Clinical obstetrics and gynecology最新文献

Fetal growth restriction complicates up to 10% of pregnancies, resulting in significant morbidity and mortality. Biomarkers of placental function, such as PIGF or the sFLT-1/PlGF ratio, are increasingly used in clinical practice, as an adjunct to ultrasound, with an aim of improving detection of the at-risk fetus and reducing morbidity and mortality. Current evidence suggests this combined approach is associated with improved prediction and hence prevention of adverse outcomes such as stillbirth, as well as optimizing delivery timing. Future research should focus on determining thresholds for intervention, possible therapeutic targets for angiogenic markers and provide cost-based analysis. Despite limitations, there is growing evidence to suggest placental biomarkers play an important role in the prenatal management of high-risk pregnancies.

Enhanced recovery after surgery (ERAS) protocols have revolutionized perioperative care, aiming to reduce surgical stress and expedite recovery. In gynecologic surgery, anesthesiologists play a pivotal role in implementing intraoperative strategies that align with ERAS principles. This manuscript delineates evidence-based intraoperative anesthetic management techniques tailored for gynecologic procedures within an ERAS framework, including multimodal analgesia, optimal fluid management, maintenance of normothermia, and lung protective ventilation (Figure 1). The integration of these strategies has demonstrated improvements in patient outcomes, including reduced hospital stays, decreased opioid consumption, and enhanced patient satisfaction.

Selective fetal growth restriction (sFGR) in monochorionic twin pregnancies is a major contributor to perinatal morbidity and mortality with unique pathophysiological mechanisms and management challenges. sFGR is defined by significant intertwin discordance in estimated fetal weight and abnormal Doppler findings, employing the Gratacós classification (types I, II, and III) for risk stratification and management. Epidemiological data indicate sFGR affects 10% to 26% of monochorionic twins, with early-onset cases associated with the highest risk of adverse outcomes. Surveillance strategies include frequent ultrasound and Doppler assessment, and management is tailored to sFGR type, gestational age, and fetal condition. Expectant management is favored for type I sFGR, while type II and III may require fetal intervention, including fetoscopic laser photocoagulation or selective reduction, though practice variation remains substantial. Recent meta-analyses highlight the importance of Doppler progression, gestational age at diagnosis, and ductus venosus findings as predictors of fetal demise. Advances in imaging, biomarkers, and intervention techniques are shaping future practice, but randomized trials are needed to clarify optimal strategies. Controversies persist regarding timing of intervention, ethical considerations, and outcome prediction. In conclusion, individualized, multidisciplinary management is essential, and ongoing research should focus on refining diagnostic criteria, improving neurodevelopmental outcomes, and developing evidence-based guidelines.

Enhanced Recovery After Surgery (ERAS) represents a paradigm shift in perioperative care, emphasizing evidence-based, multimodal strategies to minimize surgical stress and accelerate recovery. Originating in colorectal surgery in the 1990s, ERAS principles have since permeated gynecologic practice, transforming care across benign, oncologic, and urogynecologic procedures. Subspecialty adaptations, including those for minimally invasive surgery, pediatric gynecology, and pelvic floor reconstruction, illustrate the flexibility of ERAS across clinical contexts. By embracing data-driven implementation and interdisciplinary collaboration, ERAS continues to redefine perioperative care in gynecology, delivering measurable improvements in patient recovery and surgical value.

Surgical stress affects the physiology of nearly every organ system. Enhanced recovery after surgery (ERAS) protocols counter these stressors to maintain normal physiology and promote postoperative recovery. In gynecologic surgery, ERAS pathways are associated with many postoperative benefits, including shorter length of stay, decreased pain, faster return of bowel function and both lower complication and readmission rates. This review highlights the current evidence and recommendations regarding postoperative ERAS pathways in gynecologic surgery.

The epidemiology of twin pregnancies has shifted considerably over recent decades. Since 1980, the twin birth rate in the United States has increased by 76%, largely driven by the widespread use of assisted reproductive technologies (ART). This demographic change has reshaped clinical perspectives and evidence on the natural history of twin gestations, underscoring their unique risks and management needs. Twin pregnancies remain associated with a markedly higher risk of adverse outcomes compared with singletons. The perinatal mortality rate is estimated at 16.0 to 17.3 per 1000 births, with fetal growth restriction representing a major contributor. Selective fetal growth restriction (sFGR) complicates up to 10% of dichorionic and 15% of monochorionic twin pregnancies, respectively. Accurate and timely growth assessment is therefore central to surveillance strategies and clinical decision-making in these pregnancies. However, assessing growth in twins presents distinctive challenges. Physiological differences from singletons render singleton-based standards inadequate, often leading to over- or underdiagnosis of pathology. Evidence supports the use of twin-specific growth charts, particularly those stratified by chorionicity, which may improve prognostic accuracy and reduce unnecessary intervention. Additional considerations include intertwin discordance, sFGR, and evolving staging systems such as the Gratacós and modified classifications. The purpose of this review is to critically examine current approaches to fetal growth assessment in twin pregnancies. We summarize the limitations of applying singleton standards, evaluate the evidence supporting twin-specific references, and explore how chorionicity, longitudinal assessment, and Doppler studies can refine diagnosis and management. Finally, we highlight ongoing controversies, international variation in practice, and the need for further validation of diagnostic thresholds.

Risk stratification is a core challenge in fetal growth restriction (FGR) care, in part because FGR does not represent a single diagnosis but instead is a finding that is associated with morbidity. Considerable effort has been invested in the development and study of methods to identify fetuses at risk of morbidity and who warrant intervention across multiple domains: Doppler ultrasound, maternal biomarkers, multivariable modeling, and artificial intelligence. It is likely that the most promising advances will integrate findings from across these domains, but further investigation remains necessary.