Current Opinion in Obstetrics & Gynecology最新文献

Purpose of review: Improving maternal health is a clinical and policy priority in the United States. We reviewed recent literature on access to maternity care and impacts on racial and geographic equity.

Recent findings: New research indicates a wide range of consequences of obstetric unit closures, as well as health challenges for lower-volume obstetric units and those who travel long distances to care.

Summary: As maternal mortality rates rise, maternity care access is declining in the US, especially in rural areas and communities with a higher proportion of Black, Latinx, or Indigenous residents. Lack of resources and financial strain are challenges for low-volume and Black-serving obstetric units, and targeted investments may help improve safety and access.

Purpose of review: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) have emerged as a leading pharmacologic for managing weight gain across most populations, including peri and postmenopausal women who frequently suffer from weight gain. There is a paucity of data about this specific population and how they respond to these medications. This review aims to discuss the data available about the use and effects of GLP-1 RAs in the peri and postmenopausal populations.

Recent findings: GLP-1 RAs are consistently the most effective pharmacologic for weight loss and can be a valuable tool for use in peri and postmenopausal women.

Summary: Additional research is needed to determine the risks and benefits and ideal use of GLP-1 RAs in peri and postmenopausal women.

Purpose of review: Endometrial cancer (EC) is rising in incidence, particularly in younger, premenopausal women, due to increasing rates of obesity and delayed childbearing. This review evaluates current and emerging endocrine therapies, with a focus on fertility-preserving approaches for early-stage EC and treatment options for advanced or recurrent disease.

Recent findings: Fertility-sparing endocrine therapies, such as medroxyprogesterone acetate, megestrol acetate, and levonorgestrel-releasing intrauterine devices, achieve high response rates but carry recurrence risks. Biomarkers, including progesterone receptor status and molecular subtyping, are improving patient selection and outcomes. In advanced EC, single-agent and combination endocrine therapies with agents like selective estrogen receptor modulators, selective estrogen receptor down-regulators (SERDs), and aromatase inhibitors show efficacy, especially in hormone receptor-positive disease. Newer agents, including next-generation SERDs and proteolysis-targeting chimeras, hold potential for treating resistant cases.

Summary: Endocrine therapy offers a well tolerated alternative to chemotherapy in selected EC patients, particularly those with hormone-sensitive tumors. Advances in molecular profiling and the development of novel endocrine agents are refining treatment strategies, supporting endocrine therapy's continued role in managing EC across various stages.

Purpose of review: Despite the availability of Rh(D) immune globulin (RhIg) to prevent alloimmunization in Rh(D)-negative pregnant patients, anti-Rh(D) alloimmunization remains a prevalent cause of hemolytic disease of the fetus and newborn (HDFN). Recent RhIg shortages have caused clinicians and professional societies to identify methods to prioritize RhIg administration. New cell-free DNA (cfDNA) tests to predict fetal red blood cell antigen genotypes have been proposed as an option to prioritize the administration of RhIg to Rh(D)-negative pregnant people.

Recent findings: Commercial laboratories offer fetal Rh(D) genotype testing as part of cfDNA screening for fetal aneuploidy. Studies indicate that these tests have a high sensitivity and specificity for the detection of fetal Rh(D) status. Considering the current RhIg shortage, the American College of Obstetricians & Gynecologists (ACOG) suggests that utilizing cfDNA tests to determine fetal Rh(D) status is a reasonable approach to prioritize RhIg administration when supply is limited.

Summary: cfDNA screening for fetal Rh(D) status is a reasonable approach to triage the administration of RhIg in the setting of the current RhIg shortage. Utilization of cfDNA screening for fetal Rh(D) and other red blood cell antigen status is likely to increase in routine care. Research, professional society guidance, and education are necessary to ensure well tolerated and equitable utilization.

Purpose of review: A life-limiting fetal diagnosis (LLD) refers to a medical condition identified during pregnancy that is expected to lead to stillbirth, preclude ex utero survival, or significantly reduce neonatal life expectancy. The terms 'lethal' or 'life-limiting' are used to prognosticate early death for various anatomic or physiologic causes, although the expected timeframe is nonspecific. The purpose of this manuscript is to review how the terms 'lethal' or 'life limiting' are used in contemporary perinatal research.

Recent findings: Depending on the study design, 'life-limiting' is defined either prior to data analysis (such as prospective cohort studies), or after outcomes are assessed (such as case series). When 'life-limiting' is defined prior to data analysis, study-specific specific definitions may include timeframes from birth to death, probability of neonatal mortality, or a list of diagnoses based off billing codes.

Summary: Professional societies have guidelines to standardize the reporting of vital statistics, including early death. While these fall short of defining LLDs comprehensively, they present an opportunity for more specific prognostication following prenatal diagnosis, which may improve research standardization to facilitate a clearer understanding of LLDs in clinical practice.

Purpose of review: Perimenopausal and menopausal symptoms are common and may significantly impact quality of life. Menopausal hormone therapy is the most effective treatment but may not be appropriate in all cases. Nonhormonal alternatives range from lifestyle changes and dietary supplements to medical interventions and prescription therapies. This review will summarize the newest advancements in nonhormonal therapies for bothersome perimenopausal and menopausal symptoms.

Recent findings: The Menopause Society recently updated their recommendations and guidelines for nonhormonal therapies. Previous recommendations, such as clonidine and pregabalin, are no longer recommended. A new class of medication, neurokinin B antagonists, are now available to target vasomotor symptoms and show promise in addressing sleep and mood issues.

Summary: Well tolerated, effective nonhormonal therapies are available to address perimenopausal and menopausal symptoms for those patients who are not candidates for or chose not to use menopausal hormone therapy.

Purpose of review: Sleep problems are among the most prevalent and bothersome symptoms of menopause. This review characterizes menopausal sleep disturbances, describes biopsychosocial predictors, and summarizes the evidence supporting pharmacological and nonpharmacological treatment options.

Recent findings: Recent studies found that sleep changes are early indicators of perimenopause and sought to disentangle the respective impacts of menopausal status, hot flashes (HFs), and changes in reproductive hormones on peri-/postmenopausal sleep problems. Both HFs and reproductive hormones predicted sleep problems, but neither solely accounted for the myriad changes in sleep, thus highlighting the contribution of additional biopsychosocial risk factors. Inconsistencies across studies were likely due to differences in study design and methodology, participants' menopausal stage, and the presence of sleep complaints. Recent studies support the use of psychological (cognitive-behavioral therapy for insomnia) and pharmacological (e.g., neurokinin B antagonists) treatments in addition to hormone therapy.

Summary: Sleep problems are common and of critical import to women during the menopausal transition, significantly influencing treatment preferences and satisfaction. Thus, sleep problems should be routinely assessed from a biopsychosocial perspective and treated with evidence-based interventions throughout menopause. Treatment selection should be based on diagnosis and careful assessment.