Obstetrics and gynecology最新文献

With rising obesity rates and increasing glucagon-like peptide-1 receptor agonist (GLP-1 RA) use, understanding perinatal prescribing patterns is important. We conducted a retrospective cohort study to examine semaglutide and tirzepatide prescribing among pregnant patients in the United States from 2019 to 2024. We analyzed prescriptions during the year before and after delivery, grouping deliveries into 6-month periods and applying segmented linear regression with data-driven change-point detection to identify prescribing-trend shifts. Prevalence of GLP-1 RA prescribing increased from 0.2 to 6.4 per 1,000 deliveries predelivery and from 0.3 to 14.6 per 1,000 deliveries postdelivery, with significant prescribing change points indicating accelerated prescribing in June 2022 for the predelivery period and in March 2021 for the postdelivery period. These findings suggest rapid adoption of GLP-1 RAs in the perinatal period and underscore the need for evidence-based safety data for these medications.

Objective: To estimate the cumulative incidence of intrauterine synechiae in women who have ever had a dilation and curettage (D&C) procedure and to identify covariates associated with diagnosis of the disease.

Methods: This is a retrospective cohort study of female Kaiser Permanente Northern California (KPNC) members aged 18-55 years with at least one known prior D&C from January 1, 2010, to December 31, 2020. Data were collected from KPNC electronic medical records, and the diagnosis of intrauterine synechiae was identified using International Classification of Diseases codes. The cumulative incidence of intrauterine synechiae was determined and descriptive characteristics were calculated for demographic and clinical characteristics using χ 2 or Fisher exact and t tests. Extended Cox regression was used to evaluate risk factors in the diagnosis of intrauterine synechiae.

Results: A total of 467 women were diagnosed with intrauterine synechiae, corresponding to a cumulative incidence of 0.8% (467/58,607). Dilation and curettage performed for an obstetric indication was associated with increased hazard of synechiae development (hazard ratio 2.23; 95% CI, 1.77-2.82). Undergoing two D&C procedures increased the hazard 3.96-fold (95% CI, 3.08-5.04); three or more procedures elevated the risk 12.42-fold (95% CI, 7.88-18.70). Other factors significantly associated with an increased hazard of synechiae included a history of pelvic inflammatory disease and uterine artery embolization. In contrast, parity and elevated body mass index (BMI) were negatively associated with synechiae. No significant association was found between sharp curettage and synechiae.

Conclusion: The incidence of intrauterine synechiae after D&C is low, reinforcing the low-risk profile of the procedure, even when sharp curettage is used. However, multiple D&C procedures were strongly associated with an increased risk of synechiae, highlighting the importance of minimizing unnecessary interventions. Additional risk factors include a history of pelvic inflammatory disease and uterine artery embolization. Patients with multiple risk factors should receive comprehensive counseling regarding their elevated risk of developing synechiae.

Objective: To investigate the treatment effect of adjuvant chemotherapy for stage I ovarian clear cell carcinoma.

Data sources: We searched Cochrane, PubMed, International Standard Randomised Controlled Trial Number registry, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and Ichushi-Web to January 22, 2025.

Methods of study selection: We included randomized controlled trials (RCTs) and non-RCTs that included more than 50 patients with stage I ovarian clear cell carcinoma. The primary and secondary outcomes were disease-free survival and overall survival, respectively. We performed a meta-analysis of the stage-adjusted hazard ratios (HRs) of adjuvant chemotherapy compared with placebo or no intervention. The substage-related heterogeneity of effects was also assessed. A meta-analysis of proportions was also conducted to assess 5-year disease-free survival and 5-year overall survival. Risk of bias was assessed with the Risk of Bias in Non-randomized Studies of Interventions tool.

Tabulation, integration, and results: Because no RCTs reported HRs for the ovarian clear cell carcinoma subgroup, data from nine non-RCTs were analyzed. The pooled substage-adjusted HR for disease-free survival associated with use of chemotherapy was 0.47 (95% CI, 0.29-0.74) and that for overall survival was 0.66 (95% CI,0.43-1.00). Heterogeneity in the effect by substage was not evident for either disease-free survival (P for subgroup difference=.91) or overall survival (P=.60). The pooled 5-year disease-free survival was 0.80 (95% CI, 0.65-0.89) for stage I overall, 0.95 (95% CI, 0.47-1.0) for stage IA, and 0.61 (95% CI, 0.47-0.74) for stage IC. The estimated number needed to treat was 10.2 (95% CI, 5.8-18.6) for stage I overall, 40.8 (95% CI, 3.9-infinity) for stage IA, and 5.2 (95% CI, 3.9-7.8) for stage IC.

Conclusion: Adjuvant chemotherapy improves disease-free survival and may prolong overall survival in patients with stage I ovarian clear cell carcinoma. Available evidence suggests that recurrence is reduced by approximately 50%. Treatment decisions should consider the baseline recurrence risks and absolute benefits.

Clinical trial registration: PROSPERO, CRD42024562486.

Purpose: To provide evidence-based recommendations for the evaluation and diagnosis of endometriosis.

Target population: Reproductive-aged adults and adolescents with symptoms suggestive of endometriosis.

Methods: This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology and one specialist in reproductive endocrinology and infertility appointed by the American College of Obstetricians & Gynecologists' (ACOG) Committee on Clinical Practice Guidelines-Gynecology. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. The National Institute for Health and Care Excellence (NICE) evidence review on endometriosis diagnosis and management served as the evidence base for many of the clinical considerations. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

Recommendations: This Clinical Practice Guideline includes recommendations on the clinical, imaging, and surgical evaluation and diagnosis of endometriosis. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation cannot be made because of inadequate or nonexistent evidence. The recommendations included in this guideline also apply to adolescents unless otherwise specified and are based on review of the limited available evidence, extrapolated data from adult populations, and expert consensus.

Objective: To evaluate the associations among peripregnancy glucagon-like peptide-1 receptor agonist (GLP-1RA) exposure with hypertensive disorders of pregnancy (HDP) and gestational weight gain.

Methods: We conducted a retrospective cohort study that included patients who delivered between 2014 and 2024 and had GLP-1RA exposure up to 1 year before pregnancy. Participants were identified through electronic medical record query with manual medical record abstraction to confirm exposure stop dates. Exposure to GLP-1RAs was classified by indication: pregestational diabetes mellitus or weight management. Unexposed control groups for each indication cohort were identified from an existing institutional data repository from 2021 to 2022. Demographic and clinical characteristics and obstetric outcomes were compared. The two primary outcomes were gestational weight gain and HDP. Gestational weight gain was quantified as below, meeting, or exceeding recommended gestational weight gain. Crude odds ratios and adjusted odds ratios (aORs) were estimated using multivariable modeling. Regression analysis was stratified as GLP-1RA exposure prepregnancy only or during pregnancy.

Results: We included 243 patients who were exposed to GLP-1RA up to 1 year before pregnancy, with 65.4% having evidence of use during pregnancy. Overall, 103 (42.4%) patients used GLP-1RA for pregestational diabetes and 140 (57.6%) patients used it for weight management, compared with 175 unexposed patients in the pregestational diabetes control group and 200 unexposed patients in the weight-management control group (body mass index [BMI] 30-39.9: n=100; BMI 40 or higher: n=100). Exposure to GLP-1RAs was not associated with gestational weight gain in the pregestational diabetes cohort but was associated with decreased odds of gestational weight gain below recommendations (aOR 0.37, 95% CI, 0.18-0.78) in the weight-management cohort. Exposure to GLP-1RAs was not associated with HDP when compared with unexposed individuals with pregestational diabetes (aOR 0.72, 95% CI, 0.42-1.25) or with unexposed individuals who were undergoing weight management (aOR 0.83, 95% CI, 0.45-1.52).

Conclusion: In individuals undergoing weight management, peripregnancy GLP-1RA exposure was associated with decreased odds of gestational weight gain below recommendations, which may reflect rebound weight gain after cessation. Peripregnancy GLP-1RA exposure was not associated with developing HDP in either the pregestational diabetes or weight-management cohort. Additional studies are needed to guide GLP-1RA use in pregnancy and to better elucidate any risks of exposure.

Objective: To estimate the real-world incidence of abnormal uterine bleeding after oral anticoagulant initiation with a large national claims database, stratified by agent and age group.

Methods: We conducted a nested matched case-control study using the MarketScan Research Databases (2008-2022). Women 18 years of age or older initiating oral anticoagulants (warfarin, apixaban, rivaroxaban, dabigatran, and edoxaban) for deep venous thrombosis, pulmonary embolism, or atrial fibrillation or flutter were matched 1:5 to anticoagulant nonusers. The primary outcome was abnormal uterine bleeding (AUB) within 1 year. Secondary outcomes included the risk of hospitalizations, emergency department visits, and outpatient encounters related to AUB. All estimates were derived from conditional logistic regression models adjusted for matching factors and baseline clinical covariates.

Results: Among 276,911 anticoagulant users and 1,384,555 matched controls, the incidence of AUB was significantly higher in anticoagulant users (6.1% vs 3.0%, adjusted odds ratio [AOR] 1.81, 95% CI, 1.69-1.93). Anticoagulant users had higher odds of AUB-related hospitalization (0.8% vs 0.01%, AOR 62.32, 95% CI, 30.94-125.53), emergency department visits (0.9% vs 0.2%, AOR 5.78, 95% CI, 4.02-8.31), and outpatient encounters (4.6% vs 2.8%, AOR 1.42, 95% CI, 1.32-1.52). Women younger than 50 years of age had a greater relative increase in AUB (19.7% vs 9.2%, AOR 1.96, 95% CI, 1.79-2.14) compared with women 50 years of age or older (3.8% vs 2.0%, AOR 1.63, 95% CI, 1.50-1.78). Among all agents, rivaroxaban was associated with the highest risk of AUB.

Conclusion: Oral anticoagulant therapy is associated with significantly increased odds of AUB, particularly among younger women. Rivaroxaban conferred the highest AUB risk.

Maternal cardiac arrest is a catastrophic event, with data regarding outcomes and feasibility of timely resuscitative hysterotomy remaining scarce. Our retrospective cohort study identified 31 pregnant or postpartum patients with in-hospital cardiac arrest at a tertiary care center over 15.5 years, an incidence of 2 per 10,000 deliveries (95% CI, 1.4-2.8/10,000 deliveries). Return of spontaneous circulation (ROSC) occurred in 87.1% of the patients (95% CI, 75.2-98.8%) within a median of 2 minutes, and 77.4% (95% CI, 62.6-92.1%) survived until discharge. Eleven instances of cardiac arrest (35.5%) occurred antepartum, predominantly due to anesthetic complications. Two resuscitative hysterotomies were performed, with code-to-delivery time of 4 minutes and 100% neonatal survival. Twenty instances of cardiac arrest (64.5%) were immediately postpartum, primarily after hemorrhage or amniotic fluid embolism. Our findings demonstrate high rates of ROSC and survival in a tertiary care setting, which help to confirm feasibility and utility of rapid resuscitative hysterotomy.

Nearly 90% of cervical cancer and related fatalities occur in low-income and middle-income countries and low-resourced areas within developed countries. In the 1980s, self-sampling was introduced to reach this vulnerable population and those with behavioral aversion to clinician-based screening. Currently, dozens of self-sampling devices have been studied for cervical cancer screening. Here, we consolidated data from an extensive peer-reviewed literature search to summarize the prevalence, accuracy, and acceptance rates of cervical cancer screening self-sampling devices worldwide. We focused, when available, on samples detecting high-risk human papilloma virus (HPV) in cervical intraepithelial neoplasia grade 2 or more. The most studied and commonly accepted devices described in our review include the Evalyn Brush (N=73,986), Delphi Screener (n=28,020), FLOQSwab (N=13,638), Viba-Brush (N=25,565), and Digene Brush (N=12,150). Compared with clinician-based collection, samples derived from self-sampling devices had no significant difference in accurate detection of high-risk HPV. These self-sampling devices have thus been shown to effectively achieve broader global coverage for cervical cancer screening, particularly for limited-access areas. The use of self-sampling devices in populations with low resources and aversion to clinician-based sampling could have a major influence on detection of high-risk HPV and dysplasia, potentially reducing incidence of cervical cancer worldwide.

Objective: To assess the 5-year efficacy and safety of a novel, nitinol-framed, low-dose copper intrauterine device (IUD) in an ongoing phase 3 trial.

Methods: In this single-arm trial, participants aged 17-45 years at risk for pregnancy were recruited to receive the Cu 175 mm2 IUD with a flexible nitinol frame that comes preloaded with precut strings. Ongoing follow-up continues up to 8 years. We assessed the primary outcome of contraceptive efficacy in the population evaluable for pregnancy (those aged up to 35 years at enrollment) by Pearl Index, each year and cumulatively. Secondary outcomes included pregnancy percentage by life table analysis (Kaplan-Meier) and safety.

Results: The 1,620 enrollees included 1,601 (98.8%) who experienced successful IUD placement in the safety population and included 1,397 in the evaluable-for-pregnancy population, with 589 safety population participants completing 5 years of use by October 2024. We observed a 1-year Pearl Index of 0.94 (95% CI, 0.43-1.78) and a cumulative 5-year Pearl Index of 1.02 (95% CI, 0.68, 1.47). The cumulative 1-year table pregnancy rate was 1.3% (95% CI, 0.8-2.2%) and the 5-year rate was 4.1% (95% CI, 2.8-6.0%). The most common adverse events included bleeding and pain. In year 1, 140 participants (8.7%) exited the study for bleeding and pain concerns. This decreased to 13 of 673 participants (1.9%) in year 5 (P<.001). Participants reported 76 (4.7%) device expulsions over 5 cumulative years.

Conclusion: These data support the efficacy and safety of the Cu 175 mm2 IUD through 5 years of use with low rates of expulsion. Participants report low and decreasing discontinuation rates over time for bleeding and pain-related symptoms.

Clinical trial registration: ClinicalTrials.gov, NCT03633799.