Alternative Magnesium Sulfate Dosing Regimens for Women With Preeclampsia: A Population Pharmacokinetic Exposure-Response Modeling and Simulation Study

Magnesium sulfate is the anticonvulsant of choice for eclampsia prophylaxis and treatment; however, the recommended dosing regimens are costly and cumbersome and can be administered only by skilled health professionals. The objectives of this study were to develop a robust exposure-response model for the relationship between serum magnesium exposure and eclampsia using data from large studies of women with preeclampsia who received magnesium sulfate, and to predict eclampsia probabilities for standard and alternative (shorter treatment duration and/or fewer intramuscular injections) regimens. Exposure-response modeling and simulation were applied to existing data. A total of 10 280 women with preeclampsia who received magnesium sulfate or placebo were evaluated. An existing population pharmacokinetic model was used to estimate individual serum magnesium exposure. Logistic regression was applied to quantify the serum magnesium area under the curve-eclampsia rate relationship. Our exposure-response model-estimated eclampsia rates were comparable to observed rates. Several alternative regimens predicted magnesium peak concentration < 3.5 mmol/L (empiric safety threshold) and eclampsia rate ≤ 0.7% (observed response threshold), including 4 g intravenously plus 10 g intramuscularly followed by either 8 g intramuscularly every 6 hours × 3 doses or 10 g intramuscularly every 8 hours × 2 doses and 10 g intramuscularly every 8 hours × 3 doses. Several alternative magnesium sulfate regimens with comparable model-predicted efficacy and safety were identified that merit evaluation in confirmatory clinical trials

Epidemiology and factors associated with preterm births in multiple pregnancy: a retrospective cohort study

Abstract Objective Multiple pregnancies carry an increased risk of maternal and perinatal complications, notably prematurity. Few studies have evaluated the risk factors for preterm births in multiple pregnancies within the Thai population. This study aims to ascertain maternal and perinatal outcomes and identify factors linked to preterm births in multiple pregnancies. Methods This study was carried out at Khon Kaen University, Faculty of Medicine, Department of Obstetrics and Gynecology in Thailand. We reviewed the medical records of women with multiple pregnancies who delivered at a gestational age of more than 20 weeks between January 1, 2012 and December 31, 2021. We excluded patients with incomplete data or those for whom data were missing. Results Out of 21,400 pregnancies, 427 were multiple pregnancies, constituting approximately 1.99%. Over the ten-year period, 269 multiple pregnancies (65.1%) resulted in preterm births. Of these, 173 (64.3%) were monochorionic twins, and 96 (35.7%) were dichorionic twins. Monochorionic twins had a notably higher rate of preterm delivery (AOR, 2.06; 95%CI 1.29—3.30). Vaginal delivery was observed in 7.9% of the cases, while cesarean sections were performed for both twins in 91.5% of cases. In 0.5% of the cases, only the second twin was delivered by cesarean section. In terms of neonatal outcomes, 160 infants (19.4%) weighed less than 1,500 g at birth, and there were 78 perinatal deaths (9.4%). Birth asphyxia was noted in 97 cases (20.2%) among monochorionic twins and in 28 cases (8.1%) for dichorionic twins. Conclusion The prevalence of multiple pregnancies was 1.99%, with 65.1% resulting in preterm births. Neonatal complications were notably more frequent in monochorionic twins. Monochorionic placenta and antepartum complications emerged as significant risk factors for preterm birth

Risk of Severe Adverse Maternal and Neonatal Outcomes in Deliveries with Repeated and Primary Cesarean Deliveries versus Vaginal Deliveries: A Cross-Sectional Study

Objective. To determine risks of severe adverse maternal and neonatal outcomes in women with repeated cesarean delivery (CD) and primary CD compared with those with vaginal delivery (VD). Methods. Data of this cross-sectional study were extracted from 2,262 pregnant women who gave birth between August 2014 and December 2016, at Srinagarind Hospital, Khon Kaen University. Severe maternal outcomes were categorized based on the World Health Organization criteria. Adjusted odds ratio (aOR) and 95% confidence intervals (CI) were calculated to indicate the risk of severe adverse maternal and neonatal outcomes among women underwent CD compared with those who underwent VD. Results. There were no cases of maternal death in this study. CD significantly increased risk of severe adverse maternal outcomes (SMO) (aOR 10.59; 95% CI, 1.19-94.54 for primary CD and aOR 17.21; 95% CI, 1.97-150.51 for repeated CD) compared with women who delivered vaginally. When compared with vaginal delivery, the risks of neonatal near miss (NNM) and severe adverse neonatal outcomes (SNO) were significantly higher in primary CD group (aOR 1.71; 95% CI 1.17-2.51 and aOR 1.66; 95% CI 1.14-2.43), respectively. For repeated CD, the risks were borderline significant (aOR, 1.58; 95% CI, 0.98-2.56 for NNM and aOR, 1.61; 95% CI, 0.99-2.60 for SNO). Conclusion. Primary and repeated CD significantly increased the risk of SMO compared with VD. Risks of NNM and SNO were also significantly increased in women with primary CD. The risks of NNM and SNO for repeated CD trended toward a significant increase

Appropriateness of Preoperative Screenings in Patients Undergoing Elective Gynecologic Surgery at Srinagarind Hospital, Khon Kaen University, Thailand: An observational study

Objectives: To evaluate the appropriateness of routine preoperative screening for patients who undergoing elective major gynecologic surgery at a tertiary care university hospital, Khon Kaen Province based on the hospital guideline.Materials and Methods: This retrospective descriptive study reviewed 808 medical records of gynecologic patients undergoing elective surgery in 2014.results: The mean age of the patients was 44.2 years. Approximately 36% of patients had associated co-morbidity. Almost 90% of the patients had inappropriate screening tests. Complete blood count and chest x-ray were the two most appropriate screening test. The most inappropriate tests were urinalysis and fasting blood sugar. Patients were classified into 4 groups: 1) patients < 45 years old with no underlying conditions; 2) patients < 45 years old with at least one underlying conditions; 3) patients ≥ 45 years old with no underlying conditions and 4) patients ≥ 45 years old with at least one underlying conditions. The first group had highest rate of performing inappropriate preoperative tests with blood urea nitrogen/creatinine as the most overuse test. The costs of inappropriateness preoperative tests were 39.8% of the total costs of preoperative assessment.Conclusion: Almost 90% of the patients had inappropriate screening tests which increased the cost by about 40%. Hospital administrators should find appropriate mechanisms to reinforce doctors to strict their requests for only tests that are necessary

Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis

Summary: Background: Preterm birth is the leading cause of death in children younger than 5 years worldwide. Although preterm survival rates have increased in high-income countries, preterm newborns still die because of a lack of adequate newborn care in many low-income and middle-income countries. We estimated global, regional, and national rates of preterm birth in 2014, with trends over time for some selected countries. Methods: We systematically searched for data on preterm birth for 194 WHO Member States from 1990 to 2014 in databases of national civil registration and vital statistics (CRVS). We also searched for population-representative surveys and research studies for countries with no or limited CRVS data. For 38 countries with high-quality data for preterm births in 2014, data are reported directly. For countries with at least three data points between 1990 and 2014, we used a linear mixed regression model to estimate preterm birth rates. We also calculated regional and global estimates of preterm birth for 2014. Findings: We identified 1241 data points across 107 countries. The estimated global preterm birth rate for 2014 was 10·6% (uncertainty interval 9·0–12·0), equating to an estimated 14·84 million (12·65 million–16·73 million) live preterm births in 2014. 12· 0 million (81·1%) of these preterm births occurred in Asia and sub-Saharan Africa. Regional preterm birth rates for 2014 ranged from 13·4% (6·3–30·9) in North Africa to 8·7% (6·3–13·3) in Europe. India, China, Nigeria, Bangladesh, and Indonesia accounted for 57·9 million (41×4%) of 139·9 million livebirths and 6·6 million (44×6%) of preterm births globally in 2014. Of the 38 countries with high-quality data, preterm birth rates have increased since 2000 in 26 countries and decreased in 12 countries. Globally, we estimated that the preterm birth rate was 9×8% (8×3–10×9) in 2000, and 10×6% (9×0–12×0) in 2014. Interpretation: Preterm birth remains a crucial issue in child mortality and improving quality of maternal and newborn care. To better understand the epidemiology of preterm birth, the quality and volume of data needs to be improved, including standardisation of definitions, measurement, and reporting. Funding: WHO and the March of Dimes

How does hospital organisation influence the use of caesarean sections in low- and middle-income countries? A cross-sectional survey in Argentina, Burkina Faso, Thailand and Vietnam for the QUALI-DEC project

International audienceAbstract Background Improving the understanding of non-clinical factors that lead to the increasing caesarean section (CS) rates in many low- and middle-income countries is currently necessary to meet the challenge of implementing effective interventions in hospitals to reverse the trend. The objective of this study was to study the influence of organizational factors on the CS use in Argentina, Vietnam, Thailand and Burkina Faso. Methods A cross-sectional hospital-based postpartum survey was conducted in 32 hospitals (8 per country). We selected women with no potential medical need for CS among a random sample of women who delivered at each of the participating facilities during the data collection period. We used multilevel multivariable logistic regression to analyse the association between CS use and organizational factors, adjusted on women’s characteristics. Results A total of 2,092 low-risk women who had given birth in the participating hospitals were included. The overall CS rate was 24.1%, including 4.9% of pre-labour CS and 19.3% of intra-partum CS. Pre-labour CS was significantly associated with a 24-hour anaesthetist dedicated to the delivery ward (ORa = 3.70 [1.41; 9.72]) and with the possibility to have an individual room during labour and delivery (ORa = 0.28 [0.09; 0.87]). Intra-partum CS was significantly associated with a higher bed occupancy level (ORa = 1.45 [1.09; 1.93]): intrapartum CS rate would increase of 6.3% points if the average number of births per delivery bed per day increased by 10%. Conclusion Our results suggest that organisational norms and convenience associated with inadequate use of favourable resources, as well as the lack of privacy favouring women’s preference for CS, and the excessive workload of healthcare providers drive the CS overuse in these hospitals. It is also crucial to enhance human and physical resources in delivery rooms and the organisation of intrapartum care to improve the birth experience and the working environment for those providing care. Trial registration The QUALI-DEC trial is registered on the Current Controlled Trials website ( https://www.isrctn.com/ ) under the number ISRCTN67214403