Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 17 de 17
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Am J Obstet Gynecol ; 2020 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-32592693

RESUMO

BACKGROUND: Twin pregnancies with dilated cervix in the second trimester are at increased risk of pregnancy loss and early preterm birth; currently there is no proven therapy to prevent preterm birth in this group of women. OBJECTIVE: To determine if physical exam indicated cerclage reduces the incidence of preterm birth in asymptomatic women with twin gestations and cervical dilation diagnosed before 24 weeks of pregnancy. STUDY DESIGN: Multicenter, parallel-group, open-label, randomized controlled trial of women with twin pregnancy, and asymptomatic cervical dilation from 1-5 cm between 16 0/7 to 23 6/7 weeks were enrolled from 7/2015 to 7/2019 in 8 centers. Eligible women were randomized in a 1:1 ratio to either cerclage or no cerclage. We excluded women with: monochorionic-monoamniotic pregnancy, selective fetal growth restriction, twin-twin transfusion syndrome, major fetal malformation, known genetic anomaly, placenta previa, signs of labor, or clinical chorioamnionitis. The primary outcome was the incidence of preterm birth <34 weeks. Secondary outcomes were preterm birth <32, <28 and <24 weeks, interval from diagnosis to delivery, and perinatal mortality. Data were analyzed as intention to treat. RESULTS: After an interim analysis was performed, the Data Safety Monitoring Board recommended stopping the trial due to significant decrease of perinatal mortality in the cerclage group. We randomized 34 women, four were excluded due to expired informed consent. Seventeen women were randomized to physical exam indicated cerclage and 13 women to no cerclage. Four women randomized to cerclage did not receive the surgical procedure, while no women in the no cerclage group received cerclage. Maternal demographics were not significantly different. All women in the cerclage group also received indomethacin and antibiotics. When comparing cerclage vs no cerclage group, the incidence of preterm birth <34 weeks was significantly decreased: 12/17 (70%) vs 13/13 (100%) (RR: 0.71 95% CI 0.52-0.96), as well as preterm birth <32 weeks 11/17 (64.7%) vs 13/13 (100%) (RR: 0.65 95% CI 0.46-0.92), preterm birth <28 weeks 7/17 (41%) vs 11/13 (84%) (RR: 0.49 95% CI 0.26-0.89) and preterm birth <24 weeks 5/17 (30%) vs 11/13 (84%) (RR: 0.35 95% CI 0.16-0.75). The mean gestational age at delivery was later: 29.05±1.7 vs. 22.5±3.9 weeks (p<0.01); the mean interval from diagnosis of cervical dilation to delivery was longer: 8.3±5.8 vs. 2.9±3.0 weeks (p=0.02). Perinatal mortality was also significantly reduced in the cerclage group 6/34 (17.6%) vs 20/26 (77%), (RR: 0.22 95% CI 0.1-0.5). CONCLUSION: A combination of physical exam indicated cerclage, indomethacin, and antibiotics in asymptomatic twin pregnancies before 24 weeks significantly decreases preterm birth at all evaluated gestational ages. Most importantly, cerclage in this population is associated with a 50% decrease in very early preterm birth <28 weeks and with a 78% decrease in perinatal mortality.

2.
Am J Obstet Gynecol ; 2020 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-32387325

RESUMO

BACKGROUND: Trial and meta-analysis data revealed a reduction in time to delivery for Foley and prostaglandins or Foley and oxytocin vs Foley alone. However, there are limited data for the comparison of the 2 combination methods against each other. OBJECTIVE: This study aimed to determine whether Foley and prostaglandins or Foley and oxytocin decrease the time to vaginal delivery using a network meta-analysis. STUDY DESIGN: A network meta-analysis (PROSPERO CRD42018081948) was performed comparing Foley and prostaglandins (prostaglandin E1 or prostaglandin E2) vs Foley and oxytocin for cervical ripening. Foley alone and prostaglandins alone were used as nodes for indirect comparison. Database searches were performed from inception to March 2020 with data abstracted from published manuscripts. Eligibility criteria included randomized trials comparing Foley and oxytocin with Foley and prostaglandins (misoprostol or dinoprostone). Trials that compared Foley catheter or prostaglandins with a combination of Foley and prostaglandins or Foley and concurrent oxytocin were also included. Nulliparous and multiparous women were analyzed together. Foley catheters of any catheter material or size and >24 weeks' gestational age with a live fetus were included. Quasi-randomized, cohorts, and other combination methods for cervical ripening were not included. Prostaglandin E1 and prostaglandin E2 combined methods were analyzed separately in a planned subanalysis. The primary outcome was the mean time from induction to vaginal delivery in hours. Secondary outcomes included time from induction to delivery, delivery within 24 hours, cesarean delivery, chorioamnionitis, endometritis, epidural use, tachysystole, postpartum hemorrhage, meconium, neonatal intensive care unit admission, and 5-minute appearance, pulse, grimace, activity, and respiration score of <7. Data were analyzed as a network meta-analysis using multivariate meta-regression. RESULTS: A total of 30 randomized controlled trials with a total of 6465 women were considered eligible for inclusion in this network meta-analysis. When compared with Foley alone, the use of Foley-oxytocin reduced the time to vaginal delivery by 4.2 hours (mean duration, -4.2 hours; 95% confidence interval, -6.5 to -1.9). Foley-prostaglandins reduced the time to vaginal delivery compared with Foley but did not meet statistical significance (mean duration, -2.9 hours; 95% confidence interval, -5.7 to 0.0; P=.05). When compared head-to-head, there was no difference in the time to vaginal delivery between Foley-prostaglandins and Foley-oxytocin (mean duration, 1.3 hours; 95% confidence interval, -2.0 to 4.7). There was no difference in the rate of cesarean delivery, chorioamnionitis, epidural, tachysystole, postpartum hemorrhage, meconium, neonatal intensive care unit admissions, or 5-minute appearance, pulse, grimace, activity, and respiration score of <7 for Foley-prostaglandins vs Foley-oxytocin, although the rate of endometritis was high for Foley-prostaglandins. In the subanalysis by prostaglandin type, there was no difference in the time to vaginal delivery for Foley-misoprostol vs Foley-dinoprostone vs Foley-oxytocin. However, Foley-dinoprostone had a definite trend toward longer time to all deliveries compared with that of both Foley-misoprostol and Foley-oxytocin (P=.05). CONCLUSION: Time to vaginal delivery was similar when comparing Foley with combined misoprostol, combined dinoprostone, and combined oxytocin. Dinoprostone comparisons are limited by small sample size but suggest longer time to delivery compared with Foley and misoprostol or oxytocin. No significant differences were observed in maternal or neonatal adverse events except for endometritis, but this was limited by the sample size, varied reporting of studies used in the indirect comparisons, and definitions of infectious morbidity use in the studies.

3.
Artigo em Inglês | MEDLINE | ID: mdl-32471325

RESUMO

Background: Short interpregnancy interval (IPI) is associated with risk of adverse pregnancy outcomes; however, few studies have evaluated the role of depression as a risk factor for short IPI. Puerto Rican women in the United States experience disparities in adverse birth outcomes and have the highest birth rates. Methods: We analyzed the association between prenatal depressive symptoms and IPI in Proyecto Buena Salud, a prospective cohort of predominantly Puerto Rican women in Western Massachusetts (2006-2011). Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) in early, mid, and late pregnancy. We calculated follow-up time as the difference between the date of delivery of the index pregnancy and the last menstrual period of the subsequent pregnancy using medical records and billing data. We defined short IPI as ≤18 months. Results: Of 1262 eligible women, 35% (n = 440) had at least probable minor depression (EPDS scores ≥13) and 25% (n = 315) had probable major depression (EPDS scores ≥15). Participants were followed for a median of 3.7 years (interquartile range = 1.4-6.0 years) and 240 (20.6%) participants experienced a short IPI. After adjusting for risk factors, women with probable minor depression (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] = 1.02-1.88) and probable major depression (aOR = 1.42, 95% CI = 1.02-1.97) during pregnancy had increased odds of short IPI. Conclusions: Prenatal depressive symptoms were common in this Puerto Rican population and were associated with a modest increase in odds of short IPI. Further examination of the pathways through which mental health may affect IPI in vulnerable populations is warranted.

4.
Am J Obstet Gynecol ; 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32173446

RESUMO

BACKGROUND: Patients with chronic hypertension are at increased risk for superimposed preeclampsia. The 2016 American College of Obstetricians and Gynecologists guideline recommended initiating 81 mg of daily aspirin for all pregnant women with chronic hypertension to prevent superimposed preeclampsia. OBJECTIVE: (1) To evaluate the rates of implementation of the 2016 American College of Obstetricians and Gynecologists guideline over time; and (2) to evaluate the effectiveness of aspirin for the prevention of superimposed preeclampsia and other adverse maternal and neonatal outcomes in women with chronic hypertension before and after this guideline. STUDY DESIGN: This is a retrospective study of women with chronic hypertension who delivered at Thomas Jefferson University Hospital from January 2014 through June 2018. This cohort of women with chronic hypertension was divided into 2 groups, before and after the American College of Obstetricians and Gynecologists recommendation published in September 2016. Daily 81 mg of aspirin was initiated between 12 and 16 weeks. We excluded multiple gestations and incomplete records. The primary outcome was incidence of superimposed preeclampsia, and secondary outcomes were incidence of superimposed preeclampsia with or without severe features, small for gestational age, and preterm birth <37 weeks. Subgroup analysis based on risk stratification was evaluated in women with chronic hypertension requiring antihypertensive medication, history of preeclampsia, and pregestational diabetes. RESULTS: We identified 457 pregnant women with chronic hypertension, 203 in the post-American College of Obstetricians and Gynecologists group and 254 in the pre-American College of Obstetricians and Gynecologists group. Aspirin 81 mg was offered to 142 (70%) in the post-American College of Obstetricians and Gynecologists group and 18 (7.0%) in the pre-American College of Obstetricians and Gynecologists group. Maternal demographics were not significantly different. The overall incidence of superimposed preeclampsia was not significantly different: 87 (34.3%) vs 72 (35.5%), P=.79, in the pre- and post-American College of Obstetricians and Gynecologists guideline groups, respectively. Superimposed preeclampsia with severe features significantly increased: 32 (12.6%) vs 9 (4.4%), P<.01, whereas superimposed preeclampsia without severe features significantly decreased: 55 (21.7%) vs 63 (31.0%), P=.03. There were no significant differences in small for gestational age neonates or preterm birth <37 weeks incidences between groups. There were no significant differences in the subgroup analysis based on the severity of chronic hypertension requiring antihypertensive medication, history of preeclampsia, or pregestational diabetes. CONCLUSION: After the adoption of the American College of Obstetricians and Gynecologists guidelines in 70% of the cohort, superimposed preeclampsia, small for gestational age, and preterm birth were not significantly decreased after implementation of aspirin 81 mg initiated between 12 and 16 weeks of gestation.

5.
Am J Obstet Gynecol ; 221(2): 144.e1-144.e8, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30904320

RESUMO

BACKGROUND: Preterm premature rupture of membranes complicates 2-3% of pregnancies. Many institutions have advocated for the use of azithromycin instead of erythromycin. This is secondary to national shortages of erythromycin, ease of administration, better side effect profile, and decreased cost of azithromycin as compared with erythromycin. OBJECTIVE: The objective of the study was to evaluate whether there are differences in the latency from preterm premature rupture of membranes to delivery in patients treated with different dosing regimens of azithromycin vs erythromycin. STUDY DESIGN: This is a multicenter, retrospective cohort of women with singleton pregnancies with confirmed rupture of membranes between 230 and 336 weeks from January 2010 to June 2015. Patients were excluded if there was a contraindication to expectant management of preterm premature rupture of membranes. Patients received 1 of 4 antibiotic regimens: (1) azithromycin 1000 mg per os once (azithromycin 1 day group); (2) azithromycin 500 mg per os once, followed by azithromycin 250 mg per os daily for 4 days (azithromycin 5 day group); (3) azithromycin 500 mg intravenously for 2 days, followed by azithromycin 500 mg per os daily for 5 days (azithromycin 7 day group); or (4) erythromycin intravenously for 2 days followed by erythromycin per os for 5 days (erythromycin group). The choice of macrolide was based on institutional policy and/or availability of antibiotics at the time of admission. In addition, all patients received ampicillin intravenously for 2 days followed by amoxicillin per os for 5 days. Primary outcome was latency from diagnosis of rupture of membranes to delivery. Secondary outcomes included clinical and histopathological chorioamnionitis and neonatal outcomes. RESULTS: Four hundred fifty-three patients who met inclusion criteria were identified. Seventy-eight patients received azithromycin for 1 day, 191 patients received azithromycin for 5 days, 52 patients received azithromycin for 7 days, and 132 patients received erythromycin. Women who received the 5 day regimen were younger and less likely to be non-African American, have hypertension, have sexually transmitted infection, or experienced substance abuse. There was no statistical difference in median latency time of azithromycin 1 day (4.9 days, 95% confidence interval, 3.3-6.4), azithromycin 5 days (5.0, 95% confidence interval, 3.9-6.1), or azithromycin 7 days (4.9 days, 95% confidence interval, 2.8-7.0) when compared with erythromycin (5.1 days, 95% confidence interval, 3.9-6.4) after adjusting for demographic variables (P = .99). Clinical chorioamnionitis was not different between groups in the adjusted model. Respiratory distress syndrome was increased in the azithromycin 5 day group vs azithromycin 1 day vs erythromycin (44% vs. 29% and 29%, P = .005, respectively). CONCLUSION: There was no difference in latency to delivery, incidence of chorioamnionitis, or neonatal outcomes when comparing different dosing regimens of the azithromycin with erythromycin, with the exception of respiratory distress syndrome being more common in the 5 day azithromycin group. Azithromycin could be considered as an alternative to erythromycin in the expectant management of preterm premature rupture of membranes if erythromycin is unavailable or contraindicated. There appears to be no additional benefit to an extended course of azithromycin beyond the single-day dosing, but final recommendations on dosing strategies should rely on clinical trials.


Assuntos
Antibacterianos/administração & dosagem , Azitromicina/administração & dosagem , Eritromicina/administração & dosagem , Ruptura Prematura de Membranas Fetais/tratamento farmacológico , Adulto , Amoxicilina/administração & dosagem , Ampicilina/administração & dosagem , Corioamnionite/epidemiologia , Estudos de Coortes , Relação Dose-Resposta a Droga , Esquema de Medicação , Feminino , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Tempo de Internação/estatística & dados numéricos , Gravidez , Síndrome do Desconforto Respiratório do Recém-Nascido/epidemiologia , Estudos Retrospectivos
6.
Am J Perinatol ; 36(4): 406-421, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30130821

RESUMO

OBJECTIVE: To assess available evidence regarding the use of oxytocin in conjunction with Foley balloon (FB) for cervical ripening. METHODS: Databases from MEDLINE (U.S. National Library of Medicine, 1980-May 12, 2017), MEDLINE (Ovid, 1980-June 30, 2017), the Cochrane Library Controlled Trials Register, ClinicalTrials.gov, and Web of Science were queried for studies on FB cervical ripening with or without oxytocin in pregnant women. Search terms included: "balloon dilatation" OR "mechanical methods" OR "mechanical method" OR "mechanical dilation" OR "mechanical dilatation" OR "mechanical dilations" OR "mechanical dilatations" OR "balloon" OR "Foley" AND "Pitocin" OR "oxytocin." All relevant references were reviewed. Literature for inclusion and methodological quality were reviewed based on the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. RESULTS: Out of 344 citations, six randomized clinical trials (1,133 patients) fulfilled our inclusion criteria. The pooled estimate showed that the cesarean delivery (CD) rate did not differ (relative risk [RR]: 0.91 (95% confidence interval [CI] [0.76-1.10]; p = 0.23) between patients who underwent preinduction cervical ripening with FB alone versus those who received oxytocin in addition to FB. Heterogeneity was not significant among studies (I 2 0.0%; p = 0.64). Furthermore, no differences in other outcomes such as composite and maternal outcomes were detected between these two groups. Compared with simultaneous use of oxytocin with FB, the Foley alone cervical ripening group had a longer induction to delivery time, and lower deliveries within 12 and 24 hours. Subgroup analysis showed that only multiparous women in the Foley alone group had lower rate of vaginal delivery within 24 hours (RR: 0.74, 95% CI [0.61-0.89], p = 0.002) along with a trend toward higher CD rates. CONCLUSION: Adding oxytocin to FB at the time of preinduction cervical ripening does not reduce cesarean rates nor improve maternal or neonatal outcomes. Multiparous women who received FB alone seem to have lower rates of vaginal deliveries within 24 hours, but these results should be interpreted with caution.


Assuntos
Cateterismo , Maturidade Cervical , Cesárea/estatística & dados numéricos , Trabalho de Parto Induzido/métodos , Ocitócicos/uso terapêutico , Ocitocina/uso terapêutico , Maturidade Cervical/efeitos dos fármacos , Feminino , Humanos , Paridade , Gravidez , Resultado da Gravidez , Fatores de Tempo
7.
Obstet Gynecol ; 132(6): 1471-1476, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30399109

RESUMO

OBJECTIVE: To evaluate whether postpartum nonsteroidal antiinflammatory drug (NSAID) administration is associated with increased blood pressure in women with hypertensive disorders of pregnancy and to estimate the association between NSAID administration and use of opioid medication. METHODS: We conducted a retrospective cohort study of women with hypertensive disorders of pregnancy. Patients were analyzed in two groups according to whether they received NSAIDs postpartum. Study participants were women delivered at a tertiary care center from 2008 to 2015. The primary outcome was change in mean arterial pressure during the postpartum period. Secondary outcomes were postpartum pain scores, cumulative postpartum opioid requirement, initiation or dose escalation of antihypertensive agents, and adverse postpartum outcomes including acute renal failure, change in hematocrit, and maternal readmission for hypertensive disorder. RESULTS: Two hundred seventy-six women with hypertensive disorders of pregnancy were included (129 NSAID-unexposed and 147 NSAID-exposed). Postpartum NSAID administration was not associated with a statistically significant change in mean arterial pressure compared with no NSAID administration (-0.7 vs -1.8; mean difference 1.10, 95% CI -1.44 to 3.64). Similarly, no difference was observed between the cohorts in terms of need for initiation or escalation in dose of antihypertensive agents or maternal readmission for hypertensive disorder. The study was underpowered to determine whether NSAID administration was associated with any difference in less frequent secondary outcomes (eg, incidence of acute renal insufficiency, need for postpartum transfusion) or cumulative opioid use. CONCLUSION: Nonsteroidal antiinflammatory drug administration to postpartum patients with hypertensive disorders of pregnancy is not associated with a change in blood pressure or requirement for antihypertensive medication.


Assuntos
Analgésicos Opioides/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Pressão Arterial/efeitos dos fármacos , Hipertensão Induzida pela Gravidez/fisiopatologia , Dor/tratamento farmacológico , Lesão Renal Aguda/etiologia , Adulto , Anti-Inflamatórios não Esteroides/farmacologia , Anti-Hipertensivos/uso terapêutico , Feminino , Hematócrito , Humanos , Hipertensão Induzida pela Gravidez/tratamento farmacológico , Medição da Dor , Readmissão do Paciente , Período Pós-Parto , Gravidez , Estudos Retrospectivos , Adulto Jovem
8.
Acta Obstet Gynecol Scand ; 97(9): 1051-1060, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29607491

RESUMO

INTRODUCTION: Induction of labor is a common intervention. The objective was to investigate whether larger Foley catheter volumes for labor induction decrease the total time from induction to delivery. MATERIAL AND METHODS: Randomized controlled trials comparing larger single-balloon volumes (60-80 mL) during Foley catheter cervical ripening with usual volume (30 mL) in women undergoing labor induction were identified by searching electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, Scielo and the Cochrane Central Register of Controlled Trials) from inception through 2017. The primary outcome was mean time from induction to delivery in hours. Secondary outcomes included time from induction to vaginal delivery, delivery within 24 h, time to Foley expulsion, cesarean section, chorioamnionitis, epidural use, hemorrhage, meconium staining, and neonatal intensive care unit admission. Meta-analysis was performed using the random effects model of DerSimonian and Laird (PROSPERO CRD42017058885). RESULTS: Seven randomized controlled trials including 1432 singleton gestations were included in the systematic review. Women randomized to larger volumes of balloon had a significantly shorter time from induction to delivery (mean difference 1.97 h, 95% CI -3.88 to -0.06). There was no difference in cesarean section between groups (16 vs. 18%, relative risk 0.84, 95% CI 0.6-1.17). A larger balloon volume was associated with a nonsignificant decrease in time from induction to delivery in multiparous (mean difference 2.67 h, 95% CI -6.1 to 0.76) and nulliparous women (mean difference 1.82 h, 95% CI -4.16 to 0.53). CONCLUSION: Balloon volumes larger than 30 mL during Foley catheter induction reduce total time to delivery by approximately 2 h.


Assuntos
Parto Obstétrico , Trabalho de Parto Induzido/métodos , Cateterismo Urinário , Adulto , Feminino , Humanos , Gravidez
9.
J Matern Fetal Neonatal Med ; 31(15): 1993-1999, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28532255

RESUMO

PURPOSE: To determine if women with preterm superimposed preeclampsia without severe features can be successfully and safely triaged to outpatient management. MATERIALS AND METHODS: This was a multicenter, retrospective, cohort study of singleton pregnancies with superimposed preeclampsia without severe features diagnosed before 37 weeks managed outpatient versus inpatient at Thomas Jefferson University (Philadelphia, PA) and at University of Naples (Naples, Italy) from January 2008 to July 2015. The attending physician made the decision to manage outpatient or inpatient at his or her discretion. The primary outcome was composite maternal morbidity defined as development of at least one of the following: severe features, HELLP syndrome, placental abruption, eclampsia, postpartum hemorrhage, intensive care unit admission, or maternal death. Logistic regression, presented as adjusted odds ratio (aOR) with the 95% of confidence interval (CI) was performed. RESULTS: A total of 365 women with superimposed preeclampsia without severe features before 37 weeks were analyzed. 198 (54.2%) were managed outpatient, and 167 (45.8%) were managed inpatient. Women managed as outpatients had a similar rate of maternal morbidity compared to those managed as inpatients (36.4% versus 41.3%, aOR 0.82, 95%CI 0.55-1.17). Fetuses from women in the outpatient group had a significantly lower risk of small for gestational age (17.7% versus 29.3%; aOR 0.53, 95%CI 0.30-0.84), and lower risk of admission to neonatal intensive care unit (40.4% versus 47.9%; aOR 0.72, 95%CI 0.39-0.95) compared to women managed as inpatients. CONCLUSIONS: Low risk women with superimposed preeclampsia without severe features can be triaged to outpatient management without increased maternal morbidity.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Pré-Eclâmpsia/terapia , Adulto , Feminino , Humanos , Gravidez , Estudos Retrospectivos , Adulto Jovem
10.
Obstet Gynecol ; 129(6): 1046-1053, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28486381

RESUMO

OBJECTIVE: To evaluate whether adding oxytocin to preinduction cervical ripening with a Foley catheter increases the rate of delivery within 24 hours. METHODS: This was a randomized, multicenter, parallel trial of women with a singleton pregnancy at 24 weeks of gestation or greater undergoing labor induction. Women were randomly allocated to an intracervical Foley catheter followed by oxytocin or Foley with concurrent oxytocin infusion. Nulliparous and multiparous women were randomized and analyzed separately based on parallel design. The primary outcome was Foley placement to delivery at 24 hours or less. A sample size of 100 nulliparous women and 75 multiparous women per group would be required to detect a 20% increase in baseline 24-hour delivery rate with 80% power for each parity group. RESULTS: From January 2015 through July 2016, 323 patients were enrolled: 184 nulliparous women and 139 multiparous women. Nulliparous women who received concurrent Foley and oxytocin delivered more frequently within 24 hours of Foley placement than did the Foley followed by oxytocin group (64% compared with 43%, P=.003, relative risk 1.51, 95% confidence interval [CI] 1.14-2.00). Multiparous women who received concurrent Foley and oxytocin delivered more frequently within 24 hours than the Foley followed by oxytocin group (87% compared with 72%, relative risk 1.22, 95% CI 1.02-1.45). Median time to delivery was shorter in both nulliparous women (20.9 compared with 26.1 hours, P<.001) and in multiparous women, (14.9 compared with 18.6 hours, P=.01) who received concurrent Foley and oxytocin compared with Foley followed by oxytocin. There were no significant differences in the rates of cesarean delivery, postpartum hemorrhage, chorioamnionitis, or neonatal intensive care unit admission between the randomization groups. CONCLUSION: Induction with concurrent oxytocin infusion added to Foley significantly increases the rate of delivery within 24 hours in both nulliparous and multiparous compared with Foley followed by oxytocin. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov/, NCT02273115.


Assuntos
Maturidade Cervical , Trabalho de Parto Induzido , Ocitocina/administração & dosagem , Administração Intravaginal , Adulto , Cateterismo , Delaware , Feminino , Humanos , Philadelphia , Gravidez , Resultado do Tratamento
11.
Fertil Steril ; 107(2): 430-438.e3, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27887710

RESUMO

OBJECTIVE: To investigate whether treatment with progestogens in the first trimester of pregnancy would decrease the incidence of miscarriage in women with a history of unexplained recurrent miscarriage. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Women with a history of unexplained recurrent miscarriage. INTERVENTION(S): Randomized, controlled trials were identified by searching electronic databases. We included randomized, controlled trials comparing supplementation with progestogens (i.e., intervention group) in the first trimester of pregnancy with control (either placebo or no treatment) in women with a history of recurrent miscarriage. All types of progestogens, including natural P and synthetic progestins, were analyzed. MAIN OUTCOME MEASURE(S): The primary outcome was the incidence of miscarriage. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI). RESULT(S): Ten trials including 1,586 women with recurrent miscarriage were analyzed. Eight studies used placebo as control and were double-blind. Regarding the intervention, two RCTs used natural P, whereas the other eight studies used progestins: medroxyprogesterone, cyclopentylenol ether of progesterone, dydrogesterone, or 17-hydroxyprogesterone caproate. Pooled data from the 10 trials showed that women with a history of unexplained recurrent miscarriage who were randomized to the progestogens group in the first trimester and before 16 weeks had a lower risk of recurrent miscarriage (RR 0.72, 95% CI 0.53-0.97) and higher live birth rate (RR 1.07, 95% CI 1.02-1.15) compared with those who did not. No statistically significant differences were found in the other secondary outcomes, including preterm birth (RR 1.09, 95% CI 0.71-1.66), neonatal mortality (RR 1.80, 95% CI 0.44-7.34), and fetal genital abnormalities (RR 1.68, 95% CI 0.22-12.62). CONCLUSION(S): Our findings provide evidence that supplementation with progestogens may reduce the incidence of recurrent miscarriages and seem to be safe for the fetuses. Synthetic progestogens, including weekly IM 17-hydroxyprogesterone caproate, but not natural P, were associated with a lower risk of recurrent miscarriage. Given the limitations of the studies included in our meta-analysis, it is difficult to recommend route and dose of progestogen therapy. Further head-to-head trials of P types, dosing, and route of administration are required.


Assuntos
Aborto Habitual/prevenção & controle , Primeiro Trimestre da Gravidez , Progestinas/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como Assunto , Aborto Habitual/diagnóstico , Aborto Habitual/etiologia , Distribuição de Qui-Quadrado , Esquema de Medicação , Feminino , Humanos , Razão de Chances , Gravidez , Progestinas/efeitos adversos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
12.
Semin Perinatol ; 39(6): 483-7, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26341068

RESUMO

Induction of labor will affect almost a quarter of all pregnancies, but historically there has been no generally accepted definition of failed induction of labor. Only recently have studies analyzed the lengths of latent labor that are associated with successful labor induction ending in a vaginal delivery, and recommendations for uniformity in the diagnosis of failed induction have largely resulted from this data. This review assesses the most recent and inclusive definition for failed induction, risk factors associated with failure, complications, and special populations that may be at risk for a failed induction.


Assuntos
Colo do Útero/fisiopatologia , Cesárea/estatística & dados numéricos , Trabalho de Parto Induzido/efeitos adversos , Adulto , Feminino , Humanos , Trabalho de Parto Induzido/métodos , Estudos Observacionais como Assunto , Paridade , Gravidez , Resultado da Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Falha de Tratamento
13.
J Perinat Med ; 43(6): 689-93, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25294713

RESUMO

OBJECTIVE: We sought to evaluate the types of genetic screening tests that are performed in women of childbearing ages in New Jersey. METHOD: Data from patients who had a reproductive genetics consultation between January 1, 2012, and July 31, 2012, were stratified according to the referring providers, i.e., those from academic or private practices, and descriptive analyses performed. Unconventional genetic screening was defined as any test ordered by the referring health care provider outside the recommendations from the American Congress of Obstetricians and Gynecologists or the American College of Medical Genetics and Genomics. RESULTS: Overall, 30% of 371 patients referred for a genetic consultation underwent unconventional screening. As compared to patients from academic practices, the relative rate of unconventional screening was 10-fold higher among patients from private practices, resulting in a relative 34-fold increase in the estimated cost in genetic screening (P<0.01). CONCLUSION: This set of preliminary observations highlight the need for further state, nationwide, and international studies to understand the financial, personal, and societal impact that this discrepancy health care system in the use of genetic carrier screening portends.


Assuntos
Centros Médicos Acadêmicos , Testes Genéticos/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Cuidado Pré-Natal/métodos , Prática Privada , Adolescente , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , New Jersey , Gravidez , Estudos Retrospectivos , Adulto Jovem
14.
Am J Obstet Gynecol ; 213(2): 175-80, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25511243

RESUMO

The preterm birth rate in the United States declined to 11.4% in 2013, the lowest level since 1997. Although the United States has one of the highest preterm birth rates in the developed world, we are improving this outcome and therefore improving the lives of thousands of infants. Demographic changes that may be responsible include a reduced teenage birth rate and fewer higher-order multiple births. Additionally, a public policy shift to prevent nonmedically indicated births at <39 weeks' gestation and smoking bans in several states have been associated with the reduced rate of preterm births. Last, interventions such as 17 hydroxyprogesterone caproate, vaginal progesterone, and the use of cerclage in selected populations probably are contributing to the reduction in preterm deliveries. However, a large portion of these births could still be prevented with greater access and implementation of our current interventions, the reduction of modifiable risk factors for preterm birth, and expanded reporting of outcomes and risk factors to facilitate research for both prevention and treatment.


Assuntos
Cerclagem Cervical/tendências , Gravidez na Adolescência/estatística & dados numéricos , Gravidez Múltipla/estatística & dados numéricos , Nascimento Prematuro/epidemiologia , Política Antifumo/tendências , Caproato de 17 alfa-Hidroxiprogesterona , Administração Intravaginal , Adolescente , Adulto , Medida do Comprimento Cervical , Medicina Baseada em Evidências/tendências , Feminino , Humanos , Hidroxiprogesteronas/uso terapêutico , Guias de Prática Clínica como Assunto , Gravidez , Nascimento Prematuro/prevenção & controle , Progesterona/uso terapêutico , Progestinas/uso terapêutico , Recidiva , Estados Unidos/epidemiologia , Adulto Jovem
15.
Obstet Gynecol ; 124(2 Pt 2 Suppl 1): 466-8, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25004314

RESUMO

BACKGROUND: Misoprostol is a commonly used agent for induction of labor. Anaphylactic reactions are infrequent but possible complications of drugs administered to the pregnant patient. Although antibiotics, latex, and anesthetic agents are more common triggers for anaphylaxis, induction agents are also a rare cause. CASE: A 21-year-old woman received buccal misoprostol as a ripening agent for postdate labor induction and experienced anaphylaxis and tachysystole. Prompt administration of epinephrine and emergent cesarean delivery allowed for the safe delivery of the neonate and minimal maternal morbidity. CONCLUSION: When inducing labor, prompt identification and treatment of anaphylaxis and hypersensitivity reactions are necessary to prevent maternal and neonatal morbidity and mortality. Health care providers must be aware of uncommon reactions to medications used to induce labor.


Assuntos
Anafilaxia/induzido quimicamente , Trabalho de Parto Induzido , Misoprostol/efeitos adversos , Ocitócicos , Administração Bucal , Feminino , Humanos , Misoprostol/administração & dosagem , Gravidez , Adulto Jovem
16.
Maturitas ; 64(2): 109-13, 2009 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-19822268

RESUMO

It has been widely documented that advanced maternal age constitutes a risk to both mother and child. The purpose of this review is to examine the risks posed to the pregnant mother over the age of 44 and determine if they are experienced in greater frequency than in their younger cohorts. A review of the recent literature demonstrates a significant increased incidence of cesarean section, pregnancy-induced hypertension, gestational diabetes, and perinatal mortality. There also appears to be different rates of maternal complications depending on mode of conception with assisted reproductive technology conferring a higher risk in this population. Further study is recommended in mode of conception and parity to examine the effects on maternal and fetal risks.


Assuntos
Cesárea/estatística & dados numéricos , Idade Materna , Mortalidade Materna , Complicações na Gravidez/epidemiologia , Diabetes Gestacional/epidemiologia , Feminino , Humanos , Hipertensão Induzida pela Gravidez/epidemiologia , Pessoa de Meia-Idade , Gravidez , Técnicas de Reprodução Assistida , Fatores de Risco
17.
Nat Rev Urol ; 6(4): 216-22, 2009 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19352396

RESUMO

Female sexual arousal disorder (FSAD) is a common disorder encountered in clinical practice, with self-reported arousal difficulties reported in up to 26% of American women. Various oral therapies for FSAD have been studied, including sildenafil citrate, a phosphodiesterase inhibitor that is currently used to treat male erectile dysfunction. In vitro studies of sildenafil citrate have demonstrated smooth-muscle relaxation in clitoral tissue, and phosphodiesterase type-5 has been shown to be present in vaginal, clitoral and labial smooth muscle; these findings have led to theories that sildenafil citrate might be successful for treating FSAD. This Review discusses the data from clinical trials that have assessed sildenafil citrate for the treatment of FSAD; the trials show that sildenafil citrate is moderately effective. Sildenafil citrate may also be effective in women with FSAD secondary to multiple sclerosis, diabetes or antidepressant use; however, more trials in these patient populations are required to confirm these findings.


Assuntos
Piperazinas/uso terapêutico , Disfunções Sexuais Psicogênicas/tratamento farmacológico , Sulfonas/uso terapêutico , Animais , Nucleotídeo Cíclico Fosfodiesterase do Tipo 2/antagonistas & inibidores , Feminino , Previsões , Humanos , Libido/efeitos dos fármacos , Libido/fisiologia , Piperazinas/farmacologia , Purinas/farmacologia , Purinas/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Disfunções Sexuais Fisiológicas/tratamento farmacológico , Disfunções Sexuais Fisiológicas/enzimologia , Disfunções Sexuais Psicogênicas/enzimologia , Citrato de Sildenafila , Sulfonas/farmacologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA