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Accumulating evidence suggests that cesarean scar implantation represents the earliest manifestation of placenta accreta spectrum (PAS) disorders, reflecting a continuous pathophysiologic process rather than distinct clinical entities. This article examines data supporting cesarean scar pregnancy as a precursor to a substantial proportion of PAS, particularly after cesarean delivery, and advocates for unified clinical approaches to these conditions. The global rise in cesarean deliveries has triggered parallel increases in PAS disorders, characterized by abnormal placental attachment at sites of myometrial scarring where regulatory decidual mechanisms are absent. Histopathologic studies demonstrate that cesarean scar implantation and PAS are often indistinguishable, likely representing different developmental stages of the same condition, with up to 70% of expectantly managed cesarean scar pregnancies progressing to PAS at delivery. First-trimester ultrasound enables early identification of high-risk pregnancies through the use of several cesarean scar pregnancy classification systems, including the crossover sign, which categorizes cesarean scar pregnancies based on the position of the gestational sac relative to the endometrial line. Additional classifications distinguish between "on-the-scar" and "in-the-niche" implantation and implantation position relative to the uterine midline in the transverse plane. These parameters predict PAS severity and outcomes. Despite compelling evidence connecting cesarean scar pregnancy and PAS, most literature focuses on them as separate entities, resulting in fragmented clinical approaches. Here, we propose framing the cesarean scar pregnancy as an early manifestation of PAS. Equipped with an appreciation of the natural history of PAS, we recommend targeted screening for women with prior cesarean delivery, uterine surgery, previous cesarean scar pregnancy, or suspected early pregnancy loss, with critical screening windows at 5-7 and 11-14 weeks of gestation. Early identification and risk stratification enable individualized management decisions through shared decision making to reduce maternal morbidity from unanticipated uterine rupture, hemorrhage, and fertility loss. Recognizing cesarean scar pregnancy as the earliest detectable manifestation of PAS transforms management from reactive to proactive risk mitigation and fertility-sparing approaches, potentially improving outcomes and reducing PAS-associated health care burdens worldwide.

Background: To describe pregnancy complicated by deficiency of 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) lyase, an inborn error of metabolism, and kaposiform lymphangiomatosis (KLA), a lymphatic anomaly with poor prognosis.

Case: A 24-year-old woman with known HMG-CoA lyase deficiency and KLA presented at 6 weeks of gestation with severe vomiting and dehydration. Her pregnancy was complicated by worsening lung disease, fetal growth restriction, anemia, thrombocytopenia, and gestational diabetes. She required parenteral nutrition and adjustments in immunosuppressive therapy. At 37 weeks, she underwent induction of labor and delivered a male infant weighing 2,790 g with reassuring Apgar scores.

Conclusion: This case demonstrates that, with multidisciplinary management, patients with coexisting rare disorders can achieve successful pregnancy outcomes despite substantial maternal and fetal risks.

Objective: To validate an objective photo-based electronic method of quantifying menstrual blood loss against the current gold standard alkaline hematin method.

Methods: In this multicenter, prospective cohort study, 79 participants (33 in the training phase, 46 in the validation phase) 18-50 years of age who were premenopausal with self-reported heavy menstrual bleeding were recruited from February to November 2023. Participants provided demographic and medical history details at baseline and then used study-provided pads, photo mats, and smartphones to capture images of menstrual blood loss per pad in one menstrual cycle. A photo-based smartphone application used image analysis software to convert the surface area of blood staining on each menstrual pad into menstrual blood loss volume. The outcome measures were menstrual blood loss per pad and per cycle measured in milliliters, with the alkaline hematin method as the reference standard. Bland-Altman analysis was used with 46 participants from the validation phase to construct limits of agreement between the photo-based and alkaline hematin methods for measuring menstrual blood loss. The sensitivity and specificity of the photo-based method for diagnosing heavy menstrual bleeding (menstrual blood loss more than 80 mL per cycle) were also evaluated.

Results: The photo-based method correlated strongly with the alkaline hematin reference standard for both per-pad (R ²=0.75) and per-cycle (R ²=0.83) blood loss. Agreement was high, with minimal bias and limits of agreement within clinically acceptable ranges. For identifying heavy menstrual bleeding, the method achieved 100.0% sensitivity, 93.5% specificity, and 100.0% negative predictive value.

Conclusion: A photo-based method provides a valid, practical, and accessible alternative to the alkaline hematin standard, enabling accurate diagnosis and monitoring of heavy menstrual bleeding in both clinical and research settings.

Objective: To describe the final validation processes for the final English-language tool to assess sexual function and satisfaction after gender-affirming vaginoplasty.

Methods: This was a quantitative and qualitative validation study. The 32-question SatisFunction survey was distributed to 50 individuals after vaginoplasty along with the Female Sexual Distress Scale for divergent validity testing. Thirty of these 50 participants then underwent one-on-one cognitive interviews with a member of the research team. The cognitive interviews assessed the construct validity of the survey questions based on the participants' responses. A Community Advisory Board and content expert team reviewed the results of the cognitive interviews to create a final version to be further tested. The revised survey was then distributed to 100 individuals for final validation.

Results: Cognitive interviews demonstrated 99.0% concordance between participants' survey responses and verbal confirmations, supporting interpretive reliability. Strong internal consistency was observed, with each domain significantly correlating with the total score (eg, Anatomy r=0.856, Arousal r=0.767, Orgasm r=0.748; all P<.001). Expected interdomain relationships were identified, including Arousal and Orgasm (r=0.552, P<.001). Female Sexual Distress Scale-Revised scores correlated negatively with Satisfaction (r=-0.416, P<.001), Desire (r=-0.302, P=.003), Genital Self-Image (r=-0.216, P=.034), and Total SatisFunction Score (r=-0.304, P=.003), supporting divergent validity. Factor analysis supported an eight-factor structure aligning with survey domains.

Conclusion: This survey has now been developed and validated through a seven-phase process incorporating community input, physician/surgeon and psychologist expertise, and correlation to other surveys and can be reliably used clinically and in research.

Objective: To evaluate whether geospatial or sociodemographic characteristics are associated with live birth after fertility-sparing treatment for early-stage gynecologic cancer and stages I-III breast cancer.

Study design: Retrospective matched case-control study using linked data from the California Cancer Registry, the California Office of Statewide Health Planning and Development (now known as the California Department of Health Care Access and Information), and Society for Assisted Reproductive Technology. We included patients aged 18-45 years who were diagnosed with stages I-III of breast cancer or stage I cervical, endometrial, or ovarian cancer between 2000 and 2012 and underwent fertility-sparing treatment. Patients in the case group had live births after treatment; patients in the control group did not. Propensity score matching was performed in a 1:2 ratio. Generalized linear mixed models were used to estimate associations between odds of live birth and geospatial and sociodemographic exposures such as the California Healthy Places Index, clinic proximity, race and ethnicity, marital status, insurance, and socioeconomic status.

Results: Our study included 254 individuals in the case group and 455 individuals in the matched control group. On multivariable analysis, no significant associations were observed between geospatial factors and live birth. Compared with individuals living in ZIP codes within the lowest California Healthy Places Index quartile (Q, 0-25%), those in higher quartiles had similar odds of live birth (Q2: odds ratio [OR] 1.16; 95% CI, 0.45-2.96, P=.76; Q3: OR 1.29; 95% CI, 0.46-3.59, P=.62; Q4 or unknown: OR 1.19; 95% CI, 0.39-3.62, P=.75). Neither the number of nor the distance to the nearest gynecologic oncology or in vitro fertilization clinic was associated with outcome. Sociodemographic characteristics also were not significantly associated with odds of live birth. Subanalyses by treatment type and cancer type also demonstrated no significant associations variables of interest and odds of live birth.

Conclusion: Among patients who accessed fertility-sparing treatment, geospatial and sociodemographic factors were not associated with live-birth outcomes. These findings provide reassurance that once patients access fertility-sparing care, birth outcomes are not influenced by sociodemographic or geographic disadvantage.

Whole blood (WB) has been shown to improve outcomes in military acute trauma patients and, to a limited extent, in civilian trauma and acute obstetric hemorrhage. The objective of this study was to examine maternal outcomes in patients receiving WB compared with component therapy (defined as packed red blood cells with plasma) for postpartum hemorrhage (PPH). Fifty-two patients met inclusion criteria. The WB group required fewer total blood products, intravenous fluids, and repeated operative procedures. This report demonstrates the potential benefit for use of WB in cases of acute PPH.

Objective: STEEL MAGNOLIAS (shared telehealth for multidisciplinary gynecologic cancer survivorship) is a novel gynecologic cancer surveillance care-delivery program in which rural patients see a close-by gynecologist in person with simultaneous virtual gynecologic oncology consultation. This study assesses feasibility of STEEL MAGNOLIAS by examining travel burden reduction, cancer outcomes, visit activities, guideline adherence, and patient satisfaction.

Methods: We retrospectively reviewed charts of patients with gynecologic cancer in remission under the STEEL MAGNOLIAS program in rural south Louisiana (March 2020-September 2023). Travel metrics, patient satisfaction, cancer outcomes, survival status, reasons for visit, and adherence to follow-up as per National Comprehensive Cancer Network (NCCN) guidelines were recorded. A small subset of patients prospectively completed questionnaires, such as the COST-FACIT (Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy) for financial toxicity and the PSQ-18 (Patient Satisfaction Questionnaire Short Form), and responded to questions about existing barriers to care. Descriptive statistics and Wilcoxon rank sum tests for continuous data were used. We assessed feasibility by assessing continued patient compliance without erosion of satisfaction.

Results: Sixty-three patients attended 178 STEEL MAGNOLIAS appointments, and most of the patients had a history of endometrial cancer. The majority, 82.5%, were alive with no evidence of disease. Our patients traveled a median of 16.9 miles for STEEL MAGNOLIAS, compared with 137 miles for in-person visits. We identified prevalent transportation and technology barriers to in-person and conventional virtual visits. Patients demonstrated high satisfaction with appointments. Genitourinary and cancer therapy symptoms and reviews of laboratory test results and imaging often were discussed. Laboratory tests, imaging, and referrals were ordered and completed at high rates, with 76.9% of appointments adhering to NCCN follow-up guidelines.

Conclusion: The STEEL MAGNOLIAS program is a feasible, innovative hybrid telehealth model for rural gynecologic cancer surveillance that reduces travel burdens and ensures high guideline adherence and patient satisfaction. This scalable model has potential to improve outcomes and compliance, meeting patients where they are and transforming cancer survivorship.

Objective: Anemia is common among patients with gynecologic cancers receiving systemic treatment and is associated with adverse outcomes. We describe a quality-improvement initiative designed to improve screening and treatment for nutritional causes of anemia in this population, and we assess the effect of this intervention on hemoglobin levels and blood transfusions.

Methods: We implemented a quality-improvement intervention that automatized regular laboratory evaluation for nutritional causes of anemia in patients with gynecologic malignancies receiving systemic treatment who had hemoglobin levels below 12 g/dL. Patients with nutritional deficiencies were treated with intravenous iron or oral vitamin B12. We evaluated the association of the intervention and change in hemoglobin levels over three cycles of treatment (delta hemoglobin), along with the rate of blood transfusion. Thirty patients with hemoglobin levels below 12 g/dL were administered a survey regarding anemia, fatigue, and the acceptability of the intervention.

Results: The overall rates of iron and vitamin B12 deficiency were 54.2% and 8.1%, respectively. The control period included 117 patients, and the intervention period included 101 patients. Our quality-improvement process increased the rate of evaluation for iron and vitamin B12 deficiency in patients with anemia from 23.1% and 20.5%, respectively, to more than 90%. When controlling for relevant demographic and cancer-related characteristics, the delta hemoglobin was 0.45 g/dL higher in patients treated after the intervention when compared with patients treated before the intervention. In patients with hemoglobin levels below 11 g/dL, the delta hemoglobin was 0.91 g/dL higher after the intervention. There was no significant difference in the rate of blood transfusion. Patients with anemia who were surveyed were concerned about fatigue and overall accepting of the intervention.

Conclusion: Using medical record treatment plans to send reflex anemia evaluation tests was effective at increasing rates of screening for nutritional deficiencies. Proactively addressing nutritional causes of anemia was associated with maintenance of higher hemoglobin levels in patients with gynecologic cancer receiving systemic treatment.

Objective: To evaluate whether large language models (LLMs) applied to prenatal clinical notes can predict postpartum hemorrhage (PPH) before the onset of labor and to compare model performance across outcome definitions, including a novel intervention-based definition.

Methods: We conducted a retrospective cohort study within a large regional health network. Two outcome definitions for PPH were used: 1) estimated or quantitative blood loss (EBL-QBL) extracted from clinical notes; and 2) a clinical intervention-based PPH definition (cPPH) designed to capture significant hemorrhage requiring intervention, including transfusion, uterotonics, Bakri balloon, or hysterectomy. We evaluated three PPH prediction pipelines: 1) structured data only-supervised machine learning that used structured electronic medical record data; 2) LLM-direct-direct prediction that used a fine-tuned LLM applied to clinical notes; and 3) LLM-extract-interpretable models that used LLM-extracted features combined with structured data. Model performance was evaluated using an area under the receiver operating characteristic curve (AUROC) on a temporally held-out test set.

Results: Among 19,992 deliveries, 1,156 patients (5.8%) met the EBL-QBL definition of PPH, 321 (1.6%) met the cPPH definition, and 309 (1.5%) met both definitions. The LLM-based direct prediction model achieved the highest AUROC for both PPH definitions (AUROC 0.79-0.80), followed by interpretable models that combined LLM-extracted features with structured data (AUROC 0.76-0.78). Models that used only structured data had the lowest AUROC (0.65-0.71). The LLM-extracted features approach identified 47 significant predictors, including established risk factors such as multiple gestation and previous cesarean delivery.

Conclusion: These findings highlight the potential of LLM-based approaches to improve PPH risk stratification beyond structured data alone, with the feature extraction method offering a promising balance between predictive performance and clinical utility. Eventual integration of these methods into clinical workflows could improve early detection and guide targeted preventive interventions.