Obstetrical & Gynecological Survey最新文献

(Abstracted from JAMA Network Open 2025;8(5):e2511315) A single course of antenatal corticosteroids (ANCSs) is the most effective intervention for pregnant individuals at risk of preterm birth at <34 weeks of gestation. Although it is largely accepted that ANCS is most effective within 1 to 7 days before birth, it is unclear how soon within the first 24 hours the benefit takes effect, when the maximum effect is achieved, and how long the benefit will last after the first 7 days.

Importance: Perfluorobutane sulfonate (PFBS) is a short-chain per- and polyfluoroalkyl substance (PFAS) that has emerged as a significant public health concern due to its widespread environmental contamination and persistent nature. While PFBS is considered to have a shorter half-life in the environment and human body compared to other PFAS compounds, there are still growing concerns about its potential impacts on human health, particularly on female reproduction and birth outcomes.

Objective: This literature review critically examines the impact of PFBS exposure on female reproductive health, pregnancy outcomes, and fetal development, synthesizing the most recent data from both human and animal studies.

Evidence acquisition: A comprehensive literature search was conducted using data from peer-reviewed articles, clinical trials, animal models, and regulatory reports.

Results: These studies suggest that PFBS may have adverse effects on fertility, pregnancy health, and fetal development. It also explores the current regulatory landscape for PFBS, focusing on policies in Europe, the United States, and Asia while emphasizing the growing global efforts to establish more stringent guidelines and develop effective treatment technologies to mitigate PFBS exposure. Given the bioaccumulative properties of PFBS and its increasing detection through environmental surveillance, ongoing research, especially targeted studies in human populations, is urgently needed to fully elucidate its reproductive toxicity, including its potential transgenerational effects.

Conclusion and relevance: This review underscores the importance of understanding PFBS mechanisms of action at the molecular and epigenetic levels, as this knowledge will be essential for informing public health strategies, shaping regulatory policies, and developing interventions to reduce human and environmental exposure.

Importance: Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly nonalcoholic fatty liver disease, is the most common liver condition in the United States and the leading cause of cirrhosis. MASLD is closely associated with cardiovascular diseases and shares risk factors such as obesity, hypertension, and insulin resistance. Commonly seen in pregnant women, MASLD has an estimated prevalence of 10% worldwide.

Objective: For many women of childbearing age, pregnancy may be the only link to medical care, presenting a critical opportunity to diagnose MASLD. It is paramount to raise awareness among obstetrician-gynecologists of the risk factors and pregnancy-related complications arising from MASLD development.

Evidence acquisition: Data were obtained from a review of liver and obstetric and gynecological clinical practice guidelines. Relevant keyword searches encompassing MASLD and pregnancy in PubMed were conducted to survey literature in the English language.

Results: MASLD is independently associated with obstetric complications and adverse outcomes for both mother and fetus. Maternal complications include gestational diabetes mellitus, gestational hypertension, and preeclampsia, whereas fetal complications include preterm birth and large-for-gestational-age infants. Multiple studies demonstrate that dietary and exercise-related interventions to curb gestational weight gain, coupled with behavioral therapy, significantly reduce adverse maternal and neonatal outcomes.

Conclusion and relevance: The presence of predisposing risk factors in the pregnant patient should prompt screening for MASLD. If MASLD is diagnosed, interventions to mitigate pregnancy-related complications are indicated. Ultimately, referral of the pregnant patient with MASLD for risk stratification and management is suggested to avoid future liver or cardiovascular-related morbidity.

Importance: The United States continues to have one of the highest adolescent pregnancy rates compared with other high-income countries. Adolescents and their children have an increased risk of adverse health effects. These disparities demonstrate the need for access to comprehensive health resources.

Objective: This review investigates how access to a variety of care and services, such as diverse models of prenatal care; affordable health insurance; the Women, Children, and Infants program; lactation support; and targeted postpartum care, can impact the health outcomes and overall well-being of pregnant adolescents and their children.

Evidence acquisition: Original and review articles were obtained from a literature search in PubMed; pertinent articles were reviewed.

Results: Targeted interventions during pregnancy can improve outcomes for adolescents. Different models of prenatal care focus on the unique challenges faced by this population and address the limitations of traditional prenatal care for adolescents, including time constraints, low provider-patient interaction, decreased social support, and conflicts with school schedules. Other important interventions include reproductive and sexual health education, feeding and nutrition access, and postpartum care.

Conclusion and relevance: This review highlights the importance of providing culturally appropriate, age-specific prenatal care to adolescents. Nontraditional models such as group prenatal care, school-based programs, and age-specific pregnancy programs are more effective at addressing the complex social, emotional, and health care needs of adolescent mothers. Improvements in contraception access, reproductive education, expanded clinic access, and postpartum care can lead to better health outcomes for both adolescent mothers and their infants.

Importance: Venous thromboembolism (VTE), presenting either as deep vein thrombosis or as pulmonary embolism, is one of the leading causes of maternal morbidity and mortality.

Objective: The aim of this study was to review and compare the most recently published international guidelines providing recommendations on the prevention of 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 an overall agreement among the reviewed guidelines regarding the optimal anticoagulation and dosage choice, the management of low-molecular-weight heparin relating to neuraxial blockade, the importance of implementing risk assessment scores in every individual, and certain indications for obstetric thromboprophylaxis. On the other hand, controversy exists regarding management of unfractionated heparin before and after regional anesthesia, cases where calf compression stockings are suitable and indications where thrombophilia screening is required. Moreover, discrepancies exist in relation to management strategies in women with specific inherited thrombophilias. Notably, specific risk assessment scores are presented only by 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.

Conclusions: As VTE remains a significant factor affecting maternal morbidity and mortality, worldwide, developing consistent international algorithms is of utmost importance to safely guide clinical practice and consequently improve pregnancy outcomes.

Importance: The United States ranks 55th worldwide for perinatal health outcomes, worse than all other similarly resourced countries. US perinatal care access increasingly is limited, and workforce burnout is high. Adverse perinatal outcomes are greater in communities with limited access to care.

Objective: This review describes the midwifery care model, associated perinatal outcomes in the United States, and historical, fiscal, legal, legislative, regulatory, and hospital policies and practices that restrict access and utilization of the midwifery workforce. Opportunities for US midwifery workforce expansion and integration are outlined.

Evidence acquisition: PubMed, Scopus, and Google Scholar were searched for peer-reviewed literature, as well as historical sources and policy documents that informed this review.

Results: Countries with excellent perinatal outcomes share similar health system characteristics, such as paid parental leave, extended postpartum care, and a larger midwifery workforce, when compared with the United States. Six critical barriers to US midwifery workforce access and utilization include limited workforce development, systemic racism and historical dismantling of the midwifery workforce, invisibility in birth certificate data, inequitable reimbursement, regulatory and legislative restrictions, and discriminatory hospital policies. Several state health care policy case studies illustrate opportunities to increase midwifery workforce expansion and integration.

Conclusions: The midwifery model of care is well-defined and associated with perinatal outcomes that are equal or superior to the physician model of care for low-risk women. Despite this, midwifery care is not routinely utilized or integrated in standard US perinatal care systems due to current restrictions. Addressing these restrictions will improve the delivery of US perinatal care and associated outcomes.

Importance: Intrauterine devices (IUDs) are a safe and highly effective contraceptive method, but pain poses a significant barrier to IUD uptake and satisfaction. Data on existing modalities for insertional pain management are limited, and there remains no consensus on standard of care.

Objective: To summarize the existing literature on pharmacologic and nonpharmacologic pain management options available for IUD insertion pain.

Evidence acquisition: Articles published since 1995 were identified via literature search in PubMed and Ovid; relevant articles were reviewed.

Results: IUD insertion pain management interventions with the strongest evidence to date include cervical block, 10% lidocaine spray, and 5% lidocaine-prilocaine cream. Some low-risk interventions such as ultrasound guidance, music, and the "cough" method have less robust evidence but may be warranted for patients at risk for severe pain, including nulliparous patients, patients who have experienced dysmenorrhea or violence, and patients with high reported anticipated pain. More research is necessary to discern the effectiveness of certain nonsteroidal anti-inflammatory drugs, dinoprostone, transcutaneous electrical nerve stimulation, and acupuncture.

Conclusions and relevance: Despite common practice to offer ibuprofen prior to IUD insertion, topical and injectable lidocaine formulations are more effective at reducing pain. Further research is necessary to strengthen recommendations, elucidate the efficacy of other adjunctive options, and optimize clinic workflow, but these findings suggest that lidocaine-based analgesics may represent the future of IUD insertion pain management. Providers can utilize this summary to offer individualized, evidence-based pain management options for patients seeking an IUD.

Importance: Menstrual equity impacts nearly every obstetric and gynecological patient experiencing vaginal or uterine bleeding. There is a lack of information on how to incorporate menstrual equity into clinical counseling for gynecologists.

Objective: To review current evidence on menstrual bleeding across the reproductive life course and to examine the role of gynecologists in improving menstrual equity in clinical settings.

Evidence acquisition: A PubMed search was performed using appropriate keywords to identify and evaluate journal articles focused on this subject.

Results: There is a dearth of information on the clinical applications of menstrual equity for gynecologists and limited information on managing access to supplies and safe spaces to manage vaginal bleeding across the reproductive life course in the United States.

Conclusions and relevance: Health care professionals providing care for menstruators should include discussion of menstrual equity in their clinical counseling. This should include resources for supplies, risks and benefits of each menstrual management option, and discussion around barriers to safe menstruation. This review suggests best practices to improve menstrual equity across the reproductive life course.

Importance: The prevalence of eating disorders has more than doubled in the past 20 years, now affecting more than 28 million people in the United States. With eating disorders on the rise, a review of the ways in which disordered eating can present, as well as the impact on patients' gynecological health and fertility, is relevant as these causes often have reversible origins with early intervention and treatment.

Objective: The aim of this review is to address for the practicing clinician the pathophysiology, evaluation, and treatment of hypothalamic hypogonadism (HH) with a specific focus on functional hypothalamic hypogonadism (FHH).

Evidence acquisition: PubMed was used as a search engine. Key words searched were "hypothalamic hypogonadism," "hypothalamic amenorrhea," "functional hypothalamic amenorrhea," "athletes' triad," "kisspeptin and hypothalamic hypogonadism," "neuroendocrinology of hypothalamic hypogonadism," and "fertility and functional hypothalamic hypogonadism." Articles that pertained to the pathophysiology, evaluation, and treatment of HH with a specific focus on FHH were reviewed and cited as references.

Results: The most prevalent causes of FHH are disordered eating, intensive exercise, and stress or a combination thereof. Treatment should be based on cause. When disordered eating is the cause, treatment must involve psychiatric input. Pregnancy is not recommended in patients whose FHH persists, but for the majority of women who have achieved a modicum of control, pregnancy can be achieved via ovulation induction with excellent obstetrical outcomes.

Conclusions and relevance: With eating disorders on the rise, it is important for the practicing clinician to understand the etiologies, workup, and treatment of FHH for patients in general and for patients who desire pregnancy. It is important to review these causes and their treatments as they often have reversible origins. Prognosis is excellent with treatment, especially in cases where there is early recognition.