Archives of Gynecology and Obstetrics最新文献

Background

Vulvar carcinoma (VC), a rare cancer, recurs in over a third of women, usually within 2 years. Treatment options other than repeat surgery and radiotherapy are often required in the recurrence setting. Systemic chemotherapy is an option but is generally associated with stressful side effects. In the palliative setting, electrochemotherapy (ECT) is a better-tolerated alternative, which provides local tumor control while obviating systemic side effects.

Objective

To descriptively analyze a case series of patients with inoperable locally advanced or locoregionally recurrent VC receiving bleomycin-based ECT.

Methods

Descriptive analysis of prospectively collected data from a case series. Postmenopausal women with locally advanced or locoregionally recurrent VC were eligible for inclusion. Bleomycin was administered at 15 mg/m² body surface as a single 1-min intravenous injection; 8 min later, electrochemical treatment using sterile disposable electrodes was performed under anesthesia for ≤ 30 min. Postoperatively, patients received pain medication to mitigate muscle soreness.

Results

15 patients were included in the study. Median patient age at ECT was 81 (range, 51–100) years. Recurrences (1–5) were present in 12 patients. Surgery and radiotherapy were not justifiable options in 3 patients. In our clinical observation, ECT was well tolerated by all patients for the management of pain, itching, odor, and secretion. This allowed for time to be gained until further treatment became necessary or disease progression occurred.

Conclusions

In our clinical experience, bleomycin-based ECT is an oncologically efficacious and better-tolerated alternative to systemic chemotherapy or immunotherapy in patients with recurrent VC in a palliative setting with limited capacity to undergo treatment.

Objective

To evaluate current diagnostic criteria, risk stratification, and management practices for fetal intra-abdominal umbilical vein varix (FIUVV) among maternal–fetal medicine and obstetric ultrasound specialists in Israel.

Methods

A national web-based survey was distributed to specialists, collecting data on diagnostic parameters, classification of severity, surveillance protocols, and delivery timing recommendations. Responses were analyzed descriptively.

Results

45 specialists (85% response) from 18 centers participated. Diagnosis was most commonly based on FIUVV diameter, with 9 mm the most frequent cutoff, though substantial variation in criteria existed. Severity assessment relied mainly on vessel diameter, flow abnormalities, and thrombus presence. Most respondents recommended detailed anatomical survey and fetal echocardiography. Surveillance and delivery timing recommendations were tailored to risk level, with earlier induction and increased surveillance favored in high-risk cases. However, considerable variability existed among respondents regarding both the frequency of monitoring and the timing of delivery.

Conclusions

Considerable heterogeneity exists in FIUVV diagnosis and management in Israel. Consensus definitions and standardized protocols are needed to improve clinical care and enable comparative research.

Purpose

Impacted fetal head at full-dilation cesarean delivery (CD) is a major cause of adverse maternal and neonatal outcomes. The Fetal Pillow is a device designed to reduce these complications. Our study aims to evaluate the outcomes of full-dilation CD with and without the use of Fetal Pillow.

Methods

This retrospective cohort study included full-dilation CDs performed from January 2018 to July 2023, at a single tertiary center. Indications for CDs were arrest of decent, fetal distress, and failed vacuum extraction. The study cohort included cases (Fetal Pillow group) matched to controls (without the use of Fetal Pillow) according to the indication to CD, in a 1:2 ratio. The study evaluated maternal outcomes as uterine incision extensions, maternal blood loss (ml), maternal postoperative infection, and length of hospitalization (days). Neonatal outcomes included NICU admissions, cord arterial blood pH, Apgar scores, respiratory distress, intubation, and seizures.

Results

The study included 138 patients, of them 46 in the Fetal Pillow group and 92 matched controls. Maternal baseline characteristics, including age, BMI, prior CDs, and obstetric complications, were similar between groups. No significant differences were observed in median surgery duration [55 (44–68) vs. 54 (42–65) min; p = 0.361] or fetal extraction time [6 (4–8) vs. 5.5 (3–8) min; p = 0.507]. Maternal outcomes, including rates of uterine incision extensions, blood loss, and length of hospitalization, were comparable between groups. However, NICU admissions were significantly lower in the Fetal Pillow group compared to controls (17.3% vs. 33.7%, p = 0.04). In multivariable logistic regression analysis, adjusting for parity, fetal head station and position, maternal age, prior CD, and neonatal birth weight, Fetal Pillow use was associated with reduced NICU admissions [adjusted odds ratio (aOR) 0.30; 95% CI 0.11–0.82; p = 0.019].

Conclusion

The use of Fetal Pillow for impacted fetal head during full-dilation CDs may reduce NICU admissions without adversely affecting maternal outcomes.

Objectives/hypothesis

Severe fetomaternal transfusion due to an unrecognized chorangioma in a dichorionic, diamniotic twin pregnancy: case report and review of the literature.

Study design

Case report and retrospective narrative review.

Methods

Evaluation of 8 case reports.

Case report

A 32-year-old primigravida with dichorionic, diamniotic twin pregnancy developed growth discordance and hypertension. At 35 weeks, cesarean delivery revealed one viable twin and one severely anemic twin who died immediately postnatal. Fetomaternal transfusion was suspected, confirmed, and most likely caused by a 6 cm chorangioma.

Conclusion

Fetomaternal hemorrhage is a serious but underrecognized complication and can be caused of placental chorioangiomas, among other things. Although rare, it poses significant risks of fetal anemia and perinatal morbidity. Increased awareness and routine Doppler monitoring of at-risk fetuses may facilitate earlier diagnosis and timely intervention, potentially improving outcomes. Particularly in children with anemia, fetomaternal transfusion should always be considered and HbF material determined.

Purpose

In our previous studies, differences in the upper airway inner diameter between fetuses with thoracic space occupying lesions and normal fetuses were found, but their clinical value has not been further validated. We designed a prospective case–control animal experiment to validate its prognostic value in congenital diaphragmatic hernia (CDH).

Methods

Using Nitrofen to create a fetal SD-rat model of CDH. Calculate the upper airway inner diameter and lung parameters of fetal rats on ultrasonic image and histology sections, and calculate the correlation between the upper airway and lung parameters. Design experiments to rule out the impact of major cardiac malformations on airway development, the correlation between the upper airway inner diameter and the area of CDH was also calculated.

Results

There was no significant difference in lung and upper airway parameters between the control group and the group with unsuccessful CDH modeling. The upper airway and lung parameters of fetal rat with CDH were significantly smaller than those without CDH (p < 0.01). The correlation between upper airway inner diameter and lung volume is better than that with lung weight, especially the upper airway inner diameter measured on ultrasound images (p < 0.01, R = 0.76). In the CDH group, the airway lumen diameter was inversely correlated with the hernia area (p = 0.005, R = 0.507).

Conclusions

The upper airway inner diameter of fetal rat was correlated with lung volume, demonstrating the potential predictive value for fetal prognosis of congenital diaphragmatic hernia.

Research question

To what extent have fertility preservation interventions evolved between 2014 and 2023, and what factors have influenced changes in their utilization and prevalence?

Design

Based on the FertiPROTEKT registry, comprising 163 centres across Germany, Austria, and parts of Switzerland, the quantitative development of ovarian stimulation for oocyte cryopreservation and ovarian tissue cryopreservation was evaluated from 2014 to 2023. Analyses were stratified according to the kind of participating centre, patient age, and the spectrum of underlying diseases. In addition, data were statistically compared for the periods 2014/2015 (P1) and 2022/2023 (P2).

Results

Approximately 14,000 women received counselling across all three countries between 2014 and 2023. Among these, 3,996 females underwent ovarian stimulation for oocyte cryopreservation, and 3,478 underwent ovarian tissue cryopreservation. The number of oocyte cryopreservation cycles increased substantially from P1 to P2, whereas the number of ovarian tissue cryopreservation procedures remained relatively stable. The increase in oocyte cryopreservation was substantially greater in private centres (197% increase: 308 to 916 cycles) compared to public institutions (39% increase: 818 to 1,136 cycles; p < 0.001). The rise in oocyte cryopreservation cycles parallels an increase in breast cancer cases presenting for fertility preservation; this temporal coincidence suggests a potential association but does not establish causation. The predominance of breast cancer patients also influenced the age distribution of oocyte cryopreservation cases. Among oocyte cryopreservation procedures, absolute numbers increased across all age groups up to 40 years, with the largest absolute increase in women aged 31–40 years (212 to 732 cycles, 245% relative increase).The overall age distribution of procedures changed only slightly, although younger patients were more likely to undergo ovarian tissue cryopreservation. Additionally, new indications such as endometriosis and gender dysphoria have become increasingly relevant over the past 5 years.

Conclusion

The number and distribution of fertility preservation procedures have changed notably during the last decade, driven primarily by shifts in the reimbursement strategies and the type of centres providing care. These developments should be carefully considered in the future design and implementation of fertility preservation programmes. However, decisions regarding specific fertility-preserving interventions must also be guided by scientific evidence.

A relevant proportion of malignancies predominantly or exclusively affecting women, including breast and gynecologic cancers, is attributable to hereditary tumor syndromes, profoundly impacting cancer risk, prognosis, and therapeutic management. Today, the routine use of comprehensive germline panels has shifted the focus from solely pathogenic BRCA1/2 variants to include numerous pathogenic variants of other high- and moderate-risk genes. A broad spectrum of genetic alterations has been identified as causative for Hereditary Breast and Ovarian Cancer syndrome (HBOC), encompassing not only BRCA1 and BRCA2, but also PALB2, ATM, BARD1, CHEK2, BRIP1, RAD51C, and RAD51D. Beyond HBOC, numerous additional hereditary tumor syndromes are of significance in senologic and/or gynecologic oncology, including Li-Fraumeni syndrome, Lynch syndrome, DICER1 syndrome, Hereditary Diffuse Gastric Cancer, Neurofibromatosis type 1, Peutz-Jeghers syndrome, PTEN hamartoma tumor syndrome, Tuberous Sclerosis, and pathogenic variants in NBN and SMARCA4. Affected individuals are offered specialized surveillance to enable early detection or even prevention of cancer. In addition to regular clinical examinations and imaging, preventive strategies may include risk-reducing surgery. Pathogenic germline variants also influence therapeutic management of cancer patients. For specific indications, targeted therapies are available, for example PARP [poly (ADP-ribose) polymerase] inhibitors for pathogenic BRCA variant carriers across multiple tumor entities. Optimal management requires interdisciplinary coordination, encompassing genetic counseling, early detection, and risk-reducing strategies within specialized centers. This review provides a comprehensive overview of hereditary tumor syndromes predisposing to breast and gynecologic malignancies, with a focus on genetic basis, associated cancer risks, and implications for clinical management. By delineating these syndromes, it aims to assist clinicians in recognizing hereditary cancer predisposition and in guiding affected individuals within routine senologic and gynecologic practice.

Purpose

To determine whether doula support during primiparous deliveries reduces the rate of perineal injury including obstetric anal sphincter injury (OASI).

Methods

A retrospective cohort study was conducted at a single, tertiary university-affiliated medical center. This study included all primiparous women between the ages of 18 and 45 who underwent a vaginal delivery with a singleton pregnancy at term between January 2020 and January 2024. The study group consisted only of women with explicit documentation of doula presence during labor. The control group consisted of women with explicit documentation of no doula presence in the medical records. Maternal and obstetrical parameters were analyzed and compared between groups. Multivariate regression analysis was employed to assess factors associated with perineal injury.

Results

Overall, 5866 primiparous women were included: 4,583 in the routine care group and 1283 with a doula support. Parturients in the doula group were older (32.5 vs. 30.7 years, p < 0.001) with lower rate of epidural analgesia (77.6% vs. 86.9%, p < 0.001). Women with doula support had slightly lower rates of overall perineal injury (91.2% vs. 92.9%, p = 0.041), a lower incidence of episiotomy (35.9% vs. 39.5%, p = 0.022), but no significant differences in the rates OASI (0.94% vs 1.1%, p = 0.630).

Multivariate regression analysis revealed that doula support was not associated with a significant reduction in perineal injury. Epidural use (OR 1.571, p < 0.001), high birthweight (OR 2.649, p < 0.001), and vacuum extraction (OR 6.736, p < 0.001) were identified as significant contributors to perineal injury.

Conclusions

In primiparous births, doula support was not independently associated with lower overall perineal injury. Perineal protection likely depends on mechanical and clinical factors rather than continuous support alone.

Purpose

This study aimed to investigate the acute effects of pelvic floor muscle training (PFMT) on vaginal dryness in postmenopausal women using an objective measurement method within the framework of a randomized controlled trial.

Methods

This randomized controlled pilot study included postmenopausal women who were allocated into two groups: a PFMT group (n = 45) and a control group (n = 58). The PFMT group performed a single set of exercises in the lithotomy position, consisting of 10 slow and 10 fast pelvic floor muscle contractions. The control group received no intervention.

The primary outcome was vaginal dryness, assessed objectively using the Vaginal Lubrication Kit (VLK). Secondary outcomes included Visual Analog Scale (VAS) scores for vaginal dryness, burning, and dyspareunia, as well as smear test results. Associations of baseline VLK and VAS scores with smear test findings were analyzed. Pre- and post-treatment differences, as well as between-group comparisons, were evaluated using parametric and non-parametric tests, with a 95% confidence interval.

Results

Of the 105 women randomized, 103 completed the study. Baseline characteristics did not differ significantly between groups (p > 0.05). Following the intervention, the PFMT group demonstrated statistically significant improvements in VLK scores (p < 0.05). Baseline VAS scores were statistically significantly negatively correlated with the initial VLK score (VAS vaginal dryness, VLK r: −0.571, VAS vaginal burning, VLK r: −0.451, VAS dyspareunia, VLK r: −0.460, p < 0.05). In addition, the presence of atrophy in the pre-treatment smear test was found to be statistically significantly negatively correlated with the initial VLK score (r: −0.346, p < 0.05).

Conclusions

PFMT significantly reduced vaginal dryness in postmenopausal women compared with the control group. It may be considered a potential treatment option for vaginal dryness. The VLK appears to be a promising objective tool for both assessing vaginal dryness and monitoring treatment outcomes in postmenopausal women. Although these findings are promising, they should be interpreted with caution given the pilot design and the short follow-up. Larger randomized trials are needed to confirm the long-term efficacy of PFMT and to validate the VLK as an objective outcome measure.