Obstetrics and gynecology最新文献

The first published reports on the use of laser for cervical pathology date back to 1973. Technical advancements in flexible and rigid laser fibers revolutionized video laser laparoscopy in the 1990s. Fractionated lasers have been used to treat vulvovaginal symptoms associated with genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence. Review of available data suggests that fractionated lasers can improve both subjective and objective signs of vaginal atrophy and lichen sclerosus, but the evidence is weak because most of the trials are underpowered, are at risk for bias, and lack long-term follow-up. There is no strong evidence to support fractionated laser therapy for urinary incontinence or low-level laser therapy for chronic pelvic pain. Although short-term, single-arm trials suggest benefit of fractionated laser therapy for genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence, additional adequately powered, prospective, randomized, and longer-term comparative trials are needed before lasers can be recommended for these specific conditions. The purpose of this Clinical Expert Series is to review basic laser biophysics and the mechanism of action for modern fractionated lasers as relevant to the gynecologist. We also summarize safety and effectiveness data for lasers used for some of the most commonly studied gynecologic conditions: the vulvovaginal atrophy component of genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence.

Objective: To evaluate the accuracy of next-generation sequencing-based quantitative cell-free DNA analysis for fetal antigen genotyping in individuals with alloimmunized pregnancies undergoing clinical testing in practices across the United States as early as 10 weeks of gestation, with the objective of identifying individuals with pregnancies at risk for hemolytic disease of the fetus and newborn and guiding management.

Methods: This prospective cohort study included patients with alloimmunized pregnancies undergoing clinical fetal antigen cell-free DNA analysis between 10 0/7 and 37 0/7 weeks of gestation at 120 clinical sites. Both the pregnant person with the alloimmunized pregnancy and the neonates resulting from the pregnancies were included. The laboratory issued the cell-free DNA results prospectively as a part of clinical care. After delivery, neonatal buccal swabs collected between 0 and 270 days of life were sent to an outside independent laboratory for antigen genotyping. The outside laboratory was blinded to the fetal cell-free DNA results, and the results were compared. Concordance was reported for the fetal antigen cell-free DNA analysis for antigens to which the pregnant person was alloimmunized and for all antigens for which the pregnant person was genotype negative.

Results: A total of 156 pregnant people who received clinically ordered cell-free DNA fetal antigen testing provided neonatal buccal swabs for genotyping after delivery. Overall, 15.4% of participants were Hispanic, 9.0% were non-Hispanic Black, 65.4% were non-Hispanic White, 4.5% were Asian, 1.3% were more than one race or ethnicity, and 4.5% were unknown. The median gestational age at the time of testing was 16.4 weeks with a median fetal fraction of 11.1%. Concordance between cell-free DNA analysis results and neonatal genotype was determined for 465 antigen calls for the following antigens: K1 (n=143), E (124), C (60), Fya (50), c (47), and D(RhD) (41). These 465 calls included 145 in which the fetus was antigen positive and 320 in which the fetus was antigen negative. We observed complete concordance between prenatal fetal antigen cell-free DNA analysis results and neonatal genotypes for the 465 calls, resulting in 100% sensitivity, specificity, and accuracy.

Conclusion: In a diverse multicenter cohort, cell-free DNA analysis was highly sensitive and specific for determining fetal antigen genotype as early as 10 weeks of gestation in individuals with alloimmunized pregnancies. Taken together with previously published evidence, this study supports the implementation of cell-free DNA testing to manage individuals with alloimmunized pregnancies in the United States.

Objective: To evaluate a self-screening eligibility tool for medication abortion without an ultrasonogram.

Methods: We designed a patient-administered, five-question screening tool (LMP-SURE) that assesses gestational age plus factors associated with misdating or ectopic pregnancy. We recruited participants without prior ultrasonograms from family planning clinics in Alaska, Hawai'i, Idaho, and Utah to complete a brief survey including LMP-SURE and then obtained ultrasound dating by chart review. We compared eligibility for medication abortion by ultrasonogram with eligibility by the LMP-SURE screening tool.

Results: We consented 1,026 participants; 781 met eligibility requirements and completed the tool. Using the LMP-SURE tool, we identified 493 participants (65.1%) eligible for medication abortion without an ultrasonogram. The LMP-SURE tool sensitivity (ability to correctly identify a patient ineligible for medication abortion) was 83.8% (95% CI, 73.1-90.8), specificity (ability to correctly identify a patient eligible for medication abortion) was 70.0% (95% CI, 66.4-73.3), likelihood ratio (-) (probability of someone eligible by LMP-SURE to be ineligible by ultrasonogram vs eligible by ultrasonogram) was 0.23 (95% CI, 0.13-0.40), and percentage of false-negatives was 1.5%. Only 11 patients (1.5%) who met eligibility for medication abortion without an ultrasonogram by the LMP-SURE tool were found ineligible for medication abortion by their ultrasonogram. Of those with conflicts, six (0.8%) had a gestational age beyond 77 days. The two participants (0.3%) diagnosed with ectopic pregnancies both required ultrasonograms by LMP-SURE.

Conclusion: This patient-facing, brief, history-based screening tool can safely minimize the need for ultrasonogram before medication abortion.

Objective: To examine the presentation, management, and outcomes of pregnancies complicated by diabetic ketoacidosis (DKA) in a contemporary obstetric population.

Methods: This is a case series of all admissions for DKA during pregnancy at a single Midwestern academic medical center over a 10-year period. Diabetic ketoacidosis was defined per the following diagnostic criteria: anion gap more than 12 mEq/L, pH less than 7.30 or bicarbonate less than 15 mEq/L, and elevated serum or urine ketones. Demographic information, clinical characteristics, and maternal and neonatal outcomes were assessed. Patient characteristics and clinical outcomes were compared between individuals with type 1 and those with type 2 diabetes mellitus.

Results: Between 2012 and 2021, there were 129 admissions for DKA in 103 pregnancies in 97 individuals. Most individuals (n=75, 77.3%) admitted for DKA during pregnancy had type 1 diabetes. The majority of admissions occurred in the third trimester (median gestational age 29 3/7 weeks). The most common precipitating factors were vomiting or gastrointestinal illness (38.0%), infection (25.6%), and insulin nonadherence (20.9%). Median glucose on admission was 252 mg/dL (interquartile range 181-343 mg/dL), and 21 patients (17.6%) were admitted with euglycemic DKA. Fifteen admissions (11.6%) were to the intensive care unit. Pregnancy loss was diagnosed during admission in six individuals (6.3%, 95% CI, 2.3-13.7%). Among pregnant individuals with at least one admission for DKA, the median gestational age at delivery was 34 6/7 weeks (interquartile range 33 2/7-36 3/7 weeks). Most neonates (85.7%, 95% CI, 76.8-92.2%) were admitted to the neonatal intensive care unit and required treatment for hypoglycemia. The cesarean delivery rate was 71.9%. Despite similar hemoglobin A1C values before pregnancy and at admission, individuals with type 1 diabetes had higher serum glucose (median [interquartile range], 256 mg/dL [181-353 mg/dL] vs 216 mg/dL [136-258 mg/dL], P=.04) and higher serum ketones (3.78 mg/dL [2.13-5.50 mg/dL] vs 2.56 mg/dL [0.81-4.69 mg/dL] mg/dL, P=.03) on admission compared with those with type 2 diabetes. Individuals with type 2 diabetes required intravenous insulin therapy for a longer duration (55 hours [29.5-91.5 hours] vs 27 hours [19-38 hours], P=.004) and were hospitalized longer (5 days [4-9 days] vs 4 days [3-6 days], P=.004).

Conclusion: Diabetic ketoacidosis occurred predominantly in pregnancies affected by type 1 diabetes. Individuals with type 1 diabetes presented with greater DKA severity but achieved clinical resolution more rapidly than those with type 2 diabetes. These results may provide a starting point for the development of interventions to decrease maternal and neonatal morbidity related to DKA in the modern obstetric population.

Continuous glucose monitoring (CGM) has the potential to revolutionize diabetes management during pregnancy by providing detailed and real-time data to patients and clinicians, overcoming many of the limitations of self-monitoring of blood glucose. Although there are limited data on the role of CGM to improve pregnancy outcomes in patients with type 2 diabetes or gestational diabetes, CGM has been shown to reduce pregnancy complications in patients with type 1 diabetes. Despite the limited data in some populations, given its ease of use and recent U.S. Food and Drug Administration approval with expanding insurance coverage, CGM has gained widespread popularity among pregnant patients with all types of diabetes. It is critical for obstetric clinicians to understand how CGM can be successfully integrated into clinical practice. We present a practical, step-wise approach to CGM data interpretation that can be incorporated into diabetes management during pregnancy and common CGM pitfalls and solutions. Although technology will continue to advance with newer-generation CGM devices and diabetes technology such as automated insulin delivery (not covered here), these key principles form a basic foundation for understanding CGM technology and its utility for pregnant people.

Objective: To examine the association between elevated blood pressure (BP) in the early third trimester and cardiometabolic health 10-14 years after delivery.

Methods: This is a secondary analysis from the prospective HAPO FUS (Hyperglycemia and Adverse Pregnancy Outcome Follow-Up Study). Blood pressure in the early third trimester was categorized per American College of Cardiology/American Heart Association thresholds for: normal BP below 120/80 mm Hg (reference), elevated BP 120-129/below 80 mm Hg, stage 1 hypertension 130-139/80-89 mm Hg, and stage 2 hypertension 140/90 mm Hg or higher. Cardiometabolic outcomes assessed 10-14 years after the index pregnancy were type 2 diabetes mellitus and measures of dyslipidemia, including low-density lipoprotein (LDL) cholesterol 130 mg/dL or higher, total cholesterol 200 mg/dL or higher, high-density lipoprotein (HDL) cholesterol 40 mg/dL or lower, and triglycerides 200 mg/dL or higher. Adjusted analysis was performed with the following covariates: study field center, follow-up duration, age, body mass index (BMI), height, family history of hypertension and diabetes, smoking and alcohol use, parity, and oral glucose tolerance test glucose z score.

Results: Among 4,692 pregnant individuals at a median gestational age of 27.9 weeks (interquartile range 26.6-28.9 weeks), 8.5% (n=399) had elevated BP, 14.9% (n=701) had stage 1 hypertension, and 6.4% (n=302) had stage 2 hypertension. At a median follow-up of 11.6 years, among individuals with elevated BP, there was a higher frequency of diabetes (elevated BP: adjusted relative risk [aRR] 1.88, 95% CI, 1.06-3.35; stage 1 hypertension: aRR 2.58, 95% CI, 1.62-4.10; stage 2 hypertension: aRR 2.83, 95% CI, 1.65-4.95) compared with those with normal BP. Among individuals with elevated BP, there was a higher frequency of elevated LDL cholesterol (elevated BP: aRR 1.27, 95% CI, 1.03-1.57; stage 1 hypertension: aRR 1.22, 95% CI, 1.02-1.45, and stage 2 hypertension: aRR 1.38, 95% CI, 1.10-1.74), elevated total cholesterol (elevated BP: aRR 1.27, 95% CI, 1.07-1.52; stage 1 hypertension: aRR 1.16, 95% CI, 1.00-1.35; stage 2 hypertension: aRR 1.41 95% CI, 1.16-1.71), and elevated triglycerides (elevated BP: aRR 2.24, 95% CI, 1.42-3.53; stage 1 hypertension: aRR 2.15, 95% CI, 1.46-3.17; stage 2 hypertension: aRR 3.24, 95% CI, 2.05-5.11) but not of low HDL cholesterol.

Conclusion: The frequency of adverse cardiometabolic outcomes at 10-14 years after delivery was progressively higher among pregnant individuals with BP greater than 120/80 in the early third trimester.

Objective: To evaluate whether continuous glucose monitoring (CGM)-derived glycemic patterns observed throughout pregnancy were associated with adverse perinatal outcomes, specifically fetal growth disorders and hypertensive disorders of pregnancy (HDP).

Methods: We conducted a prospective observational study of individuals with viable singleton pregnancies and screening hemoglobin A1c levels less than 6.5%. Those with preexisting diabetes were excluded. Enrollment occurred at the earliest gestational age before 17 weeks. Participants wore blinded continuous glucose monitors consecutively as willing until delivery. Those with at least 14 days of CGM data were included in analysis. Rates of large-for-gestational-age (LGA) neonates, small-for-gestational age (SGA) neonates, and HDP were assessed. Continuous glucose monitoring-derived glycemic metrics were calculated, including mean glucose level and percent time above and below thresholds. Two-sample t tests were used to compare glycemic metrics between participants with and without adverse perinatal outcomes.

Results: Of 937 participants enrolled, 760 met inclusion criteria. Those delivering LGA neonates or who were diagnosed with HDP had higher mean glucose levels (102±9 vs 100±8, P=.01 and 103±8 vs 99±8, P<.001) and spent more time above 120 mg/dL (median 16% vs 12%, P=.006, and 16% vs 12%, P<.001, respectively) and above 140 mg/dL (median 3.9% vs 2.8%, P=.006, and 3.5% vs 2.8%, P<.001, respectively) throughout gestation than those without these outcomes. These findings were present regardless of gestational diabetes mellitus status. Participants with SGA neonates had lower mean glucose levels (97±7 vs 101±8, P=.01) and spent less time above 140 mg/dL (median 1.6% vs 2.3%, P=.01) and more time below 63 mg/dL (median 3.0% vs 2.3%, P=.02) than those without SGA neonates.

Conclusion: Individuals with LGA neonates or HDP exhibit a slightly higher mean glucose levels and spend more time hyperglycemic in early pregnancy than those who do not experience these outcomes.

Objective: To assess the frequency of, risk factors for, and adverse outcomes associated with diabetic ketoacidosis (DKA) at delivery hospitalization among individuals with pregestational diabetes (type 1 and 2 diabetes mellitus) and secondarily to evaluate the frequency of and risk factors for antepartum and postpartum hospitalizations for DKA.

Methods: We conducted a serial, cross-sectional study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Readmissions Database from 2010 to 2020 of pregnant individuals with pregestational diabetes hospitalized for delivery. The exposures were 1) sociodemographic and clinical risk factors for DKA and 2) DKA. The outcomes were DKA at delivery hospitalization, maternal morbidity (nontransfusion severe maternal morbidity (SMM), critical care procedures, cardiac complications, acute renal failure, and transfusion), and adverse pregnancy outcomes (preterm birth, hypertensive disorders of pregnancy, and cesarean delivery) and secondarily DKA at antepartum and postpartum hospitalizations.

Results: Of 392,796 deliveries in individuals with pregestational diabetes (27.2% type 1 diabetes, 72.8% type 2 diabetes), there were 4,778 cases of DKA at delivery hospitalization (89.1% type 1 diabetes, 10.9% type 2 diabetes). The frequency of DKA at delivery hospitalization was 1.2% (4.0% with type 1 diabetes, 0.2% with type 2 diabetes), and the mean annual percentage change was 10.8% (95% CI, 8.2-13.2%). Diabetic ketoacidosis at delivery hospitalization was significantly more likely among those who had type 1 diabetes compared with those with type 2 diabetes, who were younger in age, who delivered at larger and metropolitan hospitals, and who had Medicaid insurance, lower income, multiple gestations, and prior psychiatric illness. Diabetic ketoacidosis during the delivery hospitalization was associated with an increased risk of nontransfusion SMM (20.8% vs 2.4%, adjusted odds ratio [aOR] 8.18, 95% CI, 7.20-9.29), critical care procedures (7.3% vs 0.4%, aOR 15.83, 95% CI, 12.59-19.90), cardiac complications (7.8% vs 0.8%, aOR 8.87, 95% CI, 7.32-10.76), acute renal failure (12.3% vs 0.7%, aOR 9.78, 95% CI, 8.16-11.72), and transfusion (6.2% vs 2.2%, aOR 2.27, 95% CI, 1.87-2.75), as well as preterm birth (31.9% vs 13.5%, aOR 2.41, 95% CI, 2.17-2.69) and hypertensive disorders of pregnancy (37.4% vs 28.1%, aOR 1.11, 95% CI, 1.00-1.23). In secondary analyses, the overall frequency of antepartum DKA was 3.1%, and the mean annual percentage change was 4.1% (95% CI, 0.3-8.6%); the overall frequency of postpartum DKA was 0.4%, and the mean annual percentage change was 3.5% (95% CI, -1.6% to 9.6%). Of 3,092 antepartum hospitalizations among individuals with DKA, 15.7% (n=485) had a recurrent case of DKA at delivery hospitalization. Of 1,419 postpartum hospitalizations among individuals with DKA, 20.0% (n=285) previ

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.