Obstetrics and gynecology最新文献

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.

Objective: To examine the association between neighborhood-level social determinants of health and stillbirth.

Methods: We performed a retrospective cohort study of deliveries that occurred at a gestational age of at least 20 weeks within a five-hospital system (2012-2022). Electronic health record data mapped to the Observational Medical Outcomes Partnership Common Data Model were geocoded using addresses at the time of delivery and linked to neighborhood health indices, which included the Area Deprivation Index (ADI), Maternal Vulnerability Index (MVI), and Social Vulnerability Index (SVI) at the Census tract level. Stillbirths were adjudicated by medical record review. Modified Poisson regression generated relative risks (RRs) and 95% CIs, controlling for maternal age, body mass index (BMI), parity, marital status, chronic hypertension, and pregestational diabetes.

Results: Among 61,008 pregnancies, 288 (0.5%, 95% CI, 0.4-0.5%) resulted in stillbirths. The ADI quartiles (relative to Census tracts within the United States as a whole) 2, 3, and 4 were associated with an increased risk of stillbirth (RR [95% CI] 2.32 [1.34-4.03], 3.08 [1.74-5.44], and 2.07 [1.03-4.14], respectively) compared with quartile 1. The ADI relative to Census tracts within the states showed comparable gradients. MVI quartiles 2 and 3 were associated with an increased risk of stillbirth (RR [95% CI] 1.44 [1.01-2.05] and 1.49 [1.02-2.19], respectively) compared with quartile 1. Similarly, SVI quartiles 2 and 3 were associated with an increased risk of stillbirth (RR [95% CI] 1.46 [1.03-2.07] and 1.86 [1.32-2.63], respectively) compared with quartile 1. Neither MVI nor SVI quartile 4 showed a statistically significant association with stillbirth. Among MVI subthemes, the mental health domain demonstrated a strong association with stillbirth (quartiles 2-4 RR range 1.64-2.07).

Conclusion: Neighborhood deprivation, quantified by ADI score, was a robust independent predictor of stillbirth, whereas the associations between the MVI or SVI and stillbirth were modest. Integrating the ADI into obstetric risk assessment and directing resources, especially perinatal mental health services, to highly deprived areas may help reduce persistent stillbirth disparities.