Obstetrical & Gynecological Survey最新文献

Importance: Postnatal care refers to the ongoing health care provision of both the mother and her offspring and contributes to the timely identification and effective management of complications in the postpartum period, to secure maternal and infant short- and long-term well-being.

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

Evidence acquisition: A comparative review of guidelines from the American College of Obstetricians and Gynecologists, the World Health Organization, the National Institute for Health and Care Excellence, and the Public Health Agency of Canada regarding postnatal care was conducted.

Results: There is a consensus among the reviewed guidelines regarding the importance of health care provision in the postpartum period, including home visits and midwifery services, the use of telemedicine for the facilitation of communication with the patient, and the appropriate preparation for discharge, as well as the discharge criteria. All medical societies also agree on the clinical aspects that should be evaluated at each postnatal visit, although discrepancies exist with regard to the contact schedule. In addition, there is consistency regarding the management of postpartum infections, perineal pain, fecal and urinary incontinence, and physical activity guidance. Mental health issues should be addressed at each postnatal visit, according to all guidelines, but there is disagreement regarding routine screening for depression. As for the optimal interpregnancy interval, the American College of Obstetricians and Gynecologists recommends avoiding pregnancy for at least 6 months postpartum, whereas the National Institute for Health and Care Excellence recommends a 12-month interval. There is no common pathway regarding the recommended contraceptive methods, the nutrition guidance, and the postpartum management of pregnancy complications. Of note, the World Health Organization alone provides recommendations concerning the prevention of specific infections during the postnatal period.

Conclusions: Postnatal care remains a relatively underserved aspect of maternity care, although the puerperium is a critical period for the establishment of motherhood and the transition to primary care. Thus, the development of consistent international protocols for the optimal care and support of women during the postnatal period seems of insurmountable importance to safely guide clinical practice and subsequently reduce maternal and neonatal morbidity.

Importance: Uterine rupture is defined as a nonsurgical disruption of all layers of the uterus. Most ruptures occur in the presence of a scar, usually secondary to a previous cesarean delivery. Rupture of an unscarred uterus is rare and is associated with severe maternal and neonatal outcomes.

Objective: To outline the literature on potential predisposing factors, clinical findings, and maternal and fetal outcomes of a rupture of an unscarred uterus.

Evidence acquisition: PubMed was searched for the phrases "uterine rupture," "unscarred," and "spontaneous." Individual case reports, retrospective case series, and review articles in English between 1983 and 2020 were included.

Results: We found 84 case reports in 79 articles. The mean maternal age was 29.3 (SD, 5.7) years; 38 women (45.2%) were nulliparous. Uterine rupture occurred in 37% of the women at term; in 9.9%, the gestational age was ≤12 weeks. The most common clinical presentations were abdominal pain (77.4%), signs of hypovolemic shock (36.9%), fetal distress (31%), and vaginal bleeding (22.6%). The most common risk factors were the use of uterotonic drugs for induction or augmentation of labor and a prior curettage procedure. The most frequently ruptured site was the body of the uterus. Hysterectomy managed 36.9% of the ruptures. Four women died (4.8%). Perinatal mortality was 50.6%. Perinatal death was higher in developing than developed countries.

Conclusions and relevance: Although rare, spontaneous rupture of the unscarred uterus has serious consequences to the mother and the fetus and should be included in the differential diagnosis of acute abdomen in pregnancy.

Importance: Women experience more frequent and greater pain than men, although they receive less adequate treatment and are perceived as more anxious than males. Recent clinical research has lead to hypothesize a common etiology for overlapping chronic pain conditions and mood disorders, namely, central sensitization, which originates from an alteration of pain processing pathways in the central nervous system.

Objective: The aim of this review was to collect all available evidence regarding the potential role of central sensitization in vulvodynia and endometriosis.

Evidence acquisition: A systematic literature search was performed between July and August 2022 using the electronic database PubMed. The extracted data were summarized using a narrative approach.

Results: Ten articles were chosen for the review. Participants' mean age was 39.2 years (SD = 5.1). Among serum markers of central sensitization, nitric oxide levels were greater in women with endometriosis than in controls, whereas brain-derived neurotrophic factor and S100B levels differed among pain conditions with structural anomalies and those without. Functional magnetic resonance imaging showed different resting state networks between patients with endometriosis and controls. In neurophysiology studies, cases had reduced pain thresholds, compared with healthy controls. Lastly, self-reported questionnaires suggested a central component of pain in women with endometriosis-related dyspareunia and associated bladder/pelvic floor tenderness.

Conclusions and relevance: The management of vulvodynia and endometriosis may benefit from a new perspective, which considers their possible central etiology. It is compelling that treatment of pain starts to be considered a therapeutic goal in its own right.

Importance: Group B Streptococcus (GBS) colonization during pregnancy is associated with significant neonatal morbidity and mortality and represents a major public health concern, often associated with poor screening and management.

Objective: The aim of this study was to review and compare the most recently published influential guidelines on the screening and management of this clinical entity during antenatal and intrapartum periods.

Evidence acquisition: A descriptive review of guidelines from 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, and the Society of Obstetricians and Gynecologists of Canada on the prevention of early-onset neonatal group B streptococcal disease was carried out.

Results: There is a consensus among the reviewed guidelines regarding the optimal screening specimen type, indications for intrapartum antibiotic administration such as bacteriuria during pregnancy, clinical signs of chorioamnionitis or maternal pyrexia, and history of GBS-related neonatal disease. There is also agreement on several conditions where no intervention is recommended, that is, antepartum treatment of GBS and GBS-positive women with planned cesarean delivery and intact membranes. Controversy exists regarding the optimal screening time, with the Royal College of Obstetricians and Gynecologists stating against routine screening and on management strategies related to preterm labor and preterm prelabor rupture of membranes.

Conclusions: The development of consistent international practice protocols for the timely screening of GBS and effective management of this clinical entity both during pregnancy and the intrapartum period seems of paramount importance to safely guide clinical practice and subsequently improve neonatal outcomes.

Importance: Osteoporosis causes increased morbidity and mortality, and thus poses a significant economic burden to the health systems worldwide.

Objective: The aim of this study was to review and compare the most recently published major guidelines on diagnosis and management of this common medical entity.

Evidence acquisition: A thorough comparative review of the most influential guidelines from the RACGP (Royal Australian College of General Practitioners), the ESCEO-IOF (European Society for Clinical and Economic Aspects of Osteoporosis-International Osteoporosis Foundation), the NOGG (National Osteoporosis Guideline Group), the NAMS (North American Menopause Society), the ES (Endocrine Society), and the ACOG (American College of Obstetricians and Gynecologists) was conducted.

Results: The reviewed guidelines generally agree on the definition, the criteria, and investigations used to diagnose osteoporosis. They also concur regarding the risk factors for osteoporosis and the suggested lifestyle modifications (calcium and vitamin D intake, normal body weight, reduction of alcohol consumption, and smoking cessation). However, there is lack of consensus on indications for fracture risk assessment in the general population and the exact indications for bone mineral density assessment. Referral to a bone specialist is reserved for complex cases of osteoporosis (NOGG, NAMS, and ACOG) or in case of inadequate access to care (RACGP). The use of hip protectors to reduce the risk of fractures is supported by RACGP, NOGG, and NAMS, solely for high-risk elderly patients in residential care settings. All guidelines reviewed recognize the efficacy of the pharmacologic agents (ie, bisphosphonates, denosumab, hormone therapy, and parathyroid hormone analogs). Nonetheless, recommendations regarding monitoring of pharmacotherapy differ, primarily in the case of bisphosphonates. The proposed intervals of repeat bone mineral density testing after initiation of drug therapy are set at 2 years (RACGP), 1-3 years (NAMS, ES, and ACOG), or 3-5 years (ESCEO-IOF and NOGG). All guidelines agree upon the restricted use of bone turnover markers only in bone specialist centers for treatment monitoring purposes. Finally, the definition of treatment failure varies among the reviewed guidelines.

Conclusions: Osteoporosis is a distressing condition for women, mainly those of postmenopausal age. Thus, it seems of paramount importance to develop consistent international practice protocols for more cost-effective diagnostic and management techniques, in order to improve women's quality of life.

Importance: Periviable and previable premature rupture of membranes (pPPROM) occurs in <1% of pregnancies but can have devastating consequences for the mother and the fetus. Understanding risk factors, possible interventions, and both maternal and neonatal outcomes will improve the counseling and care provided for these patients.

Objective: The aim of this review is to describe the etiology, risk factors, management strategies, neonatal and maternal outcomes, and recurrence risk for patients experiencing pPPROM.

Evidence acquisition: A PubMed, Web of Science, and CINAHL search was undertaken with unlimited years searched. The search terms used included "previable" OR "periviable" AND "fetal membranes" OR "premature rupture" OR "PROM" OR "PPROM." The search was limited to English language.

Results: There were 181 articles identified, with 41 being the basis of review. Multiple risk factors for pPPROM have been identified, but their predictive value remains low. Interventions that are typically used once the fetus reaches 23 to 24 weeks of gestation have not been shown to improve outcomes when used in the previable and periviable stage. Neonatal outcomes have improved over time, but survival without severe morbidity remains low. Later gestational age at the time of pPPROM and longer latency period have been shown to be associated with improved outcomes.

Conclusions and relevance: Periviable and previable premature rupture of membranes are uncommon pregnancy events, but neonatal outcomes remain poor, and routine interventions for PPROM >24 weeks of gestation have not proven beneficial. The 2 most reliable prognostic indicators are gestational age at time of pPPROM and length of the latency period.

Importance: Fetal growth restriction (FGR) is a common pregnancy complication and a significant contributor of fetal and neonatal morbidity and mortality, mainly due to the lack of effective screening, prevention, and management policies.

Objective: The aim of this study was to review and compare the most recently published influential guidelines on the management of pregnancies complicated by FGR.

Evidence acquisition: A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the International Society of Ultrasound in Obstetrics and Gynecology, the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada (SOGC), the Perinatal Society of Australia and New Zealand, the Royal College of Physicians of Ireland, the French College of Gynecologists and Obstetricians (FCGO), and the German Society of Gynecology and Obstetrics on FGR was carried out.

Results: Several discrepancies were identified regarding the definition of FGR and small-for-gestational-age fetuses, the diagnostic criteria, and the need of testing for congenital infections. On the contrary, there is an overall agreement among the reviewed guidelines regarding the importance of early universal risk stratification for FGR to accordingly modify the surveillance protocols. Low-risk pregnancies should unanimously be evaluated by serial symphysis fundal height measurement, whereas the high-risk ones warrant increased sonographic surveillance. Following FGR diagnosis, all medical societies agree that umbilical artery Doppler assessment is required to further guide management, whereas amniotic fluid volume evaluation is also recommended by the ACOG, the SOGC, the Perinatal Society of Australia and New Zealand, the FCGO, and the German Society of Gynecology and Obstetrics. In case of early, severe FGR or FGR accompanied by structural abnormalities, the ACOG, the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the Royal College of Obstetricians and Gynecologists, the SOGC, and the FCGO support the performance of prenatal diagnostic testing. Consistent protocols also exist on the optimal timing and mode of delivery, the importance of continuous fetal heart rate monitoring during labor, and the need for histopathological examination of the placenta after delivery. On the other hand, guidelines concerning the frequency of fetal growth and Doppler velocimetry evaluation lack uniformity, although most of the reviewed medical societies recommend an average interval of 2 weeks, reduced to weekly or less when umbilical artery abnormalities are detected. Moreover, there is a discrepancy on the appropriate timing for corticosteroids and magnesium sulfate administration, as well as