Obstetrics and gynecology最新文献

Objective: Activity restriction is commonly recommended in pregnancy despite lacking evidence of benefit. We sought to evaluate the amount of physical activity in patients at high risk for preterm birth and pregnancy latency and preterm birth.

Methods: This is an ancillary study of two randomized trials of preterm birth prevention in people with a short cervical length. People were enrolled from 16 0/7 to 23 6/7 weeks of gestation and instructed to wear a wrist accelerometer, which calculated physical activity data (steps per day) until delivery. The number of steps per day was calculated for each participant. The primary outcome was latency from time of enrollment to delivery. Sedentary activity was defined as a median of fewer than 3,500 steps per day. We compared outcomes between those with fewer than 3,500 median steps per day and those with 3,500 or more median steps per day. Secondary outcomes included preterm birth before 32, 34, and 37 weeks of gestation.

Results: Of the 120 participants enrolled in the ancillary study, 117 (97.5%) had complete accelerometer data. At enrollment, the median gestational age was 22.8 weeks (interquartile range 21.3, 23.7), and a quarter of participants (25.8%) had been placed on activity restriction by their practitioner. The primary outcome, latency from time of enrollment to delivery, was not different between the groups (hazard ratio 0.95, 95% CI, 0.88-1.03). Steps per day did not differ by median cervical length at baseline between the groups. However, participants with fewer than 3,500 median steps per day delivered at an earlier gestational age (34.9 weeks vs 37.7 weeks, P=.04) and were more likely to deliver before 34 weeks (47.3% vs 17.7%, P=.03).

Conclusion: There was no statistically significant difference in latency from time of enrollment to delivery between those with and those without activity restriction. However, among individuals with a short cervix in the second trimester, sedentary activity (fewer than 3,500 steps per day) was associated with an increased risk of preterm birth before 34 weeks of gestation and delivery at an earlier gestational age.

Fetal cleft lip and cleft palate are among the most common craniofacial anomalies, affecting approximately 1 in 1,000 live births worldwide. Cleft lip/cleft palate is caused by a combination of genetic and environmental factors and requires prompt diagnosis and lifelong multidisciplinary care for adequate treatment of anatomic and psychosocial challenges that extend well beyond surgical procedures in infancy. Cleft lip/cleft palate is a complex anomaly present from the first trimester onward that has prenatal and postnatal considerations. Diagnosis of cleft lip/cleft palate is most common in the second trimester through ultrasound visualization of the anatomic defect. However, characterization of the defect may be further performed in the third trimester, possibly with the adjunct of magnetic resonance imaging. Prenatal management depends on the cause, genetic association, or additional anatomic abnormalities that may dictate specific timing and location of delivery. Multidisciplinary management involves perinatology, genetic counseling, orofacial surgery, and lactation specialists and speech and language therapists among experts from other specialties for comprehensive treatment. In this narrative review of cleft lip/cleft palate, the anatomic characteristics, imaging findings, causes, genetic associations, and management are discussed.

Objective: To evaluate whether the history of cesarean delivery influences the risk or clinical aggressiveness of postmolar gestational trophoblastic neoplasia.

Methods: This retrospective cohort study involved two gestational trophoblastic disease reference centers in Brazil and the United States. Medical records from patients with histopathologically confirmed hydatidiform mole between January 2002 and December 2022 were reviewed. Patients were grouped according to the presence or absence of prior cesarean delivery. The primary outcome was the development of postmolar gestational trophoblastic neoplasia; the secondary outcome was resistance to single-agent chemotherapy. Multivariable logistic regression models adjusted for relevant confounders were used to identify independent predictors.

Results: Among 2,904 patients with hydatidiform mole, prior cesarean delivery was associated in a multivariable logistic regression with an increased risk of postmolar gestational trophoblastic neoplasia (adjusted odds ratio [aOR] 1.45, 95% CI, 1.13-1.85) that was independent of age, complete hydatidiform mole histology, city of uterine evacuation, pre-evacuation human chorionic gonadotropin level, and year of hydatidiform mole diagnosis. Furthermore, neither the number of previous cesarean deliveries (aOR 1.43, 95% CI, 0.91-2.24) nor an elective indication (aOR 1.12, 95% CI, 0.60-2.08) appeared to modify this risk. Cesarean delivery history (aOR 1.27, 95% CI, 0.59-2.73) and number of (aOR 0.22, 95% CI, 0.02-1.89) or indication for (aOR 0.36, 95% CI, 0.06-2.03) prior cesarean delivery were not significantly associated with chemoresistance among 621 patients with low-risk gestational trophoblastic neoplasia.

Conclusion: A history of cesarean delivery is associated with a 45.0% increased risk of postmolar gestational trophoblastic neoplasia without evidence of greater chemoresistance. These findings support current management protocols while indicating that patients with prior cesarean delivery may benefit from heightened clinical vigilance during standard postmolar surveillance.

Vaccines administered to women during pregnancy can provide protection against serious infectious diseases for the mother, the child, or both. Maternal immunization boosts the concentration of maternal antibodies that can be transferred across the placenta to directly protect children too young to be immunized. In addition, indirect protection through prevention of maternal infection and breast-milk antibodies can be achieved through maternal immunization. In general, inactivated vaccines are considered safe for pregnant women and fetuses, whereas live attenuated vaccines are avoided due to the theoretical potential risk of infection to the fetus. However, the potential risks of vaccines need to be weighed against the risk of the disease itself and the benefits of vaccination in terms of protection of the mother and child against infectious disease. Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap); influenza; coronavirus disease 2019 (COVID-19); and respiratory syncytial virus (RSV) vaccines are routinely recommended for all pregnant women in the United States. Maternal immunization has the potential to improve the health of mothers and young children; therefore, other diseases of relevance during this period are now targets of active research and vaccine development, including group B streptococcus (GBS). Similarly, several vaccines can be administered during pregnancy in special circumstances when maternal health, travel, or other special situations arise. This article reviews the current recommendations for vaccination of women during pregnancy.

Immunization is an essential part of preventive care for adults, including pregnant individuals. Each vaccine recommended for pregnant patients is important for the protection of the maternal-child dyad. Other vaccines provide maternal protection from severe morbidity related to specific pathogens such as pneumococcus, meningococcus, and hepatitis for at-risk pregnant individuals. Obstetrician-gynecologists and other obstetric care professionals should routinely assess their pregnant patients' vaccination status, including their risk factors for vaccine-preventable diseases. Based on this assessment they should recommend and, when possible, administer needed vaccines to their pregnant patients. There is no evidence of adverse fetal effects from vaccinating pregnant women with mRNA-derived vaccines, inactivated virus vaccines, bacterial vaccines, or toxoids. Real-world data continue to demonstrate the safety and efficacy of such use. Certain vaccines should be given in the postpartum period.

In 2003, the U.S. Food and Drug Administration (FDA) issued a black box warning on menopausal hormone therapy (MHT) products based on putative harm of secondary outcomes and incompletely collected and adjudicated data from the Women's Health Initiative (WHI) oral conjugated equine estrogens and medroxyprogesterone acetate study. Despite the specific parameters and limitations of the WHI study, these warnings were inappropriately generalized across all doses, formulations, and routes of administration, including local vaginal therapies, under the mandate to prescribe the "lowest effective dose for the shortest duration." After 22 years of clinical controversy, the U.S. Department of Health and Human Services and the FDA announced removal of the boxed warning on November 10, 2025. This decision was based on the FDA's independent and comprehensive review of the scientific literature, deliberations from an expert panel on July 17, 2025, and a 60-day public comment period. The FDA's transition to product-specific labeling, the removal of the mandate for the lowest effective dose for the shortest duration, and the inclusion of guidance on the optimal timing of MHT initiation within 10 years of menopause or before age 60 years, represent critical steps toward evidence-based menopause management. By replacing misleading information with accurate data, this regulatory shift facilitates individualized benefit-risk assessments and empowers shared decision making. Ultimately, these updates ensure that MHT use is optimized for the specific needs of each patient, integrating modern risk assessment with the latest clinical evidence to improve long-term health outcomes.

Objective: To examine the growth of obstetrics and gynecology residency programs and positions compared with other core medical specialties over the past 20 years.

Methods: Obstetrics and gynecology, family medicine, emergency medicine, internal medicine, general surgery, psychiatry, pediatrics, and anesthesiology match data were obtained from the National Resident Matching Program from 2005 to 2024. Generalized least-squares regression models accounting for autocorrelation and heteroskedasticity were used to obtain yearly changes in the number of positions offered and number of programs for each specialty, as well as P values comparing the trends relative to obstetrics and gynecology before and after 2015 (the year of the transition to a single accreditation system).

Results: Between 2005 and 2015, obstetrics and gynecology residency positions increased at an average annual rate of 1.0%, along with a slight decline in the number of programs (-0.5%). In contrast, from 2016 onward, obstetrics and gynecology residency positions increased by approximately 1.3% annually, with a 2.9% growth in programs. Up to 2015, obstetrics and gynecology experienced significantly slower growth in residency positions compared with almost all other specialties (P≤.05 in all instances) apart from family medicine and surgery. During that same period up to 2015, obstetrics and gynecology programs grew more slowly than emergency medicine, psychiatry, anesthesiology, and combined anesthesiology. Beginning in 2016, all specialties except family medicine, internal medicine, and combined anesthesia increased residency positions at significantly higher rates than obstetrics and gynecology (P≤.05). Since 2016, the growth of residency programs has remained slower for obstetrics and gynecology compared with family medicine, emergency medicine, internal medicine, and psychiatry.

Conclusion: Obstetrics and gynecology residency growth has lagged behind that of other specialties both before and since the single accreditation system transition in 2015, highlighting a persistent gap in capacity to meet increasing demand. These findings highlight the need for focused efforts to match the growth of obstetrics and gynecology residency positions and programs with the expanding health care demands.

Abstract: Stroke remains a rare but life-threatening complication of pregnancy, with significant implications for both maternal and fetal health. Current stroke prevention and treatment guidelines offer limited guidance for managing stroke in pregnant and postpartum patients. Despite advances in obstetric and neurological care, the diagnosis and management of pregnancy-associated stroke continue to be challenged by delayed recognition, a lack of tailored clinical guidelines, and persistent disparities in outcomes. This scientific statement represents a multidisciplinary effort to synthesize current knowledge of the risk factors and diverse causes of stroke in pregnancy and to offer consensus-driven suggestions for prevention, acute management, and postpartum recovery. Nearly half of all US pregnancy-associated stroke hospitalizations occur in the setting of hypertensive disorders. Primary stroke prevention strategies include risk factor modification, aggressive hypertension management and prompt treatment of severe hypertension in pregnancy and postpartum, and antithrombotic therapy in some high-risk groups. Secondary stroke prevention strategies in pregnancy depend on the mechanism of the prior stroke. Pregnancy should not delay evidence-based treatments for acute stroke. The use of telemedicine can facilitate early consultation with a vascular neurologist and a maternal-fetal medicine specialist in cases of acute pregnancy-related stroke, helping to guide initial decision-making. Computed tomography, computed tomography angiography, and magnetic resonance imaging without contrast are all safe neuroimaging modalities for rapid evaluation of pregnant patients with acute stroke symptoms. Acute stroke alone is not an indication for immediate delivery, and stabilization of the mother should come first. Vaginal delivery after stroke is preferred when feasible because it avoids the surgical risks and hemodynamic stress associated with cesarean delivery. Survivors of pregnancy-associated stroke face unique challenges such as caring for an infant and breastfeeding and require support from a multidisciplinary rehabilitation team. Continued research, including inclusive clinical trials, is urgently needed to refine stroke risk assessment, to expand treatment options, and to improve maternal outcomes.

Objective: To evaluate the clinical utility and methodologic validity of noninvasive prenatal testing (NIPT) for dominant single-gene disorders by performing a systematic review and meta-analysis.

Data sources: From database inception through April 2025, we explored PubMed, EMBASE, Cochrane Library, and Web of Science.

Method of study selection: Studies that reported NIPT panels to screen for dominant single-gene disorders with confirmation testing and involved at least 50 cases were included. The Quality Assessment of Diagnostic Accuracy Studies 2 tool was used for study appraisal. Clinical utility was evaluated by using positivity rate and positive predictive value (PPV), with pooled estimates calculated through fixed- or random-effects models. Methodologic validity was assessed through sensitivity and specificity by using a bivariate random-effects model and summary receiver operating characteristic curve analysis.

Tabulation, integration and results: Ten articles comprising 12,577 cases were included. Positivity rate and PPV were calculated from nine studies, with sensitivity and specificity from seven studies. The pooled positivity rate was 2.2% (95% CI, 0.8-5.6%), and pooled PPV was 93.8% (95% CI, 86.4-97.3%). The bivariate model yielded a pooled sensitivity of 94.5% (95% CI, 85.7-98.0%) and specificity of 99.7% (95% CI, 98.8-99.9%), with an area under the curve of 0.98 (95% CI, 0.94-0.99). Subgroup analysis revealed positivity rates of 0.3% in low-risk populations, 1.2% in mixed-risk populations, and 6.0% in high-risk populations. High heterogeneity was observed in the positivity rate analysis (I2=96%). In contrast, heterogeneity was low (I2=16%) for PPV but with publication bias being detected (P=.004).

Conclusion: Noninvasive prenatal testing panels for dominant single-gene disorders achieve a high PPV with high sensitivity and specificity.

Systematic review registration: PROSPERO, CRD42024571768.