Obstetrics and gynecology最新文献

Objective: To identify the optimal hysterectomy approach for large uteri in gynecologic surgery for benign indications from a perioperative morbidity standpoint.

Data sources: PubMed and Embase databases were searched from inception through September 19, 2022. Meta-analyses were conducted as feasible.

Methods of study selection: This review included studies that compared routes of hysterectomy with or without bilateral salpingo-oophorectomy for large uteri (12 weeks or more or 250 g or more) and excluded studies with any concurrent surgery for pelvic organ prolapse, incontinence, gynecologic malignancy, or any obstetric indication for hysterectomy.

Tabulation, integration, and results: The review included 25 studies comprising nine randomized trials, two prospective, and 14 retrospective nonrandomized comparative studies. Studies were at high risk of bias. There was lower operative time for total vaginal hysterectomy compared with laparoscopically assisted vaginal hysterectomy (LAVH) (mean difference 39 minutes, 95% CI, 18-60) and total vaginal hysterectomy compared with total laparoscopic hysterectomy (mean difference 50 minutes, 95% CI, 29-70). Total laparoscopic hysterectomy was associated with much greater risk of ureteral injury compared with total vaginal hysterectomy (odds ratio 7.54, 95% CI, 2.52-22.58). There were no significant differences in bowel injury rates between groups. There were no differences in length of stay among the laparoscopic approaches. For LAVH compared with total vaginal hysterectomy, randomized controlled trials favored total vaginal hysterectomy for length of stay. When rates of blood transfusion were compared between these abdominal hysterectomy and robotic-assisted total hysterectomy routes, abdominal hysterectomy was associated with a sixfold greater risk of transfusion than robotic-assisted total hysterectomy (6.31, 95% CI, 1.07-37.32). Similarly, single studies comparing robotic-assisted total hysterectomy with LAVH, total laparoscopic hysterectomy, or total vaginal hysterectomy all favored robotic-assisted total hysterectomy for reduced blood loss.

Conclusion: Minimally invasive routes are safe and effective and have few complications. Minimally invasive approach (vaginal, laparoscopic, or robotic) results in lower blood loss and shorter length of stay, whereas the abdominal route has a shorter operative time.

Systematic review registration: PROSPERO, CRD42021233300.

Objective: To assess the effect of gestational age-based dosing of unfractionated heparin (UFH) compared with standard dosing of UFH for thromboprophylaxis on an elevated serum activated partial thromboplastin time (aPTT) during prolonged antepartum hospitalizations.

Methods: This was a randomized trial of pregnant persons who were admitted in the antepartum period for at least 72 hours. Participants were randomly allocated to the standard dose of UFH (5,000 units subcutaneously every 12 hours) or the gestational age-based dose of UFH (first trimester [less than 14 weeks]: 5,000 units subcutaneously every 12 hours; second trimester [14-27 6/7 weeks]: 7,500 units subcutaneously every 12 hours; third trimester (28 weeks or more): 10,000 units subcutaneously every 12 hours). The primary outcome was the proportion of antepartum patients who had an elevated serum aPTT value above the normal range (more than 36.2 seconds) 6 hours after an UFH dose. Secondary outcomes included the development of venous thromboembolism (VTE) and reported side effects of heparin administration.

Results: Between December 15, 2020, and April 1, 2022, 97 patients with antepartum hospitalizations were screened and 46 were randomized: 22 allocated to standard dosing and 24 allocated to gestational age-based dosing of UFH. A significantly greater proportion of antepartum patients who received gestational age-based dosing had an abnormal elevation in aPTT compared with those who received standard dosing (33.3% vs 4.8%, P =.02). Gestational age-based dosing resulted in higher maximum [interquartile range] aPTT (30.4 [27.4, 37.5] vs 26.6 [23.0, 29.6], P =.01) and anti-Xa levels (0.09 [0.09, 0.11] vs 0.09 [0.09, 0.09], P =.04). There was no significant difference in VTE between groups ( P =.47).

Conclusion: Gestational age-based dosing of UFH for thromboprophylaxis of antepartum hospitalizations was associated with significantly increased rates of elevated coagulation parameters compared with standard fixed dosing. This study suggests a need for close monitoring if higher doses of UFH during pregnancy are used later in gestation. The efficacy of gestational age-based dosing compared with standard dosing for UFH to prevent thromboembolic events remains an area for future investigation.

Clinical trial registration: ClinicalTrials.gov , NCT04635839.

Objective: To analyze health care treatment experiences among a diverse cohort of reproductive-aged women from the All of Us study, focusing on variations due to body mass index (BMI).

Methods: We conducted a cross-sectional study that used data from the All of Us Research Program. We analyzed weight bias among reproductive-aged women aged 18-44 years. Weight bias was assessed using a proxy 7-item survey that evaluated discrimination in health care experiences, including courtesy, respect, service quality, being treated as competent, displaying fear, being treated as inferior, and being listened to during health care visits.

Results: Overall, 16,791 reproductive-aged women (mean [SD] age, 35.8 [6.3]) were included in the study. Of 11,592 patients with data available on BMI, 582 were Asian (5.0%), 1,984 (17.1%) were Hispanic or Latinx, 1,007 (8.7%) were non-Hispanic Black, and 7,370 (63.6%) were non-Hispanic White. Approximately 24.2% of participants (n=2,878) had obesity, and 11.1% of participants (n=1,292) had severe obesity. In general, participants in higher BMI categories had negative experiences in the health care setting. Women with severe obesity were 1.5 to 2 times more likely to report poor experiences with their health care clinicians compared with women with healthy weight.

Conclusion: Results show significant disparities in the health care experiences among reproductive-aged women. As participants' BMI category increased, so did their negative experiences in the health care setting. These findings underscore the urgent need for targeted interventions to address these inequities. Health care systems must prioritize strategies to ensure that all individuals, regardless of weight or BMI, receive equitable and respectful care.

Objective: To compare 24-hour and 12-hour mifepristone-to-misoprostol intervals for second-trimester medication abortion.

Methods: We conducted a prospective randomized controlled trial. Participants were allocated to receive mifepristone either 24 hours or 12 hours before misoprostol administration. The primary outcome was the time from the first misoprostol administration to abortion (induction time). Secondary outcomes included the time from mifepristone to abortion (total abortion time); fetal expulsion percentages at 12, 24, and 48 hours after the first misoprostol dose; side effects proportion; and pain and satisfaction scores. A sample size of 40 per group (N=80) was planned to compare the 24- and 12-hour regimens.

Results: Eighty patients were enrolled between July 2020 and June 2023, with 40 patients per group. Baseline characteristics were comparable between groups. Median induction time was 9.5 hours (95% CI, 10.3-17.8 hours) and 12.5 hours (95% CI, 13.5-20.2 hours) in the 24- and 12-hour interval arms, respectively ( P =.028). Median total abortion time was 33.0 hours (95% CI, 34.2-41.9 hours) and 24.5 hours (95% CI, 25.7-32.4 hours) in the 24- and 12-hour interval groups, respectively ( P <.001). At 12 hours from misoprostol administration, 25 patients (62.5%) in the 24-hour arm and 18 patients (45.0%) in the 12-hour arm completed abortion ( P =.178). At 24 hours from misoprostol administration, 36 patients (90.0%) in the 24-hour arm and 30 patients (75.0%) in the 12-hour arm had complete abortion ( P =.139). The need for additional medication or surgical treatment for uterine evacuation, pain scores, side effects, and satisfaction levels were not different between groups.

Conclusion: A 24-hour mifepristone-to-misoprostol regimen for medication abortion in the second trimester provides a median 3-hour shorter induction time compared with the 12-hour interval. However, the median total abortion time was 8.5-hours longer in the 24-hour interval regimen. These findings can aid in shared decision making before medication abortion in the second trimester.

Clinical trial registration: ClinicalTrials.gov, NCT04160221.

Objective: To develop and validate a predictive model for postpartum hemorrhage that can be deployed in clinical care using automated, real-time electronic health record (EHR) data and to compare performance of the model with a nationally published risk prediction tool.

Methods: A multivariable logistic regression model was developed from retrospective EHR data from 21,108 patients delivering at a quaternary medical center between January 1, 2018, and April 30, 2022. Deliveries were divided into derivation and validation sets based on an 80/20 split by date of delivery. Postpartum hemorrhage was defined as blood loss of 1,000 mL or more in addition to postpartum transfusion of 1 or more units of packed red blood cells. Model performance was evaluated by the area under the receiver operating characteristic curve (AUC) and was compared with a postpartum hemorrhage risk assessment tool published by the CMQCC (California Maternal Quality Care Collaborative). The model was then programmed into the EHR and again validated with prospectively collected data from 928 patients between November 7, 2023, and January 31, 2024.

Results: Postpartum hemorrhage occurred in 235 of 16,862 patients (1.4%) in the derivation cohort. The predictive model included 21 risk factors and demonstrated an AUC of 0.81 (95% CI, 0.79-0.84) and calibration slope of 1.0 (Brier score 0.013). During external temporal validation, the model maintained discrimination (AUC 0.80, 95% CI, 0.72-0.84) and calibration (calibration slope 0.95, Brier score 0.014). This was superior to the CMQCC tool (AUC 0.69 [95% CI, 0.67-0.70], P <.001). The model maintained performance in prospective, automated data collected with the predictive model in real time (AUC 0.82 [95% CI, 0.73-0.91]).

Conclusion: We created and temporally validated a postpartum hemorrhage prediction model, demonstrated its superior performance over a commonly used risk prediction tool, successfully coded the model into the EHR, and prospectively validated the model using risk factor data collected in real time. Future work should evaluate external generalizability and effects on patient outcomes; to facilitate this work, we have included the model coefficients and examples of EHR integration in the article.

Background: Vesicovaginal fistula (VVF) is an uncommon cause of urinary incontinence (UI). Iatrogenic etiologies, especially abdominal hysterectomy, are most common; however, a minority of VVFs are caused by retained foreign bodies. Objects associated with VVF include intrauterine devices, gauze, pessaries, bottle caps, and sexual aids, but retained tampons or other menstrual products have not been commonly reported.

Case: We present the case of a 53-year-old woman, gravida 0, with no prior pelvic surgery, with 2 months of intermittent UI and hematuria. Although initial diagnostic test results were negative, cystoscopy and vaginoscopy eventually confirmed the diagnosis of VVF associated with a retained foreign body. In the operating room, all debris was removed using vaginoscopy, and the VVF was repaired using a modified Latzko technique. At the patient's 9-week follow-up appointment, she was found to have complete healing of the VVF and resolution of associated symptoms.

Conclusion: This is a case of VVF secondary to a retained tampon fragment. In addition to this uncommon etiology, our patient's presenting symptoms were atypical, leading to a delay in diagnosis and treatment for which vaginoscopy was critical.