amniocentesis is generally recommended forex
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Amniocentesis is generally recommended forex forex news widget

Amniocentesis is generally recommended forex

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In addition to simplicity and feasibility, I-S with expensive NIPS as a secondary screening is the most cost-beneficial method for low resource settings and should be included in universal healthcare coverage as a national policy. This study could be a model for developing countries or a guideline for international health organizations to help low resource countries, probably leading to a paradigm shift in prenatal diagnosis of fetal DS in the developing world. Prenatal screening and diagnosis of Down syndrome DS with maternal serum screening MSS has been established in developed countries [ 1 ].

However, the incidence in countries with low-resource settings has not changed much in recent years, in spite of the fact that there is more need for lower incidence in poorer countries, since DS can constitute more burdens due to the low quality of life in poor countries [ 2 , 3 ]. Moreover, in low resource countries, the socio-economic gap is even wider. We believe that economic inequality results in health inequality. In this regard, the expensive but more effective non-invasive prenatal screen NIPS has been accepted by wealthy couples but the poor do not have the opportunity to benefit from it.

The only way to overcome this problem is to include cost-benefit screening in universal health care coverage as a national policy. In Thailand, we are considering the implementation of DS screening for all women as a national policy free of charge. However, the most cost-beneficial model is not known, especially in developing countries. Additionally, the studies on the cost-benefit of such strategies are mostly based on simulations of hypothetical cohort instead of testing on real situations that are varied among geographical and racial groups.

Many cost-benefit studies [ 4 — 7 ] relied on the western data of MSS developed for western population, but its efficacy is very different from that used in other parts of the world. Moreover, CBA cost-benefit analysis in previous studies were based on assumption that all women were assumed to attend prenatal care in the first trimester. This is not true in real practice. To yield the most reliable results of CBA, the input variables must be most accurate.

Therefore, we conducted this CBA based on the effectiveness of various models of primary screenings and real probabilities of various events derived from our own large prospective project [ 8 ]. This study was done to determine the best model for developing countries based on feasibility, simplicity and cost-benefit, so as to be considered in the universal health care coverage. Accordingly, this study did not include the techniques that are not practicable in low resource settings, such as NT, which needs expertise and is not widely available; integrated MSS test, which needs two screenings and the costs are double.

However, NIPS as a secondary screening test might be cost-beneficial even in poor countries if the primary screen MSS is very effective with a low false positive rate a small number of amniocenteses. It is more feasible to make NIPS available all over a country than amniocentesis, with a large number of chromosome laboratories. Accordingly, we performed CBA for several strategies, both when combined with NIPS and when not combined, to identify the most cost-beneficial model as a national policy of screening and diagnosis of fetal Down syndrome DS in developing countries.

This study was cost-benefit analysis CBA which was conducted with ethical approval by the institutional review board, as the second part of our previous study [ 8 ], which was prospectively conducted on 41, pregnancies in the northern part of Thailand, including 33 community hospitals. CBA was based on the effectiveness of MSS and probabilities of various events derived from the previous study [ 8 ] and was performed from both societal and government perspectives.

Probabilities and costs were applied to a hypothetical cohort of , pregnant women, representing the estimated annual number of pregnancies in Thailand. The CBA was based on the concept in Fig. They also included a number of DS secondary to false negative of the screening tests, non-acceptance of pregnancy termination of fetal DS and productivity of normal fetuses ending-up with fetal loss caused by amniocentesis.

Direct non-medical cost included accommodation, meals, commuting of the patients and relatives during doctor visits and informal care of DS child. Indirect cost included productivity of: 1 the patients and relatives during doctor visits, 2 normal child terminated due to false positive tests, and 3 the relatives of taking care of the DS child.

Costs from societal perspective included all items mentioned above while costs from governmental perspective included only direct medical cost. Probabilities of events and variables in effectiveness of screening tests and prenatal diagnoses: sensitivities and specificities using risk cut-off were derived from the study in the same population [ 8 ]. The costs of screening and prenatal diagnosis were assessed from our centers with micro-costing analysis.

Direct and indirect costs of taking care of DS were derived from well-established publications [ 2 , 9 — 11 ], with conversion to be equivalent to the Thai costs of living. All costs were adjusted to the costs in with consumer price index CPI. The payment you have to make once in six months.

In this study the interviewer offered the starting point of to , Thai baht to reduce biases which might occur during bargaining. The uncertainty analysis was performed using one-way and probabilistic sensitivity analyses. The accuracy of NIPS Costs screening tests used in the CBA were calculated by micro-costing, representing costs in Thailand in the year However, the life-time cost for taking care of a DS child among Thai population with reliable and comprehensive analysis was not available.

The willingness to pay WTP to avert having DS child in women of all age was based on the survey study among Thai population. Rates of acceptance were based on the assumption that various prenatal screening tests or diagnostic tests were free of charge, according to health coverage by the national policy. Probabilities of the events used in the simulations [ 8 ].

Sensitivity and specificity of prenatal screening test and diagnostic test used in the simulations [ 8 ]. Since the information from those studies was based on samples in the United States and the studies were conducted in and , the value of transferred cost applied in this study needs to be adjusted according to Thailand context and the time of valuation.

The purchasing power and currency adjustment between Thai and the U. The CBA used decision-analytic modeling as an example in Fig. It directly compares current clinical practice in most parts of Thailand, no screening as the base case. The number of cases at each step was used for cost calculation.

At first step, Each group had branching for a further series of actions in case of positivity. For example, DS group consisted of high risk and low risk pregnancies. The low risk had no further test, though consisting of live birth DS and DS with spontaneous abortion. Failure to detect DS could occur at any cascade; and finally not all detected DS accepted intentional abortion. Likewise, of non-DS group, false positive result could occur at any cascade, though it should not lab error, specimen switching ; intentional abortion could also occur though very rare.

Expected events in various situations of , pregnant women in one year see an example of decision tree for model in Fig. Cost for each model in prenatal control of fetal Down syndrome among , pregnancies societal perspective. The important insights gained from this study are: 1 While C-S was the most effective serum screening test, the most cost-beneficial model, from societal perspective, was I-S with NIPS, though the detection rate was slightly lower than C-S plus STS model.

Nevertheless, as a national policy, CBA is better based on societal perspective since taking care of DS child both direct and indirect costs as well as productivity loss due to amniocentesis are all societal burdens. To be most accurate in cost-benefit analysis, the input values must be reliable. As seen in the part I of the same project as this study, screening performance in detecting Down syndrome is significantly different between serum markers based on Caucasian reference range and Thai reference range; for example, false positive rate of Therefore, this new study part II of the same project [ 8 ] used various input values derived from our own reference ranges.

Likewise, though natural pregnancy loss is also slightly different from the western studies [ 13 ], we preferred using our own data. Current clinical practice in obstetrics has shifted the paradigm from a conventional prenatal approach based on invasive procedures, to non-invasive prenatal testing for some fetal aneuploidies via NIPS. Since the rapid spread around the world of prenatal diagnosis based on NIPS, it is time to start thinking how this cutting-edge technology might influence current practice of obstetrics in low-resource countries since NIPS will become available in low-resource countries in the foreseeable future [ 14 ].

Most developing countries have acute limitation of chromosome laboratory and no DS screening, though some countries have DS screening, mostly based on advanced maternal age. MSS is rarely available in the public sector. The main problem is that most poor women cannot access this kind of health care service which is usually available only in the private sector.

In near future, DS will be a genetic condition of higher prevalence among those of lower socioeconomics means in comparison to their counterparts with higher socioeconomic means. Certainly, in developing countries, the percentages of NIPS uptake and serum screening are expected to be low, despite the fact that such models are more cost-beneficial than lack of screening or age-based screening as suggested.

Considering the best model for developing countries, several aspects must be taken into account: feasibility, expertise requirement, simplicity, costs of screening tests and invasive diagnosis, capacity in chromosome lab development etc. Note that this study did not include integrated tests, because of the high costs of double screenings with small additional detection rate.

It also excluded NT and genetic sonogram, because of the need for high expertise, not practical in low resource settings. FTS alone was not suitable since many women had their first visit in late gestation. C-S plus STS was most effective but had higher costs due to the high rate of intermediate risk requiring STS and was complicated by counseling as well as anxiety during waiting for the final risk.

Therefore I-S seems to be more attractive, though with slightly lower detection rate. Moreover, our findings surprisingly indicate that, even in low resource settings, incorporation of the expensive NIPS as a secondary test for high risk women is cost-beneficial, though NIPS as a primary screening is not cost-beneficial and not suitable for developing countries, unless its cost is markedly reduced.

Challengingly, the poorer the country, the higher the need for the availability of NIPS, instead of karyotype laboratories. For example, in Thailand, we may need only one effective NIPS center to serve the entire country, whereas we may need a hundred cytogenetic laboratories, including intensive training of more than technicians to cover the screening of all the , Thai pregnant women each year. To date, our country could not perform chromosome studies more than 20, cases per year.

Therefore, NIPS as a secondary screening is more feasible and more cost-effective to serve an entire country, without the overload of amniocentesis and chromosome laboratories, especially when the cost of NIPS reduces. However, although the CBA derived from this study may not be applied to many other countries with lower or higher resource setting than Thailand, it can serve as a study model for other countries.

Because health care resources are limited, CBA-based modeling must be used to guide resource allocation. Since the current practice using conventional or age-based screening would be the least costly model, decision-makers might tend to refrain from implementing NIPS in national health care. In addition to high accuracy, ease to understand, and safe option, the need for less number of experts and chromosome labs must be taken into account.

Its implementation could directly facilitate the ultimate goal of the national program for prenatal control of fetal DS. The cost-benefit of NIPS is directly related to its costs and the estimated costs of taking care of a life time of DS. Thus, investments in NIPS would in fact be outweighed by a concurrent decrease in health care and societal costs associated with DS.

Note that if we use Caucasian reference ranges of MSS, the false positive rate is very high, leading to a substantial burden of invasive diagnosis as well as fetal loss or expensive NIPS and possibly no cost-benefit. Such effects may not be so serious for the payer perspective but are very serious for societal and government perspectives. Therefore, we strongly recommend the development of the normal reference ranges of the intended population for the formation of a national policy.

The strengths of this study are as follows: 1 CBA was based on the strategy effectiveness data and event probabilities derived from the same population and real situations as well as consideration of the proportion of women with late visits of prenatal care.

The weaknesses of this study are as follows: 1 CBA did not include payer perspective. Bleeding may occur at the time of delivery and postpartum, but the patient may also be at risk following spontaneous pregnancy loss, during diagnostic procedures, and during termination of pregnancy. Women with inherited blood disorders planning a pregnancy should be evaluated by a hematologist and a high-risk obstetrician expert in the management of these disorders.

Congenital disorders of hemostasis require consideration not only for the bleeding risks of the mother: the risk of the fetus having inherited the bleeding tendency must also be taken into consideration. Women at risk of being carriers should have their status determined prior to actively seeking conception.

For autosomal-recessive disorders, paternal testing may be indicated as well. Carrier state and the risk of her fetus should be determined early in pregnancy by genetic testing. Chorionic villus sampling for diagnosis of hemophilia and other inherited bleeding disorders can be performed between 11 and 14 weeks of pregnancy.

Despite autosomal inheritance, women are more commonly diagnosed with von Willebrand disease VWD because of presentation at menarche or postpartum bleeding. For this reason, most patients with type 1 and some patients with type 2 VWD do not require prophylactic administration of concentrates prior to delivery.

Bleeding may occur late and patients should be counseled to report heavy bleeding which may occur for a month or more postpartum. Patients with type 3 VWD and FVIII levels that are low or unmeasurable will require replacement at the time of delivery to prevent hemorrhage and should continue to receive replacement therapy 3 to 4 times daily for at least 3 to 5 days or longer.

Vonvendi, recombinant VWF, was approved in late The use of desmopressin DDAVP antepartum is controversial because of a theoretical risk of vasoconstriction and placental insufficiency. DDAVP may be associated with hyponatremia and seizure, and tachyphylaxis occurs after repeated dosing due to depletion of endothelial stores. DDAVP is sometimes administered to patients with type 1 VWD at delivery, particularly with caesarean section and for several days afterward. Patients with type 2B VWD may develop severe thrombocytopenia, and are at risk of a fall in platelets.

Although a risk of thrombosis has been theorized with administration of DDAVP in these patients, this has not been reported to date. VWF concentrates may be required for delivery and afterward, as well as platelet transfusions, if bleeding does not respond completely to VWF. Published evidence-based guidelines for VWD make recommendations for management during pregnancy including the more uncommon subtypes. Treated patients had the lowest levels. Our current approach of predicting and preventing postpartum hemorrhage appears to be inadequate and in need of further research to determine optimal monitoring and therapy.

Patients with borderline levels may be treated with tranexamic acid, alone or in combination with DDAVP and factor concentrates. There are little data on bleeding risk in women with rare bleeding disorders. In women with FXIII and fibrinogen deficiencies, there may be abnormal placental implantation; an increased risk of antepartum hemorrhage due to placental abruption has been reported.

Other factor deficiencies may also result in bleeding or pregnancy loss. FXI deficiency may be associated with increased risk of miscarriage and postpartum bleeding but high-quality data regarding prophylaxis are not available. Similarly, prophylaxis for deficiencies of FX, FV, and FVII are not well characterized, but may be indicated in women with a history of bleeding complications.

Although women with inherited thrombocytopenia and their progeny are potentially at risk of bleeding, little evidence exists to guide management. A retrospective study of pregnancies in women with 13 different forms of inherited thrombocytopenia found that the thrombocytopenia and bleeding tendency did not worsen during pregnancy. There was no difference from normal women in terms of miscarriages, fetal bleeding, nor preterm births.

Although no mother died, the risk of hemorrhage was increased overall; bleeding varied from mild to very severe and was most closely related to the bleeding history prior to pregnancy. Of affected neonates, only 7 bled at the time of delivery; however, 2 died of cerebral hemorrhage. The fetus with Bernard-Soulier syndrome has been reported to bleed antepartum with fatal consequences, and in utero bleeding risk should be considered.

Similarly, little evidence exists for management of inherited platelet function disorders. Patients with Glanzmann thrombasthenia appear to be at the highest risk of bleeding whereas other defects appear less likely to result in hemorrhage at the time of delivery. The bleeding risk and optimal mode of delivery of a patient with a known bleeding disorder or a hemophilia carrier should be discussed by a team of physicians including the obstetrician, hematologist, anesthesiologist, and pediatrician.

The laboratory should be notified of any specialized testing that will need to be done urgently and the transfusion service and pharmacy alerted to any anticipated special needs. The optimal mode of delivery remains controversial. Although it is agreed that there is no indication for caesarean section in mild bleeding disorders, whether it is indicated in carriers with severe hemophilia who are pregnant with a boy with hemophilia remains under debate.

Thrombocytopenia is second only to anemia as the most common hematologic abnormality encountered during pregnancy. The thrombocytopenia is usually self-limited and rarely requires therapy. Because gestational thrombocytopenia is not immune mediated, it does not improve with corticosteroids or IV immunoglobulin IVIg and if an increase in the platelet count is for some reason necessary, platelet transfusion would be required. Gestational thrombocytopenia must be distinguished from primary immune thrombocytopenia which is managed quite differently and can have significant implications for the health and care of the neonate.

Immune thrombocytopenia may be primary, associated with another autoimmune condition such as systemic lupus erythematosus or antiphospholipid antibody syndrome, and rarely due to lymphoproliferative malignancy. Testing for platelet antibodies is not recommended. Table 1 lists recommended testing for thrombocytopenia in pregnancy. Immune thrombocytopenia may present for the first time or be exacerbated during pregnancy. Therapy should be directed toward maintaining a safe platelet count in the mother as it does not appear to affect the neonatal risk of thrombocytopenia.

IVIg and corticosteroids are first-line therapies and appear to increase platelet counts with similar efficacy and relatively little toxicity for the mother or neonate. Options for treatment of the refractory patient are limited by fetal risk. Azathioprine may be used as a steroid-sparing agent. Use of anti-RhD immune globulin, cyclosporine, and rituximab have all been reported with good outcomes but cannot be routinely recommended. There are several reports of romiplostim therapy in severe refractory thrombocytopenia in pregnancy but further evidence of its safety in pregnancy is required.

The only reliable predictor is the platelet count and course of thrombocytopenia of that of an older sibling. The optimal platelet count at delivery has not been established. Treatment consists of IVIg, sometimes accompanied by platelet transfusions. Reinitiation of breastfeeding and recurrence of thrombocytopenia may suggest antibody transfer. Preeclampsia, hemolysis, elevated liver enzymes, and low platelets, and acute fatty liver of pregnancy are frequently associated with sudden deterioration in maternal and fetal conditions and the mainstay of treatment is delivery of the fetus.

Thrombotic thrombocytopenic purpura may also occur in pregnancy due to congenital deficiency of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 ADAMTS or an autoimmune etiology. The treatment does not differ from that in the nonpregnant patient. Hemolytic uremic syndrome may also present for the first time in pregnancy and may be difficult to distinguish from thrombotic thrombocytopenic purpura. Disseminated intravascular coagulation may complicate pregnancy with placental implantation abnormalities, retained products of conception, or infection.

Treatment is generally supportive of the coagulopathy and resolution of the underlying etiology. Rarely, spontaneous autoantibody-mediated factor deficiencies may present in pregnancy. Factor replacement may require high doses of concentrate and immune suppression.

In patients with mechanical valves, an acquired VWF deficiency may occur and these patients should be screened early in pregnancy or in the planning phase of conception and managed similarly to patients with congenital deficiency. Postpartum hemorrhage requires rapid response, and obstetrical services should develop protocols in preparation for these events. A recent review of the management of postpartum hemorrhage outlines recent progress in readiness, recognition, and management.

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RISKS OF AMNIOCENTESIS

IAI is an independent risk factor for subsequent ruptured membranes after clinically indicated amniocentesis in preterm labor. Prior to. This study was done to determine the best model for developing countries If NIPS was positive, amniocentesis was offered; 4) STS (second. AMNIOCENTESIS FOR FETAL LUNG MATURITY HAS HISTORICALLY BEEN PERFORMED FOR MANY REASONS: uterine and placental complications, maternal comorbidities.