摘要:

ObjectiveTo evaluate the cost-effectiveness of an elective cesarean delivery strategy in human immunodeficiency virus (HIV)-infected women receiving zidovudine therapy to prevent perinatal transmission.MethodsA decision-analysis model was constructed to compare two delivery strategies in HIV-infected women: usual care and recommendation for elective cesarean delivery. The model followed a hypothetical cohort of 7000 HIV-infected pregnant women in the United States who were receiving zidovudine therapy for 1 year. The third-party payer perspective was taken. Cost of delivery method with and without complications and lifetime medical care cost for pediatric HIV infection were considered. The main outcome measure was cases of perinatal HIV transmission prevented.ResultsCompared with the usual care strategy, the elective cesarean delivery strategy resulted in an additional 3486 cesarean deliveries each year, prevented 142 cases (52.4%) of perinatal HIV transmission, and resulted in incremental overall cost savings to society of $5.3 million per year ($37,284 saved per case of perinatal transmission prevented). With other estimates held constant, the elective cesarean delivery strategy would not be cost saving when the baseline perinatal HIV transmission rates were all reduced by 43.3%.ConclusionsElective cesarean delivery in HIV-infected women receiving zidovudine is one management strategy for prevention of perinatal HIV transmission and can be cost saving. However, if other strategies, such as use of combination antiretroviral therapy and/or measurement of viral load, result in at least 50% reduction of the baseline perinatal HIV transmission rates, elective cesarean delivery will not be cost saving.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo examine the association between delivery method and mortality within 6 months of delivery among primiparas.MethodsWe conducted a population-based, retrospective cohort analysis using statewide, maternally linked birth certificate, hospital discharge, and death certificate data. The present cohort was all primiparas who gave birth to live-born infants in civilian hospitals in Washington State from January 1, 1987 through December 31, 1996 (n= 265,471). Odd ratios (OR) and 95% confidence intervals (CI) were calculated for overall mortality, pregnancy-related mortality, and pregnancy-unrelated mortality associated with delivery method.ResultsThirty-two women (12.1 per 100,000 singleton live births) died within 6 months of delivery of their first child. Eleven of 32 deaths were pregnancy related (4.1 per 100,000 singleton live births, 95% CI 1.6, 6.5), and 21 of the 32 deaths were not pregnancy related (7.9 per 100,000 singleton live births, 95% CI 4.5, 11.3). The pregnancy-related mortality rate was higher among women delivered by cesarean (10.3/100,000) than among women delivered vaginally (2.4/100,000). In logistic regression analyses, women who had cesarean delivery were not at significantly higher risk of death overall after adjustment for maternal age (OR 1.7, 95% CI 0.3, 3.6), pregnancy-related death after adjustment for maternal age and severe preeclampsia (OR 2.2, 95% CI 0.6, 7.9), or pregnancy-unrelated death after adjustment for maternal age and marital status (OR 0.9, 95% CI 0.3, 2.7), relative to women who had vaginal delivery.ConclusionCesarean delivery might be a marker for serious preexisting morbidities associated with increased mortality risk rather than a risk factor for death in and of itself. Data from additional sources such as medical records and autopsy reports are necessary to disentangle preexisting mortality risk from risk associated solely with delivery method.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo relate interdelivery interval to risk of uterine rupture during a trial of labor after prior cesarean delivery.MethodsWe reviewed the medical records of all women who had a trial of labor after cesarean delivery over 12 years (July 1984 to June 1996). Analysis was limited to women with only one prior cesarean delivery and no prior vaginal deliveries who delivered term singletons and whose medical records included the month and year of the prior delivery. The time in months between the prior cesarean delivery and the index trial of labor was calculated, and the women were divided accordingly to permit comparison with respect to symptomatic uterine rupture.ResultsTwo thousand four hundred nine women had trials of labor after one prior cesarean delivery and had complete data from the medical records. There were 29 uterine ruptures (1.2%) in the population. For interdelivery intervals up to 18 months, the uterine rupture rate was 2.25% (seven of 311) compared with 1.05% (22 of 2098) with intervals of 19 months or longer (P= .07). Multiple logistic regression was used to assess the risk of uterine rupture according to interdelivery interval while controlling for maternal age, public assistance, length of labor, gestational age at least 41 weeks, and oxytocin use. Women with interdelivery intervals of up to 18 months were three times as likely (95% confidence interval, 1.2, 7.2) to have symptomatic uterine rupture.ConclusionInterdelivery intervals of up to 18 months were associated with increased risk of symptomatic uterine rupture during a trial of labor after cesarean delivery compared with that for longer interdelivery intervals.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo evaluate racial variation in the frequency of intrapartum hemorrhage.MethodsUsing information from birth certificates of live singleton births in North Carolina from 1990 to 1997 (n= 807,759), we evaluated the frequency of intrapartum hemorrhage and its association with maternal race. Logistic regression models were used to evaluate the risk of any intrapartum hemorrhage, placental abruption, placenta previa, and unspecified hemorrhage in each racial group, adjusted for other risk factors.ResultsBlack women had the highest rates of any hemorrhage (1.52% black, 1.47% white, 1.33% other race,P= .006) and placental abruption (0.79% black, 0.68% white, 0.56% other race,P= .001) but had lower rates of unspecified hemorrhage (0.37% black, 0.42% white, 0.42% other race,P= .001). Race was not associated with placenta previa. Maternal race remained associated with intrapartum hemorrhage after multivariable analysis, but the direction of the association was reversed. Black women were less likely to have any intrapartum hemorrhage (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.77, 0.85), placental abruption (OR 0.76, 95% CI 0.70, 0.82), placenta previa (OR 0.89, 95% CI 0.81, 0.98), or other unspecified hemorrhage (OR 0.84, 95% CI 0.76, 0.92) compared with white women. Women of other minority races were at lower risk for placental abruption (OR 0.76, 95% CI 0.67, 0.87) but were comparable to white women for risk of placenta previa (OR 1.06, 95% CI 0.91, 1.24) and other unspecified hemorrhage (OR 1.02, 95% CI 0.88, 1.19).ConclusionAlthough black women had higher rates of intrapartum hemorrhage than whites, the increased frequency was attributable to differences in clinical presentation and other risk factors.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo compare acupuncture with sham (placebo) acupuncture for treatment of nausea of pregnancy.MethodsIn a subject- and observer-masked, randomized, controlled trial in the maternity unit at Exeter Hospital, we gave 55 women between 6 and 10 weeks' gestation genuine, traditional-style acupuncture or sham treatment with a cocktail stick on three or four occasions over 3 weeks. The main outcome measure was nausea score, as determined by subject report on a visual analogue scale in a daily diary. Anxiety and depression also were assessed.ResultsNausea scores decreased from a median of 85.5 (interquartile range 71.25–89.75) to 47.5 (interquartile range 29.25–69.5) in the acupuncture group and from 87.0 (interquartile range 73.0–90.0) to 48.0 (interquartile range 14.0–80.0) in the sham treatment group. There was strong evidence of a time effect (P< .001) but no evidence of a group effect (P= .9) or a group-time interaction (P= .8). Similarly, there was evidence of time effects in scores for anxiety and depression but no group differences. The study had a power of 95% to detect significant differences in nausea scores.ConclusionAcupuncture was as effective in treating nausea of pregnancy as a sham procedure.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo compare last menstrual period and ultrasonography in predicting delivery date.MethodsWe used ultrasound to scan 17,221 nonselected singleton pregnancies at 8–16 completed weeks. The last menstrual period (LMP) was considered certain in 13,541 and uncertain in 3680 cases. The duration of pregnancy from the scan to the day of spontaneous delivery was predicted by crown-rump length, biparietal diameter (BPD), and femur length (FL) using linear regression models, and the results were compared with estimates based on LMP.ResultsAt all gestational ages, ultrasound was superior to certain LMP in predicting the day of delivery by at least 1.7 days. When deliveries before 37 weeks were excluded, crown-rump length measurement of 15–60 mm (corresponding to 8–12.5 weeks) had the lowest prediction error of 7.3 days. After that time, BPD (at least 21 mm) showed a similar error (7.3 days) and was more precise than crown-rump length. Femur length was slightly less accurate than crown-rump length or BPD. Regression models using a combination of any two or three ultrasonic variables did not improve accuracy of prediction. When ultrasound was used instead of certain LMP, the number of postterm pregnancies decreased from 10.3% to 2.7% (P< .001).ConclusionUltrasound was more accurate than LMP in dating, and when it was used the number of postterm pregnancies decreased. Crown-rump length of 15–60 mm was superior to BPD, but then BPD (at least 21 mm) was more precise. Combining more than one ultrasonic measurements did not improve dating accuracy.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo investigate the contributions of ovulation-inducing drugs and assisted reproductive technologies to multiple birth.MethodsThis historic prospective study was conducted in a cohort of 13,151 women who delivered after 20 weeks' gestation between October 1996 and December 1999. The study setting was a Colorado health maintenance organization. Cases were women who were pregnant as a result of exposure to treatment with either assisted reproductive technologies or ovulation induction in the absence of assisted reproductive technologies. The main outcome measure was multiple birth.ResultsThere was a significant association between assisted conception and multiple birth. Compared with women with naturally conceived pregnancies, there was a 25-fold likelihood (95% confidence interval 18, 35,P< .001) of multiple birth among women exposed to any of those treatments. In the total cohort the proportion of multiple births attributable to those treatments was 33%. After adjusting for the use of assisted conception and other covariates, we found no association between advanced maternal age and multiple birth.ConclusionIn this cohort, assisted reproductive interventions were strongly associated with multiple birth. Although a higher proportion of older women sought assisted reproductive technologies, we did not find an independent relationship between advanced maternal age and multiple birth. The increasing number of multiple births attributable to assisted conception raises public health concerns regarding multiple gestation-related maternal and infant morbidities.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo evaluate the clinical outcome of in vitro fertilization (IVF) treatment cycles from individual oocyte donors who underwent multiple sequential donations.MethodsWe reviewed clinical outcome data from sequential anonymous oocyte donation cycles using donors who underwent multiple IVF stimulations. Donors were grouped by the interval between cycles and the cycle number (rank). The primary outcome measure was delivery rate by individual donor per retrieval from the combined derivative fresh and frozen embryo transfers.ResultsDuration and amount of gonadotropin therapy and the fertilization rates did not correlate significantly with the interval between cycles or cycle rank. Cumulative delivered pregnancy rates for cycles 1–6 were 51.5%, 54.6%, 50.5%, 51.5%, 51.1%, and 57.6%, respectively. Delivered pregnancy rates did not vary by interval between cycles.ConclusionYoung healthy presumed or proven fertile women can reliably donate oocytes for at least six cycles with the expectation of consistently high pregnancy rates.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo determine risk factors for pregnancy after tubal sterilization with silicone rubber bands or spring clips.MethodsA total of 3329 women sterilized using silicone rubber bands and 1595 women sterilized using spring clips were followed for up to 14 years as part of a prospective cohort study conducted in medical centers in nine US cities. We assessed the risk of pregnancy by cumulative life-table probabilities and proportional hazards analysis.ResultsThe risk of pregnancy for women who had silicone rubber band application differed by location of band application and study site. The 10-year cumulative probabilities of pregnancy varied from a low of 0.0 per 1000 procedures at one study site to a high of 42.5 per 1000 procedures in the four combined sites in which fewer than 100 procedures per site were performed. The risk of pregnancy for women who had spring clip application varied by location of clip application, study site, race or ethnicity, tubal disease, and history of abdominal or pelvic surgery. The probabilities across study sites ranged from 7.1 per 1000 procedures at 10 years to 78.0 per 1000 procedures at 5 years (follow-up was limited to 5 years at that site).ConclusionThe 10-year cumulative probability of pregnancy after silicone rubber band and spring clip application is low but varies substantially by both clinical and demographic characteristics.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID

摘要:

ObjectiveTo determine whether vaginal interleukin-6, interleukin-8, neutrophils, bacterial vaginosis, and selected vaginal bacteria are predictors of amniotic fluid (AF) infection among women in preterm labor.MethodsOne hundred ninety-seven afebrile women in preterm labor with intact membranes had vaginal and AF samples collected for Gram stain, culture, and interleukin-8 and interleukin-6 determinations. Vaginal interleukin-6, interleukin-8, neutrophils, and vaginal flora were compared in women with positive and negative AF cultures. The negative AF culture group was subdivided according to AF interleukin-6 concentration. Logistic regression was used to examine the associations between vaginal cytokines and flora and AF infection or elevated AF interleukin-6.ResultsThe vaginal interleukin-8 concentration and neutrophil count were significantly higher with both AF infection and elevated concentrations of AF interleukin-6 and interleukin-8. The vaginal interleukin-6 concentration was not associated with AF infection or high concentration of AF cytokines. Amniotic fluid infection was associated with bacterial vaginosis or intermediate vaginal flora by Gram stain, absence of hydrogen peroxide–producingLactobacillus, and presence of vaginalBacteroides ureolyticusandFusobacterium. Vaginal interleukin-8 levels greater than 30 ng/mL had 80% sensitivity and a positive predictive value of 35%, and an abnormal vaginal Gram stain (more than five neutrophils per 400× field, bacterial vaginosis species, or intermediate flora) had 90% sensitivity and a positive predictive value of 27% to detect AF infection or elevated AF interleukin-6.ConclusionA high vaginal interleukin-8 concentration, abnormal vaginal Gram stain, absent hydrogen peroxide–producingLactobacillus, and anaerobic vaginal flora were strongly associated with AF infection among women in preterm labor.

ISSN:0029-7844    

出版商:OVID    

年代:2001

数据来源: OVID