Obstetrical & Gynecological Survey最新文献

Importance: The number of patients with various genetic syndromes who are or seek to become pregnant is increasing due to advances in medical care and assisted reproductive technologies. Management of these patients requires multidisciplinary care teams and knowledge of the risks of increased morbidity and mortality. In addition, many of these inheritance patterns are autosomal dominant, with a 50% risk of an offspring inheriting the disorder with each pregnancy.

Objectives: In this first of a 2-part series, common syndromes with connective tissue, muscle, vascular, or skeletal involvement will be discussed regarding surveillance and management of mother and fetus.

Evidence acquisition: A literature search was performed for important updates in the literature regarding management of patients with genetic connective tissue disorders, aortopathies, muscular dystrophies, vascular disorders, and skeletal dysplasias.

Results: Updates have been incorporated since the last publication in 2011, including updated diagnostic criteria for several conditions (such as Marfan syndrome), international guidelines in management of aortopathies and achondroplasia, an expanded section on hypermobile Ehlers-Danlos syndrome, and a new section on familial cerebral cavernous malformation.

Conclusions: Since the last publication, many guidelines have been published or updated regarding management of pregnancies in patients with genetic disorders and are reviewed in this article.

Relevance: Clinicians who care for pregnant patients with genetic disorders should be aware of updated guidelines and recommendations in order to optimize their care during pregnancy.

Importance: Measures of ovarian reserve, particularly anti-Müllerian hormone, have been increasingly and inaccurately utilized as "fertility tests." It is important to understand the available measures of ovarian reserve and how to appropriately interpret and integrate their use into clinical practice.

Objectives: The objectives of this article are to review the process of reproductive aging, define ovarian reserve, describe the available measures of ovarian reserve, and discuss the clinical utility of these measures.

Evidence acquisition: A literature search was performed using the electronic database PubMed. Relevant guidelines, systematic reviews, and original research articles investigating ovarian reserve parameters and their clinical utility were reviewed.

Results: The fecundity of women gradually declines with increasing reproductive age as oocyte quantity and quality decline. Ovarian reserve is defined as the quantity of oocytes remaining in the ovary. Ovarian reserve can be measured indirectly with the use of serum blood tests or ultrasound imaging. Measures of ovarian reserve are clinically useful in several circumstances, particularly for use during fertility treatment and cycles of assisted reproductive technology. However, measures of ovarian reserve are poor predictors of reproductive potential and should not be used as "fertility tests."

Conclusions and relevance: Measures of ovarian reserve are poor predictors of reproductive potential and should not be used as "fertility tests." Age remains a stronger predictor of reproductive success than measures of ovarian reserve.

Importance: Ovarian stem cells (OSCs) represent a promising tool in reproductive medicine, particularly for the treatment of premature ovarian failure and fertility preservation.

Objectives: Herein, we summarize the main characteristics of adult stem cells, their status, needs, and new challenges in the application in reproductive medicine.

Evidence acquisition: Clinical studies have shown that OSCs transplantation can restore ovarian function and stimulate neo-folliculogenesis in patients with premature ovarian failure, enabling them to conceive naturally or through in vitro fertilization techniques. Moreover, OSCs gained increasing interest as a chance to preserve fertility in cancer patients undergoing gonadotoxic treatments affecting their fertility, as chemotherapy or radiotherapy.

Results: The recruitment of OSCs from fresh or thawed ovarian fragments coupled with their capability to differentiate in vitro to mature oocytes could provide a novel opportunity to verify their suitability to be expanded in vitro as oocyte like cells.

Conclusions and relevance: Research into OSCs and their applications in reproductive medicine is still in its infancy, but the results so far are promising and offer new possibilities for patients suffering from premature ovarian failure or cancer.

Importance: Infertility affects around 180 million people in the world and can be influenced by a number of nutritional factors.

Objective: The idea of a pretreatment optimization including beneficial weight loss, adequate physical activity, and good lifestyle habits could enhance fertility for many couples who want to conceive a baby.

Results: There are different aspects related to nutrition, such as obesity (affecting 23%-30% of reproductive-aged women), dietary patterns (type of diet, good or bad habits, and physical activity), nutrients (vitamins or minerals), hormones (adipokines, among others), and endocrine-disrupting chemicals (phytoestrogens and bisphenol A, among others) that have a clear impact on women's fertility.

Evidence acquisition: Findings have shown that a Mediterranean or balanced diet with an adequate weight loss in case of obesity and an appropriate serum concentration of different nutrients with low endocrine-disrupting exposure could improve female fertility. In addition, the context is quite important, as there are many differences between overweight and low-weight women, and both can encounter difficulties conceiving.

Conclusions and relevance: The aim of this review is to elucidate the impact of obesity and hormones in women's fertility. In addition, how dietary patterns could help people to increase probability of conception and birth using less fertility treatments cycles will be also analyzed. Moreover, the role of endocrine-disrupting chemicals, pollutants, and contaminants will be discussed.

Importance: To decrease associated infectious and thrombotic morbidity, it is important to understand the indications and risks of peripherally inserted central catheters (PICCs) and other vascular access means in pregnancy.

Objectives: The objectives are 3-fold: (1) discuss indications and contraindications, approach to placement, and associated complications for PICC lines, arterial catheters, centrally inserted central catheters, and peripheral intravenous catheters; (2) review available data regarding complications associated with these catheters in pregnancy; and (3) propose an evidence-based approach to clinical decision making regarding vascular access in 2 clinical scenarios among pregnant patients.

Evidence acquisition: A literature review identified relevant research, review articles, textbook chapters, databases, and societal guidelines, with a focus on obstetrical anesthesia and obstetric literature.

Results: Data on vascular access complications in pregnancy are limited; therefore, rates of complications are extrapolated from studies including nonpregnant subjects. Catheter choice is dependent on resuscitation requirements, monitoring indications, parenteral therapeutic needs, need for inpatient versus outpatient care, and anticipated duration of use.

Conclusions and relevance: All pregnant patients require vascular access. A subset requires more invasive catheters for management of specific conditions such as trauma in pregnancy, postpartum hemorrhage, and puerperal sepsis. In addition, vascular access plays an important role in operative planning for patients with placenta accreta spectrum disorder and fetal disorders requiring intrauterine surgery. Gaining an understanding of the types of catheters and their associated complications will allow obstetricians, family medicine physicians, midwives, nurses, intensivists, and anesthesiologists to make informed decisions regarding catheter selection and management.

Importance: Upper gastrointestinal cancers such as gastric and esophageal cancers are rare malignancies with poor prognosis because it is usually diagnosed in latter stages. Presenting symptoms are frequently presumed pregnancy related rather than malignancy related. This review will raise awareness to consider these aggressive cancers in evaluating gastrointestinal complaints during pregnancy.

Objectives: This review describes pregnancies with gastric and esophageal cancers including presenting symptoms, diagnosis stage, treatments, pregnancy complications, and maternal/fetal outcomes.

Evidence acquisition: Electronic databases (PubMed/EMBASE) were searched with English language limitation. Search terms, 1970-2023, included "stomach cancer" OR "gastric cancer" AND "etiology" OR "risk factors" OR "diagnosis" OR "treatment" OR "management" OR "prognosis" AND "pregnancy" OR "pregnancy complications" OR "Esophageal Neoplasms" OR "esophageal carcinoma" OR "esophageal malignancy" OR "esophageal cancer" OR "esophageal neoplasm" AND Pregnancy OR "Pregnancy."

Results: Of 611 abstracts reviewed, 63 full articles were identified as the basis of review. Gastric cancer stage was advanced stage III or IV in 88% of patients. Maternal mortality rate was 76%. First-trimester diagnosis occurred in 16%; second, 27%; and third, 18% totaling 61%. Thirty nine percent were found postpartum, postmortem, or undetermined. Ethnic groups most affected were East Asian. Half had cesarean delivery, 29% delivered vaginally, and the rest were not reported. Treatment varied: supportive care only, 8%; chemotherapy only, 34%; and chemotherapy and surgery, 21%. Neonatal outcomes were good overall: 90% survival among cases reported.

Conclusions: Gastric and esophageal cancers are rare and frequently asymptomatic in early stages. When diagnosed in pregnancy, it is usually advanced with poor prognosis and high maternal mortality rate. Diagnostic testing and treatment should proceed as needed during pregnancy with close maternal and fetal surveillance. Abdominal delivery is reserved for usual obstetrical indications.

Relevance: Gastric and esophageal cancers are rare conditions often missed or found late that affect management, mode of delivery, and maternal/fetal outcomes.

Importance: With a strong association between hepatic adenomas and estrogen established, understanding the risks, evaluation, and perinatal management of hepatic adenomas is necessary for obstetric clinicians.

Objective: The aim of this study is to review the preconception counseling, perinatal management, and postpartum care of hepatic adenomas.

Evidence acquisition: A literature review identified relevant research, review articles, textbook chapters, databases, and societal guidelines.

Results: Hepatic adenomas require individualized recommendations based on their prepregnancy size and evolution over pregnancy. Hepatic adenomas measuring greater than 5 cm are associated with a significantly increased risk during pregnancy including rupture. Ideally, optimal management of hepatic adenoma includes accurate diagnosis, discontinuation of estrogen-containing contraception, and surgical resection of large masses prior to conception. Patients should undergo serial surveillance of the adenoma during the antenatal and postpartum periods, with surgical intervention as indicated with multidisciplinary planning.

Conclusions and relevance: An individualized approach is necessary when managing hepatic adenomas in the patient who is pregnant or intends pregnancy. More contemporary data are required to guide management and patient counseling.

Importance: Rhesus alloimmunization refers to the sensitization of an Rh D-negative mother after exposure to D-positive fetal red blood cells, which can lead to significant fetal and neonatal morbidity and mortality.

Objective: The aim of this study was to review and compare the most recently published international guidelines on the prevention of maternal alloimmunization.

Evidence acquisition: A comparative review of guidelines from the American College of Obstetricians and Gynecologists, the British Committee for Standards in Hematology, the International Federation of Gynecology and Obstetrics, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, and the Society of Obstetricians and Gynecologists of Canada regarding the prevention of maternal Rh D alloimmunization was conducted.

Results: There is consensus among the reviewed guidelines regarding the timing of antenatal antibody screening; the management of an already sensitized pregnancy; the administration and timing of postnatal prophylaxis with a D-positive neonate; and the need for prophylaxis after invasive procedures, abdominal trauma, and external cephalic version. Controversies exist regarding the management of women expressing weak D blood type and the optimal dose and regimen for routine antenatal prophylaxis, with recommendations suggesting administration between 28 and 34 weeks, versus specifically at 28 weeks. Moreover, significant discrepancies exist regarding the need for prophylaxis after some sensitizing events such as threatened, spontaneous, or surgical miscarriage; termination of pregnancy; and molar and ectopic pregnancy, as well as the optimal dose of anti-D globulin after invasive antenatal procedures, abdominal trauma, external cephalic version, and postnatal prophylaxis.

Conclusions: Anti-D globulin remains an important tool for the prevention of maternal alloimmunization, thus contributing to a significant improvement in fetal and neonatal outcomes. However, due to lack of evidence, discrepancies exist between relevant guidelines. Hence, further studies and the development of consistent evidence-based protocols and algorithms are pivotal to safely guide through pregnancy and subsequently reduce fetal and neonatal morbidity, without subjecting women to unnecessary treatment.

Importance: Hereditary breast and ovarian cancer syndrome (HBOC) is most often caused by pathogenic variants in the BRCA1 or BRCA2 genes. Guidelines exist for genetic testing in patients at high risk, yet significant disparities in genetic testing and management remain. These disparities result in missed opportunities for cancer prevention and treatment.

Objective: This review details the multiple layers of disparities in genomic knowledge, testing referral, completion, and posttesting risk reduction for at-risk populations.

Evidence acquisition: A comprehensive search of the PubMed database was conducted in September 2023 for studies addressing disparities at all points of HBOC risk assessment and risk reduction.

Results: Disparities in genomic knowledge, referral and testing, and in cancer risk reduction exist by race, ethnicity, insurance status, socioeconomic status, age, and care setting in the United States. Many mitigation strategies have been explored with some success.

Conclusion: Each component contributes to a "leaky pipe" in BRCA testing and management whereby patients eligible for intervention trickle out of the pipe due to inequities at each step. Implementation of proven strategies aimed at disparity reduction in this setting is essential, as well as additional strategy development.

Relevance: This review provides clinicians with a comprehensive understanding of disparities in the identification and management of individuals at risk for or diagnosed with HBOC and strategies to reduce disparities in their own practice.

Importance: Ovarian tissue cryopreservation (OTC) is an innovative and established fertility preservation method. More than 150 live births have been reported worldwide to date with the use of this strategy. OTC is one of the options to preserve fertility in prepubertal girls and for women who have time constraints and/or contraindications for ovarian stimulation for oocyte/embryo freezing before cancer treatment. The success rate of the ovarian tissue transplantation (OTT) depends on many interrelated factors. Therefore, preoperative evaluation and preparation of the candidate patients for the procedure are of paramount importance.

Objective: In this review, our aim was to provide a guide for the clinicians, which demonstrates step-by-step assessment and preparation of the patients and ovarian tissue samples for transplantation.

Evidence acquisition: We searched for published articles in the PubMed database containing key words, such as OTT, OTC, preoperative assessment, primordial follicle density, and cancer, in the English-language literature until May 2024. We did not include abstracts or conference proceedings.

Results: OTT is still a developing method as an effective fertility preservation approach. It is essential to perform a thorough preoperative evaluation of the patient to improve the success rates of transplantation.

Conclusions and relevance: Preoperative evaluation and preparation of women for ovarian transplantation surgery should include safety management to prevent reimplantation of malignant cells, transplanting ovarian tissue with minimum follicle loss and the decision of the best transfer site.