American journal of obstetrics and gynecology最新文献

Background: The role of maternal cardiac and hemodynamic assessment during normal and complicated pregnancies has gained attention during the last few years. Some researchers suggested that the manifestation of complications in pregnancy suffering from impaired placentation is mainly driven by pre-existing cardiac changes, identifiable at an early stage by echocardiographic and hemodynamic assessment. It is therefore of great importance to determine the link between placental perfusion and maternal cardiac function and hemodynamics. Also, the impact of maternal cardiac function on birth weight has not been thoroughly studied.

Objective: To elucidate the possible association of maternal cardiovascular indices with placental perfusion at mid-gestation and birthweight.

Methods: Prospective study on women with singleton pregnancies attending Kings' College Hospital, London, UK for a routine hospital visit at 19-24 weeks' gestation. We recorded maternal characteristics and medical history, measured mean arterial pressure (MAP), heart rate, uterine artery pulsatility index (UtA-PI), umbilical artery PI, middle cerebral artery PI, and serum placental growth factor (PlGF). We also performed maternal echocardiogram to assess cardiac output and peripheral vascular resistance as well as indices of diastolic and systolic cardiac function. Multivariable regression modeling was used.

Results: Our cohort included 4006 women. Higher UtA-PI values were associated with lower MAP, heart rate, and left ventricular systolic function, after adjustment for maternal characteristics and subsequent development of hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM). In a multivariable approach that explained 17.9% of the variance of the birthweight we found that some cardiovascular indices provided small but significant contribution to the model after accounting for maternal factors, and development of HDP and GDM, UtA-PI, and PlGF.

Conclusion: The findings of our study indicate a weak but significant association between maternal cardiovascular indices with placental perfusion at mid-gestation and birthweight. Our data would not support routine maternal cardiovascular assessment for predicting birthweight.

Background: While guidelines suggest administering antibiotics 12 to 18 hours after the rupture of membranes in term premature rupture of membranes (PROM) women, in practice, clinicians tend to initiate prophylactic antibiotics as soon as possible to avoid risk of infection.

Objective: This study aimed to assess whether early administration of prophylactic antibiotics for term premature rupture of membranes reduces the incidence of maternal and neonatal infections.

Study design: This multi-center, prospective cohort study included women with term premature rupture of membranes. Participants were divided into early and late administration groups according to the duration between membranes rupture and antibiotic use. The effectiveness outcomes included the incidence of puerperal infection, the incidence of total maternal infection, the rate of neonatal sepsis, among others; the safety outcomes included the incidence of adverse reactions; and Antibiotics Use Density was used to assess the antibiotic consumption. Propensity score matching method was used to control confounding.

Results: A total of 1099 women with term PROM were enrolled, 459 in the early group-6 hours (antibiotics administration within 6 hours) and 640 in the late group-6 hours (antibiotics administration after 6 hours); 707 in the early group-12 hours (antibiotics administration within 12 hours) and 392 in the late group-12 hours (antibiotics administration after 12 hours). After propensity score matching, there were 300 women in each of the 6-hour groups and 230 women in each of the 12-hour groups. Baseline characteristics showed no significant differences between matched groups (P>0.05). The early 6-hour and 12-hour groups had lower maternal C-reactive protein levels compared to the late groups (P<0.05), but no significant differences in other maternal and neonatal outcomes. Adverse reactions showed no statistical significance between early and late groups (P=1.000). Antibiotic use density was higher in the early treatment groups by 10.1 defined daily doses (DDDs) (6-hour) and 11.7 DDDs (12-hour).

Conclusion: There was no statistical difference in the efficacy and safety when antibiotics administered within 6-12 hours after rupture of membranes, compared to after 6-12 hours in women with term PROM. Meanwhile delayed use significantly reduces the antibiotic consumption.

Background: The use of glucagon-like-peptide-1 receptor agonists (GLP-1RAs) has greatly increased in patients of reproductive age within the past four years. However, there is minimal research into the long-term impact of these medications on future pregnancies.

Objectives: We aimed to evaluate the association between adverse obstetric outcomes and antecedent GLP-1RA use using a nationally representative database.

Study design: We conducted a retrospective cohort study of female patients age ≥ 18 using the United States Collaborative Network in TriNetX. We defined the exposure cohort as individuals who received a GLP-1RA prescription within 2 years preceding a pregnancy. The unexposed cohort comprised individuals with a history of pregnancy but no prior history of GLP-1RA use. Cohorts were matched for age, race, ethnicity, and history of co-morbid conditions. ICD-10 codes for hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), preterm delivery, and rates of Cesarean section (CD) were the primary outcomes of interest compared between the cohorts. Logistic regression was performed in TriNetX to determine odds ratios (OR) and 95% confidence intervals (CI).

Results: After matching, there were 4,267 individuals in each cohort. Individuals who had a prescription for GLP-1RA were less likely to develop GDM (15.2% versus 18.2%, OR 0.81 (95% CI 0.72,0.91)), HDP (19.9% versus 22.8%, OR 0.84 (0.76,0.94)), have a preterm delivery (3.0% vs 4.4%, OR 0.68 (0.54,0.85)), and undergo a CD (17.6% vs 19.7%, OR 0.89 (0.87,0.97)) compared to the unexposed cohort.

Conclusions: A prescription of a GLP-1RA within 24 months preceding pregnancy is associated with a reduced risk of several adverse obstetric outcomes, including GDM, HDP, preterm delivery, and CD. This is suggestive that use of a GLP-1RA may be a powerful tool to improve perinatal outcomes in high-risk populations, though future work is required to define how this class of medication is best incorporated clinically into preconception health optimization.

Objective: To investigate the association between functional parameters of the microcirculation and the systemic cardiovascular system in a population of pregnant women at risk for gestational hypertension disorders.

Study design: For this observational study, women at high cardiovascular risk according to maternal anthropometrics, obstetric and medical history, were recruited at random gestational age depending on time of referral to the outpatient clinic for high risk prenatal care at Ziekenhuis Oost Limburg, Genk Belgium. After birth, data of maternal and neonatal outcome were obtained from the hospital records: only women with normal pregnancy (n = 142) and with preeclampsia (n = 34) were included in this analysis. Nailfold video capillaroscopy measurements were performed in first and/or second and/or third trimester. Video magnification of 200x was used at all fingers except thumbs, and stored images were analyzed offline. Capillary density was counted (n/mm²), mean capillary diameter measured (μm) and capillary bed was calculated as density x diameter. Cardiac output and total peripheral resistance were measured using impedance cardiography, together with sphygmomanometric blood pressure measurement. Linear mixed model for repeated measures was employed to investigate the association between the microvascular and macrovascular parameters. No correction for multiple testing was used.

Results: In normal pregnancies, a positive association was observed between capillary bed and total vascular resistance (1.807, p =0.01), and a negative association between capillary density and cardiac output (-0.269, p =0.037). In preeclampsia, a negative association was observed between capillary density and mean arterial pressure (-0.5649, p = 0.010), and between capillary diameter and cardiac output (-0.165, p=0.032).

Conclusion: A reduction of capillary density with increase of blood pressure in preeclampsia is similar to observations in chronic hypertension. Here, this is considered the result of capillary closure after constriction of precapillary arterioles. In normal pregnancy however, the increase of the capillary bed with rising vascular resistance can only be explained by a primary role for the microcirculation, preventing capillary overflow via stimulation of arteriolar constriction. These observations enlighten the very first hemodynamic origins of hypertension at the level of the microcirculation in preeclampsia.

Background: Preterm prelabor rupture of membranes (PPROM) before or around the limit of fetal viability is associated with serious maternal and neonatal complications including chorioamnionitis, extremely preterm birth, and pulmonary hypoplasia.

Objectives: To describe contemporary outcomes of extremely preterm infants born after prolonged periviable PPROM, and to identify perinatal factors associated with survival and survival without severe neurodevelopmental impairment (NDI).

Study design: Among actively treated infants born alive at <27 weeks' gestational age (GA) in centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network from 2012 to 2018, the outcomes of survival and survival without severe NDI at 22-26 months' corrected age were compared between infants exposed to prolonged (≥120 hours) periviable (<24 weeks' GA) PPROM and unexposed infants born after rupture of membranes ≤18 hours before delivery or at delivery, adjusting for birth GA, sex, multiple gestation, antenatal steroids, small for gestational age (SGA), insurance, and center. Regression models were used to identify perinatal factors associated with survival and survival without severe NDI among the infants exposed to prolonged periviable PPROM.

Results: The analysis included 609 infants exposed to prolonged periviable PPROM and 4,489 unexposed infants. In the prolonged periviable PPROM group, 444/608 (73%) infants survived and 298/533 (56%) infants survived without severe NDI. Odds of survival (OR, 0.84; 95% CI, 0.68-1.05) and survival without severe NDI (OR, 0.91; 95% CI, 0.75-1.12) were not significantly different between prolonged periviable PPROM and unexposed groups. Variables associated with higher odds of survival without severe NDI were later GA at birth (OR, 1.37; 95% CI, 1.13-1.67), later GA at PPROM (OR 1.44; 95% CI, 1.26-1.63), and female sex (OR, 1.57; 95% CI, 1.06-2.34), while SGA infants had lower odds of survival without severe NDI (OR, 0.14; 95% CI, 0.04-0.51).

Conclusions: Odds of survival and survival without severe NDI among infants exposed to prolonged periviable PPROM were not significantly different from unexposed infants, but decreased with earlier GA at birth and PPROM.