Clinical obstetrics and gynecology最新文献

Spina bifida, particularly myelomeningocele (MMC), represents a severe congenital anomaly with lifelong consequences. Advances in imaging and screening have improved prenatal detection, enabling early counseling and intervention. Over the past 2 decades, fetal surgical repair has transformed outcomes, as demonstrated by the Management of Myelomeningocele Study (MOMS), with reduced cerebrospinal shunting and improved motor function. However, fetal surgery carries maternal and fetal risks, including preterm delivery and uterine complications. This review examines current evidence on fetal open spina bifida repair, discusses patient selection, long-term outcomes, and emerging innovations, and highlights ongoing ethical and accessibility challenges.

The evolution of prenatal genetic testing has transformed prenatal diagnosis into a more precise and individualized approach. Advanced tools such as chromosomal microarray analysis and exome sequencing have enabled the prenatal diagnosis of more genetic conditions, including anomalies and disorders eligible for fetal therapy. When in utero therapy is considered, accurate genetic diagnosis is essential for guiding providers' and patients' decisions regarding management and outcomes. This chapter reviews available prenatal genetic screens and tests, their indications, and counseling strategies. It also explores genetic abnormalities associated with fetal structural anomalies and their implications for decision-making in fetal interventions.

Vasa previa is an uncommon, potentially life-threatening condition where fetal vessels traverse the membranes over the cervix without Wharton jelly protection, risking fetal exsanguination if undiagnosed. Prenatal ultrasound and planned preterm cesarean reduce perinatal mortality to under 1%, though concerns about prematurity persist. Fetoscopic laser photocoagulation, initially used for twin-twin transfusion syndrome, shows promise in select cases, potentially allowing vaginal delivery at term. This review examines vasa previa management, the feasibility of laser therapy, and its risks. While early data are promising, further studies, including the FLUMEN trial, are needed to determine the safety and efficacy of this intervention.

Transmasculine individuals require patient-centered and shared decision-making approaches to address menstrual suppression and contraceptive needs. Gender-affirming testosterone therapy may be utilized by individuals to achieve menstrual suppression but is not a reliable form of contraception. While menstrual suppression and contraception are not mutually exclusive, this article provides a framework to help determine patient goals and points of consideration when selecting treatments. A table (Table 1) and decision tree (Fig. 1) of options are provided to assist clinicians in addressing a patient's unique reproductive needs with a focus on individualized and informed care.

As visibility of transfeminine individuals increases, so does the need for inclusive and competent gender-affirming health care. Regardless of a patient's stage during their transition, gynecologists are essential health care providers for transfeminine patients. With the proper education and training, gynecologists can provide gender-affirming hormone therapy, assess and manage postoperative complications, and conduct routine health screening. The goal of this article is to provide an overview of available feminizing hormone therapies and effects, review feminizing surgical procedures, discuss the management of their complications, and highlight evidence-based screening recommendations for transfeminine patients.

Congenital heart disease is the most common major congenital abnormality with a prevalence of ∼1% of all live births and is associated with a high perinatal and long-term postnatal morbidity and mortality. This review describes recent results regarding invasive and noninvasive interventions for cardiac anomalies during gestation. Early diagnosis and intervention remain crucial for optimizing fetal outcomes and for reducing the risk of long-term cardiovascular sequelae.

Advances in prenatal diagnostics, imaging, and surgical techniques have accelerated maternal-fetal interventions (MFI), fetal care centers, and expanded options for families. Progress in this field has also raised ethical issues surrounding maternal autonomy, informed consent and decision-making, innovation versus research, equitable access, and disability and reproductive rights. We review ethical frameworks to evaluate MFIs, from innovation to research and, ideally, clinical practice. Necessary oversight and resources are summarized to promote ethical, equitable innovation and research while protecting maternal autonomy and supporting the informed consent and decision-making process. Additional implications amidst abortion restrictions are discussed, along with areas for future research.