American journal of obstetrics and gynecology最新文献

Objectives: Vaginal childbirth is a key risk factor for pelvic floor muscle injury and dysfunction, and subsequent pelvic floor disorders. Multiparity further exacerbates these risks. Using the rat model, validated for the studies of the human pelvic floor muscles, we have previously identified that a single simulated birth injury results in pelvic floor muscle atrophy and fibrosis. We hypothesized that multiple birth injuries would further overwhelm the muscle regenerative capacity, leading to functionally relevant pathological alterations long-term.

Study design: Sprague-Dawley rats underwent simulated birth injury and were allowed to recover for 8 weeks before undergoing additional birth injury. Animals were sacrificed at acute (3- and 7-days post injury), subacute (21-, 28-, and 35-days post-injury), and long-term (8- and 12-weeks post-injury) time points post-second injury (N=3-8/time point), and the pubocaudalis portion of the rat levator ani complex was harvested to assess the impact of repeated birth injuries on muscle mechanical and histomorphological properties. The accompanying transcriptional changes were assessed by a customized NanoString panel. Uninjured animals were used as controls. Data with a parametric distribution were analyzed by a two-way analysis of variance followed by post hoc pairwise comparisons using Tukey's or Sidak's tests; non-parametrically distributed data were compared with Kruskal-Wallis test followed by pairwise comparisons with Dunn's test. Data, analyzed using GraphPad Prism v8.0, San Diego, CA, are presented as mean ± SEM or median (range).

Results: Following the 1^st simulated birth injury, active muscle force decreased acutely relative to uninjured controls (12.9±0.9 vs 25.98±2.1 g/mm², P<0.01). At 4 weeks, muscle active force production recovered to baseline and remained unchanged at 8 weeks after birth injury (P>0.99). Similarly, precipitous decrease in active force was observed immediately after repeated birth injury (18.07±1.2 vs 25.98±2.1 g/mm², P<0.05). In contrast to the functional recovery after a single birth injury, a long-term decrease in muscle contractile function was observed up to 12 weeks after repeated birth injuries (18.3±1.6 vs 25.98±2.1 g/mm², P<0.05). Fiber size was smaller at the long-term time points after 2^nd injury compared to the uninjured group (12 weeks vs uninjured control: 1485 (60.7-5000) vs 1989 (65.6-4702) μm², P<0.0001). The proportion of fibers with centralized nuclei, indicating active myofiber regeneration, returned to baseline at 8 weeks post-1^st birth injury, (P=0.95), but remained elevated as far as 12 weeks post-2^nd injury (12 weeks vs uninjured control: 7.1±1.5 vs 0.84±0.13%, P<0.0001). In contrast to the plateauing intramuscular collagen content after 4 weeks post-1^st injury, fibrotic degeneration incr

Background: The US suffers from an increasing rate of severe maternal morbidity, paired with a wide disparity in maternal health by race. Doulas are posited to be a useful resource to increase positive outcomes and decrease this disparity.

Objective: Evaluate the association of doula care with a broad range of maternal and neonatal outcomes in various subpopulations.

Study design: Retrospective cohort of deliveries from 1/2021-12/2022 at a single institution receiving prenatal care. Exposure was receipt of doula care prenatally and at delivery. We evaluated both maternal (cesarean delivery, cesarean delivery of nulliparous, term, singleton, vertex infant, vaginal birth after cesarean (VBAC), gestational hypertension, preeclampsia, postpartum emergency department visit, readmission and attendance at postpartum office visit) and neonatal (neonatal intensive care unit admission, unexpected complications in term newborns, breastfeeding, preterm delivery, and intrauterine fetal growth restriction) outcomes. Because our institution previously employed targeted outreach, offering doula services to patients at highest risk, we utilized multiple methods to generate an appropriate comparison population. We conducted multivariate logistic regression and conditional regressions using propensity scores, modeling likelihood of doula care, to generate adjusted risk differences associated with doula care. Analyses were repeated in populations stratified by race (White/Black) then payor status (public/commercial).

Results: Our cohort included 17,831 deliveries; 486 with doula care and 17,345 without. Patients receiving doula care were more likely to self-report Black race, be publicly insured, and live in a more disadvantaged neighborhood. Regardless of analytic approach, for every 100 patients under doula care there were 15-34 more VBACs [adjRD 15.6 (95%CI: 3.8, 27.4); adjRD 34.2 (95%CI: 0.046, 68.0)] and 5-6 more patients attending a postpartum office visit [adjRD 5.4 (95%CI: 1.4, 9.5); adjRD 6.8 (95% CI:3.7, 9.9)] compared with those not receiving doula services. Infants born to these patients were 20% more like likely to be exclusively breastfed [adjRR 1.22 (95%CI: 1.07, 1.38)], and doula care was associated with 3-4 fewer preterm births [adjRD -3.8 (95%CI: -6.1, -1.5); -4.0 (95%CI: -6.2, -1.8)] for every 100 deliveries receiving doula care. Results were consistent regardless of race or insurance. Results were also consistent when doula care was redefined as having at least 3 prenatal encounters with a doula.

Conclusions: Doula care was associated with more VBACs, attendance at postpartum office visit, breastfeeding, and fewer preterm deliveries. The effect of doula care was consistent across race and insurance status.

Background: 'Incarcerated gravid uterus' is a morbid complication that occurs in 1 in 3000 pregnancies. It is characterized by failure of a retropositioned uterus to become an abdominal organ between 12-14 weeks of gestation. If maternal symptoms develop or gestational age surpasses 14-16 weeks, replacement of a retropositioned uterus is recommended to reduce adverse outcomes. Previously described techniques for management include passive reduction, digital replacement, or more invasive methods such as laparoscopy, laparotomy, or sigmoidoscopy. These methods are either minimally effective, painful, or risky.

Objective: The objective of this report is to describe our clinical experience with a new minimally-invasive technique that uses the transvaginal ultrasound probe for uterine replacement in cases of incarceration, to conduct a narrative literature review on 'incarcerated gravid uterus,' and to propose an algorithm for management of this condition.

Study design: This is a case series of eight patients with an incarcerated gravid uterus who were managed with the transvaginal ultrasound probe technique at one academic medical institution between March 2020 and July 2023, as well as a narrative review of the literature on 'incarcerated gravid uterus.' PubMed, Google Scholar, and Ovid MEDLINE databases were searched for the terms "incarcerated gravid uterus," "uterine incarceration," "uterine sacculation," and "retroverted uterus" up to April 2024.

Results: The transvaginal ultrasound probe technique resulted in successful uterine replacement, with resolution of symptoms, in all eight patients. All pregnancies resulted in live births with good neonatal outcomes-seven out of eight patients delivered at term, and one delivered in the late preterm period.

Conclusion: Our proposed technique for treatment of an incarcerated gravid uterus with the transvaginal ultrasound probe is simple, minimally-invasive and effective. Based on our experience and the narrative literature review, an algorithm for the management of an incarcerated gravid uterus is proposed.

Background: Prior evidence showed that placental dysfunction triggers spontaneous preterm or term births, and intrapartum fetal compromise, often requiring urgent delivery and exposing both fetus and mother to significant risks. Predicting spontaneous labor onset and intrapartum fetal compromise could improve obstetric management and outcomes, but this is currently difficult, particularly in low-risk population.

Objective: The objective of this study is to examine whether placental dysfunction assessed at 36 weeks by the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio, associates with interval to spontaneous onset of labor and intrapartum fetal compromise requiring cesarean delivery, in a routinely examined population.

Study design: Retrospective analysis of prospectively collected data of women with singleton pregnancies undergoing routine assessment at 35⁺⁰-36⁺⁶ weeks' gestation at King's College Hospital (London, England). Using a General Linear Model the study examined outcomes related to the sFlt-1/PlGF ratio including the time interval from testing to spontaneous onset of labor, and the subsequent rate of fetal compromise requiring cesarean delivery. Patients undergoing induction of labor, and prelabour cesarean deliveries were excluded from the study.. Competing risks regression and Cox regression models were used to estimate the cumulative incidence and risk of the outcomes of interest RESULTS: In the screened population of 45,375 patients, 23,831 (52.5%) had spontaneous onset of labor and were included in the analysis. Cases with sFlt-1/PlGF ratio ˃50 vs. ≤50 delivered about one week earlier (39.2 vs. 40.0 weeks; p˂0.001). General linear model showed that greater sFlt-1/PlGF ratio associated with earlier spontaneous onset of labor (p<0.001), particularly in multiparous women A significant effects on sFlt-1/PlGF ratio values was, as expected, observed for those cases who developed preeclampsia and in women of advanced age.Cumulative incidence for spontaneous onset of labor was significantly higher in cases with sFlt-1/PlGF ˃50 vs. ≤50. Cox regression showed that the risk of spontaneous onset of labor increased with sFlt-1/PlGF ˃50 (hazard ratio [HR] 1.424; 95% CI 1.253-1.618; p˂0.001) and, as expected, the risk was mitigated over time from s-Flt-1/PlGF measurement to spontaneous labour onset (p˂0.001). Cases with vs. without intrapartum fetal compromise had higher mean sFlt-1/PlGF ratio (21.79 vs. 17.67; p˂0.001). Qualitative addition of fetal compromise to the general linear model showed higher sFlt-1/PlGF ratio in cases with, compared to those without, fetal compromise (p=0.014). Competing risks regression showed a positive dose-response effect for fetal compromise with increasing sFlt-1/PlGF ratios (p˂0.001). Above and below the optimal cut-off of 50 the quoted cumulative incidences were 6.7% vs. 4.7%, respectivel

The Society of Radiologists in Ultrasound convened a multisociety panel to develop a first-trimester US lexicon based on scientific evidence, societal guidelines, and expert consensus that would be appropriate for imagers, clinicians, and patients. Through a modified Delphi process with consensus of at least 80%, agreement was reached for preferred terms, synonyms, and terms to avoid. An intrauterine pregnancy (IUP) is defined as a pregnancy implanted in a normal location within the uterus. In contrast, an ectopic pregnancy (EP) is any pregnancy implanted in an abnormal location, whether extrauterine or intrauterine, thus categorizing cesarean scar implantations as EPs. The term pregnancy of unknown location is used in the setting of a pregnant patient without evidence of a definite or probable IUP or EP at transvaginal US. Since cardiac development is a gradual process and cardiac chambers are not fully formed in the first trimester, the term cardiac activity is recommended in lieu of 'heart motion' or 'heartbeat.' The terms 'living' and 'viable' should also be avoided in the first trimester. 'Pregnancy failure' is replaced by early pregnancy loss (EPL). When paired with various modifiers, EPL is used to describe a pregnancy in the first trimester that may or will not progress, is in the process of expulsion, or has either incompletely or completely passed.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are peptide analogues that are used to treat type 2 diabetes mellitus (T2DM) and obesity. The first medication in this class, Exenatide, was approved in 2005, and these medications, specifically Semaglutide, have become more popular in recent years due to their pronounced effects on glycemic control, weight reduction, and cardiovascular health. Due to successful weight loss from these medications, many women previously diagnosed with oligomenorrhea and unable to conceive have experienced unplanned pregnancies while taking the medications. However, there is currently little data for clinicians to use in counseling patients in cases of accidental periconceptional exposure. In some studies examining small animals exposed to GLP-1RAs in pregnancy, there has been evidence of adverse outcomes in the offspring, including decreased fetal growth, skeletal and visceral anomalies, and embryonic death. Although there are no prospective studies in humans, case reports, cohort studies, and population-based studies have not shown a pattern of congenital anomalies in infants. A recent large, observational, population-based cohort study examined 938 pregnancies affected by T2DM and compared outcomes from periconceptional exposure to GLP-1RAs and insulin. The authors concluded there was not a significantly increased risk of major congenital malformations in patients taking GLP-1RAs, although there was no information on maternal glycemic control or diabetic fetopathy. As diabetic embryopathy is directly related to the degree of maternal hyperglycemia and not the diagnosis of diabetes itself, it is not possible to make this conclusion without this information. Furthermore, there is little evidence available regarding fetal growth restriction, embryonic or fetal death, or other potential complications. At this time, patients should be counseled there is not enough evidence to predict any adverse effects, or the lack thereof, of periconceptional exposure of GLP-1RAs during pregnancy. We recommend that all patients use contraception to prevent unintended pregnancy while taking GLP-1RAs.

Background: Robotic-assisted laparoscopic surgery (RALS) has become a widely and increasingly used modality of minimally invasive surgery in the treatment of endometrial cancer (EC). Due to its technical advantages, RALS offers benefits, such as a lower rate of conversions compared to conventional laparoscopy (CLS). Yet, data on long-term oncological outcomes after RALS is scarce and based on retrospective cohort studies only.

Objectives: This study aimed to assess overall survival (OS), progression-free survival (PFS), and long-term surgical complications in EC patients randomly assigned to RALS or CLS.

Study design: This randomized controlled trial was conducted at the Department of Gynecology and Obstetrics of Tampere University Hospital, Finland. Between 2010 and 2013, 101 patients with low-grade EC scheduled for minimally invasive surgery were randomized preoperatively 1:1 either to RALS or CLS. All patients underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy. A total of 97 patients (49 in the RALS group and 48 in the CLS group) were followed up for a minimum of 10 years. Survival was analyzed using Kaplan-Meier curves, log-rank test, and Cox proportional hazard models. Binary logistic regression analysis was used to analyze risk factors for trocar site hernia.

Results: In the multivariable regression analysis, OS was favorable in the RALS group (HR 0.39; 95% CI, 0.15-0.99, p=.047) compared to the CLS group. There was no difference in PFS (log-rank test, p=.598). The three-, 5- and 10-year OS were 98.0% (95% CI, 94.0-100) vs. 97.9% (93.8-100), 91.8% (84.2-99.4) vs. 93.7% (86.8-100), and 75.5% (64.5-87.5) vs. 85.4% (75.4-95.4) in the CLS and the RALS group, respectively. Trocar site hernia developed more often in the RALS group compared to the CLS group 18.2% vs. 4.1% (OR 5.42, 95% CI, 1.11-26.59, p=.028). The incidence of lymphocele, lymphedema, or other long-term complications did not differ between the groups.

Conclusions: The results of this RCT suggest a minor OS benefit in EC after RALS compared to CLS. Hence, the use of RALS in the treatment of EC seems safe, but larger RCTs are needed to confirm the potential survival benefit of RALS. No alarming safety signals were detected in the RALS group since the rate of long-term complications differed only in the incidence of trocar site hernia.