Obstetrical & Gynecological Survey最新文献

Importance: Menstrual concerns are the most common reason adolescents seek gynecologic care. Providers should be familiar with the differences among available therapies for menstrual suppression and be able to provide tailored treatment recommendations for adolescents with various medical conditions.

Objective: The aim of this article is to review available medical therapies that can be used for menstrual suppression in adolescents, evaluate their pros and cons, and help the reader apply this knowledge to specific clinical situations.

Evidence acquisition: A literature review was performed with PubMed using key words including menstrual suppression and adolescents.

Results: Multiple treatment options are effective for menstrual suppression. Each option has pros and cons for use in the adolescent patient population.

Conclusions and relevance: Menstrual suppression can be achieved with multiple medical options. Selecting between the agents should be based on clinical indication, medical eligibility, need for contraception, or the patient's individual preferences. Providers who care for adolescents should be able to counsel patients and/or their caregivers regarding the various options for menstrual suppression.

Importance: Influenza presents as respiratory illnesses that range in severity and can lead to adverse maternal health outcomes and pregnancy complications, particularly in pregnant individuals who are considered high-risk for severe disease.

Objective: To highlight the significance of seasonal influenza in pregnant people and emphasize the importance of early testing, antiviral treatment, and vaccination.

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

Results: Pregnant individuals face higher risks of severe respiratory illness from seasonal influenza due to physiological changes in pregnancy. Seasonal influenza infection in pregnancy is linked to adverse pregnancy outcomes, which correspond to illness severity.

Conclusions and relevance: Recognizing the pregnant population as a high-risk group, national and global public health agencies, such as the Centers for Disease Control and Prevention and the World Health Organization, recommend influenza vaccination in pregnancy. Early testing with available commercial tests and prompt antiviral treatment are critical interventions to decreasing morbidity and mortality.

Importance: Oropouche is an emerging virus that has become a growing cause for concern after reports of vertical transmission and detrimental effects on the developing fetus. Oropouche is an arbovirus, meaning it is transmitted by arthropods, which include mosquitos, ticks, and midges (sometimes called "no-see-ums"). Specifically, Oropouche is transmitted through the Culicoides paraensis biting midge and Culex quinquefasciatus mosquito. Infection presents most commonly with fever, headache, myalgias, and arthralgia.

Objective: The purpose of this review is to summarize current knowledge regarding the effect of Oropouche infection on maternal and fetal outcomes during pregnancy and provide anticipatory guidance for obstetric management of Oropouche infection.

Evidence acquisition: We conducted a literature review using MEDLINE to summarize the current understanding of obstetric implications of Oropouche infection.

Results: Although data are limited, reports of suspected Oropouche-associated vertical transmission, miscarriage, and congenital abnormalities have created the need for special considerations for pregnant individuals amid the current Oropouche outbreak.

Conclusions and relevance: A recent outbreak in South and Central America has captured the attention of the Pan American Health Organization and World Health Organization, each issuing travel guidance and infection management recommendations. Additionally, reports of Oropouche infection in Europe and the United States in travelers returning from areas of endemic infection have prompted a call for widespread surveillance for Oropouche infection. Although much remains unknown about Oropouche infection and its effect on pregnancy and the developing fetus, obstetric providers should remain aware of the developing outbreak and evolving guidance for management of pregnant individuals.

Importance: Intrauterine hemorrhage-control devices are key second-line therapeutic interventions for refractory postpartum hemorrhage (PPH) due to uterine atony. Less is known about the detection and clinical management of failure of 2 commonly used devices: intrauterine balloon tamponade, in particular the Bakri device, and the Jada device (a vacuum-induced hemorrhage control device).

Objective: This narrative review describes the epidemiology and management challenges of the failure of intrauterine balloon tamponade and the Jada device.

Evidence acquisition: Original research, review articles, and PPH guidelines.

Results: Unsuccessful arrest of bleeding requiring invasive intervention is 11-12% for intrauterine balloon tamponade, and 7.5% among vaginal deliveries using the Jada device, and 16.3% among cesarean deliveries using the Jada device. Rates of transfusion and hysterectomy in patients who receive intrauterine balloon tamponade are 36% and 6%, respectively. Patients' risk of intrauterine hemorrhage-control device failure may not be easily determined prior to device placement. There is a paucity of information in national and international PPH guidelines for the detection and management of intrauterine hemorrhage-control device failure. For intrauterine balloon tamponade, caudal prolapse or balloon sliding into the vagina can occur in 10-15% of cases, and the risk of hemorrhage-related morbidity is associated with balloon volume >350 mL. Point-of-care hemodynamic and hemostatic monitors can provide early warning signs of ongoing hemorrhage and maternal compromise when a diagnosis of intrauterine hemorrhage control device failure is delayed or missed.

Conclusions and relevance: Expert consensus is needed to develop device-specific criteria for the diagnosis and early management of intrauterine hemorrhage-control device failure.

Importance: Venous thromboembolism (VTE) manifesting either as deep vein thrombosis or pulmonary embolism presents as the leading cause of maternal morbidity and mortality, worldwide.

Objective: The aim of this study was to review and compare the most recently published international guidelines on the diagnosis and management of acute VTE in pregnancy and the puerperium.

Evidence acquisition: A comparative review of guidelines by the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada, the American College of Chest Physicians, the European Society of Cardiology, and the American Society of Hematology on VTE was conducted.

Results: There is a consensus among the reviewed guidelines regarding the appropriate algorithm for diagnosis of VTE in the obstetric population, the appropriate anticoagulants suitable for the pregnancy and puerperium, even in cases of contraindications for heparin, and indications for extreme management measures, such as thrombolysis. On the other hand, few discrepancies were detected on the dosage of anticoagulants, indications of anticoagulation monitoring, appropriate management of anticoagulants related to neuraxial anesthesia, and indications for thrombophilia testing following a VTE event. Notably, only the European Society of Cardiology recommends the use of models assessing the clinical likelihood of pulmonary embolism, suggests a risk stratification algorithm to guide acute management, and proposes management strategies for the prevention of hemorrhagic events during labor.

Conclusions: VTE is a significant contributor of maternal morbidity and mortality, especially if managed in a suboptimal way. Hence, the development of consistent evidence-based protocols and algorithms is crucial to safely guide pregnant women and their physicians toward reducing improving fetal and maternal outcomes.

Importance: Hemolytic disease of the fetus and newborn (HDFN) is caused by maternal alloantibodies to fetal red blood cells and is associated with significant fetal and neonatal morbidity and mortality. Rhesus D antigen (RhD)-mediated HDFN is the only preventable cause of alloimmunization in pregnancy. Widespread utilization of RhD prophylaxis reduces the risk of RhD-mediated alloimmunization from 17% to <1% in at-risk pregnancies, although RhD-mediated HDFN still occurs.

Objective: To emphasize significance of RhD prophylaxis, outline current guideline-directed indications for administration, provide clarification in areas of uncertainty regarding prophylaxis administration, and review key concepts relevant to patient education and shared decision-making.

Evidence acquisition: PubMed and Google Scholar literature search.

Results: Data over several decades have shown implementation of prenatal and postpartum RhD prophylaxis has significantly reduced incidence and morbidity of RhD-mediated HDFN. Most international guidelines recommend routine prophylaxis of Rh-negative mothers in the second trimester and peripartum, with additional prophylaxis following certain high-risk events. Recent shortages in RhD immunoglobulin (RhDIg) and new methods to determine fetal blood type have prompted renewed debate regarding criteria for prophylaxis during the first trimester.

Conclusion: Understanding indications for administration of RhD prophylaxis is essential for preventing RhD alloimmunization. Although uncertainty remains in some clinical scenarios, prophylaxis is strongly recommended in Rh-negative mothers in the second trimester, following events high-risk for sensitization in pregnancy, and postpartum.

Relevance: In this review, the etiology of alloimmunization and indications for RhDIg prophylaxis, current society recommendations, and areas of debate are summarized and discussed.

Importance: Despite the known advantages and incentives for providers and patients, reticence to performing office hysteroscopy remains due to provider inexperience, challenges to adequate pain management, and greater comfort level in the operating room setting. The relatively low utilization across the field of gynecology necessitates a deeper understanding of essential elements of hysteroscopy and the shared skills gained by experience.

Objective: This review serves to aid providers in optimizing periprocedural patient experience and procedural outcomes during in-office hysteroscopy.

Evidence acquisition: A comprehensive literature review was conducted to evaluate nonpharmacologic approaches to pain and anxiety management during in-office hysteroscopy. PubMed, Scopus, and Cochrane Library databases were searched for peer-reviewed articles published in English. Search terms included combinations of "in-office hysteroscopy," "pain management," "anxiety management," "non-pharmacologic," communication," and "office set-up." Additional references were identified from citations within relevant articles. Studies were selected based on relevance, focusing on randomized controlled trials, systematic reviews, meta-analyses, and observational studies. Findings were synthesized to provide a comprehensive overview of current evidence and highlight areas for future research.

Results: Nuanced approaches to pain and anxiety management during in-office hysteroscopy identified include virtual reality, music, hypnosis, and transcutaneous nerve stimulation. Simple strategies such as optimizing office setup while utilizing the newest technological advances and effective communication were identified as ways to alleviate patient discomfort and increase procedure acceptability.

Conclusions and relevance: An understanding of the basic elements of in-office hysteroscopy will benefit patients and providers alike, aiding the transition out of the operating room and into the office setting.

Importance: Cesarean deliveries are associated with an increased risk of immediate- and long-term complications. Ideally, clinicians could accurately predict the risk of cesarean delivery and use this knowledge to decrease maternal morbidity due to failed labor without increasing rates of unnecessary cesarean delivery. To this end, multiple obstetric calculators for predicting cesarean risk in various clinical settings have been developed.

Objective: This review describes major obstetric calculators for predicting risk of cesarean deliveries and discusses potential clinical applications, general accuracy, and limitations.

Evidence acquisition: An extensive manual review of primary research articles published on PubMed between January 2000 and February 2024 was performed. Pertinent articles that described the creation or validation of a scored system for predicting mode of delivery in an American population were reviewed.

Results: Multiple obstetric calculators have been developed and achieve fair discrimination and calibration in their derivation cohorts but do not maintain accuracy in external populations. This includes calculators that have already been applied to clinical practice, including calculators for predicting vaginal birth after cesarean and success of induction of labor.

Conclusions: Given the limited accuracy of cesarean calculators in external populations, caution is recommended when considering external implementation without further adjustment and refinement. Scores that overestimate cesarean delivery risk could falsely discourage vaginal delivery and negatively impact clinical care.

Relevance: This review provides obstetric clinicians with context for interpreting obstetric calculators for predicting cesarean risk.

Importance: Mental health disorders are frequent, challenging, and potentially devastating complications during the antenatal and postnatal period with major impact on both women and their offspring, especially if left undiagnosed and untreated or managed in a suboptimal way.

Objective: The aim of this study was to review and compare the most recently published guidelines on the screening, diagnosis, and management of the most common mental health disorders in pregnancy and the puerperium.

Evidence acquisition: A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the Center of Perinatal Excellence, and the National Institute for Health and Care Excellence on antenatal and postnatal mental health disorders was conducted.

Results: There is a consensus among the reviewed guidelines regarding the importance of a detailed personal and family history in the investigation of mental health disorders and the associated risk factors. Moreover, all the reviewed medical societies recommend universal antenatal and postnatal screening for depression and anxiety using validated screening tools, assessment of family violence exposure, and tobacco, alcohol, and illicit drug use, as well as evaluation of the woman's emotional well-being. They also agree that following a positive screening result, further assessment is required to set the diagnosis of a mental health condition based on specific criteria, whereas a positive self-harm question warrants urgent referral and management. Discrepancies were identified regarding the recommended screening tools, the frequency of screening, the algorithms that should be followed in case of positive screening, and the indications for pharmacological and psychological treatment. Regarding treatment, the reviewed guidelines recommend psychological interventions and pharmacological therapy based on the severity of the mental health disorders, suggesting selective serotonin reuptake inhibitors as first-line agents for depression and anxiety and agreeing that the lowest effective dose, a single-agent therapy, and a drug with the lowest risk profile should be preferred. Consistency also exists concerning the follow-up and monitoring of women treated for mental health disorders, as well as the management of women with preexisting mental illness.

Conclusions: Mental disorders during pregnancy and the puerperium are a sensitive, community-based issue that affects the parents' quality of life and interferes to the neonate's behavioral and emotional development. Therefore, it is of insurmountable importance to develop consistent international strategies for the early identification and the optimal management of this significant complication to improve the perinatal outcomes.

Importance: The administration of prophylactic antibiotics in obstetrics and gynecology represents a pivotal intervention with a major contribution to the prevention of maternal and neonatal infectious morbidity.

Objectives: The aim of this study was to review and compare the most recently published guidelines on prophylactic antibiotic use in obstetric and gynecologic procedures.

Evidence acquisition: A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists on antibiotic prophylaxis was carried out.

Results: There is a consensus among the reviewed guidelines regarding the importance of antibiotic prophylaxis prior to cesarean delivery, hysterectomy, colporrhaphy and surgical-induced abortions, the optimal choice of antibiotics, and the timing of administration, as well as the indications for increased and additional doses. First-generation cephalosporins are unanimously recommended as first-line antibiotics. All the reviewed guidelines recommend antibiotic prophylaxis in case of preterm prelabor rupture of membranes, whereas they discourage routine antibiotic use in case of active preterm labor with intact membranes or cervical cerclage placement. There is also an overall agreement that antibiotic prophylaxis should not be given for hysteroscopic and laparoscopic procedures with no entry into the bowel or the vagina, endometrial biopsy, intrauterine device insertion, or cervical tissue excision surgeries. Moreover, all the guidelines agree that women undergoing hysterosalpingography should receive a course of antibiotics only when the fallopian tubes are abnormal or there is a history of pelvic inflammatory disease. In contrast, inconsistency was identified on the need of antibiotic prophylaxis in case of obstetric anal sphincter injuries, operative vaginal delivery, and early pregnancy loss. Finally, American College of Obstetricians and Gynecologists states that antibiotics should not be routinely offered for oocyte retrieval and embryo transfer.

Conclusions: Infectious complications following both obstetric and gynecological procedures are significant contributors of morbidity and mortality, rendering their prevention using antibiotic prophylaxis a crucial aspect of preoperative care. Nevertheless, antibiotic overuse should be avoided. Thus, it seems of paramount importance to develop consistent international practice protocols for the appropriate use of antibiotics in everyday practice to minimize their adverse effects and maximize their associated benefits.