Positive Pregnancy Research Articles

Safety of methotrexate administration in women with pregnancy of unknown location at high risk of ectopic pregnancy.

To evaluate the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have a high risk of underlying ectopic pregnancy (EP), and to investigate whether implementation of these guidelines would result in inadvertent exposure to MTX of viable intrauterine pregnancies (IUPs). This was a retrospective observational study of consecutive clinically stable women who were classified with PUL at the early pregnancy unit of Nepean Hospital, Sydney, Australia, between 2007 and 2021. PUL was defined as a positive pregnancy test in the absence of signs of IUP or EP on transvaginal ultrasound. Patients with a PUL that behaved biochemically like an EP, but for which the location of pregnancy was not confirmed on ultrasound, were eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health and Care Excellence (NICE) were applied to the PUL database. The number of patients eligible to receive MTX and the number with an underlying viable IUP who would be inadvertently prescribed MTX were calculated. A total of 816 women with PUL were reviewed, of whom 724 had complete data and were included in the final analysis. Six patients had persistent PUL and the remaining 718 had a diagnosis of viable IUP, non-viable IUP, EP or failed PUL. According to the ACOG, ASRM, RCOG and NICE guidelines, the rate of MTX administration among patients with PUL would have been 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no persistent PUL would have received MTX according to the ACOG, ASRM and RCOG protocols (the NICE protocol identified patients with persistent PUL with a sensitivity of 100%), and the majority of MTX treatments were unnecessary because those patients were later classified as having non-viable IUP or failed PUL. Application of ACOG and ASRM guidance could result theoretically in inadvertent MTX administration to women with an underlying viable IUP at a rate of 4.1/1000 (3/724). Current guidelines used to predict high risk of EP in the PUL population lead to inadvertent MTX administration to women with an underlying viable IUP. These guidelines should be used wisely to ensure that no wanted pregnancy is exposed to MTX. Women with PUL should be monitored carefully, and MTX should be used judiciously when the location of pregnancy is yet to be confirmed. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Lower Pregnancy and Live Birth Rates with Vaginal Endometrin Plus Intramuscular Progesterone Every Third Day Versus Intramuscular Progesterone Alone in Programmed Frozen Embryo Transfers: A Retrospective Case-control Study.

This study aimed to determine whether the use of vaginal Endometrin plus intramuscular progesterone on every third day (VIM) in programmed frozen embryo transfer (FET) is associated with lower pregnancy and live birth rates compared to daily intramuscular progesterone (IM). FET data from a single program were collected between November 2018 and December 2021. A total of 903 FETs were analyzed, including 504 FETs in the IM group, and 399 FETs in the VIM group. Inclusion criteria were women undergoing FETs with either 50 mg daily IM progesterone only (control) or 200 mg Endometrin twice daily plus 50 mg IM progesterone on every third day, with the transfer of a single day 5 or 6 frozen embryo. There were no significant differences in patient age at time of FETs, BMI, endometrial thickness, blastocyst quality, or infertility diagnosis between the groups. The VIM had significantly lower positive hCG and clinical pregnancy rates compared to the IM (60.2% vs 72.0% and 40.6% vs 56.7%, respectively, P = 0.0002 and P < 0.0001). The live birth rate was 36.1% in the VIM, compared to 49.4% in the IM (P < 0.0001). These findings also remained significant when excluding FETs with donor egg (35.9% vs 50.1%, P < 0.0001). This study demonstrated that VIM in FET cycles yields significantly lower pregnancy and live birth rates compared to IM along. IM progesterone alone may be preferable to combined Endometrin and IM progesterone in patients undergoing programmed frozen embryo transfers.

Development of a Single-Visit Protocol for the Management of Pregnancy of Unknown Location Following In Vitro Fertilization: A Retrospective Study

(Abstracted from Hum Reprod 2024;39(3):509–515) Pregnancy of unknown location (PUL) refers to a positive pregnancy test that cannot be visualized on transvaginal ultrasound. No medical intervention should be initiated without a clear diagnosis in PUL, despite the term “pregnancy of unknown location” often being used synonymously with suspected ectopic pregnancy.

Optimizing IVF Success: A Case Study of Melatonin-Assisted Frozen Embryo Transfer for Poor Oocyte Quality and Endometriosis.

The case study investigates the journey of a couple facing infertility. It intensifies the challenges, including poor oocyte quality and endometriosis. In spite of two failed in vitro fertilization cycles, the decision for ovum pickup (OPU) was made, followed by intra-cytoplasmic sperm injection (ICSI), embryo treatment with melatonin, and frozen embryo transfer (FET) to optimize the chances of a successful pregnancy. The couple opted for this approach. OPU yielded four poor-quality oocytes, prompting ICSI and melatonin treatment to enhance embryo quality. The embryos were exposed to culture supplementation with melatonin for 72 hours before being transferred to conventional media. After 5 days or 120 hours, the embryos developed into 3BB quality blastocysts, indicative of developmental stage and morphology. The blastocysts were then cryopreserved, and after 2 months, FET was conducted, resulting in the transfer of two embryos, which subsequently led to a positive pregnancy indication, as indicated by a β-hCG level of 233 mUI/ml measured 14 days post transfer. This approach highlights the effectiveness of melatonin supplementation in improving embryo quality and ultimately facilitating successful pregnancy in complex scenarios like endometriosis-related infertility.

Impact of uterine artery embolization on ovarian function and pregnancy outcome after uterine-fibroids treatment: A prospective study.

Uterine fibroids are benign tumors that originate from smooth muscle cells of the uterus. It is the most common gynecological disorder, affecting up to 80% of women of reproductive age. Uterine fibroids can cause various symptoms such as abnormal uterine bleeding, pelvic pain, infertility, and pregnancy complications. The treatment options for uterine fibroids include medical therapy, surgical intervention, and minimally invasive techniques. To compare ovarian function of women with uterine fibroids who did or did not undergo uterine artery embolization (UAE). This prospective cohort study enrolled 87 women with symptomatic uterine fibroids who underwent UAE, and 87 women with the same symptoms who did not undergo UAE but received conservative management or other treatments. The two groups were matched for age, body mass index, parity, and baseline characteristics of uterine fibroids. The primary outcome was ovarian function that was evaluated by serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and anti-Müllerian hormone (AMH), as well as ovarian reserve tests, such as antral follicle count (AFC) and ovarian volume (OV). The secondary outcome was fertility that was evaluated based on the menstrual cycle, ovulation, conception, pregnancy, and delivery. The participants were followed-up for 36 months and assessed at 1, 3, 6, 12, 24, and 36 months after treatment. The study found that the most common minor complication of UAE was postembolization syndrome in 73.6% of women, resolving within a week. No significant differences were observed between the UAE group and the control group in serum levels of reproductive hormones (FSH, LH, E2, AMH) and ovarian reserve indicators (AFC, OV) at any point up to 36 months post-treatment. Additionally, there were no significant differences in conception, pregnancy, or delivery rates, with the average time to conception and gestational age at delivery being similar between the two groups. Birth weights were also comparable. Finally, there was no significant correlation between ovarian function, fertility indicators, and the type or amount of embolic agent used or the change in fibroids post-treatment. UAE resulted in significantly positive pregnancy outcomes, no adverse events post-treatment, and is a safe and effective treatment for uterine fibroids that preserves ovarian function and fertility.

Endometrial compaction to predict pregnancy outcomes in patients undergoing assisted reproductive technologies: a systematic review and meta-analysis.

Does endometrial compaction (EC) help predict pregnancy outcomes in those undergoing ART? EC is associated with a significantly higher clinical pregnancy rate (CPR) and ongoing pregnancy rate (OPR), but this does not translate to live birth rate (LBR). EC describes the progesterone-induced decrease in endometrial thickness, which may be observed following the end of the proliferative phase, prior to embryo transfer. EC is proposed as a non-invasive tool to help predict pregnancy outcome in those undergoing ART, however, published data is conflicting. A literature search was carried out by two independent authors using PubMed, Cochrane Library, MEDLINE, Embase, Science Direct, Scopus, and Web of Science from inception of databases to May 2023. All peer-reviewed studies reporting EC and pregnancy outcomes in patients undergoing IVF/ICSI treatment were included. The primary outcome is LBR. Secondary outcomes included other pregnancy metrics (positive pregnancy test (PPT), CPR, OPR, miscarriage rate (MR)) and rate of EC. Comparative meta-analyses comparing EC and no EC were conducted for each outcome using a random-effects model if I 2 > 50%. The Mantel-Haenszel method was applied for pooling dichotomous data. Results are presented as odds ratios (OR) with 95% CI. Out of 4030 screened articles, 21 cohort studies were included in the final analysis (n = 27 857). No significant difference was found between LBR in the EC versus the no EC group (OR 0.95; 95% CI 0.87-1.04). OPR was significantly higher within the EC group (OR 1.61; 95% CI 1.09-2.38), particularly when EC ≥ 15% compared to no EC (OR 3.52; 95% CI 2.36-5.23). CPR was inconsistently defined across the studies, affecting the findings. When defined as a viable intrauterine pregnancy <12 weeks, the EC group had significantly higher CPR than no EC (OR 1.83; 95% CI 1.15-2.92). No significant differences were found between EC and no EC for PPT (OR 1.54; 95% CI 0.97-2.45) or MR (OR 1.06; 95% CI 0.92-1.56). The pooled weighted incidence of EC across all studies was 32% (95% CI 26-38%). Heterogeneity due to differences between reported pregnancy outcomes, definition of EC, method of ultrasound, and cycle protocol may account for the lack of translation between CPR/OPR and LBR findings; thus, all pooled data should be viewed with an element of caution. In this dataset, the significantly higher CPR/OPR with EC does not translate to LBR. Although stratification of women according to EC cannot currently be recommended in clinical practice, a large and well-designed clinical trial to rigorously assess EC as a non-invasive predictor of a successful pregnancy is warranted. We urge for consistent outcome reporting to be mandated for ART trials so that data can be pooled, compared, and concluded on. H.A. was supported by the Hewitt Fertility Centre. S.G.P. and J.W. were supported by the Liverpool University Hospital NHS Foundation Trust. D.K.H. was supported by a Wellbeing of Women project grant (RG2137) and MRC clinical research training fellowship (MR/V007238/1). N.T. was supported by the National Institute for Health and Care Research. D.K.H. had received honoraria for consultancy for Theramex and has received payment for presentations from Theramex and Gideon Richter. The remaining authors have no conflicts of interest to report. PROSPERO CRD42022378464.

Predictors of Pregnancy Outcome for Libyan Infertile Women Underwent Intracytoplasmic Sperm Injection Cycle at Tripoli Infertility Center

Intracytoplasmic Sperm Injection (ICSI) is a crucial treatment approach in assisted reproduction technology (ART) for infertility clinics. However, low pregnancy rates in ICSI cycles are a problem. Despite its potential, ICSI can be expensive, time-consuming, and cause concerns about gametes and newborn health. The study aims to identify factors predicting pregnancy rates among infertile couples undergoing Intracytoplasmic Sperm Injection cycle at Tripoli Infertility Center in Libya. This retrospective study reviewed all infertile couples' medical files at the Infertility Tripoli Centre from January to December 2023. A structured case sheet was used to collect data on female patients' age, causes of infertility, duration of infertility, previous pregnancy, antral follicles count, endometrial thickness, number of embryos transferred, and pregnancy outcomes. The study was divided into two groups based on pregnancy test results. Statistical analysis involved simple descriptive statistics, Chi square, and independent sample t-test. This study involved 90 women, with 35.6% having a positive pregnancy test. The pregnancy rate was 59.4% in women under 35, and decreased to 9.4% in those 40 or older. No significant differences were found in infertility duration or previous pregnancy (all P &gt; 0.05). Partner analysis revealed that 64.2% had asthenospermia, while endocrinopathies were reported by 41.8% of women. No significant differences were found in antral follicle count, endometrial thickness, oocyte number, or quality between pregnant and non-pregnant women (all P &gt; 0.05). Our findings suggest that Maternal age has a significant impact on the success of ICSI, with advanced age in women negatively affecting ICSI outcomes.

#1231 Atypical uremic hemolytic syndrome diagnosis, therapeutic management, control and follow-up in pregnancy: about a case

Abstract Background and Aims Atypical hemolytic uremic syndrome (aHUS) is a clinical entity characterized by non immune hemolytic anemia, thrombopenia, and renal failure in which the lesions are mediated by a process of thrombotic microangiopathy, mutations in its genes that lead to uncontrolled activation. of C5 and formation of the membrane attack complex. Its correct diagnosis allows prescribing treatment based on eculizumab, a C5 inhibitor. The clinical case of a patient with aHUS is presented, who three months after diagnosis, becomes pregnant. The objective is to highlight the importance of early differential diagnosis for the early establishment of effective treatment of this pathology, as well as management during pregnancy, childbirth and the postpartum period. The pathophysiology, diagnosis and genetic study are updated, as well as the therapeutic management of aHUS. Case Reports 27 year old women with no personal or family history of interest. She went to the emergency room in the full pandemic by SARSCov2 due to choluric urine along with fever of 38, myalgias and generalized arthralgias. At that time, PCR positive SARSCov2, deterioration of renal function was noted with Creatinine of 1.8 mg/dl (previous normal), LDH 1954 u/l, Platelets 21000, Hemoglobin 14.4 g/dl without schistocytes in smear, albumin/creatinine ratios 8700 and intense hematuria. It was interpreted as thrombotic thrombocytopenic purpura receiving corticosteroids, rituximab and plasmapheresis. After 48 hours, thrombopenia persists, schistocytes appear in smears and renal function deteriorates creatinine to 2.8 mg/dl. ADAMS 13 is received at normal values, considering at this time a diagnosis of aHUS, the previous treatment is interrupted and a dose of eculizumab 900 mg is received, doses of 900 per week are scheduled for 4 weeks in the fifth week 1200 mg and from Then on biweekly dose 1200 mg of eculizumab. At the third week of treatment, renal function has already normalized, hemolysis data have disappeared, Htcro and platelets have returned to normal. Proteinuria and hematuria disappears which has been maintained up to now. Good tolerance to treatment without any incidence, presenting a positive pregnancy test at three months. During pregnancy treatment with eculizumab is maintained. We continued with the biweekly regimen with 1200 mg of eculizumab until delivery. Labor is induced at week 37 receiving a extra dose of 1200 mg in the first 24 hours of delivery and continuing with 4 doses of 1200 mg once a week. Afterwards the dose is changed to a biweekly dose without modifying it throughout lactation until it ends. The reason is to avoid complement deregulation in the context of pregnancy and therefore ensure blockade. Subsequently it is done Switch to ravulizumab when breastfeeding begins as follows: A loading dose of 2700 mg (according to the interval of patient's weight) 15 days after the last dose of eculizumab. The maintenance dose is 3300 mg every 8 weeks starting 2 weeks after the loading dose. Normal kidney function has been maintained. She presented on debut positive serology for parvovirus B19, receiving treatment with Immunoglobulins and PCR SARSCov2 was positive prescribing treatment with remdesivir. Vitus (CMV, HBV, HCV and HIV) serology was negative and autoimmune study as well as study of complement and proteinogram were negative or within normal limits. No data suggestive of a neoplastic process. Genetic study has been detected a pathogenic variant associated with aHUS. Conclusion We found a heterozygous carrier patient in genetic study, who developed aHUS during a Sars-cov2 infection, which could have been a trigger for its clinical expression. The clinical course of this case highlights how crucial it is to identify atypical hemolytic uremic syndrome. The early initiation of eculizumab improves the prognosis and quality of life, with pregnancy becoming increasingly more likely and therapy with eculizumab does not have safety problems in this regard, although pregnant patients with aHUS should be closely monitored close during pregnancy and postpartum.

Obstetric Antiphospholipid Syndrome: Insights on the Diagnosis, Treatment, and Hot Issues

Obstetric antiphospholipid syndrome (OAPS) is an autoimmune disorder associated with various pathological pregnancies, such as recurrent miscarriage, stillbirth, severe pre-eclampsia and severe placental insufficiency. The persistent presence of antiphospholipid antibodies (aPLs) is the most important laboratory characteristic of OAPS. OAPS severely affects the reproductive health of women of childbearing age in China. Reports indicate that approximately 9.6% stillbirths, 11.5% severe pre-eclampsia, and 54% recurrent miscarriages are associated with OAPS or aPLs. However, the pathogenesis of OAPS remains unclear. Previously, thrombosis at the maternal-fetal interface (MFI) was considered the main mechanism of OAPS-related pathological pregnancies. Consequently, the use of low molecular weight heparin and aspirin throughout pregnancy was recommended to improve outcomes in OAPS patient. In recent years, many studies have found that thrombosis in MFI is uncommon, but various inflammatory factors are significantly increased in the MFI of OAPS patients. Based on these findings, some clinicians have started using anti-inflammatory treatments for OAPS, which have preliminarily improved the pregnancy outcomes. Nevertheless, there is no consensus on these second-line treatments of OAPS. Another troubling issue is the clinical diagnosis of OAPS. Similar to other autoimmune diseases, there are only classification criteria for OAPS, and clinical diagnosis of OAPS depends on the clinicians' experience. The present classification criteria of OAPS were established for clinical and basic research purposes, not for patient clinical management. In clinical practice, many patients with both positive aPLs and pathological pregnancy histories do not meet the strict OAPS criteria. This has led to widespread issues of incorrect diagnosis and treatment. Timely and accurate diagnosis of OAPS is crucial for effective treatment. In this article, we reviewed the epidemiological research progress on OAPS and summarized its classification principles, including: 1) the persistent presence of aPLs in circulation; 2) manifestations of OAPS, excluding other possible causes. For the first point, accurate assessment of aPLs is crucial; for the latter, previous studies regarded only placenta-related pregnancy complications as characteristic manifestations of OAPS. However, recent studies have indicated that adverse pregnancy outcomes related to trophoblast damage, such as recurrent miscarriage and stillbirth, also need to be considered in OAPS. We also discussed several key issues in the diagnosis and treatment of OAPS. First, we addressed the definition of non-standard OAPS and offered our opinion on defining non-standard OAPS within the framework of the 2023 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) APS criteria. Then, we discussed the advantages and disadvantages of different aPL testing methods, emphasizing that harmonizing results across platforms and establishing specific reference values are keys to resolving controversies in aPL testing results. We also introduced the application of non-criteria aPLs, especially anti-phosphatidylserine/prothrombin antibody (aPS/PT) and anti-β2 glycoprotein Ⅰ domain Ⅰ antibody (aβ2GPⅠDⅠ). Additionally, we discussed aPL-based OAPS risk classification strategies. Finally, we proposed potential treatment methods for refractory OAPS. The goal is to provide a reference for the clinical management of OAPS.

A Study to Determine the Reason for Lower Pregnancy Rates in Younger Women with Diminished Oocyte Reserve-less Chance of Implanting vs. Fetal Demise

Most studies find lower live-delivered pregnancy rates (LDPRs) following in vitro fertilization-embryo transfer (IVF-ET) in women with diminished oocyte reserve (DOR) vs. normal oocyte reserve (NOR) even in a younger population. How much of a discrepancy may depend on the degree of oocyte depletion in the DOR group and the follicular stimulation protocol. Some fertility specialists favor an FSH receptor up-regulation technique as the protocol to attain the maximum LDPRs in women with DOR. The objective of this study was to compare chemical, clinical, and LDPRs following IVF-ET to determine if the main time of embryo loss is very early, as evidenced by the largest discrepancy occurring in attaining even a chemical pregnancy, and/ or a large discrepancy between a chemical pregnancy and attaining a clinical pregnancy (ultrasound evidence of a gestational sac) or later losses as evidenced by showing a greater loss rate from clinical evidence of pregnancy to live delivery in those with DOR compared to NOR. Overall, the DOR group, with a mean serum anti-Mullerian hormone (AMH) level of 0.42 ng/mL, had 50% as much chance to have an LDPR/transfer as women with NOR (AMH of 4.66) despite the same number of day 3 embryos transferred. The main reduction in LDPRs occurred from embryo transfer failing to attain a positive clinical pregnancy in the DOR group. The least discrepancy was from attaining a clinical pregnancy to live delivery. Thus, for NOR from positive pregnancy test 59% of this younger age group will have a live delivery vs. 50% for DOR. Thus, the reduction in LDPRS/transfer in young women with DOR vs. NOR seems mostly very early so the DOR group does not even attain a positive serum beta human chorionic gonadotropin level. This suggests that this inferiority in attaining a live delivery may be related to aneuploidy involving large chromosomes or a marked decrease in the mitochondrial DNA of the embryo.

Personalized embryo transfer guided by rsERT improves pregnancy outcomes in patients with repeated implantation failure.

Embryo implantation requires synchronous communication between the embryo and maternal endometrium. Inadequate maternal endometrial receptivity is one of the principal causes for embryo implantation failure [especially repeated implantation failure (RIF)] when biopsied good-quality euploid embryos are transferred. An RNA-seq-based endometrial receptivity test (rsERT) was previously established to precisely guide successful embryo implantation. In this study, we aimed to evaluate the effect of personalized embryo transfer (pET) via rsERT on the clinical outcomes in patients with RIF. A total of 155 patients with RIF were included in the present retrospective study and were divided into two groups: 60 patients who underwent rsERT and pET (Group rsERT) and 95 patients who underwent standard frozen embryo transfer (FET) without rsERT (Group FET). Reproductive outcomes were compared for patients who underwent rsERT-guided pET and standard FET. Forty percent (24/60) of the patients who underwent rsERT were receptive, and the remaining 60% (36/60) were non-receptive. The positive human chorionic gonadotropin (β-hCG) rate (56.3% vs. 30.5%, P = 0.003) and clinical pregnancy rate (43.8% vs. 24.2%, P = 0.017) were significantly higher in Group rsERT patients than in FET group patients. Additionally, Group rsERT patients also showed a higher implantation rate (32.1% vs. 22.1%, P = 0.104) and live birth rate (35.4% vs. 21.1%, P = 0.064) when compared with FET patients, although without significance. For subpopulation analysis, the positive β-hCG rate, clinical pregnancy rate, implantation rate, and live birth rate of receptive patients were not statistically significant different from those of non-receptive patients. The rsERT can significantly improve the pregnancy outcomes of RIF patients, indicating the clinical potential of rsERT-guided pET.

Developing comprehensive woman hand-held case notes to improve quality of antenatal care in low-income settings: participatory approach with maternal health stakeholders in Malawi

BackgroundIn the quest for quality antenatal care (ANC) and positive pregnancy experience, the value of comprehensive woman hand-held case notes cannot be emphasised enough. However, the woman’s health passport book in Malawi presents gaps which hinder provision of quality care, especially during pregnancy. We aimed to develop a compressive updated woman hand-held case notes tool (health passport book) which reflects WHO 2016 ANC guidelines in Malawi.MethodsFrom July 2022 to August 2022, we applied a co-creative participatory approach in 3 workshops with key stakeholders to compare the current ANC tool contents to the WHO 2016 ANC guidelines, decide on key elements to be changed to improve adherence and change in practice, and redesign the woman’s health passport tool to reflect the changes. Within-group discussions led to whole-group discussions and consensus, guided by a modified nominal group technique. Facilitators guided the discussions while ensuring autonomy of the group members in their deliberations. Discussions were recorded and transcribed. Data was analysed through thematic analysis, and reduction and summaries in affinity diagrams. The developed tool was endorsed for implementation within Malawi’s healthcare system by the national safe motherhood technical working group (TWG) in July 2023.ResultsFive themes were identified in the analysis. These were (i) critical components in the current tool missed, (ii) reimagining the current ANC tool, (iii) opportunity for ultrasound scanning conduct and documentation, (iv) anticipated barriers related to implementation of the newly developed tool and (v) cultivating successful implementation. Participants further recommended strengthening of already existing policies and investments in health, strengthening public private partnerships, and continued capacity building of healthcare providers to ensure that their skill sets are up to date.ConclusionAchieving goals of quality ANC and universality of healthcare are possible if tools in practice reflect the guidelines set out. Our efforts reflect a pioneering attempt in Malawi to improve women’s hand-held case notes, which we know help in enhancing quality of care and improve overall women’s satisfaction with their healthcare system.

When addressing resources is not enough: lessons learned from a respectful maternal and neonatal care provider training intervention evaluation in Kenya and Tanzania

BackgroundRespectful Maternal and Neonatal Care (RMNC) maintains and respects a pregnant person’s dignity, privacy, informed choice, and confidentiality free from harm and mistreatment. It strives for a positive pregnancy and post-pregnancy care experiences for pregnant people and their families, avoiding any form of obstetric violence. Though RMNC is now widely accepted as a priority in obstetric care, there is a gap in resources and support tools for healthcare wproviders to clearly understand the issue and change long-established practices such as non-humanized caesarean sections. MSI Reproductive Choices (MSI) manages 31 maternities across 7 countries with a zero-tolerance approach towards disrespectful maternity care and obstetric violence. MSI developed and implemented a hybrid training package, which includes an online module and 1-day in-person workshop that allows healthcare providers to explore their beliefs and attitudes towards RMNC. It leverages methodologies used in Values-Clarification-Attitudes-Transformation (VCAT) workshops and behaviour change approaches.MethodsThe impact of this training intervention was measured from the healthcare providers’ and patients’ perspectives. Patient experience of (dis)respectful care was collected from a cross-sectional survey of antenatal and postnatal patients attending MSI maternities in Kenya and Tanzania before and following the RMNC training intervention. Healthcare providers completed pre- and post-workshop surveys at day 1, 90 and 180 to measure any changes in their knowledge, attitudes and perception of intended behaviours regarding RMNC.ResultsThe results demonstrate that healthcare provider knowledge, attitudes and perceived RMNC practices can be improved with this training interventions. Patients also reported a more positive experience of their maternity care following the training.ConclusionRMNC is a patient-centred care priority in all MSI maternities. The training bridges the gap in resources currently available to support changes in healthcare wproviders’ attitudes and behaviours towards provision of RMNC. Ensuring health system infrastructure supports compassionate obstetric care represents only the first step towards ensuring RMNC. The results from the evaluation of this RMNC provider training intervention demonstrates how healthcare provider knowledge and attitudes may represent a bottleneck to ensuring RMNC that can be overcome using VCAT and behaviour change approaches.

Pipelle Endometrial Sampling With a Full Bladder Compared With Standard Care: A Randomized Controlled Trial.

To compare insertion failure rates for Pipelle endometrial sampling with a full bladder compared with the standard process (not taking into account bladder status) without cervical manipulation. A single-masked randomized trial was conducted in a single tertiary care center from July 2021 to January 2022. Two hundred fourteen participants aged 18 years or older who were scheduled for outpatient Pipelle endometrial sampling were randomized: 107 each to having a full bladder (by oral water intake) or standard process (without delayed sampling and bladder status not taken into account). Women with known cervical stenosis, gynecologic malignancy, uterine anomalies, leiomyoma distorting the uterine cavity, acute cervicitis, urge bladder dysfunction, intense anxiety, need for anesthesia or analgesic before the procedure, positive pregnancy test, or previous failed office endometrial sampling were excluded. The primary outcome was the insertion failure rate of endometrial sampling at first attempt. Secondary outcomes were pain during procedure, satisfaction score, analgesia use, procedure duration, and need for cervical manipulation. Factoring in a baseline insertion failure rate of 30.0%, relative risk of 0.45, α of 0.05, 80.0% power, and a dropout rate of 10.0%, we needed 107 participants in each arm. The insertion failure rate was significantly lower in the full bladder group compared with standard process: 25 of 107 (23.4%) compared with 45 of 107 (42.1%) (relative risk 0.56, 95% CI, 0.37-0.84; number needed to treat to benefit 6.0, 95% CI, 3.20-15.70). Pain score (median) during the procedure (interquartile range) was 4 (3-6) compared with 5 (3-8) ( P =.004); patient satisfaction score was 8 (7-9) compared with 7 (4-8) ( P <.001); and mean±SD procedure duration was 3.0±2.4 compared with 4.7±2.9 minutes ( P <.001) for the full bladder and standard process arm, respectively. Other secondary outcomes of cervical laceration, analgesia use, and adequacy of endometrial tissue for histopathologic assessment were not significantly different between groups. Pipelle endometrial sampling with a full bladder reduces the initial insertion failure rate, procedure-related pain, and duration of sampling and increases patient satisfaction compared with the standard process. ISRCTN, ISRCTN33938192.

Formation of the first plane of division relative to the pronuclear axis predicts embryonic ploidy

Research questionIs there a relationship between the pronuclear axis and the first cleavage plane formation in human pronuclear-stage embryos, and what are the effects on ploidy and clinical pregnancy rates? DesignTransferred embryos were followed up until their prognoses. A total of 762 embryos formed two cells and reached the blastocyst stage after normal fertilization in a time-lapse incubator. Embryos were classified into three groups: group A: embryos in which the first plane of division was formed parallel to the axis of the pronucleus; group B: embryos in which cases of oblique formation were observed; and group C: embryos in which cases of perpendicular formation were observed. ResultsThe euploidy rate was significantly higher in groups A and B than those in group C (P < 0.01), whereas the aneuploidy rate was significantly higher in group C (P < 0.01) than in groups A and B. No differences were found between the three groups in frequency of positive HCG-based pregnancy tests, frequency of clinical pregnancies, miscarriage rates or delivery rates. ConclusionsThe formation pattern of the first plane of division relative to the pronuclear axis was a predictor of embryonic ploidy, with a reduced rate of euploidy and a high probability of aneuploidy observed when the first plane of division was perpendicular to the pronuclear axis.

Risk Factors Associated With Being Lost to Follow-up Among Patients With Pregnancy of Unknown Location [ID 2683399

INTRODUCTION: Managing pregnancy of unknown location (PUL) is a logistical challenge for obstetrician–gynecologists. Close follow-up is a key component of management to reduce the risk of a ruptured ectopic pregnancy. We examined factors that may put patients at increased risk of being lost to follow-up. METHODS: We performed a case–control study of patients presenting to our emergency room with a positive pregnancy test and without previously confirmed intrauterine pregnancy in the first trimester between January 2020 and December 2022. Patients with newly diagnosed PUL were added to a secure list for follow-up (“beta book”). We compared patients who were lost to follow-up, which was defined as after three failed attempts at contact made multiple days apart, with those who were not. Chi-square and Fisher exact assessed demographic exposures putting patients at risk of being lost to follow-up. RESULTS: One hundred nineteen patients had PUL and were added to the beta book. Overall, 15 (12.6%) of patients were lost to follow-up (cases) compared to 104 (87.4%) of patients who were not (controls). No associations were found between sociodemographic variables and risk of being lost to follow-up, including age (P=.15), parity (P=.59), insurance type (P=.81), primary language (P=.77), race (P=.26), and ethnicity (P=.80). Finally, lost to follow-up rates were similar among women enrolled and not enrolled in the institution’s app-based medical communication system (P=.75). CONCLUSION: In a state in which pregnancy-related care is available regardless of immigration status, we found no demographic associations with risk of being lost to follow-up. As 12% of people in this study were still lost to follow-up, qualitative interviews may be useful to better understand factors not captured in a retrospective chart review to improve safe and equitable care.

Assessment of Pregnancy Desires for Patients With Pregnancy of Unknown Location Seen in the Emergency Department [ID 2683447

INTRODUCTION: Desire for pregnancy should be centered in all discussions surrounding pregnancy management, including management of pregnancy of unknown location (PUL). Little is known about the evaluation of pregnancy desires for patients presenting to the emergency department (ED) found to have PUL. METHODS: We performed a retrospective cohort study of patients presenting to a tertiary-care ED with a positive pregnancy test and previously unconfirmed intrauterine pregnancy in the first trimester between January 2020 and December 2022. We excluded patients with chief complaints regarding known intrauterine pregnancy. The primary outcome was documentation of pregnancy desire by the ED provider. The secondary outcome was assessment of pregnancy desiredness by consulting gynecologic providers. Chi-squared and Fisher exact tests assessed for demographic variables. Institutional review board approval was obtained. RESULTS: Four hundred ninety-seven patients were included. Overall, only 105 (21.1%) of all patients and 12 (13.5%) patients with PUL were asked about pregnancy desiredness by the ED provider. While not statistically significant, patients with PUL had the lowest rate of being asked their pregnancy desires, compared to patients with confirmed intrauterine pregnancy (22.7%), ongoing miscarriage (28.1%), or ectopic/adnexal pathology (20.0%) (P=.15). Of those asked, 11 patients (10.5%) reported the pregnancy was undesired and 7 (6.7%) were unsure. There were no significant associations between asking pregnancy desires and age, race, ethnicity, parity, insurance, and language. For patients added to the beta book and followed by gynecology, 59.3% of patients were asked about their pregnancy desires. CONCLUSION: This study highlights gaps in early pregnancy evaluation and counseling, with only one in five patients asked their pregnancy desires. Patients with adnexal pathology and PUL had among the lowest rates of counseling, compared to those with ongoing miscarriage. This research suggests a missed opportunity for comprehensive pregnancy options counseling and management in the ED and the potential for improvement of care for patients with undesired PUL.

The Role of Beta hCG Value Measured on the 12th and 14th Days After Embryo Transfer in Determining Early Complications of Pregnancy

Aim: This study aimed to investigate the role of beta human chorionic gonadotropin (beta hCG) levels on post embryo transfer (ET) 12th- and 14th-day, and its folding after 48 hours in predicting live birth, abortion, and biochemical pregnancy. Material and Methods: The study included 124 patients who had a positive pregnancy test after a fresh single day 3 ET at the in vitro fertilization (IVF) center between 2017 and 2021. The first beta hCG value was measured 12th day and the second 14th day after ET. The beta hCG fold was calculated by dividing the second beta hCG value by the first beta hCG value. Results: The patients' IVF indications included unexplained (n=40, 41.1%), poor ovarian reserve (n=23, 25.0%), male factor (n=31, 29.8%), and tubal factor (n=3, 4.1%). Of the 124 patients, 97 (78.2%) had a fetal sac, 81 (63.5%) had a fetal heartbeat (FHB), and 70 (56.5%) had a live birth. The results indicated that the post-ET 14th-day beta hCG level was the best predictor of biochemical pregnancy. It has a high sensitivity (92.5%) and specificity (86.6%), with an optimal cut-off value of 175 U/L. The post-ET 14th-day beta hCG level was the best predictor of a live birth. The post-ET 14th-day beta hCG value of 214.5 U/L had an 82.7% sensitivity and 74.4% specificity to predict the FHB. Conclusion: The beta hCG value, measured between the 12th and 14th days after ET, as well as the folding rate on these two days, can provide information about the pregnancy progression.

Performance of an Electronic Medical Record-Based "Syphilis Flag" in Identifying At-Risk Patients in an Emergency Department.

The United States has seen a > 40% increase in syphilis cases since 2017. Early disease identification and treatment are crucial. This review sought to identify emergency department (ED) patients at risk for syphilis. A 30-day retrospective review was conducted of visits to a single ED. Patient visits were assessed for predetermined syphilis "flags" to include a history of sexually transmitted infection (STI), current chief complaint or reason for visit (RFV) keyword(s) suggestive of potential STI or a positive pregnancy test result. Flagged charts were assessed for STI testing results within 6 months of ED visit. Data were analyzed using χ2 . There were 5537 total patient encounters, resulting in 455 flagged visits from 408 (8.4%) unique individuals, majority of whom were female (282, 69.1%; P < 0.001), Black (251, 61.5%; P < 0.001), aged 15 to 44 years (308, 75.5%; P < 0.001). Chief complaint was the most frequent flag (65.3%), followed by RFV (37.4%), prior STI (31.0%), and pregnancy (12.3%). Syphilis testing data were available for 120 flagged patients; 29 (24.2%) screened positive, including 11 (2.7% of total flagged cohort) with evidence for active infection. Among those, most were Black (90.9%), male (72.7%), aged 25 to 34 years (63.6%), and 9 (81.8%) had concomitant HIV. In active infection, prior STI flag was most common (72.7%), followed by chief complaint (54.5%) and RFV (45.5%). This review demonstrates the performance of an electronic medical record-based "syphilis risk flag" screener applied to ED patients. Sex- and race-based discrepancies exist in flag rates, which may be reflective of sex- and race-based epidemiologic discrepancies in STI incidence.

The role of Ca2+ signalling and InsP3R in the pathogenesis of intrahepatic cholestasis of pregnancy

Background In order to contribute new insights for future prevention and treatment of intrahepatic cholestasis of pregnancy (ICP), and to promote positive pregnancy outcomes, we evaluated serum Ca2+ levels and inositol 1,4,5-trisphosphate receptor (InsP3R) expression in the liver tissue of a rat ICP model. Methods After establishing the model by injection of oestradiol benzoate and progesterone into pregnant rats, animals were divided into normal control (n = 5) and ICP model groups (n = 5). The expression of InsP3R protein in the liver, and serum levels of Ca2+, glycocholic acid and bile acid were detected. Results InsP3R mRNA and protein were significantly lower in the ICP model group compared to the normal group, as determined by qPCR and immunohistochemistry, respectively. Serum enzyme-linked immunosorbent assay results revealed significantly higher levels of glycocholic acid and bile acid in the ICP model group compared to the normal group, while Ca2+ levels were significantly lower. The levers of Ca2+ were significantly and negatively correlated with the levels of glycocholic acid. The observed decrease in Ca2+ was associated with an increase in total bile acids, but there was no significant correlation. Conclusions Our results revealed that the expression of InsP3R and serum Ca2+ levels was significantly decreased in the liver tissue of ICP model rats. Additionally, Ca2+ levels were found to be negatively correlated with the level of glycocholic acid.