6% for a large hospital, and 1.2% for a teaching hospital. The probability of birth at the highest-level hospital for people with hospital transfer was increased 5.2% for a level III or IV hospital, 1.4% for a large hospital, and 14.4% for a teaching hospital.

Conclusion: Researchers can classify the maternal level of care using the American Hospital Association Database to study maternal risk-appropriate care.

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 autistic 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.

Objective: To use online screening and virtual patient education tools to improve the provision of hereditary cancer risk assessment.

Methods: We conducted a prospective, single-arm study in which clinicians at five U.S. community obstetrics and gynecology practices underwent an 8-week observation followed by 3-4 weeks of training on online patient screening and virtual patient education (prerecorded video with or without a genetic counselor phone call) for genetic testing-eligible patients. After a 4-week practice period, hereditary cancer risk assessment and patient education metrics were collected at 8 weeks and compared with preintervention metrics using univariate conditional logistic regression models stratified by site. The primary outcome was the change in genetic testing completion rate. Clinicians and patients were invited to complete a satisfaction survey.

Results: A total of 5,795 and 5,135 patients were seen before and after the intervention, respectively. The proportion of screened patients meeting testing guidelines increased from 21.6% before the intervention to 28.2% after the intervention (odds ratio [OR] 1.36, 95% CI, 1.26-1.47, P<.001). Guideline-eligible patients were significantly more likely to be offered genetic testing (59.1% vs 89.1%, OR 2.06, 95% CI, 1.87-2.27, P<.001), to submit a sample (32.9% vs 45.0%, OR 1.49, 95% CI, 1.27-1.74, P<.001), and to complete testing (16.0% vs 34.2%, OR 2.38, 95% CI, 2.00-2.83, P<.001). Most clinicians agreed or strongly agreed that the screening tool improved the identification of patients meeting hereditary cancer risk assessment guidelines (92.1%), saved time (64.9%), and was easy to incorporate (68.4%) and that patient education improved their ability to deliver hereditary cancer risk assessment standard of care (84.2%). Most patients agreed or strongly agreed that virtual education helped them understand the purpose (91.7%) and implications (92.6%) of genetic testing.

Conclusion: A guideline-based online patient screening tool and virtual patient education were well received. The online tool enabled identification of significantly more guideline-eligible candidates for hereditary cancer risk assessment, and education improved patients' genetic literacy. Together, these tools ultimately improved the genetic testing completion rate.

Objective: To compare the rates of treatment failure in cases of early pregnancy loss between mifepristone-misoprostol and misoprostol only.

Methods: This retrospective cohort study included patients who received medical treatment for early pregnancy loss between 2016 and 2023 at a single medical center. Patients returned for a follow-up ultrasonogram after 1 week and were treated again with misoprostol if needed. Finally, they were instructed to obtain an ultrasonogram after menstruation and to return for evaluation in case retained product of conception was suspected. We defined treatment failure as needing any surgical intervention because of retained product of conception, including cases when retained product of conception was diagnosed and treated after menstruation. In May 2022, we changed our protocol for treating early pregnancy loss from misoprostol to mifepristone and misoprostol. We compared the failure rate between patients who received mifepristone-misoprostol and those treated with misoprostol only.

Results: A total of 999 patients were included: 224 in the mifepristone-misoprostol group and 775 in the misoprostol-only group. The rate of treatment failure was significantly lower in the mifepristone-misoprostol group compared with the misoprostol-only group (17.8% vs 25.1%, P=.002). After multivariant analysis was performed, the use of mifepristone and misoprostol was associated with a reduction of 34% in the odds ratio for treatment failure compared with misoprostol alone (adjusted odds ratio 0.661, 95% CI, 0.44-0.97, P=.038). In addition, prior vaginal delivery was associated with a lower risk for treatment failure, and increasing gestational age (according to ultrasonogram) was correlated with a higher risk for treatment failure.

Conclusion: The addition of mifepristone to misoprostol was associated with a significantly lower rate of treatment failure, including late surgical intervention for early pregnancy loss, compared with misoprostol alone.