Current Opinion in Obstetrics & Gynecology最新文献

Purpose of review: The purpose of this review is to review the recent literature with respect to the management of missing intrauterine device (IUD) strings. As IUD use has increased over time, it is important to review management options for this uncommon but possible complication.

Recent findings: This article will cover stepwise approaches to management of missing IUD strings based on the most recent literature. Initial steps include obtaining history and using in office tools to reveal IUD strings. Subsequent steps focus on imaging guidelines including obtaining transvaginal ultrasound when available. Finally, IUD removal with tools for uterine instrumentation are discussed, focusing on using tools that do not require cervical dilation and allow for grasping of the device.

Summary: This paper details a stepwise approach to the management of missing IUD strings which, as discussed in the article, may become more frequent given the rise of IUD use in general and postpartum placement in specific.

Purpose of review: Mobile health outreach programs are an alternative way to provide family planning services for rural populations or populations affected by conflict, outbreaks, or humanitarian crises. Here, we review the current literature about mobile health outreach programs in family planning.

Recent findings: Mobile health outreach programs are effective in delivering family planning services by increasing access to family planning services including expanding method choice, contributing to resilient healthcare models, and advancing reproductive justice.Mobile health outreach programs may be a reasonable, cost saving, person-centered alternative to delivering healthcare particularly when traditional systems are strained.

Summary: Mobile health outreach programs in family planning exist in the United States and globally. Current literature suggests that mobile and outreach programs are effective in increasing knowledge and access to family planning in part by expanding method choice. A mobile health outreach approach is a resilient model that is person-centered and lends itself well to empower patients to practice self-care. The findings and lessons learned may be helpful in guiding future mobile health outreach programs in family planning and other services conducive to an out of clinic model, particularly as a response to overburdened health systems.

Purpose of review: Female periurethral masses are an uncommon occurrence. The purpose of this review is to describe etiologies of female urethral and periurethral masses and to provide an update on diagnosis and management.

Recent findings: The most common causes of periurethral and urethral masses in women are urethral caruncles, urethral diverticula, and Skene's gland cysts. Urethral meatal lesions such as urethral caruncles and prolapse can be managed conservatively with topical estrogen therapy and close follow-up or should be excised in the setting of thrombosis, significant or recurrent bleeding, acute urinary retention, or persistent pain. Benign periurethral gland masses, such as Skene's gland cysts, Gartner's duct cysts, and Mullerian duct cysts, remain rare. Recent case series reveal a high rate of surgical management of these lesions with few complications. Urethral malignancy or malignant transformation of benign etiologies are even rarer but can be aggressive in nature and should be treated promptly.

Summary: Nonspecific urinary and vaginal symptoms as well as similar physical presentations make diagnosis of urethral and periurethral lesions in females difficult. Magnetic resonance imaging is useful for differentiation of periurethral masses. The decision for conservative or surgical management is typically guided by patient symptom bother, as well as concern for urethral malignancy.

Purpose of review: The aim of this study was to describe the common postpartum urinary sequelae including urinary retention and incontinence, and to summarize the management of these conditions.

Recent findings: Despite the high frequency of urinary disorders in obstetrics, screening and management protocols are rarely utilized by providers. Large variation exists in the literature regarding assessment of postpartum urinary retention, values of postvoid residuals and management of indwelling catheters in the immediate postpartum population. Recent expert guidance outlines a strategy for managing this condition.Research also highlights that screening for peripartum urinary incontinence is not a routine practice. The diagnosis is made more challenging by the fact that patients commonly understate and over-normalize their symptoms. Emerging studies have found that pelvic floor muscle training is cost-effective, preventive, and may improve symptoms in the postpartum setting.

Summary: Increased awareness of urinary disorders in pregnancy and postpartum is imperative for appropriate diagnosis and management. Instituting standardized voiding protocols postpartum will allow providers to avoid undiagnosed postpartum urinary retention and its repercussions. Improved screening and education regarding urinary incontinence in the peripartum is important for early management, such as pelvic floor muscle training, and improved quality of life.

Purpose of review: To review the evidence-informed options for cervical preparation prior to second-trimester dilation and evacuation (D&E).

Recent findings: As abortion restrictions increase and the number of abortion clinics and providers decreases, pregnant people are facing more barriers to abortion access. Those in need are now often required to travel for second-trimester abortion care, only to be faced with additional restrictions, such as mandatory waiting periods. Cervical preparation is recommended prior to D&E and takes time for effect. Given the increasing time required to obtain an abortion, patients and providers may prefer same-day cervical preparation to decrease the total time required. Options for same-day cervical preparation include misoprostol alone with single or serial doses, and misoprostol combined with osmotic dilators or transcervical balloon (Foley catheter). Same-day preparation may require additional clinical space to accommodate people after initiation of cervical preparation to manage side-effects and timing of the abortion. Overnight options are also used and more frequently later in the second trimester. Overnight options include mifepristone, osmotic dilators, and transcervical balloon and are often combined with same-day misoprostol. Medication alone preparation is well tolerated and effective in the second trimester, with the addition of mechanical methods with advancing gestation. With many options and combinations being safe and effective, providers can be dynamic and alter approach with supply shortages, adjust to different clinical settings, consider patient medical and surgical factors, and accommodate provider and patient preferences.

Summary: Multiple pharmacologic and mechanical options have been shown to be safe and effective for cervical preparation prior to D&E. Consideration for multiple factors should influence the method of cervical preparation and methods may vary by patient, provider and setting.

Purpose of review: Chronic pelvic main is a complex process that includes many causes. In gynecology, the treatment of myofascial pelvic pain and high tone pelvic floor disorders can be managed with skeletal muscle relaxants for select clinical indications. A review of skeletal muscle relaxants will be included for gynecologic indications.

Recent findings: There are limited studies on vaginal skeletal muscle relaxants, but there can be oral forms used for chronic myofascial pelvic pain. They function as antispastic, antispasmodic, and combination of the two modes of action. Diazepam is the most studied for myofascial pelvic pain in both oral and vaginal formulations. Its use can be combined with multimodal management to optimize outcomes. Other medications have limitations due to dependency and limited studies that demonstrate improvement in pain scales.

Summary: Skeletal muscle relaxants have limited high quality studies for chronic myofascial pelvic pain. Their use can be combined with multimodal options to improve clinical outcomes. Additional studies are needed for vaginal preparations and evaluation of safety and clinical efficacy for patient reported outcomes measures in patients living with chronic myofascial pelvic pain.

Purpose of review: Obesity is associated with several gynecologic conditions. While bariatric surgery is regarded as the most effective treatment option for obesity, gynecologic counseling for patients planning bariatric surgery is limited and often focused on fertility. The goal of this scoping review is to investigate the current recommendations for gynecologic counseling prior to bariatric surgery.

Recent findings: A comprehensive search was conducted to find peer reviewed studies written in English discussing a gynecologic issue of patients who were planning or previously had bariatric surgery. All the included studies identified a gap in preoperative gynecologic counseling. The majority of the articles made specific recommendations for a multidisciplinary approach to preoperative gynecologic counseling with a call to involve gynecologists or primary care providers.

Summary: Patients deserve to receive appropriate counseling about how obesity and bariatric surgery impact their overall gynecologic health. We advocate that the scope of gynecologic counseling includes more than pregnancy and contraception counseling. We propose a gynecologic counseling checklist for female patients undergoing bariatric surgery. Offering patients a referral to a gynecologist from the patient's first entry to a bariatric clinic is imperative to facilitate appropriate counseling.