Archives of Gynecology and Obstetrics最新文献

Purpose: The purpose of this study was to identify and determine the frequency and nature of near misses in pregnant women and in the postpartum period.

Methods: In the Turkestan region (Kazakhstan), a retrospective review of cases of critical situations and cases of maternal mortality that occurred during the 12 months of 2022 was conducted. 201 cases of critical conditions in obstetric-gynaecological practice that occurred in 22 regional institutions of all three levels of perinatal care were analysed.

Results: The causes of cases of near misses in the provision of medical care to pregnant women, maternity women, and women in labour were determined. 0.3% of maternal near misses from the total number of births were registered in the region, of which obstetric causes accounted for 58.2% and extragenital-41.8%.

Conclusion: It was found that cases of maternal near misses were 1.2 times more often recorded in the postpartum period compared to the antenatal period. A difficult situation regarding the management of the postpartum period has developed in institutions of the second level of perinatal care, where 62% of maternal near misses were observed in the postpartum period.

Introduction: PD1/PD-L1 inhibition (ICi) has recently become a new standard of care for patients with advanced MMR-deficient (MMRd) endometrial cancers. Nevertheless, response to immunotherapy is more complex than the presence of a single biomarker and therefore it remains challenging to predict patients response to ICi beyond MMRd tumors. Elevated PD-L1 expression (CPS ≥ 1) is often used as a prognostic marker as well as a predictive biomarker of response to ICi in different tumor types. In a retrospective, patient derived study, we analyzed PD1- and PD-L1 staining and correlated the results of different scores to clinical data to evaluate the prognostic impact of these scores.

Materials and methods: Immunohistochemical analysis of the receptor PD1 and the receptor ligand PD-L1 were performed on TMAs of primary paraffin‑embedded tumor samples. All patients were treated for primary endometrial cancer in the Department of Gynecology and Obstetrics, University Medical Center Schleswig-Holstein, Campus-Lübeck, Germany between the years 2006-2018. The evaluation and determination of the tumor proportion scoring (TPS), the combined positive score (CPS) and the immune cell scoring (IC) was automatically assessed semi-quantitatively, and results were correlated with clinicopathological characteristics and survival.

Results: 130 samples were evaluable and 64% showed a positivity (IC > 0) for the receptor PD1 and 56% for the receptor ligand PD-L1. Patients with a PD1 IC Score ≥ 1 showed a significant longer disease-free survival of 140 months (95% confidence interval (CI): 124-158) compared to patients with a lower IC < 1 for PD1 of 89 months (95% confidence interval (CI): 69-110); p = 0.017). Furthermore, the disease-free survival for patients with a CPS ≥ 5 for PD1 was longer (153.7 months (95% confidence interval (CI): 134-173.6) vs. 98.6 months (95% confidence interval (CI): 83-114); p = 0.036). Additionally, a PD1 CPS ≥ 5 showed a better overall survival but the result was not statistically significant. No difference in survival was found between patients with PD-L1 higher or lower than CPS 5.

Conclusion: In this study we pointed out that there are significant clinical differences among several immunohistochemical scoring systems. In our trial, a PD1-positivity with CPS ≥ 5 and IC ≥ 1 were significantly associated to a better disease-free survival while there was no association with TPS. The PD1-IC scoring was associated with MMRd while the TPS scoring was not. Therefore, PD1-IC could be more appropriate for endometrial carcinomas compared to TPS and could also add prognostic information beside the more established PD-L1-staining. Further prospective studies are needed for a validation of these scores in combination with other biomarkers.

Purpose: We aimed to determine fetal liver perfusion in PGDM and GDM pregnancies and to assess the relation of ductus venosus (DV) shunt fraction with adverse pregnancy outcomes.

Methods: We conducted a prospective longitudinal observational study including 188 pregnant women: group I-patients with pregestational DM (PGDM, n = 86), group II-patients with gestational DM (GDM, n = 44), group III-control (n = 58). The patients included in the study underwent ultrasound examination at 30⁺⁰-40⁺⁰ weeks of pregnancy. We evaluated volumetric blood flow adjusted to EFW (Q, ml/min/kg) for umbilical vein, DV, left and main portal vein. The relative risk was calculated for adverse pregnancy outcomes.

Results: In PGDM pregnancies, umbilical blood flow was redistributed to the fetal liver, increasing left portal and total liver volumetric blood flow (p < 0.001) compared with GDM and control groups. Pathological reduction in the DV shunt fraction (≤ 16.5%) was associated with an increased relative risk of preterm delivery (3.61 [95%CI 1.68; 7.71]), LGA-birth (1.64 [95% CI 1.26; 2.12]), neonatal adiposity (1.53 [95%CI 1.18; 1.98]), fetal hypoxia (3.47 [95%CI 1.34; 9.05]), emergency cesarean Sect. (1.93 [95%CI 1.26; 2.97]), and neonatal intensive care unit stay of more than 5 days (1.78 [95%CI 1.08; 2.93]).

Conclusion: Decreased DV shunt fraction reflects changes in fetal hemodynamics in PGDM-pregnancies and associated with an increased risk of adverse perinatal outcomes.

Purpose: To investigate the clinical characteristics and prognosis of surgically treated ovarian endometrioma (OMA) in pregnant women.

Methods: This retrospective cohort study analyzed 30 patients with pathologically confirmed ovarian endometrioma during pregnancy and delivery. Clinical characteristics and follow-up data were summarized.

Results: Among the 30 patients, 21 underwent laparoscopic surgery during pregnancy. A total of 24 OMAs were identified in 21 patients and exhibited various changes during pregnancy: 13 did not show significant changes, 10 increased in size and 1 decreased in size. The indications for surgery included suspicion of malignancy (16/21), large and progressive growth (3/21), and ovarian cyst torsion (2/21). The postoperative pathology results showed that decidualization occurred in 7 cases, while only 1 case was diagnosed with malignancy, and there appears to be a lack of specific clinical characteristics to distinguish between malignant cysts and de ci du a l I zed cysts. Of the 21 patients, 19 underwent successful follow-up. Among them, 2 cases were preterm births, 1 experienced recurrence, and 2 developed adenomyosis during long-term follow-up. Besides, 9 patients underwent cystectomy during the cesarean section. All the ultrasound findings showed regular and smooth-walled unilocular cysts, with diameters smaller than 6 cm and no apparent growth during pregnancy. Postoperative pathology revealed decidualization in 3 cases, and 1 case experienced recurrence during follow-up.

Conclusions: OMA presents various changes during pregnancy and caution should also be taken for recurrence after delivery. Surgical intervention is prompted mainly by suspected malignancies which is difficult to distinguish with decidualization, and laparoscopic surgery is relatively safe during mid-pregnancy.

Purpose: To evaluate the association between lateral placentation and adverse perinatal outcomes, including rates of small for gestational age (SGA) neonates, hypertensive (HTN) disorders, and preterm delivery, as well as postpartum hemorrhage and retained placenta.

Methods: This retrospective cohort study included all women with singleton pregnancies who underwent a trial of labor after reaching 24 weeks of gestation, at a single tertiary medical center, over a period of 6 years. The study group included women with lateral placentation. Controls were women with anterior, posterior, or fundal placentation. Power analysis indicated that 882 women in each group would be sufficient to detect an increased rate of the primary outcomes: preterm delivery, hypertensive disorders or SGA in the lateral placenta group. Secondary outcomes were Apgar score, cord pH and retained placenta.

Results: Overall, 1,817 (7.6%) women had lateral placenta and 21,991 (92.4%) anterior, posterior, or fundal placentation. No significant differences were observed between groups in the rates of hypertensive disorders, SGA or preterm birth. Lateral placentation was associated with a longer third stage of labor (11.1 ± 8.6 min vs. 10.4 ± 7.2 min, p = 0.001) and higher rate of retained placenta (5.7% vs. 4.2%, p = 0.002). Multivariate regression found that lateral placentation was independently associated with longer third stage of labor.

Conclusion: Lateral placentation was not associated with increased rates of hypertensive disorders, preterm birth or SGA infants. It was linked to a longer third stage of labor but without a significant impact on maternal or perinatal complications.

Purpose: The number of frozen-thawed embryo transfers (FETs) has recently increased, and FET must be completed in the ovulatory (NC-FET) or programmed hormone replacement cycle (HRC-FET). However, the relationship between FET and abnormal placentation is unclear. This study aimed to determine whether the two distinct endometrial preparation protocols affect the incidence of several pathologic conditions caused by abnormal placentation, such as placenta with velamentous umbilical cord insertion (VCI), hypertensive disorders of pregnancy (HDP), and placenta accreta spectrum (PAS).

Methods: For this retrospective cohort study, the medical records of 1,161 singleton term FET-conceived and -delivered cases were reviewed from January 2016 to July 2024. The study population was categorized into HRC-FET (Group A: n = 846) and NC-FET (Group B: n = 315) cases. After adjusting for confounding factors, the odds ratios (ORs) of the investigated targeted variables in Group A compared to Group B were calculated using multivariate logistic regression.

Results: The incidence of VCI and PAS in Groups A and B was 7.0% and 2.5% for VCI and 5.1% and 1.0% for PAS, respectively, with a significant difference (P < 0.01). The adjusted ORs for VCI, PAS, and HDP in Group A compared to those in Group B were 3.07 (P < 0.01), 5.73 (P < 0.01), and 1.24 (P = 0.42), respectively.

Conclusion: Pregnancies achieved through HRC-FET have higher risks of developing abnormal placentation (i.e., VCI and PAS) than those achieved through NC-FET. These pregnancies are high risk and should be managed carefully for a healthy perinatal course.

Introduction: Preterm birth remains a global health challenge with significant perinatal morbidity and mortality rates. Despite extensive research, the underlying mechanisms triggering preterm birth remain elusive, needing a deeper understanding of cervical cellular remodelling processes.

Purpose: This study aims to elucidate the cellular mechanisms underlying cervical remodelling in spontaneous preterm labour (PTL) compared to term labour (TL), focusing on the roles of inflammatory cells and fibroblasts.

Methods: We conducted a prospective observational study from October 2018 to March 2021, at two hospitals. Participants were categorized into two groups: PTL (n = 14), TL (n = 14). A small set (n = 6) of preterm not in labour (PTnotL) was also included. Cervical biopsies were obtained and analysed for the density of fibroblasts and inflammatory cells (neutrophils and mononuclear cells) using digital image analysis. Statistical analysis was performed employing Mann-Whitney and Kruskal-Wallis tests.

Results: There was no significant overall difference in global inflammatory cell density between PTL and TL (p = 0.154). However, a detailed analysis revealed significantly higher inflammation in the exocervix of PTL compared to TL, particularly involving neutrophils (p = 0.021) and mononuclear cells (p = 0.028). Neutrophils (p = 0.035), but not mononuclear cells (p = 0.111), were significantly decreased in PTnotL exocervix compared to PTL. No differences were found in inflammatory cell density in the endocervix. Fibroblast densities were similar across groups.

Conclusions: This study highlights the distinct cellular profiles in the cervix during preterm and term labour, with neutrophils playing a pivotal role in preterm labour. These findings may guide the development of targeted interventions to prevent preterm birth.

Purpose: To determine the rate of precancer and cancer in women presenting with PMB who have a visually atrophic endometrium at hysteroscopy and assess the value of endometrial biopsy in this situation and the adequacy of the samples obtained.

Methods: Retrospective reviews of all patients with a visually atrophic endometrium at hysteroscopy who had presented with PMB and had an ET > / = 4 mm or ET < 4 mm with focal changes or irregular features between 2013 and 2024 at University Hospitals of Derby and Burton were included (n = 1096). Patients who had previously had cancer or precancer or had unclear hysteroscopy findings were excluded. The endometrial biopsy histology result was considered the main outcome measure.

Results: 188 patients did not have a biopsy performed (17.15%), 660 patients had benign pathology (60.22%), and 239 patients had an inadequate sample result (21.81%). Nine patients had precancerous changes (0.82%). The rate of cancer was 0.00% (n = 0). The NPV of a visually atrophic endometrial cavity at hysteroscopy in detecting precancer or cancer was 99.2%. Patients with an ET < 4 mm pre-hysteroscopy and an atrophic endometrial cavity at hysteroscopy were 2.25 times more likely than those whose ET is > 4 mm to have an inadequate sample (p < 0.001, 95% CI 1.61-3.16). 10 patients who had an inadequate sample at initial biopsy had a repeat inadequate sample (n = 23, 43.48%).

Conclusions: The incidence of precancer/cancer in patients presenting with PMB with a visually atrophic endometrium at hysteroscopy is low. Many patients within this cohort have an inadequate sample at biopsy, and therefore, repeat sampling is of questionable value.

Purpose: The application of narrow-band imaging for missed early miscarriage treatment remains unclear. This study determined the application advantages of NBI combined with hysteroscopic 7Fr cold knife embryo removal for treating missed early miscarriage.

Methods: A retrospective selection of 208 patients who were hospitalized for missed early miscarriage at Hubei Provincial Maternal and Child Health Hospital from January 2023 to June 2023 were included. The patients were divided into three groups according to the treatment methods: Group A (medical abortion), Group B (NBI combined with hysteroscopic 7Fr cold knife), and Group C (ultrasound-guided vacuum aspiration). The clinical data of the three groups were analyzed, and endometrial recovery after treatment was compared to identify risk factors affecting complications after treatment for missed early miscarriage.

Results: The endometrial thickness was greatest in Group A and thinnest in Group C two weeks post-treatment. Group B had the earliest menstrual recovery and the lowest intrauterine residual and intrauterine adhesion incidences. The pregnancy termination method was the only independent risk factor for intrauterine adhesions after treatment. The time to menstrual recovery after treatment, the serum beta-human chorionic gonadotropin level at 2 weeks post-treatment, and the endometrial thickness had predictive value for intrauterine retention. The combined prediction of the above indicators showed high accuracy.

Conclusion: The use of NBI combined with hysteroscopic 7Fr cold knife embryo removal in patients with missed early miscarriage results in a lower risk of intrauterine residuals and IUA than ultrasound-guided vacuum aspiration and medical abortion. This approach leads to earlier menstrual recovery and protects the endometrium.

Purpose: Despite the advent of the ERAS Program, recovery after urogynecological surgery is still a highly debated topic in clinical practice. The majority of gynecologic surgeons, in fact, continue to advise patients to home rest and to avoid lifting heavy objects after surgery. The aim of the present study was to verify the impact of a moderate-high physical activity and recovery after surgery on anatomical results after LSC, with a 2-year follow-up (FU).

Methods: Two hundred and one consecutive patients with pelvic prolapse were retrospectively selected from our database among women who underwent, from October 2019 to February 2022, a laparoscopic sacral colpopexy. Three-six and 24 months follow-up were studied. At 3 months, patients completed the IPAQ-SF Questionnaire to assess physical activity. According to IPAQ-SF, patients were divided in two arms: Low and Moderate-High activity level.

Results: At 3 months follow-up, we obtained a high anatomic success rate in absences of statistical differences between populations, with a significative persistence of these results even at 6 and 24 months. No differences were found in terms of subjective success and vaginal mesh erosions at 3-6 months and 2-years follow-ups between patients despite differences in IPAQ-SF activity levels.

Conclusion: Our data highlight the need for urogynecologists, especially after LSC, to invest heavily in patient education and to shift away from the outdated concept of home rest after surgery.