Since 60 years, pH measurement in fetal scalp blood samples (FBS) is used to diagnose fetal hypoxia during labor, although the last three decades lactate measurement in FBS has been increasingly used as a safe alternative with a lower chance of failure. However, studies demonstrating the direct relation between lactate and pH in FBS with the currently used measurement systems are lacking. Therefore, clinical acceptance and implementation is impeded. This study investigated the relation between lactate and pH in FBS and derived an appropriate lactate cutoff value. This observational prospective single-center study included 263 FBS in the period of 8 months. After collection of FBS, pH was assessed first (iSTAT®), after which lactate was assessed (StatStrip® Lactate 2). Clinical decisions were based on pH results only. Our primary objective was to assess the correlation between lactate and pH in FBS and to establish a lactate cutoff value for ruling out a low Apgar score at 5 minutes and neonatal acidosis, with corresponding sensitivity and specificity as secondary outcomes. Diagnostic performance of lactate was assessed by using the area under the curve (AUC) of the receiver operation characteristic curve (ROC curve), from which cutoff values were derived. In FBS, lactate and pH showed a moderate inverse linear correlation (r = -0.53). The AUC of the ROC curve was 0.88 (0.83-0.93), indicating a good diagnostic performance of lactate to identify an abnormal pH (pH <7.20 in FBS). A cutoff value for lactate of ≥5.6 mmol/L seemed to have the most optimal balance between sensitivity (78.1% [60.0-90.7%]) and specificity (79.2% [73.4-84.3%]) for a pH <7.20 in FBS. This study confirmed that the StatStrip® Lactate 2 is a suitable alternative analyzer for measurement of lactate compared with measurement of pH with the iSTAT in FBS. Despite only a moderate correlation between lactate and pH, a lactate cutoff value of ≥5.6 mmol/L could be proposed for clinical decision-making. This knowledge increased confidence of our gynecologists in this relatively new method and paved the way for successful and universal implementation of lactate in FBS, eventually without measuring pH.
The timing of gestational diabetes mellitus (GDM) diagnosis may influence maternal and neonatal outcomes, yet the differential impact of early-onset versus late-onset GDM remains incompletely characterized, particularly in Chinese populations. To compare maternal and neonatal outcomes between early-onset GDM (diagnosed before 20 weeks' gestation) and late-onset GDM (diagnosed at 24-28 weeks' gestation). This retrospective cohort study included 1847 singleton pregnancies complicated by GDM at Qingdao Municipal Hospital from January 2020 to December 2023. Participants were classified into early-onset (n = 583) and late-onset (n = 1264) groups. Primary outcomes included composite adverse neonatal outcome, preeclampsia, and cesarean delivery. Multivariate logistic regression was performed to calculate adjusted odds ratios (aOR) after controlling for maternal age, pre-pregnancy BMI, nulliparity, family history of diabetes, and chronic hypertension. Women with early-onset GDM demonstrated significantly higher rates of insulin requirement (45.8% vs. 21.1%, p < 0.001). Early-onset GDM was associated with increased risks of preeclampsia (aOR 1.85, 95% CI 1.38-2.47), cesarean delivery (aOR 1.84, 95% CI 1.53-2.28), and preterm birth (aOR 2.69, 95% CI 2.05-3.47). Neonatal complications were substantially elevated in the early-onset group, including macrosomia (aOR 1.86, 95% CI 1.41-2.37), neonatal hypoglycemia (aOR 2.04, 95% CI 1.57-2.67), respiratory distress (aOR 2.60, 95% CI 1.78-3.71), and NICU admission (aOR 2.16, 95% CI 1.69-2.74). The composite adverse neonatal outcome occurred in 61.2% of early-onset versus 37.7% of late-onset cases (aOR 2.57, 95% CI 2.13-3.15). Early-onset GDM may represent a clinically distinct, higher-risk phenotype with notably elevated maternal and neonatal morbidity compared to late-onset disease. Given the observational design and the potential for residual confounding, these findings should be regarded as hypothesis-generating rather than definitive. They require confirmation in prospective, multicenter studies before risk stratification by diagnostic timing or intensified surveillance can be advocated for routine clinical implementation.
Our objective was to compare the severity of pelvic inflammatory disease (PID) in hospitalized women with and without endometriosis, and to assess whether deep endometriosis is associated with worse clinical outcomes. A single-center retrospective cohort study was conducted from January 2018 to December 2023, including women hospitalized for PID in a tertiary care endometriosis center. Patients were classified based on the presence of endometriosis, as diagnosed by transvaginal ultrasound (TVUS). Clinical, microbiological, and imaging data were analyzed. Primary outcomes included treatment failure, length of hospital stay, need for urgent surgery, and recurrence. A subgroup analysis was performed within the endometriosis group to assess the impact of deep endometriosis. Of 159, 48 (30.2%) had endometriosis. Compared to those without the disease, women with endometriosis were older and had significantly higher rates of adnexal findings on TVUS (95.8% vs. 73.8%, p = 0.01), mostly suspected infected endometrioma. Vaginal and endocervical cultures were negative in 72.9% of endometriosis patients, and only one tested positive for sexually transmitted disease, in contrast to 42.3% positivity in the non-endometriosis group (p <0.01). Patients with endometriosis showed significantly higher rates of treatment failure (35.4% vs. 17.1%, p = 0.01), recurrence (31.3% vs. 11.7%, p = 0.01), and longer hospital stays (6.1 vs. 3.9). In the deep endometriosis subgroup, treatment failure and recurrence rates were higher, although these differences did not reach statistical significance. Endometriosis is a significant risk factor for more severe PID, contributing to worse clinical outcomes, including higher treatment failure, prolonged hospitalization, and greater recurrence. Particularly, those with deep endometriosis seem to have a more severe clinical course.
Nausea and vomiting in pregnancy is highly prevalent and can significantly impact pregnant women's quality of life. Despite this, access to effective pharmacotherapies can be constrained by stringent regulatory controls and socioeconomic barriers. The objective of this study was to examine the socioeconomic distribution of antiemetics (metoclopramide, ondansetron, and prochlorperazine) dispensed to pregnant women through Australia's publicly subsidized Pharmaceutical Benefits Scheme. We used the Maternity1000 linked administrative dataset to characterize antiemetics dispensed during 297 630 pregnancies in Queensland, Australia (July 2013 to June 2018). Using a population-based historical cohort study design, we analyzed dispensing volume, prevalence, and government expenditure across socioeconomic quintiles, with socioeconomic disadvantage defined using the Australian Bureau of Statistics' Index of Relative Socioeconomic Disadvantage. Inequalities in medication access and public expenditure were assessed using concentration indices (C) and concentration curves. Off-label ondansetron dispensings for nausea and vomiting in pregnancy (i.e., use outside Therapeutic Goods Administration-approved indications and not subsidized under the Pharmaceutical Benefits Scheme) accounted for the largest share of public expenditure (53.5%), followed by metoclopramide (45.2%) and prochlorperazine (1.3%). Across all three antiemetics, prevalence was highest among women in the most socioeconomically disadvantaged quintiles and declined progressively across the two least disadvantaged groups. Small pro-poor inequalities in access (C < -0.10) and moderate pro-poor inequalities in public expenditure (C > -0.25) were observed across all antiemetics. (Medication access: Cmetoclopramide = -0.07, 95% CI (-0.080 to -0.068); Condansetron = -0.09, 95% CI (-0.114 to -0.075); Cprochlorperazine = -0.08, 95% CI (-0.109 to -0.045). Government expenditure: Cmetoclopramide = -0.30, 95% CI (-0.316 to -0.285); Condansetron = -0.25, 95% CI (-0.297 to -0.198); Cprochlorperazine = -0.28, 95% CI (-0.350 to -0.205)). Off-label ondansetron access accounted for the majority of public expenditure on antiemetics dispensed during pregnancy, revealing a disconnect between health policy, clinical practice, public expenditure, and pregnant women's needs. While pro-poor access and public subsidies for antiemetics align with the equity elements embedded in the design of the Pharmaceutical Benefits Scheme, they may also be reflective of inequitable access to other unsubsidized, guideline-recommended pharmacotherapies for nausea and vomiting in pregnancy.
Numerous studies have shown that the diagnostic performance and reproducibility of visual recognition of endometriosis during laparoscopy are poor. The use of artificial intelligence (AI) seems relevant for exhaustive lesion recognition. Standardization of the visual classification of lesions, in the form of an ontology, is an essential prerequisite to enable medical experts to annotate surgical data consistently and subsequently allow engineers to train and build an artificial intelligence tool for endometriosis recognition. A systematic search was conducted in the MEDLINE (via PubMed), EMBASE, and the Cochrane Library databases up to May 2022, aiming to identify studies describing the laparoscopic visual appearance of superficial endometriosis, endometriomas, and deep infiltrating endometriosis. The accumulated data in the literature concerning the visual appearance of the different forms of endometriosis were used to create an ontology that could be used for artificial intelligence applications. Out of 932 articles screened, 35 studies were selected based on the inclusion criteria of human subjects with histologically confirmed endometriosis lesions visualized via laparoscopy. The selected studies were reviewed to develop a visual ontology of endometriosis lesions observed via laparoscopy. The lesions were categorized into 4 classes and further subdivided into 11 subclasses: superficial (black, red, white, or subtle), adhesions (dense or filmy), deep (obliteration, retraction, or deformation), and ovarian (endometrioma or chocolate fluid). The positive predictive value (PPV) varied across lesion types: black lesions (PPV 47%-97%), red lesions (PPV 33%-100%), white lesions (PPV 20%-81%), and ovarian endometriosis (PPV 42%-98%). Nonspecific lesions such as adhesions (PPV 16%-50%) and subtle superficial lesions (PPV 0%-67%) presented lower PPVs. Deep endometriosis lesions, often buried within organs, required indirect signs (obliteration, retraction, deformation) for identification. The visual ontology proposed in this systematic search could facilitate the detection and classification of endometriosis lesions using artificial intelligence. This study highlights the challenges of reaching a consensus on lesion recognition and classification in AI projects due to the diverse visual presentations of endometriosis.
Risk prediction models for gestational diabetes mellitus (GDM) offer potential for early identification and targeted prevention. External validation is crucial to assess model performance across diverse populations. Despite the availability of numerous GDM prediction models, limited evidence exists on their external validation frequency, methodological quality, and clinical applicability. This systematic review evaluated externally validated GDM prediction models, focusing on methodological rigor, reporting standards, and clinical relevance to inform future research and implementation. Databases including Ovid MEDLINE, Embase, Scopus, Emcare, and CINAHL were searched up to May 1, 2025. Studies reporting external validation of GDM risk prediction models were included. Two reviewers independently screened studies. Data were extracted using the CHARMS framework, and risk of bias and applicability were assessed using PROBAST+AI. The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251125758). Twenty-six studies validated 33 models, with validation sample sizes ranging from 50 to 75 161. Over half used the IADPSG criteria to define GDM. Discrimination metrics were commonly reported, but calibration, overall performance, and clinical utility were often lacking. Meta-analysis was feasible for only four models: Teede et al., Nanda et al., Naylor et al., and Van Leeuwen et al., each showing fair discrimination. The Teede et al. model was the most widely validated, with 11 external validations across six continents and a pooled AUC of 0.72 (95% CI: 0.67-0.76). Despite fewer validations, the Nanda et al. model achieved the highest pooled discrimination (5 validations; pooled AUC 0.77, 95% CI: 0.74-0.80). The Naylor et al. and van Leeuwen et al. models also underwent meta-analysis, as sufficient external validation studies were available to support comparative performance assessment. Notably, 69.23% of studies had a high risk of bias. While many models showed acceptable predictive performance, most validations were methodologically weak. Future studies should follow best-practice guidelines and promote scalable validation strategies, such as algorithm sharing, to enhance clinical utility.
To examine associations between personal burnout symptoms and the intention to leave the current hospital across different career stages among physicians in obstetric care in Germany. In addition, we compared burnout levels among surveyed obstetricians relative to the general physician and the German working population. In this nationwide, cross-sectional study, physicians from all 595 obstetric departments in Germany were invited to complete an anonymous, standardized survey. We assessed burnout, intentions to leave the workplace within the next 5 years, career stage, age, gender, and employment status. Comparative data on burnout were obtained from a national database on mental stress in the workplace. Data were analyzed visually using Sankey plots and Firth-corrected multivariable logistic regression. A total of 872 obstetricians responded. Overall, 380 physicians (50.9%) reported intention to leave the current hospital within the next 5 years. Moderate personal burnout was reported by 332 physicians (40.2%), while 168 (20.4%) reported high or severe burnout. Average burnout levels among surveyed obstetricians (mean: 50.6) were comparable to those of other physicians (mean: 51.4) and the general working population (mean: 49.9) in Germany. Intentions to leave were most frequent among residents (176, 74.2%), followed by specialists (46, 57.5%). Regression analyses showed that higher burnout scores were significantly associated with intention to leave the current hospital (OR = 1.03, 95%-CI: 1.02, 1.04, p < 0.001), particularly among physicians in earlier career stages. With each one-point increase in burnout scores, odds of intending to leave increased by 3.3% for residents (95%-CI: 1.02, 1.05, p < 0.001), 3.2% for specialists (95%-CI: 1.01, 1.06, p = 0.005), and 3.2% for consultants without executive responsibilities (95%-CI: 1.02, 1.05, p < 0.001). Personal burnout symptoms are significantly associated with the intention to leave the current hospital, particularly among early-career obstetricians. While career-stage-related mobility can partly explain turnover, burnout appears to be an independent determinant. Our findings highlight the importance of addressing burnout early in medical careers to support physician retention in obstetric care.
The objective of this study is to evaluate, in fetuses with early-onset fetal growth-restricted (FGR) requiring delivery before 30 weeks, the relationship between the longitudinal Doppler changes and severe morbidity and mortality. A retrospective cohort was constructed of singleton pregnancies between January 2013 and December 2021 with antenatal suspicion of FGR, born before 30 weeks in a single tertiary center in Barcelona (Hospital Sant Joan de Déu and Hospital Clínic). A total of 103 cases of FGR fetuses were included. Accurate anatomical examination, fetal biometry, and prenatal Doppler ultrasound examination were performed by experienced operators. The association between the intervals from diagnosis to abnormal Doppler and severe adverse outcome was evaluated with Cox and logistic regression, adjusted for gestational age at onset and preeclampsia. The primary outcome was a composite of severe adverse outcomes defined as mortality or severe neurological morbidity. Among the 83 pregnancies with ductus venosus (DV) pulsatility index (PI) ≤95th centile at admission, the median time to a DV PI >95th centile was 16 days in pregnancies presenting severe adverse outcomes and 20 days in those without (p = 0.007). Among the 64 pregnancies with a positive umbilical artery (UA) end-diastolic velocity (EDV), the median time to be absent/reversed was 11 days in pregnancies presenting severe adverse outcome and 14 days in those without (p = 0.016). Among the 86 pregnancies with nonreversed UA EDV, the median time to reversed flow was 18 days in pregnancies destined to present severe outcomes and 26 days in those without (p = 0.001). The prediction of mortality or severe morbidity could be better achieved with longitudinal Doppler assessment in FGR fetuses born before 30 weeks.
The finding of basal plate myometrial fibers (BPMF) delivered with the placenta has been associated with many different pregnancy and delivery complications. This study aims to evaluate the clinical utility of this histopathological finding in obstetrics. We searched PubMed, Google Scholar, and Embase for studies published in English reporting an association between obstetric complications and placental BPMF, using combinations of relevant medical subject heading terms and keywords, published between March 1996 and December 2025. Study characteristics were evaluated by two independent reviewers using a predesigned protocol. The PRISMA Extension for Scoping Review (PRISMA-ScR) was used to extract data and report the results. Sixteen studies met our eligibility criteria for inclusion in this review. There were five cohorts and 11 studies, involving 5770 participants from four different countries. Nine studies reported on the association between BPMF on histopathologic examination in the setting of a delivered placenta and maternal or fetal pregnancy and delivery complications, and the remaining seven studies investigated the association between BPMF at birth in the index pregnancy and abnormal placental attachment at the next delivery. The most common prenatal and perinatal disorders were hypertensive disorders of pregnancy, placenta previa, preterm delivery, pre-labor rupture of the membranes, suspicion of intrauterine infection, diabetes, stillbirth, and fetal growth restriction, and the most common intrapartum complications were placental abruption and placental retention. A higher incidence of abnormal placental attachment was reported in the subsequent pregnancy in cases where BPMF were found in the first pregnancy, but wide heterogeneity was observed across the included studies, particularly in the clinical criteria used to report placental attachment at delivery and interpretations of corresponding results. The clinical usefulness of reporting on BPMF in delivered placentas from pregnancies complicated by maternal or fetal disorders is currently difficult to evaluate due to variability in inclusion criteria, methodological protocols, and reported outcomes. The study of BPMF in delivered placentas may help fill evidence gaps in our knowledge of the pathophysiology of placental-related pregnancy disorders involving the uteroplacental interface and the link between these disorders and long-term maternal cardiovascular complications.
Pelvic and genital pain is a common symptom among women with endometriosis and may negatively affect sexual functioning. Pelvic floor muscle training (PFMT) may improve sexual functioning, but whether this applies to women with endometriosis remains to be explored. This study is a planned secondary analysis in which we aimed to examine how general exercise and PFMT, when added to pain management, affect sexual functioning among women with endometriosis. Planned secondary analysis of a two-armed, parallel-group randomized controlled trial with intention-to-treat analysis. Women aged 18-45 years with laparoscopically confirmed endometriosis and experiencing pelvic/genital pain were eligible. All participants attended a pain management course. In addition to weekly home training, the exercise group (n = 41) participated in weekly supervised general exercise training, including PFMT, for 4 months. The control group (n = 40) received no further intervention. Between-group differences in sexual function were assessed using the total score of the Female Sexual Function Index (FSFI) at the end of the 4-month intervention and at the 12-month follow-up. We also examined differences in the subdomains-desire, arousal, lubrication, orgasm, satisfaction, and pain-at these time points. NCT05091268. Four months post-intervention, the exercise group showed significantly higher total FSFI scores compared to the control group (mean difference = 3.52, 95% CI 0.49-6.54, p = 0.023). Significant between-group differences were also observed for the subdomains lubrication (mean difference = 0.90, 95% CI 0.17-1.63, p = 0.016) and orgasm (mean difference = 0.81, 95% CI 0.07-1.55, p = 0.033). No significant between-group differences were found for desire, arousal, or pain at the end of the 4-month intervention, or at 12 months follow-up for any domain. The findings suggest that the combined intervention of supervised exercise and PFMT, when added to pain management, may lead to short-term improvements in sexual function at the end of the 4-month intervention. Whether this effect is attributable to general exercise, PFMT, or their combination cannot be determined from the present study. However, the findings should be interpreted cautiously due to differences in sexual activity status between groups.
Fetal central nervous system (CNS) abnormalities have diverse etiologies, with genetic factors as a major contributor. Prenatal exome sequencing (ES) is a powerful tool for precise molecular diagnosis of CNS anomalies, but its diagnostic yield varies among studies. This study aimed to evaluate the additional diagnostic yield of prenatal ES compared with chromosomal microarray analysis (CMA) in fetuses with CNS anomalies detected by prenatal imaging. We collected ES results from fetuses diagnosed with CNS anomalies by prenatal imaging (2019-2024) who had negative results. Subgroup analyses assessed phenotype-specific ES diagnostic yield for associated genes and variants. A systematic review and meta-analysis incorporating our data and published studies further explored the association between phenotype and diagnostic yield. In the cohort study of 219 cases, ES identified pathogenic/likely pathogenic single nucleotide variations in 36 cases (16%). The highest diagnostic yield of ES was in cases with multisystem malformations (25%, 14/55), followed by multiple CNS anomalies (15%, 2/13) and isolated CNS anomalies (13%, 20/151). The most commonly identified isolated CNS anomaly was agenesis of the corpus callosum (31%, 5/16). Neural tube defects with urogenital anomalies were associated with a positive ES finding in 57% (4/7) of cases. The meta-analysis of 989 cases from 22 studies showed a pooled diagnostic yield of ES of 27% (95% CI, 21%-34%). The highest diagnostic yield of ES was in cases of corpus callosum anomalies with facial abnormalities (75%, 8/11) and neural tube defects with urogenital malformations (80%, 12/15). The diagnostic yield of ES for three or more CNS abnormalities was 43% (95% CI, 31%-58%), significantly higher than that for only two abnormalities (10%, 95% CI, 4%-18%). No significant difference in diagnostic yield was found between cases identified by prenatal MRI combined with ultrasound (27%, 95% CI, 20%-36%) and those identified by ultrasound alone (25%, 95% CI, 17%-35%). ES provided a significantly higher diagnostic yield than CMA for fetal CNS abnormalities, with diagnostic yields varying by phenotype. The systematic review and meta-analysis confirmed that the complexity and combination of malformations are key factors associated with differences in ES diagnostic yield.
This retrospective cohort study investigated whether preoperative bilateral ureteral stent placement reduces urinary system injuries in pregnant women with placenta accreta spectrum (PAS) undergoing peripartum cesarean hysterectomy. The sociodemographic, clinical characteristics, and laboratory results of 273 women who underwent peripartum cesarean hysterectomy due to suspected PAS during the study period were documented and compared. One hundred and twenty-three of these did not receive preoperative urinary stent placement (Group 1), while 150 had such stents installed (Group 2). Red blood cell counts (4.10 ± 1.78 vs. 3.06 ± 0.96, odds ratio (OR): 0.782, 95% confidence interval (CI): 0.619-0.989; p = 0.027) and fresh frozen plasma replacement values (2.22 ± 0.63 vs. 3.22 ± 1.01, OR: 1.238, CI: 1.009-1.518; p = 0.035), operative times (120.0 [100.0-165.0] mins vs. 110.0 [80.0-120.0] mins , OR: 0.984, CI: 0.972-0.997; p = 0.012), days of hospitalization (6.34 ± 1.98 vs. 4.68 ± 1.45, OR: 0.849, CI: 0.736-0.979; p = 0.017), and urinary tract complications (14 [11.4%] vs. 5 [3.3%], OR: 8.357, CI: 1.784-39.153; p = 0.007) differed significantly between the groups. Additionally, while preoperative hemoglobin, hematocrit, and platelet counts were comparable between the groups (p > 0.05), postoperative hemoglobin (9.61 ± 1.75 vs. 10.08 ± 1.81 gm/dl; p = 0.004) and hematocrit (28.88 ± 1.80 vs. 30.19 ± 2.30; p = 0.003) levels differed between them. In multivariable logistic regression analysis, both the number of previous cesarean sections (OR: 1.687; 95% CI: 1.079-2.636; p = 0.022) and the absence of ureteral stent placement (OR: 3.964; 95% CI: 1.199-13.107; p = 0.024) were independently associated with urinary tract injury. This retrospective cohort study suggests that prophylactic temporary ureteral stent placement may be associated with a reduction in urinary tract injury in women with PAS undergoing peripartum cesarean hysterectomy. However, given the non-randomized design, potential selection bias, and limited number of events, these findings should be interpreted with caution. Larger, multicenter prospective studies with appropriate adjustment for confounding variables are needed to confirm these results.
Current international (FIGO) and Swedish cardiotocography (CTG) interpretation templates exhibit limited diagnostic accuracy for the detection of fetal acidemia. The objective of this study was to develop a novel intrapartum CTG classification template incorporating CTG parameters demonstrated to be strongly associated with acidemia, and to evaluate the diagnostic performance of the models by assessing their sensitivity and specificity in identifying CTG recordings from neonates with acidemia. A retrospective case-control study based on 1092 births in Region Skåne. The study material included 364 cases with umbilical cord blood pH <7.05, or <7.10 after 1st stage cesarean, and 728 controls with pH ≥7.15 and Apgar scores ≥9 at 5 and 10 min. CTG patterns were systematically evaluated across a set of predefined variables, and associations between specific patterns and fetal acidemia were quantified using ORs. Two models defining pathological patterns were created: Model 1 based on the presence of one of several listed criteria resulting in a positive test and Model 2 also including the presence of ≥2 B-criteria resulting in a positive test. The main outcomes, sensitivity, and specificity to identify fetal acidemia at birth were calculated and compared with the current FIGO, NICE, and SWE guidelines. The sensitivity to identify fetal acidemia was 86.3%, 86.5%, 50.8%, 57.1%, and 87.4% for Model 1, Model 2, FIGO, SWE, and NICE, respectively. The corresponding specificity was 77.9%, 76.4%, 92.6%, 91.2%, and 70.6%. The sensitivity to identify severe acidemia (pH <7.0) was 90.4% for Model 1 and for NICE; 64.4% for SWE, and 56.7% for FIGO. A variable not included in current classification systems, "fetal heart rate below baseline for >50% of the time during 30 minutes" was the criterion contributing most to the sensitivity. Our models show higher sensitivity but lower specificity for the defined outcome compared with SWE and FIGO, and similar sensitivity but higher specificity compared with NICE. Validating the model on a new material is essential before considering clinical use.
Intravaginal products, including silicon dioxide-based gels, are marketed to support short-term high-risk human papillomavirus (hrHPV) clearance or loss of detectability, but independent randomized evidence testing these short-term claims against observation is limited. We evaluated whether daily intravaginal silicon dioxide-based gel treatment increases the proportion of women with no detectable cervical hrHPV DNA compared with observation alone. This prospective, single-center, parallel-group, randomized, open-label controlled trial included women with PCR-confirmed cervical hrHPV infection and no indication for immediate treatment. Participants were randomized 1:1 to 3 months of self-administered daily intravaginal gel treatment or observation alone. The primary outcome was absence of detectable cervical hrHPV DNA by PCR at 3 months. Secondary outcomes during the randomized study period were patient-reported satisfaction and adverse events. ClinicalTrials.gov, NCT05509413, https://clinicaltrials.gov/study/NCT05509413. Between November 2022 and January 2025, 242 women were randomized, with 121 allocated to each group. Primary-endpoint data were available for 208 women. At 3 months, hrHPV DNA was not detected in 18/99 women (18%) in the gel treatment group and 23/109 women (21%) in the observation group (absolute risk difference -2.9 percentage points, 95% CI -14 to 8; p = 0.60). A reduced post hoc adjusted sensitivity analysis did not materially change the interpretation of the primary comparison. Patient-reported adverse events were more frequent in the gel treatment group than in the observation group (32/99 [32%] vs. 2/106 [2%]; absolute risk difference 30 percentage points, 95% CI 21 to 40; p < 0.001). Satisfaction scores were high in both groups but lower with gel treatment. In this randomized trial, 3 months of daily intravaginal silicon dioxide-based gel treatment did not improve short-term loss of detectable cervical hrHPV DNA compared with observation alone. The trial did not reproduce the large short-term virologic benefit suggested by prior product-related studies. The findings do not support routine use of this intervention solely to promote short-term hrHPV non-detectability in women without an indication for immediate treatment, particularly given the higher frequency of local adverse events.
High-risk pregnancies require close monitoring and frequent hospital visits. Home telemonitoring offers a potential alternative to improve access and satisfaction while reducing healthcare use. This retrospective cohort study characterized the clinical course and events during home telemonitoring including home-based cardiotocography during a pilot program for women with high-risk pregnancies at an urban tertiary hospital. This retrospective three-year cohort study included 117 singleton pregnancies enrolled in a home telemonitoring program at Helsinki University Hospital between January 2021 and December 2023. Participants were grouped by primary indication: premature rupture of membranes, preeclampsia and/or fetal growth restriction, or other high-risk conditions. The main outcomes included the course and duration of home telemonitoring, rates of hospital visits and readmissions, the onset of labor or emergency cesarean delivery, and severe complications during home telemonitoring, including maternal or fetal death, placental abruption, prolapse of umbilical cord, placenta previa with bleeding, chorioamnionitis, eclampsia, and worsening of preeclampsia. The median gestational age at initiation of home telemonitoring was 32.4 weeks, and the median monitoring duration was 7 days (IQR 2.5-13.5). Thirty-eight women (32.6%) were readmitted. The median gestational age at delivery was 34.6 (range 25.1-41.4) weeks, and 87.2% (102/117) delivered preterm. The overall cesarean rate was 47.0% (55/117). Spontaneous onset of labor occurred in 11 (9.4%) women during the home telemonitoring period; no home deliveries were recorded. 38 women (32.5%) underwent an emergency cesarean delivery. No maternal or intrauterine fetal deaths occurred. Complications occurred in 36 cases (30.8%). The most common complications were chorioamnionitis (n = 21,17.9%) and worsening of preeclampsia (n = 11, 9.4%). No eclampsia was observed. Two cases of placental abruption (n = 2, 1.7%) and two cases of bleeding due to placenta previa (n = 2, 1.7%) occurred. In all the preceding cases, immediate readmission and prompt management resulted in favorable maternal and neonatal outcomes. This pilot study suggests that home telemonitoring represents an acceptable approach for the management of selected high-risk pregnancies. However, careful patient selection and strict adherence to evidence-based clinical protocols are essential to ensure safe and effective implementation.
Oxytocin is widely used to augment uterine contractions during labor. However, its use has been associated with fetal heart rate (FHR) abnormalities and neonatal morbidity, which may be reduced by discontinuing oxytocin during labor. We aimed to assess the impact of oxytocin discontinuation at the onset of the active phase of labor on FHR patterns and uterine contractility. This study is a pre-specified ancillary analysis of the STOPOXY trial, a multicenter, randomized, open-label, controlled superiority trial conducted in 21 French maternity units between January 2020 and January 2022, which aimed to assess the impact of oxytocin discontinuation during active labor on neonatal morbidity. Participants who received oxytocin before 4 cm dilation were randomly assigned (1:1) to either oxytocin discontinuation or oxytocin continuation. For the present analysis, we included women from the per-protocol discontinuation group of the parent trial. Inclusion was restricted to the six centers with electronic cardiotocography storage where valid cardiotocography recordings were available for at least 1 h before and 1 h after oxytocin discontinuation. Using a paired before-and-after design, FHR parameters (classified according to FIGO criteria) and uterine activity were compared during the 60 min preceding versus the 60 min following oxytocin discontinuation by independent obstetricians blinded to neonatal outcomes. Changes in FHR pattern were categorized as no change, improvement, or deterioration. 284 women fulfilled the eligibility criteria. Following oxytocin discontinuation, mean FHR increased (135 vs. 137.5 bpm; p < 0.002) and FHR variability significantly changed (p = 0.010), with a lower rate of reduced variability (3.9% vs. 2.5%) and a higher rate of normal variability (48.2% vs. 53.3%). The proportion of tracings with decelerations significantly decreased (64.1% vs. 48.6%; p < 0.001). Uterine activity decreased, with fewer uterine contractions (4.0 vs. 3.5 contractions per 10 min; p < 0.001). Among women receiving oxytocin during early labor, discontinuation at the onset of the active phase was associated with improved FHR patterns and reduced uterine activity, suggesting a lower fetal stress and tachysystole. Further studies are needed to assess whether these changes affect labor management or maternal experience.
Uterine leiomyomata are the most common neoplasms among women of reproductive age. Laparoscopic myomectomy is desirable for patients who wish to preserve their fertility or retain their uterus. There lacks a large-scale study to compare the surgical safety between transumbilical laparoendoscopic single-site surgery (single-site laparoscopy) and conventional multi-port laparoscopy. This registered retrospective observational study (MR-51-23-020457, ChiCTR) included patients with leiomyomata who underwent single-site laparoscopy or multi-port laparoscopy for myomectomy. The patients' characteristics, perioperative outcomes, obstetric outcomes, and satisfaction scores for the incision were recorded and analyzed between the two groups. The primary outcome was the incidence of intraoperative adverse events, including organ injury and bleeding, and the secondary outcomes were Enhanced Recovery After Surgery indicators, including surgery-related pain, flatulence time, postoperative hospital stay, and cosmetic satisfaction of incisions. A total of 1437 single-site laparoscopy and 2514 multi-port laparoscopy patients were included. The incidence of Grade I intraoperative adverse events (organ injury) was 0.70% in single-site laparoscopy and 0.44% in multi-port laparoscopy (p = 0.624), the Grade II intraoperative adverse events (bleeding requiring blood transfusion) were 6.75% in single-site laparoscopy and 6.24% in multi-port laparoscopy (p = 0.533). Single-site laparoscopy patients had shorter postoperative hospital stay (2.21 ± 1.18 vs. 2.70 ± 1.37, p < 0.001) and lower surgery-related pain score (2.82 ± 0.58 vs. 2.89 ± 0.63, p < 0.001). Besides, patients from single-site laparoscopy had a higher satisfaction score for incisional healing (4.60 ± 0.62 vs. 4.43 ± 0.66, p < 0.001) than those from the multi-port laparoscopy group. Additionally, seven single-site laparoscopy patients and nine multi-port laparoscopy patients were diagnosed with uterine sarcoma. During the second surgery, the isolated and minor pelvic implantation found in one patient (0.5 × 0.5 cm) from the single-site laparoscopy group had a smaller size and narrower distribution than that found in the three patients (1.0 × 1.0 cm, 3.0 × 3.0 cm,3.0 × 3.0 cm) from the multi-port laparoscopy group. These findings support the notion that single-site laparoscopy and multi-port laparoscopy for myomectomy show similar performance in terms of surgical safety. Single-site laparoscopy outperforms multi-port laparoscopy with respect to postoperative hospital stays and cosmetic satisfaction with the incision.
The freebirth movement, planned birth without any qualified professional attendant, is expanding internationally, including in Scandinavia, where rising rates and incomplete outcome reporting have raised clinical and ethical concerns. A recent editorial in this journal emphasizes respectful engagement with women considering out-of-hospital birth and the importance of rebuilding trust through less coercive models of care. We argue that insufficient distinction between professionally attended home birth and planned unassisted birth risks conflating two distinct professional obligations: respecting patient autonomy and maintaining clinical neutrality in the face of preventable fetal and neonatal harm. These are not equivalent obligations. Respect for autonomy requires accurate, complete, evidence-based counseling and a clear professional recommendation when the evidence warrants one, while preserving the patient's right to decline. After viability, the fetus acquires patient status with corresponding beneficence-based obligations that planned unassisted birth forecloses entirely. Directive counseling against a practice associated with increased risk of preventable fetal and neonatal death is not coercion. It is what informed consent requires of the clinician. Professional responsibility does not ask clinicians to choose between compassion and clarity. It requires both.
Interpreting the histopathology report after stillbirth and applying it to care in a subsequent pregnancy can be challenging. A retrospective cohort study of singleton stillbirths in Iceland 1996-2021 (n = 338). Clinical information and description of placenta and umbilical cord were reviewed, and microscopic slides re-evaluated according to the Amsterdam Consensus. Clinical and histopathological findings, including major patterns of placental injury and umbilical cord at risk, were correlated and compared between gestational age groups: <28 weeks (n = 102), ≥28 but <37 weeks (n = 114), and ≥37 weeks (n = 122). Placental slides were reviewed for 96.4% (326/338) of singleton stillbirths and classified into major patterns of placental injury. Maternal vascular malperfusion (MVM) was diagnosed in 19.0% of placentas (62/326), fetal vascular malperfusion (FVM) in 31.6% (103/326), acute chorioamnionitis (ACA) in 32.2% (105/326), chronic villitis of unknown etiology (VUE) in 15.9% (52/326), and none of the major patterns in 27.9% (91/326). More than one pattern of placental injury was found in 7.7% of placentas (25/326), most often at term. A similar proportion of MVM was found irrespective of gestational age; FVM was more common after 28 weeks, ACA before 28 weeks, but VUE most frequent at term. A higher proportion of MVM was found in stillbirths with small for gestational age (SGA) infants than non-SGA (23.0 vs. 6.1%), as well as in stillbirths with maternal hypertensive disorder of pregnancy than in stillbirths with a normotensive mother (23.9 vs. 11.8%). The latter association was not seen with high-grade FVM nor VUE. The umbilical cord was at risk in 53.8% (175/326) of singleton stillbirths, increasing with gestational age to 71.7% (86/120) at term. Hypercoiled, excessive long, and wrapped cords were most common. Term stillbirths with cord at risk often also had placental MVM or VUE. Understanding major patterns of placental injury and their correlation with clinical phenotypes can help counseling after stillbirth. Stillbirths with placental MVM often had clinical signs suggesting a high-risk pregnancy. However, term stillbirths with placental VUE or FVM and umbilical cord at risk were commonly without recognized risk factors.
Placenta accreta spectrum (PAS) disorders are associated with substantial maternal morbidity and remain one of the most challenging conditions in modern obstetrics. Although cesarean hysterectomy with the placenta left in situ is widely regarded as the standard treatment, uterus-preserving surgical strategies have emerged as viable alternatives in carefully selected cases managed in specialized centers. Building on our recently published systematic review and meta-analysis, this expert-illustrated review provides a comprehensive and critical appraisal of conservative surgical approaches for PAS, with a particular focus on operative techniques, patient selection, and short- and long-term outcomes. We clearly differentiate two fundamentally distinct conservative strategies: myometrial resection techniques and leaving the placenta in situ. For each approach, we synthesize current evidence, describe procedural nuances, highlight technical prerequisites, and discuss expected intraoperative and delayed complications. The most commonly performed myometrial resection techniques-including one-step conservative surgery, the Triple-P procedure, and the Kasr Alainy technique-are detailed step-by-step and illustrated to emphasize key surgical principles. Expectant management with the placenta left in situ is also reviewed, with particular attention to indications, postoperative surveillance, delayed morbidity, and fertility outcomes. Data from 50 studies encompassing 2659 patients undergoing myometrial resection and 552 managed with the placenta left in situ are integrated to contextualize reported outcomes and failure rates. This expert review aims to support clinical decision-making by clarifying the indications, limitations, and risks of conservative PAS management. We argue that uterus-preserving strategies can be safely and effectively implemented in selected patients when performed by experienced multidisciplinary teams, while emphasizing that readiness to convert to hysterectomy remains essential. By distinguishing techniques and aligning them with patient-specific factors, this review provides practical guidance for maternal-fetal medicine specialists managing PAS in contemporary clinical practice.