American journal of obstetrics and gynecology最新文献

{"title":"Umbilical Cord Management in Extremely Preterm Infants Born by Cesarean Delivery.","authors":"Haifaa Kashkari,Prakesh S Shah,Jehier K Afifi,Eugene Yoon,Joan M Crane,Sarah D McDONALD,Marc Beltempo,Walid I El-Naggar, ","doi":"10.1016/j.ajog.2025.09.036","DOIUrl":"https://doi.org/10.1016/j.ajog.2025.09.036","url":null,"abstract":"BACKGROUNDDeferred cord clamping reduces mortality in preterm infants. However, there is a controversy whether it is as effective in cesarean deliveries as in vaginal deliveries.OBJECTIVESTo compare mortality and short-term outcomes of extremely preterm singleton infants who received deferred cord clamping after cesarean deliveries with those who received it after vaginal deliveries and those who received early cord clamping after cesarean deliveries.STUDY DESIGNWe conducted a national retrospective review of maternal, perinatal, and neonatal data of preterm infants <29 weeks' gestation who were admitted to units participating in the Canadian Neonatal Network between January 2015 and December 2022. We assessed the rates and trends of deferred cord clamping (≥ 30 seconds) and compared infants who received deferred cord clamping after cesarean deliveries with: (a) those who received deferred cord clamping after vaginal deliveries and (b) those who received early cord clamping (< 30 seconds) after caesarean deliveries. Our primary outcome was hospital mortality/severe brain injury (defined as grade 3/4 intraventricular hemorrhage and/or periventricular leukomalacia). Multivariable regression models with generalized estimation equation were used to account for clustering of infants within each site after adjusting for potential confounders.RESULTSOf 6137 infants included, 1952 (31.8%) received deferred cord clamping after cesarean deliveries, 1804 (29.4%) received it after vaginal deliveries and 2381 (38.8%) received early cord clamping after cesarean deliveries at a median (IQR) gestational age of 27 (25, 28), 26 (25, 28) and 26 (25, 28) weeks, respectively. There was a slow increase in practicing deferred cord clamping in cesarean deliveries from 32% in 2015 to ∼50% in 2021-2022. After adjustment for potential confounders, infants who received deferred cord clamping after cesarean deliveries had lower odds of a composite of mortality/severe brain injury [281/1952 (14%)] than those who received deferred cord clamping after vaginal deliveries [347/1804 (19%)]; aOR (95% CI): 0.69 (0.54, 0.87) and those who received early cord clamping after cesarean deliveries [543/2381 (23%)]; aOR (95% CI): 0.69 (0.57, 0.83). Deferred cord clamping after cesarean deliveries was not associated with significant changes in other adverse short-term outcomes.CONCLUSIONDeferred cord clamping is associated with reduction in a composite of mortality/ severe brain injury in singleton preterm infants <29 weeks' gestation born by cesarean delivery.","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"3 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145181177","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Immune Tolerance Breakdown in Pregnancy: Transplantation Parallels in Chronic Intervillositis and Villitis of Unknown Etiology.","authors":"Pierre Hannoun,Marion Rabant,Cédric Usureau,Jean-Luc Taupin,Julien Zuber,Alexandra Benachi","doi":"10.1016/j.ajog.2025.09.032","DOIUrl":"https://doi.org/10.1016/j.ajog.2025.09.032","url":null,"abstract":"Pregnancy represents a unique immunological paradox, requiring a delicate balance between immune tolerance and protective immune responses. While historically conceptualized as a semi-allogeneic graft, emerging evidence suggests that the maternal-fetal interface is a highly specialized immune environment with distinct regulatory mechanisms. Disruptions in these mechanisms have been implicated in severe obstetric complications, including chronic histiocytic intervillositis and villitis of unknown etiology, which exhibit striking immunopathological similarities to solid organ transplant rejection. This expert review examines the fundamental principles of maternal-fetal immune tolerance, focusing on complement regulation, decidual natural killer cells, regulatory T cells, and trophoblastic immune evasion strategies, including HLA-G expression and extracellular vesicle-mediated immunomodulation. We further explore how failures in these tolerance mechanisms can lead to T-cell-mediated rejection and antibody-mediated rejection, highlighting their mechanistic parallels with transplantation immunobiology. Chronic intervillositis and villitis share key histopathological features with T-cell-mediated rejection and antibody-mediated rejection, including the infiltration of maternal cytotoxic T cells, the presence of donor-specific anti-HLA antibodies, and the deposition of complement component C4d in the placental microvasculature. The loss of immune privilege at the maternal-fetal interface, marked by aberrant HLA class I and II expression on chorionic villi, recapitulates classical mechanisms of allograft rejection. These findings strongly suggest that intervillositis and villitis represent manifestations of maternal immune rejection, emphasizing the need for targeted immunomodulatory approaches. These insights have profound implications for developing novel therapeutic strategies. Building on approaches used in transplantation medicine, emerging evidence supports the potential role of intravenous immunoglobulins, hydroxychloroquine, and targeted inflammasome inhibition in managing these obstetric syndromes. Despite these advancements, further research is required to refine diagnostic biomarkers and optimize immunomodulatory treatments. Recognizing chronic intervillositis and villitis of unknown etiology as immune rejection syndromes not only enhances our understanding of immune tolerance but also offers new avenues for integrating transplant-derived immunomodulatory strategies into obstetric care. A multidisciplinary approach involving obstetricians, immunologists, and transplant specialists will be essential in translating these insights into clinical practice.","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"39 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145153521","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Educational Experience and Ethical Tensions in Pelvic Exam Training: A Mixed-Methods Study in the Obstetrics and Gynecology Clerkship.","authors":"Michelle L Shui,Monica L Lypson,Taylor B Sewell,Rini B Ratan,Said S Saab","doi":"10.1016/j.ajog.2025.09.035","DOIUrl":"https://doi.org/10.1016/j.ajog.2025.09.035","url":null,"abstract":"BACKGROUNDThe pelvic exam is used in the evaluation of many gynecologic complaints. Providers across all specialties should be able to perform this exam accurately with an emphasis on consent and patient comfort. The OB/GYN clerkship is an important time for medical students to develop the technique and interpersonal skills necessary to perform pelvic exams on patients assigned female at birth. Graduating students should be able to independently perform these examinations accurately and sensitively; however, students report limited exposure in the clinical setting.OBJECTIVESTo explore medical student and preceptor experiences with pelvic exam learning and teaching during the obstetrics and gynecology (OB/GYN) clerkship, and to identify barriers to student participation in pelvic exams on awake patients in the clinical setting.STUDY DESIGNThis was a prospective, mixed-methods study of medical students and OB/GYN preceptors at a large academic center between June 2024 and March 2025. The authors developed surveys using a modified Delphi process and refined them through cognitive interviews. Students logged the number of pelvic exams they performed and completed a survey at the end of the 5-week clerkship. Preceptors were surveyed via email. Quantitative analysis included descriptive statistics and nonparametric tests. Qualitative data from open-ended survey responses were analyzed inductively to identify key themes.RESULTSAmong 93 student respondents (out of 102, 91.2% response rate), the average number of exams performed per student was 4.25 speculum and 2.17 bimanual exams. Students at the academic center performed significantly fewer exams than those at the community hospital. Over half of students (51.6%, 48 of 93) did not perform any bimanual exams. Cisgender male students performed fewer speculum exams than cisgender female students (p&lt;.01). Students reported increased confidence and reduced anxiety with pelvic exams after the clerkship. Simulation and gynecologic teaching associate sessions were rated as helpful, but students emphasized the need for real clinical opportunities. Among 89 preceptor respondents (out of 171, 52.0% response rate), barriers to student participation included patient preference, exam complexity, time constraints, and institutional culture. Preceptors at the academic center cited time constraints (p&lt;.01) and institutional culture (p&lt;.01) more often than those at the community hospital.CONCLUSIONSIn this single-institution study, despite improved confidence, many students performed few pelvic exams during the OB/GYN clerkship. Preceptor behavior, institutional culture, and clinical context significantly impacted student opportunity. While these findings may not be generalizable to all institutions, they underscore the importance of supplementing clinical training with simulation, engaging preceptors, and clarifying policies around student participation and patient consent so that students can meet pelvic exam learning","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"759 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145153295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prophylactic oxytocin dose following vaginal birth to prevent postpartum hemorrhage: A systematic review and dose-response meta-analysis.","authors":"Vanessa Hébert,Rohan D'Souza,Nancy Santesso,Dena Zeraatkar,Irina Oltean,Meagan Furnivall,Behnam Sadeghirad,Elizabeth K Darling","doi":"10.1016/j.ajog.2025.09.034","DOIUrl":"https://doi.org/10.1016/j.ajog.2025.09.034","url":null,"abstract":"OBJECTIVEA systematic review and dose-response meta-analysis assessing the effect of different oxytocin prophylaxis doses on preventing postpartum hemorrhage after vaginal birth.DATA SOURCESMEDLINE, EMBASE, CINAHL, Web of Science, Global Health, CENTRAL and ClinicalTrials.gov (inception - June 9, 2025), along with reference lists of eligible trials.STUDY ELIGIBILITY CRITERIARandomized controlled trials comparing different intravenous or intramuscular doses of prophylactic oxytocin, or a single prophylactic dose with no oxytocin, following vaginal birth were included.METHODSTwo authors independently evaluated studies for inclusion and risk of bias. A random-effects dose-response meta-analysis was conducted using a one-stage approach with a restricted maximum likelihood heterogeneity estimator and modelled using restricted cubic splines to detect departure from linearity. Certainty of evidence was assessed using GRADE methodology. Sufficient data were available to undertake a dose-response meta-analysis for blood loss ≥1000 mL, mean blood loss, blood transfusion, and use of additional uterotonics.RESULTS13 studies involving 8,961 participants were included, with oxytocin doses ranging from 2.5 and 80 IU. A J-shaped, non-linear relationship was observed for blood loss ≥ 1,000 mL, mean blood loss, and use of additional uterotonics. Doses of 4 to 10 IU resulted in 6 to 7 fewer individuals per 1,000 experiencing blood loss ≥ 1,000 mL (high certainty; risk with no oxytocin: 19 per 1,000 individuals), likely 10 to 12 fewer individuals per 100 requiring additional uterotonics (moderate certainty; risk with no oxytocin: 26 per 100 individuals), but likely resulted in little to no difference in mean blood loss (moderate certainty). Lower doses (2.5-3 IU) likely reduced the risk of severe blood loss (moderate certainty) and may reduce additional uterotonic use (low certainty). At 20 IU, the risk of severe blood loss was probably reduced (moderate certainty), with possible diminishing returns at higher doses (low certainty). Additional uterotonics may increase at doses ≥20 IU (low certainty). No dose-response relationship was observed for blood transfusion.CONCLUSIONAvailable evidence suggests the optimal range for oxytocin prophylaxis after vaginal birth is 4 to10 IU, with lower doses within this range offering the best balance of efficacy and safety. However, limitations in the evidence base, including narrow dose ranges, underrepresentation of high-risk populations, and inconsistent reporting of safety outcomes, highlight the need for further research across clinical contexts.","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"321 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145153519","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outcome of supra-cervical compared to total hysterectomy for emergency peri-partum hemorrhage: a systematic review and meta-analysis.","authors":"Alessandro Lucidi,Eric Janiaux,Danilo Buca,Albaro Jose Nieto-Calvache,Asma Khalil,Giuseppe Rizzo,Jose Palacios-Jaraquemada,Conrado Coutinho,Maria Elena Flacco,Lamberto Manzoli,Francesco D'Antonio","doi":"10.1016/j.ajog.2025.09.033","DOIUrl":"https://doi.org/10.1016/j.ajog.2025.09.033","url":null,"abstract":"OBJECTIVESTo report the outcome of patients undergoing supracervical (SCAH) compared to total (TAH) abdominal emergency peripartum hysterectomy (EPH) for postpartum hemorrhage (PPH).DATA SOURCESA systematic search was conducted in Medline, Embase, and Cochrane Library from January 2000 to December 2024, using MeSH terms and keywords related to peripartum hysterectomy and maternal outcomes.STUDY ELIGIBILITY CRITERIASTUDY DESIGN: Observational cohort and case-control studies.POPULATIONPatients undergoing emergency SCAH vs. TAH for PPH within 24 hours of delivery.EXCLUSION CRITERIAStudies exclusively reporting cases with placenta accreta spectrum (PAS), case reports, conference abstracts, and studies with <10 cases per arm.STUDY APPRAISAL AND SYNTHESIS METHODSTwo independent reviewers screened studies, extracted data, and assessed quality using the Newcastle-Ottawa Scale (NOS). Head-to-head meta-analyses were conducted using random-effects models. Heterogeneity (I2) and publication bias were assessed.RESULTS25 studies were included, analyzing 1,478 patients (715 SCAH, 763 TAH). No significant differences were found in maternal mortality (p=0.532), ICU admission (p=0.415), reoperation (p=0.884), or major complications (p>0.05). SCAH was associated with: Lower risk of ureteric injuries (OR: 0.38, 95% CI 0.18-0.77; p=0.007). Reduced estimated blood loss (EBL) (MD: -446.03 mL, 95% CI -747.72 to -144.35; p=0.004). Fewer blood transfusions (MD: -1.46 units, 95% CI -2.37 to -1.14; p=0.002). Shorter operative time (MD: -53.22 min, 95% CI -86.48 to -19.95; p=0.002) CONCLUSION: SCAH appears to offer advantages over TAH in emergency PPH cases, particularly in reducing ureteric injuries, operative time, and blood loss. However, heterogeneity and lack of standardized PAS diagnosis criteria limit the generalizability of findings. Future research with standardized protocols is required to refine surgical decision-making.","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"11 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145140362","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Catheter removals after cesarean deliveries (Letter-to-the-Editor).","authors":"David M Haas,Krista Wagner,Maryann Chimhanda","doi":"10.1016/j.ajog.2025.09.023","DOIUrl":"https://doi.org/10.1016/j.ajog.2025.09.023","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"39 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145093547","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Continuous glucose monitoring: criteria for the diagnosis of type 2 diabetes mellitus with clinical obesity after gestational diabetes.","authors":"Cristina Gómez Fernández,Rea Mitsigiorgi,Micaela Fochini,Angel Leung,Cristina Fernández Pérez,Kypros H Nicolaides","doi":"10.1016/j.ajog.2025.09.031","DOIUrl":"https://doi.org/10.1016/j.ajog.2025.09.031","url":null,"abstract":"OBJECTIVETo compare Continuous Glucose Monitoring (CGM) to American Diabetes Association (ADA) criteria, in the postpartum period in women who had developed gestational diabetes (GDM) during their recent pregnancy, for diagnosis of type 2 diabetes (DMT2) complicated by clinical obesity.STUDY DESIGNBetween September 2023-April 2025, we conducted a multiproposal cohort study at King's College Hospital, London, UK. We invited consecutive women with and without GDM at 5-months postpartum. GDM patients were also invited for a 1-year follow-up clinic. Blinded CGM (Dexcom G7; Dexcom, San Diego, CA) was performed for 10 days. The primary outcome was T2DM with clinical obesity, defined by first, the ADA criteria (HbA1c ≥6.5%, FPG ≥126 mg/dL, or 2-hour OGTT of ≥200 mg/dL), and second, CGM average glucose ≥131.5 mg/dL, which is the mean + 2SD of our non-GDM group. Clinical obesity was defined by the recently published The Lancet Diabetes and Endocrinology Commission, as excess body fat directly affecting the function of organs and tissues.RESULTSWe examined 1,118 women, including 276 (24.7%) non-GDM controls at 5- months postpartum, 539 (48.2%) post-GDM at 5-months postpartum and 303 (27.1%) post-GDM at 1-year postpartum. In the non-GDM group the mean + 2SDs average glucose was ≥131.5 mg/dL. At 5-months postpartum in the GDM group, CGM classified 8.9% (48/539) women as DMT2 with clinical obesity and the respective value by the ADA criteria was 4.3% (23/539). Women diagnosed by CGM but not the ADA criteria (n=35) had a worse cardiometabolic profile than those diagnosed by the ADA criteria alone (n=10). Out of the 35 additional cases, classified only by CGM, 26 attended to the 1-year postnatal clinic and all still had an average glucose ≥131.5 mg/dL measured by CGM and abnormal cardiometabolic profile.CONCLUSIONSPostpartum follow-up in women who had GDM should not only focus on dysglycemia but on their cardiometabolic profile. In this respect, CGM is superior to ADA criteria for diagnosis of DMT2 with clinical obesity.","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"77 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145093548","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Discussing the implementation of a restrictive use of episiotomy in operative vaginal delivery in nulliparous women (Reply to Letter-to-the-Editor).","authors":"Bertrand Gachon,Yoann Foucher,Xavier Fritel","doi":"10.1016/j.ajog.2025.09.026","DOIUrl":"https://doi.org/10.1016/j.ajog.2025.09.026","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"4 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145093545","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"AJOG GR Table of Contents","authors":"","doi":"10.1016/S0002-9378(25)00561-7","DOIUrl":"10.1016/S0002-9378(25)00561-7","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"233 4","pages":"Page A10"},"PeriodicalIF":8.4,"publicationDate":"2025-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145095367","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"AJOG MFM Table of Contents","authors":"","doi":"10.1016/S0002-9378(25)00560-5","DOIUrl":"10.1016/S0002-9378(25)00560-5","url":null,"abstract":"","PeriodicalId":7574,"journal":{"name":"American journal of obstetrics and gynecology","volume":"233 4","pages":"Page A9"},"PeriodicalIF":8.4,"publicationDate":"2025-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145095366","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}