Best Practice & Research Clinical Obstetrics & Gynaecology最新文献

Placenta accreta spectrum (PAS) can be associated massive intra- and post-operative hemorrhage which when not controlled can lead to maternal death. Important advances have occurred in understanding the pathophysiology and therapeutic options for this condition. The prevalence of PAS at birth is direct association with the cesarean delivery (CD) rate in the corresponding population and is increasing worldwide. Limited health infrastructure in low- and middle-income countries increases the morbidity and mortality of patients with PAS at birth. In many cases, obstetricians working in limited resources settings cannot follow some of the international guideline’s recommendations and have to opt for low-cost management procedures. In this review, we describe the particularities of managing PAS care in low- and middle-income countries from of prenatal evaluation of patients at risk of PAS at birth, therapeutic options, and inter-institutional collaboration. We also propose a management protocol based on training of the local obstetric teams rather than on sophisticated technological resources that are almost never available in low-resource scenarios.

Peripartum cardiomyopathy (PPCM) causes pregnancy-associated heart failure, typically during the last month of pregnancy, and up to 6 months post-partum, in women without known cardiovascular disease.

PPCM is a global disease, but with a significant geographical variability within and between countries. Its true incidence in Africa is still unknown because of the lack of a PPCM population-based study. The variability in the epidemiology of PPCM between and within countries could be due to differences in the prevalence of both genetic and non-genetic risk factors.

Several risk factors have been implicated in the aetiopathogenesis of PPCM over the years.

Majority of patients with PPCM present with symptoms and signs of congestive cardiac failure.

Diagnostic work up in PPCM is prompted by strong clinical suspicion, but Echocardiography is the main imaging technique for diagnosis.

The management of PPCM involves multiple disciplines - cardiologists, anaesthetists, intensivists, obstetricians, neonatologists, and the prognosis varies widely.

Venous thrombosis and thromboembolism (VTE) remain the leading cause of direct maternal deaths, occurring within 42 days of the end of pregnancy in the UK. Pregnancy is associated with an overall 10-fold higher incidence of VTE than in the non-pregnant state and has been reported to reach up to 30-fold higher in the puerperium. This increased risk is further exacerbated by maternal obesity in a relationship that appears to be proportional with increasing Body Mass Index (BMI).

Maternal obesity is the most common health problem in women of reproductive age with clinically significant health risks to women during pregnancy and after delivery. It is associated with poor perinatal and maternal outcomes, The incidence of maternal obesity has increased significantly worldwide over the last few decades and increasingly, pregnancy is being complicated by extreme or morbid obesity.

In this review we discuss the challenges associated with the diagnosis and management of VTE in obese pregnant women and provide a review of the available current evidence.

Preeclampsia is a relatively common pregnancy complication and constitutes a major cause of morbidity and mortality for mothers and children worldwide. It disproportionally affects low-resource countries. Appropriate identification of individuals at increased risk and prevention of the disease and its complications remain healthcare and research priorities, and the investigation of potential interventions to prevent preeclampsia has driven much of the obstetric research in recent decades. In this article, we review the scientific literature on the topic, highlighting established benefits and remaining questions regarding different non-pharmacological and pharmacological strategies, including exercise, the timing of birth, aspirin and calcium use, among others, as well as potential novel therapies under investigation.

Despite notable advancements in minimizing maternal mortality during recent decades, a pronounced disparity persists between high-income nations and low-to middle-income countries (LMICs), particularly in intensive and high-care for pregnant and postpartum individuals. This divergence is multifactorial and influenced by factors such as the availability and accessibility of community-based maternity healthcare services, the quality of preventive care, timeliness in accessing hospital or critical care, resource availability, and facilities equipped for advanced interventions. Complications from various conditions, including human immunodeficiency virus (HIV), unsafe abortions, puerperal sepsis, and, notably, the COVID-19 pandemic, intensify the complexity of these challenges. In confronting these challenges and deliberating on potential solutions, we hope to contribute to the ongoing discourse around maternal healthcare in LMICs, ultimately striving toward an equitable health landscape where every mother, regardless of geographic location or socioeconomic status, has access to the care they require and deserve. The use of traditional and innovative methods to achieve adequate knowledge, appropriate skills, location of applicable resources, and strong leadership is essential. By implementing and enhancing these strategies, limited-resource settings can optimize the available resources to promptly recognize the severity of illness in obstetric individuals, ensuring timely and appropriate interventions for mothers and children. Additionally, strategies that could significantly improve the situation include increased investment in healthcare infrastructure, effective resource management, enhanced supply chain efficiency, and the development and use of low-cost, high-quality equipment.

Through targeted investments, innovations, efficient resource management, and international cooperation, it is possible to ensure that every maternal high-care and ICU unit, regardless of geographical location or socioeconomic status, has access to high-quality critical care to provide life-saving care.

Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.

Birth related perineal trauma (BRPT) and obstetric anal sphincter injuries (OASIS) are leading causes of anal incontinence in women, which negatively impacts on their quality of life, resulting in low self-esteem and abandonment. In low resource countries (LRC), the true incidence is not known and since most births are unattended or occur in community-based health care systems, one can anticipate that it is a significant problem. Dissemination of information to women, education of traditional birth attendants, improvement of resources and transport, and training of health professionals on the detection and appropriate surgical management of these injuries will reduce morbidity and improve outcome. Intrapartum measures such as controlled head descent and perineal support, correct episiotomy techniques and selective use of instruments to assist vaginal births is pivotal in avoiding these injuries. Policy makers should prioritize maternity care in LRC, and research is urgently needed to address all aspects of BRPT.

Anatomical and functional aspects of the lymphatic drainage of the uterine corpus in endometrial cancer are demonstrated. Main lymphatic pathway runs along the upper pelvic pathway from the uterine artery first line to the medial external iliac nodes, followed by the lateral external and common iliac node basin. The second important pathway runs along the ovarian vessels directly to the paraaortic nodes. Pathways may visualized best by injection of indocyanine green (ICG) into the uterus. In contrast to the upper pelvic pathway visualized by cervical injection, the paraaortic drainage can only be marked by corporal injection. Lymphatic drainage works downstream (peripheral to central, with respect to vascular valves) only. Clinically, pelvic sentinel node excision replaced systematic lymphadenectomy for diagnostic purposes and even paraaortic node staging can be omitted in most of pelvic node negative patients. For therapeutic purposes compartmental resection of the uterus together with its lymphovascular system and first line nodes “en bloc” could be an option as performed in peritoneal mesometrial resection/targeted compartmental lymphadenctomy (PMMR/TCL).

While gynecological malignancies are more commonly diagnosed in elderly women, a substantial proportion of women will still be diagnosed with some type of gynecologic cancer during their reproductive age. Over 10% of newly diagnosed ovarian cancers and over one third of newly diagnosed cervical cancers involve women who are under the age of 45. This, coupled with the rising trend of women having their first child after the age of 35, has led to a concerning prevalence of complex fertility issues among women who have been diagnosed with cancer. Since the advent of robotic-assisted surgeries in gynecology, there has been a rise in the occurrence of these procedures. Fertility preserving gynecological surgeries require precise management in order to avoid fertility disorders. Therefore, we conducted a narrative review of robotic assisted fertility sparing surgery in gynecologic malignancies in order to highlight the role of this approach in preserving fertility.

Postpartum Family Planning is a critical strategy in the first 12 months post-childbirth. It aims to prevent unintended, closely spaced pregnancies and thereby help reducing maternal, neonatal as well as child morbidity and mortality. Despite its significance, many women remain without contraception despite a desire to avoid pregnancy. The World Health Organization suggests a 24-month inter-pregnancy interval after delivery, emphasizing the importance of contraceptive counselling from the antenatal to the immediate postpartum period. In South Asia, utilization of PPFP is minimal, even though the inclination towards birth spacing is high. Addressing these needs requires strengthening the capacity of service providers and promoting evidence-based practices. Novel training approaches in South Asia are Competency-Based On-the-Job Training, Group Based Training, Simulation Training, E-Learning, Mentorship Programs, and Continuing Professional Development. Among these, On-the-Job Training and Group Based Training were notably implemented. Emphasizing PPFP and ensuring proper training in this domain is essential for women's health and well-being post-delivery.