Importance: Nonalcoholic steatohepatitis/nonalcoholic fatty liver disease (NASH/NALFD) is coupled with a substantial risk of morbidity and mortality and is increasingly identified as a comorbidity in pregnancy. Information about the effect of NAFLD on pregnancy and perinatal outcomes is incomplete. Objectives: This review examines the etiology, pathophysiology, risk factors, diagnosis, management, maternal and perinatal outcomes, and recurrence risk in pregnancies complicated by NASH/NALFD. Evidence Acquisition: Electronic databases searched were (PUBMED and Embase). The search terms used were “pregnancy” OR “perinatal care” AND “nonalcoholic steatohepatitis” OR “NASH” OR “NALFD” OR “nonalcoholic fatty liver disease. The search was limited to the English language, but not to the years searched. Results: There were 515 abstracts identified, of which 73 are the basis of this review. NAFLD is seen as the hepatic manifestation of the metabolic syndrome (abdominal obesity, low HDL cholesterol, elevated fasting glucose, overweight/obese body mass index). The overall prevalence among pregnant women with NAFLD from a large prospective study was 14%. Consistent risk factors of NAFLD in pregnancy include prepregnancy obesity, metabolic syndrome, type 2 diabetes, and polycystic ovarian syndrome. Diagnosis is confirmed by steatosis, ballooning, and inflammation on liver biopsy. Treatment is primarily weight reduction and lifestyle modifications. Maternal complications during pregnancy include gestational diabetes, hypertension, cesarean delivery, postpartum hemorrhage, and congestive heart failure. Fetal complications include spontaneous abortion, fetal growth restriction, large-for-gestational-age neonates, and preterm birth. Conclusions: The increase in NAFLD in pregnancy parallels the increase in maternal obesity and metabolic syndrome. Unfavorable pregnancy outcomes include hypertensive disorders of pregnancy, cesarean delivery, postpartum hemorrhage, congestive heart failure, early pregnancy losses, fetal growth restriction, large neonates, and preterm deliveries. Management primarily consists of weight reduction and lifestyle modifications. Relevance: The escalating rate of overweight or obese women who become pregnant and the neonates of these women, both of which are being diagnosed with NAFLD at an increasing rate, is very worrisome. Particularly since our only current treatment is weight reduction and lifestyle modifications, neither of which, to date, has been very successful in maternal weight reduction.
Importance: Congenital diaphragmatic hernia (CDH) has significant implications for neonatal morbidity and mortality that require multidisciplinary antenatal and post-delivery care. Objective: To describe the current evidence behind the etiology, diagnosis, and management of congenital diaphragmatic hernia, with specific attention to risk stratification, multidisciplinary management strategies, fetal cardiovascular morbidity, genetic evaluation, and surgical management of this condition. Evidence Acquisition: Evidence for this review was acquired through a comprehensive search of PubMed-indexed articles using MeSH terms and text to search for concepts related to “Congenital Diaphragmatic Hernia,” “prenatal diagnosis,” “genetics,” “fetal therapy,” “embryology,” “extracorporeal life support,” “surgical management,” “prognosis,” and their synonyms. Results: Neonatal survival and long-term outcomes vary by severity of CDH and are primarily driven by the development of pulmonary hypoplasia. Various factors, including the amount of measurable fetal lung tissue, stomach and liver position, side (right vs. left) of CDH, underlying genetic diagnoses, and concomitant anomalies (especially cardiac) contribute to the prognosis in the setting of prenatally diagnosed CDH. Given the need for multidisciplinary care coordination and anticipated postnatal surgical management, patients identified with a CDH in their fetus should be referred to a tertiary center for antenatal surveillance and delivery. Conclusions and Relevance: CDH is associated with high morbidity and mortality; continued attention to prenatal diagnosis and multidisciplinary management of this condition may help improve the quality of life for affected patients.
Despite greater risk for neonatal and surgical complications, nearly one-third of babies in the United States are delivered through cesarean section. Previous efforts to reduce the rate of primary cesareans using labor guideline changes have proved unsuccessful. However, prior research showed that certified nurse midwife (CNM) management of labor for low-risk patients is associated with fewer interventions and lower rates of unplanned cesarean delivery compared with obstetrician (OB) management. Less than 10% of all US births are attended by CNMs, suggesting a possible avenue for reducing unplanned cesarean section rates. This study evaluated delivery mode, labor interventions, and maternal and neonatal outcomes for patients who were managed intrapartum by CNMs versus OBs. This retrospective cohort study included patients who delivered at a single academic tertiary hospital between 2013 and 2018. Eligible patients were 18 to 50 years old with term, singleton, vertex pregnancies and an attempted vaginal birth. To expand on previous research, both nulliparous and multiparous, induced and spontaneous labor, and labor after cesarean cases were included. Patients were excluded if they had planned cesarean delivery, multiple gestation, major fetal anomaly, fetal growth restriction, preterm birth, intrauterine fetal demise, or other high-risk conditions requiring OB management. Provider type was determined based on the admitting intrapartum provider, even if transfer occurred later for operative vaginal delivery or unplanned cesarean. Maternal, obstetric, delivery, and neonatal outcomes were abstracted from the medical record. Analyses compared CNM and OB-managed patients and adjusted for factors associated with unplanned cesarean. Of the 7694 included deliveries, 3543 were managed by OB providers and 4151 by CNMs. Patients managed by OBs had higher rates of unplanned cesarean delivery than CNM-managed patients (15.2% vs. 8.9%, P < 0.01). After adjustment for confounders, CNM management was associated with lower odds of unplanned cesarean compared with OB management (OR: 0.49, 95% CI: 0.40-0.60), which remained similarly low after stratifying by nulliparous and multiparous patients. OB-managed patients were more likely to undergo induction or augmentation of labor, neuraxial anesthesia, amniotomy, and operative vaginal delivery, while CNM-managed patients were more likely to have physiological birth. VBAC success did not differ significantly between groups. Individual adverse outcome rates varied between groups, but composite maternal and neonatal adverse outcome rates did not differ significantly. The study found that CNM intrapartum management was associated with lower rates of unplanned cesarean delivery for a cohort of mixed-risk patients at an academic hospital. These findings are consistent with prior studies and remained consistent after ACOG updated labor guidelines in 2104 in an attempt to safely reduce primary cesarean rates. The findings suggest that provider type may influence delivery mode, possibly due to differences in labor management, intervention usage, and higher motivation for vaginal delivery among CNM-managed patients. Strengths include a large, risk-diverse cohort, use of direct EMR abstraction and intention-to-treat analysis, and adjustment for known confounders. Limitations include the retrospective single-center design, nonrandom assignment to provider type, possible selection bias, and missing data on labor details. Overall, the results suggest that greater utilization of CNM intrapartum care for eligible patients could help reduce unnecessary cesarean births, though further studies are needed to clarify the mechanisms underlying differences in delivery outcomes. (Summarized from Simon NT, Agarwal T, Lijewski V, et al. Birth outcomes for obstetrician- or midwife-led intrapartum care. Birth. 2026;53:181-191. doi:10.1111/birt.70012)
Detecting abnormal growth of a fetus during pregnancy is important for clinicians to monitor and intervene when necessary. Multiple fetal growth references are used internationally to classify fetal size, including the World Health Organization (WHO) and INTERGROWTH-21st (IG21st) standards and the Swedish Maršál and Lindström references. The differences in expected fetal weight (EFW) for gestational age (GA) across these references can affect how well fetuses are identified and managed to prevent adverse perinatal outcomes. The aim of this study was to compare the four fetal weight references and assess which reference most accurately identifies infants at risk of perinatal mortality and morbidity. This was a population-based cohort study, using data from Swedish registries on antenatal, obstetric, neonatal care, and postnatal deaths. Included were 1,126,059 singleton, term births in Sweden from 2010 to 2020. Excluded were pregnancies with unknown GA or birthweight, GA <37+0 or >42+6 weeks, birthweight z-score >5 or <−5 SD from the mean for GA and sex, and structural malformations or chromosome aberrations. The 4 references included the Lindström reference, which covers the longest gestational span of 12 to 42 weeks (n=585 women in the study population); the Maršál reference, which begins at 25 weeks (n=86 women); and the WHO and IG21st growth, which end at 40 weeks (n=1362 and 4231, respectively). Small-for-gestational age (SGA) was defined as birthweight <3rd centile and <10th centile. Large-for-gestational age (LGA) was defined as EFW or birthweight >90th and >97th centile. Models to assess the predictive performance of the 4 references were designed to assess adverse perinatal outcomes, including perinatal death, serious neonatal morbidity, severe asphyxia, hypoxic ischemic encephalopathy, neonatal sepsis, neonatal resuscitation ≥10 minutes, admission to the neonatal ward, metabolic acidosis, Apgar score <6 at 10 minutes, or fetal distress requiring instrumental or cesarean delivery. Sensitivity and false-positive rates were calculated for SGA thresholds. The proportion of infants classified as SGA <3rd centile were 9.6% for the Lindström reference, 2.5% for Maršál, 1.9% for WHO, and 0.7% for IG21st. The proportion of infants classified >97th centile was 1.7% for Lindström, 4.1% for Maršál, 4.2% for WHO, and 14.4% for IG21st. Stillbirth and neonatal death occurred in 1.5 and 0.2 per 1000 births, respectively. When SGA was defined as <3rd centile, stillbirth sensitivity was 28.9% with the Lindström, 11.8% for Maršál, 11.3% for WHO, and 6.0% for IG21st, while false-positive rates ranged from 9.6% for Lindström to 0.7% for IG21st. A similar pattern was observed for detecting neonatal death and serious neonatal morbidity using SGA <3rd and <10th centiles, with the highest sensitivity and false-positive rate for Lindström and lowest for IG21st. In conclusion, all 4 references were comparable in predicting adverse perinatal outcomes. However, they differed in fetal size classification, sensitivity, and false-positive rates. The Lindström reference identified more at-risk infants but generated higher false-positive rates, while IG21st identified fewer at-risk infants and had lower false-positive rates. (Summarized from Lindström L, Ahlsson F, Axelsson Ove, et al. Differences in prediction of adverse perinatal outcome in term pregnancies by choice of fetal growth reference: A validation study. Acta Obstet Gynecol Scand. 2026; 105:466–478. doi: 10.1111/aogs.70136).
Asymptomatic microscopic hematuria (AMH) is often a benign condition, but it is occasionally associated with occult urological malignancy and the diagnosis often delayed in patients of African American descent. Previous literature has shown that health care disparities contribute to a reduced likelihood of these African American patients to receive the recommended evaluation for AMH. In addition, if AMH is associated with malignancy, prognosis is often poor due to the greater likelihood of advanced disease at diagnosis. This article is a commentary on the guidelines surrounding AMH and clinical implications surrounding them. Clinicians may sometimes be less likely to assess female patients for AMH because of the high rate of negative testing or a tendency to attribute findings of AMH to other causes. A recent meta-analysis showed that 859 patients would need to be evaluated to signal one urinary tract malignancy, meaning that there is a high cost burden associated with this screening. However, the American Urological Association (AUA) guidelines have previously not been gender-specific, and many of the test characteristic data surrounding AMH came from male-predominant populations. In 2012, AUA recommended that all women aged over 35 with unexplained AMH have a full evaluation, which was followed by a joint declaration by the American College of Obstetricians and Gynecologists (ACOG) and American Urogynecologic Society (AUGS) recommended that low-risk women between the age of 35 and 50 undergo evaluation only at a higher threshold. Updated guidelines released by AUA with the Society of Urodynamics/Female Pelvic Medicine and Urogenital Reconstruction (SUFU) in 2020 and 2025 included risk-stratified recommendations for evaluation for women with AMH. The newest AUA/SUFU recommendations for women are mostly consistent with the ACOG/AUGS recommendations, although the age cutoff and inclusion of intermediate risk are notable differences. Risk factors for intermediate risk of malignancy include irritative lower urinary tract symptoms, prior pelvic irradiation, history of cyclophosphamide/ifosfamide chemotherapy, family history of urothelial carcinoma or Lynch syndrome, occupational exposure to benzene chemicals or aromatic amines, and chronic indwelling urinary tract foreign body. These provide a more nuanced approach to evaluation for malignancy in patients with AMH, optimizing potential costs while not sacrificing the earlier detection of malignancy that should be treated. Future research should assess the effects of race and other sociodemographic factors on rates of evaluation and treatment. (Summarized from Asfaw TS, Rickey LM, Jeppson PC. Risk-stratified evaluation of asymptomatic microscopic hematuria in women: clinical implications of new guidelines. Urogynecology (Phila) . 2026; 32(6):567-568. doi:10.1097/SPV.0000000000001838)
Traditionally, early-stage cervical cancer has been treated with radical hysterectomy and lymphadenectomy.Recently, this approach has changed due to advances in understanding the disease, surgical approaches and the adoption of the idea that radical procedures are not necessary for all patients. The concept of surgical de-escalation in cervical cancer is increasing in traction. Examples of de-escalation include sentinel lymph node mapping, simple hysterectomy, fertility-sparing surgery, intraoperative assessment to tailor surgical extent, and neoadjuvant treatment. These reflect the growing shift toward individualized care in cervical cancer. This review summarizes the evidence for de-escalation in surgical management for cervical cancer. Radical hysterectomy was introduced in 1895, and in 1911 a landmark study was published showing its significantly improved rates of mortality and cure. In 2018, the first study comparing minimally invasive to open radical hysterectomy (the LACC trial) showed inferior disease-free and overall survival in patients who underwent minimally invasive surgery compared with open surgery, prompting guidelines recommending open radical hysterectomy as the standard of care. There are 2 ongoing trials comparing robotic radical hysterectomy to open radical hysterectomy, but results are not yet published. Surgical complications linked to radical hysterectomy mainly stem from the removal of the parametrium, which is performed to remove metastatic spread beyond the cervix; most patients, particularly those with low-risk disease, do not have parametrial involvement and do not need this resectioin . In this subset of individuals, simple hysterectomy has been explored as a less invasive alternative to open radical hysterectomy, and research has supported this by showing no significant difference in overall survival at 5 years. Several studies of both prospective and retrospective design have shown similar results. Recent guidelines also reflect these findings and recommend simple hysterectomy for patients with low-risk early-stage cervical cancer. Previously, comprehensive pelvic lymphadenectomy was the standard for assessment of pelvic nodal status, though the rate of positive nodes in early-stage disease is low. Multiple studies have assessed the accuracy of sentinel lymph node assessment for cervical cancer and have found that the sensitivity and negative predictive values were efficacious. Oncologic outcomes of this procedure have been favorable, though this applies to a select subset of low-risk patients. Current recommendations also suggest that sentinel lymph node biopsy can replace pelvic lymphadenectomy. When lymph node involvement is found during surgery, studies show that combined morbidity of surgical and medical management is high. One study showed no significant differences between completed and abandoned hysterectomy for recurrence and overall survival, as well as the absence of a survival benefit from completing the surgery. These findings were replicated in subsequent studies, but current guidelines vary widely based on location. Administration of preoperative brachytherapy has been proposed to reduce the need for adjuvant postoperative radiotherapy; systematic reviews and retrospective analyses have shown that this method resulted in a higher rate of no residual disease and lower rates of the need for adjuvant radiotherapy. As treatments evolve, select patients may benefit from less invasive procedures, but care should be taken in surgical planning and practicing individualized care. (Summarized from Viveros-Carreño D, Agustí N, Mora-Soto N, et al De-escalation in definitive surgical management for cervical cancer. Int J Gynecol Cancer . Volume 36, Issue 3 102711 March 2026)
Importance: Wilson disease (WD) is a rare genetic disorder that results in an accumulation of excess copper and can severely impact quality of life through its effects on numerous organ systems. Less is understood, however, about how WD alters the female reproductive system, where its impact is suspected to be wide-ranging. Objective: To provide an overview of the impact of WD on various aspects of women’s health, including menstruation, fertility, pregnancy, and menopause. Key considerations and recommendations for management are highlighted throughout. Evidence Acquisition: Articles were obtained through a literature search of PubMed and Google Scholar. Results: WD impacts multiple aspects of women’s health. WD may lead to delayed menarche, amenorrhea, and decreased fertility. Timely treatment can largely diminish these effects. WD’s neuropsychiatric and hepatic manifestations, along with its respective medical therapy, may lead to higher rates of sexual dysfunction. There are many safe contraceptive options available for patients with WD. Treatment should be continued throughout pregnancy, although there are no conclusive guidelines. The safety of breastfeeding in patients with WD is under-studied. Lastly, WD is not known to directly impact menopause. Conclusions: Complete care of female patients with WD requires consideration of its impact on various stages of the reproductive lifespan. Thus, an interdisciplinary team is an important component of optimizing care. Primary research in the field remains limited, and further studies are necessary to advance evidence-based care. Relevance: This review highlights the latest evidence regarding how WD affects women’s health, along with recommendations for best management.
Graves disease is an autoimmune disease characterized by thyrotropin receptor antibodies (TRAbs), which can cross the placenta and cause fetal or neonatal thyroid dysfunction. Neonatal hyperthyroidism is uncommon, but more likely when maternal TRAb levels are elevated. Therefore, monitoring this value is used for risk assessment, but guidelines are limited by small studies, differing TRAb assays, and a lack of trimester-specific thresholds, especially for patients with a history of Graves disease who became euthyroid following treatment. Because TRAb testing is often first performed in the third trimester, earlier fetal thyroid dysfunction may be missed. This study evaluated whether trimester-specific TRAb thresholds could improve the prediction of fetal and neonatal hyperthyroidism or hypothyroidism in pregnant patients with active or prior Graves disease. This prospective observational study was conducted at 44 Dutch centers and enrolled pregnant patients 18 years old or above with active Graves disease or a history of Graves disease. Patients with multiple gestations or missing fetal/neonatal diagnostic data were excluded. Participants received routine obstetric and endocrine care, including fetal heart rate monitoring and fetal thyroid ultrasound antenatally, and cord blood sampling, neonatal examination, and neonatal thyroid function testing after delivery. Maternal TRAb levels were measured during each trimester using a centralized chemiluminescence assay, and neonatal thyroid function was assessed via TSH and free T4 measurements. The primary outcome was overt fetal or neonatal hyperthyroidism, defined biochemically as suppressed TSH alongside elevated free T4 in the setting of elevated maternal TRAbs. Logistic regression and ROC analyses were used to assess the association between TRAb levels and fetal/neonatal thyroid dysfunction and to find thresholds that maximized sensitivity. The study included 678 pregnancies, of which 500 involved patients with a history of Graves disease and 178 involved active Graves disease. Fetal/neonatal hyperthyroidism was more common with active Graves than prior Graves disease (6.7% vs. 2.6%, P =0.01). Maternal TRAb titers were significantly higher in active cases across all trimesters, with titers declining at similar rates throughout pregnancy in both groups. Among patients with a history of Graves disease, thresholds of 27, 21, and 7 IU/L in the first, second, and third trimesters, respectively, achieved 100% sensitivity and 96% to 99% specificity. In patients with active Graves disease, trimester-specific thresholds of 11, 13, and 11 IU/L identified most cases of fetal/neonatal hyperthyroidism, but positive predictive value varied, with only 29% of patients above the first-trimester threshold later developing hyperthyroidism. In a subset of patients, assay comparison showed that TRAb values differed between testing platforms. These findings demonstrate the value of trimester-specific TRAb titer measurements and suggest that TRAb thresholds may be most useful for ruling out fetal/neonatal complications in patients with a history of Graves disease. This could reduce unnecessary repeat testing following subthreshold values in the first trimester. In contrast, for patients with active Graves disease, neonatal hyperthyroidism still occurred in some cases below the identified thresholds, particularly in those receiving antithyroid drugs with low TRAb levels. Continued fetal and neonatal surveillance throughout pregnancy remains warranted in patients with active Graves disease. The findings also caution against using a single TRAb threshold for all assays and instead support the creation of assay-specific standards. Strengths include the large multicenter cohort, prospective design, centralized testing, and trimester-specific analysis. Limitations include missing TRAb measurements in some trimesters and limited assay comparison data. (Summarized from Saleh L, Schreurs MWJ, Boersma E, et al. Maternal TSH-receptor antibodies predict fetal/neonatal hyperthyroidism in pregnancies with a history of Graves disease. J Clin Endocrinol Metab. 2026; 111: e2161-e2170. doi:10.1210/clinem/dgag118).
Maternal mortality and severe maternal morbidity (SMM) are urgent public health concerns in the United States. The rates of maternal mortality continue to exceed those of peer nations per capita and have racial, geographic, and socioeconomic disparities. Nearly 2% of births are complicated by SMM, and most pregnancy-related deaths are considered preventable. Leading causes of maternal mortality include infection, mental health conditions, substance use disorders, cardiovascular disease, hemorrhage, and hypertensive disorders. Perinatal Quality Collaboratives (PQCs) were established in all 50 states, the District of Columbia, and the Armed Forces to implement evidence-based quality-improvement (QI) initiatives. This commentary describes how PQCs improve maternal outcomes and reduce disparities. PQCs are statewide partnerships that bring together hospitals, clinicians, public health agencies, payers, and community stakeholders to implement evidence-based practices. Common strategies for PQCs to achieve change at scale include hospital engagement, QI methodology including rapid-cycle data review, data to drive improvement, collaborative learning, technical assistance, and strategic partnerships. The authors highlighted 4 state examples: The Louisiana Perinatal Quality Collaborative incorporates respectful patient partnership in its health equity initiatives as part of its QI efforts. The Illinois Perinatal Quality Collaborative built strategies to embed equity and patient and community partnerships into its QI processes. The California Maternal Quality Care Collaborative was able to reduce the risk of Black to White SMM in patients experiencing hemorrhage from 1.46 to 1.22. The Iowa Perinatal Quality Care Collaborative decreased the rate of singleton, cesarean deliveries in publicly insured patients compared with commercially insured patients. While PQCs have focused on QI in traditional labor and delivery settings, emergency departments (EDs), emergency medical services, and ambulatory care are noted as areas for expansion. Examples include an ED obstetric-readiness initiative and outpatient postpartum depression screening in Louisiana, simulation-based training for counties without obstetric services in Iowa, outpatient programs targeting perinatal mental health and substance use disorders in Illinois, and prenatal use of low-dose aspirin to manage prenatal anemia in California. State PQCs serve as partners to public health systems, hospitals, clinicians, and communities to bring evidence-based recommendations into practice. The authors recommend continuing to incentivize change through external sources, such as the Joint Commission or Leap Frog; using clinical champions who prioritize QI to improve patient care and outcomes; and securing stable funding to sustain the efforts of PQCs. (Summarized from Radke S, Borders A, Gillispie-Bell V, et al. The role of state Perinatal Quality Collaboratives in addressing maternal morbidity and mortality. Obstet Gynecol. 2026; 147: 769-779. doi:10.1097/AOG.0000000000006239).
Cystic fibrosis (CF) is a multisystem genetic disease caused by pathogenic variants in the cystic fibrosis transmembrane receptor ( CFTR ) gene, leading to abnormal function in the lungs, pancreas, intestines, and other organs. CFTR modulators (CFTRm), small molecule therapies for CF, have significantly improved disease prognosis. As a result, more patients with CF can conceive, and pregnancy has become more common. While data surrounding CFTRm use during pregnancy are limited, the significant risk of untreated CF on maternal and pregnancy outcomes means that many patients opt to continue CFTRm during gestation. In addition, CF begins to manifest before birth, with potential in-utero complications like pancreatic injury and meconium ileus. This review article summarizes pregnancy safety data, animal studies, and emerging case reports with prenatal CFTRm therapy for fetuses affected by CF. Available data are generally reassuring for patients with CF who continue CFTRm during pregnancy. Continuation has been associated with preserved maternal lung function, while discontinuation has been linked in some cases to clinical decline that resolves when therapy is restarted. These medications can cross the placenta, with fetal levels equal to or higher than maternal levels, and are present at low levels in breastmilk. Some safety concerns remain, including rare hepatotoxicity, and complications seen in animal models include development of cataracts and drug accumulation in the fetal brain. However, in a CF ferret model, in utero ivacaftor prevented intestinal disease, preserved exocrine pancreatic function, and preserved the vas deferens in male offspring. This supports the possibility that treatment before birth could protect against some fetal CF manifestations. Human data on CFTRm during pregnancy remain limited but suggest possible fetal benefits. Twenty published cases describe prenatal CFTRm use in unaffected pregnant carriers whose fetuses were diagnosed with CF. Most received standard adult dosing of elexacaftor/tezacaftor/ivacaftor (Trikafta or triple therapy) after invasive prenatal diagnosis. Among 15 fetuses with meconium ileus who were treated through maternal CFTRm during pregnancy, ultrasound findings resolved before delivery in 10 cases. Findings were less likely to resolve when treatment began later or when complications such as volvulus, meconium peritonitis, or meconium pseudocyst were already present. Among published cases, the mean gestational age at diagnosis of meconium ileus was 23.8 weeks, while treatment began at a mean of 30.4 weeks, reflecting delays in diagnosis and access to therapy. Several reports also described preserved or borderline pancreatic function and lower-than-expected sweat chloride levels. Because prenatal treatment can reduce biochemical signs of pancreatic injury, newborn screening may be falsely negative, so infants with known prenatal CF diagnoses still need postnatal diagnostic evaluation. Prenatal CFTRm therapy is promising but remains investigational. Standardized guidelines for treatment have not been created, and care should include multidisciplinary counseling, genetic confirmation of fetal CF, maternal liver function monitoring, fetal ultrasound surveillance, and postnatal follow-up. Significant unanswered questions include the optimal timing of treatment, minimum effective dose, neurodevelopmental safety, and whether treatment should continue after birth to avoid withdrawal effects. Access is also a major ethical issue because therapy is expensive and insurance delays can push treatment later into gestation. Overall, the review suggests that prenatal CFTRm may prevent or improve fetal manifestations of CF, particularly meconium ileus, but prospective studies are needed before this approach can become routine care. (Summarized from Zaretsky MV, Blumenfeld YJ, Szentpetery SS, et al Translating emerging data for fetal treatment of cystic fibrosis. Prenat Diagn. 2026;46:417-423. doi:10.1002/pd.70098)
The prevalence of obesity has been rising in the United States over the past decades. It is a major contributor to all-cause mortality, cancers, cardiovascular disease, diabetes, and other morbidities. It also contributes to increased health care costs. The aim of this study is to estimate trends in the prevalence of obesity in the United States from 1990 to 2022 and estimate the prevalence through 2035, based on age, sex, race, ethnicity, and state. This was a cross-sectional analysis of body mass index (BMI) from nationally representative survey data. Estimates were modeled from 11,243,644 participants in the Behavior Risk Surveillance System (BRFSS) and Gallup Daily Survey, plus 71,777 participants from the National Health and Nutrition Examination Survey (NHANES). Obesity was defined as a BMI ≥30. Estimates through 2035 were generated using an ensemble modeling approach. Analyses were stratified by sex and race/ethnicity, including Hispanic, non-Hispanic Black, and non-Hispanic White populations. The prevalence of obesity among individuals 20 years or older increased from 19.3% [95% uncertainty intervals (UI), 17.3% to 21.3%] in 1990 to 42.5% (95% UI, 40.2% to 45.0%) in 2022. By 2035, the prevalence of obesity was estimated to increase to 126 million individuals, or 46.9% (95% UI, 43.9% to 49.9%) of the adult population in the United States. Disparities were observed across race and ethnicity and age. In 2022, obesity prevalence was highest among non-Hispanic Black females (56.9%; 95% UI, 54.1% to 59.9%), followed by Hispanic females (49.4%; 95% UI, 46.3% to 52.4%). For Hispanic males, non-Hispanic White males and females, and non-Hispanic males, the prevalence of obesity ranged from 40.1% (95% UI, 36.8% to 42.5%) to 42.6% (95% UI, 39.1% to 46.2%). Adults aged 45 to 64 years had the highest obesity prevalence, and females >35 years of age had the largest increase from 1990 to 2022. At the state level, the highest prevalence of obesity among Hispanics was in the Midwest and South in 2022 and 2035. By 2035, the prevalence was estimated to be 53.6% (95% UI, 45.1% to 59.3%) for males in Indiana and 59.5% (95% UI, 51.8% to 64.7%) for females in South Dakota. In conclusion, the prevalence of adult obesity in the United States has increased from 19.3% in 1990 to 42.5% in 2022 and is estimated to rise to 46.9% by 2035. Variation in obesity prevalence was observed across states, age, sex, race, and ethnicity. (Summarized from DeCleene NK, Kahn E, Yuan C-W. US State-Level Prevalence of Adult Obesity by Race and Ethnicity From 1990 to 2022 and Forecasted to 2035. JAMA. 2026; 335(11):975-985. doi:10.1001/jama.2025.26817).
Maternal diabetes has been linked to increases in autism spectrum disorder attention-deficit hyperactivity disorder in offspring. Yet, no interventions are available to improve the fetal neurodevelopmental effects of maternal diabetes. Metformin has been used in pregnancies complicated by type 2 diabetes mellitus (T2DM) and gestational diabetes (GDM). Compared with insulin treatment, it has a lower cost and is easier to administer. Metformin also has demonstrated neuroprotective effects in preclinical models. However, because metformin readily crosses the placenta, there are concerns that it may have long-term effects on a fetus. The aim of this study was to examine whether metformin treatment in pregnancies with T2DM or GDM is associated with beneficial changes in biomarkers of fetal brain health. This was a nested case-control study of the Medical Optimization of Management of Overt Type 2 Diabetes in Pregnancy (MOMPOD) trial. The MOMPOD trial involved pregnancies with pre-existing T2DM or GD before 23 weeks of gestation. These pregnancies were randomized 1:1 to compare metformin plus insulin (MET/INS) with insulin (INS) alone on a composite of neonatal complications. No differences between the MET/INS and INS groups were observed in the MOMPOD trial. This nested study used the maternal serum samples collected from participants between 24 and 30 weeks of gestation. In addition, there was an additional substudy among patients who elected termination of pregnancy that sampled fetal brain tissue. Fetal neuronally derived extracellular vesicles were isolated from maternal blood to assess the independent effect of metformin on the fetal brain. Three biomarkers associated with oxidative stress (Sirtuin-1 [SIRT-1]), neuroinflammation (tumor necrosis factor-alpha [TNF-α]), and apoptosis (Bcl-2-associated X protein [BAX]) were used to assess the protective effects. Correlations between extracellular vesicle biomarkers and matched fetal brain tissue concentrations were also evaluated. A total of 80 participants were included in this study—with 40 in the MET/INS group and 40 in the INS group. Those in the MET/INS group saw a 39.2% increase in fetal neuronal extracellular vesicle SIRT-1 concentrations versus INS alone ( b =0.331; 95% CI: 0.023-0.640; P =0.039). No significant differences were observed for TNF-α or BAX. A significant correlation was observed in SIRT-1 concentrations in fetal neuronally derived extracellular vesicles and corresponding fetal brain tissue concentrations ( P =0.513; 95% CI: 0.211-0.720; P =0.003). Male fetuses showed an 86.5% increase in SIRT-1 concentrations over female fetuses ( b =0.623; 95% CI: 0.345-0.900; P <0.001). In conclusion, maternal metformin treatment in pregnancies complicated by T2DM or GD was associated with increased fetal brain SIRT-1, a biomarker that has been associated with protection against oxidative stress. (Summarized from Ibarra C, Fekry B, Ugartemendia L, et al. Can maternal metformin protect the developing fetal brain? Am J Obstet Gynecol . 2026 Mar;234(3):741-751. doi: 10.1016/j.ajog.2025.10.025)
Female permanent contraception includes tubal ligation or salpingectomy (tubal PC) and is the most common form of contraception in the United States in women aged 15 to 49. Male permanent contraception (male PC), or vasectomy, is less frequently used, although it is more cost-effective and less invasive. Previous studies have shown that female patients are more likely to rely on tubal PC, though a significant percentage have the desire to use vasectomy as their primary method of contraception. Data on counseling show that many men who are eligible for vasectomy do not receive counseling about family planning in general, or about vasectomy in particular; in addition, there is a lack of data surrounding how pregnant and postpartum patients receive counseling about vasectomy. This study is designed to close that gap by evaluating how postpartum patients considered their partner’s vasectomy when pursuing tubal PC, as well as evaluating OB-GYN approaches and attitudes surrounding counseling for vasectomy. Inclusion criteria for this study were individuals with a documented desire for tubal PC at the time of delivery between March 2022 and January 2023, with English or Spanish fluency, aged 21 or above, with delivery at one of the four study sites. Interviews of patients and their delivering OB-GYN were conducted at 6 to 8 weeks postpartum. Final analysis included 65 patients and 52 OB-GYNs. While only about half of patients reported discussing vasectomy during prenatal contraceptive counseling, nearly three-quarters of OB-GYNs reported vasectomy as part of their standard counseling. Three themes were identified from this qualitative analysis, including OB-GYN lack of clarity about their role in vasectomy counseling, patients and OB-GYNs taking into account assumptions about current relationship stability and partner follow-through before permanent contraception consideration, and OB-GYN consideration of meaningful clinical factors directing patients away from vasectomy. Some clinicians refrained from counseling about vasectomy due to the absence of a male partner, their inability to provide the procedure, or other similar reasons. One clinician mentioned that they often briefly discuss vasectomy as an option but do not go into detail unless the patient specifically states that their partner is getting a vasectomy. Some patients reported needing to ask for explicit information on vasectomy rather than their practitioner volunteering the information. Some also stated that when vasectomy was not discussed during counseling, the education of their partner fell to them. Another aspect of OB-GYN counseling, including vasectomy or not, was the perceived stability of the patient’s relationship; some clinicians expressed that if they did not feel that the relationship was stable, vasectomy would be a less effective form of contraception due to the possibility of the patient having a new partner. Another concern from clinicians surrounded the ability of a partner to follow through with a vasectomy, and anecdotal evidence shows that many in this position end up with another pregnancy due to the lack of follow-through on the partner’s commitment to get a vasectomy. OB-GYNs often do offer counseling on vasectomy; however, due to several benefits for the health of their patients, there are fewer procedural risks, and vasectomy is less invasive and lower in cost. One clinician expressed that after a vaginal delivery, if a patient desires permanent contraception, she always recommends vasectomy over tubal ligation. The results of this study show that many patients who desired tubal PC after delivery did not recall receiving counseling about vasectomy as an option for permanent contraception despite most OB-GYNs thinking that they did offer it. This highlights the importance of addressing the comfort of OB-GYNs in offering this counseling and assisting patients and their partners in informed decision-making even if the partner is not present or a vasectomy will not be performed by the clinician offering counseling. Future research should attempt to develop and assess effective counseling methods for vasectomy to improve both patient education and clinician comfort in vasectomy counseling. (Summarized from Larkin S, Mubarack S, White K, et al. Consideration of vasectomy among patients desiring postpartum permanent contraception and their obstetrician-gynecologists: A United States-based study. Contraception . 2026;158:111355. doi:10.1016/j.contraception.2025.111355)
The most common gynecologic malignancy is endometrial cancer (EC), with an estimated annual case number of 69,120. Cancer and pre cancer (endometrial intraepithelial neoplasia, EIN) patients present with abnormal uterine bleeding (AUB)in 90% of cases but the risk of EC and EIN in patients with AUB is thought to be low (0.3% to 1.3%). Recent studies have shown that alterations in metabolic factors impact the risk of developing precursor diseases; obesity, insulin resistance, type 2 diabetes, and unopposed estrogen may drive EC. Recent evidence suggests that glucagon-like peptide-1 receptor agonists (GLP-1RAs) may have therapeutic potential in some obesity-related malignant neoplasms, with preclinical models showing that the combined treatment of GLP1-RAs and progestins can significantly reduce tumor cell viability of progesterone receptor tumors. Data are lacking, however, on the impact of combining GLP-1RAs with progestins on EC risk compared to progestin alone or other metabolic therapies. This study aimed to address this lack of evidence and assess the association of GLP1-RAs in combination with progestins with the risk of EC in patients with endometrial hyperplasia (EH) or other benign uterine pathology. This was a retrospective cohort study using data from TriNetX. Inclusion criteria were women aged 18 and above diagnosed with EH or benign uterine pathology and receiving progestins between May 2005 and December 2022. Benign uterine pathology was defined as AUB, submucosal leiomyoma, endometrial polyp, or simple hyperplasia, indicating these as low-risk patients. EIN and EH were indicated as high-risk patients. Exclusion criteria were hysterectomy or EC diagnosis before the index event. The primary outcome for this study was the risk of EC, and the secondary outcome was the incidence of hysterectomy. Comparisons were made between GLP1-RAs plus progestins versus progestins only, GLP1-RAs plus progestin versus metformin plus progestin, triple therapy of GLP1-RAs, progestin and metformin versus metformin plus progestin and triple therapy versus progestin only. Final analysis included 444,820 patients with a mean age of 35.5. In the first comparison, a total of 18,414 patients received GLP1-RAs and progestins, and 426,406 received progestins alone. Propensity score matching was applied to match the 2 groups, and the final analysis for this comparison included 15,747 patients in each group. A significantly lower risk of EC was shown in the GLP-1RA group compared with the progestin-only group. Subgroup analyses stratified by risk showed the same result in both high and low-risk patients. This was also true when accounting for the route of progestin administration, stratifying by body mass index (BMI), and age (51 and older). In the second comparison, 3165 patients received GLP-1RAs and progestins, and 25,957 patients received metformin and progestins. This analysis showed similar results to the first, in that the risk of EC was significantly reduced in the GLP-1RA group. In the triple therapy versus metformin plus progestin comparison, these results were again significant and consistent, as were the results from the comparison of triple therapy to progestin only. The rate of total hysterectomy was also significantly lower in the GLP-1RA group compared with progestins only, and this result was consistent between low-risk and high-risk subgroups. These results indicate that GLP-1RAs are associated with a significantly reduced risk of developing EC in patients with EH or benign uterine pathology. This result was consistent across multiple comparisons and stratifications, and across risk levels. This is consistent with previous research on the mechanisms of GLP-1RAs and EC and adds an additional level to previous research reporting reduced risk of EC with metformin plus progestins compared with progestins alone. Future research should validate these results in a prospective setting as well as attempt to reduce unmeasured confounding from medication adherence, duration, lifestyle, and socioeconomic factors. (Summarized from Yen TT, Hsieh TYJ, Lee GY, et al. GLP-1 receptor agonists plus progestins and endometrial cancer risk in nonmalignant uterine diseases. JAMA Netw Open . 2026; 9(2):e2558205. 2026. doi:10.1001/jamanetworkopen.2025.58205).
Clinical management of patients with a low prognosis for success in in vitro fertilization (IVF) remains a challenge despite advances in technology over the last several decades. Current criteria defining low prognosis include patients with 9 or fewer oocytes retrieved or poor ovarian reserve, and the prevalence of patients who meet these criteria is nearly 40% in IVF patients. Low prognosis is associated with a 50% lower cumulative live birth rate on average compared with patients with a normal prognosis. A new strategy in IVF of freezing all embryos and then proceeding with a planned frozen embryo transfer has been adopted in the last few years in the hope of avoiding unfavorable endometrial conditions due to the treatments necessary for oocyte retrieval. Previous trials have found that compared with fresh embryo transfer, this strategy yielded comparable or higher live birth rates in patients with normal or good prognosis, but there is little prospective data surrounding the implementation of this strategy in patients with low prognosis. This study aims to address this gap. This was a prospective randomized controlled trial conducted at 9 sites in China. Inclusion criteria were patients undergoing their first or second IVF cycle with or without intracytoplasmic sperm injection (ICSI) with low prognosis as defined previously. Exclusion criteria were conditions that were unsuitable for fresh embryo transfer, natural cycles for oocyte retrieval, and diagnosis of polycystic ovary syndrome, hydrosalpinx, malformed uterus, or a history of intrauterine adhesions or recurrent clinical pregnancy loss. Randomization was performed in a 1:1 ratio on the day of oocyte retrieval. Standard IVF protocols were used at the discretion of clinicians for each patient. The primary outcome for this study was live birth after first embryo transfer, defined as delivery of a neonate with heartbeat and respiratory activity at 28 weeks of gestation or later. Secondary outcomes included clinical pregnancy, singleton or twin pregnancy, pregnancy loss, ectopic pregnancy, singleton or twin live birth, birth weight, maternal complications, neonatal complications, healthy singleton live birth, and cumulative live birth of embryo transfers within 1 year of randomization. Final analysis included 838 patients, with 419 randomized to each group. A total of 62 patients who were randomized to the frozen transfer group were given fresh embryo transfers at patient request, and 31 patients who were randomized to the fresh transfer group were given frozen embryo transfers due to asynchronous development and other factors. In addition, 22 patients in the frozen embryo transfer group and 2 patients in the fresh transfer group had not undergone embryo transfer within 1 year of randomization. Intention-to-treat analysis showed a live birth rate of 40% in the fresh embryo transfer group compared with 32% in the frozen transfer group ( P = 0.009). Rates of twin live birth were also lower in the frozen transfer group, at 5% versus 9% ( P = 0.01), as was the rate of clinical pregnancy (39% vs. 47%, P = 0.02). Pregnancy loss was also more common in the frozen transfer group (31% vs. 23%, P = 0.05). No significant difference was reported in mean birth weight of singletons or twins, rates of healthy singleton live birth, obstetric or neonatal complications, congenital anomalies, or other adverse events. The cumulative live birth rate of embryo transfers within 1 year of randomization was 44% in the frozen transfer group and 51% in the fresh transfer group ( P = 0.04). Per protocol analyses showed similar results. These results indicate an overall lower success rate of IVF for patients with low prognosis undergoing frozen embryo transfer compared with fresh embryo transfer. This directly contrasts with results of previous studies in patients with normal or good prognosis. Mechanisms underlying these findings are unclear. Future research should attempt to elucidate mechanisms underlying this difference in outcomes between fresh and frozen embryo transfers in patients with low prognosis, as well as evaluating the effect of fresh versus frozen transfers in patients with other comorbid conditions. In addition, future studies should attempt to identify biomarkers that could predict the best choice of transfer strategy for each patient as well as the best number and stage of embryos to transfer in patients with low prognosis. (Summarized from Wei D, Sun Y, Zhao H, et al. Frozen versus fresh embryo transfer in women with low prognosis for in vitro fertilisation treatment: pragmatic, multicentre, randomised controlled trial. BMJ . 2025;388:e081474. doi:10.1136/bmj-2024-081474)
The most severe complication of pelvic inflammatory disease (PID) is tubo-ovarian abscess (TOA), which can include pyosalpinx, ovarian abscess, and expanding pelvic abscess. Approximately 1 in 10 women have PID, and an estimated 15% to 35% of patients who are hospitalized for PID develop TOA in the United States. Recent advances in technology and treatment options have changed the treatment course for TOA; current guidelines recommend parenteral antibiotic therapy and drainage for abscesses larger than 3 cm. Though recent guidelines also recommend that transvaginal puncture is preferred to laparoscopic drainage, no prospective or retrospective studies have compared the two approaches directly. This study was designed to assess the noninferiority of transvaginal ultrasound-guided puncture compared with laparoscopic drainage in TOA treatment. This was a prospective, randomized, parallel, monocentric, noninferiority trial conducted at Estaing University Hospital in France between October 2017 and April 2022. Inclusion criteria were women aged 18 to 43 with an uncomplicated TOA ≥2 cm on ultrasound, hemodynamically stable, without septic shock, abscess rupture, peritonitis, or suspicion of adnexal malignancy. Exclusion criteria were complicated or postoperative abscess, suspected malignancy or borderline tumor, prior TOA surgery, inaccessible abscess to transvaginal puncture, pregnancy, immunosuppression, mental disorders impairing informed consent, no fluency in French, and patients under the age of 18. Patients were randomized in a 1:1 ratio to laparoscopic drainage or ultrasound-guided transvaginal puncture performed within 24 hours. Antibiotic therapy was given to all patients according to current guidelines. The primary outcome for this study was recovery, assessed through a composite score, and biological improvement as measured by inflammatory markers. Secondary outcomes included intraoperative and postoperative complications, rehospitalization, and persistent abscess at 1 or 3 months. The noninferiority margin for this study was 0.8. Final analysis included 38 patients, with 20 in the laparoscopy group and 18 in the transvaginal puncture group. The mean age in the laparoscopy group was slightly older, as was body mass index, but there were no significant differences in abscess size, inflammatory syndrome, or bacteriology between the two groups. At day 3 post-procedure, the changes from baseline were more favorable in the transvaginal puncture group, and no significant differences were reported between groups at 1 month in primary or secondary outcomes. There were no intraoperative complications, and correction for age did not alter the results. These results indicate that transvaginal puncture of TOA is noninferior to laparoscopic drainage in terms of outcomes immediately postoperatively and in the short term. Previous studies have demonstrated the effectiveness of laparoscopic drainage, and this study supports current guidelines that recommend a preference for transvaginal puncture when possible. In addition, in this study, sedation was often sufficient for transvaginal puncture, whereas laparoscopic procedures require general anesthesia. The procedure is quicker, less invasive, and has reduced intraoperative sufentanil use as well as a shorter time to recovery. Future research should validate these findings in larger and more diverse samples, as well as assess these outcomes in patients with abscesses of different sizes. There were two repeat surgeries: one in each group, including a recurrence on day 20 in the vaginal drainage group. (Summarized from Gremeau AS, Duchon M, Pereira B, et al. Comparison of early clinical efficacy of transvaginal and laparoscopic drainage of tubo-ovarian abscesses: prospective randomized trial of noninferiority. J Minim Invasive Gynecol . 2026;33(5):622-629. doi:10.1016/j.jmig.2026.01.034)
Gynecologic disorders such as uterine fibroids, endometriosis, and polycystic ovary syndrome (PCOS) affect many women of reproductive age. The primary goal in treatment for reproductive age women is to treat the condition while preserving fertility potential. Advances in gynecologic surgery have led to the use of minimally invasive surgery (MIS) , but even this surgical approach can compromise fertility if principles for fertility preservation are not applied. This committee opinion highlights the importance of reproductive function-sparing gynecologic surgery for common benign conditions and provides recommendations for optimizing outcomes when performing benign gynecologic procedures. A procedure commonly performed for the management of pregnancy loss and retained placental tissue is dilation and curettage (D&C), which can be associated with the development of intrauterine adhesions that can affect future pregnancy. Compared with D&C using a metal curette, hysteroscopic removal is superior for fertility preservation, as it reduces the likelihood of intrauterine adhesions. Recommendations surrounding D&C include first-line medical management for pregnancy loss, a preference for hysteroscopic removal, and the avoidance of sharp curettage. In patients with low-risk early-stage cervical cancer, loop electrosurgical excision (LEEP) is an option for fertility-preserving treatment to prevent cervical cancer progression. Previous studies have reported that a short interval between LEEP and conception increases the chance of early pregnancy loss, as well as an increased risk for preterm delivery after LEEP, with a larger excision area associated with a more severe adverse outcome. If LEEP is unsuccessful, cone biopsy is the next line of treatment, which further increases the risk of adverse obstetric and gynecologic outcomes, including cervical stenosis, reduced fertility, labor dystocia, cervical insufficiency, and preterm delivery. Many of these complications are unfortunately unavoidable if LEEP or cone excision surgery are required for treatment. Hysteroscopy is the mainstay of diagnosis for uterine anomalies, polyps, myomas, adhesions, and endometrial malignancies. It is known that intrauterine instrumentation is one of the major causes of intrauterine adhesions, so procedures should be considered carefully. Recommendations surrounding hysteroscopy include adequate assessment of pathology preoperatively to reduce surgical risks, using adhesion-reducing products and temporary uterine wall separation to reduce the risk of intrauterine adhesions, and adhesiolysis using cold scissors to reduce the risk of recurrence. Myomectomy is performed to remove symptom-causing myomas and preserve the uterus. Though removal of all visible myomas may seem logical, research has shown that multiple excisions significantly reduce overall fertility outcomes. . It is recommended that only the largest and/or symptomatic lesions be removed. In addition, it is recommended that multilayered closure approaches be used to address uterine defects to restore anatomic integrity and that the use of anti-adhesion substances be employed to minimize the risk of adhesions. Extensive surgery should be avoided in adenomyosis just as in myomectomy if fertility is to be preserved. Treatment and removal of ovarian endometriomas focuses on only removing these if they are impacting fertility or quality of life. If they must be removed, fertility preservation should be attempted using techniques such as attempting gentle pseudocapsule separation, discontinuing stripping in cases of deep adhesion, using minimal cautery and opting for suturing, and avoiding excessive thermal energy. Recommendations for fertility preservation in patients with hydrosalpinx include salpingectomy before IVF treatment for optimization of obstetric outcomes, dissection close to the fallopian tube to preserve blood supply to the ovary, minimal thermal energy use, sharp dissection, when possible, preservation of the utero-ovarian ligament and medial mesosalpinx, and the avoidance of excessive electrocautery. The rise of assisted reproductive technology has curbed the training and expertise of reproductive surgeons, though the need remains for surgical techniques that preserve fertility. The authors propose that reproductive surgeries should be performed by specialists with the appropriate training, all gynecologists should understand fertility-preserving principles and techniques, clinicians should participate in reproductive surgery courses and workshops regularly, and that systemic audits of reproductive outcomes after surgeries should be implemented. (Summarized from Tulandi T, Mocanu E, Purandare N, et al. Gynecologic surgery for benign disease: preserving reproductive potential. Int J Gynaecol Obstet . 2025; 171(3):1022-1028. doi:10.1002/ijgo.70546)
Frozen embryo transfer in in vitro fertilization (IVF) treatments has now surpassed fresh embryo transfer in the annual number of cycles due to increases in the use of preimplantation genetic testing and the freeze-all strategy. In frozen transfer cycles, the endometrium requires preparation to receive the embryo, and the most common regimens are a natural ovulation regimen and a programmed regimen using exogenous estrogen and progesterone. Great controversy surrounds the issue of which regimen provides better safety and efficacy; previous studies have focused on pregnancy and live birth rate, but have not been powered to detect differences in obstetric or neonatal complications. This study was designed to assess the association of natural ovulation regimens with healthy live birth, preeclampsia, and eclampsia compared with a programmed regimen. This was a 2-arm, assessor-blinded, multicentre, randomised controlled trial that included 24 study sites in China. Inclusion criteria were patients aged 20 to 40 with regular menstrual cycles undergoing a frozen single blastocyst transfer after IVF or intracytoplasmic sperm injection cycles after preimplantation genetic testing. Exclusion criteria were blastocysts derived from oocyte donation, frozen oocytes, or blastocysts that had been thawed and refrozen; patients who did not achieve pregnancy after 2 or more previous embryo transfers; patients who had previously canceled cycles due to endometrial thickness; and patients with a history of intrauterine adhesions, untreated submucosal uterine fibroids, or untreated hydrosalpinx. Randomization occurred in a 1:1 ratio between a natural ovulatory regimen and a programmed regimen. The primary outcome for this study was healthy live birth defined as a singleton liveborn infant delivered at 37 weeks of gestation or after and weighing between 2500 and 4000g without major congenital anomalies. An additional primary outcome was diagnosis of preeclampsia or eclampsia. Secondary outcomes included cancellation of the transfer cycle, biochemical pregnancy, clinical pregnancy, ongoing pregnancy, pregnancy loss, ectopic pregnancy, live birth, birth weight, and maternal, fetal, and neonatal complications. Final analysis included 4376 patients, with final follow-up concluded on January 31, 2025. Baseline characteristics were similar between groups. A total of 56 patients in the natural ovulation group and 41 in the programmed group had not had an embryo transfer within a year of randomization; 72 patients in the programmed group and 64 in the natural ovulation group had 2 embryos transferred or cleavage stage embryos, and 222 in the programmed group and 183 in the natural ovulation group received different endometrial preparation regimens than planned. In addition, 19 patients were discovered to be ineligible after randomization and were excluded. Intention-to-treat analysis showed that 910 patients in the natural ovulation group and 890 in the programmed group had healthy live births (41.6% and 40.6%, respectively), with no significant difference between groups. Patients in the natural ovulation group had a lower risk of preeclampsia ( P = 0.02), and there were no instances of eclampsia. Patients who had natural ovulation cycles also had a decreased risk of first-trimester pregnancy loss ( P = 0.02), vaginal bleeding ( P < 0.001), hypertensive disorders of pregnancy ( P = 0.004), and placenta accreta ( P = 0.005). Cesarean delivery was also less common ( P = 0.001), as was postpartum hemorrhage ( P < 0.001). Other outcomes were not significantly different between groups. Per protocol analysis showed similar results. These results indicate that a natural ovulation regimen for frozen embryo transfer was as effective as a programmed regimen for achieving healthy live birth, with the additional benefit of reduced risk for certain obstetric complications. This is consistent with previous studies focusing on live birth, but adds the element of assessing safety for mothers and neonates. Future research should focus on serum and endometrial biomarkers and maternal-fetal interactions that may explain the mechanisms for the findings of this study. (Summarized from Wei D, Qin Y, Sun Y, et al Natural ovulation versus programmed regimens before frozen embryo transfer in ovulatory women: multicentre, randomised clinical trial. BMJ . 2026; 392:e087045. doi:10.1136/bmj-2025-087045)
An estimated 1.5% of women are affected by inflammatory bowel disease (IBD), which includes Crohn disease (CD) and ulcerative colitis. IBD is characterized by a relapsing and remitting pattern of inflammatory episodes in the gastrointestinal (GI) tract, and can affect outcomes for abdominal surgeries. IBD frequently occurs in conjunction with pelvic floor dysfunction, but prevalence of pelvic organ prolapse (POP) in IBD patients is not established. In addition, there are no published studies that assess GI complications related to IBD after surgery for POP. This study was designed to evaluate whether patients with IBD are at increased risk of postoperative complications after POP repair surgery compared with those without IBD. This was a retrospective cohort study using data from the Premier Healthcare Database. Inclusion criteria were female, age older than 18, and having POP surgery between January 2000 and March 2020. Included procedures were a full range of POP vaginal and laparoscopic surgeries, with and without mesh implant. Exclusion criteria were concomitant oncologic, gastrointestinal, or colorectal procedures, and new or potentially active inflammatory disease (within 1 year of diagnosis). The primary outcome for this study was a composite of any GI complication within 3 months of POP surgery, including ileus, small bowel obstruction (SBO), large bowel obstruction, intraoperative bowel injury, bowel perforation, and GI fistula. Secondary outcomes included GI complications at 12 months post-surgery and non-GI complication rates. Final analysis included 173,489 patients, with 6349 in the IBD group. Propensity score matching was used to match a control group in a 1:1 ratio, and patient characteristics were similar between groups. Patients with IBD more commonly experienced urinary tract infection (UTI, P <0.001) and GI complications ( P =0.029) at 3 months compared with controls. At 12 months, individuals diagnosed with IBD more commonly experienced ileus ( P =0.0026), SBO ( P =0.0082), UTI ( P <0.001), and GI complications ( P <0.001). Although wound complications were rare events, they were more common in the IBD group at 12 months post-surgery ( P =0.032). Sub-analysis by both surgical approach and IBD type yielded similar results. After adjustment in multivariate models, IBD (adjusted odds ratio [aOR]: 1.55, 95% CI: 1.27-2.13), obesity (aOR: 1.43, 95% CI: 1.25-1.65), tobacco use (aOR: 1.30, 95% CI: 1.15-1.46), and intraperitoneal surgical approach (aOR: 1.66, 95% CI: 1.49-1.85) were associated with an increased risk of GI complications at 3 months post-surgery. Age over 60 (aOR: 1.28, 95% CI: 1.11-1.49) was associated with an increased risk of GI complications at 12 months post-surgery. These findings indicate that a history of IBD is associated with an increased likelihood of GI complications after POP repair surgery. Although these events remain rare, it is important that clinicians remain aware of the elevated risk for these patients and counsel their patients appropriately. This is consistent with previous literature surrounding other abdominal surgeries. Future research should assess differing types of POP surgery as well as implement controls for steroid use and disease severity, as this study was unable to do so. (Summarized from Le Neveu M, Abou Zeki J, Chakraborty NN, et al. Inflammatory bowel disease and complications after pelvic organ prolapse repair. Urogynecology (Phila) . 2026; 32(6):677-686. doi:10.1097/SPV.0000000000001713)
Anemia during pregnancy is associated with adverse maternal outcomes such as severe maternal morbidity, blood transfusion, and postpartum depression. Prior estimates of anemia prevalence in the United States have varied widely, at anywhere from 5% to 27%, with more recent studies suggesting it may be more common than previously recognized. However, existing estimates are limited by selective study populations, missing data, and reliance on diagnostic codes, which may artificially deflate prevalence. This study evaluated trends in anemia during pregnancy using measured hemoglobin and hematocrit values from a large database of commercially insured individuals. This retrospective study used a national database of commercially insured patients to identify singleton live births or stillbirths at ≥28 weeks’ gestation between 2018 and 2023. Patients with hereditary anemia diagnoses were excluded. The primary analysis included individuals with hemoglobin and hematocrit values available in both the first trimester and mid-pregnancy, in alignment with ACOG’s routine screening recommendations. Anemia was defined using trimester-specific thresholds: hemoglobin <11 g/dL or hematocrit <33% in the first and third trimesters, and hemoglobin <10.5 g/dL or hematocrit <32% in the second trimester. Prevalence was calculated separately at the initial and mid-pregnancy time points, with trends assessed by delivery year. The secondary analysis was broader, estimating anemia prevalence cross-sectionally by trimester without requiring laboratory values at both ACOG-recommended time points. Among 65,528 pregnancies with hemoglobin and hematocrit measured during the routine screening periods, the overall prevalence of anemia was 25.6%. Prevalence did not change significantly by year, measuring 27.2% in 2018 and 24.6% in 2023. When assessed by date of blood collection, anemia was much less common in the first trimester than at mid-pregnancy, with a prevalence of 4.3% at 4 to 14 weeks’ gestation and 24.5% at 22 to 30 weeks’ gestation. Neither first-trimester nor mid-pregnancy anemia prevalence changed significantly between 2018 and 2023. In the secondary analysis, anemia prevalence increased by trimester, from 4.5% in the first trimester to 20.2% in the second trimester and 36.2% in the third trimester. The results show that the overall prevalence of anemia was more than twice that of prior national estimates, potentially due to the use of measured laboratory values rather than diagnostic codes. Because the cohort was limited to commercially insured individuals, anemia prevalence may be even higher in publicly insured or uninsured populations. Limitations include limited inpatient laboratory values, which may have led to underestimation of anemia at delivery, absence of iron levels to classify anemia type, and inability to assess differences by race, ethnicity, or structural determinants of health. Overall, these findings demonstrate the need for improved strategies in the identification and treatment of anemia as pregnancy progresses. (Summarized from Igbinosa II, Booman A, Duverge-Corporan M, et al. Anemia during pregnancy in a U.S. nationwide cohort, 2018–2023. Obstet Gynecol . 2026; 148: 421-424. doi:10.1097/AOG.0000000000006270).
