Obstetrical & Gynecological Survey最新文献

Importance: The identification of the cavum septum pellucidum (CSP) is an integral part of the routine second trimester fetal anatomy scan. The absence or nonvisualization of the CSP has significant clinical implications and requires further evaluation and counseling for the pregnant patient.

Objective: The aim of this review is to review the importance of accurate sonographic identification of the CSP and the underlying pathologies that can be associated with nonvisualization of this structure.

Evidence acquisition: A literature review was performed with PubMed using key words including CSP, fetal anatomy ultrasound, and fetal anomalies.

Results: The absence of the CSP is associated with several central nervous system pathologies, all with a wide range of phenotypic outcomes, ranging from normal to very severe or lethal.

Relevance: Most obstetrician-gynecologists will have a patient in whom a CSP is not identified on fetal ultrasound. Thus, it is imperative to have a general understanding of this relatively common entity.

Importance: Ovarian torsion is a gynecological emergency caused by the twisting of the ovary and/or fallopian tube, further resulting in ischemic changes of the adnexa. Early diagnosis is likely to preserve ovarian function.

Objective: The purpose of this review is to review the current findings of ovarian torsion including clinical presentations, diagnostic criteria, surgical procedures, and prognosis.

Evidence acquisition: The literature search is mainly available in PubMed and Web of Science platforms by searching "ovarian torsion" combined with one or several terms including "diagnosis" "risk factors" "surgery" and "torsion recurrence."

Results: Abdominal pain, nausea, and vomiting were normal clinical presentations. In order to increase the accuracy of diagnosis, it is necessary to integrate clinical presentation and the findings of imaging and laboratory examinations. Computed tomography findings, plasma d-dimer level, and the time from pain onset play a critical role in distinguishing ovarian necrosis. The efficiency of oophoropexy on preventing recurrent ovarian torsion is controversial.

Conclusion: Most patients with early diagnosis of ovarian torsion may have a better prognosis with conservative surgery.

Relevance: Better understanding of ovarian torsion is critical for gynecologists to promote accuracy of diagnosis and select the optimal surgical procedure.

Importance: Women are increasingly postponing pregnancy to achieve specific goals, and as it is known, the ovarian reserve (OR) declines with age, especially after the 30s. Assessing the OR helps in managing the care of women seeking pregnancy. Several OR tests (ORTs) have been advocated for assessing OR.

Objectives: This review aims to discuss the different ORTs and the consequences of their use.

Evidence acquisition: For each topic, a PubMed search was conducted using MeSH terms. The following terms were used: ovarian reserve, ovarian reserve tests, anti-Müllerian hormone, antral follicle count, and diminished ovarian reserve. The search for further references was complemented by manual search, review, synthesis, and summarization of retrieved articles.

Results: In this review, we clarified the concept of OR and the different ORTs and provided a guide for the ultrasound to assess OR. In addition, the clinical value of ORTs was highlighted to explain the implications of the results of these tests and how they can aid in patient counseling.

Conclusion and relevance: A number of ORTs are available to the clinician. Anti-Müllerian hormone and antral follicle count are the most valuable, but as with all ORTs, they are best used as screening, not diagnostic tests for OR. Screening for OR is most helpful when applied to specific groups.

Importance: Axial downregulation with a 3- to 6-month administration of gonadotropin-releasing hormone agonists (GnRH-a) prior to assisted reproduction techniques has been proposed in order to improve clinical pregnancy rates in women with endometriosis. Although reduced inflammation, improved oocyte quality, and restored endometrial receptivity have been postulated, further investigation of their actual benefit and mechanism of action is considered essential. In that direction, well-designed clinical trials regarding the role of GnRH-a in IVF are necessary.

Objective: The purpose of this review is to clarify whether GnRH-a administration prior to IVF-FET procedures improves pregnancy rates in women with endometriosis.

Evidence acquisition: A literature review was conducted in MEDLINE (PubMed), Cochrane, and Google Scholar and concluded on September 10, 2022.

Results: Two Cochrane meta-analyses and 16 selected studies present various interesting data of assisted reproduction technique procedures on patients with endometriosis-related infertility with or without depot GnRH-a pretreatment.

Conclusions: The regimen may have a positive clinical effect on cases of severe endometriosis (American Society for Reproductive Medicine stages III-IV), but their use is not routinely recommended in order to improve pregnancy rates.

Relevance: Endometriosis and infertility are closely related through various pathogenetic mechanisms. Endometriosis has been traditionally considered to negatively affect fundamental aspects of the in vitro fertilization-frozen embryo transfer procedure. Numerous interventions, both medical and surgical, have been proposed in order to improve IVF success rates, and the optimal management of these cases poses an ever pressing challenge.

Importance: Diabetes mellitus is one of the most common complications in pregnancy with adverse maternal and neonatal risks proportional to the degree of suboptimal glycemic control, which is not well defined. Literature guiding providers in identifying and managing patients at highest risk of complications from diabetes is lacking.

Objective: This article reviews the definition, epidemiology, and pathophysiology of suboptimal control of diabetes in pregnancy, including "diabetic fetopathy"; explores proposed methods of risk stratification for patients with diabetes; outlines existing antepartum management and delivery timing guidelines; and guides direction for future research.

Evidence acquisition: Original research articles, review articles, and professional society guidelines on diabetes management in pregnancy were reviewed.

Results: The reviewed available studies demonstrate worsening maternal and neonatal outcomes associated with suboptimal control; however, the definition of suboptimal based on parameters followed in pregnancy such as blood glucose, hemoglobin A_1c, and fetal growth varied from study to study. Studies demonstrating specific associations of adverse outcomes with defined suboptimal control were reviewed and synthesized. Professional society recommendations were also reviewed to summarize current guidelines on antepartum management and delivery planning with respect to diabetes in pregnancy.

Conclusions: The literature heterogeneously characterizes suboptimal glucose control and complications related to this during pregnancy in individuals with diabetes. Further research into antepartum management and delivery timing for patients with varying levels of glycemic control and at highest risk for diabetic complications is still needed.

Importance: Polycystic ovary syndrome (PCOS) is a common endocrine syndrome with multiple causes and polymorphic clinical manifestations, which is one of the important causes of menstrual disorders in women of childbearing age. It has been found that branched-chain amino acids (BCAAs), a class of essential amino acids that cannot be synthesized by the human body, play a significant role in the metabolic changes of PCOS, which may be involved in the pathogenesis of PCOS.

Objective: The purpose of this review is to summarize the relevance between BCAAs and metabolic abnormalities in PCOS and to explore their possible mechanisms.

Evidence acquisition: The evidence is mainly obtained by reviewing the literature on PubMed related to PCOS, BCAAs, and related metabolic abnormalities and conducting summary analysis.

Results: The metabolism of BCAAs can affect the homeostasis of glucose metabolism, possibly by disrupting the balance of gut microbiota, activating mTORC1 targets, producing mitochondrial toxic metabolites, and increasing the expression of proinflammatory genes. The correlation between obesity and BCAAs in PCOS patients may be related to the gene expression of BCAA metabolism-related enzymes in adipose tissue. The association between BCAA metabolic changes and nonalcoholic fatty liver disease in PCOS patients has not been fully clarified, which may be related to the lipid accumulation caused by BCAAs. At present, it is believed that hyperandrogenism in patients with PCOS is not related to BCAAs. However, through the study of changes in BCAA metabolism in prostate cancer caused by hyperandrogenism, we speculate that the relationship between BCAAs and hyperandrogenism may be mediated by mTORC1 and amino acid transporters.

Conclusions and relevance: Review of prior articles reveals that BCAAs may be related to insulin resistance, obesity, nonalcoholic fatty liver, and hyperandrogenism in PCOS patients, and its mechanisms are complex, diverse, and interrelated. This review also discussed the mechanism of BCAAs and these metabolic disorders in non-PCOS patients, which may provide some help for future research.

Importance: Antenatal care plays a crucial role in safely monitoring and ensuring the well-being of both the mother and the fetus during pregnancy, ultimately leading to the best possible perinatal outcomes.

Objective: The aim of this study was to review and compare the most recently published guidelines on antenatal care.

Evidence acquisition: A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Public Health Agency of Canada, the World Health Organization, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists regarding antenatal care was conducted.

Results: There is a consensus among the reviewed guidelines regarding the necessary appointments during the antenatal period, the proper timing for induction of labor, the number and frequency of laboratory examinations for the assessment of mother's well-being, and management strategies for common physiological problems during pregnancy, such as nausea and vomiting, heartburn, pelvic pain, leg cramps, and symptomatic vaginal discharge. In addition, special consideration should be given for mental health issues and timely referral to a specialist, reassurance of complete maternal vaccination, counseling for safe use of medical agents, and advice for cessation of substance, alcohol, and tobacco use during pregnancy. Controversy surrounds clinical evaluation during the antenatal period, particularly when it comes to the routine use of an oral glucose tolerance test and symphysis-fundal height measurement for assessing fetal growth, whereas routine cardiotocography and fetal movement counting are suggested practices only by Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Of note, recommendations on nutritional interventions and supplementation are offered only by Public Health Agency of Canada and World Health Organization, with some minor discrepancies in the optimal dosage.

Conclusions: Antenatal care remains a critical factor in achieving positive outcomes, but there are variations depending on the socioeconomic status of each country. Therefore, the establishment of consistent international protocols for optimal antenatal care is of utmost importance. This can help provide safe guidance for healthcare providers and, consequently, improve both maternal and fetal outcomes.