Pub Date : 2024-08-02DOI: 10.1016/j.ajogmf.2024.101458
{"title":"Glycemic control before delivery using continuous glucose monitoring and neonatal outcomes","authors":"","doi":"10.1016/j.ajogmf.2024.101458","DOIUrl":"10.1016/j.ajogmf.2024.101458","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141890281","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1016/j.ajogmf.2024.101391
Background
Early identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models.
Objective
To develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower risk laboring obstetric population.
Study Design
This retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks’ gestation) at 19 US hospitals (2016–2021) using data from 58,023 births at 11 hospitals to train a generalized additive model (GAM) and 27,743 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen.
Results
The GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64–0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50–0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01–41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40–22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2–1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI 1.4–1.6).
Conclusion
Our model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.
{"title":"Interpretable machine learning predicts postpartum hemorrhage with severe maternal morbidity in a lower-risk laboring obstetric population","authors":"","doi":"10.1016/j.ajogmf.2024.101391","DOIUrl":"10.1016/j.ajogmf.2024.101391","url":null,"abstract":"<div><h3>Background</h3><p>Early identification of patients at increased risk for postpartum hemorrhage<span><span> (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for </span>postpartum hemorrhage<span><span> with severe maternal morbidity. Current tools for </span>hemorrhage risk assessment use lists of risk factors rather than predictive models.</span></span></p></div><div><h3>Objective</h3><p>To develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower risk laboring obstetric population.</p></div><div><h3>Study Design</h3><p><span><span>This retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks’ gestation) at 19 US hospitals (2016–2021) using data from 58,023 births at 11 hospitals to train a generalized additive model (GAM) and 27,743 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular </span>embolization<span>, intrauterine balloon tamponade, </span></span>uterine artery<span><span><span> ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of </span>vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) </span>Obstetric Hemorrhage Risk Factor Assessment Screen.</span></p></div><div><h3>Results</h3><p>The GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64–0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50–0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01–41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40–22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2–1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI 1.4–1.6).</p></div><div><h3>Conclusion</h3><p>Our model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.</p></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141293800","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1016/j.ajogmf.2024.101421
As the number of placenta accreta spectrum cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetrician-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process through which key personnel within departments of obstetrics and gynecology are identified and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the cesarean delivery complexity level can be matched with specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is 2-fold; first, to return cases with higher levels of surgical complexity back to obstetricians and, second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.
{"title":"Complex obstetrical surgery: building a team and defining roles","authors":"","doi":"10.1016/j.ajogmf.2024.101421","DOIUrl":"10.1016/j.ajogmf.2024.101421","url":null,"abstract":"<div><p>As the number of placenta accreta spectrum cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetrician-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process through which key personnel within departments of obstetrics and gynecology are identified and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the cesarean delivery complexity level can be matched with specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is 2-fold; first, to return cases with higher levels of surgical complexity back to obstetricians and, second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.</p></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141538753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1016/j.ajogmf.2024.101417
{"title":"Reply to: Letter to editor regarding randomized trial of screening for preterm birth in low-risk women: the preterm birth study","authors":"","doi":"10.1016/j.ajogmf.2024.101417","DOIUrl":"10.1016/j.ajogmf.2024.101417","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141477565","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1016/j.ajogmf.2024.101328
<div><h3>OBJECTIVE</h3><p>Cesarean scar pregnancy may lead to varying degrees of complications. There are many treatment methods for it, but there are no unified or recognized treatment strategies. This systematic review and network meta-analysis aimed to observe the efficacy and safety of treatment modalities for patients with cesarean scar pregnancy.</p></div><div><h3>DATA SOURCES</h3><p>MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to January 31, 2024. In addition, relevant reviews and meta-analyses were manually searched for additional references.</p></div><div><h3>STUDY ELIGIBILITY CRITERIA</h3><p>Our study incorporated head-to-head trials involving a minimum of 10 women diagnosed with cesarean scar pregnancy through ultrasound imaging or magnetic resonance imaging, encompassing a detailed depiction of primary interventions and any supplementary measures. Trials with a Newcastle-Ottawa scale score <4 were excluded because of their low quality.</p></div><div><h3>METHODS</h3><p>We conducted a random-effects network meta-analysis and review for cesarean scar pregnancy. Group-level data on treatment efficacy and safety, reproductive outcomes, study design, and demographic characteristics were extracted following a predefined protocol. The quality of studies was assessed using the Cochrane risk-of-bias tools for randomized controlled trials and the Newcastle‒Ottawa scale for cohort studies and case series. The main outcomes were efficacy (initial treatment success) and safety (complications), of which summary odds ratios and the surface under the cumulative ranking curve using pairwise and network meta-analysis with random effects.</p></div><div><h3>RESULTS</h3><p>Seventy-three trials (7 randomized controlled trials) assessing a total of 8369 women and 17 treatment modalities were included. Network meta-analyses were rooted in data from 73 trials that reported success rates and 55 trials that reported complications. The findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage demonstrated the highest cure rates, as evidenced by surface under the cumulative ranking curve rankings of 91.2, 88.2, 86.9, and 75.3, respectively. When compared with suction curettage, the odds ratios (95% confidence intervals) for efficacy were as follows: 6.76 (1.99–23.01) for laparoscopy, 5.92 (1.47–23.78) for transvaginal resection, 5.00 (1.99–23.78) for hysteroscopic curettage, and 3.27 (1.08–9.89) for high-intensity focused ultrasound combined with suction curettage. Complications were more likely to occur after receiving uterine artery chemoembolization, suction curettage, methotrexate+hysteroscopic curettage, and systemic methotrexate; hysteroscopic curettage, high-intensity focused ultrasound combined with suction curettage, and Lap were safer than the other options derived from finite evidence; and the conf
{"title":"Efficacy and safety of treatment modalities for cesarean scar pregnancy: a systematic review and network meta-analysis","authors":"","doi":"10.1016/j.ajogmf.2024.101328","DOIUrl":"10.1016/j.ajogmf.2024.101328","url":null,"abstract":"<div><h3>OBJECTIVE</h3><p>Cesarean scar pregnancy may lead to varying degrees of complications. There are many treatment methods for it, but there are no unified or recognized treatment strategies. This systematic review and network meta-analysis aimed to observe the efficacy and safety of treatment modalities for patients with cesarean scar pregnancy.</p></div><div><h3>DATA SOURCES</h3><p>MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to January 31, 2024. In addition, relevant reviews and meta-analyses were manually searched for additional references.</p></div><div><h3>STUDY ELIGIBILITY CRITERIA</h3><p>Our study incorporated head-to-head trials involving a minimum of 10 women diagnosed with cesarean scar pregnancy through ultrasound imaging or magnetic resonance imaging, encompassing a detailed depiction of primary interventions and any supplementary measures. Trials with a Newcastle-Ottawa scale score <4 were excluded because of their low quality.</p></div><div><h3>METHODS</h3><p>We conducted a random-effects network meta-analysis and review for cesarean scar pregnancy. Group-level data on treatment efficacy and safety, reproductive outcomes, study design, and demographic characteristics were extracted following a predefined protocol. The quality of studies was assessed using the Cochrane risk-of-bias tools for randomized controlled trials and the Newcastle‒Ottawa scale for cohort studies and case series. The main outcomes were efficacy (initial treatment success) and safety (complications), of which summary odds ratios and the surface under the cumulative ranking curve using pairwise and network meta-analysis with random effects.</p></div><div><h3>RESULTS</h3><p>Seventy-three trials (7 randomized controlled trials) assessing a total of 8369 women and 17 treatment modalities were included. Network meta-analyses were rooted in data from 73 trials that reported success rates and 55 trials that reported complications. The findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage demonstrated the highest cure rates, as evidenced by surface under the cumulative ranking curve rankings of 91.2, 88.2, 86.9, and 75.3, respectively. When compared with suction curettage, the odds ratios (95% confidence intervals) for efficacy were as follows: 6.76 (1.99–23.01) for laparoscopy, 5.92 (1.47–23.78) for transvaginal resection, 5.00 (1.99–23.78) for hysteroscopic curettage, and 3.27 (1.08–9.89) for high-intensity focused ultrasound combined with suction curettage. Complications were more likely to occur after receiving uterine artery chemoembolization, suction curettage, methotrexate+hysteroscopic curettage, and systemic methotrexate; hysteroscopic curettage, high-intensity focused ultrasound combined with suction curettage, and Lap were safer than the other options derived from finite evidence; and the conf","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2589933324000545/pdfft?md5=35155ed4df2e0775d265c005d950fa58&pid=1-s2.0-S2589933324000545-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140132762","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1016/j.ajogmf.2024.101355
{"title":"Interpretable machine learning predicts postpartum hemorrhage at time of admission","authors":"","doi":"10.1016/j.ajogmf.2024.101355","DOIUrl":"10.1016/j.ajogmf.2024.101355","url":null,"abstract":"","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140913144","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1016/j.ajogmf.2024.101415
Background
While the association between uterine fibroids and preterm birth is well known, data regarding whether fibroid characteristics such as number and size modify such risk are limited.
Objective
To evaluate the association between fibroid number and size and risk of preterm birth and determine whether these characteristics impact the severity of preterm birth.
Study Design
Multicenter retrospective cross-sectional study including all patients with singleton gestations who had at least one prenatal ultrasound at 18 0/7 weeks of gestation or later and delivered within a large university health system from January 1, 2019 to December 31, 2022. When fibroids were identified on ultrasound, their characteristics (i.e., number, size, and location) were documented. Patients with more than one delivery during the study period had only their first included for analysis. The primary outcome of preterm birth, stratified by gestational age (<37, <34, <32, and <28 weeks), was assessed based on fibroid number (1, 2, ≥3) and size (largest dimension <5 cm, 5–10 cm, >10 cm) separately in patients who had prenatally detected fibroids compared to those with no fibroids. Multivariate logistic regression was performed to adjust for potential confounders. Data were presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).
Results
Among the 65,950 patients studied, 4,421 (6.7%) had at least one fibroid. The prevalence of preterm birth <37 weeks was 8.6%. The presence of any fibroid, regardless of number, was associated with an increased risk of preterm birth <37 weeks compared to no fibroids (1 fibroid: 12.8% vs. 8.2%, aOR 1.26, 95% CI 1.10–1.44; 2 fibroids: 12.7% vs. 8.2%, aOR 1.27, 95% CI 1.01–1.58; ≥3 fibroids: 18.5% vs. 8.2%, aOR 1.60, 95% CI 1.29–1.99). Patients with 2 fibroids were at increased risk of preterm birth <34, <32, and <28 weeks compared to those without fibroids, while patients with ≥3 fibroids were at increased risk of preterm birth <34 and <28 weeks compared to those without fibroids. The presence of at least one fibroid, regardless of the size of their largest dimension, was associated with an increased risk of preterm birth <37 weeks compared to no fibroids (<5 cm: 12.4% vs. 8.2%, aOR 1.19, 95% CI 1.04–1.36; 5–10 cm: 15.5% vs. 8.2%, aOR 1.47, 95% CI 1.23–1.75; >10 cm: 21.4% vs. 8.2%, aOR 2.26, 95% CI 1.55–3.28). Increasing fibroid size by largest dimension was associated with an increased risk of preterm birth <34 weeks. Patients with fibroids >10 cm by largest dimension were at increased risk of preterm birth <28 weeks compared to those without fibroids. There was no association between increasing fibroid size by largest dimension and preterm birth <32 weeks.
Conclusions
Data from this large cohort suggest that fibroid characteristics such as number
{"title":"The association between uterine fibroid number and size and risk of preterm birth","authors":"","doi":"10.1016/j.ajogmf.2024.101415","DOIUrl":"10.1016/j.ajogmf.2024.101415","url":null,"abstract":"<div><h3>Background</h3><p>While the association between uterine fibroids and preterm birth is well known, data regarding whether fibroid characteristics such as number and size modify such risk are limited.</p></div><div><h3>Objective</h3><p>To evaluate the association between fibroid number and size and risk of preterm birth and determine whether these characteristics impact the severity of preterm birth.</p></div><div><h3>Study Design</h3><p>Multicenter retrospective cross-sectional study including all patients with singleton gestations who had at least one prenatal ultrasound at 18 0/7 weeks of gestation or later and delivered within a large university health system from January 1, 2019 to December 31, 2022. When fibroids were identified on ultrasound, their characteristics (i.e., number, size, and location) were documented. Patients with more than one delivery during the study period had only their first included for analysis. The primary outcome of preterm birth, stratified by gestational age (<37, <34, <32, and <28 weeks), was assessed based on fibroid number (1, 2, ≥3) and size (largest dimension <5 cm, 5–10 cm, >10 cm) separately in patients who had prenatally detected fibroids compared to those with no fibroids. Multivariate logistic regression was performed to adjust for potential confounders. Data were presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).</p></div><div><h3>Results</h3><p>Among the 65,950 patients studied, 4,421 (6.7%) had at least one fibroid. The prevalence of preterm birth <37 weeks was 8.6%. The presence of any fibroid, regardless of number, was associated with an increased risk of preterm birth <37 weeks compared to no fibroids (1 fibroid: 12.8% vs. 8.2%, aOR 1.26, 95% CI 1.10–1.44; 2 fibroids: 12.7% vs. 8.2%, aOR 1.27, 95% CI 1.01–1.58; ≥3 fibroids: 18.5% vs. 8.2%, aOR 1.60, 95% CI 1.29–1.99). Patients with 2 fibroids were at increased risk of preterm birth <34, <32, and <28 weeks compared to those without fibroids, while patients with ≥3 fibroids were at increased risk of preterm birth <34 and <28 weeks compared to those without fibroids. The presence of at least one fibroid, regardless of the size of their largest dimension, was associated with an increased risk of preterm birth <37 weeks compared to no fibroids (<5 cm: 12.4% vs. 8.2%, aOR 1.19, 95% CI 1.04–1.36; 5–10 cm: 15.5% vs. 8.2%, aOR 1.47, 95% CI 1.23–1.75; >10 cm: 21.4% vs. 8.2%, aOR 2.26, 95% CI 1.55–3.28). Increasing fibroid size by largest dimension was associated with an increased risk of preterm birth <34 weeks. Patients with fibroids >10 cm by largest dimension were at increased risk of preterm birth <28 weeks compared to those without fibroids. There was no association between increasing fibroid size by largest dimension and preterm birth <32 weeks.</p></div><div><h3>Conclusions</h3><p>Data from this large cohort suggest that fibroid characteristics such as number ","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141471285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1016/j.ajogmf.2024.101413
BACKGROUND
In the United States, approximately 1% of pregnancies are complicated by pregestational diabetes. Individuals with type 1 diabetes have an increased risk of adverse maternal and neonatal outcomes. While continuous glucose monitoring has demonstrated benefits for patients with type 1 diabetes, its cost is higher than traditional intermittent fingerstick monitoring, particularly if used only during pregnancy.
OBJECTIVE
To develop an economic analysis model to compare in silico the cost of continuous glucose monitoring and self-monitoring of blood glucose in a cohort of pregnant individuals with type 1 diabetes mellitus.
STUDY DESIGN
We developed an economic analysis model to compare two glucose monitoring strategies in pregnant individuals with type 1 diabetes: continuous glucose monitoring and self-monitoring. The model considered hypertensive disorders of pregnancy, large for gestational age, cesarean delivery, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia. The primary outcome was the total cost per strategy in 2022 USD from a health system perspective, with self-monitoring as the reference group. Probabilities, relative risks, and costs were extracted from the literature, and the costs were adjusted to 2022 US dollars. Sensitivity analyses were conducted by varying parameters based on the probability, relative risk, and cost distributions. The robustness of the results was tested through 1000 Monte Carlo simulations.
RESULTS
In the base-case analysis, the cost of pregnancy using continuous glucose monitoring was $26,837 compared to $29,039 for self-monitoring, resulting in a cost reduction of $2,202 per individual. The parameters with the greatest effect on the incremental cost included the relative risk of NICU admission, cost of NICU admission, continuous glucose monitoring costs, and usual care costs. Monte Carlo simulations indicated that continuous glucose monitoring was the optimal strategy 98.7% of the time. One-way sensitivity analysis showed that continuous glucose monitoring was more economical if the relative risk of NICU admission with continuous glucose monitoring vs. self-monitoring was below 1.15.
CONCLUSION
Compared to self-monitoring, continuous glucose monitoring is an economical strategy for pregnant individuals with type 1 diabetes mellitus.
{"title":"Continuous glucose monitoring vs. self-monitoring in pregnant individuals with type 1 diabetes: an economic analysis","authors":"","doi":"10.1016/j.ajogmf.2024.101413","DOIUrl":"10.1016/j.ajogmf.2024.101413","url":null,"abstract":"<div><h3>BACKGROUND</h3><p>In the United States, approximately 1% of pregnancies are complicated by pregestational diabetes. Individuals with type 1 diabetes have an increased risk of adverse maternal and neonatal outcomes. While continuous glucose monitoring has demonstrated benefits for patients with type 1 diabetes, its cost is higher than traditional intermittent fingerstick monitoring, particularly if used only during pregnancy.</p></div><div><h3>OBJECTIVE</h3><p>To develop an economic analysis model to compare in silico the cost of continuous glucose monitoring and self-monitoring of blood glucose in a cohort of pregnant individuals with type 1 diabetes mellitus.</p></div><div><h3>STUDY DESIGN</h3><p>We developed an economic analysis model to compare two glucose monitoring strategies in pregnant individuals with type 1 diabetes: continuous glucose monitoring and self-monitoring. The model considered hypertensive disorders of pregnancy, large for gestational age, cesarean delivery, neonatal intensive care unit (NICU) admission, and neonatal hypoglycemia. The primary outcome was the total cost per strategy in 2022 USD from a health system perspective, with self-monitoring as the reference group. Probabilities, relative risks, and costs were extracted from the literature, and the costs were adjusted to 2022 US dollars. Sensitivity analyses were conducted by varying parameters based on the probability, relative risk, and cost distributions. The robustness of the results was tested through 1000 Monte Carlo simulations.</p></div><div><h3>RESULTS</h3><p>In the base-case analysis, the cost of pregnancy using continuous glucose monitoring was $26,837 compared to $29,039 for self-monitoring, resulting in a cost reduction of $2,202 per individual. The parameters with the greatest effect on the incremental cost included the relative risk of NICU admission, cost of NICU admission, continuous glucose monitoring costs, and usual care costs. Monte Carlo simulations indicated that continuous glucose monitoring was the optimal strategy 98.7% of the time. One-way sensitivity analysis showed that continuous glucose monitoring was more economical if the relative risk of NICU admission with continuous glucose monitoring vs. self-monitoring was below 1.15.</p></div><div><h3>CONCLUSION</h3><p>Compared to self-monitoring, continuous glucose monitoring is an economical strategy for pregnant individuals with type 1 diabetes mellitus.</p></div>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141440934","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-08-01DOI: 10.1016/j.ajogmf.2024.101369
<div><h3>OBJECTIVE</h3><p><span>Clinical-sonographic scoring systems combining clinical features and ultrasound imaging markers have been proposed for the screening of </span>placenta accreta<span> spectrum, but their usefulness in different settings remains limited. This study aimed to assess and compare different clinical-sonographic score systems applied from mid-pregnancy for the prenatal evaluation of patients at risk of placenta accreta spectrum at birth.</span></p></div><div><h3>DATA SOURCES</h3><p>PubMed/MEDLINE, Google Scholar, and Embase were searched between October 1982 and October 2022 to identify eligible studies.</p></div><div><h3>STUDY ELIGIBILITY CRITERIA</h3><p>Observational studies providing data on the use of a combined clinical-ultrasound score system applied from mid-pregnancy for the prenatal evaluation of placenta accreta spectrum were included.</p></div><div><h3>METHODS</h3><p>Study characteristics were evaluated by 2 independent reviewers using a predesigned protocol registered on PROSPERO (CRD42022332486). Heterogeneity among studies was analyzed with Cochran's Q-test and I<sup>2</sup> statistics. Statistical heterogeneity was quantified by estimating the variance between the studies using I<sup>2</sup> statistics. The area under the receiver operating characteristic curve of each score and their summary receiver operating characteristic curves were calculated with sensitivity and specificity, and the integrated score of the summaries of the receiver operating characteristic curves of all sonographic markers was calculated. Forest plots were used to develop the meta-analysis of each sonographic marker and for the integrated sonographic score.</p></div><div><h3>RESULTS</h3><p>Of 1028 articles reviewed, 12 cohorts and 2 case–control studies including 1630 patients screened for placenta accreta spectrum by clinical-ultrasound scores met the eligibility criteria. A diagnosis of placenta accreta spectrum was reported in 602 (36.9%) cases, for which 547 (90.9%) intraoperative findings and/or histopathologic data were described. A wide variation was observed among the studies in reported sensitivities and specificities and in thresholds used for the identification of patients with a high probability of placenta accreta spectrum at birth. The summaries of the areas under the curve of the individual sonographic scores ranged from 0.85 (the lowest) for subplacental hypervascularity to 0.91 for placental location in the lower uterine segment, myometrial thinning, and placental lacunae and 0.95 for the loss of clear zone. Only 4 studies included placental bulging in their sonographic score system, and therefore no meta-analysis for this score was performed. The integrated summary of the areas under the curve was 0.83 (95% confidence interval, 79–0.86). Forest plot analysis revealed integrated sensitivities and specificities of 0.68 (95% confidence interval, 0.53–0.80) and 0.88 (95% confidence interval, 0.68–0.96), respectively.</p>
{"title":"Clinical-sonographic scores for the screening of placenta accreta spectrum: a systematic review and meta-analysis","authors":"","doi":"10.1016/j.ajogmf.2024.101369","DOIUrl":"10.1016/j.ajogmf.2024.101369","url":null,"abstract":"<div><h3>OBJECTIVE</h3><p><span>Clinical-sonographic scoring systems combining clinical features and ultrasound imaging markers have been proposed for the screening of </span>placenta accreta<span> spectrum, but their usefulness in different settings remains limited. This study aimed to assess and compare different clinical-sonographic score systems applied from mid-pregnancy for the prenatal evaluation of patients at risk of placenta accreta spectrum at birth.</span></p></div><div><h3>DATA SOURCES</h3><p>PubMed/MEDLINE, Google Scholar, and Embase were searched between October 1982 and October 2022 to identify eligible studies.</p></div><div><h3>STUDY ELIGIBILITY CRITERIA</h3><p>Observational studies providing data on the use of a combined clinical-ultrasound score system applied from mid-pregnancy for the prenatal evaluation of placenta accreta spectrum were included.</p></div><div><h3>METHODS</h3><p>Study characteristics were evaluated by 2 independent reviewers using a predesigned protocol registered on PROSPERO (CRD42022332486). Heterogeneity among studies was analyzed with Cochran's Q-test and I<sup>2</sup> statistics. Statistical heterogeneity was quantified by estimating the variance between the studies using I<sup>2</sup> statistics. The area under the receiver operating characteristic curve of each score and their summary receiver operating characteristic curves were calculated with sensitivity and specificity, and the integrated score of the summaries of the receiver operating characteristic curves of all sonographic markers was calculated. Forest plots were used to develop the meta-analysis of each sonographic marker and for the integrated sonographic score.</p></div><div><h3>RESULTS</h3><p>Of 1028 articles reviewed, 12 cohorts and 2 case–control studies including 1630 patients screened for placenta accreta spectrum by clinical-ultrasound scores met the eligibility criteria. A diagnosis of placenta accreta spectrum was reported in 602 (36.9%) cases, for which 547 (90.9%) intraoperative findings and/or histopathologic data were described. A wide variation was observed among the studies in reported sensitivities and specificities and in thresholds used for the identification of patients with a high probability of placenta accreta spectrum at birth. The summaries of the areas under the curve of the individual sonographic scores ranged from 0.85 (the lowest) for subplacental hypervascularity to 0.91 for placental location in the lower uterine segment, myometrial thinning, and placental lacunae and 0.95 for the loss of clear zone. Only 4 studies included placental bulging in their sonographic score system, and therefore no meta-analysis for this score was performed. The integrated summary of the areas under the curve was 0.83 (95% confidence interval, 79–0.86). Forest plot analysis revealed integrated sensitivities and specificities of 0.68 (95% confidence interval, 0.53–0.80) and 0.88 (95% confidence interval, 0.68–0.96), respectively.</p>","PeriodicalId":36186,"journal":{"name":"American Journal of Obstetrics & Gynecology Mfm","volume":null,"pages":null},"PeriodicalIF":3.8,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140784019","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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