Archives of Gynecology and Obstetrics最新文献

Purpose: Uterine fibroids are the most common pelvic tumors in women, representing the primary indication of hysterectomy. Gonadotropin-releasing hormone (GnRH) antagonists represent a new therapeutic option for premenopausal women. The aim of this review is to evaluate the efficacy and safety of GnRH antagonists in the treatment of uterine fibroids (size reduction and symptom control).

Methods: A review of studies from electronic databases (PubMed and Cochrane Central) published up to December 2023 was performed. Eleven randomized clinical trials with a total of 4164 patients were included in the review, which evaluated GnRH antagonists (Relugolix, Elagolix, Linzagolix and Cetrorelix) against placebo or GnRH agonists in premenopausal women with uterine fibroids and heavy menstrual bleeding.

Results: The results of the measures evaluated to determine the efficacy and safety of GnRH antagonists versus placebo are favorable for the variables of control of uterine bleeding (Relative risk (RR) = 5.09; 95% CI 3.19 to 8.14), percentage reduction of fibroid volume (Mean difference (MD) = -27.36; 95% CI -38.89 to -15.83) and lower reduction of bone density (MD -0.35; 95% CI -0.47 to -0.24). The results do not allow us to conclude whether there are differences between the alternatives compared in the control of vasomotor symptoms.

Conclusions: GnRH antagonists represent an effective alternative for uterine fibroids treatment as they allow a superior reduction in menstrual bleeding and uterine fibroid volume compared to the placebo group.

Objective: This systematic review aims to evaluate the impact of microplastics on female reproductive health by analyzing experimental studies.

Method: A comprehensive search was conducted in PubMed, Web of Science, and Scopus databases to identify experimental studies published between 2021 and 2023. Studies investigating the effects of microplastics on reproductive organs, hormone levels, fertility rates, and offspring development in female subjects were included. The quality of the studies was assessed using the Cochrane risk of bias tool.

Results: A total of 15 studies met the inclusion criteria. The results indicate that exposure to microplastics significantly affects ovarian function, decreases fertility rates, and disrupts hormone levels in female subjects. Several studies also reported negative effects on embryo development and offsprings health. The quality of the studies varied, with some showing a high risk of bias.

Conclusion: The evidence from experimental studies suggests that microplastics have a detrimental effect on female reproductive health. However, the variation in study quality highlights the need for more rigorous research to confirm these results and better understand the underlying mechanisms.

Objectives: To produce standards of references for quality control and assess the reproducibility of fetal ultrasound Doppler measurements commonly used for blood flow assessment in fetal growth.

Methods: Women with singleton normal pregnancies were prospectively recruited at University College London Hospital, UK, between 24 and 41 weeks. Umbilical artery (UA), middle cerebral artery (MCA), and their pulsatility indices (PI), resistance indices (RI) and ratios such as cerebro-placental (CPR) and umbilical cerebral ratio (UCR) were obtained twice by two sonographers in training or after completion of training, blind to each other's measurements. Bland-Altman plots were generated, the mean differences and 95% limits of agreement (LOA) were calculated to assess intra- and interobserver reproducibility. Values were expressed as absolute values or as z-score.

Results: One hundred ten women were recruited. Overall reproducibility was variable for absolute values and highly variable for z-scores, independently from vessel sampled, index or ratio used, intra- or interobserver reproducibility. The widest absolute values of 95% LOA were 0.3 for UA PI, 0.7 for MCA PI, 0.9 for CPR and 0.3 for UCR, respectively. Regarding z-score, the widest 95% LOA were 1.9 for UA PI, 2.1 for CPR and 1 for UCR. Reproducibility was slightly better for intra- compared with interobserver variability. There was significant difference in z-score reproducibility between MCA peak systolic velocity and CPR vs UCR.

Conclusions: Reference standards of reproducibility of fetal Doppler parameters are produced for standardization and quality-control purposes. Overall, the reproducibility for fetal Doppler parameters was variable independently from vessel sampled, Doppler index (PI or RI) or ratio used, intra- and interobserver comparison. UCR was the most reproducible parameter which should be recommended, together with UA PI, for clinical use and in research studies on fetal growth.

Objectives: Congenital thoracic masses (CTMs) are suspected in presence of solid or cystic thoracic lesions at ultrasound. The common typical fetal CTMs encompass: hyperechogenic lung lesions such as congenital pulmonary airway malformation (CPAM), broncopulmonary sequestration (PS) and congenital high airway obstruction syndrome (CHAOS); less common solid thoracic masses are mediastinal/pericardial tumors as rhabdomyoma and teratoma. The aim of our study is to gather the available evidence on cases of atypical CTMs of difficult classification, for which the diagnosis remains often uncertain.

Methods: A review of the literature on the prenatal diagnosis of CTMs was performed, focusing on ultrasound features, postnatal manifestation, treatment and neonatal outcome. Inclusion criterion was prenatal diagnosis of CTM cases with difficult classification in six typical categories. A summary of results was carried out.

Results: The literature review included six studies in the analysis. Two cases experienced intrauterine fetal death, one with hydrops in rhabdomyoma and another one for a rapid growth of the mass, with autopsies precising the diagnoses. In two other instances, surgery after birth provided also different histologic diagnoses. All surviving children were asymptomatic at follow-up. One case with rhabdomyoma and another one with atypical pericardial teratoma showed spontaneous regression. Moreover we are presenting our unpublished case of an atypical mass diagnosed as rhabdomyoma or broncopulmonary sequestration.

Conclusions: Some masses may present atypical presentation of a known disease or we may face rare diagnosis for which there is lack of information in the literature. The definitive diagnosis still relies on histologic analysis.

Purpose: To investigate an optimal strategy by assessing the effectiveness of varying follicular sizes on trigger day during luteal phase stimulation protocol and provide evidence for personalized protocol adjustment.

Methods: This was a retrospective study including a total of 661 patients who had started their in vitro fertilization cycle with a luteal phase stimulation (LPS) protocol during 2015-2023. We classified patients into groups according to the size of the dominant proportion of follicles on the human chorionic gonadotropin (hCG) trigger day: large, medium, and small. The metaphase II (MII) oocyte rate, immature oocyte rate, two pronuclei (2PN) fertilization rate, and available embryo rate were compared between groups. General linear model (GLM) analysis was performed for inter-group comparison of the oocyte and embryo quality.

Results: There was a statistically significant difference in the immature oocyte rate between the three groups (p = 0.005), with the Large group having the lowest immature oocyte rate and the Small group having the highest immature oocyte rate, and there was no difference in MII oocyte rate among the three groups. As for the 2PN fertilization rate, there was a statistical difference among the three groups, with the highest 2PN fertilization rate in the Large group and the lowest in the Small group. However, there was no statistically significant difference in the available embryo rate among the three groups. The GLM analysis suggested that different follicle sizes on the trigger day influenced the immature oocyte rate and the 2PN fertilization rate. But among the young women, applying different follicle sizes on the trigger day of the LPS regimen did not influence the oocyte and embryo quality, while in older women it affected the 2PN fertilization rate.

Conclusion: Triggering when there is a high proportion of large follicles results in lower immature oocyte rate and higher 2PN fertilization rate when applying LPS protocol. However, age is a factor to be considered and the timing of triggering needs to be decided in clinical application with consideration of age and the actual situation.

Background: sFLT-1 has been implicated in the pathogenesis of HDP. We aimed to examine the role of maternal and fetal polymorphisms in risk of HDP and severe-spectrum disease.

Methods: Cases of HDP (143) and controls (169) from mother-baby dyads were recruited at the Los Angeles County Women's and Children's Hospital (WCH). Cases of severe disease (99) and controls (31) from mother-father-baby triads were recruited through HELLP syndrome websites. Four sFLT-1 SNPs (rs7993594, rs3751395, rs7983774, and rs664393) were genotyped. Data was analyzed using a log-linear regression model in the Haplin package in R.

Results: Maternal double dose of the A allele (rs7993594) exhibited a nominally significant increased risk of HDP (RR = 3.52, 95% CI 1.08, 11.20). In the severe-spectrum cohort, a marginally significant protective effect among mothers carrying infants with a single dose of the A allele (rs7993594) was observed (RR = 0.59, 95% CI 0.36, 0.98) and double-dose maternal carriage of the G-t-G-G haplotype increased risk of severe disease (RR = 4.13, 95% CI 1.22, 13.80).

Conclusion: The maternal rs7993594 A allele appears to be associated with increased risk of HDP. Double-dose maternal carriage of the G-t-G-G haplotype increased risk of severe disease whereas the fetal rs7983774 A allele appears to be associated with decreased risk.

Background: There is frequent academic exchange between Switzerland, Germany and Austria, facilitated by the common language. Additionally, the postgraduate training curricula in obstetrics and gynecology show some similarities. We aimed to compare self-perceived level of ability, availability of simulation training and teaching and feedback culture among residents in obstetrics and gynecology in Switzerland, Germany, and Austria. The focus was on Switzerland to gain a better understanding of strengths and room for improvement.

Methods: With a cross-sectional design, a web-based survey with 30 questions was distributed to obstetrics and gynecology residents in the three countries in August and September 2020. The primary outcome was the self-perception of skills in between-country comparisons of mid-training trainees, i.e., omitting trainees in their first year as well as very advanced trainees and specialists. The secondary outcomes were reported teaching, simulation training and feedback culture. German and Austrian responses were calculated together and compared with the Swiss replies.

Results: A total of 422 participants took part in the survey, 27.5% (n = 116) of whom were from Switzerland, corresponding to a questionnaire response rate of approximately 19%. 48% of Swiss trainees were in training years 2-5. 57% of Swiss participants felt confident in obstetric procedures and 69% in gynecological procedures, compared to 52% and 68% of non-Swiss participants (p = 0.005 and p = 0.176, respectively). Swiss participants felt significantly more confident in performing gynecological than obstetric procedures (p = 0.015). A total of 63% of the Swiss participants had obstetric simulation training, and 28% had gynecological simulation training compared to 37% and 17% in Germany and Austria, respectively (p < 0.001 and p = 0.007). 56% of Swiss participants reported "sufficient structured teaching", 43% reported a "good teaching culture", 47% of Swiss participants stated that they received regular feedback.

Conclusions: The majority of trainees in Switzerland feel confident in a range of procedures and interventions. Simulation training is relatively widespread, although in particular surgical simulation training should be expanded. Clinical teaching and feedback culture should be strengthened. "Teach the teacher" courses should be encouraged to promote a sustainable feedback culture.

Purpose: To provide a comprehensive understanding and propose a strategy for the management of extragonadal malignant germ cell tumors (EMGCTs) arising from extracranial and nonvaginal sites.

Methods: We retrospectively reviewed the cases of 12 patients with EMGCTs arising from extracranial and nonvaginal sites treated in our center over the past 38 years. Data on clinicopathological characteristics, treatment modalities, and follow-up information were analyzed.

Results: Among 209 patients diagnosed with EMGCTs, 12 women (5.7%) with EMGCTs of extracranial and nonvaginal sites were identified. These patients had tumors in the sacrococcygeal region (n = 4), abdominal cavity (n = 3), groin region (n = 2), uterus (n = 2), and mediastinum (n = 1). The median age at diagnosis was 23 years. Symptoms included abnormal uterine bleeding (n = 3), abdominal discomfort (n = 3), compression symptoms (n = 3), palpable mass (n = 2), and asymptomatic (n = 1). Yolk sac tumors (YSTs) were the most common histologic type. The median level of serum alpha-fetoprotein (AFP), a sensitive tumor marker, was 8216 ng/ml (2.7-74,157 ng/ml). One patient started bleomycin/etoposide/cisplatin without a pathologic diagnosis based on clinical diagnosis (high AFP levels and imaging findings), and 11 patients started chemotherapy following tumor biopsy or surgical resection. During the follow-up, one patient suffered a recurrence, two patients were alive with disease, and nine patients were disease-free.

Conclusions: Extracranial and nonvaginal EMGCTs are a heterogeneous group of tumors due to their varied onset ages, location, and clinical presentation. An all-around clinical evaluation is crucial for selecting appropriate treatment. Most patients achieve a good prognosis after surgical resection and chemotherapy. Patients with these rare diseases may benefit from individualized treatment and timely referral to experienced medical centers.