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As obstetric services disappear from rural communities, family physicians are increasingly asked whether operative maternity care remains part of their role. This reflection argues that maintaining cesarean delivery capacity is not an expansion of scope, but a commitment to continuity and to remaining present for patients at moments of greatest vulnerability. Drawing on rural clinical experience, this essay explores how trust, built over time, extends into the operating room, where continuity takes on a different but no less essential form. It also considers the ethical implications of physicians stepping away from operative obstetrics, as individual decisions accumulate into system-level loss for communities with limited alternatives. In this context, operative obstetrics emerges not only as a technical skill, but as a means of preserving access, accountability, and relational care within family medicine.
Persistent patient safety issues in low-resource hospitals are often underreported, delaying corrective actions and increasing preventable harm. This project aimed to implement a low-cost, structured weekly reporting system to improve patient safety processes and outcomes across departments at a tertiary hospital in Phnom Penh, Cambodia. A one-page Departmental Wise Checklist was introduced in the emergency room/intensive care unit (ER), obstetrics and gynaecology, outpatient department and paediatrics. Weekly reviews, feedback loops and departmental champions supported consistent reporting and follow-through. Implementation emphasised planning, stakeholder engagement, iterative refinement through Plan-Do-Study-Act (PDSA) cycles and integration into routine workflows. Challenges including resistance to extra work, inconsistent submissions and escalation fatigue were addressed through simplified checklists, coaching and departmental champions, while oversight from the hospital quality improvement committee ensured accountability. After 3 months, process measures showed substantial change: formally adopted Standard Operating Procedures (SOP) increased from 0 to 10, Basic Life Support-trained ER staff rose from 38% to 98%, incidents of expired blood products fell from 2 per month to none and reporting compliance averaged 92%. Concurrently, patient-level outcomes demonstrated change: monthly cases of neonatal hypothermia decreased from 6 to 2 and ER adverse events dropped from 4 to 1. These findings suggest that structured weekly reporting, combined with iterative feedback and active departmental engagement, may be associated with strengthening patient safety and accountability in low-resource settings. Long-term sustainability of these improvements is likely to depend on embedding the process into routine quality assurance activities, ongoing staff training and continued leadership oversight. However, sustainability beyond the 12-week intervention period has not yet been empirically assessed. The approach may provide a practical model for consideration and adaptation in similar low- and middle-income country hospitals, subject to local context and resources.
The Illinois Perinatal Quality Collaborative (ILPQC) aims to enhance perinatal care in Illinois. However, up to 50% of women do not attend postpartum care. This study assessed the impact of universal screening for social determinants of health (SDoH) during labor and delivery on postpartum care attendance. A retrospective chart review was conducted for women who delivered at a large academic medical center. The study received exempt status from Loyola University Institutional Review Board. Universal SDoH screening was implemented in March 2022. Data were collected from a control group (six months pre-implementation) and an intervention group (six months post-implementation). The primary outcome was attendance at both scheduled postpartum visits. Comparisons were made using Pearson chi-square for categorical variables and ANOVA for continuous variables. Finally, a multinomial regression model, adjusted for patient characteristics, was used to estimate the effect of universal screening on postpartum appointment attendance. Significance was set at p < .05. The sample included 1,098 women, with 541 in the control group and 557 in the intervention group. The SDoH screening completion rate was 75.0% (n = 415). Basic demographics were similar, with minor differences addressed in regression models. Women in the intervention group were 1.69 times more likely to attend both postpartum visits (RRR = 1.69, 95% CI [1.14, 2.51], p = .009) compared to those in the control group. Implementing SDoH screening at our hospital improved postpartum visit attendance.
Peripartum cardiomyopathy (PPCM) is a rare but potentially fatal form of heart failure occurring in the peripartum period without an identifiable cause. We report the case of a 36-year-old woman who conceived 2 months after bariatric surgery (BS). At 37 weeks of gestation, she underwent cesarean delivery and developed acute respiratory failure and seizures immediately after extubation. Further evaluation was performed to exclude other acute obstetric and cardiopulmonary conditions, including pulmonary embolism, and transthoracic echocardiography revealed global left ventricular hypokinesia with a left ventricular ejection fraction (LVEF) of 30%. Serial follow-up demonstrated a characteristic recovery pattern, with LVEF improving to 45% on postpartum Day 8 and to 55% at 12 weeks postpartum, supporting the diagnosis of PPCM. BS results in substantial hemodynamic, metabolic, and nutritional changes that require time for maternal adaptation, and pregnancy during this early postoperative period may impose additional cardiovascular stress. Although previous studies suggest that BS may reduce the long-term risk of PPCM, this potential benefit may not extend to pregnancies occurring shortly after surgery. This case highlights the importance of effective contraception, preconception counseling, and careful cardiovascular monitoring in women who conceive during the early period after BS.
Three-dimensional (3D) ultrasound has emerged as a valuable non-invasive imaging modality in gynecologic oncology, particularly in the evaluation of endometrial and cervical cancers. This technique offers enhanced spatial visualization of pelvic anatomy compared to conventional two-dimensional ultrasound, improving diagnostic accuracy and preoperative staging. In endometrial cancer, 3D ultrasound provides detailed assessment of endometrial thickness, volume, and vascular patterns through power Doppler angiography, aiding in the detection of malignancy. Furthermore, it allows for accurate measurement of myometrial invasion depth, which is a critical factor in staging and treatment planning. In cervical cancer, 3D ultrasound facilitates delineation of tumor margins, stromal infiltration, and parametrial involvement, contributing to more precise local staging. The integration of multiplanar reconstruction and volume contrast imaging improves the sensitivity and specificity of lesion characterization. Several studies have demonstrated that 3D ultrasound approaches the diagnostic performance of magnetic resonance imaging (MRI) for local staging, while being more accessible, cost-effective, and tolerable for patients. Despite these advantages, limitations include operator dependency and reduced image quality in certain patient populations. Nevertheless, ongoing advances in ultrasound technology and standardized protocols are enhancing its clinical utility. In this narrative review we summarize current evidence regarding the role of three-dimensional ultrasound in the diagnosis and staging of endometrial and cervical cancer.
Assessing and treating menopause in transgender and gender diverse (TGD) individuals is of increasing interest to clinicians providing gender-affirming care. There currently exists a small body of literature that describes cardiovascular, bone health, neurocognitive, and other outcomes in the TGD population who experience loss of endogenous sex hormone production, whether through gender-affirming hormone therapy, surgical gonadectomy, or natural aging. However, the literature is currently insufficient to provide clear evidence-based guidance for the medical management of menopause in TGD individuals. As a result, clinical care largely relies on extrapolation from cisgender populations, expert opinion, clinical consensus, and shared decision-making.
To evaluate the diagnostic performance and reproducibility of the Ovarian-Adnexal Reporting and Data System (O-RADS) ultrasound version 2022 (v2022) compared with O-RADS ultrasound version 2019 (v2019) and the Assessment of Different NEoplasias in the adneXa (ADNEX) model for adnexal mass risk stratification. This retrospective analysis of prospectively collected data included 434 women with surgically confirmed adnexal masses who underwent pelvic ultrasound from January 2022 to December 2023. Three radiologists independently assigned O-RADS ultrasound v2019 and v2022 categories, with consensus classifications used for diagnostic performance analysis. ADNEX malignancy risks were calculated using the official online calculator with serum CA125 included. Diagnostic performance was assessed using receiver operating characteristic analysis, and reader agreement using weighted κ statistics. The cohort included 192 benign and 242 malignant lesions. O-RADS ultrasound v2022 showed excellent discriminatory performance, with an area under the curve of 0.935, sensitivity of 98.3%, specificity of 70.8%, and accuracy of 86.2% at the threshold of category ≥ 4. The areas under the curve of O-RADS ultrasound v2022, O-RADS ultrasound v2019, and ADNEX were not significantly different: 0.935, 0.919, and 0.930, respectively. Compared with v2019 and ADNEX, v2022 showed numerically higher specificity. Compared with v2019, v2022 also showed consistently higher inter- and intra-reader agreement. O-RADS ultrasound v2022 demonstrated diagnostic performance comparable to that of v2019 and the ADNEX model, while showing numerically higher specificity and greater reader agreement. These findings support v2022 as a refined and reproducible framework for ultrasound-based adnexal mass risk stratification.
Osteoporosis is a systemic skeletal disorder characterized by reduced bone strength and increased fracture risk, posing a major public health challenge. Hip and vertebral fractures, which predominantly affect older postmenopausal women, lead to significant disability and reduced quality of life. Accelerated bone loss begins during the menopausal transition, and early fractures (eg, wrist) can signal underlying skeletal fragility. Although effective screening tools and evidence-based lifestyle and pharmacologic interventions can prevent fractures, osteoporosis remains underdiagnosed and undertreated. Women's health clinicians play a critical role in integrating bone health assessment, prevention, and management into routine care for perimenopausal and postmenopausal women.
Neurokinin (NK) receptor antagonists represent a significant advancement in nonhormonal treatment of vasomotor symptoms (VMS) by targeting the underlying neuronal pathways driving thermoregulatory dysfunction. Fezolinetant, a selective NK 3 receptor antagonist, and elinzanetant, a dual NK1/NK3 receptor antagonist, provide rapid and clinically meaningful reductions in VMS, with elinzanetant offering additional improvements in sleep. Both agents show favorable safety profiles, and elinzanetant is supported for use in women receiving endocrine therapy for breast cancer. Ongoing research explores broader applications in metabolic health and individualized therapy.
The genetic status of embryos obtained during in vitro fertilization (IVF) programs using spermatozoa selected by microfluidic sorting was evaluated. Genetic testing was conducted on 127 embryos in the main group and 194 in the control group. The embryos were cultured under standard conditions; blastocyst biopsy was performed on day 5 for subsequent preimplantation genetic testing for aneuploidies using high-throughput sequencing. The use of microfluidic chips significantly increased the yield of blastocysts (p = 0.03) without affecting fertilization rates or embryo quality. However, when assessing the genetic status of embryos, no significant differences were found: the frequency of embryos with a normal karyotype was 29.9% in the main group and 32.4% in the control group (odds ratio, OR = 0.88). Microfluidic sperm sorting improves embryological parameters, particularly blastulation rates, but has no statistically significant effect on the genetic status of preimplantation human embryos, leaving this topic open for further investigation.
The rigorous conduct of well designed clinical trials is critical to improving outcomes for patients with gynaecological cancers. The Gynecologic Cancer InterGroup (GCIG) has promoted collaboration and harmonisation to guide clinical trials in ovarian and endometrial cancer through a series of consensus meetings with published statements. GCIG convened the inaugural Cervical Cancer Consensus Conference in Clinical Research in Dublin, Ireland, on Oct 14-15, 2024, to develop a consensus on design elements, essential questions, and unmet needs in cervical cancer research. All 33 GCIG member groups and additional representatives from patient advocates, young investigators, investigators from low-income and middle-income countries, and the Cervical Cancer Research Network participated in developing, refining, and adopting 16 statements within four topic groups: diagnosis and staging, early-stage disease, locally advanced disease, and persistent or recurrent disease. Consensus was obtained for all statements. Areas of unmet need were identified and tabulated. The high agreement rates generated through a process of debates, discussions, and consensus represent a positive commitment that incorporates harmonisation, inclusion, and pragmatism in the conduct of academic clinical trials globally.
Four recent prospective trials demonstrated that de-escalation of radical surgery for select patients with apparent low-risk, FIGO Stage I cervical cancer does not compromise cancer-related survival but does improve quality of life and provide the opportunity to preserve fertility. We present a critical review of ConCerv, SHAPE, GOG-278, and LESSER, which have set the stage for de-escalation of surgery for low-risk, early-stage cervical cancer. ConCerv, a prospective phase II study evaluating the feasibility and oncologic outcomes of conization alone or simple hysterectomy in patients with early-stage cervical carcinoma, found a low recurrence rate of 2.4% in patients who underwent a cone biopsy with lymph node assessment and 0% in those who underwent simple hysterectomy with lymph node evaluation. SHAPE, a phase III trial assessing the safety of simple hysterectomy compared to radical hysterectomy in this patient population, showed no difference in pelvic recurrences between both groups. GOG-278, an international cohort study evaluating the efficacy of cone biopsy versus simple hysterectomy with pelvic nodal assessment, found a 3-year recurrence-free survival rate of 94.8% in the cone biopsy group, with no recurrences noted in the simple hysterectomy group. Finally, LESSER, a phase II proof-of-concept trial studying cancer and quality-of-life outcomes in patients who underwent either a simple or modified radical hysterectomy for early-stage cervical cancer, found no difference in the disease-free survival rate or overall survival between both groups. Rates of postoperative complications were also similar in both arms. Based on these trials, we propose the following set of criteria for which de-escalation of surgical intervention would be appropriate for select Stage I disease: tumors ≤2 cm on cone biopsy; magnetic resonance imaging showing <50% of cervical stromal invasion with no evidence of metastasis; and a histology of either squamous cell carcinoma of any grade or either grade 1 or 2 adenocarcinoma, with depth of invasion <10 mm and no lymphovascular invasion.
Congenital uterine anomalies occur as a result of a failure of the fusion and resorption of the Müllerian ducts in utero. Although Müllerian anomalies are relatively uncommon, they can complicate reproductive health and even cause death.We report a case of an asymptomatic Caucasian woman in her 30s who was misdiagnosed with a tubal ectopic pregnancy at 12 weeks 0 days during a routine dating scan, ultimately revealing a right-sided unicornuate uterus with a non-communicating rudimentary horn. The diagnosis of the Müllerian anomaly was made based on two-dimensional sonography and laparoscopy but was eventually confirmed with MRI. Due to the high risk of uterine rupture, intrauterine growth restriction and preterm birth, it was felt continuation of the pregnancy was not advisable. Thus, the woman underwent a laparotomy, during which a left hemi-hysterectomy of the rudimentary horn was performed and the pregnancy was terminated.
Oocyte development requires coordinated metabolic and signaling support from granulosa and theca cells. By performing integrated single-cell RNA sequencing and spatial transcriptomic analyses of murine and human ovaries, we discovered a functionally specialized stromal subtype essential for folliculogenesis. These stromal cells (SCs) with glutamyl aminopeptidase (ENPEP) function, designated perifollicular SCs based on their circumferential follicle localization, exhibit two hallmark features: (1) dynamic proliferation synchronized with follicular maturation from primary to secondary to antral stages, and (2) secretion of midkine (MDK), which activates nucleolin (NCL) receptor signaling to drive granulosa cell (GC) expansion. Furthermore, analyses of ovarian aging revealed the concurrent depletion of perifollicular SCs and the attenuation of MDK-NCL signaling between perifollicular SCs and GCs. The unique spatial confinement and regulatory capacity of perifollicular SCs endow them with the potential to become important components of the follicular functional unit, providing new theoretical support for understanding the molecular regulatory mechanisms of ovarian aging from the perspective of the follicular microenvironment.
Testosterone therapy may benefit postmenopausal women beyond treating low sexual desire and shows cardiovascular safety with potential protective effects. While improvement in sexual desire remains the only guideline-supported indication, expanding research has prompted investigation into testosterone's broader physiologic effects. Evidence supports cardiovascular safety with potential protective vascular effects as well as improvements in sexual function, genitourinary health, lubrication, and tissue integrity. Long-term safety data remain limited, though serious adverse events appear uncommon when testosterone levels are maintained within normal female ranges. These emerging applications should be viewed as hypothesis-generating and do not yet support guideline-level changes to clinical practice.
Alcohol-serving venues are high-risk sites for HIV transmission in East Africa. Understanding how venue characteristics influence HIV screening outcomes may help to target venue-based outreach. In eight rural communities in Kenya and Uganda, we mapped all alcohol-serving venues (N = 530) and invited owners to participate in a cluster-randomized trial to promote biomedical HIV prevention uptake: 527 (99%) owners agreed to participate. We distributed cards recruiting adults (≥18 years) for free HIV testing with rapid initiation of HIV biomedical prevention or treatment. We characterized the yield of venue-based recruitment and evaluated venue-level correlates of being newly diagnosed with HIV, being previously diagnosed but out-of-care, and having self-reported HIV risk. Of 480 participating venues (Kenya = 89, Uganda = 391; 41 closed pre-recruitment and 6 had no one present), 61 (13%) had rooms for sex work; 91 (19%) offered condoms, and the median patrons/venue was 10/weekend-day. Staff distributed 9,375 cards and 7,744 (83%) adults participated in HIV screening. Of those screened, the median age was 34 years (IQR:26-43), 62% were men, and 1,620 (21%) had HIV. Among persons without known HIV, 141/6,265 (2.3%) were newly-diagnosed with HIV. Among persons with known HIV, 78/1,479 (5.3%) were out-of-care. Among persons without HIV, 2,285/6,124 (37%) reported HIV risk. The odds of having newly-diagnosed HIV increased significantly with each additional patron/weekend-day at a given venue (adjusted odds ratio [aOR]=1.03, 95%CI:1.00-1.05, p = 0.025). The odds of being previously diagnosed but out-of-care were significantly lower among attendees at venues with condoms on site (aOR=0.39, 95%CI:0.16-0.99, p = 0.047). The odds of reporting HIV risk were significantly higher among attendees at venues with condoms (aOR=1.25, 95%CI:1.04-1.49, p = 0.015), more patrons/weekday (aOR=1.01, 95%CI:1.00-1.02, p = 0.022), and more barmaids (aOR=1.07, 95%CI:1.01-1.13, p = 0.013). Alcohol-serving venue characteristics were predictive of the yield of persons with untreated HIV or high HIV risk, and could aid programs in targeting venues for HIV prevention and treatment.
Comprehensive genomic profiling (CGP) has been widely introduced into precision oncology; however, its real-world implementation in gynecologic oncology remains unclear. This study evaluated nationwide CGP utilization, treatment translation, and management of secondary germline findings in Japanese gynecologic oncology. A nationwide survey was conducted across 98 institutions participating in gynecologic oncology training and/or Japan's cancer genomic medicine network. Institutional characteristics, workforce composition, treatment translation, and management of germline findings were assessed. Associations between institutional factors and CGP utilization or trial-related treatment translation were analyzed using incidence rate ratios (IRRs) with 95% confidence intervals. Among 68 institutions with complete CGP volume data, 6,964 CGP tests were performed, including 922 for gynecologic malignancies. The median number of gynecologic CGP tests per institution was 10. In multivariate analysis, the number of board-certified obstetrician-gynecologists was associated with CGP utilization (IRR, 1.05; 95% CI 1.01-1.08). CGP-guided therapy was delivered to 80 patients (8.7%). Trial-related treatment translation was associated with the number of board-certified obstetrician-gynecologists (IRR, 1.09; 95% CI 1.02-1.16) and the presence of a medical oncology department (IRR, 7.93; 95% CI 1.41-44.72). Presumed germline pathogenic variants were identified in 100 cases (10.8%); however, confirmatory germline testing was performed in only 38 cases. CGP utilization in Japanese gynecologic oncology was associated with gynecologic workforce capacity and multidisciplinary genomic infrastructure. Collaboration between gynecologic oncology and medical oncology may facilitate treatment translation. CGP may also serve as an entry point for hereditary cancer evaluation despite incomplete downstream germline evaluation.
Insomnia is prevalent among pregnant women, yet safe and effective treatment options remain limited. While preliminary evidence suggests that Auricular Acupressure (AA) may alleviate insomnia, its efficacy during pregnancy has not been thoroughly investigated. This study aimed to evaluate the effectiveness of AA in improving sleep quality among pregnant women with insomnia. In this randomized, double-blind trial, 86 pregnant women (≥28 weeks' gestation) with insomnia were randomized to AA (n = 43) or sham AA (SAA, n = 43); 77 participants (AA, n = 37; SAA, n = 40) completed the trial and were included in the final analysis. The AA group received targeted acupressure at insomnia-related acupoints, while SAA involved non-specific points. Sleep quality (Pittsburgh Sleep Quality Index, PSQI), mental health symptoms, and salivary cortisol were assessed over 5 weeks. A total of 86 participants were randomized (43 to the AA group and 43 to the SAA group), and 77 (37 in the AA group and 40 in the SAA group) completed the study and were included in the analysis. Participants in the AA group exhibited significant improvements in sleep quality, as evidenced by a reduction in the PSQI score by 3.51 points (p < 0.01) and increased nightly sleep duration (p < 0.01). No significant changes were observed in the SAA group. Additionally, AA was associated with reduced depressive and anxiety symptoms and improved diurnal cortisol rhythms. No adverse events occurred in either group. AA is a safe, effective, and non-invasive intervention for improving insomnia symptoms during pregnancy. These findings suggest that AA may also benefit maternal mental health and pregnancy outcomes, offering a viable alternative to pharmacological treatments. ClinicalTrials.gov Identifier: ITMCTR2024000282.
Vulvovaginal candidiasis (VVC) is a pressing gynecological issue in sub-Saharan Africa (SSA), where non-albicans Candida (NAC) species are increasingly prevalent, challenging treatment due to variable antifungal resistance patterns. Despite this, species-level NAC data from SSA remain fragmented, and no prior meta-analysis has separately quantified the population-level prevalence of NAC infection alongside the species-specific proportions of NAC among confirmed Candida isolates. This systematic review and meta-analysis was performed to estimate the pooled prevalence and determinants of NAC vaginal infections among women of reproductive age. A PRISMA 2020-compliant systematic review and meta-analysis was conducted. Four electronic databases were searched for studies published from January 1, 2015 to December 31, 2025; all four databases were searched in February 2026. Eligible studies enrolled women of reproductive age (15-49 years) from SSA and confirmed Candida species identity using validated laboratory methods. Six random-effects meta-analyses were performed on logit-transformed proportions; pooled estimates were back-transformed for presentation. Publication bias was assessed using standard funnel-plot methods. Fourteen cross-sectional studies from nine countries (N = 3,587 women) met inclusion criteria. Pooled NAC prevalence was 12.56% (95% CI 8.73-17.83%; I2 = 66.4%). Pooled NAC proportion among confirmed Candida isolates was 34.98% (95% CI 25.29-46.11%; I2 = 68.8%). Species-specific proportions were: C. glabrata 16.38% (95% CI 10.72-24.27%); C. krusei 4.52% (95% CI 2.07-9.56%); C. tropicalis 4.15% (95% CI 2.12-7.91%); and C. parapsilosis 1.46% (95% CI 0.61-3.46%). These four species collectively account for 26.51% of total Candida isolates. The remaining proportion reflects other, less common NAC taxa not individually meta-analyzed due to data sparsity. Pooled estimates suggested an appreciable burden of NAC species in the region, but the magnitude should be interpreted in light of substantial between-study heterogeneity and differences in laboratory identification methods. NAC species contribute substantially to VVC in women of reproductive age in SSA. However, the studies included varied in laboratory identification methods, so these findings should inform surveillance and diagnostic strengthening rather than immediate empirical treatment changes. Standardized species identification and antifungal susceptibility testing with isolate-level minimum inhibitory concentration reporting are needed. PROSPERO CRD420251071725.
Millions of women worldwide are diagnosed with cancer annually. Although most of these cancers do not directly impact reproductive organs, the cancer therapies used treat these tumors, namely surgery, radiation, chemotherapy, immunotherapies and hormonal agents, can drastically alter women's lives forever. The direct effects of cancer treatment on reproductive organs may alter fertility and induce temporary or permanent menopause. The psychological and physiologic impact of menopause on survivors is enormous. The loss of estrogen impacts cardiovascular, musculoskeletal, and neurologic health, quality of life, and long-term well-being.