Minerva obstetrics and gynecology最新文献

Background: Numerous studies indicate that non-White individuals and/or those who are of low socioeconomic status (SES) are preferentially prescribed long-acting reversible contraception more frequently than their white counterparts. This cohort is also more likely to have medical and obstetric complications that put them at high risk for adverse pregnancy outcomes due to the systematic racism within the medical system and its interaction with underlying conditions. Medical complications themselves may be a risk factor for contraceptive coercion. We looked to evaluate if contraceptive use and patient perception of contraceptive counseling is impacted by obstetric risk factors for adverse pregnancy outcomes, and if this varies by SES or race/ethnicity.

Methods: This is a retrospective analysis of the National Survey of Family Growth (NSFG) 2017-2019 cohort. Participants were grouped into categories of either high or low risk for adverse birth outcomes. The primary outcome was contraceptive choice. Bivariate comparison was performed using complex survey weighting. Secondary outcomes included participant ratings of provider counseling and respect. Multivariable regression was performed for use of long-acting reversible contraceptives, accounting for demographic variables that were significantly different between groups.

Results: A total of 1655 participants met inclusion criteria for this analysis. Of these participants, 310 were at risk for adverse pregnancy outcomes as defined by study criteria. Participants at risk for adverse pregnancy outcomes were more likely to receive public assistance, have fewer years of formal education, and were less likely to report having "good" or "excellent health". There were no differences in the types of contraceptives used in the last 12 months between those at high risk for adverse pregnancy outcomes and those with low risk. Between groups, there were no differences of participant ratings of provider counseling and respect.

Conclusions: Participants in the NSFG reported no differences in contraceptive methods when comparing those at high risk for adverse pregnancy outcomes as compared to those with low risk.

Introduction: The objective of this study was to perform a systematic review to assess whether metformin therapy in patients diagnosed with gestational diabetes mellitus (GDM) in early pregnancy is associated with improved perinatal outcomes. We searched Ovid MEDLINE, Scopus, and Cochrane library (inclusive of ClinicalTrials.gov) from inception through November 29, 2023. We included all randomized trials that assessed metformin use in early GDM.

Evidence acquisition: The 3665 results produced from the database searches were imported into Covidence, a systematic review screening tool, and duplicates were removed. The remaining 2731 citations were screened by title and abstract against predetermined inclusion and exclusion criteria by 2 independent reviewers with discrepancies resolved after group discussion. After screening was completed, 46 studies underwent full text review, with 1 study eligible for inclusion.

Evidence synthesis: The included study showed no difference in a composite adverse perinatal outcome between those diagnosed with early GDM and treated with metformin (59.3%) vs. placebo (57.1%).

Conclusions: There is a paucity of data regarding the management of early GDM and the lack of standardization in its definition for this condition.

Background: Surgical audits are quality improvement initiatives developed to enhance the quality of surgical care and to highlight sub-optimal local practices. The aim of this audit was to collate necessary data to track and analyze gynecological surgery complications for quality assurance in operative care.

Methods: A retrospective study of all patients who underwent both elective and emergency gynecological surgery across two health care institutions was undertaken over a 10-year period.

Results: The incidence of complications and mortality was low in a review of over 9000 gynecological surgeries. Patients who underwent major surgeries such as operative laparoscopies and hysterectomies, which made up of 30% of all surgeries, had a longer postoperative mean length of stay - one variable noted was majority of these patients live in remote areas. Other morbidities such as postoperative pneumonia, bradycardia and hypotension related intensive care admissions were associated with obesity and medical co-morbidities. There was no statistical difference in operative complication between elective and emergency surgeries.

Conclusions: The morbidity and mortality associated with modern gynecological surgery occurred infrequently, especially postoperative venous thromboembolism and wound site infection. Implementation of an enhanced recovery after surgery program and an increasing trend in minimally invasive surgery were key practices contributing to this low rate. Future assessments should include comparison of outcomes against local and international outcome databases such as the American College of Surgeons National Surgical Quality Improvement Program for further evaluation.

Polycystic ovary syndrome (PCOS) is a prevalent endocrine-metabolic disorder characterized by hyperandrogenism, chronic anovulation, and polycystic ovarian morphology, affecting 6-10% of women during their reproductive years. It is a leading cause of female infertility, impacting up to 40% of cases. First described in 1935, PCOS manifests with various clinical features, including hirsutism, amenorrhea, and metabolic disturbances. Additionally, PCOS patients exhibit hormonal imbalances and ovarian dysfunction, contributing to the overall clinical picture. Notably, PCOS is linked to metabolic comorbidities like hepatic steatosis, glucose intolerance, dyslipidemia, type 2 diabetes mellitus (T2DM), and hypertension. This review explores the key aspects of PCOS, providing an overview of ovulation induction strategies, including lifestyle modifications, pharmacological interventions, and emerging approaches. The review synthesizes findings from relevant studies. Effective management of PCOS necessitates early detection and intervention to prevent progression to severe health conditions. Evidence underscores the importance of addressing oxidative stress and low-grade inflammation in treatment plans. A holistic approach, including individualized medication, diet, and lifestyle modifications, is crucial for improving insulin resistance, promoting weight loss, enhancing ovulation rates, and addressing broader metabolic concerns. Key therapeutic strategies include insulin sensitizers like metformin, ovulation induction agents like clomiphene citrate (CC) and aromatase inhibitors (AIs) such as letrozole, and the use of gonadotropins for resistant cases. Combining these treatments with dietary and lifestyle interventions, such as an anti-inflammatory diet, nutritional education, and personalized exercise programs, can enhance treatment outcomes. Through an integrated approach, significant improvements in metabolic health and reproductive function for women with PCOS are possible.

Introduction: Polycystic ovary syndrome (PCOS) is a heterogeneous endocrine-metabolic syndrome mainly characterized by ovarian dysfunction, which is only one manifestation of a more complex syndrome with a significant systemic impact.

Evidence acquisition: We review scientific literature on the pathophysiology and diagnosis of PCOS evaluating the most relevant data from original articles, reviews and meta-analyses published until June 2024.

Evidence synthesis: From a pathophysiological point of view, the concurrence of both metabolic aspects, such as insulin resistance and obesity, and hormonal alterations, such as hyperandrogenemia, might produce the most relevant clinical signs and/symptoms of this syndrome, for instance menstrual irregularities, hair loss, acne and hirsutism. In the latest years, many pieces of evidence highlighted the importance of family history and genetics in the development of the syndrome during adolescence and adult life. According to the available data, hypovitaminosis D could play a detrimental role in the pathogenesis and clinical manifestations of PCOS.

Conclusions: PCOS is a challenging endocrine and metabolic dysfunction, due to its different expression among women and to the difficulty in obtaining an accurate diagnosis. The most appropriate approach to women affected by PCOS should involve a multi-step strategy, taking into account the characteristics of each patient, in order to identify the best non-pharmacologic and pharmacologic approach to manage both short- and medium-, and long-term sequelae.

Introduction: Relaxin is a hormone primarily produced by the corpus luteum during pregnancy, and it plays a critical role in various physiological processes related to pregnancy and childbirth.

Evidence acquisition: Studies have suggested a possible link between relaxin levels and preterm birth. Relaxin's effects on the cervix and pelvic ligaments suggest it could influence the mode of delivery. Higher relaxin levels have been hypothesized to facilitate vaginal delivery by promoting cervical ripening and softening of the pelvic ligaments, thereby reducing the need for cesarean sections. The involvement of relaxin in extracellular matrix remodeling suggests it could play a role in placental attachment. Some experimental studies have proposed that aberrant relaxin signaling might contribute to the development of placenta accreta by influencing the invasive properties of trophoblast cells.

Evidence synthesis: The current evidence on relaxin's role in preterm birth, mode of delivery, and placenta accreta is not definitive. While there are plausible mechanisms by which relaxin could influence these outcomes, clinical studies have yet to provide strong, consistent evidence. Future research should focus on well-designed, large-scale studies to better understand the relationship between relaxin levels and these critical pregnancy outcomes.

Conclusions: The focus of this review is to evaluate relaxin as a potential biomarker and its potential future therapeutic applications during pregnancy and consider the limitations that must be addressed in future studies.

Background: Vaginal delivery in twins is feasible but challenging. Successful vaginal delivery of a non-vertex second twin depends on knowledge of specific obstetrical maneuvers. Skill acquisition at the patient's bedside is difficult, making simulation training an integral part of obstetrics and gynecology residency programs.

Methods: This prospective, randomized, controlled, single-center study involved obstetrics and gynecology residents. Group A attended a frontal lecture followed by practical simulation; Group B received digital home learning. One month later, both groups underwent a simulation test to identify fetal small parts using a birth simulator with a fetus model placed in a simulated amniotic cavity. Training was conducted with an actor facilitator and supervised by six specialists, focusing on obtaining information, using external and internal hands. A 25-question Likert scale questionnaire was administered via Google Forms. Metrics evaluated included time to reach foot/feet, number of attempts, and answers on Kirkpatrick levels 1-4.

Results: Twenty-four participants were recruited and randomized into two groups, with five lost to follow-up at the time of the simulation test. Group A required less time for internal podalic version and breech extraction of the second twin (P=0.02) and fewer attempts to reach the foot/feet of the second twin (P=0.01). Supervisor evaluations of "asking information" and "internal hand use" were better in Group A.

Conclusions: Simulation training for the vaginal delivery of a non-vertex second twin is feasible and has a favorable impact on resident performance.

Reproductive failures, such as recurrent pregnancy loss (RPL) and recurrent implantation failures (RIF) are a major challenge for reproductive medicine. The current management of RPL and RIF cases identifies some causes for unsuccessful pregnancy in up to half of patients. Several studies have suggested that immune disorders are responsible for an important portion of unexplained cases of RPL and RIF. Moreover, the immune abnormalities responsible for reproductive failures can be classified into disorders related to autoimmunity and changes in cellular immunity. Antiphospholipid syndrome (APS), testing for antiphospholipid (aPL) antibodies, antinuclear antibodies, and antithyroid antibodies are identified as biomarkers of autoimmunity that can predict reproductive failure. The cellular immune response in cases of RPL and RIF can be investigated through the study of natural killer (NK) cells (uterine and peripheral blood) and T lymphocytes (T helper [Th]-1, Th-2, regulatory T and Th-17 cells). Several types of laboratory assays have been used to evaluate the endometrial immune microenvironment, such as the endometrial immune profile and decidualization score. However, the effectiveness of the treatment of RPL and RIF with immunomodulatory drugs has not yet been confirmed. Recently, a group of experts from the International Federation of Gynecology and Obstetrics and the European Society of Human Reproduction and Embryology recommended the investigation of some immune factors and treatment with immunosuppressants in women with RPL. In conclusion, it is important to consider immune abnormalities when managing women with RPL and RIF. The use of immunotherapies must be personalized and based on a specific diagnosis to obtain favorable outcomes.

Background: Intensive physical activity and rigid dietary regimes can act as modifiers of neuroendocrine axes in women, inducing hormonal disorders and related menstrual irregularities such as functional hypothalamic amenorrhea (FHA). It would be important to evaluate if such disturbances may worsen female fertility. The aim of this study was to evaluate ovarian reserve markers and neuroendocrine axis in young military academy female cadets with years of training and occurrence of FHA.

Methods: This is a prospective pilot study involving young female cadets from the Military Academy training program. Ovarian reserve markers and metabolic and neuroendocrine factors in the early follicular phase were measured with blood tests and transvaginal ultrasound.

Results: The study group consisted of 11 women belonging to the first year of training and the control group of 33 women belonging to the second to sixth year of training. No differences were found about ovarian reserve markers between the two groups. Moreover, the occurrence of FHA did not modify the ovarian reserve compared to eumenorrhea in both groups. Women from the study group showed significantly higher levels of fasting Insulin (42.18±26.14 uUI/mL versus 11.9±10.2 ng/mL, P value <0.001) and insulin-like growth factor 1 (310.06±67.90 uUI/mL versus 248.67±61.57 uUI/mL, P value = 0.015) compared with control group.

Conclusions: Both intense physical training and FHA do not appear to impact the ovarian reserve of young female cadets. Although preliminary, these findings seem reassuring about the reproductive health of these women and their future fertility.

Endometriosis is a chronic gynecological condition which can lead to infertility in women during reproductive age. Endometriosis influences the assisted reproductive technology (ART) outcomes by its impact on oocyte and embryo quality, oocyte numbers and subsequently the embryo numbers and endometrial receptivity. There has been clinical dilemma as to whether it is predominantly the oocyte, or the endometrium which affects the pregnancy outcomes in women with endometriosis. In this review we provide an overview of the effect of endometriosis on the oocyte molecular mechanism, the overall effect of endometriosis and its various stages as well as the effect of endometrioma on the oocyte quality in autologous study models. We have also provided a review of the donor oocyte models to study the effect of endometriosis on the endometrium. While initial small donor oocyte-based model studies suggested a possible major detrimental impact of oocyte quality on ART outcomes in women with endometriosis, the more recent studies have found minimal or no impact of oocyte quality on treatment outcomes. There is growing evidence to suggest an important contributory role of reduced oocyte yield on ART success in women with endometriosis. There is a need to explore whether oocyte yield and not the oocyte quality or endometrial receptivity, is the main reason for lower success in women with endometriosis following ART.