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Background: Prior literature has described an association between preeclampsia and offspring congenital heart disease (CHD), while suggesting there may be a stronger relationship in individuals with early preeclampsia. Objectives: The authors sought to explore the relationship between offspring CHD and preeclampsia among pregnancies in a population-based study. Methods: Retrospective cohort study all singleton pregnancies delivered in the state of California 2000 to 2012. We included singleton births with gestational ages of 23 to 42 weeks and excluded pregnancies complicated by pre-existing diabetes or identified fetal chromosomal anomalies. We used multivariable logistic regression to estimate ORs for associations between offspring CHD and preeclampsia. Further subanalyses examined the relationships in deliveries <34 weeks and >34 weeks to analyze if there was a difference according to timing of preeclampsia development. Results: Preeclampsia was strongly associated with offspring CHD (aOR: 1.38; 99% CI: 1.29-1.49) in the same pregnancy. Among patients with preeclampsia in the index pregnancy, there was an increased risk of fetal CHD in the subsequent pregnancy (aOR: 1.39; 99% CI: 1.20-1.61). Among patients with offspring CHD in the index pregnancy, there was an increased risk of preeclampsia in the subsequent pregnancy (aOR: 1.39; 99% CI: 1.15-1.68). In all 3 analyses, results remained significant when stratified by <34 weeks and ≥34 weeks. Conclusions: Our findings suggest a need for further investigation into the etiology of preeclampsia and its relationship to embryologic development of cardiovascular structures.
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OBJECTIVE: To estimate the cost effectiveness of Medicaid covering immediate postpartum long-acting reversible contraception (LARC) as a strategy to reduce future short interpregnancy interval (IPI), severe maternal morbidity (SMM), and preterm birth. METHODS: We built a decision analytic model using TreeAge software to compare maternal health and cost outcomes in two settings, one in which immediate postpartum LARC is a covered option and the other where it is not, among a theoretical cohort of 100,000 people with Medicaid insurance who were immediately postpartum and did not have permanent contraception. The primary outcome was the incremental cost-effectiveness ratio (ICER), which represents the incremental cost increase per an incremental quality-adjusted life-years (QALY) gained from one health intervention compared with another. Secondary outcomes included subsequent short IPI , defined as time between last delivery and conception of less than 18 months, as well as SMM, preterm birth, overall costs, and QALYs. We performed sensitivity analyses on all costs, probabilities, and utilities. RESULTS: Use of immediate postpartum LARC was the cost-effective strategy, with an ICER of -11,880,220,102. Use of immediate postpartum LARC resulted in 299 fewer repeat births overall, 178 fewer births with short IPI, two fewer cases of SMM, and 34 fewer preterm births. Coverage of immediate postpartum LARC resulted in 25 additional QALYs and saved $2,968,796. CONCLUSION: Coverage of immediate postpartum LARC at the time of index delivery can improve quality of life and reduce health care costs for Medicaid programs. Expanding coverage to include immediate postpartum LARC can help to achieve optimal IPI and decrease SMM and preterm birth.
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Análise de Custo-Efetividade , Contracepção Reversível de Longo Prazo , Medicaid , Período Pós-Parto , Adulto , Feminino , Humanos , Gravidez , Intervalo entre Nascimentos/estatística & dados numéricos , Contracepção Reversível de Longo Prazo/economia , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Medicaid/economia , Nascimento Prematuro/economia , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/prevenção & controle , Anos de Vida Ajustados por Qualidade de Vida , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: The American College of Obstetricians and Gynecologists (ACOG) suggests expectant management until 34 weeks for patients with preterm premature rupture of membranes (PPROM). New data suggest extending to 37 weeks might enhance neonatal outcomes, reducing prematurity-linked issues. This study aims to assess adverse neonatal outcomes across gestational ages in women with PPROM. STUDY DESIGN: A retrospective cohort study was performed using linked vital statistics and the International Classification of Diseases, Ninth Revision data. Gestational age at delivery ranged from 32 to 36 weeks. Outcomes include neonatal intensive care unit (NICU) admission >24 hours, neonatal sepsis, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, and neonatal death. Multivariate regression analyses and chi-square tests were employed for statistical comparisons. RESULTS: In this cohort of 28,891 deliveries, there was a statistically significant decline in all studied adverse neonatal outcomes with increasing gestational age, without an increase in neonatal sepsis. At 32 weeks, 93% of newborns were in the NICU >24 hours compared with 81% at 34 weeks and 22% at 36 weeks (p < 0.001). At 32 weeks, 20% had neonatal sepsis compared with 11% at 34 weeks and 3% at 36 weeks (p < 0.001). At 32 weeks, 67% had respiratory distress syndrome compared with 44% at 34 weeks and 12% at 36 weeks (p < 0.001). CONCLUSION: In the setting of PPROM, later gestational age at delivery is associated with decreased rates of adverse neonatal outcomes without an increase in neonatal sepsis. KEY POINTS: · The ACOG recommends expectant management until 34 weeks for patients with PPROM.. · However, expectant management to 37 weeks might improve neonatal outcomes.. · Later gestational age at delivery was associated with decreased rates of adverse neonatal outcomes.. · Later gestational age at delivery was not associated with an increase in neonatal sepsis.. · The management of PPROM is complex and should be individualized..
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Importance: The prevalence of cannabis use in pregnancy is rising and is associated with adverse perinatal outcomes. In parallel, combined prenatal use of cannabis and nicotine is also increasing, but little is known about the combined impact of both substances on pregnancy and offspring outcomes compared with each substance alone. Objective: To assess the perinatal outcomes associated with combined cannabis and nicotine exposure compared with each substance alone during pregnancy. Design, Setting, and Participants: This retrospective population-based cohort study included linked hospital discharge data (obtained from the California Department of Health Care Access and Information) and vital statistics (obtained from the California Department of Public Health) from January 1, 2012, through December 31, 2019. Pregnant individuals with singleton gestations and gestational ages of 23 to 42 weeks were included. Data were analyzed from October 14, 2023, to March 4, 2024. Exposures: Cannabis-related diagnosis and prenatal nicotine product use were captured using codes from International Classification of Diseases, Ninth Revision, Clinical Modification, and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification. Main Outcome and Measures: The main outcomes were infant and neonatal death, infants small for gestational age, and preterm delivery. Results were analyzed by multivariable Poisson regression models. Results: A total of 3â¯129â¯259 pregnant individuals were included (mean [SD] maternal age 29.3 [6.0] years), of whom 23â¯007 (0.7%) had a cannabis-related diagnosis, 56â¯811 (1.8%) had a nicotine-use diagnosis, and 10â¯312 (0.3%) had both in pregnancy. Compared with nonusers, those with cannabis or nicotine use diagnoses alone had increased rates of infant (0.7% for both) and neonatal (0.3% for both) death, small for gestational age (14.3% and 13.7%, respectively), and preterm delivery (<37 weeks) (12.2% and 12.0%, respectively). Moreover, risks in those with both cannabis and nicotine use were higher for infant death (1.2%; adjusted risk ratio [ARR], 2.18 [95% CI, 1.82-2.62]), neonatal death (0.6%; ARR, 1.76 [95% CI, 1.36-2.28]), small for gestational age (18.0%; ARR, 1.94 [95% CI, 1.86-2.02]), and preterm delivery (17.5%; ARR, 1.83 [95% CI, 1.75-1.91]). Conclusions and Relevance: These findings suggest that co-occurring maternal use of cannabis and nicotine products in pregnancy is associated with an increased risk of infant and neonatal death and maternal and neonatal morbidity compared with use of either substance alone. Given the increasing prevalence of combined cannabis and nicotine use in pregnancy, these findings can help guide health care practitioners with preconception and prenatal counseling, especially regarding the benefits of cessation.
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Nicotina , Efeitos Tardios da Exposição Pré-Natal , Humanos , Feminino , Gravidez , Recém-Nascido , Adulto , Estudos Retrospectivos , Nicotina/efeitos adversos , California/epidemiologia , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Nascimento Prematuro/epidemiologia , Recém-Nascido Pequeno para a Idade Gestacional , Resultado da Gravidez/epidemiologia , Lactente , Cannabis/efeitos adversos , Adulto JovemRESUMO
BACKGROUND: Although methamphetamine use has been increasing in recent years and occurring within new populations and in broader geographical areas, there is limited research on its use and effect in pregnancy. OBJECTIVE: This study aimed to examine the association between prenatal methamphetamine use and maternal and neonatal outcomes in a large, contemporary birth cohort. STUDY DESIGN: This was a retrospective cohort study using California-linked vital statistics and hospital discharge data from 2008 to 2019. Methamphetamine use was identified using the International Classification of Disease, Ninth Revision and Tenth Revision, codes. Chi-square tests and multivariable Poisson regression models were used to evaluate the associations between methamphetamine use and maternal and neonatal outcomes. RESULTS: A total of 4,775,463 pregnancies met the inclusion criteria, of which 18,473 (0.39%) had methamphetamine use. Compared with individuals without methamphetamine use, individuals with methamphetamine use had an increased risk of nonsevere hypertensive disorders (adjusted risk ratio, 1.81; 95% confidence interval, 1.71-1.90), preeclampsia with severe features (adjusted risk ratio, 3.38; 95% confidence interval, 3.14-3.63), placental abruption (adjusted risk ratio, 3.77; 95% confidence interval, 3.51-4.05), cardiovascular morbidity (adjusted risk ratio, 4.30; 95% confidence interval, 3.79-4.88), and severe maternal morbidity (adjusted risk ratio, 3.53; 95% confidence interval, 3.29-3.77). In addition, adverse neonatal outcomes were increased, including preterm birth at <37 weeks of gestation (adjusted risk ratio, 2.85; 95% confidence interval, 2.77-2.94), neonatal intensive care unit admission (adjusted risk ratio, 2.46; 95% confidence interval, 2.39-2.53), and infant death (adjusted risk ratio, 2.73; 95% confidence interval, 2.35-3.16). CONCLUSION: Methamphetamine use in pregnancy is associated with an increased risk of adverse maternal and neonatal outcomes that persists after adjustment for confounding variables and sociodemographic factors. Our results can inform prenatal and postpartum care for this high-risk, socioeconomically vulnerable population.
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Transtornos Relacionados ao Uso de Anfetaminas , Metanfetamina , Humanos , Feminino , Gravidez , Metanfetamina/efeitos adversos , Adulto , Estudos Retrospectivos , Recém-Nascido , Transtornos Relacionados ao Uso de Anfetaminas/epidemiologia , Transtornos Relacionados ao Uso de Anfetaminas/complicações , California/epidemiologia , Adulto Jovem , Pré-Eclâmpsia/epidemiologia , Complicações na Gravidez/epidemiologia , Resultado da Gravidez/epidemiologia , Descolamento Prematuro da Placenta/epidemiologia , Nascimento Prematuro/epidemiologia , Estudos de Coortes , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Fatores de RiscoRESUMO
BACKGROUND: Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants. OBJECTIVE: This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery. STUDY DESIGN: A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies. RESULTS: Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy. CONCLUSION: The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.
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Análise Custo-Benefício , Medicaid , Anos de Vida Ajustados por Qualidade de Vida , Adulto , Feminino , Humanos , Gravidez , Assistência Integral à Saúde/economia , Análise de Custo-Efetividade , Emigrantes e Imigrantes/estatística & dados numéricos , Cadeias de Markov , Medicaid/economia , Cuidado Pós-Natal/economia , Cuidado Pós-Natal/métodos , Cuidado Pós-Natal/estatística & dados numéricos , Pobreza , Gravidez não Planejada , Estados UnidosRESUMO
BACKGROUND: Respiratory distress syndrome is strongly associated with prematurity, including late preterm births. Respiratory distress syndrome has been shown to be associated with certain neonatal morbidities and mortality, but these associations are not well described among late preterm births. OBJECTIVE: We sought to determine the association between respiratory distress syndrome and adverse neonatal outcomes among late preterm (34-36 weeks) born singleton neonates. STUDY DESIGN: This is a retrospective cohort study using California's linked vital statistics and patient discharge data (2008-2019). We included singleton, nonanomalous births with a gestational age of 34-36 weeks. Outcomes of interest were interventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, neonatal sepsis, length of hospital stay, neonatal death, and infant death. Chi-square and multivariable Poisson regression analyses were used to examine the association of respiratory distress syndrome with outcomes at each gestational age. Adjusted risk ratio and 95% confidence interval values were estimated. RESULTS: A total of 242,827 births were included, of which 11,312 (4.7%) had respiratory distress syndrome. We found that among neonates with respiratory distress syndrome, necrotizing enterocolitis was higher at 35 weeks (adjusted risk ratio, 3.97 [95% confidence interval, 1.88-8.41]) and 36 weeks (adjusted risk ratio, 4.53 [95% confidence interval, 1.45-14.13]). Intraventricular hemorrhage, retinopathy of prematurity, neonatal sepsis, and length of hospital stay were significantly higher at 34-36 weeks of gestation in neonates with respiratory distress syndrome. Neonatal death was significantly higher among neonates with respiratory distress syndrome at 35 weeks (adjusted risk ratio, 3.04 [95% confidence interval, 1.58-5.85]) and 36 weeks (adjusted risk ratio, 3.25; 95% confidence interval, 1.59-6.68). In addition, infant death was significantly higher at 35 weeks (adjusted risk ratio, 2.27 [95% confidence interval, 1.43-3.61]) and 36 weeks (adjusted risk ratio, 2.60 [95% confidence interval, 1.58-4.28]). CONCLUSION: We found that respiratory distress syndrome was associated with intraventricular hemorrhage, retinopathy of prematurity, and sepsis at 34-36 weeks of gestation, whereas respiratory distress syndrome was associated with neonatal death, infant death, and necrotizing enterocolitis at 35 and 36 weeks. Clinicians should keep these outcomes in mind when making decisions about delivery timing, the potential benefits of antenatal steroids in pregnancies in the late preterm period, and the management of respiratory distress syndrome in late preterm neonates.
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Enterocolite Necrosante , Idade Gestacional , Recém-Nascido Prematuro , Síndrome do Desconforto Respiratório do Recém-Nascido , Retinopatia da Prematuridade , Humanos , Feminino , Recém-Nascido , Estudos Retrospectivos , Síndrome do Desconforto Respiratório do Recém-Nascido/epidemiologia , Enterocolite Necrosante/epidemiologia , Enterocolite Necrosante/mortalidade , Masculino , Gravidez , Retinopatia da Prematuridade/epidemiologia , Retinopatia da Prematuridade/diagnóstico , California/epidemiologia , Tempo de Internação/estatística & dados numéricos , Lactente , Adulto , Nascimento Prematuro/epidemiologia , Mortalidade Infantil/tendências , Sepse Neonatal/epidemiologia , Sepse Neonatal/mortalidade , Sepse Neonatal/diagnóstico , Hemorragia Cerebral Intraventricular/epidemiologia , Morte Perinatal , Doenças do Prematuro/epidemiologia , Doenças do Prematuro/mortalidadeRESUMO
IMPORTANCE: The associated effect of duration of the second stage of labor (SSL) on pelvic floor symptoms development is not well studied. OBJECTIVE: This study aimed to examine the association between duration of SSL and pelvic floor symptoms at 6 months postpartum among primiparous women. STUDY DESIGN: A planned secondary analysis of a multicenter randomized trial evaluating the impact of immediate versus delayed pushing on vaginal delivery rates, maternal morbidity, and neonatal outcomes was conducted between 2014 and 2018. For pelvic floor arm participants, demographic, pelvic examination, and validated questionnaire data were collected postpartum. Primary outcome was change in Pelvic Floor Distress Inventory 20 (PFDI-20) score from immediate to 6 months postpartum. Secondary outcomes included changes in the Pelvic Floor Impact Questionnaire, Fecal Incontinence Severity Index, Modified Manchester Health Questionnaire scores, and Pelvic Organ Prolapse Quantification measurements at 6 months postpartum. Participants were analyzed by SSL duration ≤60 minutes or >60 minutes. RESULTS: Of the 2,414 trial participants, 767 (32%) completed pelvic floor assessments at 6 months. Pelvic Floor Distress Inventory 20 scores significantly improved at 6 months in the ≤60 minutes SSL group compared with >60 minutes SSL (-14.3 ± 48.0 and -3.2 ± 45.3, respectively; P = 0.04). Changes from immediate postpartum in total and subscale scores for other questionnaires at 6 months did not differ between groups. Prolapse stage did not differ between groups. Perineal body was significantly shorter in the >60 minutes SSL group (3.7 ± 0.7, 3.5 ± 0.8; P = 0.03). CONCLUSIONS: Women with SSL >60 minutes experience less improvement in PFDI-20 scores at 6 months. Greater tissue and innervation trauma in those with SSL >60 minutes may explain persistently less improvement in PFDI-20 scores.
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Incontinência Fecal , Prolapso de Órgão Pélvico , Gravidez , Recém-Nascido , Feminino , Humanos , Diafragma da Pelve , Segunda Fase do Trabalho de Parto , Incontinência Fecal/epidemiologia , Período Pós-PartoRESUMO
OBJECTIVE: To determine intrapartum factors associated with perineal laceration at delivery. METHODS: This was a planned secondary analysis of a multicenter randomized clinical trial of delayed versus immediate pushing among term nulliparous women in labor with neuraxial analgesia conducted in the United States. Intrapartum characteristics were extracted from the medical charts. The primary outcome was perineal laceration, defined as second degree or above, characterized at delivery in women participating in longer term pelvic floor assessments post-delivery. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, birth weight, and maternal age. RESULTS: Among the 941 women participating in the pelvic floor follow-up, 40.6% experienced a perineal laceration. No first stage labor characteristics were associated with perineal laceration, including type of labor or length of first stage. Receiving an amnioinfusion appeared protective of perineal laceration (adjusted odds ratio, 0.48; 95% confidence interval 0.26-0.91; P = 0.01). Second stage labor characteristics associated with injury were length of stage (2.01 h vs. 1.50 h; adjusted odds ratio, 1.36; 95% confidence interval 1.18-1.57; P < 0.01) and a prolonged second stage (adjusted odds ratio, 1.64; 95% confidence interval 1.06-2.56; P < 0.01). Operative vaginal delivery was strongly associated with perineal laceration (adjusted odds ratio, 3.57; 95% confidence interval 1.85-6.90; P < 0.01). CONCLUSION: Operative vaginal delivery is a modifiable risk factor associated with an increased risk of perineal laceration. Amnioinfusion appeared protective against injury, which could reflect a spurious finding, but may also represent true risk reduction similar to the mechanism of warm perineal compress.
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Parto Obstétrico , Segunda Fase do Trabalho de Parto , Lacerações , Complicações do Trabalho de Parto , Períneo , Humanos , Feminino , Períneo/lesões , Gravidez , Lacerações/epidemiologia , Lacerações/etiologia , Adulto , Fatores de Risco , Complicações do Trabalho de Parto/epidemiologia , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Modelos Logísticos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: The diagnosis of failure to progress, the most common indication for intrapartum cesarean delivery, is based on the assessment of cervical dilation and station over time. Labor curves serve as references for expected changes in dilation and fetal descent. The labor curves of Friedman, Zhang et al, and others are based on time alone and derived from mothers with spontaneous labor onset. However, labor induction is now common, and clinicians also consider other factors when assessing labor progress. Labor curves that consider the use of labor induction and other factors that influence labor progress have the potential to be more accurate and closer to clinical decision-making. OBJECTIVE: This study aimed to compare the prediction errors of labor curves based on a single factor (time) or multiple clinically relevant factors using two modeling methods: mixed-effects regression, a standard statistical method, and Gaussian processes, a machine learning method. STUDY DESIGN: This was a longitudinal cohort study of changes in dilation and station based on data from 8022 births in nulliparous women with a live, singleton, vertex-presenting fetus ≥35 weeks of gestation with a vaginal delivery. New labor curves of dilation and station were generated with 10-fold cross-validation. External validation was performed using a geographically independent group. Model variables included time from the first examination in the 20 hours before delivery; dilation, effacement, and station recorded at the previous examination; cumulative contraction counts; and use of epidural anesthesia and labor induction. To assess model accuracy, differences between each model's predicted value and its corresponding observed value were calculated. These prediction errors were summarized using mean absolute error and root mean squared error statistics. RESULTS: Dilation curves based on multiple parameters were more accurate than those derived from time alone. The mean absolute error of the multifactor methods was better (lower) than those of the single-factor methods (0.826 cm [95% confidence interval, 0.820-0.832] for the multifactor machine learning and 0.893 cm [95% confidence interval, 0.885-0.901] for the multifactor mixed-effects method and 2.122 cm [95% confidence interval, 2.108-2.136] for the single-factor methods; P<.0001 for both comparisons). The root mean squared errors of the multifactor methods were also better (lower) than those of the single-factor methods (1.126 cm [95% confidence interval, 1.118-1.133] for the machine learning [P<.0001] and 1.172 cm [95% confidence interval, 1.164-1.181] for the mixed-effects methods and 2.504 cm [95% confidence interval, 2.487-2.521] for the single-factor [P<.0001 for both comparisons]). The multifactor machine learning dilation models showed small but statistically significant improvements in accuracy compared to the mixed-effects regression models (P<.0001). The multifactor machine learning method produced a curve of descent with a mean absolute error of 0.512 cm (95% confidence interval, 0.509-0.515) and a root mean squared error of 0.660 cm (95% confidence interval, 0.655-0.666). External validation using independent data produced similar findings. CONCLUSION: Cervical dilation models based on multiple clinically relevant parameters showed improved (lower) prediction errors compared to models based on time alone. The mean prediction errors were reduced by more than 50%. A more accurate assessment of departure from expected dilation and station may help clinicians optimize intrapartum management.
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Primeira Fase do Trabalho de Parto , Trabalho de Parto Induzido , Humanos , Feminino , Gravidez , Primeira Fase do Trabalho de Parto/fisiologia , Adulto , Trabalho de Parto Induzido/métodos , Estudos Longitudinais , Aprendizado de Máquina , Cesárea/estatística & dados numéricos , Estudos de Coortes , Trabalho de Parto/fisiologia , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVE: To assess the cost effectiveness of targeting a blood pressure of less than 140/90 mm Hg compared with 160/105 mm Hg. METHODS: A decision-analytic model was constructed to compare the treatment of chronic hypertension in pregnancy at mild-range blood pressures (140/90 mm Hg) with the treatment of chronic hypertension before 20 weeks of gestation at severe-range blood pressures (160/105 mm Hg) in a theoretical cohort of 180,000 patients with mild chronic hypertension. Probabilities, costs, and utilities were derived from literature and varied in sensitivity analyses. Primary outcomes included incremental cost per quality-adjusted life-year (QALY), cases of preeclampsia, preeclampsia with severe features, severe maternal morbidity (SMM), preterm birth, maternal death, neonatal death, and neurodevelopmental delay. The cost-effectiveness threshold was $100,000 per QALY. RESULTS: Treating chronic hypertension in a population of 180,000 pregnant persons at mild-range blood pressures, compared with severe-range blood pressures, resulted in 14,177 fewer cases of preeclampsia (43,953 vs 58,130), 11,835 of which were cases of preeclampsia with severe features (40,530 vs 52,365). This led to 817 fewer cases of SMM (4,375 vs 5,192), and 18 fewer cases of maternal death (102 vs 120). Treating at a lower threshold also resulted in 8,078 fewer cases of preterm birth (22,000 vs 30,078), which led to 26 fewer neonatal deaths (276 vs 302) and 157 fewer cases of neurodevelopmental delay (661 vs 818). Overall, treating chronic hypertension at a lower threshold was a dominant strategy that resulted in decreased costs of $600 million and increased effectiveness of 12,852 QALYs. CONCLUSION: Treating chronic hypertension at a threshold of mild-range blood pressures is a dominant (lower costs, better outcomes) and cost-effective strategy that results in fewer neonatal and maternal deaths compared with the standard treatment of treating at severe range blood pressures.
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Hipertensão , Morte Perinatal , Pré-Eclâmpsia , Nascimento Prematuro , Gravidez , Feminino , Humanos , Recém-Nascido , Análise de Custo-Efetividade , Pré-Eclâmpsia/terapia , Nascimento Prematuro/epidemiologia , Análise Custo-BenefícioRESUMO
BACKGROUND: Severe maternal morbidity and mortality are worse in the United States than in all similar countries, with the greatest effect on Black women. Emerging research suggests that disrespectful care during childbirth contributes to this problem. PURPOSE: To conduct a systematic review on definitions and valid measurements of respectful maternity care (RMC), its effectiveness for improving maternal and infant health outcomes for those who are pregnant and postpartum, and strategies for implementation. DATA SOURCES: Systematic searches of Ovid Medline, CINAHL, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, and SocINDEX for English-language studies (inception to July 2023). STUDY SELECTION: Randomized controlled trials and nonrandomized studies of interventions of RMC versus usual care for effectiveness studies; additional qualitative and noncomparative validation studies for definitions and measurement studies. DATA EXTRACTION: Dual data abstraction and quality assessment using established methods, with resolution of disagreements through consensus. DATA SYNTHESIS: Thirty-seven studies were included across all questions, of which 1 provided insufficient evidence on the effectiveness of RMC to improve maternal outcomes and none studied RMC to improve infant outcomes. To define RMC, authors identified 12 RMC frameworks, from which 2 main concepts were identified: disrespect and abuse and rights-based frameworks. Disrespect and abuse components focused on recognizing birth mistreatment; rights-based frameworks incorporated aspects of reproductive justice, human rights, and antiracism. Five overlapping framework themes include freedom from abuse, consent, privacy, dignity, communication, safety, and justice. Twelve tools to measure RMC were validated in 24 studies on content validity, construct validity, and internal consistency, but lack of a gold standard limited evaluation of criterion validity. Three tools specific for RMC had at least 1 study demonstrating consistency internally and with an intended construct relevant to U.S. settings, but no single tool stands out as the best measure of RMC. LIMITATIONS: No studies evaluated other health outcomes or RMC implementation strategies. The lack of definition and gold standard limit evaluation of RMC tools. CONCLUSION: Frameworks for RMC are well described but vary in their definitions. Tools to measure RMC demonstrate consistency but lack a gold standard, requiring further evaluation before implementation in U.S. settings. Evidence is lacking on the effectiveness of implementing RMC to improve any maternal or infant health outcome. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42023394769).
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Serviços de Saúde Materna , Obstetrícia , Lactente , Gravidez , Feminino , Humanos , Respeito , Parto Obstétrico , Período Pós-Parto , Qualidade da Assistência à SaúdeRESUMO
Oxytocin is a peptide hormone that plays a key role in regulating the female reproductive system, including during labor and lactation. It is produced primarily in the hypothalamus and secreted by the posterior pituitary gland. Oxytocin can also be administered as a medication to initiate or augment uterine contractions. To study the effectiveness and safety of oxytocin, previous studies have randomized patients to low- and high-dose oxytocin infusion protocols either alone or as part of an active management of labor strategy along with other interventions. These randomized trials demonstrated that active management of labor and high-dose oxytocin regimens can shorten the length of labor and reduce the incidence of clinical chorioamnionitis. The safety of high-dose oxytocin regimens is also supported by no associated differences in fetal heart rate abnormalities, postpartum hemorrhage, low Apgar scores, neonatal intensive care unit admissions, and umbilical artery acidemia. Most studies reported no differences in the cesarean delivery rates with active management of labor or high-dose oxytocin regimens, thereby further validating its safety. Oxytocin does not have a predictable dose response, thus the pharmacologic effects and the amplitude and frequency of uterine contractions are used as physiological parameters for oxytocin infusion titration to achieve adequate contractions at appropriate intervals. Used in error, oxytocin can cause patient harm, highlighting the importance of precise administration using infusion pumps, institutional safety checklists, and trained nursing staff to closely monitor uterine activity and fetal heart rate changes. In this review, we summarize the physiology, pharmacology, infusion regimens, and associated risks of oxytocin.
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Trabalho de Parto , Ocitócicos , Gravidez , Recém-Nascido , Humanos , Feminino , Ocitocina/farmacologia , Ocitocina/uso terapêutico , Trabalho de Parto Induzido/métodos , CesáreaRESUMO
BACKGROUND AND OBJECTIVES: Neonatal brain injury is a common and devastating diagnosis conferring lifelong challenges for children and families. The role of mechanical forces applied to the head, often referred to as "birth trauma," are often considered although evidence for this association is lacking. The objective of this study was to investigate the association between common types of neonatal brain injury and scalp swelling using a novel method to quantify scalp swelling as an unbiased proxy for mechanical forces applied to the head. METHODS: Case-control study using population-based, prospectively collected tertiary care center databases and healthy controls from the Human Connectome Development Project. Included were infants born 32-42 weeks gestational age and MRI in the first 9 days. Outcomes categories included healthy neonates, hypoxic ischemic encephalopathy (HIE) with or without brain injury, or stroke (ischemic or hemorrhagic). Volume of scalp swelling was objectively quantified by a novel imaging method blinded to brain injury. Variables included mode of delivery and use of instrumentation. Statistical tests included Kruskal-Wallis test, chi square, and multivariable and multinomial logistic regression. RESULTS: There were 309 infants included (55% male): 72 healthy controls, 77 HIE without brain injury on MRI, 78 HIE with brain injury, and 82 with stroke (60 ischemic, 22 hemorrhagic). Scalp swelling was present in 126 (40.8%, 95% confidence interval [CI] 35.2%-46.5%) with no difference in proportions between outcome groups. Compared to healthy controls, median volume was higher in those with HIE without brain injury (17.5 mL, 95% CI 6.8-28.2), HIE with brain injury (12.1 mL, 95% CI 5.5-18.6), but not ischemic stroke (4.7 mL, 95% CI -1.2-10.6) nor hemorrhagic stroke (8.3 mL, 95% CI -2.2-18.8). Scalp swelling was associated with instrumented delivery (OR 2.1, 95% CI 1.0-4.1), but not associated with increased odds of brain injury in those with HIE (OR 1.5, 95% CI 0.76-3.30). Scalp swelling measures were highly reliable (ICC = 0.97). DISCUSSION: "Birth trauma" quantified by scalp swelling volume was more common in infants with difficult deliveries, but not associated with greater odds of brain injury due to hypoxia or stroke. These results may help parents and practitioners to dissociate the appearance of trauma with the risk of brain injury.
Assuntos
Lesões Encefálicas , Traumatismos Craniocerebrais , Hipóxia-Isquemia Encefálica , Acidente Vascular Cerebral , Recém-Nascido , Lactente , Criança , Humanos , Masculino , Feminino , Estudos de Casos e Controles , Imageamento por Ressonância Magnética , Traumatismos Craniocerebrais/complicações , Lesões Encefálicas/complicações , Acidente Vascular Cerebral/complicações , Hipóxia-Isquemia Encefálica/complicações , Hipóxia-Isquemia Encefálica/diagnóstico por imagemRESUMO
OBJECTIVE: Our objective was to determine the optimal timing of delivery of growth restricted fetuses with gastroschisis in the setting of normal umbilical artery (UA) Dopplers. METHODS: We designed a decision analytic model using TreeAge software for a hypothetical cohort of 2000 fetuses with isolated gastroschisis, fetal growth restriction (FGR), and normal UA Dopplers across 34-39 weeks of gestation. This model accounted for costs and quality adjusted life years (QALYs) for the pregnant individual and the neonate. Model outcomes included stillbirth, respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), short gut syndrome (SGS), neonatal sepsis, neonatal death, and neurodevelopmental disability (NDD). RESULTS: We found 38 weeks to be the optimal timing of delivery for minimizing overall perinatal mortality and leading to the highest total QALYs. Compared to 37 weeks, delivery at 38 weeks resulted in 367.98 more QALYs, 2.22 more cases of stillbirth, 2.41 fewer cases of RDS, 0.02 fewer cases of NEC, 1.65 fewer cases of IVH, 0.5 fewer cases of SGS, 2.04 fewer cases of sepsis, 11.8 fewer neonatal deaths and 3.37 fewer cases of NDD. However, 39 weeks were the most cost-effective strategy with a savings of $1,053,471 compared to 38 weeks. Monte Carlo analysis demonstrated that 38 weeks was the optimal gestational age for delivery 51.70% of the time, 39 weeks were optimal 47.40% of the time, and 37 weeks was optimal 0.90% of the time. CONCLUSION: Taking into consideration a range of adverse perinatal outcomes and cost effectiveness, 38-39 weeks gestation is ideal for the delivery of fetuses with gastroschisis, FGR, and normal UA Dopplers. However, there are unique details to consider for each case, and the timing of delivery should be individualized using shared multidisciplinary decision making.
Assuntos
Gastrosquise , Morte Perinatal , Síndrome do Desconforto Respiratório do Recém-Nascido , Gravidez , Feminino , Recém-Nascido , Humanos , Lactente , Natimorto , Feto , Ultrassonografia Doppler/métodos , Idade Gestacional , Retardo do Crescimento Fetal , Técnicas de Apoio para a DecisãoRESUMO
OBJECTIVE: Despite a downward trend in recent years, adolescent pregnancies in the United States remain higher than any other western country. Adolescent pregnancies have been inconsistently associated with adverse perinatal outcomes. The objective of this study is to investigate the association between adolescent pregnancies and adverse perinatal and neonatal outcomes in the United States. STUDY DESIGN: This is a retrospective cohort study of singleton births in the United States from 2014 to 2020 using national vital statistics data. Perinatal outcomes included gestational diabetes, gestational hypertension, preterm delivery <37 weeks (preterm birth [PTB]), cesarean delivery (CD), chorioamnionitis, small for gestational age (SGA), large for gestational age (LGA), and neonatal composite outcome. Chi-square tests were used to compare outcomes among adolescent (13-19 years) versus adult (20-29 years) pregnancies. Multivariable logistic regression models were used to examine association of adolescent pregnancies with perinatal outcomes. For each outcome, we utilized three models: unadjusted logistic regression, adjusted for demographics, and adjusted for demographics and medical comorbidities. Similar analyses were used to compare younger (13-17 years) and older (18-19 years) adolescent pregnancies to adults. RESULTS: In a cohort of 14,014,078 pregnancies, we found that adolescents were at an increased risk of PTB (adjusted odds ratio [aOR]: 1.12, 99% confidence interval (CI): 1.12-1.13) and SGA (aOR: 1.02, 99% CI: 1.01-1.03) compared with adult pregnancies. We also found that multiparous adolescents with a prior history of CD were at an increased risk of CD, compared with adults. For all other outcomes, adult pregnancies were at higher risk for adverse outcomes in the adjusted models. When comparing birth outcomes among adolescents, we found that older adolescents are at an increased risk of PTB, whereas younger adolescents are at an increased risk of both PTB and SGA. CONCLUSION: After adjusting for confounders, our study demonstrates adolescents have an increased risk of PTB and SGA, compared with adults. KEY POINTS: · Adolescents as a whole subgroup have an increased risk of PTB and SGA compared with adults.. · Younger adolescents have a risk of PTB and SGA, whereas older adolescents have a risk of PTB only.. · Adverse birth outcomes in adults are gestational diabetes, chorioamnionitis, LGA, and worse neonatal composite score..