Preterm birth in singleton and multiple pregnancies: evaluation of costs and perinatal outcomes (2023)

Citation Excerpt :

A consistent inverse association was observed between gestational age at birth and initial hospitalization costs regardless of date of publication, country of publication, underpinning study design, costing methodology, or the denominators applied within the cost calculus (live births or survivors). Two studies estimated a less than two-fold differential in initial hospitalization costs between infants born late term and a comparator group born at term (≥37 weeks) [39,49], whilst a further two studies estimated an 8–10-fold differential in initial hospitalization costs between infants born at 34 weeks gestation and those born at term [42,50]. A further study analysed state-level-linked vital statistics and hospital discharge records in California covering 84,540 infants born late preterm and 92,241 infants born at term [47].

Citation Excerpt :

In 2005, the annual national cost of preterm birth was estimated at over $26 billion.11 Because initial hospital costs (representing inpatient maternity care and newborn care between birth and the first homebound hospital discharge) are largely driven by the expense of neonatal intensive care, an inverse relationship between gestational age at birth and costs has been identified.12–14 However, due to the larger number of infants born during the late to moderate preterm period (32–36 weeks of gestation), the reduction of preterm birth incidence at virtually any stage of gestation should yield considerable cost savings.15–18

To develop generalizable methods for estimating the economic impact of preterm birth at the community level on initial hospital expenditures, educational attainment and lost earnings as well as to estimate potential savings associated with reductions in preterm birth.

The retrospective, population-based analysis used vital statistics and population demographics from Hamilton County, Ohio, USA, in 2012.

We adjusted previously reported, mean initial hospital cost estimates (stratified by each week of gestation) to 2012 dollars using national cost-to-charge ratios. Next, we calculated excess costs attributable to prematurity and potential hospital cost savings, which could be realized by prolonging each preterm pregnancy by a single week of gestation. Using reported associations among preterm birth, educational attainment and adult earnings, we developed generalizable formulas to calculate lost academic degrees and lost income estimates attributable to preterm birth. The formulas generated estimates based on local population demographics.

The annual initial hospital cost associated with 1444 preterm infants was estimated at $93 million. In addition, over 9000 fewer college degrees and over $300 million in lost annual earnings were attributed to local adults who were born preterm. Prolonging each preterm birth by 1 week could potentially reduce initial hospital expenditures by over $25 million. Additional potential savings could be realized as healthier infants attain higher levels of education and earnings as adults.

The generalizable methods developed for estimating the economic impact of preterm birth at the community level can be used by any community in which vital statistics and population demographics are available. Cost estimates can serve to rally support for local stakeholder investment in developing strategies for preterm birth intervention leading to improved pregnancy outcomes.

To identify the clinical/colposcopic variables that associate with low-grade/negative cone histology in screening-age women undergoing conization for high-grade cervical intraepithelial neoplasia (CIN). The follow-up outcomes of study participants were also compared.

In this retrospective cohort study, 585 consecutive screening-age women who underwent immediate conization for CIN2-3 were divided according to cone histology (CIN2+ versus ≤CIN1) and assessed in relation to clinical/colposcopic variables by univariate and multivariate analyses.

Low-grade [adjusted odds ratio (AOR)=52.67, 95% confidence interval (CI) 22.49–123.34] or normal (AOR=9.81, 95% CI 2.38–40.44) colposcopic impression and CIN2 on cervical biopsy (AOR=19.59, 95% CI 6.62–57.92) associated with CIN1/negative cone histology. Multivariate analysis also showed that Eastern European ethnicity (AOR=0.13, 95% CI 0.03–0.52) and high-risk-Human Papillomavirus (hr-HPV)-positivity (AOR=0.38, 95% CI 0.17–0.87), associated with CIN2+ cone histology. Overall, there were no significant differences between the two groups in terms of high-grade recurrence during the 2-year follow-up. Conversely, a higher rate of high-grade recurrence was present in CIN2-3 (positive cone margins) than in CIN1/negative cone histology (21.9% versus 7.4%, P=0.008, respectively).

The presence of CIN2 on cervical biopsy and a low-grade colposcopic impression were predictive of a minor cone histology, unless the subject was of East European ethnicity or was positive for hr-HPV test. Given the follow-up outcomes, the same women need to perform a close monitoring. However, positive cone margins in women with CIN2-3 cone histology seem to define a population at greater risk of high-grade recurrence.

Gestational diabetes mellitus (GDM) is a world-widely prevalent disease with adverse outcomes. This study aims to identify its disease genes through bioinformatics analysis.

The raw gene expression profiling (ID: GSE19649) was downloaded from Gene Expression Omnibus database, including 3 GDM and 2 healthy control specimens. Then limma package in R was utilized to identify differentially expressed genes (DEGs, criteria: p value <0.05 and |log₂ FC|>1). Simultaneously, known disease genes of GDM were downloaded from Online Mendelian Inheritance in Man database. Then, DEGs and known disease genes were uploaded to STRING to investigate their protein–protein interactions (PPIs). Gene pairs with confidence score >0.8 were utilized to construct PPI network. Furthermore, pathway and functional enrichment analyses were performed through KOBAS (criterion: p value <0.05) and DAVID (The Database for Annotation, Visualization and Integrated Discovery) software (criterion: false discovery rate <0.05), respectively.

A total of 404 DEGs were identified, including 273 up-regulated and 131 down-regulated DEGs. Moreover, 68 known disease genes of GDM were obtained. Then, 190 gene pairs were identified to significantly interact with each other. After deleting PPIs between DEGs, PPI network was constructed, consisting of 115 gene pairs. Furthermore, genes in PPI network were significantly enriched in 10 functions and 8 pathways.

Based on PPI network and functional consistency, 6 candidate genes of GDM were considered to be candidate disease genes of GDM, including CYP1A1, LEPR, ESR1, GYS2, AGRP, and CACNA1G. However, further studies are required to validate these results.

Para-aortic lymph node dissemination in endometrioid endometrial cancer is uncommon, and systematic para-aortic lymph node dissection increases morbidity. The purpose of this study was to identify a subgroup of endometrioid endometrial cancer patients who did not require para-aortic lymphadenectomy.

All patients who had undergone surgery for endometrioid endometrial cancer between 1 January 1995 and 31 December 2012 were retrospectively reviewed. Patients with higher risk factors for nodal metastasis and inadequate lymphadenectomy were excluded. Para-aortic lymph node dissemination was defined as nodal metastasis when pelvic and para-aortic lymph node dissection was performed, when para-aortic lymph node recurrence occurred after negative para-aortic lymph node dissection or when para-aortic lymph node dissection was not performed. Multivariate logistic regression models were used to identify the pathological features as predictors for para-aortic lymphatic dissemination.

A total of 827 patients were assessed, 516 (62.4%) of whom underwent pelvic and para-aortic lymph node dissection. Sixty-seven (13%) patients (37 with only pelvic, 26 with pelvic and para-aortic, and 4 with only para-aortic metastasis) had positive lymph nodes in the pelvic and para-aortic lymph node dissection group. Multivariate analysis confirmed positive pelvic nodes (odds ratio 20.58; p<0.001) and lymphovascular space invasion (odds ratio 8.10; p=0.022) as independent predictors of para-aortic lymphatic dissemination. When these two factors were absent (in 83% of patients), the predicted probability of para-aortic lymph node metastasis was 0.1%.

Positive pelvic nodes and lymphovascular space invasion are highly associated with para-aortic lymph node metastasis. These markers may be useful for identifying those patients who require para-aortic lymph node dissection.

To study cervix elastography measurement and its relation with pregnancy outcome.

A two year prospective longitudinal study evaluated cervical elasticity by HI-RTE (Hitachi real-time tissue elastography) imaging during three trimesters of pregnancy.

The main outcome measure was elastography index the cervical elastogram color-coded.

Three hundred eighty seven measurements were realized among 72 pregnant women prospectively enrolled. In the first trimester, the elasticity index was significantly lower in women who subsequently had unfavorable outcome than in women who delivered at term (respectively, EI=0.51 (±0.04) and 0.59 (±0.02); P=0.037). The negative predictive value of posterior lip color (blue, blue-green=hard cervix) was high NPV=83.8 95% CI [68.8–92.4] in the first trimester (SE=64.7 95% CI [41.3–82.7]; SP=60.8 95% CI [47.1–72.9]; VPP=35.5 95% CI [21.1–53.1]). A first-trimester elasticity index threshold value ≤0.38 had a specificity of 98.0% and a NPV of 80.9% (Se 29.4%, PPV 83.3%). This index value, when combined with a cervical length less than or equal to 36mm, increased the risk of adverse outcome (HR 8.87 95% CI [3.22–23.7]).

Cervical elastography index is associated with unfavorable obstetrical outcomes, independently of cervical length.

The study was registered in ClinicalTrials.gov under Identifier number NCT01032564.

The APOSTEL-II trial was a multicenter randomized placebo-controlled trial, assessing the effectiveness of maintenance tocolysis with nifedipine. The trial showed maintenance tocolysis not to have an effect on perinatal outcome. Objective of the current study is to evaluate the effect of a negative trial on the length of hospital admission of women with threatened preterm labor.

We evaluated length of hospital admission of all patients admitted with threatened preterm labor with a gestational age <32 weeks in 8 perinatal centers that participated in the APOSTEL-II trial. We studied only the first admission with threatened preterm labor, readmissions were excluded. We distinguished between the period before, the period during and the period after the trial. In a subgroup analysis, we differentiated for the group of women who delivered and for the group of women who did not deliver during the initial admission.

The mean length of hospital admission was 9.3 days before the start of the trial, 8.4 days during the recruitment period and 8.1 days after the trial was completed. The difference in mean length of hospital admission before and during the recruitment period was significantly different (p<001).

The length of hospital admission of women with threatened preterm labor is found to be reduced during the recruitment period of the APOSTEL-II trial. This shows that the conduct of a randomized controlled trial itself has the potential to change daily practice.

Tubal patency in women with endometriosis has traditionally been evaluated by laparoscopy. The aim of this study was to investigate the accuracy of hysterosalpingo-contrast-sonography (HyCoSy) in the assessment of tubal patency in these women.

A retrospective study was conducted at Physiopathology of Human Reproduction Unit. Infertile women who underwent HyCoSy and then a laparoscopy (dye test) within 6 months from the HyCoSy were included. Tubal patency was assessed by HyCoSy and the findings were compared with the results of laparoscopy, which was considered the gold standard for assessment of tubal patency. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) and positive and negative likelihood ratios (Lh+, Lh−) were calculated including the 95% confidence interval (CI).

A total of 1452 women underwent HyCoSy and 126 of them received a laparoscopy within 6 months from the HyCoSy. Of the 126 women, 42 (33.3%) had a diagnosis of pelvic endometriosis and 84 (66.7%) had no endometriosis. In the endometriosis population, HyCoSy showed a sensitivity, specificity, PPV, NPV, Lh+ and Lh− of 85% (95% CI 62–96), 93% (95% CI 82–97), 81% (95% CI 58–94), 94% (95% CI 84–98), 12.6 (95% CI 4.8–33) and 0.15 (95% CI 0.05–0.4) respectively. In the non-endometriosis group, HyCoSy showed a sensitivity, specificity, PPV, NPV, LR+ and LR− of 85% (95% CI 65–95), 93% (95% CI 87–96), 71% (95% CI 53–85), 97% (95% CI 92–99), 13.2 (95% CI 6.9–25) and 0.15 (95% CI 0.06–0.3) respectively. The diagnostic accuracy of HyCoSy was 91% in the endometriosis group and 92% in the non-endometriosis patients.

HyCoSy showed high accuracy in evaluating tubal patency in infertile non-endometriosis women and in those affected by endometriosis.