Maternal-fetal medicine (Wolters Kluwer Health, Inc.)最新文献

Objective: To investigate the effectiveness and efficiency of different evaluation indices in assessing adequate prenatal care (PNC) in relation to maternal and fetal outcomes.

Methods: A secondary data analysis of multiple cross-sectional surveys of 221,381 new mothers (weighted estimate 10,932,150) from Phase 8 Pregnancy Risk Assessment Monitoring System between 2016 and 2021. PNC adequacy was assessed using the Kessner, Kotelchuck, and Michigan Plan for Appropriate Tailored Healthcare in Pregnancy (MiPATH) indices. Descriptive, bi-variate, and multivariate analyses were performed to evaluate the impact of each index on maternal and fetal outcomes, with the level of statistical significance set at P < 0.010 and 95% confidence interval (CI).

Results: The prevalence of adequate PNC using the Kessner, Kotelchuck, and MiPATH indices was 74.1% (7,675,029/10,361,625), 77.1% (8,218,603/10,664,993) and 20.1% (2,131,242/10,597,981), respectively. Women with adequate PNC, according to all three indices, showed lower rates of adverse fetal and maternal outcomes. Each index was significantly associated with fetal outcomes (neonatal infant care unit admission, small for gestational age, and preterm birth) and mode of delivery (P < 0.010). In multivariate analysis, MiPATH index consistently predicted lower odds of neonatal intensive care unit admission (odds ratio (OR): 0.475, 95% CI: 0.417-0.541), cesarean delivery (OR: 0.786, 95% CI: 0.757-0.816), and preterm birth (OR: 0.285, 95% CI: 0.263-0.309). Adequate PNC as defined by Kessner was associated with decreased the odds of neonatal intensive care unit admission (OR: 0.890, 95% CI: 0.821-0.965), small for gestational age (OR: 0.849, 95% CI: 0.729-0.990), and preterm birth (OR: 0.453, 95% CI: 0.430-0.476), while Kotelchuck was associated with increased odds of preterm birth (OR: 2.820, 95% CI: 2.661-2.989), and cesarean delivery (OR: 1.231, 95% CI: 1.187-1.277).

Conclusion: While all indices effectively assessed adequate PNC, the MiPATH index proved to be the most effective, considering its criteria for flexibility and individualized care, along with its association with improved fetal and maternal outcomes among women with adequate PNC.

Objective: To analyze factors influencing satisfaction in pregnant women during labor as patients and the relationship of the level of satisfaction with pain management through transcutaneous electrical nerve stimulation (TENS).

Methods: A randomized and double-blind controlled trial was conducted. All participants completed the satisfaction scale immediately after childbirth. A total of 63 participants were randomly assigned to one TENS device to relieve the pain, with a different dose in each group. Patients' responses were measured with 2 scales; the satisfaction level was measured with the Care in Obstetrics: Measure for Testing Satisfaction scale, and pain was measured with the visual analogue scale.

Results: A total of 63 women were randomized into three groups: Active TENS (n = 21), Placebo TENS (n = 21), and Control (n = 21). Baseline characteristics, including maternal age, parity, body mass index, and gestational age, showed no significant differences among the groups (P > 0.05). The active TENS group showed significantly greater pain relief, with a mean visual analogue scale score reduction of (3.3 ± 1.2) compared to (1.1 ± 0.9) in the placebo group and (0.8 ± 0.7) in the Control group (P < 0.001). Maternal satisfaction scores were also highest in the Active TENS group (median 8.0, interquatile range (IQR): 7.0-9.0) compared to Placebo (median 6.0, IQR: 5.0-7.0) and Control (median 5.0, IQR: 4.0-6.0) groups (P < 0.001). Multivariate linear regression indicated that only the type of TENS used was significantly associated with maternal satisfaction (β = 0.42, P = 0.007). Other variables, including parity, BMI, perceived support, and baseline pain severity, were not statistically significant predictors (P > 0.05).

Conclusion: Overall, a high level of satisfaction with care during the labor process was obtained; we recommend the use of TENS for pain relief to improve general satisfaction.

Registration: ClinicalTrials.gov ID: NCT03137251.

Objective: To investigate the risk factors for severe postpartum hemorrhage (SPPH) in vaginal delivery and explore targeted prediction and prevention strategies.

Methods: A retrospective cohort study of singleton pregnancies with vaginal deliveries after 28 weeks of gestation from January 1, 2021, to December 31, 2024, in the Peking Union Medical College Hospital was conducted. Women with multiple pregnancies, those with gestational age less than 28 weeks, and those giving birth through cesarean section were excluded. The primary outcome was SPPH, defined as blood loss of 1000 mL or more within 24 h of childbirth, or the presence of signs or symptoms of low blood volume requiring a transfusion of four or more units of red blood cells. Multivariate logistic regression was used to identify potential risk factors for SPPH.

Results: A total of 6784 women were included in the study, with a SPPH rate of 1.31%. Low-lying placenta or placenta previa (adjusted odds ratio (aOR) = 17.54, 95% confidence interval (CI): 5.01-61.41), placenta accreta spectrum (aOR = 5.25, 95% CI: 3.14-8.77), thrombocytopenia (aOR = 5.37, 95% CI: 1.12-25.78), precipitate labor (aOR = 3.35, 95% CI: 1.68-6.66), and episiotomy (aOR = 2.16, 95% CI: 1.20-3.90) were identified as independent risk factors for SPPH. Gestational age at delivery, use of assisted reproductive technology, neonatal birth weight, induction of labor or cervical ripening with prostaglandins, instrumental delivery, and duration of the second or third stage of labor showed statistical significance in the univariate analysis but not in the multivariate analysis.

Conclusion: Placenta-related factors (placenta accreta spectrum, low-lying placenta, or placenta previa), thrombocytopenia, episiotomy, and precipitate labor were identified as factors potentially associated with SPPH in vaginal delivery. These findings should be interpreted with caution, given the limited number of events, and further validation through larger, multicenter studies is warranted.

Augmentation of labor remains the cornerstone of intrapartum care, typically employed to expedite delivery by enhancing the frequency, strength, and duration of uterine contractions. The decision to augment depends on the stage of labor and the woman's obstetric history. While up to half of all women who enter spontaneous or induced labor may require augmentation, its use is not without risk. Although augmentation in nulliparous women during the first stage of labor is generally uncontroversial, its application in multiparous women, during the second stage of labor, in breech presentation, or in women who have had a previous cesarean section remains contentious. Emerging debate also surrounds whether oxytocin should be routinely discontinued once active labor is established. In this review, we appraise contemporary evidence on the diagnosis of labor dystocia, indications, and methods for labor augmentation, outcomes, complications, and areas of clinical uncertainty. Current international guidelines are compared, and evidence-based recommendations are provided. We conclude by highlighting unresolved areas that warrant further research to inform future policy and clinical practice.