Minerva obstetrics and gynecology最新文献

Background: The relationship between perioperative antibiotic choice and surgical site infection (SSI) associated with hysterectomy warrants more investigation on a national scale.

Methods: This was a retrospective cohort study utilizing data from the Premier Healthcare Database. Overall, 242,349 patients were identified using CPT codes who underwent hysterectomy for benign indications between January 2000 and March 2020. Patients were grouped by antibiotic regimen and characteristics and surgical information and postoperative complications were collected. Multivariable logistic regression and inverse probability of treatment weighted analysis (IPTW) were performed.

Results: The most utilized prophylaxis was cefazolin alone (67.3%). About 3.9% of patients received cefazolin with metronidazole and 28.8% received other antibiotics. There were significantly more episodes of SSI at 1 month in those receiving other antibiotics when compared to those receiving either cefazolin or cefazolin with metronidazole (P<0.001). Multivariable logistic regression revealed a significant relationship between SSI and tobacco use, obesity, Charlson Comorbidity Index, and diabetes. Cefazolin with metronidazole was associated with a similar probability of developing SSI as cefazolin alone (OR 0.98, P=0.90). After IPTW, the probability of SSI at 1 month was not significantly different between cefazolin and cefazolin with metronidazole (OR 1.003, 95% CI: [0.81, 1.24]).

Conclusions: After weighting based on preoperative characteristics, the addition of metronidazole to cefazolin for prophylaxis at the time of hysterectomy did not significantly decrease the probability of developing SSI compared to cefazolin alone. Any regimen of antibiotics other than cefazolin or cefazolin with metronidazole was associated with increased probability of SSI.

Background: Different gonadotropins (Gn) have been developed to stimulate the ovaries as part of in-vitro fertilization (IVF). Studies comparing these formulations in poor responders are limited. The objective of this study was to evaluate clinical outcomes comparing follitropin-δ to follitropin-α in expected poor responders.

Methods: Retrospective analysis of IVF cycles in expected poor responders, identified based on the POSEIDON criteria (women with low ovarian reserve - POSEIDON groups 3 and 4) that reached the oocyte collection between January 2020 to December 2022. Clinical outcomes were compared between those using follitropin-δ or follitropin-α and a sub analysis based on POSEIDON subgroup was performed. Chi square, Student's t-test, and Mann-Whitney Test were used.

Results: In total, 279 cycles were included. While those using follitropin-δ (N.=49) compared to follitropin-α (N.=230) had more oocytes collected (P=0.002), the number of good quality embryos was similar and clinical outcomes including fresh (24.5% vs. 18.2%, P=0.31) and cumulative live birth rate (30.6% vs. 23.0%, P=0.26) were comparable. Among POSEIDON 3 patients utilizing follitropin-δ, while the number of good quality embryos was higher (P=0.04), pregnancy outcomes were comparable. Among POSEIDON 4 patients using follitropin-δ, there were more MII oocytes (P<0.001) and embryos (P=0.007), however pregnancy outcomes were comparable.

Conclusions: The treatment of poor responders is often challenging. Among POSEIDON 3-4 patients undergoing IVF, follitropin-δ appears to result in similar pregnancy outcomes as follitropin-α. Future studies should compare different drug doses and the potential benefits of combination regimens in these well-defined poor ovarian response patients.

Introduction: Considering the prevalence and the importance of low ovarian response, it is important to update the evidence base on whether using higher compared to lower starting doses of gonadotrophins during ovarian stimulation of patients expected to exhibit low ovarian response is beneficial.

Evidence acquisition: A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed by performing literature search until December 2024 in MEDLINE, Embase, Cochrane CENTRAL, Scopus, Web of Science and Clinicaltrials.gov. The primary outcome was live birth. Secondary outcomes included clinical and ongoing pregnancy, cumulative live birth, clinical and ongoing pregnancy, number of oocytes retrieved and number of usable embryos.

Evidence synthesis: Six eligible RCTs were identified (N.=2262). No significant difference was observed in live birth rates (RR: 0.96, 95% CI: 0.80-1.15; I²=0%, 2 studies, N.=1171), ongoing pregnancy rates (RR: 0.99, 95% CI: 0.81-1.19; I²=0%, 3 studies, N.=775), clinical pregnancy rates (RR: 1.04, 95% CI: 0.89-1.21; I²=0%, 5 studies, N.=1179) and the number of oocytes retrieved (WMD: -0.61, 95% CI: -2.52 to +1.31; I²=86.6%, 4 studies, N.=1286) between the groups compared. A lower number of usable embryos was observed (WMD: -0.38, 95% CI: -0.63 to -0.13; I²=0%, 3 studies, N.=1223) when using a lower compared to a higher starting dose of gonadotrophins in expected low responders undergoing ovarian stimulation for IVF/ICSI.

Conclusions: The available evidence is currently insufficient to conclude whether the use of a higher starting dose of gonadotrophins is beneficial in terms of live birth rates for patients expected to exhibit low response after ovarian stimulation.

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.

Background: Vulvodynia is a chronic painful entity that poses diagnostic and therapeutic challenges. The aim of this work was to describe the characteristics of women affected by vulvodynia and to estimate the effectiveness of currently available therapeutic options.

Methods: A retrospective observational study has been carried out with a sample of 50 women who presented vulvodynia at a chronic pelvic pain unit between 2019 and 2021.

Results: The mean age at diagnosis was 38.44 years. Mean delay to diagnosis was 29.82 months. According to the classification currently used, vulvodynia was mainly localized, provoked, intermittent, and immediate. Most of the women also reported dyspareunia with mean baseline pain and dyspareunia according to the Visual Analog Scale (VAS) of 4 and 8, respectively. Among the therapeutic options used, neuromodulatory drugs have shown to be effective in symptom control and improving quality of life both at 6 and 12 months. At 24 months improvement in dyspareunia was not statistically significant, probably due to the small sample size due to losses in the follow-up. Non-pharmacological treatments such as physical therapy and cognitive behavioral therapy may also play a role in symptom improvement.

Conclusions: Most of the available evidence is based on retrospective studies. Quality randomized clinical trials are necessary to better test the efficacy of treatments, especially neuromodulatory drugs.

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.

The etiopathogenesis of endometriosis, a chronic debilitating disease affecting nearly 10% of women, has evaded elucidation until the recent epigenetic discoveries. Although still deemed multifactorial, endometriosis is likely predisposed in women with genetic and epigenetic alterations, which are activated by environmental factors. There are many epigenetic changes that have recently been associated with endometriosis: DNA methylation and phosphorylation, modifications to histones and non-coding RNA, and chromatin remodeling and organization. Gene markers, such as HOXA10, SF-1, and GATA transcription factors, are also debatably correlated to endometriosis. An improved understanding of the etiopathogenesis of endometriosis may propel our field toward our objectives: sooner and more efficient detection as well as targeted therapy. In this comprehensive review, we will identify and discuss the current literature on epigenetic changes seen in endometriosis. A primary computerized search was performed on PubMed and Google scholar of publications from 1990 to 2022. We searched for keyword terms such as "endometriosis" and "endometriosis epigenetics." We also looked through the references of prior articles to find other relevant articles to this topic. Articles were categorized by type of epigenetic change found such as DNA hypo- or hyper- methylation, histone hyper- or hypo-acetylation, chromatin remodeling, and non-coding RNA-mediated down-regulation and the research was elaborated in sections based on the type of epigenetic change. There are many articles on TET, DNMTs, EZH2, HDACs, HATs, let-7 family, miRNAs, Hox proteins, GATA family, sirtuins (e.g. SIRT1, SIRT3), ARID1A, SF-1, USF1, USF2, STRA6, ESR1, ESR2, PGR, ALDHIA2, and CTCF; however, the studies analyzed in this review were heterogeneous in comparison populations, analysis methods, tissues types (e.g. endometriomas, ectopic endometriotic tissue, eutopic endometrial tissue). Due to this, it is difficult to synthesize over-arching conclusions based on the current literature; however, there are many epigenetic changes and genes linked to endometriosis as noted in the literature.

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.