American journal of obstetrics and gynecology最新文献

Substance use and substance use disorders (SUDs) among pregnant and postpartum individuals have risen dramatically, necessitating enhanced clinician education and intervention strategies. This expert review offers obstetricians and gynecologists (OBGYNs) a comprehensive overview of substance use during the prenatal and postpartum periods. We discuss the epidemiology, maternal and fetal adverse effects, as well as treatment approaches for major substances: nicotine, cannabis, alcohol, benzodiazepines, stimulants, and opioids. Additionally, we address the ethical and legal implications of substance use during pregnancy and emphasize the importance of equitable and non-stigmatizing care. By integrating evidence-based practices, we aim to support OBGYNs in providing optimal care for pregnant and postpartum individuals affected by SUDs.

Background: With increasingly restricted access to facility-based abortion in the United States, pregnant people are increasingly relying on models of care that utilize history-based or no-test approaches to eligibility assessment. Minimal research has examined the accuracy of abortion patients' self-assessment of eligibility for medication abortion using their health history, a necessary step towards ensuring optimal access to history-based or no-test models, as well as potential over-the-counter access.

Objective: To examine the accuracy of pregnant people's eligibility for medication abortion determined using their self-reported health history as compared to clinician assessment with ultrasound and other tests.

Study design: In this diagnostic accuracy study, we recruited people seeking medication or procedural abortion from 9 abortion facilities, aged > 15, English- or Spanish-speaking, and with no prior ultrasound at recruitment facility. Before ultrasound, we surveyed participants on medication abortion eligibility, including estimated gestational duration, medical history, contraindications, and ectopic risk factors such as pain and bleeding symptoms. We compared patients' eligibility based on self-reported history to subsequent clinician assessment, focusing on overall diagnostic accuracy, or area under the receiver operating characteristic curve, sensitivity, specificity, and proportion with discordant patient and clinician eligibility assessment using 77 days as the upper gestational duration limit.

Results: Overall, 22.1% of 1,386 participants were ineligible for medication abortion according to clinician assessment. Overall diagnostic accuracy of self-assessment was acceptable (area under the receiver operating characteristic curve=0.65, 95% CI: 0.63,0.67), with sensitivity of 92.2% (88.6, 94.9%) and specificity of 37.8% (34.9, 40.7%). Very few participants (n=24, 1.7%) screened themselves as eligible when the clinician deemed them ineligible; many more (n=672, 48.5%) screened themselves as ineligible when the clinician deemed them eligible. The most common patient-reported contraindications included unexplained pain (55.5%), gestational duration >77 days (36.5%), and anemia (29.0%). On its own, unexplained pain had poor sensitivity identifying those with clinician-concern for ectopic pregnancy (41.7%, 95% CI: 15.2, 72.3%). Removing unexplained pain as a screening criterion resulted in higher accuracy (0.71, 95% CI: 0.69, 0.74) (p<0.001).

Conclusions: History-based screening protocols are highly effective at ensuring few people receive medication abortion when ineligible. However, a sizeable group screens as ineligible when they are in fact eligible, suggesting a need for more specific screening questions.

Objective: To compare the rates of surgical site infection (SSI) after hysterectomy using vaginal antisepsis with chlorhexidine gluconate (CHG) versus povidone-iodine (PI).

Data sources: PubMed, Embase, and Clinicaltrials.gov databases were queried from January 1, 1985 through Dec 7, 2023.

Study eligibility criteria: Randomized controlled trials (RCTs) and nonrandomized comparisons of interventions (NRCIs) of CHG and PI vaginal antiseptic preparation prior to hysterectomy were included. The primary outcome was SSI as defined by the CDC. Secondary outcomes included postoperative urinary tract infections (UTIs) and vaginal culture specimens. Large single group studies of vaginal CHG reporting adverse events and case reports of desquamation were also included.

Study appraisal and synthesis methods: Methodologic quality of each study was assessed using the original Cochrane Risk of Bias and Risk of Bias in Nonrandomized Studies Intervention tools. Restricted maximum likelihood meta-analyses of odds ratios (OR) were conducted.

Results: 5,289 abstracts were screened. 10 met inclusion with a total of 9,618 participants. The studies included 4 RCTs (n=306), 3 prospective NRCIs (n=1,089), and 3 retrospective NRCIs (n=8,223). PI was compared to 4% CHG in 4 studies (n=2,491), 2% CHG in 2 studies (n=236), 0.1% in 1 study (n=50), and both 2% and 4% CHG in 1 study (n=49). Meta-analysis revealed no statistically significant difference in SSIs, although SSIs were somewhat more common with CHG (summary OR 1.22, 95% CI 0.91-1.63). The relative effect of antiseptic preparations on UTIs was unclear, with an imprecise summary OR (1.18, 95% CI 0.65-2.12). Positive vaginal cultures were less common with CHG preparation (summary OR 0.10, 95% CI 0.04-0.27). Two studies reported no adverse events with CHG, and two found no difference in vaginal irritation when compared with PI. Two case reports described vaginal desquamation or hypersensitivity with CHG.

Conclusion: There is no evidence of a difference in postoperative infection with CHG use compared to PI, but CHG vaginal preparation results in lower rates of positive intraoperative vaginal cultures. Despite inadequate reporting, risk of adverse events appears low.