American Journal of Obstetrics and Gynecology

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ISSN / EISSN : 0002-9378 / 1097-6868
Published by: Elsevier BV (10.1016)
Total articles ≅ 88,532
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American Journal of Obstetrics and Gynecology, Volume 225; doi:10.1016/s0002-9378(21)00631-1

American Journal of Obstetrics and Gynecology, Volume 225; doi:10.1016/s0002-9378(21)00618-9

, Laura K. Vricella, Virginia Andrews, Erika Christensen, Cara C. Heuser, Sarah Horvath, Clark T. Johnson, Judette M. Louis, Alicia T. Luchowski, Mary E. Norton, et al.
American Journal of Obstetrics and Gynecology, Volume 225; doi:10.1016/j.ajog.2021.04.220

Following a collaborative workshop at the 39th Annual Pregnancy Meeting, the Society for Maternal-Fetal Medicine Reproductive Health Advisory Group identified a need to assess attitudes of maternal-fetal medicine subspecialists about abortion services and available resources at the local and regional levels. The purpose of this study was to identify trends in attitudes, beliefs, and behaviors of practicing maternal-fetal medicine subspecialists in the United States regarding abortion. An online survey was distributed to Associate and Regular members of the Society for Maternal-Fetal Medicine assessing their personal training experience, abortion practice patterns, factors that influence their decision to provide abortion care, and their responses to a series of scenarios about high-risk maternal or fetal medical conditions. Frequencies were analyzed and univariable and multivariable analyses of survey responses were conducted. Of the 2,751 members contacted, 546 SMFM members who completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey. Over 80% of respondents reported availability of abortion in their state, 70% reported availability in their primary institution, and 44% reported provision as part of their personal medical practice. Ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education were identified as the most significant factors in respondent's limiting their scope of abortion services or not performing abortion. In univariable analysis, exposure to formal family planning training programs, fewer years since residency completion, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute's abortion policy landscape were associated with abortion provision (all P < 0.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P = 0.20, adjusted odds ratio 1.34, 95% CI 0.85–2.10), whereas a favorable state policy environment and fewer years from residency retained their association. The results of this survey suggest factors at the individual, institution, and state level impact provision of abortion care by maternal-fetal medicine subspecialists. The subspecialty of maternal-fetal medicine should be active in ensuring adequate training and education to create a community of maternal-fetal medicine physicians able to provide comprehensive reproductive healthcare.
, Naomi L.C. Luban, Shuhui Li, Dong Guo, , Jogarao V.S. Gobburu, Jeffrey S. Berger, Andra H. James, Alisa S. Wolberg, John Van Den Anker
American Journal of Obstetrics and Gynecology, Volume 225, pp 85.e1-85.e11; doi:10.1016/j.ajog.2020.11.035

Background Every 2 minutes there is a pregnancy related death worldwide, with one third due to severe postpartum hemorrhage (PPH). While international trials demonstrated efficacy of 1,000 mg TXA in treating PPH, to our knowledge there are no dose finding studies of TXA in pregnant women for PPH prevention. Objective To determine the optimal TXA dose needed to prevent PPH. Methods We enrolled 30 pregnant women undergoing scheduled cesarean delivery in an open-label, dose ranging study. Subjects were divided into 3 cohorts receiving 5, 10 or 15 mg/kg (max 1000 mg) of intravenous TXA at umbilical cord clamping. Inclusion criteria were ≥34 week's gestation and normal renal function. Primary endpoints were pharmacokinetic and pharmacodynamic profiles. TXA plasma concentration greater than 10 μg/mL and maximum lysis less than 17% were defined as therapeutic targets independent to the current study. Rotational thromboelastometry (ROTEM) of tissue plasminogen activator (tPA)-spiked samples was used to evaluate pharmacodynamic profiles at time points up to 24 hours after TXA administration. Safety was assessed by plasma thrombin generation, D-dimer, and TXA concentrations in breast milk. Results There were no serious adverse events including hemorrhage or venous thromboembolism. Plasma concentrations of TXA increased in a dose-proportional manner. The lowest dose cohort received an average of 448 ± 87 mg TXA. Plasma TXA exceeded 10 μg/mL and maximum lysis was less than 17% more than 1 hour after administration for all TXA doses tested. Median estimated blood loss for cohorts receiving 5, 10, or 15 mg/kg TXA was 750, 750 and 700 mL, respectively. Plasma thrombin generation did not increase with higher TXA concentrations. D-dimer changes from baseline were not different among the cohorts. Breast milk TXA concentrations were 1% or less than maternal plasma concentrations. Conclusions While large randomized trials are necessary to support clinical efficacy of TXA for prophylaxis, we propose an optimal dose of 600 mg in future TXA efficacy studies to prevent PPH.
Isabel Galic, Amelia Swanson, Christopher Warren, Olivia Negris, Alexandria Bozen, Dannielle Brown, Angela Lawson,
American Journal of Obstetrics and Gynecology, Volume 225, pp 61.e1-61.e11; doi:10.1016/j.ajog.2021.02.015

Background Though infertility affects an estimated 6.1 million individuals in the United States, only half of those individuals seek fertility treatment and the majority of those patients are white and of high socioeconomic status. Research has shown that insurance mandates are not enough to ensure equal access. Many workplaces, schools and medical education programs have made efforts in recent years to improve the cultural humility of providers in efforts to engage more racially and economically underrepresented groups in medical care. However, these efforts have not been assessed on a population of patients receiving fertility care, an experience that is uniquely shaped by individual social, cultural and economic factors. Objective To better understand the racial, cultural, economic and religious factors that impact patient experiences obtaining fertility care. Study Design A cross-sectional self-administered survey was administered at an academic fertility center in Chicago, Illinois. Of 5,000 consecutive fertility care patients, 1,460 completed the survey and were included in the study sample. No interventions were used. Descriptive univariate frequencies and percentages were calculated to summarize sociodemographic and other relevant patient characteristics (e.g. race/ethnicity, age, household income, religious affiliation, insurance coverage). Rates of endorsing perceived physician cultural competency were compared among demographic subgroups using Pearson Chi-Squared tests with two-sided p<.05 indicative of statistical significance. To identify key determinants of patient-reported worry regarding nine different fertility treatment outcomes and related concerns, a series of multiple logistic regression models were fit to examine factors associated with patient-report of being "very worried" or "extremely worried". Results Members of our sample (N=1460) were between 20 and 58 years (Meanadjusted=36.2, SD=4.4). Among Black participants, 42.3% reported that their physician does not understand their cultural background, compared to 16.5% of white participants (p<0.0001). Participants that identified as Latinx were significantly more likely than white participants to report being very/extremely worried about side-effects of treatment, a miscarriage, ectopic pregnancies, and birth defects (p<0.05, 0.02, 0.002, 0.001, respectively). Individuals that identify as Hindu were nearly 4 times more likely to report being very/extremely worried about experiencing an ectopic pregnancy than non-religious participants (p<0.0002). Respondents most strongly identified the biology or physiology of the couple (Meanadjusted: 21.6, CI: 20.4-22.7) and timing or age (Meanadjusted: 27.8, CI: 26.5-29.1) as being associated with fertility. Overall, respondents most strongly disagreed that the ability to bear children rests upon God's will (Meanadjusted: 65.4, CI: 63.7-67.1), which differed most significantly by race (p<0.0001) and religion (p<0.0001). Conclusion Of patient characteristics investigated, racial and ethnic subgroups showed the greatest degree of variation in regard to worries and concerns surrounding the experience of fertility treatment. Our findings emphasize a need for improved cultural humility on behalf of physicians, in addition to affordable psychological support for all patients seeking fertility care.
, Katherine T. Lofgren, Ann Thomas, Andrea Lanes, Randi Goldman, Elizabeth S. Ginsburg, Mark D. Hornstein
American Journal of Obstetrics and Gynecology, Volume 225, pp 55.e1-55.e17; doi:10.1016/j.ajog.2021.01.021

Structured Abstract Background A controversial and unresolved question in reproductive medicine is the utility of preimplantation genetic testing for aneuploidy (PGT-A) as an adjunct to in vitro fertilization (IVF). Infertility is prevalent, but its treatment is notoriously expensive and typically not covered by insurance. Therefore, cost-effectiveness is critical to consider in this context. Objective To analyze the cost-effectiveness of PGT-A for the treatment of infertility in the United States Study design IVF cycles occurring between 2014 and 2016 in the United States, as reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System, a national data registry, were analyzed. A probabilistic decision tree was developed using empiric outputs to simulate the events and outcomes associated with IVF with and without PGT-A. The treatment strategies were (1) IVF with intended PGT-A, and (2) IVF with transfer(s) of untested embryo(s). Patients progressed through the treatment model until they achieved a live birth or twelve months after ovarian stimulation. Clinical costs related to both treatment strategies were extracted from the literature and considered from both the patient and payer perspectives. Outcome metrics included incremental cost (measured in 2018 US dollars), live birth outcomes, incremental cost-effectiveness ratio (ICER) and incremental cost per live birth between treatment strategies. Results The study population included 114,157 first fresh IVF stimulations and 44,508 linked frozen embryo transfer cycles. 16.2% intended PGT-A and 83.8% did not. In patients younger than 35, PGT-A was associated with worse clinical outcomes and higher costs. At age 35 and older, PGT-A led to more cumulative births, but was associated with higher costs from both perspectives. From a patient perspective, the incremental cost per live birth favored the no PGT-A strategy from <35 until age 38, and beginning at age 39 favored PGT-A. From a payer perspective, the incremental cost per live birth favored PGT-A regardless of patient age. Conclusions The cost-effectiveness of PGT-A is dependent on patient age and perspective. From an economic perspective, routine PGT-A should not be universally adopted, but may be cost-effective in certain scenarios.
Erica M. Lokken, Emily M. Huebner, G. Gray Taylor, Sarah Hendrickson, Jeroen Vanderhoeven, Alisa Kachikis, Brahm Coler, Christie L. Walker, Jessica S. Sheng, Benjamin J.S. Al-Haddad, et al.
American Journal of Obstetrics and Gynecology, Volume 225, pp 77.e1-77.e14; doi:10.1016/j.ajog.2020.12.1221

Evidence is accumulating that coronavirus disease 2019 (COVID-19) increases the risk for hospitalization and mechanical ventilation in pregnant patients and for preterm delivery. However, the impact on maternal mortality and whether morbidity is differentially affected by disease severity at delivery and trimester of infection is unknown. To describe disease severity and outcomes of SARS-CoV-2 infections in pregnancy across Washington State including pregnancy complications and outcomes, hospitalization, and case fatality. Pregnant patients with a polymerase chain reaction confirmed SARS-CoV-2 infection between March 1 and June 30, 2020 were identified in a multi-center retrospective cohort study from 35 sites in Washington State. Sites captured 61% of annual state deliveries. Case fatality rates in pregnancy were compared to COVID-19 fatality rates in similarly aged adults in Washington State using rate ratios and rate differences. Maternal and neonatal outcomes were compared by trimester of infection and disease severity at the time of delivery. The principal study findings were: 1) among 240 pregnant patients in Washington State with SARS-CoV-2 infections, 1 in 11 developed severe or critical disease, 1 in 10 were hospitalized for COVID-19, and 1 in 80 died; 2) the COVID-19-associated hospitalization rate was 3.5-fold higher than in similarly-aged adults in Washington State [10.0% vs. 2.8%; rate ratio (RR) 3.5, 95% confidence interval (CI) 2.3-5.3]; 3) pregnant patients hospitalized for a respiratory concern were more likely to have a comorbidity or underlying conditions including asthma, hypertension, type 2 diabetes, autoimmune disease, and Class III obesity; 4) three maternal deaths (1.3%) were attributed to COVID-19 for a maternal mortality rate of 1,250/100,000 pregnancies (95%CI 257-3,653); 5) the COVID-19 case fatality in pregnancy was a significant 13.6-fold (95%CI 2.7-43.6) higher in pregnant patients compared to similarly aged individuals in Washington State with an absolute difference in mortality rate of 1.2% (95%CI -0.3-2.6); and 6) preterm birth was significantly higher among women with severe/critical COVID-19 at delivery than for women who had recovered from COVID-19 (45.4% severe/critical COVID-19 vs. 5.2% mild COVID-19, p<0.001). COVID-19 hospitalization and case fatality rates in pregnant patients were significantly higher compared to similarly aged adults in Washington State. This data indicates that pregnant patients are at risk for severe or critical disease and mortality compared to non-pregnant adults, as well as preterm birth.
, Elana Jaffe, Richard H. Beigi, Ruth A. Karron, Carleigh B. Krubiner, Chizoba B. Wonodi, Ruth R. Faden
American Journal of Obstetrics and Gynecology, Volume 225, pp 95-99; doi:10.1016/j.ajog.2021.03.015

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