Obstetrics and gynecology最新文献

Objective: To aid in cancer control and prevention activities by developing, calibrating, and validating three distinct natural history simulation models of uterine cancer, a growing public health concern.

Methods: To perform comparative analyses, we developed two state-transition microsimulation models and a multistage clonal expansion model of uterine cancer. The models simulate uterine cancer incidence and mortality. All three models were calibrated to common data on the incidence of uterine cancer from the Surveillance, Epidemiology, and End Results (SEER) 18 database. Each model accounts for changing trends in hysterectomy and obesity over time and simulates incidence and mortality for endometrioid and nonendometrioid tumors and uterine sarcoma. After calibration, we projected the incidence and mortality of uterine cancer to 2050.

Results: The three uterine cancer models were well calibrated to population data and produced comparable results for projecting the burden of disease through 2050. Among non-Hispanic White women aged 40 years or older, the models project that by 2050 the incidence of uterine cancer will rise to 76.1-81.8 per 100,000 woman-years, up from 2018 SEER incidence of 60.0 per 100,000 woman-years. Among non-Hispanic Black women, new cases will rise to 90.3-107.2 per 100,000 woman-years, up from 2018 SEER incidence of 61.3 per 100,000 woman-years. Within these populations, incidence-based mortality will increase to 11.3-12.3 deaths per 100,000 woman-years for non-Hispanic White women and to 28.2-35.7 deaths per 100,000 woman-years for non-Hispanic Black women.

Conclusion: Three distinct mathematical simulation models of uterine cancer have been calibrated to observed population-based incidence and mortality. All three models project substantial and continued increases in the incidence and mortality of uterine cancer.

Objective: Evidence related to anemia in early pregnancy, and its resolution or persistence by late pregnancy, is limited. We evaluated pregnancy outcomes associated with anemia in early pregnancy and resolution compared with persistence in late pregnancy.

Methods: We used the Merative™ Marketscan® Commercial Database of nationwide insurance claims (2018-2023) and included pregnant individuals without hereditary anemias. We used hemoglobin and hematocrit to identify anemia in early pregnancy (before 14 weeks of gestation) and late pregnancy (at or after 24 weeks of gestation). Pregnancy outcomes included preeclampsia, placenta previa, placental abruption, severe postpartum hemorrhage, blood products transfusion, cesarean birth, nontransfusion severe maternal morbidity (SMM), spontaneous preterm birth, medically indicated preterm birth, and small-for-gestational-age (SGA) birth weight. We used modified Poisson regression to estimate associations between: 1) anemia in early pregnancy and pregnancy outcomes; and 2) anemia resolution by late pregnancy and pregnancy outcomes, adjusting for confounders by inverse probability weighting.

Results: Among 73,586 individuals, 4.4% (95% CI, 4.3-4.6%) had anemia in early pregnancy. Early pregnancy anemia was associated with higher risk of each outcome assessed, with the exception of placenta previa, with the highest associated risk of blood products transfusion (2.4% vs 0.8%; adjusted risk ratio [aRR] 2.45; 95% CI, 1.91-3.13). Of those with early pregnancy anemia and laboratory values in late pregnancy (72.1%), 53.4% had persistent anemia and 46.6% had resolved anemia. Persistent anemia was associated with nontransfusion SMM (2.6% vs 1.1%, aRR 1.64; 95% CI, 1.13-2.37), blood products transfusion (2.9% vs 0.8%, aRR 2.60; 95% CI, 1.84-3.69), and SGA birth weight (8.5% vs 6.8%, aRR 1.23; 95% CI, 1.01-1.50), compared with those without anemia in the first trimester. The resolution of anemia by late pregnancy was not associated with nontransfusion SMM (1.6% vs 1.1%; aRR 1.07; 95% CI, 0.65-1.74) but was associated with blood products transfusion (1.6% vs 0.8%; aRR 1.64; 95% CI, 1.01-2.67) and SGA birth weight (10.0% vs 6.8%; aRR 1.38; 95% CI, 1.15-1.67) compared with those without anemia in the first trimester.

Conclusion: Anemia in the first trimester was associated with adverse maternal and neonatal outcomes. The resolution of anemia by late pregnancy eliminated the association with nontransfusion SMM but not other outcomes, emphasizing the importance of treating anemia in early pregnancy and before pregnancy.

The care of young women with breast cancer can be influenced by pregnancy and desire for future fertility. Here, we provide an overview of breast cancer management in young women with special emphasis on gestational breast cancer and postpartum breast cancer, which are now understood to be distinct clinical entities with disparate outcomes. Typically, breast cancer is detected in young women after self-identification of a breast mass. The initial workup consists of diagnostic breast ultrasonogram and mammogram. Breast cancer treatments vary by histologic subtype of cancer and stage. Chemotherapy and surgery are safe during pregnancy, and it is now known that pregnant women with breast cancer have oncologic outcomes equivalent to those of nonpregnant women when treated according to standard of care. Postpartum breast cancer, however, has higher rates of metastatic disease and mortality. In general, breastfeeding can be safely continued during treatment with appropriate counseling and guidance from a breastfeeding medicine expert. Similarly, fertility preservation and future fertility can be safely pursued with appropriate interventions in young women with breast cancer.

Immigrants face challenges in navigating complex policies that govern access to health care, shelter, food, and clean water, resulting in profound effects on health care outcomes, including increased risk of preterm births and decreased access to preventive health services. These disparities are further exacerbated when immigration policies result in mass detention, incarceration, and deportation, leading to profound trauma among undocumented immigrants and their communities. Obstetrician-gynecologists and other reproductive health care professionals should be prepared to practice immigration-informed care and ensure clinical spaces are welcoming to immigrants. Unless mandated by law, health care professionals should document only information related to a patient's migration history that is necessary for the ongoing clinical care. Health care institutions should provide robust guidance and support for health care personnel and patients faced with the continued complexities of the dynamic landscape of immigration policies. Obstetrician-gynecologists should advocate for the unique needs of patients who are immigrants to promote reproductive justice and health equity.

Objective: To evaluate cabergoline's efficacy at decreasing lactation symptoms after early second-trimester abortion or pregnancy loss.

Methods: This is a multisite, double-blind, gestational-age stratified superiority trial that compared cabergoline 1 mg once with placebo for preventing bothersome breast symptoms immediately after uterine evacuation. We enrolled pregnant people at 16-20 weeks of gestation who were English- or Spanish-speaking and without contraindication to the study drug. Participants received cabergoline within 4 hours of uterine evacuation or fetal expulsion and, at baseline and at multiple time points through 2 weeks postprocedure, completed a validated electronic survey that assessed breast symptoms, side effects, and bother. Our primary outcome was breast symptoms (a composite of engorgement, milk leakage, tenderness, and need for pain relief) on day 4; we planned to enroll 30 participants in each gestational duration strata to show a 40% difference in breast symptoms (80% power, α=0.049).

Results: After screening 145 patients from February 2024 through May 2025, we enrolled 69 eligible participants. Baseline demographics were balanced between groups: Median gestational duration was 18 weeks (range 16 0/7-19 6/7 weeks), 53.0% were nulliparous, 63.6% self-identified as Hispanic, and 68.2% had public insurance. On day 4, significantly fewer participants who received cabergoline reported any breast symptoms compared with placebo (50.0% vs 88.2%, P<.001) (primary outcome) and fewer participants reported significant bother from breast symptoms (3.1% vs 20.6%, P=.05) (secondary outcome). These differences persist even in the earlier gestational duration strata.

Conclusion: Cabergoline is an effective and well-tolerated medication to prevent breast symptoms after early second-trimester abortion or pregnancy loss.

Clinical trial registration: ClinicalTrials.gov: NCT06029673.

The current treatment of provoked vestibulodynia involving neuroproliferation is often complete vestibulectomy; however, less invasive treatments are biologically plausible, yet lack study. The International Society for the Study of Women's Sexual Health, the National Vulvodynia Association, the Gynecologic Cancers Research Foundation, and Tight Lipped, a grassroots nonprofit organization that supports people with chronic vulvovaginal and pelvic pain, collectively sponsored a conference, the Vulvodynia Therapeutic Research Summit, held in April 2024. The primary objective of the Vulvodynia Therapeutic Research Summit was to identify options for further research of the treatment of provoked vestibulodynia through expert consensus. After the conference, attendees scored the presented therapeutics in rank order, leading to a hierarchy of merit. Fifteen therapeutic options were presented and ranked in order of most promising to least promising for further study on treating the neuroinflammation of provoked vestibulodynia. The top identified therapeutics for further research were: 1) ketotifen fumarate (mast cell stabilizer with potential to prevent mast cell activation), 2) resiniferatoxin (transient receptor vanilloid 1 agonist causing chemo-inactivation of nerve terminals), 3) specialized pro-resolving mediators or strategies to boost their levels (eg, maresin 1 and 1-trifluoromethoxy-phenyl-3-[1-propionylpiperidin-4-yl] urea), 4) luteolin (flavonoid with potent anti-inflammatory, antioxidant, and neuroprotective properties), 5) alpha-lipoic acid (antioxidant with nerve-specific anti-inflammatory and mast cell stabilizing qualities), and 6) NGFR121W -SNAP IR700 trimer exposed to near-infared light (photoablation targeting nociceptors and sparing surrounding tissue). This executive summary describes the rationale for identifying specific pharmacologic agents and medical devices as targets for research directed toward treatment of the neuroinflammatory process found in the vestibular mucosa of provoked vestibulodynia.

Obstetric anal sphincter injuries occur in 4% or less of vaginal deliveries, but the potential downstream consequences of the injury (most commonly anal incontinence) can drastically alter a person's quality of life. The main risk factors for obstetric anal sphincter injuries are those that contribute to difficult vaginal birth and the need to perform an operative vaginal delivery (most notably forceps-assisted vaginal delivery). Successful repair of an obstetric anal sphincter injury is achieved with a thorough understanding of the perineal and perianal anatomy and careful attention to layer-by-layer reconstruction. Close follow-up of patients who sustain obstetric anal sphincter injuries can help identify possible complications earlier in their course. For patients who are considering subsequent pregnancy and delivery, there should be a thoughtful, patient-centered discussion, recognizing that, although cesarean delivery can prevent recurrent sphincter laceration itself, it has its own immediate surgical and future pregnancy risks and is not guaranteed to prevent anal incontinence.