Obstetrics and gynecology最新文献

Objective: To evaluate whether disparities exist in adverse neonatal outcomes among the offspring of lesbian, gay, bisexual, and other sexually minoritized (LGB+) birthing people.

Methods: We used longitudinal data from 1995 to 2017 from the Nurses' Health Study II, a cohort of nurses across the United States. We restricted analyses to those who reported live births (N=70,642) in the 2001 or 2009 lifetime pregnancy questionnaires. Participants were asked about sexual orientation identity (current and past) and same-sex attractions and partners. We examined preterm birth, low birth weight, and macrosomia among 1) completely heterosexual; 2) heterosexual with past same-sex attractions, partners, or identity; 3) mostly heterosexual; 4) bisexual; and 5) lesbian or gay participants. We used log-binomial models to estimate risk ratios for each outcome and weighted generalized estimating equations to account for multiple pregnancies per person over time and informative cluster sizes.

Results: Compared with completely heterosexual participants, offspring born to parents in all LGB+ groups combined (groups 2-5) had higher estimated risks of preterm birth (risk ratio 1.22, 95% CI, 1.15-1.30) and low birth weight (1.27, 95% CI, 1.15-1.40) but not macrosomia (0.98, 95% CI, 0.94-1.02). In the subgroup analysis, risk ratios were statistically significant for heterosexual participants with past same-sex attractions, partners, or identity (preterm birth 1.25, 95% CI, 1.13-1.37; low birth weight 1.32, 95% CI, 1.18-1.47). Risk ratios were elevated but not statistically significant for lesbian or gay participants (preterm birth 1.37, 95% CI, 0.98-1.93; low birth weight 1.46, 95% CI, 0.96-2.21) and bisexual participants (preterm birth 1.29, 95% CI, 0.85-1.93; low birth weight 1.24, 95% CI, 0.74-2.08).

Conclusion: The offspring of LGB+ birthing people experience adverse neonatal outcomes, specifically preterm birth and low birth weight. These findings highlight the need to better understand health risks, social inequities, and health care experiences that drive these adverse outcomes.

Objective: To compare long-term decision regret between younger (30 years or younger) and older (31-49 years) patients who underwent laparoscopic hysterectomy for benign disease.

Methods: We conducted a matched retrospective cohort study to analyze patients who underwent laparoscopic hysterectomies for benign indications from 2009 to 2016. Respondents completed surveys including two validated decision regret scales: one measuring surgical decision regret and the other measuring loss-of-fertility regret. Participant aged was dichotomized as 30 years or younger and 31-49 years. Chi square, Fisher exact, and Wilcoxon rank sum tests and logistic regression were used to compare groups.

Results: Two hundred eighty-seven participants were successfully contacted, and 241 completed the survey (84.0%). Seventy-seven respondents (32.0%) were aged 30 years or younger, and 164 (68.0%) were aged 31-49 years. The average time since surgery was 7.2 years (±2.2 years; range 3.7-12.1 years). Participants aged 30 years or younger regretted both undergoing surgery (32.5% vs 9.1%, P<.001; OR 4.8, 95% CI, 2.3-9.8) and loss of fertility (39.0% vs 13.4%, P<.001, OR 4.1, 95% CI, 2.2-7.8) at significantly higher rates than participants aged 31-49 years. Overall, 83.1% of younger participants agreed that hysterectomy was the right choice compared with 97% of older participants (P<.001). Higher rates of surgical and loss-of-fertility regret were seen in participants with self-reported pelvic pain (P=.003, P=.011), preoperative diagnosis of endometriosis (P=.037, P=.046), and postoperative complications (P=.043, P<.001). Although time since hysterectomy did not affect rate of surgical regret (P=.138), participants further from their hysterectomies had lower rates of loss-of-fertility regret (P=.003). Patient age remained significantly associated with both surgical regret (adjusted OR 2.9 (95% CI, 1.3-6.5) and loss-of-fertility regret (adjusted OR 2.8 (95% CI, 1.3-6.0) on multivariable logistic regression.

Conclusion: Participants aged 30 years or younger were more likely to regret their decision to undergo hysterectomy than participants aged 31-49 years, regardless of parity, prior sterilization, or previous treatment.

Vaginitis is the presenting symptom at millions of office visits each year in the United States. Although treatment of sporadic cases is often straightforward, recurrent cases present both diagnostic and treatment challenges. Molecular diagnostic tests are likely superior to in-office microscopy for most clinicians and most cases. In both recurrent bacterial vaginosis and recurrent vulvovaginal candidiasis, national treatment guidelines recommend an extended treatment duration with one of the first-line agents. In cases in which such treatment is not successful, vaginal boric acid is likely the cheapest and easiest alternative option. New antifungal medications offer additional but limited treatment options. Probiotics are not recommended for prevention of vulvovaginal candidiasis; however, vaginal products containing Lactobacillus crispatus may have promise for recurrent bacterial vaginosis. Trichomoniasis should be treated with a 1-week course of metronidazole; this is the only sexually transmitted infection for which treatment recommendations vary by sex. In cases in which patients do not respond to initial treatment, the diagnosis should be reconsidered, and other potential causes such as desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia should be considered.

Objective: To assess the rates of adherence to triage testing after positive screening results and referral to treatment for precancerous lesions in global cervical cancer screening programs.

Data sources: We searched three electronic databases (Medline, EMBASE, and Web of Science) for articles published in the English language from January 1, 2018, to December 31, 2023. We included studies reporting the compliance rate of triage testing and precancer treatment in cervical cancer screening programs. ClinicalTrials.gov was reviewed, and no more studies were identified.

Methods of study selection: The combined search strategies identified 1,673 titles, of which 858 titles and abstracts were screened and 113 full-text articles were assessed for eligibility. A total of 33 studies met the inclusion criteria and were included in the meta-analysis.

Tabulation, integration, and results: Thirty-three studies were included in the systematic review and meta-analysis. The average compliance rate for women screening positive was 77.1% for triage testing and 69.4% for referral to treatment. Compliance varied by country income level, screening guideline approach, and target population.

Conclusion: The current compliance rate was lower than the 90% target set by the World Health Organization's global strategy to eliminate cervical cancer. Inadequate follow-up of participants screening positive revealed a gap between the screening program and clinical care.

Objective: To assess whether routine postpartum human papillomavirus (HPV) vaccination is acceptable and feasible and to identify key themes and strategies that can be used to increase postpartum HPV vaccination rates.

Data sources: PubMed and ClinicalTrials.gov were queried from inception to July 2024 for postpartum and HPV vaccination. Studies were limited to human subjects and the English language.

Methods of study selection: Screening was performed for studies of any method that evaluated HPV vaccination in the postpartum period (N=60). Only original research that reported either uptake or acceptability of the HPV vaccine was included. Thirty-nine studies were eliminated after abstract review because they did not meet the inclusion criteria.

Tabulation, integration, and results: Nine studies were categorized according to the primary aim of the study (defining the problem, assessing patient perspectives, or testing interventions to increase vaccination) and demonstrated that postpartum HPV vaccination programs can significantly increase HPV vaccination rates and are feasible and acceptable to patients.

Conclusion: Incorporating HPV vaccination into standard postpartum care provides an opportunity to reach vulnerable patient populations, reduces cost for patients, and has the ability to prevent HPV-related cancers.

Objective: To estimate the effect of late preterm antenatal steroids on the risk of respiratory morbidity among subgroups of patients on the basis of the planned mode of delivery and gestational age at presentation.

Methods: This was a secondary analysis of the ALPS (Antenatal Late Preterm Steroid) Trial, a multicenter trial conducted within the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network of individuals with singleton gestations and without preexisting diabetes who were at high risk for late preterm delivery (34-36 weeks of gestation). We fit binomial regression models to estimate the risk of respiratory morbidity, with and without steroid administration, by gestational age and planned mode of delivery at the time of presentation. We assumed a homogeneous effect of steroids on the log-odds scale, as was reported in the ALPS trial. The primary outcome was neonatal respiratory morbidity, as defined in the ALPS Trial.

Results: The analysis included 2,825 patients at risk for late preterm birth. The risk of respiratory morbidity varied significantly by planned mode of delivery (adjusted risk ratio [RR] 1.90, 95% CI, 1.55-2.33 for cesarean delivery vs vaginal delivery) and week of gestation at presentation (adjusted RR 0.56, 95% CI, 0.50-0.63). For those planning cesarean delivery and presenting in the 34th week of gestation, the risk of neonatal respiratory morbidity was 39.4% (95% CI, 30.8-47.9%) without steroids and 32.0% (95% CI, 24.6-39.4%) with steroids. In contrast, for patients presenting in the 36th week and planning vaginal delivery, the risk of neonatal respiratory morbidity was 6.9% (95% CI, 5.2-8.6%) without steroids and 5.6% (95% CI, 4.2-7.0%) with steroids.

Conclusion: The absolute risk difference of neonatal respiratory morbidity between those exposed and those unexposed to late preterm antenatal steroids varies considerably by gestational age at presentation and planned mode of delivery. Because only communicating the relative risk reduction of antenatal steroids for respiratory morbidity may lead to an inaccurate perception of benefit, more patient-specific estimates of risk expected with and without treatment may inform shared decision making.