Pub Date : 2025-11-27DOI: 10.1016/j.xagr.2025.100589
Ivo Vukasović MD , Dinka Pavičić Baldani MD, PhD , Lana Škrgatić MD, PhD , Magdalena Karadža MD, PhD
Objective
To describe fertility-sparing management of atypical polypoid adenomyoma (APA) in two premenopausal women and to review the relevant literature on treatment strategies aimed at preserving fertility.
Case Report
A 39-year-old nulliparous woman presented with heavy menstrual bleeding and was diagnosed with APA via hysteroscopy and histopathology. Rapid recurrence prompted a second-look hysteroscopy and complete lesion resection. The second case involved a 30-year-old nulliparous woman with prolonged bleeding and a suspected submucosal fibroid; hysteroscopic resection confirmed APA. She received a levonorgestrel-releasing intrauterine device and regular follow-up. Both cases highlight diagnostic and therapeutic challenges in managing APA while preserving fertility.
Conclusion
These cases illustrate the diagnostic and therapeutic challenges of APA while preserving fertility. Based on our cases and a review of the literature, complete hysteroscopic resection, combined with hormonal therapy when appropriate, may be effective. Close follow-up is essential due to the risk of recurrence and potential malignant transformation, and individualized management is recommended to optimize fertility outcomes.
{"title":"Fertility-sparing management of atypical polypoid adenomyoma in a premenopausal woman: a two-case report and literature review","authors":"Ivo Vukasović MD , Dinka Pavičić Baldani MD, PhD , Lana Škrgatić MD, PhD , Magdalena Karadža MD, PhD","doi":"10.1016/j.xagr.2025.100589","DOIUrl":"10.1016/j.xagr.2025.100589","url":null,"abstract":"<div><h3>Objective</h3><div>To describe fertility-sparing management of atypical polypoid adenomyoma (APA) in two premenopausal women and to review the relevant literature on treatment strategies aimed at preserving fertility.</div></div><div><h3>Case Report</h3><div>A 39-year-old nulliparous woman presented with heavy menstrual bleeding and was diagnosed with APA via hysteroscopy and histopathology. Rapid recurrence prompted a second-look hysteroscopy and complete lesion resection. The second case involved a 30-year-old nulliparous woman with prolonged bleeding and a suspected submucosal fibroid; hysteroscopic resection confirmed APA. She received a levonorgestrel-releasing intrauterine device and regular follow-up. Both cases highlight diagnostic and therapeutic challenges in managing APA while preserving fertility.</div></div><div><h3>Conclusion</h3><div>These cases illustrate the diagnostic and therapeutic challenges of APA while preserving fertility. Based on our cases and a review of the literature, complete hysteroscopic resection, combined with hormonal therapy when appropriate, may be effective. Close follow-up is essential due to the risk of recurrence and potential malignant transformation, and individualized management is recommended to optimize fertility outcomes.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"6 1","pages":"Article 100589"},"PeriodicalIF":0.0,"publicationDate":"2025-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145841272","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-23DOI: 10.1016/j.xagr.2025.100586
Geoges Lubuto Bushu MD , Christophe Kambale , Seraphin Kikwabantu , Faida Boelongo Benedite , Wolfgang Weber MD, MPH , Benjamin O. Black MD , Kim J.C. Verschueren MD, PhD
<div><h3>Background</h3><div>Globally rising caesarean section (CS) rates have resulted in more women with a scarred uterus. In low-resource, high-fertility settings, this likely contributes to a growing number of high-risk pregnancies and births. Exploring and understanding this trend in low-resource settings is essential to reduce maternal and perinatal mortality globally.</div></div><div><h3>Objective</h3><div>This study aimed to assess CS practices in Walikale, eastern Democratic Republic of Congo (DRC), using the Robson classification, clinical indications, maternal and perinatal complications, and quality of care, to improve CS decision-making and clinical outcomes.</div></div><div><h3>Study Design</h3><div>A cross-sectional study was conducted at the General Referral Hospital of Walikale, North Kivu, DRC, from January 1 to March 31, 2024. Data from all births were reviewed, and clinical case reviews were performed systematically for each CS by a team of health care providers. Descriptive statistics were used for analysis.</div></div><div><h3>Results</h3><div>The CS rate was 15.7%, with 136 CS of 868 births. Women in Robson group 5 (previous CS, term, cephalic presentation), accounted for 50% of all CS (68/136). Among CS in Robson groups 6 to 10 (malpresentation, twins, preterm), 65.6% (21/32) were also performed in women with a previous CS. Vaginal birth after CS (VBAC) rates were high: 71.2% (79/111) after one and 50.0% (23/46) after two previous CS. Among women with a previous CS (191/868, 22.0% of the population), uterine rupture occurred in 5.8% (11/191) and abnormally invasive placenta in 3.7% (7/191). Surgical site infections occurred in 7.4% (10/136) of CS. Perinatal mortality was 60 per 1000 births (53/886 total births). Case reviews showed that 9.6% (13/136) of CS were performed “too late” and 24.3% (33/136) “too soon.” Positive findings included high antenatal care attendance and short decision-to-CS intervals. Recommendations following from case review included strengthening clinical supervision and training health workers, team decision-making for CS with relative indications, ensuring access to the hospital, medication, blood, and contraception, especially for women with prior CS.</div></div><div><h3>Conclusion</h3><div>In this conflict-affected, high-fertility, low-resource context, the CS rate is rising as well as the proportion of women with a scarred uterus. The majority of CS are performed in women with a previous CS. VBAC rates are notably high, though both VBAC and multiple repeat CS carry important safety considerations. Applying the Robson classification is challenging in low-resource settings, where gestational age is often unknown. To optimize CS care and reduce adverse outcomes, it is crucial to prevent the first unnecessary CS, ensure timely and appropriate indications through context-adapted guidelines, clinical supervision, and routine case reviews, and strengthen both basic and comprehensive antenatal and obste
{"title":"Caesarean section Robson classification, complications, and lessons learned in a rural hospital in Walikale, North Kivu, Democratic Republic of Congo: a cross-sectional study","authors":"Geoges Lubuto Bushu MD , Christophe Kambale , Seraphin Kikwabantu , Faida Boelongo Benedite , Wolfgang Weber MD, MPH , Benjamin O. Black MD , Kim J.C. Verschueren MD, PhD","doi":"10.1016/j.xagr.2025.100586","DOIUrl":"10.1016/j.xagr.2025.100586","url":null,"abstract":"<div><h3>Background</h3><div>Globally rising caesarean section (CS) rates have resulted in more women with a scarred uterus. In low-resource, high-fertility settings, this likely contributes to a growing number of high-risk pregnancies and births. Exploring and understanding this trend in low-resource settings is essential to reduce maternal and perinatal mortality globally.</div></div><div><h3>Objective</h3><div>This study aimed to assess CS practices in Walikale, eastern Democratic Republic of Congo (DRC), using the Robson classification, clinical indications, maternal and perinatal complications, and quality of care, to improve CS decision-making and clinical outcomes.</div></div><div><h3>Study Design</h3><div>A cross-sectional study was conducted at the General Referral Hospital of Walikale, North Kivu, DRC, from January 1 to March 31, 2024. Data from all births were reviewed, and clinical case reviews were performed systematically for each CS by a team of health care providers. Descriptive statistics were used for analysis.</div></div><div><h3>Results</h3><div>The CS rate was 15.7%, with 136 CS of 868 births. Women in Robson group 5 (previous CS, term, cephalic presentation), accounted for 50% of all CS (68/136). Among CS in Robson groups 6 to 10 (malpresentation, twins, preterm), 65.6% (21/32) were also performed in women with a previous CS. Vaginal birth after CS (VBAC) rates were high: 71.2% (79/111) after one and 50.0% (23/46) after two previous CS. Among women with a previous CS (191/868, 22.0% of the population), uterine rupture occurred in 5.8% (11/191) and abnormally invasive placenta in 3.7% (7/191). Surgical site infections occurred in 7.4% (10/136) of CS. Perinatal mortality was 60 per 1000 births (53/886 total births). Case reviews showed that 9.6% (13/136) of CS were performed “too late” and 24.3% (33/136) “too soon.” Positive findings included high antenatal care attendance and short decision-to-CS intervals. Recommendations following from case review included strengthening clinical supervision and training health workers, team decision-making for CS with relative indications, ensuring access to the hospital, medication, blood, and contraception, especially for women with prior CS.</div></div><div><h3>Conclusion</h3><div>In this conflict-affected, high-fertility, low-resource context, the CS rate is rising as well as the proportion of women with a scarred uterus. The majority of CS are performed in women with a previous CS. VBAC rates are notably high, though both VBAC and multiple repeat CS carry important safety considerations. Applying the Robson classification is challenging in low-resource settings, where gestational age is often unknown. To optimize CS care and reduce adverse outcomes, it is crucial to prevent the first unnecessary CS, ensure timely and appropriate indications through context-adapted guidelines, clinical supervision, and routine case reviews, and strengthen both basic and comprehensive antenatal and obste","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"6 1","pages":"Article 100586"},"PeriodicalIF":0.0,"publicationDate":"2025-11-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145799050","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Placenta accreta spectrum (PAS) is a serious obstetric condition characterized by abnormal invasion of placental tissue into the uterine wall, leading to severe maternal complications. Early and accurate diagnosis, both antenatally and intraoperatively, is crucial for effective management and for reducing associated morbidity and mortality.
Objective
The primary objective is to evaluate agreement between intraoperative clinical grading using the FIGO 2018 criteria of PAS and antenatal ultrasound diagnoses, and the secondary objective to assess the correlation between clinical outcomes and postpartum histopathological findings.
Study Design
In this prospective study, we enrolled 70 pregnant women with placenta previa suspected of having PAS, who were managed at an accredited PAS Center from September 2022 to July 2023. Antenatal ultrasound evaluations were performed in the third trimester, and patients underwent surgery between 34 and 36+6 weeks. The experienced surgeons assessed the intraoperative PAS grading using the FIGO 2018 criteria. Postoperatively, antenatal and intraoperative PAS grading were compared with histopathological findings. The agreement between antepartum and intraoperative grading, along with their correlations with clinical outcomes, was analyzed using kappa statistics.
Results
Twenty-eight patients (40%) had isolated placenta previa. Forty-two (60%) had PAS, including six with accreta (8.6%), 15 with increta (21.4%), and 21 with percreta (30%). Cesarean hysterectomy was performed in 39 (92.9%) of PAS and had confirmed with histopathological examination. The kappa agreement between ultrasound diagnosis and intraoperative grading was substantial (kappa=0.88; 95% confidence interval [CI]: 0.64–0.94). The agreement between intraoperative grading and histopathology was moderate (kappa=0.68; 95% CI: 0.40–0.91).
Conclusion
Antenatal ultrasound diagnoses and intraoperative clinical grading of PAS demonstrated a high level of concordance. Although antenatal ultrasound enables early preparation and correlation well with histopathology and clinical outcomes, intraoperative assessment remains crucial for accurately determining PAS severity and guiding surgery.
{"title":"Agreement of intraoperative clinical grading by the FIGO criteria with antenatal ultrasound diagnosis of placenta accreta spectrum and correlation with clinical outcomes","authors":"Warittha Limsirisawat MD , Yuthasak Suphasynth MD , Thiti Ajimakul MD , Atitthan Ratanaburi MD , Aroontorn Pichatechaiyoot MD , Ingporn Jiamset MD , Kulisara Nantamongkolkul MD , Ekasak Thiangphak MD , Kanet Kanjanapradit MD , Savitree Pranpanus MD","doi":"10.1016/j.xagr.2025.100590","DOIUrl":"10.1016/j.xagr.2025.100590","url":null,"abstract":"<div><h3>Background</h3><div>Placenta accreta spectrum (PAS) is a serious obstetric condition characterized by abnormal invasion of placental tissue into the uterine wall, leading to severe maternal complications. Early and accurate diagnosis, both antenatally and intraoperatively, is crucial for effective management and for reducing associated morbidity and mortality.</div></div><div><h3>Objective</h3><div>The primary objective is to evaluate agreement between intraoperative clinical grading using the FIGO 2018 criteria of PAS and antenatal ultrasound diagnoses, and the secondary objective to assess the correlation between clinical outcomes and postpartum histopathological findings.</div></div><div><h3>Study Design</h3><div>In this prospective study, we enrolled 70 pregnant women with placenta previa suspected of having PAS, who were managed at an accredited PAS Center from September 2022 to July 2023. Antenatal ultrasound evaluations were performed in the third trimester, and patients underwent surgery between 34 and 36+6 weeks. The experienced surgeons assessed the intraoperative PAS grading using the FIGO 2018 criteria. Postoperatively, antenatal and intraoperative PAS grading were compared with histopathological findings. The agreement between antepartum and intraoperative grading, along with their correlations with clinical outcomes, was analyzed using kappa statistics.</div></div><div><h3>Results</h3><div>Twenty-eight patients (40%) had isolated placenta previa. Forty-two (60%) had PAS, including six with accreta (8.6%), 15 with increta (21.4%), and 21 with percreta (30%). Cesarean hysterectomy was performed in 39 (92.9%) of PAS and had confirmed with histopathological examination. The kappa agreement between ultrasound diagnosis and intraoperative grading was substantial (kappa=0.88; 95% confidence interval [CI]: 0.64–0.94). The agreement between intraoperative grading and histopathology was moderate (kappa=0.68; 95% CI: 0.40–0.91).</div></div><div><h3>Conclusion</h3><div>Antenatal ultrasound diagnoses and intraoperative clinical grading of PAS demonstrated a high level of concordance. Although antenatal ultrasound enables early preparation and correlation well with histopathology and clinical outcomes, intraoperative assessment remains crucial for accurately determining PAS severity and guiding surgery.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"6 1","pages":"Article 100590"},"PeriodicalIF":0.0,"publicationDate":"2025-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145799048","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The accuracy of the cerebroplacental ratio (CPR) in predicting cesarean section for intrapartum fetal compromise (CS-IFC) prior to the onset of labor remains controversial.
Objectives
To determine whether advancing gestational age (GA) in the final weeks of pregnancy enhances the predictive performance of CPR and other sonographic parameters for CS-IFC before labor.
Study design
This multicentre retrospective study analysed 590 singleton pregnancies across four tertiary centres in Spain, Italy, and the UK. All participants underwent Doppler ultrasound assessment between 35+0 and 41+0 weeks of gestation and delivered within 24 hours of examination. CS-IFC was defined by abnormal intrapartum fetal heart rate patterns or fetal scalp pH <7.20 necessitating emergency caesarean delivery. The predictive performance of CPR, middle cerebral artery (MCA) pulsatility index (PI), and umbilical artery (UA) PI—expressed as multiples of the median (MoM)—was evaluated using ROC curve analysis and logistic regression, alone and in combination with estimated fetal weight centile (EFWc), fetal sex, and type of labour onset (TLO), stratified by gestational age.
Results
The highest overall predictive performance between 35 and 40 weeks of gestation was observed with the use of CPR MoM and MCA PI MoM (AUC 0.71, 95% confidence interval [95% CI], 0.64–0.79, P<.00001, AIC 343.6; AUC 0.70, 95% CI, 0.63–0.77, P<.00001, AIC 346.5, respectively). Predictive accuracy further improved with the inclusion of estimated fetal weight centile (EFWc) (AUC 0.73, CI 0.66–0.80, P<.00001, AIC 339.3; AUC 0.74, CI 0.68–0.80, P<.00001, AIC 336.4), and was enhanced even more when additional clinical variables, such as fetal sex and type of labor onset were incorporated (AUC 0.77, CI 0.71–0.83, P<.00001, AIC 327; AUC 0.78, CI 0.72–0.84, P<.00001, AIC 323.9).
Across all models, predictive accuracy improved with advancing GA (P<.00001), peaking at 39 to 40 weeks. This trend was evident for cerebral Doppler indices (CPR MoM and MCA PI MoM), but not for UA PI or EFWc. The improvement in performance remained significant even when only fetuses appropriate for gestational age were analyzed.
Conclusion
The predictive ability of cerebral Doppler for CS-IFC, in both high- and low-risk pregnancies, increases with advancing gestational age during the last weeks of gestation.
背景：脑胎盘比（CPR）在临产前预测剖宫产术中产内胎儿妥协（CS-IFC）的准确性仍有争议。目的探讨妊娠末周提前孕龄是否能提高临产前心肺复苏术及其他超声参数对CS-IFC的预测效果。这项多中心回顾性研究分析了西班牙、意大利和英国四所高等教育中心的590例单胎妊娠。所有参与者在妊娠35+0至41+0周期间接受多普勒超声评估，并在检查后24小时内分娩。CS-IFC的定义为产时胎儿心率异常或胎儿头皮pH值7.20，需要紧急剖腹产。使用ROC曲线分析和logistic回归评估CPR、大脑中动脉（MCA）搏动指数（PI）和脐动脉（UA） PI（以中位数（MoM）的倍数表示）的预测性能，并结合估计的胎儿体重百分数（EFWc）、胎儿性别和分娩类型（TLO），按胎龄分层。结果使用CPR MoM和MCA PI MoM在妊娠35 - 40周期间观察到最高的总体预测性能（AUC 0.71, 95%可信区间[95% CI]， 0.64-0.79, P< 0.00001, AIC 343.6; AUC 0.70, 95% CI, 0.63-0.77, P< 0.00001, AIC 346.5）。纳入估计胎儿体重百分位数（EFWc）后，预测准确性进一步提高（AUC 0.73, CI 0.66-0.80, P< 0.00001, AIC 339.3; AUC 0.74, CI 0.68-0.80, P< 0.00001, AIC 336.4），当纳入胎儿性别和分娩类型等其他临床变量时，预测准确性进一步提高（AUC 0.77, CI 0.71-0.83, P< 0.00001, AIC 327; AUC 0.78, CI 0.72-0.84, P< 0.00001, AIC 323.9）。在所有模型中，预测精度随着遗传算法的推进而提高（P<.00001），在39至40周达到峰值。这种趋势在脑多普勒指数（CPR MoM和MCA PI MoM）中很明显，但在UA PI或EFWc中则不明显。即使只对胎龄合适的胎儿进行分析，性能的改善仍然是显著的。结论在妊娠最后几周，脑多普勒对高危和低危妊娠CS-IFC的预测能力随胎龄的增加而增加。
{"title":"Does gestational age influence the predictive accuracy of the cerebroplacental ratio for intrapartum fetal compromise?","authors":"José Morales-Roselló MD, PhD , Asma Khalil MD , Silvia Buongiorno MD , Maia Brik MD , Manel Mendoza MD , Carolina Di Fabrizio MD , Elisa Scarinci MD , Silvia Salvi MD","doi":"10.1016/j.xagr.2025.100585","DOIUrl":"10.1016/j.xagr.2025.100585","url":null,"abstract":"<div><h3>Background</h3><div>The accuracy of the cerebroplacental ratio (CPR) in predicting cesarean section for intrapartum fetal compromise (CS-IFC) prior to the onset of labor remains controversial.</div></div><div><h3>Objectives</h3><div>To determine whether advancing gestational age (GA) in the final weeks of pregnancy enhances the predictive performance of CPR and other sonographic parameters for CS-IFC before labor.</div></div><div><h3>Study design</h3><div>This multicentre retrospective study analysed 590 singleton pregnancies across four tertiary centres in Spain, Italy, and the UK. All participants underwent Doppler ultrasound assessment between 35+0 and 41+0 weeks of gestation and delivered within 24 hours of examination. CS-IFC was defined by abnormal intrapartum fetal heart rate patterns or fetal scalp pH <7.20 necessitating emergency caesarean delivery. The predictive performance of CPR, middle cerebral artery (MCA) pulsatility index (PI), and umbilical artery (UA) PI—expressed as multiples of the median (MoM)—was evaluated using ROC curve analysis and logistic regression, alone and in combination with estimated fetal weight centile (EFWc), fetal sex, and type of labour onset (TLO), stratified by gestational age.</div></div><div><h3>Results</h3><div>The highest overall predictive performance between 35 and 40 weeks of gestation was observed with the use of CPR MoM and MCA PI MoM (AUC 0.71, 95% confidence interval [95% CI], 0.64–0.79, <em>P</em><.00001, AIC 343.6; AUC 0.70, 95% CI, 0.63–0.77, <em>P</em><.00001, AIC 346.5, respectively). Predictive accuracy further improved with the inclusion of estimated fetal weight centile (EFWc) (AUC 0.73, CI 0.66–0.80, <em>P</em><.00001, AIC 339.3; AUC 0.74, CI 0.68–0.80, <em>P</em><.00001, AIC 336.4), and was enhanced even more when additional clinical variables, such as fetal sex and type of labor onset were incorporated (AUC 0.77, CI 0.71–0.83, <em>P</em><.00001, AIC 327; AUC 0.78, CI 0.72–0.84, <em>P</em><.00001, AIC 323.9).</div><div>Across all models, predictive accuracy improved with advancing GA (<em>P</em><.00001), peaking at 39 to 40 weeks. This trend was evident for cerebral Doppler indices (CPR MoM and MCA PI MoM), but not for UA PI or EFWc. The improvement in performance remained significant even when only fetuses appropriate for gestational age were analyzed.</div></div><div><h3>Conclusion</h3><div>The predictive ability of cerebral Doppler for CS-IFC, in both high- and low-risk pregnancies, increases with advancing gestational age during the last weeks of gestation.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"6 1","pages":"Article 100585"},"PeriodicalIF":0.0,"publicationDate":"2025-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145841274","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-10DOI: 10.1016/j.xagr.2025.100583
Yuguo Deng MD , Lanyun Liu BS , Danxiu Lu BS , Qiulu Wu MD , Ying Li PhD , Jinying Yang PhD
Background
The study of 24-hour urinary total protein (24-h UTP) excretion is an essential parameter for the assessment of renal function and early detection of pregnancy complications. However, data on reference interval for 24-h UTP in women with twin pregnancies are scarce.
Objective
We aimed to establish the reference interval for 24-h UTP excretion in women with twin pregnancies and compare it with that in women with singletons.
Study Design
A total of 12,633 participants with singletons or twin pregnancies were recruited. They were instructed to collect standard 24-hour urinary samples. Information was extracted from the electronic medical record. The nonparametric percentile method was used to determine reference interval for 24-h UTP excretion during different trimesters in women (excluding, among others, those with preexisting renal disease, gestational or chronic hypertension, pre-eclampsia, and pregestational diabetes mellitus).
Results
In twin pregnancies, the 24-h UTP levels expressed as medians and percentiles (5th, 95th) for each trimester were as follows: 74.2 (32.7, 195.5) mg, 104.5 (41.9, 213.1) mg, and 152.6 (46.1, 415.7) mg in the first, second, and third trimesters, respectively. A significant increase in 24-h UTP excretion was observed throughout pregnancy (all P<.001). Furthermore, the median (25th, 75th) of 24-h UTP values in the singleton group and twin groups were 70.2 (48.5, 98.3) vs 74.2 (47.3, 108.2) mg, 84.8 (58.5, 118.2) vs 104.5 (78.4, 135.6) mg, and 108.0 (73.4, 149.3) vs 152.6 (90.8, 192.8) mg in the first, second, and third trimesters, respectively. (Part of the data on singleton pregnancy has previously been published). The 24-h UTP excretion in the twin group was significantly higher than those in the singleton group in the second and third trimesters (both P<.001).
Conclusion
Physiological proteinuria levels were approximately doubled in late pregnancy in women with twin pregnancies compared to early pregnancy, and the upper limit of normal 24-h UTP excretion is 415.7 mg in late pregnancy. Moreover, the threshold for elevated proteinuria in twin pregnancies could be higher than in singletons from the second trimester onwards. Understanding these changes is essential for precise twin management and patient counseling.
{"title":"Reference interval for 24-hour urinary protein excretion in uncomplicated women with twin pregnancies","authors":"Yuguo Deng MD , Lanyun Liu BS , Danxiu Lu BS , Qiulu Wu MD , Ying Li PhD , Jinying Yang PhD","doi":"10.1016/j.xagr.2025.100583","DOIUrl":"10.1016/j.xagr.2025.100583","url":null,"abstract":"<div><h3>Background</h3><div>The study of 24-hour urinary total protein (24-h UTP) excretion is an essential parameter for the assessment of renal function and early detection of pregnancy complications. However, data on reference interval for 24-h UTP in women with twin pregnancies are scarce.</div></div><div><h3>Objective</h3><div>We aimed to establish the reference interval for 24-h UTP excretion in women with twin pregnancies and compare it with that in women with singletons.</div></div><div><h3>Study Design</h3><div>A total of 12,633 participants with singletons or twin pregnancies were recruited. They were instructed to collect standard 24-hour urinary samples. Information was extracted from the electronic medical record. The nonparametric percentile method was used to determine reference interval for 24-h UTP excretion during different trimesters in women (excluding, among others, those with preexisting renal disease, gestational or chronic hypertension, pre-eclampsia, and pregestational diabetes mellitus).</div></div><div><h3>Results</h3><div>In twin pregnancies, the 24-h UTP levels expressed as medians and percentiles (5th, 95th) for each trimester were as follows: 74.2 (32.7, 195.5) mg, 104.5 (41.9, 213.1) mg, and 152.6 (46.1, 415.7) mg in the first, second, and third trimesters, respectively. A significant increase in 24-h UTP excretion was observed throughout pregnancy (all <em>P</em><.001). Furthermore, the median (25th, 75th) of 24-h UTP values in the singleton group and twin groups were 70.2 (48.5, 98.3) vs 74.2 (47.3, 108.2) mg, 84.8 (58.5, 118.2) vs 104.5 (78.4, 135.6) mg, and 108.0 (73.4, 149.3) vs 152.6 (90.8, 192.8) mg in the first, second, and third trimesters, respectively. (Part of the data on singleton pregnancy has previously been published). The 24-h UTP excretion in the twin group was significantly higher than those in the singleton group in the second and third trimesters (both <em>P</em><.001).</div></div><div><h3>Conclusion</h3><div>Physiological proteinuria levels were approximately doubled in late pregnancy in women with twin pregnancies compared to early pregnancy, and the upper limit of normal 24-h UTP excretion is 415.7 mg in late pregnancy. Moreover, the threshold for elevated proteinuria in twin pregnancies could be higher than in singletons from the second trimester onwards. Understanding these changes is essential for precise twin management and patient counseling.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"6 1","pages":"Article 100583"},"PeriodicalIF":0.0,"publicationDate":"2025-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145750361","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-07DOI: 10.1016/j.xagr.2025.100584
Jin Hee Kim MD , Charles E. Miller MD , James A. Simon MD , James W. Thomas MS , Anna Chan PharmD , Michael C. Snabes MD, PhD
<div><h3>Background</h3><div>Elagolix (ELA) 200 mg twice daily is an oral treatment approved for moderate-to-severe endometriosis-associated pain. However, the clinical use of ELA is limited by potential hypoestrogenic effects, including the loss of bone mineral density (BMD). The addition of hormonal add-back (AB) therapy (1-mg estradiol/0.5-mg norethindrone acetate once daily) may attenuate BMD loss.</div></div><div><h3>Objectives</h3><div>To provide long-term safety results from a 48-month phase 3 trial assessing ELA+AB therapy in premenopausal women with moderate-to-severe endometriosis-associated pain.</div></div><div><h3>Study Design</h3><div>This multicenter, phase 3 trial was conducted between July 7, 2017, and December 6, 2023, and included a 12-month double-blind treatment period, a 36-month open-label extension period, and a 12-month post-treatment follow-up (PTFU) period. At the beginning of the double-blind period, premenopausal women (aged 18−49 years) with moderate-to-severe endometriosis-associated pain were randomized 4:1:2 to ELA+AB therapy, ELA monotherapy for 6 months followed by ELA+AB therapy for the remaining 6 months, or placebo. After the double-blind treatment period, all patients were treated with open-label ELA+AB therapy (referred to as the ELA+AB/ELA+AB, ELA/ELA+AB, and placebo/ELA+AB groups) for the remainder of the 36-month open-label treatment period. Safety was assessed throughout the open-label treatment period. BMD was measured by dual-energy X-ray absorptiometry in the lumbar spine, total hip, and femoral neck during the screening period and every 6 months throughout the study. BMD was analyzed using an analysis of covariance model with treatment as the main effect and baseline values as covariates.</div></div><div><h3>Results</h3><div>Among 380 patients who entered the open-label period, 140 (36.8%) completed the treatment period, and 240 (63.2%) discontinued, primarily due to withdrawn consent and adverse events (AEs). In total, 159 (74.0%) patients in the ELA+AB/ELA+AB group, 41 (69.5%) patients in the ELA/ELA+AB group, and 80 (75.5%) patients in the placebo/ELA+AB group reported at least 1 treatment-emergent adverse event (TEAE) during the open-label period. TEAEs were generally mild or moderate and nonserious. The most commonly reported TEAEs were COVID-19, bone density decreases, and sinusitis. No serious AEs were reported in >1 patient in any study group. BMD remained generally stable, with a least squares mean percent decrease from baseline to week 48 <2% in all groups and at all anatomical sites. Similarly, the least squares mean decrease from baseline in BMD was <2% in the ELA+AB/ELA+AB group at all anatomical sites and all time points throughout the study period. For patients in the ELA+AB/ELA+AB group with ≥48 months of treatment and reduced BMD at the final on-treatment visit, the majority (lumbar spine, 13 [59.1%]; total hip, 8 [53.3%]; femoral neck, 12 [57.1%]) partially or fully recove
{"title":"Safety of 48 months of elagolix with add-back therapy for endometriosis-associated pain","authors":"Jin Hee Kim MD , Charles E. Miller MD , James A. Simon MD , James W. Thomas MS , Anna Chan PharmD , Michael C. Snabes MD, PhD","doi":"10.1016/j.xagr.2025.100584","DOIUrl":"10.1016/j.xagr.2025.100584","url":null,"abstract":"<div><h3>Background</h3><div>Elagolix (ELA) 200 mg twice daily is an oral treatment approved for moderate-to-severe endometriosis-associated pain. However, the clinical use of ELA is limited by potential hypoestrogenic effects, including the loss of bone mineral density (BMD). The addition of hormonal add-back (AB) therapy (1-mg estradiol/0.5-mg norethindrone acetate once daily) may attenuate BMD loss.</div></div><div><h3>Objectives</h3><div>To provide long-term safety results from a 48-month phase 3 trial assessing ELA+AB therapy in premenopausal women with moderate-to-severe endometriosis-associated pain.</div></div><div><h3>Study Design</h3><div>This multicenter, phase 3 trial was conducted between July 7, 2017, and December 6, 2023, and included a 12-month double-blind treatment period, a 36-month open-label extension period, and a 12-month post-treatment follow-up (PTFU) period. At the beginning of the double-blind period, premenopausal women (aged 18−49 years) with moderate-to-severe endometriosis-associated pain were randomized 4:1:2 to ELA+AB therapy, ELA monotherapy for 6 months followed by ELA+AB therapy for the remaining 6 months, or placebo. After the double-blind treatment period, all patients were treated with open-label ELA+AB therapy (referred to as the ELA+AB/ELA+AB, ELA/ELA+AB, and placebo/ELA+AB groups) for the remainder of the 36-month open-label treatment period. Safety was assessed throughout the open-label treatment period. BMD was measured by dual-energy X-ray absorptiometry in the lumbar spine, total hip, and femoral neck during the screening period and every 6 months throughout the study. BMD was analyzed using an analysis of covariance model with treatment as the main effect and baseline values as covariates.</div></div><div><h3>Results</h3><div>Among 380 patients who entered the open-label period, 140 (36.8%) completed the treatment period, and 240 (63.2%) discontinued, primarily due to withdrawn consent and adverse events (AEs). In total, 159 (74.0%) patients in the ELA+AB/ELA+AB group, 41 (69.5%) patients in the ELA/ELA+AB group, and 80 (75.5%) patients in the placebo/ELA+AB group reported at least 1 treatment-emergent adverse event (TEAE) during the open-label period. TEAEs were generally mild or moderate and nonserious. The most commonly reported TEAEs were COVID-19, bone density decreases, and sinusitis. No serious AEs were reported in >1 patient in any study group. BMD remained generally stable, with a least squares mean percent decrease from baseline to week 48 <2% in all groups and at all anatomical sites. Similarly, the least squares mean decrease from baseline in BMD was <2% in the ELA+AB/ELA+AB group at all anatomical sites and all time points throughout the study period. For patients in the ELA+AB/ELA+AB group with ≥48 months of treatment and reduced BMD at the final on-treatment visit, the majority (lumbar spine, 13 [59.1%]; total hip, 8 [53.3%]; femoral neck, 12 [57.1%]) partially or fully recove","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"6 1","pages":"Article 100584"},"PeriodicalIF":0.0,"publicationDate":"2025-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145799051","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Traditional methods of teaching anatomical landmarks and their clinical and surgical significance often exhibit low retention rates. Medical educators have consistently sought to integrate innovative pedagogical approaches in response to evolving educational needs. The advent of multimedia technologies has significantly enhanced engagement and retention in learning, thus promoting a deeper contextual understanding in various clinical settings.
Aims
To compare the effectiveness of laparoscopic interactive demonstration of retroperitoneal vascular anatomy against traditional classroom teaching among medical students concerning knowledge acquisition, memory consolidation, and their perception of the teaching method.
Design
A prospective single-center, two-arm, Quasi-randomized Educational Intervention Trial (allocation ratio 1:1) assigned 152 final-year undergraduate medical students to either the intervention (live interactive schooling) or the control group (conventional classroom teaching). The primary outcome measured was an enhancement in fundamental pelvic retroperitoneal anatomy, which was assessed by administering pre- and post-test questionnaires of equal difficulty. Feedback forms were used to compare the acceptability and perception of the novel and traditional methods. Statistical analysis was performed using STRATA 14.4, paired t-tests for pre- and post-test comparisons, and Likert scale responses for feedback analysis.
Results
Both groups had comparable mean pretest scores. Post-test, the novel-method group demonstrated a significantly greater improvement (8.67±2.81) than the conventional group (5.74±3.18), with a mean difference of 2.93 (95% CI: 1.96–3.90; P<.001) and a large effect size (Cohen’s d=0.98), which reflected the principal outcome measure. At six-month follow-up, performance declined in both groups (P=.064). Student feedback indicated greater enthusiasm and acceptability for the novel approach.
Conclusion
Live interactive educational techniques were found to be effective, acceptable, and more student-oriented than traditional teaching-learning methods.
{"title":"In-theatre demonstration of laparoscopic retroperitoneal anatomy as an educational tool for final-year MBBS students: a novel quasi randomized experiment","authors":"Rumi Bhattacharjee MD , Sangita Pandey MD , Manisha Jana MBBS , Jaishree Ganjiwale MSc , Nitin Raithatha MD , Somashekhar Nimbalkar MD","doi":"10.1016/j.xagr.2025.100572","DOIUrl":"10.1016/j.xagr.2025.100572","url":null,"abstract":"<div><h3>Introduction</h3><div>Traditional methods of teaching anatomical landmarks and their clinical and surgical significance often exhibit low retention rates. Medical educators have consistently sought to integrate innovative pedagogical approaches in response to evolving educational needs. The advent of multimedia technologies has significantly enhanced engagement and retention in learning, thus promoting a deeper contextual understanding in various clinical settings.</div></div><div><h3>Aims</h3><div>To compare the effectiveness of laparoscopic interactive demonstration of retroperitoneal vascular anatomy against traditional classroom teaching among medical students concerning knowledge acquisition, memory consolidation, and their perception of the teaching method.</div></div><div><h3>Design</h3><div>A prospective single-center, two-arm, Quasi-randomized Educational Intervention Trial (allocation ratio 1:1) assigned 152 final-year undergraduate medical students to either the intervention (live interactive schooling) or the control group (conventional classroom teaching). The primary outcome measured was an enhancement in fundamental pelvic retroperitoneal anatomy, which was assessed by administering pre- and post-test questionnaires of equal difficulty. Feedback forms were used to compare the acceptability and perception of the novel and traditional methods. Statistical analysis was performed using STRATA 14.4, paired t-tests for pre- and post-test comparisons, and Likert scale responses for feedback analysis.</div></div><div><h3>Results</h3><div>Both groups had comparable mean pretest scores. Post-test, the novel-method group demonstrated a significantly greater improvement (8.67±2.81) than the conventional group (5.74±3.18), with a mean difference of 2.93 (95% CI: 1.96–3.90; <em>P</em><.001) and a large effect size (Cohen’s d=0.98), which reflected the principal outcome measure. At six-month follow-up, performance declined in both groups (<em>P</em>=.064). Student feedback indicated greater enthusiasm and acceptability for the novel approach.</div></div><div><h3>Conclusion</h3><div>Live interactive educational techniques were found to be effective, acceptable, and more student-oriented than traditional teaching-learning methods.</div></div><div><h3>Trial Registration</h3><div>Clinical Trials Registry-India, CTRI/2024/02/062476</div><div>URL: <span><span>https://ctri.nic.in/</span><svg><path></path></svg></span>.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"5 4","pages":"Article 100572"},"PeriodicalIF":0.0,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145466165","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.xagr.2025.100576
Monica Rodriguez DO, MPH , Nicole Tenzel MD , Rachel Russo MD, MAS , Robert Cohen MD
Introduction
Few reports exist on the prophylactic use of a resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter and its application for prolonged occlusion times exceeding 60 minutes during cesarean hysterectomy in placenta accreta spectrum disorders.
Case
In the case of suspected placenta percreta, the prophylactic placement of a REBOA catheter before cesarean hysterectomy provided prompt life-saving post-arrest resuscitation and 166 minutes of occlusion time without any REBOA-related complications.
Conclusion
Prophylactic REBOA catheter placement is a groundbreaking approach with the potential to revolutionize the management of obstetric hemorrhage. This case underscores the efficacy of prolonged endovascular occlusion, using both partial and complete aortic occlusion techniques and core aortic blood pressure monitoring to assess hemodynamic status.
{"title":"Prophylactic resuscitative endovascular balloon occlusion in the management of placenta percreta: a case report","authors":"Monica Rodriguez DO, MPH , Nicole Tenzel MD , Rachel Russo MD, MAS , Robert Cohen MD","doi":"10.1016/j.xagr.2025.100576","DOIUrl":"10.1016/j.xagr.2025.100576","url":null,"abstract":"<div><h3>Introduction</h3><div>Few reports exist on the prophylactic use of a resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter and its application for prolonged occlusion times exceeding 60 minutes during cesarean hysterectomy in placenta accreta spectrum disorders.</div></div><div><h3>Case</h3><div>In the case of suspected placenta percreta, the prophylactic placement of a REBOA catheter before cesarean hysterectomy provided prompt life-saving post-arrest resuscitation and 166 minutes of occlusion time without any REBOA-related complications.</div></div><div><h3>Conclusion</h3><div>Prophylactic REBOA catheter placement is a groundbreaking approach with the potential to revolutionize the management of obstetric hemorrhage. This case underscores the efficacy of prolonged endovascular occlusion, using both partial and complete aortic occlusion techniques and core aortic blood pressure monitoring to assess hemodynamic status.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"5 4","pages":"Article 100576"},"PeriodicalIF":0.0,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145519612","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1016/j.xagr.2025.100566
Emilia Lahtinen MS , Luisa W. Hugerth PhD , Gabriella Edfeldt PhD , Annette Säfholm PhD , Sten Kornfält MS , Lars Engstrand PhD, MD , Helena Strevens PhD, MD , Ina Schuppe-Koistinen PhD
Background
Bacterial vaginosis (BV) is the most common vaginal infection among women of reproductive age worldwide, caused by dysbiosis of the vaginal microbiome. Despite its prevalence, the underlying molecular mechanisms remain poorly understood, making diagnosis and treatment challenging. Although antibiotics are the standard therapy, recurrence rates are high, up to 50% within 1 year, and repeated treatments contribute to the rise of antimicrobial resistance. There is an urgent need for alternative, sustainable, and microbiome-friendly treatment options.
Objective
To evaluate whether pHyph, a novel antibiotic-free treatment, promotes a shift in the vaginal microbiome toward a health-associated composition in women with clinically diagnosed BV.
Study design
In a randomized, double-blind, placebo-controlled trial, vaginal swabs were collected from 152 women diagnosed with BV. Microbiome composition was assessed before and after a 6-day treatment with pHyph or a placebo-like comparator, using qPCR targeting 25 bacterial, 2 viral, and 8 eukaryotic species.
Results
pHyph significantly increased the abundance of Lactobacillus iners, Lactobacillus gasseri and Lactobacillus jensenii after treatment, while decreasing the abundance of BV-associated species, such as Gardnerella vaginalis, BVAB2, and Fannyhessea vaginae (Wilcoxon signed rank test, P<.05). The growth-promoting effect on Lactobacillus was more pronounced in women who had detectable levels at baseline. Notably, a substantial number of participants in the pHyph group (n=33) transitioned to a Lactobacillus-dominated community state type (CST), compared to none in the comparator group.
Conclusions
pHyph supports BV resolution by promoting a Lactobacillus-dominated vaginal microbiome and reducing BV-associated species, offering a promising antibiotic-free alternative.
{"title":"pHyph, a novel antibiotic-free treatment for bacterial vaginosis, promotes Lactobacillus growth and reduces the abundance of pathogens in the vagina","authors":"Emilia Lahtinen MS , Luisa W. Hugerth PhD , Gabriella Edfeldt PhD , Annette Säfholm PhD , Sten Kornfält MS , Lars Engstrand PhD, MD , Helena Strevens PhD, MD , Ina Schuppe-Koistinen PhD","doi":"10.1016/j.xagr.2025.100566","DOIUrl":"10.1016/j.xagr.2025.100566","url":null,"abstract":"<div><h3>Background</h3><div>Bacterial vaginosis (BV) is the most common vaginal infection among women of reproductive age worldwide, caused by dysbiosis of the vaginal microbiome. Despite its prevalence, the underlying molecular mechanisms remain poorly understood, making diagnosis and treatment challenging. Although antibiotics are the standard therapy, recurrence rates are high, up to 50% within 1 year, and repeated treatments contribute to the rise of antimicrobial resistance. There is an urgent need for alternative, sustainable, and microbiome-friendly treatment options.</div></div><div><h3>Objective</h3><div>To evaluate whether <em>p</em>Hyph, a novel antibiotic-free treatment, promotes a shift in the vaginal microbiome toward a health-associated composition in women with clinically diagnosed BV.</div></div><div><h3>Study design</h3><div>In a randomized, double-blind, placebo-controlled trial, vaginal swabs were collected from 152 women diagnosed with BV. Microbiome composition was assessed before and after a 6-day treatment with <em>p</em>Hyph or a placebo-like comparator, using qPCR targeting 25 bacterial, 2 viral, and 8 eukaryotic species.</div></div><div><h3>Results</h3><div><em>p</em>Hyph significantly increased the abundance of <em>Lactobacillus iners, Lactobacillus gasseri</em> and <em>Lactobacillus jensenii</em> after treatment, while decreasing the abundance of BV-associated species, such as <em>Gardnerella vaginalis</em>, BVAB2, and <em>Fannyhessea vaginae</em> (Wilcoxon signed rank test, <em>P<.</em>05). The growth-promoting effect on <em>Lactobacillus</em> was more pronounced in women who had detectable levels at baseline. Notably, a substantial number of participants in the <em>p</em>Hyph group (n=33) transitioned to a <em>Lactobacillus</em>-dominated community state type (CST), compared to none in the comparator group.</div></div><div><h3>Conclusions</h3><div><em>p</em>Hyph supports BV resolution by promoting a <em>Lactobacillus</em>-dominated vaginal microbiome and reducing BV-associated species, offering a promising antibiotic-free alternative.</div></div>","PeriodicalId":72141,"journal":{"name":"AJOG global reports","volume":"5 4","pages":"Article 100566"},"PeriodicalIF":0.0,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145519614","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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