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1.
JAMA ; 2021 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-34747970

RESUMO

Importance: US life expectancy and health outcomes for preventable causes of disease have continued to lag in many populations that experience racism. Objective: To propose iterative changes to US Preventive Services Task Force (USPSTF) processes, methods, and recommendations and enact a commitment to eliminate health inequities for people affected by systemic racism. Design and Evidence: In February 2021, the USPSTF began operational steps in its work to create preventive care recommendations to address the harmful effects of racism. A commissioned methods report was conducted to inform this process. Key findings of the report informed proposed updates to the USPSTF methods to address populations adversely affected by systemic racism and proposed pilots on implementation of the proposed changes. Findings: The USPSTF proposes to consider the opportunity to reduce health inequities when selecting new preventive care topics and prioritizing current topics; seek evidence about the effects of systemic racism and health inequities in all research plans and public comments requested, and integrate available evidence into evidence reviews; and summarize the likely effects of systemic racism and health inequities on clinical preventive services in USPSTF recommendations. The USPSTF will elicit feedback from its partners and experts and proposed changes will be piloted on selected USPSTF topics. Conclusions and Relevance: The USPSTF has developed strategies intended to mitigate the influence of systemic racism in its recommendations. The USPSTF seeks to reduce health inequities and other effects of systemic racism through iterative changes in methods of developing evidence-based recommendations, with partner and public input in the activities to implement the advancements.

2.
BJOG ; 2021 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-34773367

RESUMO

OBJECTIVE: Investigate maternal and neonatal outcomes following waterbirth. DESIGN: Retrospective cohort study, with propensity score matching to address confounding. SETTING: Community births, United States. SAMPLE: Medical records-based registry data from low-risk births were used to create waterbirth and land birth groups (n=17,530 each), propensity score-matched on >80 demographic and pregnancy risk covariables METHODS: Logistic regression models compared outcomes between the matched waterbirth and land birth groups MAIN OUTCOME MEASURES: Maternal: immediate postpartum transfer to a hospital, any genital tract trauma, severe (3rd /4th degree) trauma, haemorrhage >1000 cc, diagnosed haemorrhage regardless of estimated blood loss, uterine infection, uterine infection requiring hospitalisation, any hospitalisation in the first 6 weeks. Neonatal: umbilical cord avulsion; immediate neonatal transfer to a hospital; respiratory distress syndrome; any hospitalisation, neonatal intensive care unit (NICU) admission, or neonatal infection in the first 6 weeks; and neonatal death. RESULTS: Waterbirth was associated with improved or no difference in outcomes for most measures, including neonatal death (aOR 0.56 [95% CI, 0.31 - 1.0]), and maternal or neonatal hospitalisation in the first 6 weeks (0.87 [0.81 - 0.92] and 0.95 [0.90 - 0.99], respectively). Increased morbidity in the waterbirth group was observed for two outcomes only: uterine infection (1.25 [1.05 - 1.48]) (but not hospitalisation for infection) and umbilical cord avulsion (1.57 [1.37 - 1.82]). Our results are concordant with other studies: waterbirth is neither as harmful as some current guidelines suggest, nor as benign as some proponents claim.

3.
J Perinatol ; 2021 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-34675372

RESUMO

OBJECTIVE: To examine the association between the Weighted Adverse Outcome Score (WAOS) and race/ethnicity among a large and diverse population-based cohort of women and neonates in the United States. STUDY DESIGN: This was a retrospective cohort study of women who delivered in the United States between 2011 and 2013. We identified mother-infant pairs with adverse maternal and/or neonatal outcomes. These outcomes were assigned weighted scores to account for relative severity. The association between race/ethnicity and WAOS was examined using chi-square test and multivariable logistic regression. RESULTS: Compared to White women and their neonates, Black women and their neonates were at higher odds of an adverse outcome. CONCLUSION(S): The vast majority of women and neonates had no adverse outcome. However, Black women and their neonates were found to have a higher WAOS. This tool could be used to designate hospitals or regions with higher-than-expected adverse outcomes and target them for intervention.

4.
J Matern Fetal Neonatal Med ; : 1-9, 2021 Oct 19.
Artigo em Inglês | MEDLINE | ID: mdl-34665081

RESUMO

BACKGROUND: Cesarean delivery rates continue to remain high despite recent attempts to decrease these rates. Prior data suggest that there is great variation in cesarean rates by hospital. OBJECTIVE: The intent of this study is to examine the association of several hospital characteristics and cesarean delivery rates in California. METHODS: We performed a retrospective study of singleton, non-anomalous, term (37-42 week) deliveries in California. We excluded hospitals with <50 deliveries per year and missing hospital information. We separated hospitals by volume based on previously published categories: low-volume (<1200 deliveries/year), medium-volume (1200-2399 deliveries/year), and medium-high-volume (2400-3599 deliveries/year, and high-volume (3600 deliveries/year). We also evaluated rural versus urban and non-teaching versus teaching hospitals. We examined overall cesarean rates as well as stratified by parity and with and without prior cesarean. We analyzed data with chi-square tests and multivariable logistic regression models. RESULTS: In a total of 2,545,464 pregnancies, 772,539 (30.35%) resulted in cesarean deliveries. After controlling for race/ethnicity, age, body mass index, education, and insurance, rates of cesarean delivery were higher in low-volume hospitals (aOR: 1.07; 95% CI: 1.0-1.08) and lower in medium-high-volume hospitals (aOR: 0.97; 95% CI: 0.96-0.98) as compared to high-volume hospitals. Rural hospitals had higher rates of cesarean delivery (aOR: 1.08; 95% CI: 1.06-1.10) as compared to urban hospitals while non-teaching hospitals had higher odds of cesarean deliveries (aOR: 1.27; 95% CI: 1.25-1.28) as compared with teaching hospitals. Among nulliparous patients, medium- and medium-high-volume hospitals had lower rates of cesarean deliveries (aOR: 0.95; 95% CI: 0.93-0.96; aOR: 0.93; 95% CI: 0.91-0.94) as compared to high-volume hospitals, while non-teaching hospitals had higher rates of cesarean deliveries than teaching hospitals (aOR: 1.11; 95% CI: 1.10-1.13). Multiparous patients without prior cesarean had higher rates of cesarean delivery at low-volume hospitals and lower rates of cesarean delivery at medium-high-volumes (aOR: 1.07; 95% CI: 1.05-1.10; aOR: 0.96; 95% CI: 0.94-0.098) as compared to high-volume hospitals. Additionally, multiparous patients without prior cesarean had higher rates of cesarean delivery at non-teaching hospitals than teaching hospitals (aOR: 1.16; 95% CI: 1.13-1.19). Multiparous patients with prior cesarean had high rates of cesarean delivery at all volume hospitals with the highest odds at low-volume hospitals (aOR: 1.81; 95% CI: 1.74, 1.89) as well as at rural and non-teaching hospitals. CONCLUSION: Cesarean delivery rates were higher at low and high-volume hospitals for nulliparous and multiparous patients without prior cesarean, but increased with decreasing hospital volume for multiparous patients with prior cesarean. Additionally, cesarean delivery was more likely at rural and non-teaching hospitals. Our results suggest that further investigation is necessary to determine the structural and mechanistic causes of the differences in practice by hospital type in order to identify targets for approaches in reducing cesarean deliveries.

5.
Obstet Gynecol ; 138(5): 693-702, 2021 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-34619716

RESUMO

OBJECTIVE: To describe rates of maternal and perinatal birth outcomes for community births and to compare outcomes by planned place of birth (home vs state-licensed, freestanding birth center) in a Washington State birth cohort, where midwifery practice and integration mirrors international settings. METHODS: We conducted a retrospective cohort study including all births attended by members of a statewide midwifery professional association that were within professional association guidelines and met eligibility criteria for planned birth center birth (term gestation, singleton, vertex fetus with no known fluid abnormalities at term, no prior cesarean birth, no hypertensive disorders, no prepregnancy diabetes), from January 1, 2015 through June 30, 2020. Outcome rates were calculated for all planned community births in the cohort. Estimated relative risks were calculated comparing delivery and perinatal outcomes for planned births at home to state-licensed birth centers, adjusted for parity and other confounders. RESULTS: The study population included 10,609 births: 40.9% planned home and 59.1% planned birth center births. Intrapartum transfers to hospital were more frequent among nulliparous individuals (30.5%; 95% CI 29.2-31.9) than multiparous individuals (4.2%; 95% CI 3.6-4.6). The cesarean delivery rate was 11.4% (95% CI 10.2-12.3) in nulliparous individuals and 0.87% (95% CI 0.7-1.1) in multiparous individuals. The perinatal mortality rate after the onset of labor (intrapartum and neonatal deaths through 7 days) was 0.57 (95% CI 0.19-1.04) per 1,000 births. Rates for other adverse outcomes were also low. Compared with planned birth center births, planned home births had similar risks in crude and adjusted analyses. CONCLUSION: Rates of adverse outcomes for this cohort in a U.S. state with well-established and integrated community midwifery were low overall. Birth outcomes were similar for births planned at home or at a state-licensed, freestanding birth center.

6.
Am J Perinatol ; 2021 Oct 19.
Artigo em Inglês | MEDLINE | ID: mdl-34666381

RESUMO

OBJECTIVE: To determine the rate of perinatal mortality among nulliparous women compared to primiparous women at term and further characterize the risk of stillbirth by each week of gestation. STUDY DESIGN: A retrospective cohort study of all term, singleton, non-anomalous births comparing perinatal mortality (stillbirth and neonatal demise [NND]) between primiparous (parity=1, with no history of abortion) and nulliparous (parity = 0) women who delivered in California between 2007 and 2011. Chi squared tests and multivariable logistic regression analyses were performed to determine the frequencies and strength of association of perinatal mortality and parity, adjusting for maternal age, race, body mass index (BMI), pre-gestational diabetes, chronic hypertension, fetal sex, smoking status, and socioeconomic status. The risk of stillbirth at each gestational age at term was calculated using a pregnancies-at-risk life table method. A p-value less than 0.05 was used to indicate statistical significance. RESULTS: Of 1,317,761 total deliveries, 765,995 (58.1%) were to nulliparous women and 551,766 (41.9%) were to primiparous women with one prior birth. Nulliparous women had increased odds of stillbirth (adjusted odds ratio [aOR] 3.30, 95% confidence interval (CI) 2.93-3.72) and NND (aOR 1.54, 95% CI 1.19-1.98) compared to primiparous women. The risk of stillbirth in nulliparous women was greater at every gestational age between 37 0/7 and 41 0/7 weeks compared to primiparous women. Nulliparous women also had increased odds of small for gestational age (SGA) infants at <10% birth weight (aOR 1.76, 95% CI 1.72-1.79), <5% birth weight (aOR 1.91, 95% CI 1.86-1.98), and <3% birth weight (aOR 2.02, 95% CI 1.93-2.11). CONCLUSION: Perinatal mortality is significantly greater in nulliparous women compared to primiparous women with term deliveries. These findings suggest that low-risk nulliparous women may require increased surveillance. There may be a role in improving maternal health by maximizing physiologic adaptation in nulliparous women.

7.
JAMA ; 326(19): 1953-1961, 2021 11 16.
Artigo em Inglês | MEDLINE | ID: mdl-34694343

RESUMO

Clinical preventive service recommendations from the US Preventive Services Task Force (USPSTF) are based on transparent, systematic, and rigorous methods that consider the certainty of the evidence and magnitude of net benefit. These guidelines aim to address the needs of diverse populations. Biological sex and gender identity are sources of diversity that are not often considered in studies of clinical preventive services that inform the recommendations, resulting in challenges when evaluating the evidence and communicating recommendations for persons in specific gender identification categories (man/woman/gender nonbinary/gender nonconforming/transgender). To advance its methods, the USPSTF reviewed its past recommendations that included the use of sex and gender terms, reviewed the approaches of other guideline-making bodies, and pilot tested strategies to address sex and gender diversity. Based on the findings, the USPSTF intends to use an inclusive approach to identify issues related to sex and gender at the start of the guideline development process; assess the applicability, variability, and quality of evidence as a function of sex and gender; ensure clarity in the use of language regarding sex and gender; and identify evidence gaps related to sex and gender. Evidence reviews will identify the limitations of applying findings to diverse groups from underlying studies that used unclear terminology regarding sex and gender. The USPSTF will use gender-neutral language when appropriate to communicate that recommendations are inclusive of people of any gender and will clearly state when recommendations apply to individuals with specific anatomy associated with biological sex (male/female) or to specific categories of gender identity. The USPSTF recognizes limited evidence to inform the preventive care of populations based on gender identity.


Assuntos
Identidade de Gênero , Serviços Preventivos de Saúde , Sexo , Comitês Consultivos , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Serviços Preventivos de Saúde/normas , Pessoas Transgênero , Estados Unidos
8.
JAMA Netw Open ; 4(9): e2127956, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34591111
9.
JAMA ; 326(10): 949-956, 2021 09 14.
Artigo em Inglês | MEDLINE | ID: mdl-34519796

RESUMO

Importance: Chlamydia and gonorrhea are among the most common sexually transmitted infections in the US. Infection rates are highest among adolescents and young adults of both sexes. Chlamydial and gonococcal infections in women are usually asymptomatic and may lead to pelvic inflammatory disease and its associated complications. Newborns of pregnant persons with untreated infection may develop neonatal chlamydial pneumonia or gonococcal or chlamydial ophthalmia. Infection in men may lead to urethritis and epididymitis. Both types of infection can increase risk of acquiring or transmitting HIV. Objective: To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for chlamydia and gonorrhea in sexually active adolescents and adults, including pregnant persons. Population: Asymptomatic, sexually active adolescents and adults, including pregnant persons. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection has moderate net benefit. The USPSTF concludes with moderate certainty that screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection has moderate net benefit. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. Recommendation: The USPSTF recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. (I statement).


Assuntos
Infecções por Chlamydia/diagnóstico , Gonorreia/diagnóstico , Programas de Rastreamento/normas , Adolescente , Adulto , Fatores Etários , Doenças Assintomáticas , Infecções por Chlamydia/complicações , Feminino , Gonorreia/complicações , Humanos , Masculino , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/métodos , Técnicas de Amplificação de Ácido Nucleico , Doença Inflamatória Pélvica/etiologia , Doença Inflamatória Pélvica/prevenção & controle , Gravidez , Fatores de Risco , Sensibilidade e Especificidade , Comportamento Sexual , Adulto Jovem
10.
JAMA ; 326(12): 1186-1191, 2021 09 28.
Artigo em Inglês | MEDLINE | ID: mdl-34581729

RESUMO

Importance: Preeclampsia is one of the most serious health problems that affect pregnant persons. It is a complication in approximately 4% of pregnancies in the US and contributes to both maternal and infant morbidity and mortality. Preeclampsia also accounts for 6% of preterm births and 19% of medically indicated preterm births in the US. There are racial and ethnic disparities in the prevalence of and mortality from preeclampsia. Non-Hispanic Black women are at greater risk for developing preeclampsia than other women and experience higher rates of maternal and infant morbidity and perinatal mortality. Objective: To update its 2014 recommendation, the USPSTF commissioned a systematic review to evaluate the effectiveness of low-dose aspirin use to prevent preeclampsia. Population: Pregnant persons at high risk for preeclampsia who have no prior adverse effects with or contraindications to low-dose aspirin. Evidence Assessment: The USPSTF concludes with moderate certainty that there is a substantial net benefit of daily low-dose aspirin use to reduce the risk for preeclampsia, preterm birth, small for gestational age/intrauterine growth restriction, and perinatal mortality in pregnant persons at high risk for preeclampsia. Recommendation: The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication for preeclampsia after 12 weeks of gestation in persons who are at high risk for preeclampsia. (B recommendation).


Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Aspirina/uso terapêutico , Pré-Eclâmpsia/prevenção & controle , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Feminino , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Morte Perinatal/prevenção & controle , Pré-Eclâmpsia/etnologia , Gravidez , Nascimento Prematuro/prevenção & controle , Medição de Risco , Fatores de Risco
11.
JAMA Netw Open ; 4(8): e2118912, 2021 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-34338791

RESUMO

Importance: Access to prenatal and postpartum care is restricted among women with low income who are recent or undocumented immigrants enrolled in Emergency Medicaid. Objective: To examine the association of extending prenatal care coverage to Emergency Medicaid enrollees with postpartum contraception and short interpregnancy interval births. Design, Setting, and Participants: This cohort study used a difference-in-differences design to compare the staggered rollout of prenatal care in Oregon with South Carolina, a state that does not cover prenatal or postpartum care. Linked Medicaid claims and birth certificate data from 2010 to 2016 were examined for an association between prenatal care coverage for women whose births were covered by Emergency Medicaid and subsequent short IPI births. Additional maternal and infant health outcomes were also examined, including postpartum contraceptive use, preterm birth, and neonatal intensive care unit admission. The association between the policy change and measures of policy implementation (number of prenatal visits) and quality of care (receipt of 8 guideline-based screenings) was also analyzed. Statistical analysis was performed from August 2020 to March 2021. Exposures: Medicaid coverage of prenatal care. Main Outcomes and Measures: Postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery; short IPI births, defined as occurring within 18 months of a previous pregnancy. Results: The study population consisted of 26 586 births to women enrolled in Emergency Medicaid in Oregon and South Carolina. Among these women, 14 749 (55.5%) were aged 25 to 35 years, 25 894 (97.4%) were Black, Hispanic, Native American, Alaskan, Pacific Islander, or Asian women or women with unknown race/ethnicity, and 17 905 (67.3%) lived in areas with urban zip codes. Coverage of prenatal care for women in Emergency Medicaid was associated with significant increases in mean (SD) prenatal visits (increase of 10.3 [0.9] prenatal visits) and prenatal quality. Prenatal care screenings (eg, anemia screening: increase of 65.7 percentage points [95% CI, 54.2 to 77.1 percentage points]) and vaccinations (eg, influenza vaccination: increase of 31.9 percentage points [95% CI, 27.4 to 36.3 percentage points]) increased significantly following the policy change. Although postpartum contraceptive use increased following prenatal care expansion (increase of 1.5 percentage points [95% CI, 0.4 to 2.6 percentage points]), the policy change was not associated with a reduction in short IPI births (-4.5 percentage points [95% CI, -9.5 to 0.5 percentage points), preterm births (-0.6 percentage points [95% CI, -3.2 to 2.0 percentage points]), or neonatal intensive care unit admissions (increase of 0.8 percentage points [95% CI, -2.0 to 3.6 percentage points]). Conclusions and Relevance: This study found that expanding Emergency Medicaid benefits to include prenatal care significantly improved receipt of guideline-concordant prenatal care. Prenatal care coverage alone was not associated with a meaningful increase in postpartum contraception or a reduction in subsequent short IPI births.

12.
JAMA ; 326(8): 736-743, 2021 08 24.
Artigo em Inglês | MEDLINE | ID: mdl-34427594

RESUMO

Importance: An estimated 13% of all US adults (18 years or older) have diabetes, and 34.5% meet criteria for prediabetes. The prevalences of prediabetes and diabetes are higher in older adults. Estimates of the risk of progression from prediabetes to diabetes vary widely, perhaps because of differences in the definition of prediabetes or the heterogeneity of prediabetes. Diabetes is the leading cause of kidney failure and new cases of blindness among adults in the US. It is also associated with increased risks of cardiovascular disease, nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis and was estimated to be the seventh leading cause of death in the US in 2017. Screening asymptomatic adults for prediabetes and type 2 diabetes may allow earlier detection, diagnosis, and treatment, with the ultimate goal of improving health outcomes. Objective: To update its 2015 recommendation, the USPSTF commissioned a systematic review to evaluate screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant adults and preventive interventions for those with prediabetes. Population: Nonpregnant adults aged 35 to 70 years seen in primary care settings who have overweight or obesity (defined as a body mass index ≥25 and ≥30, respectively) and no symptoms of diabetes. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for prediabetes and type 2 diabetes and offering or referring patients with prediabetes to effective preventive interventions has a moderate net benefit. Conclusions and Recommendation: The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity. Clinicians should offer or refer patients with prediabetes to effective preventive interventions. (B recommendation).


Assuntos
Diabetes Mellitus Tipo 2/diagnóstico , Programas de Rastreamento/normas , Estado Pré-Diabético/diagnóstico , Adulto , Idoso , Glicemia/análise , Diabetes Mellitus Tipo 2/prevenção & controle , Diabetes Mellitus Tipo 2/terapia , Progressão da Doença , Feminino , Hemoglobina A Glicada/análise , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Sobrepeso/complicações , Estado Pré-Diabético/terapia , Comportamento de Redução do Risco
13.
J Matern Fetal Neonatal Med ; : 1-8, 2021 Aug 16.
Artigo em Inglês | MEDLINE | ID: mdl-34392786

RESUMO

OBJECTIVE: To evaluate the cost-effectiveness of universal screening for HCV among all pregnant women in the United States. METHODS: We designed a decision-analytic model to evaluate the cost-effectiveness and outcomes associated with universal HCV screening in pregnancy compared to no screening. A theoretical cohort of 3.9 million women, the approximate number of annual live births in the United States was used. Outcomes included hepatocellular carcinoma, decompensated cirrhosis, liver transplant and death, in addition to cost and quality-adjusted life years (QALYs). Model inputs were derived from the literature and the willingness-to-pay threshold was $100,000 per QALY. Sensitivity analysis were conducted to evaluate the robustness of the results. RESULTS: In a theoretical cohort of 3.9 million women, universal HCV screening resulted in 3003 fewer cases of hepatocellular carcinoma, 1484 fewer decompensated cirrhosis, 46 fewer liver transplants and 2665 fewer deaths from HCV when compared to no screening. Universal HCV screening was found to be the dominant strategy, meaning it resulted in lower costs and higher QALYs. Sensitivity analyses showed our model was robust over a wide range of assumptions. CONCLUSION: Among pregnant women in the United States, universal HCV screening is cost effective compared with no screening.

14.
Prenat Diagn ; 41(11): 1449-1459, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34346064

RESUMO

OBJECTIVE: We investigated the cost-effectiveness of three sequential prenatal cystic fibrosis (CF) carrier screening strategies: genotyping both partners, genotyping one partner then sequencing the second, and sequencing both partners. METHOD: A decision-analytic model compared the strategies in a theoretical cohort of four million pregnant couples in the US population and five racial/ethnic sub-populations. Inputs were obtained from literature and varied in sensitivity analysis. Outcomes included cost per quality-adjusted life year (QALY), missed carrier couples, affected newborns, missed prenatal diagnoses, terminations, and procedure-related losses. The cost-effectiveness threshold was $100,000/QALY. RESULTS: Sequencing both partners identified 1099 carrier couples that were missed by genotyping both partners, leading to 273 fewer missed prenatal diagnoses, 152 more terminations, and 152 fewer affected newborns. A similar trend was observed in the genotyping followed by sequencing strategy. The incremental cost-effectiveness ratio of genotyping followed by sequencing compared to genotyping both partners was $180,004/QALY and the incremental cost-effectiveness ratio of sequencing both partners compared to genotyping followed by sequencing was $17.6 million/QALY. Sequencing both partners was cost-effective below $339 per test, genotyping/sequencing between $340 and $1837, and genotyping both partners above $1838. Sequencing was not cost-effective among five racial/ethnic sub-populations. CONCLUSION: Despite improved outcomes, sequencing for prenatal CF carrier screening was not cost-effective compared to genotyping. The clinical significance of the incremental cost-effectiveness of CF carrier screening is a matter of deliberation for public policy debate.

15.
JAMA ; 326(6): 531-538, 2021 08 10.
Artigo em Inglês | MEDLINE | ID: mdl-34374716

RESUMO

Importance: Gestational diabetes is diabetes that develops during pregnancy. Prevalence of gestational diabetes in the US has been estimated at 5.8% to 9.2%, based on traditional diagnostic criteria, although it may be higher if more inclusive criteria are used. Pregnant persons with gestational diabetes are at increased risk for maternal and fetal complications, including preeclampsia, fetal macrosomia (which can cause shoulder dystocia and birth injury), and neonatal hypoglycemia. Gestational diabetes has also been associated with an increased risk of several long-term health outcomes in pregnant persons and intermediate outcomes in their offspring. Objective: The USPSTF commissioned a systematic review to evaluate the accuracy, benefits, and harms of screening for gestational diabetes and the benefits and harms of treatment for the pregnant person and infant. Population: Pregnant persons who have not been previously diagnosed with type 1 or type 2 diabetes. Evidence Assessment: The USPSTF concludes with moderate certainty that there is a moderate net benefit to screening for gestational diabetes at 24 weeks of gestation or after to improve maternal and fetal outcomes. The USPSTF concludes that the evidence on screening for gestational diabetes before 24 weeks of gestation is insufficient, and the balance of benefits and harms of screening cannot be determined. Recommendation: The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes in asymptomatic pregnant persons before 24 weeks of gestation. (I statement).


Assuntos
Diabetes Gestacional/diagnóstico , Programas de Rastreamento/normas , Feminino , Teste de Tolerância a Glucose , Humanos , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/métodos , Gravidez , Segundo Trimestre da Gravidez , Trimestres da Gravidez , Medição de Risco , Fatores de Risco
16.
Am J Obstet Gynecol MFM ; 3(6): 100434, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34217856

RESUMO

BACKGROUND: Recent studies have compared maternal and neonatal outcomes associated with fetoscopic surgical approach for repair of myelomeningocele compared with an open approach. OBJECTIVE: In this study, we compared the cost-effectiveness of these techniques in the setting of a woman seeking future pregnancies. STUDY DESIGN: A decision-analytical model using TreeAge software was designed to compare the costs and outcomes of fetoscopic vs open repair in patients with prenatally diagnosed myelomeningocele. We assumed a theoretical cohort of 500 women with a pregnancy affected by myelomeningocele planning to have a future pregnancy. Our model accounted for costs and quality-adjusted life years of the woman, the neonate with myelomeningocele, and the neonate in a subsequent pregnancy. Neonatal outcomes from the incident pregnancy included motor function >2 levels better than the anatomic level, motor function <2 levels better than the anatomic level, and same motor function as the anatomic level, preterm birth in the index pregnancy, neonatal death in the index pregnancy, and major neurodevelopmental disability as a result of preterm birth in the index pregnancy. Neonatal outcomes in the subsequent pregnancy included stillbirth, preterm birth, and neonatal and major neurodevelopmental disability as a result of preterm birth. Probabilities were derived from the literature, and we used a willingness-to-pay threshold of $100,000 per quality-adjusted life year. RESULTS: In the index pregnancy, fetoscopic surgical technique resulted in 140 fewer cases of preterm birth and fewer cases of neurodevelopmental disability and neonatal death. Fetoscopic technique resulted in 130 more cases of functional level >2 levels better than the anatomic level, 35 fewer cases of functional level >2 levels worse than the anatomic level, and 107 fewer cases of function same as the anatomic level. In the subsequent pregnancy, fetoscopic surgery led to 22 fewer cases of delivery complications (uterine dehiscence, uterine rupture, and excessive bleeding), 24 fewer cases of stillbirth, and 22 fewer cases of preterm birth. Although the fetoscopic approach was more costly, it was cost-effective with an incremental cost-effectiveness ratio of $1029 per quality-adjusted life year in our theoretical cohort of 500 patients. Monte Carlo probabilistic sensitivity analysis showed that fetoscopic technique is cost-effective 100% of the time. CONCLUSION: In our theoretical cohort, the fetoscopic approach was more costly, but resulted in improved outcomes when a subsequent pregnancy was considered.


Assuntos
Meningomielocele , Nascimento Prematuro , Análise Custo-Benefício , Feminino , Fetoscopia/efeitos adversos , Humanos , Recém-Nascido , Meningomielocele/cirurgia , Gravidez , Nascimento Prematuro/epidemiologia , Natimorto
17.
J Matern Fetal Neonatal Med ; : 1-8, 2021 Jun 06.
Artigo em Inglês | MEDLINE | ID: mdl-34096464

RESUMO

OBJECTIVE: To evaluate risk factors and describe the association between maternal pre-pregnancy body-mass-index (BMI) and neonatal brachial plexus palsy (BPP) in vaginal deliveries with and without shoulder dystocia. METHODS: This is a retrospective cohort study of singleton, non-anomalous, term vaginal deliveries in California (2007-2011). Deliveries were classified as with or without shoulder dystocia. Our primary outcome was BPP and the independent variable of interest was maternal pre-pregnancy BMI, which was categorized as underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obesity I (30-34.9 kg/m2), obesity II (35-39.9 kg/m2) and obesity III (≥40 kg/m2). We evaluated demographics, maternal, labor, and neonatal characteristics using chi-squared tests and assessed the association of pre-pregnancy BMI with BPP using multivariable logistic regression models. RESULTS: In our cohort of 1,395,761 women, there were 21,463 deliveries with shoulder dystocia and 1,374,298 deliveries without shoulder dystocia. Among deliveries with shoulder dystocia, BPP was observed more frequently in neonates born to women with BMI categorized as overweight (32% vs. 29%; p < .001), obesity I (22% vs. 14%; p < .001), obesity II (10% vs. 6%; p < .001), and obesity III (8% vs. 3%; p < .001). After adjusting for confounders, the odds of BPP in deliveries with shoulder dystocia was significantly higher for women who were overweight (aOR = 1.65; 95% CI: 1.35-2.01), obesity I (aOR = 2.33; 95% CI: 1.86-2.90), obesity II (aOR = 2.56; 95% CI: 1.92-3.40), and obesity III (aOR = 3.80; 95% CI: 2.75-5.25). In deliveries without shoulder dystocia, BPP was more common in women with a BMI that was overweight (29% vs. 25%; p < .001), obesity I (17% vs. 11%; p < .001), obesity II (9% vs. 4%; p < .001), and obesity III (8% vs. 2%; p < .001). In this cohort, multivariable regression model showed similar results in women with a BMI that was overweight (aOR = 1.47; 95% CI: 1.19-1.81), obesity I (aOR = 1.99; 95% CI: 1.55-2.54), obesity II (aOR = 2.79; 95% CI: 2.04-3.83), and obesity III (aOR = 5.05; 95% CI: 3.63-7.03). CONCLUSION: Rising maternal pre-pregnancy BMI is associated with an increased risk of BPP in vaginal deliveries with and without shoulder dystocia. Preconception interventions targeting weight management may be beneficial in reducing BPP in all deliveries.

18.
J Matern Fetal Neonatal Med ; : 1-6, 2021 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-34154507

RESUMO

OBJECTIVE: To examine the outcomes of twins and singletons in the late preterm period. MATERIALS AND METHODS: This is a retrospective cohort study of data obtained for 165,894 births in California who delivered between 34 + 0 and 36 + 6 weeks. The primary outcome was neonatal and infant mortality. The secondary outcomes included the following neonatal morbidities: respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), seizure, and sepsis. Univariate analysis was performed using chi-square test and multivariable logistic regression was used to adjust for potential confounders. RESULTS: There were 143,891 singleton and 22,003 twin gestations included in the study. There was no difference in the primary outcome, neonatal and infant mortality between twins and singletons delivered at 34 and 36 weeks. After controlling for multiple potential confounders, significant differences in secondary outcomes of neonatal morbidity were identified. At 34 weeks, twins had significantly higher rates of IVH (aOR 2.47 (95%CI 1.08-5.64)), NEC (aOR 2.46 (95%CI 1.42-4.29)), RDS (aOR 1.60 (95%CI 1.45-1.77)), and sepsis (aOR 1.19 (95%CI 1.05-1.34)) compared to singletons. By 36 weeks, only an increased risk of RDS persisted among twins. CONCLUSIONS: While there was no difference in mortality among twins and singletons in the late preterm period, twins may have significantly increased neonatal morbidity compared to singletons delivered between 34 + 0 and 36 + 6 weeks.

19.
Am J Obstet Gynecol ; 225(3): 331.e1-331.e8, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34023313

RESUMO

BACKGROUND: Severe maternal morbidity is a composite variable that includes adverse maternal outcomes during pregnancy that are associated with maternal mortality. Previous literature has shown that interpregnancy interval is associated with preterm birth, fetal growth restriction, and low birthweight, but the association of interpregnancy interval and composite severe maternal morbidity is not well studied. OBJECTIVE: We sought to determine the relationship between interpregnancy interval (stratified as <6, 6-11, 12-17, 18-23, 24-59, and ≥60 months) and severe maternal morbidity, which we considered both with and without blood transfusion. STUDY DESIGN: This was a retrospective cohort study of multiparous women 15 to 54 years old with singleton, nonanomalous births between 23 and 42 weeks gestation in California (2007-2012). We defined severe maternal morbidity as the composite score of a published list of the International Classification of Diseases, ninth Revision, diagnoses and procedure codes, provided by the Centers for Disease Control and Prevention. We used chi-square tests for categorical variables, and multivariable logistic regression models were used to determine the association of interpregnancy interval (independent variable) with severe maternal morbidity (dependent variable), adjusted for maternal race and ethnicity, age, education, body mass index, insurance, prenatal care, smoking status, and maternal comorbidity index score. RESULTS: Here, 1,669,912 women met the inclusion criteria, and of these women, 14,529 (0.87%) had severe maternal morbidity and 4712 (0.28%) had nontransfusion severe maternal morbidity. Multivariable logistic regression models showed that compared with women with 18 to 23 months interpregnancy interval, women with an interpregnancy interval of <6 months (adjusted odds ratio, 1.23; 95% confidence interval, 1.14-1.34) and ≥60 months (adjusted odds ratio, 1.11; 95% confidence interval, 1.04-1.19) had significantly higher adjusted odds of severe maternal morbidity. The odds of nontransfusion severe maternal morbidity is higher in women with long interpregnancy intervals (≥60 months) after controlling for the same potential confounders (adjusted odds ratio, 1.17, 95% confidence interval, 1.04-1.31). In addition, we found significantly higher odds of requiring ventilation (adjusted odds ratio, 1.34; 95% confidence interval, 1.03-1.75) and maternal sepsis (adjusted odds ratio, 2.08; 95% confidence interval, 1.31-3.31) in women with long interpregnancy interval. CONCLUSION: The risk of severe maternal morbidity was higher in women with short interpregnancy interval (<6 months) and long interpregnancy interval (≥60 months) compared with women with normal interpregnancy interval (18-23 months). The risk of nontransfusion severe maternal morbidity was significantly higher in women with long interpregnancy interval (≥60 months). Interpregnancy interval is a modifiable risk factor, and counseling women to have an adequate gap between pregnancies may be an important strategy to decrease the risk of severe maternal morbidity.


Assuntos
Intervalo entre Nascimentos , Complicações na Gravidez/epidemiologia , Adolescente , Adulto , Transfusão de Sangue , California/epidemiologia , Estudos de Coortes , Coagulação Intravascular Disseminada/epidemiologia , Feminino , Humanos , Histerectomia , Pessoa de Meia-Idade , Gravidez , Respiração Artificial , Estudos Retrospectivos , Sepse/epidemiologia , Adulto Jovem
20.
JAMA ; 325(20): 2087-2093, 2021 05 25.
Artigo em Inglês | MEDLINE | ID: mdl-34032823

RESUMO

Importance: The prevalence of overweight and obesity is increasing among persons of childbearing age and pregnant persons. In 2015, almost half of all persons began pregnancy with overweight (24%) or obesity (24%). Reported rates of overweight and obesity are higher among Black, Alaska Native/American Indian, and Hispanic women and lower among White and Asian women. Excess weight at the beginning of pregnancy and excess gestational weight gain have been associated with adverse maternal and infant health outcomes such as a large for gestational age infant, cesarean delivery, or preterm birth. Objective: The USPSTF commissioned a systematic review to evaluate the benefits and harms of behavioral counseling interventions to prevent adverse health outcomes associated with obesity during pregnancy and to evaluate intermediate outcomes, including excess gestational weight gain. This is a new recommendation. Population: Pregnant adolescents and adults in primary care settings. Evidence Assessment: The USPSTF concludes with moderate certainty that behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy have a moderate net benefit for pregnant persons. Recommendation: The USPSTF recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. (B recommendation).


Assuntos
Terapia Comportamental , Aconselhamento , Ganho de Peso na Gestação , Adolescente , Adulto , Feminino , Macrossomia Fetal/prevenção & controle , Comportamentos Relacionados com a Saúde , Humanos , Obesidade/prevenção & controle , Obesidade/terapia , Gravidez , Complicações na Gravidez/prevenção & controle
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