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1.
Healthcare (Basel) ; 9(11)2021 Oct 27.
Artigo em Inglês | MEDLINE | ID: mdl-34828500

RESUMO

Granulosa cell tumors are rare ovarian tumors that can arise during pregnancy. We present a new case of recurrent adult granulosa cell tumor (AGCT) in pregnancy and a systematic review of the literature. The new case described is a 41-year-old woman G5P1122 with a prior history of AGCT that was referred to our center at 29 weeks because of a symptomatic abdominal mass, compatible with a possible recurrence of AGCT. At 36 + 3 weeks, she underwent a cesarean delivery for preterm labor and a total hysterectomy with a radical surgical staging. A healthy female infant was delivered. The patient received a platinum-based chemotherapy, with a 26-month follow-up negative for recurrence. Analyzing our case with the four identified by the literature review, three were recurrent and two were primary AGCT. Only one required surgery for AGCT at 15 weeks, while another underwent chemotherapy in pregnancy. In the other three cases, surgery for AGCT was done at the time of cesarean delivery. There were three cases of preterm delivery. All five pregnancies resulted in the birth of live babies with weight adequate for gestational age. In conclusion, AGCT diagnosed in pregnancy is rare, reported in only five cases. All gave birth to live babies in the third trimester, and maternal outcome at up to 18 months showed no recurrence.

2.
Am J Obstet Gynecol MFM ; : 100538, 2021 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-34813974

RESUMO

OBJECTIVE: To compare the rates of adverse outcomes among pregnancies with fetal growth restriction (FGR) undergoing induction of labor with and without prostaglandins (PG) METHODS: We performed a propensity score based secondary analysis of the Consortium on Safe Labor (CSL) database. We included term, singleton, non-anomalous pregnancies with FGR (EFW < 10th percentile for gestational age). We excluded prior cesarean deliveries (CD). The primary exposure was induction using PG (PGE1 or PGE2) compared to other methods. The primary outcome was a composite of adverse neonatal outcomes. Secondary outcomes included all CD and CD for non-reassuring fetal heart tracings (NRFHT). A subgroup analysis comparing type of PG was planned a priori. Results are expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS: Of 756 (0.3%) inductions, 212 (28%) used PG (108 PGE1, 94 PGE2), and 553 (72%) used non-PG methods including oxytocin (348, 63%), amniotomy (211, 38%), and/or mechanical dilation (9, 1%). There were no differences in the composite of adverse neonatal outcomes between the PG (10.4%) and non-PG group (6.7%), aOR 1.39 (0.64-3.03). The rate of CD was higher in inductions that received PG compared to those that did not (25.5% vs 14.8%, aOR 1.80; 1.07-3.02). The rate of CD for NRFHT was higher for those that received PG compared to those that did not (16.0% vs 8.7%, aOR 2.37; 1.28-4.41). When PGE1 and PGE2 were examined independently, there were similar increases in composite of adverse neonatal outcomes and CD rates for both PGE1 and PGE2 compared to non-PG controls. CONCLUSION: There were no differences in composite of adverse neonatal outcomes when PG were used for induction in pregnancies with FGR compared to other methods. However, there was a higher rate of CD, and CD indicated for NRFHT, when PG (both PGE1 and PGE2) were used compared to non-PG methods.

4.
Obstet Gynecol ; 138(4): 627-632, 2021 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-34623075

RESUMO

OBJECTIVE: To examine compliance with a guideline to reduce exposure to supplemental oxygen for category II fetal heart rate (FHR) tracings in normally oxygenated laboring patients. METHODS: All patients in labor in an urban academic medical center from January 1 to July 31, 2020 were assessed. The preintervention group included those who delivered from January 1 to March 19, 2020. On March 20, 2020, a new guideline took effect that recommended no maternal supplemental oxygen for category II FHR tracings. The postintervention group delivered from March 20 to July 31, 2020. Exclusion criteria were planned cesarean delivery, multiple gestations, delivery at less than 24 weeks of gestation, intrauterine fetal death, and patients who received supplemental oxygen for an oxygen saturation lower than 95%. The primary outcome was the percentage of patients who received oxygen in labor analyzed by control charts and the rules of special cause variation. Chi-squared and t tests were used for secondary outcome assessment. P<.05 was considered significant. RESULTS: A total of 1,333 patients were included, 474 patients in the preintervention group and 859 in the postintervention group. Oxygen was administered to 22.6% of patients before guideline implementation, compared with 0.6% after the guideline. Special cause variation was detected with an 8-point shift starting the month that the guideline was implemented, indicating statistical significance. There were no differences in any studied secondary maternal or fetal outcomes, although our statistical power to detect differences in infrequent outcomes was limited. CONCLUSION: This quality-improvement study demonstrated significant adherence to the guideline that supplemental oxygen would no longer be given to patients with category II FHR tracings in the absence of maternal hypoxemia, with no significant change in maternal or perinatal outcomes.

6.
Am J Obstet Gynecol MFM ; 4(1): 100509, 2021 Oct 14.
Artigo em Inglês | MEDLINE | ID: mdl-34656731

RESUMO

BACKGROUND: There has been an increasing number of randomized controlled trials published in obstetrics and maternal-fetal medicine to reduce biases of treatment effect and to provide insights on the cause-effect of the relationship between treatment and outcomes. OBJECTIVE: This study aimed to identify obstetrical randomized controlled trials published in top weekly general medical journals and monthly obstetrics and gynecology journals, to assess their quality in reporting and identify factors associated with publication in different journals. STUDY DESIGN: The 4 weekly medical journals with the highest 2019 impact factor (New England Journal of Medicine, The Lancet, The Journal of the American Medical Association, and British Medical Journal), the top 4 monthly obstetrics and gynecology journals with obstetrics-related research (American Journal of Obstetrics & Gynecology, Ultrasound in Obstetrics & Gynecology, Obstetrics & Gynecology, and the British Journal of Obstetrics and Gynaecology), and the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine were searched for obstetrical randomized controlled trials in the years 2018 to 2020. The primary outcome was the number of obstetrical randomized controlled trials published in the obstetrics and gynecology journals vs the weekly medical journals and the percentage of trials published, overall and per journal. The secondary outcomes included the proportion of positive vs negative trials overall and per journal and the assessment of the study characteristics of published trials, including quality assessment criteria. RESULTS: Of the 4024 original research articles published in the 9 journals during the 3-year study period, 1221 (30.3%) were randomized controlled trials, with 137 (11.2%) randomized controlled trials being in obstetrics (46 in 2018, 47 in 2019, and 44 studies in 2020). Furthermore, 33 (24.1%) were published in weekly medical journals, and 104 (75.9%) were published in obstetrics and gynecology journals. The percentage of obstetrical randomized controlled trials published ranged from 1.5% to 9.6% per journal. Overall, 34.3% of obstetrical trials were statistically significant or "positive" for the primary outcome. Notably, 24.8% of the trials were retrospectively registered after the enrollment of the first study patient. Trials published in the 4 weekly medical journals enrolled significantly more patients (1801 vs 180; P<.001), received more often funding from the federal government (78.8% vs 35.6%; P<.001), and were more likely to be multicenter (90.9% vs 42.3%; P<.001), non-United States based (69.7% vs 49.0%; P=.03), and double blinded (45.5% vs 18.3%; P=.003) than trials published in the obstetrics and gynecology journals. There was no difference in study type (noninferiority vs superiority) and trial quality characteristics, including pretrial registration, ethics approval statement, informed consent statement, and adherence to the Consolidated Standards of Reporting Trials guidelines statement between studies published in weekly medical journals and studies published in obstetrics and gynecology journals. CONCLUSION: Approximately 45 trials in obstetrics are being published every year in the highest impact journals, with one-fourth being in the weekly medical journals and the remainder in the obstetrics and gynecology journals. Only about a third of published obstetrical trials are positive. Trials published in weekly medical journals are larger, more likely to be funded by the government, multicenter, international, and double blinded. Quality metrics are similar between weekly medical journals and obstetrics and gynecology journals.

7.
Am J Obstet Gynecol ; 2021 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-34492220

RESUMO

OBJECTIVE: This study aimed to assess the efficacy of sonographic assessment of fetal occiput position before operative vaginal delivery to decrease the number of failed operative vaginal deliveries. DATA SOURCES: The search was conducted in MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid, and Cochrane Library as electronic databases from the inception of each database to April 2021. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA: Selection criteria included randomized controlled trails of pregnant women randomized to either sonographic or clinical digital diagnosis of fetal occiput position during the second stage of labor before operative vaginal delivery. METHODS: The primary outcome was failed operative vaginal delivery, defined as a failed fetal operative vaginal delivery (vacuum or forceps) extraction requiring a cesarean delivery or forceps after failed vacuum. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I2 (Higgins I2) >0% was used to identify heterogeneity. RESULTS: A total of 4 randomized controlled trials including 1007 women with singleton, term, cephalic fetuses randomized to either the sonographic (n=484) or clinical digital (n=523) diagnosis of occiput position during the second stage of labor before operative vaginal delivery were included. Before operative vaginal delivery, fetal occiput position was diagnosed as anterior in 63.5% of the sonographic diagnosis group vs 69.5% in the clinical digital diagnosis group (P=.04). There was no significant difference in the rate of failed operative vaginal deliveries between the sonographic and clinical diagnosis of occiput position groups (9.9% vs 8.2%; relative risk, 1.14; 95% confidence interval, 0.77-1.68). Women randomized to sonographic diagnosis of occiput position had a significantly lower rate of occiput position discordance between the evaluation before operative vaginal delivery and the at birth evaluation when compared with those randomized to the clinical diagnosis group (2.3% vs 17.7%; relative risk, 0.16; 95% confidence interval, 0.04-0.74; P=.02). There were no significant differences in any of the other secondary obstetrical and perinatal outcomes assessed. CONCLUSION: Sonographic knowledge of occiput position before operative vaginal delivery does not seem to have an effect on the incidence of failed operative vaginal deliveries despite better sonographic accuracy in the occiput position diagnosis when compared with clinical assessment. Future studies should evaluate how a more accurate sonographic diagnosis of occiput position or other parameters can lead to a safer and more effective operative vaginal delivery technique.

8.
J Matern Fetal Neonatal Med ; : 1-5, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34470119

RESUMO

OBJECTIVE: To evaluate if a reminder postpartum screening system, providing patients with laboratory requisition on the postpartum ward followed by a telephone reminder one week prior to their 6 weeks appointment, would increase the diabetes mellitus screening rate. METHODS: Parallel group, open label, multicenter randomized trial. Patients were recruited between July 2015 and March 2016. All women with gestational diabetes mellitus in their index pregnancy with access to a mobile or landline phone were eligible for participation. Gestational diabetes mellitus diagnosis was made with a one-hour 50 g OGTT ≥135 mg/dl, and a subsequent 3 h OGTT with ≥2 values above fasting 95 mg/dl, 1 h 180 mg/dl, 2 h 155 mg/dl, and 3 h 140 mg/dl. Participants were assigned in a 1:1 ratio to "reminder system" (intervention group) or to "routine care (control group)." Those assigned to the reminder system were provided with two reminders. The first was a laboratory requisition slip given to them while on the postpartum ward. The second was a telephone reminder on the fifth week postpartum, consisting of a standardized script to encourage contacted participants to complete the screening test during the sixth week postpartum. The primary outcome was completion of the two-hour 75 g OGTT 6-12 weeks postpartum. RESULTS: A total of 75 patients were included in the study. Thirty-eight patients were randomized to the reminder system, and 37 patients were randomized to routine care. A total of 22 women (29.3%) completed the test. In the "reminder" group, 31.6% completed the test, and in the "routine care" group 27% of patients completed the test. This increase in screening uptake in the reminder group was not noted to be statistically significant (p=.8). When evaluating whether perinatal or sociodemographic factors influenced the effect of reminder systems on screening uptake, only insurance type was noted to have a statistically significant influence. Screening uptake was significantly increased in patients with public insurance assigned to "reminder group" (13.5%) compared to those assigned to "routine care" (0%). Of those women who completed the test, seven patients (31.8 %) were diagnosed with prediabetes and none with diabetes. CONCLUSIONS: Telephone reminders were not found to have a significant impact on increasing postpartum screening for diabetes. The exception was among the publicly insured population. These findings suggest a targeted role for reminder systems, particularly among those with socioeconomic disadvantage.

9.
J Matern Fetal Neonatal Med ; : 1-4, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34470131

RESUMO

INTRODUCTION: Magnesium sulfate decreases the risk of eclampsia in patients with severe preeclampsia. There is a theoretical risk that magnesium sulfate increases the risk of intrapartum hemorrhage. We evaluated whether there was a quantitative difference in blood loss in patients receiving magnesium sulfate at the time of cesarean delivery (CD) compared to those who were not. MATERIALS AND METHODS: A retrospective cohort study was performed using a database of patients with preeclampsia with severe features or eclampsia. The primary outcome was calculated estimated blood loss (cEBL) compared between patients who received magnesium sulfate during CD and those who did not. cEBL was derived through a validated equation by multiplying the patient's blood volume by percent of blood volume loss. Secondary outcomes were hematocrit change, visual EBL (vEBL), hemorrhage, cEBL >1500mL, Apgar <7 at 5 min, and NICU admission. Exclusion criteria were incomplete records or negative cEBL, as well as blood transfusion prior to collection of a postpartum hematocrit. RESULTS: We identified 124 patients with preeclampsia with severe features or eclampsia at time of CD. There were 57 (46%) that received magnesium sulfate during CD and 67 (54%) in which magnesium was stopped during the CD. The mean differences for hematocrit value (0.8, 95% confidence interval (CI) -0.3 to 1.8) and cEBL (108, 95% CI -102 to 318) were not significantly different after adjusting for obesity and history of CD. CONCLUSION: Magnesium sulfate administration for seizure prevention in patients with preeclampsia with severe features at the time of CD does not appear to be associated with an increase in the cEBL.

10.
Eur J Obstet Gynecol Reprod Biol ; 266: 23-30, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34560330

RESUMO

OBJECTIVE: Our objective was to examine if US obstetrician-gynecologists (OBGYNs) practice outside of evidenced-based guidelines and use a combination of interventions to prevent spontaneous preterm birth (sPTB). STUDY DESIGN: An electronic survey was distributed to members of the Pregnancy-Related Care Research Network (PRCRN), and also to members of the Society of Maternal-Fetal Medicine (SMFM). The survey consisted of questions regarding physician demographics, and the use of interventions to prevent sPTB in women with 1) a prior sPTB, 2) an incidental short cervix (no prior sPTB), and 3) a history of cervical insufficiency. RESULTS: The PRCRN response rate was 58.6% (283/483) with an additional 143 responses from SMFM members. Among PRCRN responders, 82.7% were general OBGYNs and 17.3% were Maternal-Fetal Medicine subspecialists. Respondents were from all geographic regions of the country; most practiced in a group private practice (42.6%) or academic institution (31.4%). In women with prior sPTB, 45.2% of respondents would consider combination therapy, most commonly weekly intramuscular progesterone (IM-P) and serial cervical length (CL) measurements. If the patient then develops a short cervix, 33.7% would consider adding an ultrasound-indicated cerclage. In women with an incidental short cervix, 66.8% of respondents were likely to recommend single therapy with daily vaginal progesterone (VP). If a patient developed an incidentally dilated cervix, 40.8% of PRCRN respondents would recommend dual therapy, most commonly cerclage + VP, whereas 64.3% of SMFM respondents were likely to continue with VP only. In women with a history of cervical insufficiency, 47% of PRCRN respondents indicated they would consider a combination of IM-P, history-indicated cerclage and serial CL measurements. CONCLUSION: Although not currently supported by evidence-based medicine, combination therapy is commonly being used by U.S. OBGYNs to prevent sPTB in women with risk factors such as prior sPTB, short or dilated cervix or more than one of these risks.


Assuntos
Cerclagem Cervical , Nascimento Prematuro , Administração Intravaginal , Medida do Comprimento Cervical , Colo do Útero/diagnóstico por imagem , Feminino , Humanos , Recém-Nascido , Gravidez , Nascimento Prematuro/prevenção & controle , Progesterona
11.
Am J Obstet Gynecol ; 2021 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-34384775

RESUMO

OBJECTIVE: This study aimed to investigate the diagnostic performance of transperineal ultrasound-measured angles of progression at the onset of the second stage of labor for the prediction of spontaneous vaginal delivery in singleton term pregnancies with cephalic presentation. DATA SOURCES: We performed a predefined systematic search in PubMed, Embase, Scopus, Web of Science, and Google Scholar from inception to February 5, 2021. STUDY ELIGIBILITY CRITERIA: Prospective cohort studies that evaluated the diagnostic performance of transperineal ultrasound-measured angles of progression (index test) at the onset of the second stage of labor (ie, when complete cervical dilation is diagnosed) for the prediction of spontaneous vaginal delivery (reference standard) were eligible for inclusion. Eligible studies were limited to those published as full-text articles in the English language and those that included only parturients with a singleton healthy fetus at term with cephalic presentation. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Summary receiver operating characteristic curves, pooled sensitivities and specificities, area under the curve, and summary likelihood ratios were calculated using the Stata software. Subgroup analyses were done based on angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°. RESULTS: A total of 8 studies reporting on 887 pregnancies were included. Summary estimates of the sensitivity and specificity of transperineal ultrasound-measured angle of progression at the onset of the second stage of labor for predicting spontaneous vaginal delivery were 94% (95% confidence interval, 88%-97%) and 47% (95% confidence interval, 18%-78%), respectively, for an angle of progression of 108° to 119°, 81% (95% confidence interval, 70%-89%) and 73% (95% confidence interval, 57%-85%), respectively, for an angle of progression of 120° to 140°, and 66% (95% confidence interval, 56%-74%) and 82% (95% confidence interval, 66%-92%), respectively, for an angle of progression of 141° to 153°. Likelihood ratio syntheses gave overall positive likelihood ratios of 1.8 (95% confidence interval, 1-3.3), 3 (95% confidence interval, 2-4.7), and 3.7 (95% confidence interval, 1.7-8.1) and negative likelihood ratios of 0.13 (95% confidence interval, 0.07-0.22), 0.26 (95% confidence interval, 0.18-0.38), and 0.42 (95% confidence interval, 0.29-0.60) for angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°, respectively. CONCLUSION: Angle of progression measured by transperineal ultrasound at the onset of the second stage of labor may predict spontaneous vaginal delivery in singleton, term, cephalic presenting pregnancies and has the potential to be used along with physical examinations and other clinical factors in the management of labor and delivery.

12.
Am J Obstet Gynecol MFM ; 3(5): 100435, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34214717

RESUMO

OBJECTIVE: This study aimed to evaluate the effect of music on anxiety in patients undergoing cesarean delivery. DATA SOURCES: An electronic search of PubMed, CINAHL, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials was performed from inception to November 2020. STUDY ELIGIBILITY CRITERIA: Eligibility criteria included all randomized controlled trials of pregnant women undergoing cesarean delivery who were randomized to either the music intervention or control. Studies needed to measure preoperative, intraoperative, or postoperative anxiety via a visual analog scale, State-Trait Anxiety Inventory, or Zung Self-Rating Anxiety Scale, for inclusion. The primary outcome was intraoperative anxiety during cesarean delivery. Secondary outcomes included preoperative and postoperative anxiety, postoperative pain, postoperative opioid requirements, blood pressure, and heart rate. STUDY APPRAISAL AND SYNTHESIS METHODS: The methodologic quality of the included studies was evaluated using the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce a summary of treatment effects in terms of mean difference with 95% confidence intervals. A prespecified subgroup analysis of patients undergoing a scheduled or an unscheduled cesarean delivery was carried out for the main outcomes. RESULTS: Of the 1296 studies screened, 15 met the inclusion criteria (n=613 music group vs n=748 controls). Three trials (n=217 music group vs n=215 controls) reported on intraoperative anxiety specifically. Among studies using a visual analog scale for anxiety assessment, women in the intervention group had lower intraoperative anxiety levels than the controls (mean difference, -0.54; 95% confidence interval, -0.87 to -0.20; I2=0%; n=2 studies). One trial used the State-Trait Anxiety Inventory and 1 trial used the Zung Self-Rating Anxiety Scale for intraoperative anxiety assessment. In both of these studies, music exposure was associated with lower anxiety levels when compared with the controls (State-Trait Anxiety Inventory: mean difference, -2.80; 95% confidence interval, -4.57 to -1.03; Zung Self-Rating Anxiety Scale: mean difference, -4.80; 95% confidence interval, -7.08 to -2.52). In the subgroup analyses, the same relationship persisted when the cesarean delivery was unscheduled and when the music was selected by the patient or by the study team. The effect of music on preoperative and postoperative anxiety varied depending on which anxiety assessment tool was used. Music was also associated with decreased opioid use (mean difference, -0.87; 95% confidence interval, -1.55 to -0.19; I2=0%). CONCLUSION: In patients undergoing a cesarean delivery, music is associated with decreased intraoperative anxiety.


Assuntos
Musicoterapia , Música , Ansiedade/prevenção & controle , Transtornos de Ansiedade , Cesárea/efeitos adversos , Feminino , Humanos , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
15.
Am J Obstet Gynecol MFM ; 3(5): 100425, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34153513

RESUMO

OBJECTIVE: This study aimed to evaluate the incidence of chorioamnionitis in women with singleton gestations with ≥36 weeks' prelabor rupture of membranes induced with oxytocin within or after 12 hours of prelabor rupture of membranes. DATA SOURCES: The search was conducted using MEDLINE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and Cochrane Library as electronic databases from their inception to May 2020. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials of women with singleton cephalic gestations and prelabor rupture of membranes at ≥36 weeks comparing induction of labor with oxytocin either ≤12 hours after prelabor rupture of membranes or >12 hours after prelabor rupture of membranes (expectant management group). STUDY APPRAISAL AND SYNTHESIS METHODS: The risk of bias in each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. All analyses were done using an intention-to-treat approach, evaluating women according to the treatment group to which they were randomly allocated in the original trials. The primary outcome was the incidence of chorioamnionitis. RESULTS: After exclusions, 9 randomized controlled trials including 3759 women were analyzed. Women with singleton cephalic gestations and prelabor rupture of membranes at ≥36 weeks who have induction of labor ≤12 hours after prelabor rupture of membranes have shorter time between prelabor rupture of membranes and delivery (-12.68 hours; 95% confidence interval, -16.15 to -9.21) and higher chance of delivering within 24 hours of prelabor rupture of membranes (91% vs 46%; relative risk, 1.93; 95% confidence interval, 1.59-2.35). Cesarean and operative vaginal deliveries were not significantly different between the groups. Induction of labor ≤12 hours after prelabor rupture of membranes was also associated with significantly fewer incidences of chorioamnionitis (5.3% vs 9.9%; relative risk, 0.62; 95% confidence interval, 0.40-0.97), endometritis (2.4% vs 4.2%; relative risk, 0.59; 95% confidence interval, 0.40-0.87), neonatal sepsis (6.1% vs 11.8%; relative risk, 0.46; 95% confidence interval, 0.27-0.79), and admission to neonatal intensive care unit (6.4% vs 12.0%; relative risk, 0.54; 95% confidence interval, 0.43-0.69) compared with women managed expectantly, usually at >24 hours. The subgroup analysis of 3323 women with induction of labor at ≤6 hours showed similar results, including similar significant reductions in chorioamnionitis, endometritis, neonatal sepsis, and admission to neonatal intensive care unit. CONCLUSION: Women with symptoms of prelabor rupture of membranes at ≥36 weeks should be evaluated promptly, and if prelabor rupture of membranes is confirmed, they should have induction of labor within 12 hours and perhaps even within 6 hours since the first symptom of prelabor rupture of membranes. This management is associated with significantly less morbidity, especially in terms of infections, for both the mother and the baby, with no evidence of any harm.


Assuntos
Corioamnionite , Ruptura Prematura de Membranas Fetais , Corioamnionite/epidemiologia , Parto Obstétrico , Feminino , Ruptura Prematura de Membranas Fetais/epidemiologia , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Ocitocina , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
17.
Am J Obstet Gynecol MFM ; 3(5): 100398, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33992831

RESUMO

BACKGROUND: The obstetrical landscape in the United States has changed over the past several decades, during which there has been a decline in the number of operative vaginal deliveries performed. Procedural cases of obstetrics and gynecology residents are tracked in the Accreditation Council for Graduate Medical Education database, with a minimum requirement of 15 operative vaginal deliveries before graduation. Nowadays, it is unknown whether the decreasing numbers of operative vaginal deliveries are affecting the delivery case volume and experience of obstetrics and gynecology residents. OBJECTIVE: This study aimed to analyze the trends in the number and route of obstetrical deliveries, including operative vaginal deliveries, performed by graduating obstetrics and gynecology residents in the United States as logged within the Accreditation Council for Graduate Medical Education database. STUDY DESIGN: The Accreditation Council for Graduate Medical Education case log data were examined for graduating obstetrics and gynecology residents between 2003 and 2019. Delivery case volume numbers for spontaneous vaginal delivery, cesarean delivery, forceps-assisted vaginal delivery, and vacuum-assisted vaginal delivery were extracted and analyzed over time using linear regression. To compare the variability in logged cases, residents at the 70th percentile for number of cases logged were compared with residents at the 30th percentile for number of cases logged for each delivery type (spontaneous vaginal delivery, cesarean delivery, forceps-assisted vaginal delivery, and vacuum-assisted vaginal delivery). RESULTS: Overall, obstetrical delivery data for 20,268 obstetrics and gynecology residents were collected from 2003 to 2019. Over this period, the mean number of spontaneous vaginal deliveries significantly decreased over time by 20% from 320.8±138.7 to 256.1±75.6 (slope, -2.6; P<.001); however, no significant difference was noted in the reported cesarean delivery cases, with an 8% increase from 191.8±80.1 to 206.8±69.7 per graduating resident (slope, 0.136; P=.873). Notably, the mean reported cases of forceps-assisted vaginal deliveries decreased by 75% from 23.8±21.9 to 6±6.8 per graduating resident (slope, -0.851; P<.001). Similarly, the mean logs of vacuum-assisted vaginal delivery decreased by 37% from 23.8±17.1 to 15±9.5 (slope, -0.542; P<.001). The ratio of reported resident case logs comparing the volume at the 70th percentile with the volume at the 30th percentile demonstrated a significant decrease over time for spontaneous vaginal delivery (slope, -0.015; P<.001), cesarean delivery (slope, -0.015; P<.001), and vacuum-assisted vaginal delivery (slope, -0.033; P<.001) but was significantly increased for forceps-assisted vaginal delivery (slope, 0.07, P=.0065). CONCLUSION: In the reported Accreditation Council for Graduate Medical Education case logs, we identified that the reported number of obstetrical deliveries performed by obstetrics and gynecology residents in the United States is changing, with a significant decline recognized from 2003 to 2019 in logged numbers of spontaneous vaginal deliveries, vacuum-assisted vaginal deliveries, and forceps-assisted vaginal deliveries, without a difference in reported cesarean delivery cases per graduating resident. Furthermore, substantial variation is seen among resident volume nationwide, with the difference in high- and low-volume resident forceps-assisted vaginal delivery experience increasing over time. Awareness of these data should notify the Accreditation Council for Graduate Medical Education and educators about reasonable targets, increased need for simulation, and new ways to teach all modes of deliveries effectively in all residency programs.


Assuntos
Ginecologia , Internato e Residência , Obstetrícia , Competência Clínica , Educação de Pós-Graduação em Medicina , Feminino , Ginecologia/educação , Humanos , Obstetrícia/educação , Gravidez , Estados Unidos
18.
Eur J Obstet Gynecol Reprod Biol ; 261: 166-177, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33946019

RESUMO

OBJECTIVE: To determine the role of progesterone, pessary and cervical cerclage in reducing the risk of (preterm birth) PTB in twin pregnancies and compare these interventions using pairwise and network meta-analysis. STUDY DESIGN: Medline, Embase, CINAHL and Cochrane databases were explored. The inclusion criteria were studies in which twin pregnancies were randomized to an intervention for the prevention of PTB (any type of progesterone, cervical cerclage, cervical pessary, or any combination of these) or to a control group (e.g. placebo or treatment as usual). Interventions of interest were either progesterone [vaginal or oral natural progesterone or intramuscular 17a-hydroxyprogesterone caproate (17-OHPC)], cerclage (McDonald or Shirodkar), or cervical pessary. The primary outcome was PTB < 34 weeks of gestation. Both primary and secondary outcomes were explored in an unselected population of twin pregnancies and in women at higher risk of PTB (defined as those with cervical length <25 mm). Random-effect head-to-head and a multiple-treatment meta-analyses were used to analyze the data and results expressed as risk ratios. RESULTS: 26 studies were included in the meta-analysis. When considering an unselected population of twin pregnancies, vaginal progesterone, intra-muscular17-OHPC or pessary did not reduce the risk of PTB < 34 weeks of gestation (all p > 0.05). When stratifying the analysis for spontaneous PTB, neither pessary, vaginal or intramuscular 17-OHPC were associated with a significant reduction in the risk of PTB compared to controls (all p > 0.05), while there was no study on cerclage which explored this outcome in an unselected population of twin pregnancies. When considering twin pregnancies with short cervical length (≤25 mm), there was no contribution of either pessary, vaginal progesterone, intra-muscular 17-OHPC or cerclage in reducing the risk of overall PTB < 34 weeks of gestation. CONCLUSIONS: Cervical pessary, progesterone and cerclage do not show a significant effect in reducing the rate of PTB or perinatal morbidity in twins, either when these interventions are applied to an unselected population of twins or in pregnancies with a short cervix.


Assuntos
Cerclagem Cervical , Nascimento Prematuro , Feminino , Humanos , Recém-Nascido , Metanálise em Rede , Pessários , Gravidez , Gravidez de Gêmeos , Nascimento Prematuro/prevenção & controle , Progesterona
19.
J Matern Fetal Neonatal Med ; : 1-6, 2021 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-34030560

RESUMO

BACKGROUND: Induction abortion in the second trimester may be favored in some instances, such as in women with compounding medical conditions or when skilled providers are not available. Various methods of pre-induction cervical preparation have been used to shorten the length of induction and decrease the risk of complications. The benefits of cervical preparation with laminaria before D&E have been well studied, but the benefits of laminaria before medical induction are less clear. OBJECTIVE: To determine if overnight cervical preparation with laminaria tents shortens delivery interval in women undergoing 2nd trimester induction of labor (IOL) with misoprostol. STUDY DESIGN: This was a retrospective cohort study comparing overnight intracervical laminaria placement followed by misoprostol to misoprostol alone for 2nd trimester IOL between 1/2000 and 12/2010. Women were excluded if the reason for IOL was preterm labor or preterm premature rupture of membranes or if misoprostol was not used as the primary induction agent. The primary outcome was time from misoprostol administration to delivery. RESULTS: 126 women were analyzed including 36 (29%) who received laminaria + misoprostol and 90 (71%) who received misoprostol alone. Women in the laminaria + misoprostol group were significantly older (30 yrs [14-44] vs. 27 yrs [17-43], p = .029). Induction for fetal anomaly (92% vs. 34%, p ≤ .001) and the use of feticide (56% vs. 13%, p ≤ .001) were more common in the laminaria + misoprostol group. The mean time to delivery in the laminaria + misoprostol group was 6 h longer compared to the misoprostol only group; 19 ± 8 h compared to 13 ± 12hrs (p = .007). There was no difference in fetal to placental delivery time (p = .329), total misoprostol dose (p = .182), or length of hospitalization (p = .144) however, significantly more women completed abortion at 24 hrs in the misoprostol alone group (90% vs. 61%, p ≤ .001). CONCLUSIONS: The use of laminaria tents for overnight cervical preparation does not expedite delivery times in patients undergoing 2nd trimester IOL with misoprostol.

20.
Am J Obstet Gynecol MFM ; 3(4): 100374, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33836306

RESUMO

OBJECTIVE: This study aimed to determine if maternal intrapartum administration of oxygen altered the rate of cesarean delivery compared with room air. DATA SOURCES: This study was a systematic review and meta-analysis of randomized controlled trials. Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials using a combination of key words related to "pregnant patients," "labor," "oxygen," "fetus," "newborn," and pregnancy outcomes from database inception until April 2020. The study was registered in PROSPERO (registration number CRD42020162110). STUDY ELIGIBILITY CRITERIA: The inclusion criteria were randomized controlled trials of maternal administration of oxygen compared with room air in labor. The exclusion criteria were quasi-randomized trials and oxygen administered for planned cesarean deliveries. The primary outcome was the rate of cesarean delivery. Secondary maternal and neonatal outcomes, including cord gas values, were analyzed. METHODS: The Cochrane Handbook guidelines were used to assess bias in trials. To calculate the relative risk or mean differences with confidence intervals, a random-effects model was employed. Subgroup analyses were performed for women who received oxygen for nonreassuring fetal heart rate monitoring or prophylactically. RESULTS: Five randomized controlled trials, including 768 women, were included in the meta-analysis, 3 using prophylactic oxygen and 2 using oxygen for nonreassuring fetal heart rate monitoring. The risk of bias was generally considered low. There was no statistically significant difference in the rate of cesarean delivery between patients administered oxygen and patients provided room air (16 of 365 [4.4%] vs 11 of 379 [2.9%]; risk ratio 1.5; 95% confidence interval, 0.7-3.3). In addition, there were no statistically significant differencs in the rates of cesarean delivery for nonreassuring fetal heart rate monitoring, operative vaginal deliveries, Apgar scores of <7, neonatal intensive care unit admissions, or cord blood gas values. There were no statistically significant difference when analyzing oxygen for nonreassuring fetal heart rate monitoring alone or prophylactic oxygen alone. Data regarding FHT is mixed, with one study suggesting an improvement and three suggesting no change. CONCLUSION: Maternal intrapartum oxygen administration was not associated with any differences in the rate of cesarean delivery or any secondary outcomes compared with room air overall and in the subgroups of therapeutic (for nonreassuring fetal heart rate monitoring) or prophylactic administration in this meta-analysis. Large randomized controlled trials are necessary to further examine any possible benefits or harms of oxygen administration in labor, particularly for nonreassuring fetal heart rate monitoring.


Assuntos
Trabalho de Parto , Oxigênio , Cesárea , Parto Obstétrico , Feminino , Frequência Cardíaca Fetal , Humanos , Recém-Nascido , Gravidez
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