American journal of obstetrics and gynecology最新文献

Background: Universal prenatal screening for cytomegalovirus is not currently recommended in the United States as no effective interventions have previously been available. With growing evidence that treating maternal first trimester primary cytomegalovirus infections with valacyclovir reduces vertical transmission, universal screening may become an important tool in congenital cytomegalovirus prevention.

Objective: This study examined the cost-effectiveness of a universal screening approach for maternal cytomegalovirus in the first trimester of pregnancy followed by valacyclovir treatment in positive cases for prevention of the sequelae of congenital cytomegalovirus.

Study design: A decision-analytic model was constructed to compare outcomes of universal screening and subsequent valacyclovir treatment in a theoretical cohort of 2,869,141 individuals, the estimated number of pregnant people in the United States who receive prenatal care by the first trimester. Individuals found to be IgG+, IgM+, and to have low IgG avidity were considered to have primary cytomegalovirus infection and received valacyclovir. Outcomes included cases of vertical cytomegalovirus transmission, abortions, stillbirths, neonatal deaths, cases of hearing loss, cases of neurodevelopmental disabilities, costs, and quality adjusted life years (QALYs). Model inputs were derived from literature. Sensitivity analyses were performed via tornado analysis, univariable sensitivity analysis, and multivariable sensitivity analysis with Monte Carlo simulation.

Results: In our study, universal screening in the first trimester for primary cytomegalovirus and subsequent treatment with valacyclovir in positive cases decreased adverse outcomes by preventing 2,898 vertical transmissions, 94 abortions, 19 stillbirths, 11 neonatal deaths, 460 cases of hearing loss, and 263 cases of neurodevelopmental disability. Universal screening and subsequent treatment was the dominant strategy as it saved 242.2 million dollars and led to 3,437 additional QALYs. Tornado analysis demonstrated that there were no threshold values which would change the model results, when all variables were varied across a predetermined range. Univariable sensitivity analyses demonstrated that even with decreasing specificity of screening tests, decreasing maternal utility of neonatal hearing loss, and increasing the price of screening up to 17 times the current cost, universal screening remained the cost-effective strategy. Monte Carlo analysis demonstrated that the screening strategy remained cost-saving in 100 percent of trials.

Conclusions: Our results demonstrate that screening for first trimester primary cytomegalovirus may be a cost-saving intervention, as identification of cases allows for the provision of treatment, which in turn reduces vertical cytomegalovirus transmission and costly sequelae.

Background: Ibuprofen has been shown to increased blood pressure in nonpregnant adults with hypertension, but its impact on blood pressure when used for postpartum analgesia in patients with a hypertensive disorder of pregnancy is less clear, particularly for those with severe hypertension.

Objective: To evaluate the impact of ibuprofen on postpartum blood pressure outcomes in patients with hypertensive disorders of pregnancy with severe hypertension.

Study design: In this randomized, double-blind trial, we randomly assigned patients with hypertensive disorders of pregnancy with severe hypertension to receive a postpartum analgesic regimen with either ibuprofen 600mg or acetaminophen 650mg (control) every 6 hours. The primary outcome was severe hypertension during postpartum hospitalization. Secondary outcomes included other measures of blood pressure control such as antihypertensive medication use and average postpartum mean arterial pressure, and outpatient blood pressure as well as patient satisfaction, pain control, and diuresis. A sample size of 132 was needed to detect a 35% difference in severe postpartum hypertension.

Results: We enrolled 140 participants from January 2017 to October 2019. The prevalence of severe hypertension postpartum did not differ between participants receiving ibuprofen (38.6%) versus control (41.4%); the absolute difference was 2.8 percentage points, 95% confidence interval -13.1% to 18.5%, p= 0.73. There was no difference between the ibuprofen and control groups for antihypertensive medication use (35.7% versus 40.0%, p=0.60) or average postpartum mean arterial pressure (95.7+8.2 versus 95.9+9.5, p=0.91, respectively). Measures of outpatient blood pressure, patient satisfaction, diuresis, and pain control were also similar.

Conclusion: In patients with hypertensive disorders of pregnancy with severe hypertension, use of ibuprofen postpartum did not increase the prevalence of postpartum severe hypertension. Ibuprofen use did not impact other blood pressure outcomes, pain control, or patient satisfaction. These findings support ibuprofen use during the postpartum period in patients with hypertensive disorders of pregnancy.

Background: ovarian tissue cryopreservation (OTC) is an increasingly utilized fertility preservation method in young women, with this technique being largely implemented across Europe and Australia. Australia is a pioneer of OTC, but the clinical perinatal outcomes are currently unknown for the Australian population. These outcomes are important as they contribute to the global understanding of which patients can benefit from this fertility preservation option.

Objective: To examine the pregnancy and mortality outcomes of patients who have undergone ovarian tissue cryopreservation and/or ovarian tissue transplantation in Victoria, Australia, and investigate predictors of success.

Study design: A retrospective cohort study was conducted including patients who underwent ovarian tissue cryopreservation from July 1995 to July 2022 at the largest OTC center in Victoria, Australia. Patients over the age of 18 at the time of the study were included in the study. Perinatal and mortality data were obtained through data linkage from the Victorian Perinatal Data Collection and Births Deaths and Marriages databases.

Results: Overall, 593 patients had undergone OTC between July 1995 and July 2022 in Victoria, Australia. All 593 patients were successfully linked to the perinatal and mortality databases, of whom six (1.0%) had pregnancies lacking perinatal data, and 17 had mortality data not reflected in the linkage but next of kin reported their deaths to the OTC providing clinic. Of this cohort, 48 (8.1%) underwent ovarian tissue transplantation and 106 (17.9%) died from complications of their medical indication for tissue freezing. A total of 192 neonates from 114 women were reported from both transplant (n=12/48, 25.0%) and non-transplant (n=102/545, 18.7%) cohorts. Most women had reported pregnancies by 15 years after OTC, with transplant cases having a similar overall pregnancy rate as per the time-to-event analysis (adjusted sub-distribution hazard ratio 1.378, 95% CI 0.755 - 2.515, p = 0.296).

Conclusion: This is a large single-center cohort study within the southern hemisphere that investigates patients who have undergone ovarian tissue cryopreservation, with one in five women achieving a pregnancy, emphasizing the clinical feasibility of OTC as a fertility preservation option for future fertility counseling.