Pub Date : 2024-08-01DOI: 10.1016/j.xagr.2024.100379
BACKGROUND
Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting.
OBJECTIVE
To determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features.
STUDY DESIGN
We conducted a mixed method study on the pre-referral management of pregnant women complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who are complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20–30 minutes of semistructured, qualitative, face-to-face, in-depth interviews with 14 health professionals. Quantitative data were analyzed using SPSS (version 23), and simple descriptive statistics were employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data.
RESULTS
A total of 261 pregnant women who had preeclampsia with severity features were included in the study, and 14 care providers were interviewed about existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3 mm Hg and 100.3 mm Hg, respectively. The total perinatal mortality was 6.5% (17/261). Three of 261 mothers (1.1%) were complicated by intracranial hemorrhage, and other 1.1% (3/261) of other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulfate before referral. Similarly, antihypertensive medication was given only to 35 of 261 patients (13.4%) pre-referral. Eight of 261 mothers convulsed (3.1%) during referral. Two of 261 mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Similarly, another 2 of 261 (0.8%) women developed disseminated intravascular coagulation by the time of arrival from the referring health institution. On the basis of qualitative data analysis, 3 overarching themes were recognized: (1) challenges related to patient and family resistance, (2) Challenges related to healthcare providers’ knowledge, skill, and confidence, and (3) health system-related challenges. Low use of magnesium sulfate and antihypertensive drugs, patient misperceptions regarding reasons for referral, providers’ lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institutions, and nonexistence of uniform preeclamp
{"title":"Pre-referral management of preeclampsia with severity features in a low-income country—characteristics and challenges in a Sub-Saharan setting: a mixed method study","authors":"","doi":"10.1016/j.xagr.2024.100379","DOIUrl":"10.1016/j.xagr.2024.100379","url":null,"abstract":"<div><h3>BACKGROUND</h3><p>Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting.</p></div><div><h3>OBJECTIVE</h3><p>To determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features.</p></div><div><h3>STUDY DESIGN</h3><p>We conducted a mixed method study on the pre-referral management of pregnant women complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who are complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20–30 minutes of semistructured, qualitative, face-to-face, in-depth interviews with 14 health professionals. Quantitative data were analyzed using SPSS (version 23), and simple descriptive statistics were employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data.</p></div><div><h3>RESULTS</h3><p>A total of 261 pregnant women who had preeclampsia with severity features were included in the study, and 14 care providers were interviewed about existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3 mm Hg and 100.3 mm Hg, respectively. The total perinatal mortality was 6.5% (17/261). Three of 261 mothers (1.1%) were complicated by intracranial hemorrhage, and other 1.1% (3/261) of other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulfate before referral. Similarly, antihypertensive medication was given only to 35 of 261 patients (13.4%) pre-referral. Eight of 261 mothers convulsed (3.1%) during referral. Two of 261 mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Similarly, another 2 of 261 (0.8%) women developed disseminated intravascular coagulation by the time of arrival from the referring health institution. On the basis of qualitative data analysis, 3 overarching themes were recognized: (1) challenges related to patient and family resistance, (2) Challenges related to healthcare providers’ knowledge, skill, and confidence, and (3) health system-related challenges. Low use of magnesium sulfate and antihypertensive drugs, patient misperceptions regarding reasons for referral, providers’ lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institutions, and nonexistence of uniform preeclamp","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S266657782400073X/pdfft?md5=ee0353a07d74582068d7f3d50cb21241&pid=1-s2.0-S266657782400073X-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141715783","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100377
Background
This study aimed to assess the utility of real-time-polymerase chain reaction (PCR) for diagnosing chronic endometritis (CE) by targeting 11 prevalent pathogens and to compare the outcomes with conventional culture-based diagnosis.
Study Design
A retrospective analysis was conducted on 500 patients with clinical conditions such as abnormal bleeding, in vitro fertilization failure, recurrent implantation failure, recurrent miscarriage, and recurrent pregnancy loss. The prevalence of 11 key pathogens associated with CE was evaluated in endometrial biopsy samples.
Results
In our study, PCR identified 318 cases (63.6%) positive for at least one of the 11 investigated pathogens, while culture-based methods detected 115 cases (23%). Predominant pathogens detected by PCR included Enterococcus faecalis (E. faecalis) (19%), Escherichia coli (E. coli) (6.8%), Staphylococcus aureus (S. aureus) (9%), Mycoplasma hominis (5%), Mycoplasma genitalium (6.2%), Streptococcus agalactiae (S. agalactiae) (4.2%), Ureaplasma urealyticum (4%), nontuberculous Mycobacterium (5.2%), Mycobacterium tuberculosis (1.2%), Neisseria gonorrhoeae (0.6%), and Chlamydia trachomatis (2.4%). Standard culture methods identified E. faecalis (10.8%), S. aureus (6.2%), E. coli (3.8%), and S. agalactiae (2.2%).
Conclusion
The DICE panel proves itself as a swift, precise, and cost-effective diagnostic tool for detecting both culturable and nonculturable endometrial pathogens in CE. Demonstrating superiority, the Molecular method outshines microbial culture, ensuring accurate and sensitive detection of CE-associated pathogens, harmonizing seamlessly with histology and hysteroscopy findings.
{"title":"Revolutionizing chronic endometritis diagnosis: real-time polymerase chain reaction unveils microbial pathogens in Indian women with abnormal bleeding and reproductive challenges","authors":"","doi":"10.1016/j.xagr.2024.100377","DOIUrl":"10.1016/j.xagr.2024.100377","url":null,"abstract":"<div><h3>Background</h3><p>This study aimed to assess the utility of real-time-polymerase chain reaction (PCR) for diagnosing chronic endometritis (CE) by targeting 11 prevalent pathogens and to compare the outcomes with conventional culture-based diagnosis.</p></div><div><h3>Study Design</h3><p>A retrospective analysis was conducted on 500 patients with clinical conditions such as abnormal bleeding, in vitro fertilization failure, recurrent implantation failure, recurrent miscarriage, and recurrent pregnancy loss. The prevalence of 11 key pathogens associated with CE was evaluated in endometrial biopsy samples.</p></div><div><h3>Results</h3><p>In our study, PCR identified 318 cases (63.6%) positive for at least one of the 11 investigated pathogens, while culture-based methods detected 115 cases (23%). Predominant pathogens detected by PCR included <em>Enterococcus faecalis</em> (<em>E. faecalis</em>) (19%), <em>Escherichia coli</em> (<em>E. coli</em>) (6.8%), <em>Staphylococcus aureus</em> (<em>S. aureus</em>) (9%), <em>Mycoplasma hominis</em> (5%), <em>Mycoplasma genitalium</em> (6.2%), <em>Streptococcus agalactiae</em> (<em>S. agalactiae</em>) (4.2%), <em>Ureaplasma urealyticum</em> (4%), nontuberculous <em>Mycobacterium</em> (5.2%), <em>Mycobacterium tuberculosis</em> (1.2%), <em>Neisseria gonorrhoeae</em> (0.6%), and <em>Chlamydia trachomatis</em> (2.4%). Standard culture methods identified <em>E. faecalis</em> (10.8%), <em>S. aureus</em> (6.2%), <em>E. coli</em> (3.8%), and <em>S. agalactiae</em> (2.2%).</p></div><div><h3>Conclusion</h3><p>The DICE panel proves itself as a swift, precise, and cost-effective diagnostic tool for detecting both culturable and nonculturable endometrial pathogens in CE. Demonstrating superiority, the Molecular method outshines microbial culture, ensuring accurate and sensitive detection of CE-associated pathogens, harmonizing seamlessly with histology and hysteroscopy findings.</p></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000716/pdfft?md5=2570037d6c2f5734f5463577dcf2222f&pid=1-s2.0-S2666577824000716-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141697972","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100371
Introduction
Episiotomy is a surgical procedure involving the enlargement of the posterior vagina to facilitate the delivery of the baby. This study aims to further investigate the associated risk factors for episiotomy and the specific indications for its use in spontaneous labor.
Methodology
This institutional-based cross-sectional study was conducted among 349 vaginal births with a ratio of 1:4 from January 2020 to December 2020. We recruited study participants using consecutive sampling techniques. The sample size was calculated with a hypothesis test for two population proportions (one-sided test formula). Adjusted odds ratio with the corresponding 95% confidence interval was used to declare the significance of variables.
Results
In our multivariate analysis, it was found that pregnant women who underwent instrumental delivery (P-value=.00; OR=25.63; 95% CI: 5.76–114.0) and those with fetal birth weight >3,000 grams (P-value=.00; OR=11.31; 95% CI: 3.96–32.32) had the highest risk of undergoing an episiotomy. Subsequently, the duration of the second stage of labor >30 minutes (P-value=.049; OR=16.34; 95% CI: 1.01–264.48) was associated with a slightly increased risk of episiotomy. Fetal head circumference >34 cm was not found to be risk of an increased risk of episiotomy in this study. However, pregnant women aged >30 years (P-value=.049; OR=0.306; 95% CI: 0.94–0.99) showed a reduced risk of episiotomy.
Conclusion
The prevalence of episiotomy practice in this study exceeds the recommended threshold set by the World Health Organization (WHO). Instrumental delivery, high birth weight, and prolonged second-stage labor emerged as significant factors influencing episiotomy practice. Hence, further interventions are warranted to mitigate the prevalence of episiotomy practice.
{"title":"Analysis of episiotomy incidence and risk factors in vaginal deliveries: a single-center","authors":"","doi":"10.1016/j.xagr.2024.100371","DOIUrl":"10.1016/j.xagr.2024.100371","url":null,"abstract":"<div><h3>Introduction</h3><p>Episiotomy is a surgical procedure involving the enlargement of the posterior vagina to facilitate the delivery of the baby. This study aims to further investigate the associated risk factors for episiotomy and the specific indications for its use in spontaneous labor.</p></div><div><h3>Methodology</h3><p>This institutional-based cross-sectional study was conducted among 349 vaginal births with a ratio of 1:4 from January 2020 to December 2020. We recruited study participants using consecutive sampling techniques. The sample size was calculated with a hypothesis test for two population proportions (one-sided test formula). Adjusted odds ratio with the corresponding 95% confidence interval was used to declare the significance of variables.</p></div><div><h3>Results</h3><p>In our multivariate analysis, it was found that pregnant women who underwent instrumental delivery (<em>P</em>-value=.00; OR=25.63; 95% CI: 5.76–114.0) and those with fetal birth weight >3,000 grams (<em>P</em>-value=.00; OR=11.31; 95% CI: 3.96–32.32) had the highest risk of undergoing an episiotomy. Subsequently, the duration of the second stage of labor >30 minutes (<em>P</em>-value=.049; OR=16.34; 95% CI: 1.01–264.48) was associated with a slightly increased risk of episiotomy. Fetal head circumference >34 cm was not found to be risk of an increased risk of episiotomy in this study. However, pregnant women aged >30 years (<em>P</em>-value=.049; OR=0.306; 95% CI: 0.94–0.99) showed a reduced risk of episiotomy.</p></div><div><h3>Conclusion</h3><p>The prevalence of episiotomy practice in this study exceeds the recommended threshold set by the World Health Organization (WHO). Instrumental delivery, high birth weight, and prolonged second-stage labor emerged as significant factors influencing episiotomy practice. Hence, further interventions are warranted to mitigate the prevalence of episiotomy practice.</p></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000650/pdfft?md5=572b25fe9f2f8de04d5874b5ecd2ba0a&pid=1-s2.0-S2666577824000650-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141842845","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100374
Purpose
Since the Consensus Statement diffused by the Amsterdam Placental Workshop Group, knowledge of the meaning of placental vascular malperfusion has become essential in the unavoidable analysis of obstetrical history in a patient followed for autoimmune disease or any other maternal comorbidity. We aimed to analyse the prevalence of various placental lesions from a 6-months prospective observational study and to correlate the various placental profiles to obstetrical outcome, maternal diseases and pregnancy treatments. The frequency of foetal vascular malperfusion lesion could be estimated at 8.7%, in our population and to understand its neonatal associations.
Methods
The study groups consisted of 208 consecutive women which ended the pregnancy and have placental analysis during the period of the study.
Results
From December 2015 to October 2017, from overall 4398 delivered pregnancies in university obstetrical department, 208 (4.7%) placental analysis have been done and included in the study. The placental analysis have been done for vascular obstetrical complications during the pregnancy (n = 106; 51%), unexplained abnormal foetal heart rate tracings (n = 59; 28,3%), suspicion of intra-amniotic infection (n = 12; 5,7%%), term new-borns Apgar score <7 or arterial cord blood pH ≤ 7 (n = 7; 3,5%), spontaneous preterm delivery (n = 19; 9,1%), intrahepatic cholestasis of pregnancy (n = 5; 2,4%). An adverse obstetrical event was noted in 87 cases (42%): preeclampsia or HELLP syndrome (n = 15; 7%), FGR (n = 59; 28%), gestational diabetes (n = 33; 16%) and gestational hypertension (n = 19; 9%). Placental histological analysis showed abnormal vascular features in 159 cases (76%), inflammatory features in 16 placentas (8%), vascular and inflammatory features in 10 cases (4%), chorioamnionitis in 38 cases (18%) and absence of any abnormality in 43 cases (21%). A cluster analysis of histological features allowed distinguishing three placental patterns: a normal pattern characterised by the absence of any placental lesions, an inflammatory pattern characterised by the presence of villitis and/or chronic intervillositis; a vascular pattern with the presence of thrombosis, maternal floor infarct with massive perivillous fibrin deposition, infarction and chronic villositis hypoxia. Women with inflammatory placental profile have significantly increased frequencies of tobacco use (50% vs. 9%; P = 0.03), pathological vascular Doppler (50% vs. 5%; P = 0.001), FGR (100% vs. 14%; P = 0.0001) and oligohydramnios (67% vs. 5%; P = 0.0001) than those with normal placentas. A higher rate of vascular or inflammatory lesion were observed in women with Hypertensive disorder of pregnancy, where as those with inflammatory pattern have significantly more frequent FGR (100% vs 34%; P = 0.02) and oligohydramnios (67% vs 5%; P = 0.0002).
{"title":"Prevalence and association of placental lesions with obstetrical features and outcome: data from French prospective study","authors":"","doi":"10.1016/j.xagr.2024.100374","DOIUrl":"10.1016/j.xagr.2024.100374","url":null,"abstract":"<div><h3>Purpose</h3><p>Since the Consensus Statement diffused by the Amsterdam Placental Workshop Group, knowledge of the meaning of placental vascular malperfusion has become essential in the unavoidable analysis of obstetrical history in a patient followed for autoimmune disease or any other maternal comorbidity. We aimed to analyse the prevalence of various placental lesions from a 6-months prospective observational study and to correlate the various placental profiles to obstetrical outcome, maternal diseases and pregnancy treatments. The frequency of foetal vascular malperfusion lesion could be estimated at 8.7%, in our population and to understand its neonatal associations.</p></div><div><h3>Methods</h3><p>The study groups consisted of 208 consecutive women which ended the pregnancy and have placental analysis during the period of the study.</p></div><div><h3>Results</h3><p>From December 2015 to October 2017, from overall 4398 delivered pregnancies in university obstetrical department, 208 (4.7%) placental analysis have been done and included in the study. The placental analysis have been done for vascular obstetrical complications during the pregnancy (n = 106; 51%), unexplained abnormal foetal heart rate tracings (n = 59; 28,3%), suspicion of intra-amniotic infection (n = 12; 5,7%%), term new-borns Apgar score <7 or arterial cord blood pH ≤ 7 (n = 7; 3,5%), spontaneous preterm delivery (n = 19; 9,1%), intrahepatic cholestasis of pregnancy (n = 5; 2,4%). An adverse obstetrical event was noted in 87 cases (42%): preeclampsia or HELLP syndrome (n = 15; 7%), FGR (n = 59; 28%), gestational diabetes (n = 33; 16%) and gestational hypertension (n = 19; 9%). Placental histological analysis showed abnormal vascular features in 159 cases (76%), inflammatory features in 16 placentas (8%), vascular and inflammatory features in 10 cases (4%), chorioamnionitis in 38 cases (18%) and absence of any abnormality in 43 cases (21%). A cluster analysis of histological features allowed distinguishing three placental patterns: a normal pattern characterised by the absence of any placental lesions, an inflammatory pattern characterised by the presence of villitis and/or chronic intervillositis; a vascular pattern with the presence of thrombosis, maternal floor infarct with massive perivillous fibrin deposition, infarction and chronic villositis hypoxia. Women with inflammatory placental profile have significantly increased frequencies of tobacco use (50% vs. 9%; <em>P</em> = 0.03), pathological vascular Doppler (50% vs. 5%; <em>P</em> = 0.001), FGR (100% vs. 14%; <em>P</em> = 0.0001) and oligohydramnios (67% vs. 5%; <em>P</em> = 0.0001) than those with normal placentas. A higher rate of vascular or inflammatory lesion were observed in women with Hypertensive disorder of pregnancy, where as those with inflammatory pattern have significantly more frequent FGR (100% vs 34%; <em>P</em> = 0.02) and oligohydramnios (67% vs 5%; <em>P</em> = 0.0002).</p></div><div><h","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000686/pdfft?md5=15fe6687c353a665bac8dda6b31be442&pid=1-s2.0-S2666577824000686-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141951861","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100381
Objective
To assess pathways to parenthood, pregnancy outcomes, future pregnancy desire, and fertility counseling experiences among a cross-sectional sample of transgender men and gender diverse individuals assigned female or intersex at birth in the United States
Methods
Participants were recruited from The Population Research in Identity and Disparities for Equality (PRIDE) Study and the general public. Eligible participants for this analysis were able to read and understand English, assigned female or intersex at birth, US residents, 18+ years old, and identified as transgender, nonbinary, or gender diverse. We analyzed responses to close-ended survey questions, overall and stratified by gender identity, race/ethnicity, and testosterone use. We also qualitatively assessed open-text responses on fertility counseling.
Results
Among the 1694 participants, median age was 27 years (range: 18–72), 12% had ever been pregnant, and 12% were parents. Carrying a pregnancy where the individual was the egg source (36%) was the most common pathway to parenthood. Individuals with an exclusively binary gender identity (ie, transgender man or man) more often reported becoming parents through adoption than individuals with gender diverse identities (19% vs 12%). A third of individuals did not receive fertility counseling prior to initiating testosterone; individuals who exclusively reported nonbinary identities were recommended to investigate fertility preservation options less often (36%) compared to transgender men (50%).
Conclusion
Transgender men and gender diverse individuals who were assigned female or intersex at birth build their families through a variety of pathways, including pregnancy, stepparenting, and adoption. Clinicians should avoid making assumptions about reproductive desires in these populations based on gender identities or testosterone use and should provide consistent fertility counseling prior to and after hormone initiation.
{"title":"Pathways to parenthood among transgender men and gender diverse people assigned female or intersex at birth in the United States: analysis of a Cross-Sectional 2019 Survey","authors":"","doi":"10.1016/j.xagr.2024.100381","DOIUrl":"10.1016/j.xagr.2024.100381","url":null,"abstract":"<div><h3>Objective</h3><p>To assess pathways to parenthood, pregnancy outcomes, future pregnancy desire, and fertility counseling experiences among a cross-sectional sample of transgender men and gender diverse individuals assigned female or intersex at birth in the United States</p></div><div><h3>Methods</h3><p>Participants were recruited from The Population Research in Identity and Disparities for Equality (PRIDE) Study and the general public. Eligible participants for this analysis were able to read and understand English, assigned female or intersex at birth, US residents, 18+ years old, and identified as transgender, nonbinary, or gender diverse. We analyzed responses to close-ended survey questions, overall and stratified by gender identity, race/ethnicity, and testosterone use. We also qualitatively assessed open-text responses on fertility counseling.</p></div><div><h3>Results</h3><p>Among the 1694 participants, median age was 27 years (range: 18–72), 12% had ever been pregnant, and 12% were parents. Carrying a pregnancy where the individual was the egg source (36%) was the most common pathway to parenthood. Individuals with an exclusively binary gender identity (ie<em>,</em> transgender man or man) more often reported becoming parents through adoption than individuals with gender diverse identities (19% vs 12%). A third of individuals did not receive fertility counseling prior to initiating testosterone; individuals who exclusively reported nonbinary identities were recommended to investigate fertility preservation options less often (36%) compared to transgender men (50%).</p></div><div><h3>Conclusion</h3><p>Transgender men and gender diverse individuals who were assigned female or intersex at birth build their families through a variety of pathways, including pregnancy, stepparenting, and adoption. Clinicians should avoid making assumptions about reproductive desires in these populations based on gender identities or testosterone use and should provide consistent fertility counseling prior to and after hormone initiation.</p></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000753/pdfft?md5=4b69557ce7c1d87e40fd4196eb30a5a3&pid=1-s2.0-S2666577824000753-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141839589","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100385
The Health Equity Leadership & Exchange Network states that “health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location, or other societal constructs, have fair and just access, opportunity, and resources to achieve their highest potential for health.” It is clear from the wide discrepancies in maternal and infant mortalities, by race, ethnicity, location, and social and economic status, that health equity has not been achieved in pregnancy care. Although the most obvious evidence of inequities is in low-resource settings, inequities also exist in high-resource settings. In this presentation, based on the Global Pregnancy Collaboration Workshop, which addressed this issue, the bases for the differences in outcomes were explored. Several different settings in which inequities exist in high- and low-resource settings were reviewed. Apparent causes include social drivers of health, such as low income, inadequate housing, suboptimal access to clean water, structural racism, and growing maternal healthcare deserts globally. In addition, a question is asked whether maternal health inequities will extend to and be partially due to current research practices. Our overview of inequities provides approaches to resolve these inequities, which are relevant to low- and high-resource settings. Based on the evidence, recommendations have been provided to increase health equity in pregnancy care. Unfortunately, some of these inequities are more amenable to resolution than others. Therefore, continued attention to these inequities and innovative thinking and research to seek solutions to these inequities are encouraged.
{"title":"Global inequities in adverse pregnancy outcomes: what can we do?","authors":"","doi":"10.1016/j.xagr.2024.100385","DOIUrl":"10.1016/j.xagr.2024.100385","url":null,"abstract":"<div><p>The Health Equity Leadership & Exchange Network states that “health equity exists when all people, regardless of race, sex, sexual orientation, disability, socioeconomic status, geographic location, or other societal constructs, have fair and just access, opportunity, and resources to achieve their highest potential for health.” It is clear from the wide discrepancies in maternal and infant mortalities, by race, ethnicity, location, and social and economic status, that health equity has not been achieved in pregnancy care. Although the most obvious evidence of inequities is in low-resource settings, inequities also exist in high-resource settings. In this presentation, based on the Global Pregnancy Collaboration Workshop, which addressed this issue, the bases for the differences in outcomes were explored. Several different settings in which inequities exist in high- and low-resource settings were reviewed. Apparent causes include social drivers of health, such as low income, inadequate housing, suboptimal access to clean water, structural racism, and growing maternal healthcare deserts globally. In addition, a question is asked whether maternal health inequities will extend to and be partially due to current research practices. Our overview of inequities provides approaches to resolve these inequities, which are relevant to low- and high-resource settings. Based on the evidence, recommendations have been provided to increase health equity in pregnancy care. Unfortunately, some of these inequities are more amenable to resolution than others. Therefore, continued attention to these inequities and innovative thinking and research to seek solutions to these inequities are encouraged.</p></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000790/pdfft?md5=789fcac4101e40c738c1fbb095b7807f&pid=1-s2.0-S2666577824000790-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141848506","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100378
Background
Previous studies that suggest a shorter time from cervical ripening balloon placement to delivery with shorter total balloon placement time have excluded patients with prior cesarean deliveries.
Objective
To evaluate, in patients with a prior history of cesarean delivery undergoing cervical ripening with a double-balloon catheter, whether planned removal of device after 6 vs 12 hours would result in shorter time to vaginal delivery.
Study Design
A before-and-after study was performed after a practice change occurred November 2020, shortening the planned time of double-balloon catheter placement for cervical ripening from 12 to 6 hours. Data were collected via retrospective electronic chart review. Primary outcome was time from balloon placement to vaginal delivery. Secondary outcomes included rates of cesarean delivery, maternal intraamniotic infection, and uterine rupture. Kaplan–Meier curves compared median times to delivery between the groups. A Cox proportional-hazards model was used to adjust for time of balloon placement, number of previous vaginal deliveries, and co-medications used.
Results
From November 2018 to November 2022, 189 analyzable patients with a prior history of cesarean delivery received a double-balloon catheter for cervical ripening during their trial of labor. Patients were separated into pre- and postpolicy change groups (n=91 and 98, respectively). The median time to vaginal delivery for the pregroup was 28 hours (95% CI: 26, 35) and 25 hours (95% CI: 23, 29) for those in the postgroup (P value .052). After adjusting for dilation at time of balloon placement, number of previous vaginal deliveries, and co-medication, the estimated hazard ratio for successful vaginal delivery postpolicy change was 1.89 (95% CI: 1.27, 2.81). There were no differences in rates of secondary outcomes.
Conclusion
In patients with prior cesarean delivery undergoing mechanical cervical ripening with a double-balloon catheter, planned removal at 6 hours compared to 12 hours may result in higher chances of successful vaginal delivery and possibly a shorter time to delivery, without increasing rates of cesarean delivery and intraamniotic infection.
{"title":"Duration of double balloon catheter for patients with prior cesarean: a before and after study","authors":"","doi":"10.1016/j.xagr.2024.100378","DOIUrl":"10.1016/j.xagr.2024.100378","url":null,"abstract":"<div><h3>Background</h3><p>Previous studies that suggest a shorter time from cervical ripening balloon placement to delivery with shorter total balloon placement time have excluded patients with prior cesarean deliveries.</p></div><div><h3>Objective</h3><p>To evaluate, in patients with a prior history of cesarean delivery undergoing cervical ripening with a double-balloon catheter, whether planned removal of device after 6 vs 12 hours would result in shorter time to vaginal delivery.</p></div><div><h3>Study Design</h3><p>A before-and-after study was performed after a practice change occurred November 2020, shortening the planned time of double-balloon catheter placement for cervical ripening from 12 to 6 hours. Data were collected via retrospective electronic chart review. Primary outcome was time from balloon placement to vaginal delivery. Secondary outcomes included rates of cesarean delivery, maternal intraamniotic infection, and uterine rupture. Kaplan–Meier curves compared median times to delivery between the groups. A Cox proportional-hazards model was used to adjust for time of balloon placement, number of previous vaginal deliveries, and co-medications used.</p></div><div><h3>Results</h3><p>From November 2018 to November 2022, 189 analyzable patients with a prior history of cesarean delivery received a double-balloon catheter for cervical ripening during their trial of labor. Patients were separated into pre- and postpolicy change groups (<em>n</em>=91 and 98, respectively). The median time to vaginal delivery for the pregroup was 28 hours (95% CI: 26, 35) and 25 hours (95% CI: 23, 29) for those in the postgroup (<em>P</em> value .052). After adjusting for dilation at time of balloon placement, number of previous vaginal deliveries, and co-medication, the estimated hazard ratio for successful vaginal delivery postpolicy change was 1.89 (95% CI: 1.27, 2.81). There were no differences in rates of secondary outcomes.</p></div><div><h3>Conclusion</h3><p>In patients with prior cesarean delivery undergoing mechanical cervical ripening with a double-balloon catheter, planned removal at 6 hours compared to 12 hours may result in higher chances of successful vaginal delivery and possibly a shorter time to delivery, without increasing rates of cesarean delivery and intraamniotic infection.</p></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000728/pdfft?md5=1bc068d6cb1c4a8fa9c65d8a1a2e03db&pid=1-s2.0-S2666577824000728-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141953080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100384
Objective
Screening questionnaires are one option for identification of at-risk substance use and substance use disorder (SUD) during pregnancy. We report the experience of a single institution following universal implementation of a brief screening tool for self-reported substance use at the first prenatal encounter.
Study Design
This is a prospective implementation study evaluating screening for substance use in pregnancy in a large safety net healthcare system. Universal screening with the National Institute of Drug Abuse (NIDA) Quick Screen V1.0 was integrated into the electronic medical record (EMR) and administered at the first point of contact with the healthcare system. SUD was identified initially with diagnosis within the EMR by a healthcare provider and was confirmed with toxicology (maternal or neonatal) results corroborating a pattern of substance use and maternal and neonatal ICD-10 codes for SUD. Patients identified with SUD were then classified as moderate or severe SUD based on criteria established by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. We measured rates of NIDA implementation across different healthcare settings, evaluated NIDA concordance with ascertainment of SUD, and compared adverse pregnancy outcomes associated with moderate and severe SUD.
Results
From July 28, 2021, through June 25, 2022, 14,634 unique pregnant individuals accessed care at ambulatory and acute care sites. Universal implementation of the NIDA Quick Screen identified at-risk substance use in 2146 (14.7%) of those who accessed our system, or 17.1% of 12,550 screened across the system, with greater screen completion in ambulatory over acute care settings. SUD was identified in 256 (1.7%) of 14,634 individuals and moderate or severe SUD was identified in 184 (1.3%). Among those with moderate or severe SUD, 90 (48.9%) were NIDA positive, 22 (12.0%) NIDA negative, and 72 (39.1%) unscreened. Of 94 individuals with NIDA discordance or who were unscreened 76 (81%) accessed initial care through an acute care setting. Of 96 individuals with opioid use disorder, 68 (70.8%) were treated with medication-assisted therapy, and 56 (58.3%) were screened with the NIDA Quick Screen. Among delivered individuals with available outcomes, those with moderate or severe SUD were less likely to seek prenatal care (71 (76%) vs 9852 (98%), <0.001)) and more likely to deliver before 37 weeks, (18 (20%) vs 909 (9%), RR (95% CI) 2.13 (1.40, 3.24)) compared to individuals without SUD. Neonates exposed to moderate or severe SUD were more likely to have birth weight <10th centile for gestational age (20 (22%) vs 1147 (12%), RR (95% CI) 1.92 (1.29, 2.85)) and require admission to the neonatal intensive care unit (NICU) (19 (21%) vs 964 (10%), RR (95%) 1.95 (1.30, 2.93)).
Conclusion
Universal screening was implemented across a large public healthcare system at a
目的筛查问卷是识别孕期药物使用风险和药物使用障碍（SUD）的一种方法。研究设计这是一项前瞻性实施研究，评估了大型安全网医疗保健系统对孕期药物使用情况的筛查。美国国家药物滥用研究所（NIDA）的快速筛查 V1.0 被整合到电子病历（EMR）中，并在与医疗保健系统的首次接触时进行普遍筛查。通过医疗服务提供者在 EMR 中的诊断初步确定 SUD，并通过证实药物使用模式的毒理学（孕产妇或新生儿）结果以及孕产妇和新生儿 SUD 的 ICD-10 编码进行确认。然后，根据《精神疾病诊断与统计手册》第 5 版制定的标准，将确定为 SUD 的患者划分为中度或重度 SUD。我们测量了不同医疗机构的 NIDA 实施率，评估了 NIDA 与 SUD 确定的一致性，并比较了与中度和重度 SUD 相关的不良妊娠结局。在使用我们系统的人中，有 2146 人（14.7%）通过普遍实施 NIDA 快速筛查发现有药物使用风险，占整个系统筛查的 12,550 人的 17.1%，非住院医疗机构的筛查完成率高于急诊医疗机构。在 14634 人中，有 256 人（1.7%）被确认患有药物滥用症，184 人（1.3%）被确认患有中度或重度药物滥用症。在中度或重度 SUD 患者中，90 人（48.9%）NIDA 阳性，22 人（12.0%）NIDA 阴性，72 人（39.1%）未接受筛查。在 94 名 NIDA 不一致或未经筛查的患者中，有 76 人（81%）通过急症护理机构获得了初步护理。在 96 名阿片类药物使用障碍患者中，68 人（70.8%）接受了药物辅助治疗，56 人（58.3%）接受了 NIDA 快速筛查。与无阿片类药物滥用症的患者相比，有中度或重度阿片类药物滥用症的患者不太可能寻求产前护理（71 (76%) vs 9852 (98%)，<0.001)），而且更有可能在 37 周前分娩（18 (20%) vs 909 (9%)，RR (95% CI) 2.13 (1.40, 3.24)）。接触中度或重度 SUD 的新生儿出生体重超过胎龄第 10 百分位数的几率更高（20 (22%) vs 1147 (12%)，RR (95% CI) 1.92 (1.29, 2.85)），需要入住新生儿重症监护室（NICU）的几率更高（19 (21%) vs 964 (10%)，RR (95%) 1.结论在一个大型公共医疗系统中，普遍筛查的实施率很高，在门诊环境中的实施率更高。在 17% 的 SUD 群体中，NIDA 成功识别了高危药物使用，但未能识别 50% 以上的中度或重度 SUD 患者。中度和重度 SUD 患者主要通过急诊科接受治疗，产科和新生儿不良后果发生率较高。今后需要努力识别、参与并留住这一最高风险群体。
{"title":"Implementation of universal screening for substance use in pregnancy in a public healthcare system","authors":"","doi":"10.1016/j.xagr.2024.100384","DOIUrl":"10.1016/j.xagr.2024.100384","url":null,"abstract":"<div><h3>Objective</h3><p>Screening questionnaires are one option for identification of at-risk substance use and substance use disorder (SUD) during pregnancy. We report the experience of a single institution following universal implementation of a brief screening tool for self-reported substance use at the first prenatal encounter.</p></div><div><h3>Study Design</h3><p>This is a prospective implementation study evaluating screening for substance use in pregnancy in a large safety net healthcare system. Universal screening with the National Institute of Drug Abuse (NIDA) Quick Screen V1.0 was integrated into the electronic medical record (EMR) and administered at the first point of contact with the healthcare system. SUD was identified initially with diagnosis within the EMR by a healthcare provider and was confirmed with toxicology (maternal or neonatal) results corroborating a pattern of substance use and maternal and neonatal ICD-10 codes for SUD. Patients identified with SUD were then classified as moderate or severe SUD based on criteria established by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. We measured rates of NIDA implementation across different healthcare settings, evaluated NIDA concordance with ascertainment of SUD, and compared adverse pregnancy outcomes associated with moderate and severe SUD.</p></div><div><h3>Results</h3><p>From July 28, 2021, through June 25, 2022, 14,634 unique pregnant individuals accessed care at ambulatory and acute care sites. Universal implementation of the NIDA Quick Screen identified at-risk substance use in 2146 (14.7%) of those who accessed our system, or 17.1% of 12,550 screened across the system, with greater screen completion in ambulatory over acute care settings. SUD was identified in 256 (1.7%) of 14,634 individuals and moderate or severe SUD was identified in 184 (1.3%). Among those with moderate or severe SUD, 90 (48.9%) were NIDA positive, 22 (12.0%) NIDA negative, and 72 (39.1%) unscreened. Of 94 individuals with NIDA discordance or who were unscreened 76 (81%) accessed initial care through an acute care setting. Of 96 individuals with opioid use disorder, 68 (70.8%) were treated with medication-assisted therapy, and 56 (58.3%) were screened with the NIDA Quick Screen. Among delivered individuals with available outcomes, those with moderate or severe SUD were less likely to seek prenatal care (71 (76%) vs 9852 (98%), <0.001)) and more likely to deliver before 37 weeks, (18 (20%) vs 909 (9%), RR (95% CI) 2.13 (1.40, 3.24)) compared to individuals without SUD. Neonates exposed to moderate or severe SUD were more likely to have birth weight <10th centile for gestational age (20 (22%) vs 1147 (12%), RR (95% CI) 1.92 (1.29, 2.85)) and require admission to the neonatal intensive care unit (NICU) (19 (21%) vs 964 (10%), RR (95%) 1.95 (1.30, 2.93)).</p></div><div><h3>Conclusion</h3><p>Universal screening was implemented across a large public healthcare system at a","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000789/pdfft?md5=f18b439e9878396139ed787ccfd877cc&pid=1-s2.0-S2666577824000789-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141852055","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100382
We present a rare case of uterine artery pseudoaneurysm (UAP) following an emergency cesarean section, which led to severe vaginal bleeding and subcutaneous hematoma. The patient, a 40-year-old woman with no history of hemophilia or hemostasis disorders, presented with sudden profuse vaginal bleeding and multiple subcutaneous hematomas at the site of the cesarean scar ten days postoperation. Ultrasound and CT scan confirmed the presence of a pseudoaneurysm in the right uterine artery. Due to the unavailability of radiological embolization, surgical ligation of the right internal iliac artery was performed. Postoperative follow-up showed successful resolution of the pseudoaneurysm and cessation of bleeding. This case highlights the importance of considering UAP in the differential diagnosis of postpartum hemorrhage and demonstrates the efficacy of surgical intervention when embolization is not available.
{"title":"Uterine artery pseudoaneurysm presenting with subcutaneous hematoma and vaginal bleeding following cesarean delivery","authors":"","doi":"10.1016/j.xagr.2024.100382","DOIUrl":"10.1016/j.xagr.2024.100382","url":null,"abstract":"<div><p>We present a rare case of uterine artery pseudoaneurysm (UAP) following an emergency cesarean section, which led to severe vaginal bleeding and subcutaneous hematoma. The patient, a 40-year-old woman with no history of hemophilia or hemostasis disorders, presented with sudden profuse vaginal bleeding and multiple subcutaneous hematomas at the site of the cesarean scar ten days postoperation. Ultrasound and CT scan confirmed the presence of a pseudoaneurysm in the right uterine artery. Due to the unavailability of radiological embolization, surgical ligation of the right internal iliac artery was performed. Postoperative follow-up showed successful resolution of the pseudoaneurysm and cessation of bleeding. This case highlights the importance of considering UAP in the differential diagnosis of postpartum hemorrhage and demonstrates the efficacy of surgical intervention when embolization is not available.</p></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000765/pdfft?md5=0cc4fd8382e471a4c5a3cb31cb5e1eee&pid=1-s2.0-S2666577824000765-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141842019","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","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.xagr.2024.100380
National guidance conflicts regarding the use of RhD immune globulin administration <12w. Recent Society for Maternal Fetal Medicine (SMFM) guidelines suggest liberal use of this product while other guidelines, including Society of Family Planning and the World Health Organization, propose a more conservative approach. Medicine is not practiced in a vacuum, and potential harms must include not only individual but communal and public health effects. We aim to critically examine the practical implications of the new SMFM guidelines with a focus on equity and access.
{"title":"A tale of two societies: implications of conflicting Rh-immunoglobulin guidelines","authors":"","doi":"10.1016/j.xagr.2024.100380","DOIUrl":"10.1016/j.xagr.2024.100380","url":null,"abstract":"<div><p>National guidance conflicts regarding the use of RhD immune globulin administration <12w. Recent Society for Maternal Fetal Medicine (SMFM) guidelines suggest liberal use of this product while other guidelines, including Society of Family Planning and the World Health Organization, propose a more conservative approach. Medicine is not practiced in a vacuum, and potential harms must include not only individual but communal and public health effects. We aim to critically examine the practical implications of the new SMFM guidelines with a focus on equity and access.</p></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2666577824000741/pdfft?md5=3680cdeed5d1db06712f5e4e601f6be1&pid=1-s2.0-S2666577824000741-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141695084","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
扫码关注我们
求助内容：
应助结果提醒方式：
京公网安备 11010802042870号