American journal of obstetrics and gynecology最新文献

Background: Cervical cancer continues to disproportionately affect marginalized populations, with significant disparities in treatment and outcomes. Social determinants of health (SDOH) and insurance status have been associated with delays in treatment initiation, which can adversely affect clinical outcomes.

Objective: To determine the risk factors associated with delays in treatment initiation among patients with locally advanced cervical cancer (LACC) and identify the time period of delay in treatment initiation.

Study design: We conducted a retrospective cohort study of patients with LACC at a single institution between 2003 and 2023. The primary outcome was timely initiation of treatment, defined as treatment initiation within 60 days of diagnosis by biopsy. Multivariate analysis was used to assess the impact of insurance status and other demographic factors on treatment delays.

Results: 280 patients were identified. Median time from biopsy to treatment initiation was 68.5 days (IQR, 52-104). 37.1% of patients received timely treatment initiation. Univariate analyses indicated patients with Medicaid had significantly increased odds of delayed treatment (OR 2.76, 95% CI 1.46-5.23) and living in a geographic location with a higher social vulnerability index (SVI) (quartile 3 OR 2.68 95% CI 1.22-5.85). Multivariate analysis indicated that Medicaid was independently associated with delayed treatment compared to private insurance (OR 2.42, 95% CI 1.18-4.93). When time to treatment was stratified by time from biopsy to staging and time from staging to treatment start, delay was primarily attributable to time from biopsy to staging. In patients within the upper quartile of delay (>104 days), social risk factors including insurance-related issues and unmet social needs (e.g. psychosocial distress, unstable housing, substance abuse) were identified as contributors to significant delays.

Conclusion(s): Medicaid insurance was independently associated with lower odds of timely cervical cancer treatment, driven largely by delays between biopsy and staging. These findings underscore the need for targeted interventions to address insurance-mediated barriers to initiation of care, which may include screening and addressing unmet health-related social needs and social risks.

Background: Abortion care is safe and commonly needed. While pain and bleeding are expected, patients' experience of pain and bleeding at the time of abortion can affect patient satisfaction and the abortion experience. There is limited research characterizing factors associated with patient-reported severe pain and heavy bleeding with contemporary abortion methods.

Objective: To assess clinical predictors of patient-reported heavy bleeding and pain among first-trimester abortion patients.

Study design: We conducted a secondary analysis of a multicenter prospective cohort study of 644 participants undergoing medication or procedural abortion up to 11w6d. The primary outcome was participant-reported severe post-abortion pain; secondary outcomes included bleeding severity and discordance between expected and experienced pain and bleeding. We developed logistic regression models assessing clinical factors associated with severe pain, heavy bleeding, more than expected pain, and heavier than expected bleeding.

Results: Of 644 eligible participants, 516 (80%) responded, 347 (67%) of whom had medication abortion and 169 (33%) of whom had procedural abortion. One-fourth reported severe pain, 35.0% heavy bleeding, 31.6% more than expected pain, and 33.5% heavier than expected bleeding. Factors most strongly associated with participant-reported severe pain included medication abortion (OR=4.69 [95% C1: 2.56-8.58]), history of severe menstrual pain (OR=2.60 [95% CI: 1.38-4.89]), and screening positive for depression at baseline (OR=2.13 [95% CI: 1.18-3.85]). Independent risk factors for pain discordance included first abortion experience (aOR=2.03 [95% CI: 1.18-3.48]), nulliparity (aOR=2.21 [95% CI: 1.26-3.85]), history of a prior cesarean delivery (aOR= 2.06 [95% CI: 1.14-3.72]), and baseline depression (aOR=1.72 [95%CI: 1.05-2.82), adjusted for gravidity, abortion method, and location of care. Self-reported heavy bleeding was most strongly associated with medication abortion regimen (aOR=9.19 [95% CI: 5.09-16.61]) and screening positive for depression at baseline (aOR=2.15 [95% CI: 1.28-3.61]). Abortion method and gestational length were the only significant predictors of discordance between bleeding expectations and experience.

Conclusion: While most patients were prepared for the pain and bleeding experienced after abortion, the patient experience may be improved by anticipatory guidance that incorporates risk factors for severe pain and heavy bleeding.

Background: Sustained intrauterine hypoxia causes some four million perinatal deaths annually worldwide. The condition is predicated by neonatal acidemia, as determined by pH in umbilical cord blood at birth. We aimed to evaluate the association between umbilical cord arterial pH and long-term outcomes up to 20 years of follow-up.

Study design: Using a retrospective cohort design, umbilical cord arterial pH values from singleton births at Skåne University Hospital Malmö, Sweden, from 1997-2012 were cross-linked to data from the Swedish Medical Birth Register, Swedish Patient Register, and Cause of Death Register. The Hazard Ratio (HR) for developing disease later in life, as defined organ-wise with the International Classification of Diseases version 10 with codes 00-99, was calculated relative to umbilical cord arterial pH <7.05 and ≥7.05, respectively. In addition, umbilical cord arterial pH thresholds at 6.95, 7.00, 7.05, 7.10, 7.15, and 7.20 were evaluated for mental and behavioral disorders.

Results: Of the 35931 births that met the inclusion criteria of complete and validated data, 912 (2.5%) had acidemia (umbilical cord arterial pH <7.05) at birth, while 35019 (97.5%) had non-acidemic values (pH ≥7.05). Acidemia was associated with higher mortality (P=0.043). Among groups of organ system diseases, a pH <7.05 was not associated with increased risk of disease. At the group level, the risk was not significantly increased for mental and behavioral disorders (crude HR 1.05, 95%CI 0.75-1.46), however, sub-analysis showed an increased risk of cerebral palsy (crude HR 4.30, 95%CI 2.16-8.58) and epilepsy (crude HR 1.70, 95%CI 1.02-2.86). After adjustment for maternal age, parity, smoking, body mass index, and gestational age, the associations strengthened (cerebral palsy adjusted HR 4.35, 95% CI 2.17-8.73), (epilepsy adjusted HR 1.71, 95% CI 1.02-2.88). The threshold of umbilical cord arterial pH <6.95 was significantly associated with increased risk of cerebral palsy (HR 18.38, 95%CI 7.34-46.08), epilepsy (HR 8.16, 95%CI 4.18-15.92) and intellectual disability (HR 4.19, 95%CI 1.73-10.17), whereas thresholds 7.00, 7.05, 7.10, and 7.15 were not.

Conclusions: Neonatal acidemia, defined as cord arterial pH<7.05, was associated with an increased risk of death, cerebral palsy and epilepsy, but not of other types of mental and behavioral disorders or other organ system diseases. An umbilical cord arterial pH <6.95 was significantly associated with cerebral palsy, epilepsy and intellectual disability whereas pH <7.00 and other thresholds between 7.05 and 7.20 were not.

Recently, the International Papillomavirus Society (IPVS) convened a working group on cervical HPV latency, which resulted in an updated understanding of the HPV natural history. While the previous HPV natural history model considered HPV detection a result of HPV acquisition or possibly re-infection, and loss of HPV detection a result of viral clearance, the updated understanding of the HPV natural history is more nuanced. Thus, HPV detection may occur as a result of autoinoculation, deposition from a recent sex act, or as a redetection of a previously acquired infection. Similarly, loss of HPV detection likely reflects immune control rather than complete viral clearance. As it is practically impossible to identify the "true" source of a new HPV detection or determine why HPV is no longer detectable, we propose that health care providers and researchers use the terminology HPV detected vs HPV not detected. Moreover, we describe the updated understanding in a clinical context. Specifically, we discuss the potential implications of the updated understanding on clinical counseling in screening, and recommendations on cervical screening and HPV vaccination. We also suggest key phrases health care providers may use when counseling women attending routine HPV-based cervical screening.

Objective: Prenatal repair of open spina bifida has become well-established. Several surgical approaches have emerged, each focused on optimizing outcomes while minimizing risks. This study aims to compare the gestational age at delivery following the various surgical techniques.

Data sources: This systematic review and meta-analysis synthesizes data from 37 studies between 2010 and 2023.

Study eligibility criteria: Eligible studies included pregnant patients diagnosed with open spina bifida who underwent the following intrauterine repair techniques: open, mini-hysterotomy, laparotomy-assisted fetoscopic, and percutaneous fetoscopic repair.

Study appraisal and synthesis methods: The primary outcome investigated was gestational age (GA) at delivery, while secondary outcomes were preterm premature rupture of membranes (PPROM), vaginal birth, and perinatal mortality. The programming language software R (version 4.0.5) was used to execute the analysis.

Results: In this meta-analysis, 2,333 prenatal repair of open spina bifida procedures arising from 14 countries were analyzed. Of these, open repair accounted for 65.7%, mini-hysterotomy 14.4%, laparotomy-assisted fetoscopic 5.36%, and percutaneous fetoscopic 14.6%. Subgroup analyses revealed a non-significant mean GA at birth:34⁺¹ weeks for open repair, 34⁺² weeks for mini-hysterotomy, 35⁺³ weeks for laparotomy-assisted, and 32⁺³ weeks for percutaneous fetoscopic method (p=0.26). While the GA at birth was not different, there were significant differences (P<0.01) in pooled proportions of PPROM and preterm birth by surgical approach. (Overall rates: 75% and 30% respectively). Vaginal birth rates had significant subgroup differences (P<0.01), with the laparotomy-assisted fetoscopic group more likely to have vaginal deliveries (0.02, 0.04, 0.49, 0.18 for open, mini, laparotomy, and percutaneous, respectively).

Conclusions: The advanced secondary Bayesian analysis of data from this meta-analysis suggests that the mean gestational age at birth may differ among the four surgical techniques for prenatal repair of open spina bifida, with a potential advantage for the decrease in preterm births associated with a laparotomy-assisted approach. However, these findings should be interpreted cautiously, and further direct comparison studies are needed to confirm these observations.

Background: Delivery at 34 0/7 - 35 6/7 weeks is recommended for patients with prenatally suspected placenta accreta spectrum (PAS); however, there is limited data to support these recommendations. As a large volume tertiary care center, in an otherwise uncomplicated pregnancy with prenatal concern for PAS, we have historically planned delivery at 36 0/7 - 37 6/7 weeks.

Objectives: To describe the impact of our later delivery timing in cases of suspected PAS on maternal and fetal outcomes.

Study design: We examined pregnancies ≥ 24w0d gestation complicated by prenatally suspected PAS from August 2009 to April 2022. Maternal and neonatal outcomes were compared according to delivery timing (beyond 36 0/7 weeks versus prior to this gestational age). Indication for early delivery was also extracted. Statistical analysis included χ² for categorical variables and student's t-test for continuous variables.

Results: Of 202 patients with prenatal concern for PAS, 65 (32%) had an early indication for delivery (bleeding, preeclampsia, premature rupture of membranes or labor) whereas 137 (68%) were planned deliveries beyond 36 0/7 weeks for concern for PAS. There was no difference in maternal age, race/ethnicity, parity, BMI, or number of prior cesarean deliveries. Median gestational age at delivery in the indicated group was 35 (31-36) weeks, versus 37 (36-37) weeks for those without complications (p< 0.001). Prenatally suspected severity of PAS did not differ between the groups, nor on pathology. Of patients delivered for an indication 42 (65%) were delivered for bleeding, 11 (17%) for labor, and 12 (18%) for other indications. The only maternal outcomes of noted difference between the groups was increased whole blood transfusions (more commonly used at our institution in emergent situations) in those with indicated deliveries (0 [0-6] vs 0 [0-4], p=0.007) and decreased platelet transfusions (0 [0-6] vs 0 [0-10], p=0.021). Neonates in the indicated cohort were more likely to have lower birthweights, neonatal intensive care unit admission, respiratory distress syndrome, need for mechanical ventilation, and longer hospital stays, all likely secondary to prematurity.

Conclusion: Patients with suspected placenta accreta spectrum without other indications for delivery such as bleeding, labor, rupture of membranes, or preeclampsia can have a planned delivery in the late preterm or early term period at specialized centers that are geographically in close proximity to the patient. Later delivery does not impact maternal outcomes and improves neonatal outcomes.