Minerva obstetrics and gynecology最新文献

Background: Controlled ovarian stimulation during in-vitro fertilization (IVF) is personalized based on anticipated hyper, normal, poor response. With respect to poor responders, who are often treated using higher gonadotropin dosing and combination of urinary and recombinant gonadotropins (rFSH) with marginal benefit, we report our experience with a newer, more potent rFSH (Follitropin-δ) undergoing IVF.

Methods: Retrospective analysis of all IVF cycles in which follitropin-δ was used alone or combined with urinary gonadotropins over a 3-year period. Patients were grouped according to the POSEIDON Classification as expected low responders (POSEIDON 3-4; AMH<1.2; N.=45), unexpected low responders (POSEIDON 1-2; retrieval of ≤9 oocytes; N.=67) and those with a normal response (N.=93). Demographic, stimulation (including target number of retrieved oocytes [8 to14]), embryology and clinical outcome parameters (clinical pregnancy rate [CPR], live birth rate [LBR], cumulative live birth rate [cLBR]) were compared.

Results: Those categorized as POSEIDON patients were older, had lower ovarian reserve, were more likely to use a mixed protocol, less likely to reach the target oocytes retrieved (35.7% vs. 51.6%, P<0.001), and had a lower cLBR per patient (29.5% vs. 38.7%, P=0.006) when compared to non-POSEIDON patients. Expected low responders (POSEIDON 3-4) were older and had lower AMH when compared to unexpected low responders (POSEIDON 1-2), but no differences in the target of oocytes retrieved (33.3% vs. 37.3%, P=0.66) and cLBR (28.9% vs. 37.3%, P=0.06) were noted.

Conclusions: In expected low responders, follitropin-δ can be used to optimize oocyte collection and clinical outcome though one may need to deviate from the algorithm-suggested dose. Future studies should explore stimulation modifications in unexpected low responders.

Contraceptive use in adolescence remains a challenging issue. Adolescents are at high risk of unintended pregnancies and sexual transmitted infections. During the past few decades intrauterine devices are recommended from global health organization, including the American Academy of Pediatrics, American College of Obstetricians and Gynecologists and World Health Organization as a method of contraception for adolescents. Intrauterine devices are part of the long-acting reversible contraceptives (LARCs) and include the copper bearing device (CU-IUD) and the levonorgestrel intrauterine system (LNG-IUS). IUDs are a safe and effective contraceptive method for adolescents with a failure rate less than 1%. Their use is not limited only in contraception. LNG-IUS 52 mg is approved for treating heavy menstrual bleeding and protection from endometrial hyperplasia in women receiving hormone replacement therapy. It can also be an effective tool in the management of dysmenorrhea, while CU-IUD can provide emergency contraception. Nevertheless, IUDs remain underutilized in this group of population. Adolescents' lack of proper education about contraception and sexual behavior creates myths and misconceptions about the possible side effects and the suitability of IUDs in this age group. Furthermore, health care providers remain skeptical and hesitate to suggest IUDs to adolescents. Other barriers including high cost, concern about confidentiality and difficulties in access contribute to its limited use. It is of high importance to eliminate barriers and offer more accessible contraceptive services to adolescents.

Background: The aim of this study was to determine factors involved in urinary incontinence (UI), and psychological resilience in postmenopausal women.

Methods: In this cross-sectional study, 137 postmenopausal women (aged 50-75 years) filled out the 4-item International Consultation on Incontinence Questionnaire short form (ICIQ-SF), the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10), the 10-item Connor-Davidson Resilience Scale (CD-RISC), and a questionnaire containing personal data. We designed a directed acyclic graph (DAG) to identify covariates related to urinary incontinence and resilience in postmenopausal women.

Results: The mean age of all surveyed women was 58.7±5.1 years, the majority were Caucasian (92.7%). There was an inverse correlation between item-1 ICIQ-SF scores and CD-RISC Scores. Women with severe UI had a higher median total ICIQ-SF score and lower total CD-RISC Scores as compared to those with nil or mild (P<0.05 for both). Odds ratios of sociodemographic and clinical characteristics indicate that phytoestrogen use (OR: 10.80; 95% CI 2.42-48.13) and economic problems (OR: 2.46; 95% CI 1.22-4.93) were associated with UI. However, a multivariable logistic model only identified urinary incontinence significantly associated with phytoestrogen use and age (P<0.05). The effect of other variables was attenuated in the model when controlling for population confounders, and significance was not achieved.

Conclusions: Urinary incontinence was significantly associated with economic problems, phytoestrogen use, and depressive symptoms compared to women without urinary complaints. The multivariable logistic model confirmed age and phytoestrogen use as causal factors for urinary incontinence.

Background: The mean wait time for new patient appointments has been growing across specialties, including obstetrics and gynecology, in recent years. This study aimed to assess the impact of insurance type (Medicaid versus commercial insurance) on new patient appointment wait times in general obstetrics and gynecology practices.

Methods: A cross-sectional study used covert mystery calls to general obstetrician gynecologists. Physicians were selected from the American College of Obstetricians and Gynecologists directory and stratified by districts to ensure nationwide representation. Wait times for new patient appointments were collected and analyzed.

Results: Regardless of insurance type, the mean wait time for all obstetrician gynecologists was 29.9 business days. Medicaid patients experienced a marginally longer wait time of 4.8% (Ratio: 1.048). While no statistically significant difference in wait times based on insurance type was observed (P=0.39), the data revealed other impactful factors. Younger physicians and those in university-based practices had longer wait times. The gender of the physician also influenced wait times, with female physicians having a mean wait time of 34.7 days compared to 22.7 days for male physicians (P=0.03). Additionally, geographical variations were noted, with physicians in American College of Obstetricians and Gynecologists District I (Atlantic Provinces, CT, ME, MA, NH, RI, VT) having the longest mean wait times and those in District III (DE, NJ, PA) the shortest.

Conclusions: While the type of insurance did not significantly influence the wait times for general obstetrics and gynecology appointments, physician demographic and geographic factors did.

Background: Cesarean scar pregnancy (CSP), a rare iatrogenic form of ectopic pregnancy (EP), cause of severe maternal morbidity. Each subtype of CSP needs different treatment and there is no consensus about this topic. Despite improvements, the lack of universally accepted therapeutic management and discordance present in literature indicates that treatment has been mainly based on experiences reported.

Methods: A case series of our double combined approach with methotrexate (MTX) administration followed by vacuum aspiration or resectoscopic approach was reported, with an overview of literature. Eleven patients with CSP underwent a double-step treatment: systemic MTX therapy followed by vacuum aspiration or by resectoscopy, if the gestational sac was embedded deeply in myometrium. For CSP type 1, according to Delphi sonographic classification, with minor potentially risk of complications with a myometrial thickness >3.5 mm, we preferred to adopt vacuum aspiration, while type 2-3 of CSP and myometrial thickness ≤3.5mm were managed with resectoscopy.

Results: The average gestational age was 59.1±7.22 days. On the seventh day after MTX administration, the serum β hCG levels decreased in 80% of all patients. After the MTX injection, the CSP mass did not disappear in any patient. MTX therapy was followed by vacuum aspiration in six and by resectoscopy in five cases. In one case bleeding was controlled by Foley balloon treated with vacuum. In type II-III, CSP was performed UAE (uterine artery embolization) followed by resectoscopy procedure.

Conclusions: Compared with the results in previous studies, MTX administration followed by suction curettage was more effective than dilatation and curettage and systemic MTX in treatment of CSP. We consider very useful this procedure in case of slow absorption and when the camera was embedded deeply in myometrium (CSP2-3), because that hysteroscopy evaluation of uterine cavity under direct vision is highly accurate in identifying the real cleavage of the gestational camera. We have only used vacuum aspiration in CSP type 1 for minor risk of bleeding.

Background: Clinical stages, histologic type, degree of cell differentiation, myometrial invasion, and lymph-vascular space invasion (LVSI) have been identified as clinicopathological factors that are predictive for endometrial cancer, however, further prognostic indicators are still required to account for the heterogeneity of this cancer. Adhesion molecule CD44, affects the invasion, metastasis, and prognosis of many forms of cancer. The purpose of this study is to examine the expression of CD44 in endometrial cancer and its correlation with established prognostic variables.

Methods: A cross-sectional study was conducted on 64 samples of endometrial cancer from Wahidin Sudirohusodo Hospital and Hasanuddin University Hospital. Immunohistochemical analysis was used to detect CD44 expression using mouse anti-human CD44 monoclonal antibody. Differences in Histoscore were studied to determine the association between CD44 expression and clinicopathological factors of endometrial cancer.

Results: Of the overall sample, 46 samples were in the early stage, whereas 18 samples were in the advanced stage. High expression of CD44 was associated with advanced stage compare than early stage (P=0.010), poor differentiation compare than well-moderate differentiation (P=0.001), myometrial invasion ≥50% compare than myometrial invasion <50% (P=0.004), and positive LVSI compare than negative LVSI (P=0.043) in endometrial cancer, but not associated with histological type of endometrial cancer (P=0.178).

Conclusions: High expression of CD44 may be considered as a poor prognostic marker and predictive marker for targeted therapy in endometrial cancer.

Introduction: Gestational diabetes mellitus is the most common metabolic disorder in pregnancy, and it is associated with detrimental short- and long-term consequences to both the fetus and the mother. Some studies in the literature have found an association between the identification of fetal hyperechogenic pancreas via prenatal ultrasound and the presence of gestational diabetes mellitus. The aim of our study was to assess the association of fetal hyperechogenic pancreas with gestational diabetes mellitus using the meta-analytic method.

Evidence acquisition: We searched electronic databases for articles describing association (or lack of) between fetal hyperechogenic pancreas and gestational diabetes mellitus. For each study, we identified patients with or without fetal hyperechogenic pancreas and with or without gestational diabetes mellitus. We then calculated risk ratios for gestational diabetes mellitus using the meta-analytic Mantel-Haenszel method with a random effect to estimate the risk ratio.

Evidence synthesis: We identified 286 patients in 2 studies. The risk ratio of gestational diabetes mellitus in women with fetal hyperechogenic pancreas was 3.34, P<0.0001 (95% CI, 1.56-7.17; I²=82% [95% CI 22.7-95.7%]).

Conclusions: The presence of a fetal hyperechogenic pancreas was associated with gestational diabetes mellitus. We concluded that the detection of fetal pancreas echogenicity may be a promising indicator of gestational diabetes mellitus that, pending further research studies, can potentially help the clinician in making this diagnosis.

Background: We seek to identify risk factors associated with abnormal umbilical artery cord gas (UACG).

Methods: This was a secondary analysis of the multicenter Consortium for Safe Labor dataset. This study included singleton, term deliveries with UACG available. Abnormal UACG was defined as pH≤7.0 or base excess >12 mmol/L. Odds Ratios were calculated using a multivariable logistic regression to determine clinical factors associated with abnormal UACG.

Results: 18,589 patients met inclusion criteria, with approximately 2% having an abnormal UACG. Those with prior Cesarean delivery (OR=1.49, 95% CI: 1.15-1.93), maternal diabetes (OR=1.67, 95% CI: 1.06-2.64), magnesium sulfate use (OR=1.81, 95% CI: 1.25-2.60), current Cesarean delivery (OR=2.56, 95% CI: 2.06-3.19), pre-eclampsia/HELLP (hemolysis, elevate liver enzymes, low platelet count) syndrome (OR=2.80, 95% CI: 1.79-4.36), and placental abruption (OR=4.81, 95% CI: 3.35-6.91) had increased odds of having abnormal UACG at delivery compared to those without.

Conclusions: Diabetes, pre-eclampsia, placental abruption, and a history of prior Cesarean delivery were all associated with abnormal UACG in this cohort of singleton, term deliveries. These findings indicate that patients with pre-existing risk factors may be at an increased likelihood of adverse neonatal outcomes.

Background: Iron deficiency and iron deficiency anemia represent global health issues, particularly during pregnancy and the postpartum. The present paper aims to summarize the appropriate management of these conditions in order to try to improve how clinicians perceive, diagnose and treat iron deficiency and iron deficiency anemia.

Methods: An expert panel of Italian obstetricians of Lazio region was convened to evaluate the available literature on iron deficiency and iron deficiency anemia during pregnancy and the post-partum in order to try to define a flow chart on the appropriate management of such conditions; aspects related to the patient blood management have also been investigated.

Results: According to both hemoglobin level and ferritin values, five the flow charts on the appropriate management of iron deficiency and iron deficiency anemia have been drawn.

Conclusions: It is desired to define appropriate flow charts to treat iron deficiency and iron deficiency anemia, which are too often not promptly diagnosed and managed, in order to try to improve antenatal care.