Minerva obstetrics and gynecology最新文献

Episiotomy is a common surgical procedure during childbirth that involves incising the woman's perineum to facilitate the passage of the fetus. This procedure is used to speed up the delivery, but only in emergencies. It has been reported that explicit consent is unnecessary when the woman in labor is subresponsive or unresponsive. This manuscript analyzes and describes ethical issues regarding the need for explicit consent to use this procedure. The analysis has been made from two perspectives: applying the principlist approach, a system of biomedical ethics that uses the four bioethical principles formulated by Childress and Beauchamp and the principle of vulnerability in its complex relationship with the concepts of dependence and care as articulated in the Barcelona Declaration of 1998. Based on our analysis, we conclude that explicit consent is a fundamental prerequisite in medical practice that should always be sought, even in complex situations such as performing an episiotomy. A table reporting recommendations to enhance communication with the woman throughout the prenatal phase and during labor has also been provided to improve informed consent processes and ensure more effective patient engagement and decision-making.

Introduction: Polycystic ovary syndrome (PCOS) is a multifactorial endocrine-metabolic disease that requires pharmacological and non-pharmacological treatments. The aim of this paper is to review the major evidence about current lifestyle and dietary approaches to manage this syndrome.

Evidence acquisition: We include in our research the most relevant publications about lifestyle and diet in PCOS published between 1995 and 2025.

Evidence synthesis: According to the most recent recommendations, regular physical activity is crucial to ameliorate hormonal and metabolic parameters as well as to maintain and/or reduce weight in PCOS women. As for the foods, although there is not agreement on a specific diet, low-glycemic index nutrients associated with high fiber intake should be generally preferred in hyperinsulinemic patients.

Conclusions: In conclusion, suggestions about lifestyle and diet should represent a cornerstone of the personalized multi-step therapy of PCOS.

Introduction: Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting reproductive-aged women, which is associated with a significantly higher risk of developing cardiometabolic abnormalities. The present review is aimed to understand the different mechanism related to the cardiometabolic alteration of women with PCOS.

Evidence acquisition: A literature search was made on terms encompassing PCOS, hyperandrogenism, obesity, lipid metabolism, insulin resistance, inflammation, oxidative stress, gut microbiota, cardiovascular event, and mortality.

Evidence synthesis: Hyperandrogenism is the key signature of women with PCOS. Androgens by reducing the intracellular signal of insulin, induce an insulin resistance that is compensated by hyperinsulinemia. Hyperinsulinemia and insulin resistance are the key determinants of the metabolic syndrome and therefore of the cardiovascular risk. Obesity, oxidative stress and chronic inflammation further increase insulin resistance and represent adjunctive pejorative risk factors. Modification of gut microbiota is common in women with PCOS, and it is consequent to hyperandrogenism and obesity. Gut dysbiosis contributes to induce metabolic alterations. In women with PCOS the cardiovascular risk depends upon syndrome manifestation. The risk is maximal in hyperandrogenic obese anovulatory women, milder in hyperandrogenic non obese women, and is not increased in non-hyperandrogenic PCOS women.

Conclusions: Among PCOS women, phenotypes characterized by hyperandrogenism, anovulation and obesity are at high risk of cardiometabolic alterations. In general, a careful investigation on the presence of cardiovascular risk factors, and the use of appropriate remedies to reduce them, is useful in all PCOS women with hyperandrogenism, and in particular in those with associated anovulation and obesity.

Background: Congenital anomalies of the kidney and urinary tract (CAKUT) represent 15-20% of prenatally diagnosed congenital anomalies, often presenting unilaterally. This study aimed to describe sonographic features of fetuses with unilateral renal anomalies and evaluate their postnatal outcomes. Additionally, we assessed whether specific prenatal ultrasound findings predicted postnatal complications.

Methods: This was a retrospective, observational study including singleton pregnancies referred to our center from 2008 to 2023 for unilateral renal anomalies identified in second or third trimester ultrasounds. Sequential prenatal ultrasound evaluations were conducted to monitor disease progression and associated anomalies. Postnatal outcomes were retrieved from delivery records and pediatric follow-ups. Statistical analyses included Chi-square tests, t-tests, and ROC curve analysis to assess the predictive value of the antero-posterior diameter (DAP) of the renal pelvis for postnatal complications.

Results: A total of 226 cases were included: 116 (51.3%) pyelectases, 51 (22.6%) hydroureteronephroses, 48 (21.2%) multicystic kidneys, and 11 (4.9%) renal dysplasias. Diagnosis occurred at an average gestational age of 25 weeks, with 19.3% showing progression during pregnancy and 23% having associated anomalies detected during ultrasound examinations. Of 135 children with follow-up data, 47.4% required surgery, 1.5% developed hypertension, and 1.5% developed chronic kidney disease (CKD). Associated anomalies significantly correlated with unfavorable outcomes, such as need for intervention (P=0.001), risk of developing postnatal recurrent urinary infections (P=0.025), vesicoureteral reflux (P=0.001) and CKD (P=0.010). Progression during pregnancy correlated with vesicoureteral reflux (P=0.002) and development of anomalies in the contralateral kidney (P=0.012). DAP measurement did not reliably predict postnatal complications (AUC=0.590, P=0.191).

Conclusions: Unilateral renal anomalies are often associated with other congenital anomalies, influencing postnatal outcomes. DAP measurement was not a significant predictor of postnatal complications. Comprehensive prenatal ultrasound assessments are critical for guiding parental counseling, pregnancy management, and postnatal care.

Introduction: Polycystic ovary syndrome (PCOS) is a common endocrinological disorder and is frequently associated with other medical conditions such as hyperinsulinemia and obesity. The aim of this review is to identify the role of PCOS as a potential risk factor for endometrial, breast and ovarian cancer.

Evidence acquisition: A literature search was conducted including most relevant peer-reviewed articles regarding the possible association between PCOS and gynecological cancer published from 1996 to the present.

Evidence synthesis: A narrative synthesis was performed. PCOS is linked to an increased risk of endometrial cancer. However, the risk varies based on factors like BMI, parity, and phenotype. The association between PCOS and ovarian cancer is uncertain. Some studies suggest a two-fold increased risk, particularly in women with infertility or treated for infertility, but more recent reviews find no clear association. The role of androgen and estrogen imbalances in different ovarian cancer types remains debated. Even the link between PCOS and breast cancer is unclear. While high androgen levels are theorized to play a role, local hormone conversion and factors like weight, environment, and genetics are likely more important.

Conclusions: The association between PCOS and gynecological cancers is complex. Further reviews and new studies that control individual confounding factors are needed to accurately establish the real oncological risk of PCOS.

Background: The aim of this study is to determine the human oocyte CCs global transcriptome sequencing and its correlation of embryo development to the blastocyst-stage.

Methods: Expanded cumulus granulosa cells (CGC) that surround metaphase 2 were collected and cryopreserved until analysis. Their corresponding oocytes trajectories were followed up to the blastocyst stage. From each patient, CGCs of oocyte that developed to the blastocyst stage and one that was arrested (sibling oocytes) were analyzed. Global transcriptome sequencing (NEBNext^® Single Cell/Low Input RNA Library Prep Kit for Illumina) was compared between CGCs of oocytes that developed to the blastocyst stage and those that were arrested.

Results: Seven patients aged 31.4+2.5 years donated CGCs. The Differential Gene Expression Analysis identified five genes that were differentially expressed between blastocyst and arrested CGCs. The most significantly differentially expressed gene was AL031598.1 (padj = 8.40e-03, log2FC = 5.76), followed by AC126773.5 (padj = 1.83e-02, log2FC = 6.63), CBLN2 (padj = 2.62e-02, log2FC = -6.24), AL022721.1 (padj = 3.28e-02, log2FC = 5.73), and AC093334.1 (padj = 8.53e-02, log2FC = 6.07). Among these genes, CBLN2 was the only one showing significant downregulation in the blastocyst group, while the other four genes demonstrated substantial upregulation.

Conclusions: This study provides valuable insights into the transcriptional landscape of CGC from oocytes that develop to different stages, revealing key genes and long non-coding RNAs that may serve as markers for oocyte quality and its potential to develop to the blastocyst stage. Future research with larger cohorts and independent validation methods is necessary to confirm these findings and their potential application in fertility treatments.

Endometrial carcinoma (EC) is the most common gynecologic malignancy in the USA, with surgical staging as the cornerstone of treatment. Although most patients are diagnosed at an early stage, adjuvant therapies, including external beam radiation therapy (EBRT), vaginal brachytherapy (VBT), and systemic treatments, are employed in select cases to reduce recurrence risk. This review highlights data from randomized controlled trials assessing the efficacy of adjuvant radiotherapy in early-stage EC. For low-risk EC, studies suggest that postoperative brachytherapy has minimal impact on locoregional recurrence and is not recommended without significant uterine risk factors. In intermediate-risk EC, trials such as GOG 99 and PORTEC-1 demonstrated reduced recurrence with pelvic RT, particularly in high-intermediate risk subsets, though overall survival benefits were not observed. For high-intermediate risk EC, PORTEC-2 showed that VBT effectively controls vaginal recurrence with less morbidity compared to EBRT, recommending VBT as the preferred modality. Medium-risk cases benefit similarly from VBT alone, as shown in Swedish trials. In high-risk EC, RCTs such as GOG 249 and PORTEC-3 examined the addition of chemotherapy to radiotherapy, finding comparable recurrence and survival outcomes between VBT with chemotherapy and EBRT, though acute toxicity was higher with combined therapy. Across these trials, the degree of lymphovascular space invasion (LVSI), patient age, tumor grade, and histology were key prognostic factors influencing treatment recommendations. Despite advancements in molecular classification and modern radiotherapy techniques, most data derive from earlier studies, emphasizing the need for updated research to refine treatment paradigms.

Background: Advanced ovarian cancer is the deadliest gynecological malignancy, with treatment combining cytoreductive surgery and platinum/taxane chemotherapy. Surgical success is defined by residual tumor size, but visual assessment may underestimate residual disease. Postoperative computed tomography (CT) scans can detect residual tumors in up to 49% of cases initially deemed tumor-free. Structured radiologic reporting, such as the Peritoneal Carcinomatosis Index (PCI), improves accuracy and prognosis correlation. This study aims to validate a simplified structured reporting method based on the Lakhman index.

Methods: Patients with advanced ovarian cancer (FIGO stages II and IV) diagnosed between 2007 and 2019 at Hospital La Fe Valencia were included in the study. All underwent cytoreductive surgery with R0 or R1 outcomes, followed by a postoperative CT scan performed between the third and eighth weeks after surgery and before the initiation of chemotherapy. Two gynecologic oncology-specialized radiologists independently analyzed the CT scans in a double-blind manner. They assessed the images using the Lakhman Index, which divides the abdominopelvic cavity into eight regions. Additionally, they applied the Qualitative Assessment (QA) scale to determine the presence of tumor disease in each region, classifying them as QA 1-2 (definitely/probably normal), QA 3 (indeterminate) and QA 4-5 (probably/definitely metastatic).

Results: The study analyzed a cohort of 117 patients. Radiological evaluation detected macroscopic measurable tumor disease in 44%-49% of patients following optimal primary cytoreduction (R0 or R1). Kappa analysis showed a moderate level of concordance between the two radiologists (0.589). Findings from both radiologists (A and B) were significantly associated with reduced disease-free survival (DFS) and overall survival (OS) in patients with macroscopic disease compared to those without (P<0.05).

Conclusions: The identification of radiological tumor presence on standardized, systematic postoperative CT scans prior to adjuvant chemotherapy is linked to the prognosis of patients with advanced ovarian cancer.

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.

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.