Pub Date : 2024-09-16DOI: 10.1016/j.ajog.2024.09.013
Ming-Wei Lin,Hung-Yuan Li
{"title":"Hysteroscopic Myomectomy and the Risk for Placenta Accreta Spectrum: Implications for Subfertile Patients and Underlying Pathophysiology.","authors":"Ming-Wei Lin,Hung-Yuan Li","doi":"10.1016/j.ajog.2024.09.013","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.013","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":9.8,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142246900","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-16DOI: 10.1016/j.ajog.2024.09.015
Meihua Zheng,Juan Tang,Huixia Li
{"title":"Advancing Maternal and Neonatal Health: A Comprehensive Approach to Methamphetamine Use in Pregnancy.","authors":"Meihua Zheng,Juan Tang,Huixia Li","doi":"10.1016/j.ajog.2024.09.015","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.015","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":9.8,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142246901","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-16DOI: 10.1016/j.ajog.2024.09.014
Yafei Wang,Fang He
{"title":"Risk of placenta accreta spectrum following myomectomy.","authors":"Yafei Wang,Fang He","doi":"10.1016/j.ajog.2024.09.014","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.014","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":9.8,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142246910","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-16DOI: 10.1016/j.ajog.2024.09.016
Sarena Hayer,Jamie O Lo,Aaron B Caughey
{"title":"Methamphetamine use in pregnancy: Avenues for future research.","authors":"Sarena Hayer,Jamie O Lo,Aaron B Caughey","doi":"10.1016/j.ajog.2024.09.016","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.016","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":9.8,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142246902","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-15DOI: 10.1016/j.ajog.2024.09.006
Lorie M Harper,Hui-Chien Kuo,Kim Boggess,Lorraine Dugoff,Baha Sibai,Kirsten Lawrence,Brenna L Hughes,Joseph Bell,Kjersti Aagaard,Rodney K Edwards,Kelly S Gibson,David M Haas,Lauren Plante,Torri D Metz,Brian M Casey,Sean Esplin,Sherri Longo,Matthew Hoffman,George R Saade,Kara Hoppe,Janelle Foroutan,Methodius G Tuuli,Michelle Y Owens,Hyagriv N Simhan,Heather A Frey,Todd Rosen,Anna Palatnik,Phyllis August,Uma M Reddy,Wendy Kinzler,Emily J Su,Iris Krishna,Nguyet A Nguyen,Mary E Norton,Daniel Skupski,Yasser Y El-Sayed,Zorina S Galis,Namasivayam Ambalavanan,Suzanne Oparil,Jeff M Szychowski,Alan T N Tita
BACKGROUNDThe Chronic Hypertension and Pregnancy Study (CHAP) demonstrated that a target blood pressure of <140/90 mm Hg during pregnancy is associated with improved perinatal outcomes. Outside of pregnancy, pharmacologic therapy for patients with diabetes and hypertension is adjusted to a target blood pressure of <130/80 mm Hg. During pregnancy, patients with both diabetes and chronic hypertension may also benefit from tighter control with a target blood pressure (BP) <130/80 mm Hg.OBJECTIVEWe compared perinatal outcomes in patients with hypertension and diabetes who achieved BP <130/80 versus 130-139/80-89 mm Hg.STUDY DESIGNThis was a secondary analysis of a multi-center randomized controlled trial. Participants were included in this secondary analysis if they had diabetes diagnosed prior to pregnancy or at <20 weeks' gestation and at least two recorded BP measurements prior to delivery. Average systolic and diastolic BP were calculated using ambulatory antenatal BPs. The primary composite outcome was preeclampsia with severe features, indicated preterm birth <35 weeks, or placental abruption. Secondary outcomes were components of the primary outcome, cesarean delivery, fetal or neonatal death, neonatal intensive care unit (NICU) admission, and small for gestational age (SGA). Comparisons were made between those with an average systolic BP <130 mm Hg and average diastolic BP <80 mm Hg and those with an average systolic blood pressure 130-139 mm Hg or diastolic blood pressure 80-89 mm Hg using Student's t-test and chi-squared tests. Multivariable log-binomial regression models were used to evaluate risk ratios between blood pressure groups for dichotomous outcomes while accounting for baseline covariates.RESULTSOf 434 participants included, 150 (34.6%) had an average blood pressure less than 130/80 mm Hg. Participants with an average blood pressure less than 130/80 were more likely to be on antihypertensive medications at the start of pregnancy and more likely to have newly diagnosed DM prior to 20 weeks. Participants with an average blood pressure less than 130/80 mm Hg were less likely to have the primary adverse perinatal outcome (19.3% vs 46.5%, adjusted relative risk (aRR) 0.43, 95% CI 0.30-0.61, p<0.01), with decreased risks specifically of preeclampsia with severe features (aRR 0.35, 95% CI 0.23-0.54) and indicated preterm birth prior to 35 weeks (aRR 0.44, 95% CI 0.24-0.79). The risk of NICU admission was lower in the lower blood pressure group (aRR 0.74, 95% CI 0.59-0.94). No differences were noted in cesarean delivery (aRR 1.04, 95% CI 0.90-1.20), fetal or neonatal death (aRR 0.59, 95% CI 0.12-2.92). SGA less than the 10th percentile was lower in the lower blood pressure group (aRR 0.37, 95% CI 0.14-0.96).CONCLUSIONIn those with chronic hypertension and diabetes prior to 20 weeks, achieving an average goal blood pressure of <130/80 mm Hg may be associated with improved perinatal outcomes.
背景慢性高血压与妊娠研究（CHAP）表明，妊娠期目标血压小于 140/90 mm Hg 与围产期预后的改善有关。在妊娠期外，糖尿病和高血压患者的药物治疗目标血压应调整为小于 130/80 mm Hg。在怀孕期间，糖尿病和慢性高血压患者也可以从目标血压（BP）<130/80 mm Hg 的严格控制中获益。目的我们比较了血压<130/80 mm Hg 与 130-139/80-89 mm Hg 的高血压和糖尿病患者的围产期预后。如果参与者在妊娠前或妊娠小于 20 周时被诊断出患有糖尿病，并且在分娩前至少有两次血压测量记录，则被纳入本次二次分析。平均收缩压和舒张压是通过产前动态血压计算得出的。主要综合结果是具有严重特征的子痫前期、妊娠<35周的早产或胎盘早剥。次要结果包括主要结果的组成部分、剖宫产、胎儿或新生儿死亡、入住新生儿重症监护室（NICU）和胎龄小（SGA）。采用学生 t 检验和卡方检验对平均收缩压小于 130 mm Hg 和平均舒张压小于 80 mm Hg 的产妇与平均收缩压 130-139 mm Hg 或舒张压 80-89 mm Hg 的产妇进行比较。在考虑基线协变量的情况下，采用多变量对数二叉回归模型评估血压组间二分法结果的风险比。结果 在纳入的 434 名参与者中，150 人（34.6%）的平均血压低于 130/80 mm Hg。平均血压低于 130/80 的参与者更有可能在怀孕初期服用降压药，也更有可能在怀孕 20 周前新诊断出糖尿病。平均血压低于 130/80 mm Hg 的受试者发生围产期主要不良结局的几率较低（19.3% vs 46.5%，调整后相对风险 (aRR) 0.43，95% CI 0.30-0.61，p<0.01），尤其是发生重度子痫前期（aRR 0.35，95% CI 0.23-0.54）和 35 周前早产（aRR 0.44，95% CI 0.24-0.79）的风险较低。低血压组的新生儿重症监护室入院风险较低（aRR 0.74，95% CI 0.59-0.94）。在剖宫产（aRR 1.04，95% CI 0.90-1.20）、胎儿或新生儿死亡（aRR 0.59，95% CI 0.12-2.92）方面无差异。结论 对于那些在 20 周前患有慢性高血压和糖尿病的孕妇，平均目标血压小于 130/80 mm Hg 可能与围产期预后的改善有关。
{"title":"Blood Pressure Control in Pregnant Patients with Chronic Hypertension and Diabetes: Should <130/80 be the Target?","authors":"Lorie M Harper,Hui-Chien Kuo,Kim Boggess,Lorraine Dugoff,Baha Sibai,Kirsten Lawrence,Brenna L Hughes,Joseph Bell,Kjersti Aagaard,Rodney K Edwards,Kelly S Gibson,David M Haas,Lauren Plante,Torri D Metz,Brian M Casey,Sean Esplin,Sherri Longo,Matthew Hoffman,George R Saade,Kara Hoppe,Janelle Foroutan,Methodius G Tuuli,Michelle Y Owens,Hyagriv N Simhan,Heather A Frey,Todd Rosen,Anna Palatnik,Phyllis August,Uma M Reddy,Wendy Kinzler,Emily J Su,Iris Krishna,Nguyet A Nguyen,Mary E Norton,Daniel Skupski,Yasser Y El-Sayed,Zorina S Galis,Namasivayam Ambalavanan,Suzanne Oparil,Jeff M Szychowski,Alan T N Tita","doi":"10.1016/j.ajog.2024.09.006","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.006","url":null,"abstract":"BACKGROUNDThe Chronic Hypertension and Pregnancy Study (CHAP) demonstrated that a target blood pressure of <140/90 mm Hg during pregnancy is associated with improved perinatal outcomes. Outside of pregnancy, pharmacologic therapy for patients with diabetes and hypertension is adjusted to a target blood pressure of <130/80 mm Hg. During pregnancy, patients with both diabetes and chronic hypertension may also benefit from tighter control with a target blood pressure (BP) <130/80 mm Hg.OBJECTIVEWe compared perinatal outcomes in patients with hypertension and diabetes who achieved BP <130/80 versus 130-139/80-89 mm Hg.STUDY DESIGNThis was a secondary analysis of a multi-center randomized controlled trial. Participants were included in this secondary analysis if they had diabetes diagnosed prior to pregnancy or at <20 weeks' gestation and at least two recorded BP measurements prior to delivery. Average systolic and diastolic BP were calculated using ambulatory antenatal BPs. The primary composite outcome was preeclampsia with severe features, indicated preterm birth <35 weeks, or placental abruption. Secondary outcomes were components of the primary outcome, cesarean delivery, fetal or neonatal death, neonatal intensive care unit (NICU) admission, and small for gestational age (SGA). Comparisons were made between those with an average systolic BP <130 mm Hg and average diastolic BP <80 mm Hg and those with an average systolic blood pressure 130-139 mm Hg or diastolic blood pressure 80-89 mm Hg using Student's t-test and chi-squared tests. Multivariable log-binomial regression models were used to evaluate risk ratios between blood pressure groups for dichotomous outcomes while accounting for baseline covariates.RESULTSOf 434 participants included, 150 (34.6%) had an average blood pressure less than 130/80 mm Hg. Participants with an average blood pressure less than 130/80 were more likely to be on antihypertensive medications at the start of pregnancy and more likely to have newly diagnosed DM prior to 20 weeks. Participants with an average blood pressure less than 130/80 mm Hg were less likely to have the primary adverse perinatal outcome (19.3% vs 46.5%, adjusted relative risk (aRR) 0.43, 95% CI 0.30-0.61, p<0.01), with decreased risks specifically of preeclampsia with severe features (aRR 0.35, 95% CI 0.23-0.54) and indicated preterm birth prior to 35 weeks (aRR 0.44, 95% CI 0.24-0.79). The risk of NICU admission was lower in the lower blood pressure group (aRR 0.74, 95% CI 0.59-0.94). No differences were noted in cesarean delivery (aRR 1.04, 95% CI 0.90-1.20), fetal or neonatal death (aRR 0.59, 95% CI 0.12-2.92). SGA less than the 10th percentile was lower in the lower blood pressure group (aRR 0.37, 95% CI 0.14-0.96).CONCLUSIONIn those with chronic hypertension and diabetes prior to 20 weeks, achieving an average goal blood pressure of <130/80 mm Hg may be associated with improved perinatal outcomes.","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":9.8,"publicationDate":"2024-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142245581","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"A longitudinal study investigating the reference ranges of B- type natriuretic peptide (BNP), N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) during gestation and the postpartum period of twin pregnancies.","authors":"Haruna Kawaguchi,Chizuko Aoki-Kamiya,Ryo Yamamoto,Shusaku Hayashi,Itaru Yanagihara,Jun Yoshimatsu,Keisuke Ishii","doi":"10.1016/j.ajog.2024.09.005","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.005","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":9.8,"publicationDate":"2024-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142231383","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-10DOI: 10.1016/j.ajog.2024.09.004
Araba Amonu Jackson,Sara Caitlin Frisco,Catherine Marie Lynch,Jean Paul Tanner,Katie Propst
BACKGROUNDVaginal pessaries are an inexpensive non-surgical treatment for pelvic organ prolapse and stress urinary incontinence. Pessary maintenance includes periodic removal, cleaning, and reinsertion, which can be painful. Lidocaine-prilocaine cream has been shown to significantly reduce pain during pessary maintenance exams. In some practices, Lidocaine HCl 2% jelly may be more readily available and serve as an alternative to lidocaine-prilocaine cream. However, the effect of Lidocaine HCl 2% jelly use during pessary maintenance exams has not been tested.OBJECTIVETo estimate the effect of Lidocaine HCl 2% jelly versus lubricating jelly on pain at the time of office pessary removal and reinsertion.STUDY DESIGNThis study is a single-blind, randomized clinical trial among patients presenting to a urogynecology office at a tertiary care center. Participants were randomized to the application of 5cc of Lidocaine HCl 2% jelly or a water-based lubricating jelly five minutes before pessary removal. Visual analog scale pain scores were collected from the participants at baseline, at pessary removal, and at pessary reinsertion. The primary outcome was the visual analog scale pain score at the time of pessary removal. A sample size of 33 per group (n=66) was planned to estimate an absolute mean difference in visual analog pain scale of 2.05 cm at the time of pessary removal.RESULTSBetween September 2022 and June 2023, 192 women were screened, and 66 were enrolled. Thirty-three participants were randomized into the lubricating jelly group and 33 participants were randomized into the Lidocaine HCl 2% jelly group. The two groups were similar in baseline characteristics. Most participants were postmenopausal, using vaginal estrogen, wearing a 70 mm ring pessary with support for pelvic organ prolapse, and reported being very satisfied with the pessary. Other pessaries worn included ring without support, incontinence rings with and without support, Gellhorn, and donut. The pessary sizes ranged from 51 mm to 96 mm. There was no significant difference in pessary type and size between groups. Visual analog scale pain scores at pessary removal were low in both groups: 3.23±3.00 cm in the lubricating group and 2.66±2.77 cm in the lidocaine group. After adjusting for baseline pain, there was no significant difference in pain at pessary removal between the lidocaine jelly and the lubricating jelly groups (mean difference=-0.56 cm, 95% CI: -1.97 to 0.85; p=0.44). Despite no significant difference in visual analog scale pain scores, 71.2% of participants reported a desire for numbing jelly at future pessary examinations.CONCLUSIONPain during pessary removal and reinsertion is low. Compared to lubricating jelly, lidocaine jelly did not further reduce pain during pessary examinations.
{"title":"Topical Lidocaine for Pessary Removal and Reinsertion Pain Reduction: A Randomized Clinical Trial.","authors":"Araba Amonu Jackson,Sara Caitlin Frisco,Catherine Marie Lynch,Jean Paul Tanner,Katie Propst","doi":"10.1016/j.ajog.2024.09.004","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.004","url":null,"abstract":"BACKGROUNDVaginal pessaries are an inexpensive non-surgical treatment for pelvic organ prolapse and stress urinary incontinence. Pessary maintenance includes periodic removal, cleaning, and reinsertion, which can be painful. Lidocaine-prilocaine cream has been shown to significantly reduce pain during pessary maintenance exams. In some practices, Lidocaine HCl 2% jelly may be more readily available and serve as an alternative to lidocaine-prilocaine cream. However, the effect of Lidocaine HCl 2% jelly use during pessary maintenance exams has not been tested.OBJECTIVETo estimate the effect of Lidocaine HCl 2% jelly versus lubricating jelly on pain at the time of office pessary removal and reinsertion.STUDY DESIGNThis study is a single-blind, randomized clinical trial among patients presenting to a urogynecology office at a tertiary care center. Participants were randomized to the application of 5cc of Lidocaine HCl 2% jelly or a water-based lubricating jelly five minutes before pessary removal. Visual analog scale pain scores were collected from the participants at baseline, at pessary removal, and at pessary reinsertion. The primary outcome was the visual analog scale pain score at the time of pessary removal. A sample size of 33 per group (n=66) was planned to estimate an absolute mean difference in visual analog pain scale of 2.05 cm at the time of pessary removal.RESULTSBetween September 2022 and June 2023, 192 women were screened, and 66 were enrolled. Thirty-three participants were randomized into the lubricating jelly group and 33 participants were randomized into the Lidocaine HCl 2% jelly group. The two groups were similar in baseline characteristics. Most participants were postmenopausal, using vaginal estrogen, wearing a 70 mm ring pessary with support for pelvic organ prolapse, and reported being very satisfied with the pessary. Other pessaries worn included ring without support, incontinence rings with and without support, Gellhorn, and donut. The pessary sizes ranged from 51 mm to 96 mm. There was no significant difference in pessary type and size between groups. Visual analog scale pain scores at pessary removal were low in both groups: 3.23±3.00 cm in the lubricating group and 2.66±2.77 cm in the lidocaine group. After adjusting for baseline pain, there was no significant difference in pain at pessary removal between the lidocaine jelly and the lubricating jelly groups (mean difference=-0.56 cm, 95% CI: -1.97 to 0.85; p=0.44). Despite no significant difference in visual analog scale pain scores, 71.2% of participants reported a desire for numbing jelly at future pessary examinations.CONCLUSIONPain during pessary removal and reinsertion is low. Compared to lubricating jelly, lidocaine jelly did not further reduce pain during pessary examinations.","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":9.8,"publicationDate":"2024-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142231388","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-09DOI: 10.1016/j.ajog.2024.09.003
Elizabeth A Gill,Wu Zeng,Jaqueline S Lamme,Tetsuya Kawakita,Monica A Lutgendorf,Patrick Richard,Jill E Brown,
BACKGROUNDActive-duty service women rely on the civilian sector for most abortion care due to limits on federal funding for abortion. Abortion is now banned in many states with large military presences. The Department of Defense has implemented policies to assist active-duty service women in accessing abortion, but there is debate to reverse this support.OBJECTIVEOur goal was to compare the cost-effectiveness and incidence of adverse maternal and neonatal outcomes of a hypothetical cohort of active-duty service women living in abortion-restricted states comparing restricted abortion access (abortion not available cohort) to abortion available with Department of Defense travel support (abortion available cohort).STUDY DESIGNWe developed a decision tree model to compare abortion not available and abortion available cohorts for active-duty service women living in abortion-restricted states. Our cohorts were subdivided into normal pregnancies and those with a major fetal anomaly. Cost estimates, probabilities, and disability weights of various health conditions associated with abortion and pregnancy were obtained and derived from the literature. Effectiveness was expressed in disability-adjusted life years and the willingness to pay threshold was set to $100,000 per disability-adjusted life year gained or averted. We completed probabilistic sensitivity analyses with 10,000 simulations to test the robustness of our results. Secondary outcomes included numbers of stillbirths, neonatal deaths, neonatal intensive care unit admissions, maternal deaths, severe maternal morbidities, and first and second trimester abortions.RESULTSThe abortion not available cohort had a higher annual cost to the military ($299.1 million, 95% CI 239.2 - 386.6, vs. $226.0 million, 95% CI 181.9 - 288.5) and was associated with 203 more disability-adjusted life years compared to the abortion available cohort. The incremental cost effectiveness ratio was dominant for abortion available. Abortion not available resulted in an annual additional 7 stillbirths, 1 neonatal death, 112 neonatal intensive care unit admissions, 0.016 maternal deaths, 24 severe maternal morbidities, 27 less second trimester abortions, and 602 less first trimester abortions. Probabilistic sensitivity analysis revealed that the chance of the abortion available cohort being the more cost-effective strategy was greater than 95%.CONCLUSIONLimiting active-duty service women's access to abortion care increases costs to the military, even with costs of travel support, and increases adverse maternal and neonatal outcomes. This analysis provides important information for policymakers about economic and health burdens associated with barriers to abortion care in the military.
{"title":"Decision and economic evaluation of abortion availability in the United States military.","authors":"Elizabeth A Gill,Wu Zeng,Jaqueline S Lamme,Tetsuya Kawakita,Monica A Lutgendorf,Patrick Richard,Jill E Brown,","doi":"10.1016/j.ajog.2024.09.003","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.003","url":null,"abstract":"BACKGROUNDActive-duty service women rely on the civilian sector for most abortion care due to limits on federal funding for abortion. Abortion is now banned in many states with large military presences. The Department of Defense has implemented policies to assist active-duty service women in accessing abortion, but there is debate to reverse this support.OBJECTIVEOur goal was to compare the cost-effectiveness and incidence of adverse maternal and neonatal outcomes of a hypothetical cohort of active-duty service women living in abortion-restricted states comparing restricted abortion access (abortion not available cohort) to abortion available with Department of Defense travel support (abortion available cohort).STUDY DESIGNWe developed a decision tree model to compare abortion not available and abortion available cohorts for active-duty service women living in abortion-restricted states. Our cohorts were subdivided into normal pregnancies and those with a major fetal anomaly. Cost estimates, probabilities, and disability weights of various health conditions associated with abortion and pregnancy were obtained and derived from the literature. Effectiveness was expressed in disability-adjusted life years and the willingness to pay threshold was set to $100,000 per disability-adjusted life year gained or averted. We completed probabilistic sensitivity analyses with 10,000 simulations to test the robustness of our results. Secondary outcomes included numbers of stillbirths, neonatal deaths, neonatal intensive care unit admissions, maternal deaths, severe maternal morbidities, and first and second trimester abortions.RESULTSThe abortion not available cohort had a higher annual cost to the military ($299.1 million, 95% CI 239.2 - 386.6, vs. $226.0 million, 95% CI 181.9 - 288.5) and was associated with 203 more disability-adjusted life years compared to the abortion available cohort. The incremental cost effectiveness ratio was dominant for abortion available. Abortion not available resulted in an annual additional 7 stillbirths, 1 neonatal death, 112 neonatal intensive care unit admissions, 0.016 maternal deaths, 24 severe maternal morbidities, 27 less second trimester abortions, and 602 less first trimester abortions. Probabilistic sensitivity analysis revealed that the chance of the abortion available cohort being the more cost-effective strategy was greater than 95%.CONCLUSIONLimiting active-duty service women's access to abortion care increases costs to the military, even with costs of travel support, and increases adverse maternal and neonatal outcomes. This analysis provides important information for policymakers about economic and health burdens associated with barriers to abortion care in the military.","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":9.8,"publicationDate":"2024-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142174787","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-06DOI: 10.1016/j.ajog.2024.09.001
Sarah M Bjørnholt, Mogens Groenvold, Morten A Petersen, Ole Mogensen, Kirsten Bouchelouche, Sara E Sponholtz, Gudrun Neumann, Signe F Bjørn, Bushra H Hamid, Katja Dahl, Pernille T Jensen
<p><strong>Background: </strong>Sentinel lymph node mapping is a minimally invasive surgical staging procedure that allows identification of macro- and micrometastases. The implementation of sentinel lymph node mapping to women with low-grade endometrial cancer allows detection of lymph node metastases and avoids the morbidity of radical pelvic lymphadenectomy. The extent of myometrial invasion is highly predictive of lymph node metastases but is hard to determine precisely preoperatively. The exact rate of lymph node metastases in the large group of women with <50% myometrial invasion is low but unknown. The benefit of detecting metastases in this group should balance the risk of lymphedema. There is limited knowledge of early and late lymphedema and its impact on the quality of life in women with low-grade endometrial cancer following sentinel lymph node mapping.</p><p><strong>Objective: </strong>The primary objective was to investigate the risk of patient-reported lymphedema after SLN mapping in women with low-grade endometrial cancer. In addition, we aimed to evaluate risk factors for lymphedema and the condition-specific quality of life (QoL) among women who reported lymphedema 12 months after surgery.</p><p><strong>Study design: </strong>Women with presumed stage I low-grade endometrial cancer were included in a national prospective cohort study on SLN mapping from March 2017-February 2022. Women completed a package of validated patient-reported outcome measures (PROMs) before surgery, three and 12 months after surgery. The primary outcome was the leg lymphedema domain score from the European Organisation for Research and Treatment of Cancer endometrial cancer-specific module (EORTC QLQ-EN24). The lymphedema assessment was further supplemented by seven validated single items from the EORTC item library addressing lymphedema of legs, genitals, and groin. The disease-specific QoL was assessed using the validated Lymphedema quality of life tool (LYMQOL). Scores were linearly transformed to 0-100. A change from baseline of 8 points in leg lymphedema sum-score was considered clinically important. Mean difference scores over time with 95% CI were estimated. Multiple linear regression models evaluated baseline predictors associated with the 12 month postoperative lymphedema score, and if early lymphedema predicted lymphedema at 12 months after surgery. Lymphedema condition-specific QoL was evaluated for women with lymphedema.</p><p><strong>Results: </strong>Seventy-nine % (486/617) completed PROMs at baseline and 12 months. The mean difference score of leg lymphedema from baseline to 12 months was 5.0, CI [3.3, 6.8], i.e., below the threshold for clinical importance. Baseline leg lymphedema score and BMI were positively associated with the leg lymphedema score at 12 months. The leg lymphedema score at three months was associated with a higher 12-month score. High scores of lymphedema at 12 months were negatively associated with the women's daily a
{"title":"Patient-reported lymphedema after sentinel lymph node mapping in women with low-grade endometrial cancer.","authors":"Sarah M Bjørnholt, Mogens Groenvold, Morten A Petersen, Ole Mogensen, Kirsten Bouchelouche, Sara E Sponholtz, Gudrun Neumann, Signe F Bjørn, Bushra H Hamid, Katja Dahl, Pernille T Jensen","doi":"10.1016/j.ajog.2024.09.001","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.001","url":null,"abstract":"<p><strong>Background: </strong>Sentinel lymph node mapping is a minimally invasive surgical staging procedure that allows identification of macro- and micrometastases. The implementation of sentinel lymph node mapping to women with low-grade endometrial cancer allows detection of lymph node metastases and avoids the morbidity of radical pelvic lymphadenectomy. The extent of myometrial invasion is highly predictive of lymph node metastases but is hard to determine precisely preoperatively. The exact rate of lymph node metastases in the large group of women with <50% myometrial invasion is low but unknown. The benefit of detecting metastases in this group should balance the risk of lymphedema. There is limited knowledge of early and late lymphedema and its impact on the quality of life in women with low-grade endometrial cancer following sentinel lymph node mapping.</p><p><strong>Objective: </strong>The primary objective was to investigate the risk of patient-reported lymphedema after SLN mapping in women with low-grade endometrial cancer. In addition, we aimed to evaluate risk factors for lymphedema and the condition-specific quality of life (QoL) among women who reported lymphedema 12 months after surgery.</p><p><strong>Study design: </strong>Women with presumed stage I low-grade endometrial cancer were included in a national prospective cohort study on SLN mapping from March 2017-February 2022. Women completed a package of validated patient-reported outcome measures (PROMs) before surgery, three and 12 months after surgery. The primary outcome was the leg lymphedema domain score from the European Organisation for Research and Treatment of Cancer endometrial cancer-specific module (EORTC QLQ-EN24). The lymphedema assessment was further supplemented by seven validated single items from the EORTC item library addressing lymphedema of legs, genitals, and groin. The disease-specific QoL was assessed using the validated Lymphedema quality of life tool (LYMQOL). Scores were linearly transformed to 0-100. A change from baseline of 8 points in leg lymphedema sum-score was considered clinically important. Mean difference scores over time with 95% CI were estimated. Multiple linear regression models evaluated baseline predictors associated with the 12 month postoperative lymphedema score, and if early lymphedema predicted lymphedema at 12 months after surgery. Lymphedema condition-specific QoL was evaluated for women with lymphedema.</p><p><strong>Results: </strong>Seventy-nine % (486/617) completed PROMs at baseline and 12 months. The mean difference score of leg lymphedema from baseline to 12 months was 5.0, CI [3.3, 6.8], i.e., below the threshold for clinical importance. Baseline leg lymphedema score and BMI were positively associated with the leg lymphedema score at 12 months. The leg lymphedema score at three months was associated with a higher 12-month score. High scores of lymphedema at 12 months were negatively associated with the women's daily a","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":8.7,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153024","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-06DOI: 10.1016/j.ajog.2024.09.002
Mary Katherine Anastasio, Lisa Spees, Sarah A Ackroyd, Ya-Chen Tina Shih, Bumyang Kim, Haley A Moss, Benjamin B Albright
<p><strong>Background: </strong>While utilization of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time for surgical management of early-stage uterine cancer, practice varies significantly in the United States, with disparities among low-volume centers and patients of Black race. A significant number of counties in the US are without a gynecologic oncologist, and almost half of counties with the highest gynecologic cancer rates lack a local gynecologic oncologist.</p><p><strong>Objective: </strong>To evaluate relationships of distance traveled and proximity to gynecologic oncologists with receipt of and racial disparities in the quality of surgical care in patients undergoing hysterectomy for nonmetastatic uterine cancer.</p><p><strong>Study design: </strong>Patients who underwent hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in 2012-2018 State Inpatient Database and State Ambulatory Surgery Services Database files. County-to-county distances were used for distances traveled and to nearest gynecologic oncologist. Factors associated with receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models including assessment for interactions of travel for surgery with patient race.</p><p><strong>Results: </strong>Among 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; 55.5% overall traveled to another county for surgery, including 88% of those lacking a local gynecologic oncologist. Patients lacking local access to a gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were even more likely. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had similar likelihood of minimally invasive surgery (71%) but greater likelihood of lymph node dissection (64.7% vs 57.2%) compared to non-travelers. Among counties without a gynecologic oncologist, longer distance traveled was associated with receipt of lymph node assessment. Compared to non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models controlling for a diagnosis of fibroids, Black race was an independent risk factor for receipt of open surgery. There was a significant interaction of Black race and travel for surgery, with Black patients who lived in counties without a gynecologic oncologist who did not travel facing incrementally lower likelihood of receiving minimally invasive surgery (OR=0.57 vs non-Black patients who traveled for surgery; OR=0.60 as interaction term; p<0.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county f
背景：虽然随着时间的推移，微创手术和前哨淋巴结活检在早期子宫癌手术治疗中的使用率大幅提高，但美国的做法差异很大，在低流量中心和黑人患者中存在差异。美国有相当多的县没有妇科肿瘤专家，妇科癌症发病率最高的县几乎有一半没有当地的妇科肿瘤专家：目的：评估因非转移性子宫癌而接受子宫切除术的患者，其旅行距离和与妇科肿瘤专家的距离与接受手术治疗的质量及种族差异之间的关系：从2012-2018年州住院病人数据库和州非住院手术服务数据库文件中识别了肯塔基州、马里兰州、佛罗里达州和北卡罗来纳州因非转移性子宫癌接受子宫切除术的患者。县与县之间的距离用于计算旅行距离和到最近的妇科肿瘤专家的距离。使用多变量逻辑回归模型分析了接受微创手术和淋巴结清扫的相关因素，包括评估手术旅行与患者种族的交互作用：在 21,837 例病例中，45.5% 的患者居住在没有妇科肿瘤专家的县城；55.5% 的患者前往其他县城接受手术，其中 88% 的患者在当地没有妇科肿瘤专家。本县没有妇科肿瘤专家的患者如果不前往其他县接受手术，则更有可能接受开放性手术且不进行淋巴结清扫，而周边县没有妇科肿瘤专家的患者则更有可能接受开放性手术且不进行淋巴结清扫。在没有妇科肿瘤专家的县中，出差接受手术的患者接受微创手术的几率相似（71%），但接受淋巴结清扫术的几率（64.7% 对 57.2%）高于不出差的患者。在没有妇科肿瘤专家的县中，旅行距离较远与接受淋巴结评估有关。与非黑人患者相比，黑人患者接受微创手术的可能性较低（57.0% vs 74.1%）。在控制子宫肌瘤诊断的调整回归模型中，黑人种族是接受开放手术的独立风险因素。黑人种族与出差接受手术之间存在明显的交互作用，居住在没有妇科肿瘤专家且不出差的县的黑人患者接受微创手术的可能性会逐渐降低（OR=0.57 vs 出差接受手术的非黑人患者；交互作用项为 OR=0.60；P结论：当地缺乏妇科肿瘤专科医疗服务的患者，尤其是黑人患者，可通过前往专科中心就医来确保获得高质量的非转移性子宫癌手术治疗。还需要进一步努力，通过患者旅行或专科医生外联，确保公平、普遍地获得高质量的医疗服务。
{"title":"Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer.","authors":"Mary Katherine Anastasio, Lisa Spees, Sarah A Ackroyd, Ya-Chen Tina Shih, Bumyang Kim, Haley A Moss, Benjamin B Albright","doi":"10.1016/j.ajog.2024.09.002","DOIUrl":"https://doi.org/10.1016/j.ajog.2024.09.002","url":null,"abstract":"<p><strong>Background: </strong>While utilization of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time for surgical management of early-stage uterine cancer, practice varies significantly in the United States, with disparities among low-volume centers and patients of Black race. A significant number of counties in the US are without a gynecologic oncologist, and almost half of counties with the highest gynecologic cancer rates lack a local gynecologic oncologist.</p><p><strong>Objective: </strong>To evaluate relationships of distance traveled and proximity to gynecologic oncologists with receipt of and racial disparities in the quality of surgical care in patients undergoing hysterectomy for nonmetastatic uterine cancer.</p><p><strong>Study design: </strong>Patients who underwent hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in 2012-2018 State Inpatient Database and State Ambulatory Surgery Services Database files. County-to-county distances were used for distances traveled and to nearest gynecologic oncologist. Factors associated with receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models including assessment for interactions of travel for surgery with patient race.</p><p><strong>Results: </strong>Among 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; 55.5% overall traveled to another county for surgery, including 88% of those lacking a local gynecologic oncologist. Patients lacking local access to a gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were even more likely. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had similar likelihood of minimally invasive surgery (71%) but greater likelihood of lymph node dissection (64.7% vs 57.2%) compared to non-travelers. Among counties without a gynecologic oncologist, longer distance traveled was associated with receipt of lymph node assessment. Compared to non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models controlling for a diagnosis of fibroids, Black race was an independent risk factor for receipt of open surgery. There was a significant interaction of Black race and travel for surgery, with Black patients who lived in counties without a gynecologic oncologist who did not travel facing incrementally lower likelihood of receiving minimally invasive surgery (OR=0.57 vs non-Black patients who traveled for surgery; OR=0.60 as interaction term; p<0.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county f","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":null,"pages":null},"PeriodicalIF":8.7,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153023","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：