The United States has the highest maternal mortality rate among high-income countries, with a disproportionate burden among underserved populations. This narrative review examines the association between Medicaid expansion under the Affordable Care Act and pregnancy outcomes in these groups. Ten studies published between 2020 and 2025, including over 60 million births, were included. Medicaid expansion was consistently associated with improvements in serious maternal outcomes, including reductions in eclampsia, severe maternal morbidity, and pregnancy-related mortality. Prenatal care access also improved, particularly during the COVID-19 pandemic. In contrast, evidence for improvements in preterm birth, low birth weight, and common gestational complications was limited at the national level. Racial and ethnic disparities persisted across all outcomes. Medicaid expansion improves access to care and is associated with meaningful gains in maternal health, but its effects are uneven. Outcomes most closely linked to healthcare access show the greatest benefit, while broader perinatal outcomes and disparities remain largely unchanged. These findings highlight the need for policies that extend beyond coverage, including postpartum care expansion and targeted efforts to address social and structural drivers of inequity.
This review revisits human placental function, bringing together its classical physiological concepts and emerging insights into immune regulation, metabolic control, neuroendocrine signalling, hematopoiesis, and developmental programming. Recent advances in cellular, molecular, and immunological research have shown that the placenta functions as an active signaling interface between the mother and fetus. Beyond its established transport and endocrine roles, the placenta integrates maternal metabolic, immune, and environmental signals to influence maternal adaptation, fetal growth, and long-term health outcomes. The placenta functions as an immunologically active organ that promotes maternal–fetal tolerance while retaining the capacity to respond to certain inflammatory and infectious challenges. Placental endocrine activity is now recognized to encompass roles in metabolic and neuroendocrine regulation, including the synthesis of neurotransmitters and detoxification enzymes. In addition, the placenta has been identified as a transient hematopoietic niche and a protective barrier capable of modulating xenobiotic and environmental exposures. The placenta is the central regulator of homeostasis during pregnancy. Through coordinated immune, endocrine, metabolic, and developmental functions, the placenta influences maternal adaptation, fetal development, and susceptibility to disease later in life. Improved understanding of these integrated placental roles may provide important insights into the mechanisms underlying pregnancy complications and support future translational research in maternal–fetal medicine.
To review polyendocrine metabolic ovarian syndrome (PMOS) in adolescents, including the history of the condition, pathophysiology, diagnosis, and management. Formerly known as PCOS (polycystic ovarian syndrome), the recent nomenclature change to PMOS (polyendocrine metabolic ovarian syndrome) shifts the focus from a sole ovarian cause and acknowledges the interplay of complex metabolic factors that drive the condition. PMOS is a multifaceted medical condition that affects up to 20
This review aims to highlight recent advances in the laparoscopic management of Müllerian anomalies, emphasizing how minimally invasive approaches can improve diagnosis, symptom control, and individualized surgical outcomes. We examine when and how laparoscopy should be applied to optimize care across the full spectrum of congenital anomalies. Over the past five years, a growing number of case series and reports have demonstrated the utility of laparoscopy for both diagnostic and therapeutic management of Müllerian anomalies. Recent literature highlights the successful use of laparoscopy for uterine remnant excision, use of intraoperative fluoroscopy or antegrade genitography for enhanced diagnostic accuracy, minimally invasive reconstruction in patients with obstructive anomalies, and complex urological or gastrointestinal associations. Studies increasingly support conservative management to preserve uterine function and fertility whenever feasible. Laparoscopic techniques now play a central role in the management of Müllerian anomalies, offering less invasive, anatomically precise, and goal-directed care. Patient-centered outcomes, such as pain resolution, restoration of menstrual function, preservation of reproductive potential, sexual health, and avoidance of unnecessary hysterectomy, are increasingly prioritized. Preoperative imaging is becoming increasingly accurate to assist with patient counseling and surgical planning. While long-term data remain limited, current evidence supports laparoscopy as a safe, effective, and adaptable strategy across a wide range of anatomic variants. Ongoing innovation and multidisciplinary collaboration are essential to refining treatment strategies and improving quality of life for affected patients.
Labor pain management remains a central challenge in obstetric practice. While epidural analgesia provides effective relief, it carries limitations and may restrict maternal mobility. This review and meta-analysis aimed to evaluate whether birthing ball use during labor reduces pain intensity, shortens labor duration, and affects maternal or neonatal outcomes compared with standard care. Recent studies confirm birthing balls reduce labor pain via sacroiliac pressure relief and gate control mechanisms. Upright positions enhance pelvic flexibility, facilitate fetal descent, and improve circulation, thereby optimizing contractions. Evidence suggests that maternal comfort benefits, although the effects on labor duration and neonatal outcomes remain inconsistent across randomized controlled trials (RCTs). Based on 24 RCTs (2,828 patients), birthing ball use significantly reduced pain scores after 30 minutes (SMD = -1.04, 95
Labor dystocia remains the leading indication for primary cesarean delivery in the United States (US), yet its definition and management have remained largely unchanged, despite shifts in obstetric population characteristics and clinical practice. This review examines current evidence on the diagnosis, predictors, intrapartum assessment and management of labor dystocia, with particular attention to how maternal obesity, intrapartum ultrasound, and racial and ethnic disparities in cesarean rates challenge and complicate our existing framework. Time-based thresholds for dystocia were built using patient populations that no longer reflect the demographics of pregnant people in the US. These historic datasets excluded cesarean deliveries and thus may systematically over-diagnose arrest in normal labors. Maternal obesity, now present in nearly a third of pregnant people in the US, is a physiologically distinct context in which standard uterine activity benchmarks and augmentation protocols may not apply. Intrapartum ultrasound offers a more objective approach to characterizing mechanical contributors to dystocia that digital examination may not reliably identify. Racial and ethnic disparities in cesarean rates persist after adjustment for clinical and socioeconomic factors, suggesting that provider decision-making and structural drivers may be an underappreciated contributor to high cesarean rates in the US. A more individualized approach to diagnosis and management of labor dystocia may include integration of objective intrapartum data and accounting for population and individual level differences in labor physiology. This is needed to reduce unnecessary cesarean delivery and address persistent disparities in its use. Emerging machine learning models incorporating multiple labor parameters show promise in improving predictive accuracy beyond time-based approaches alone.
This comprehensive summary of the evaluation and management of patients who present with a vaginal septum provides an update on the most recent literature and highlights the paucity of recent research in this topic. Case reports of innovative surgical techniques for vaginal septum excision have been published, with success reported after hysteroscopic and pneumovaginal approaches. More research is needed to determine the comparable outcomes to a traditional vaginal approach. Vaginal septums are a relatively uncommon mullerian anomaly associated with concurrent anomalies of the uterus, urinary tract, anorectum, cardiac and skeletal systems. The differential diagnosis of a vaginal septum includes vaginal cyst, imperforate hymen and complete or partial vaginal agenesis. Septum presentation can range in severity from asymptomatic to obstructive and painful. They can be relatively straight-forward or surgically challenging. In complex cases, an in-depth knowledge of anatomy and classification of the anomaly can help the surgeon to read imaging studies, counsel patients on outcomes, plan an anatomic approach to surgery, and involve a multdisciplinary team, as needed.
Valvular heart disease (VHD) in pregnancy remains an important cause of maternal and fetal morbidity worldwide. Risk is influenced by lesion type and severity, prosthetic valve status, associated aortopathy, and access to specialized cardio-obstetric care. This review summarizes current evidence on the epidemiology, risk stratification, lesion-specific management, anticoagulation challenges, and multidisciplinary care of VHD from preconception through the postpartum period. Recent evidence supports structured risk assessment using the modified World Health Organization (mWHO 2.0) classification, with adjunctive tools such as CARPREG II and selected valve-specific models in appropriate populations. Left-sided stenotic lesions, mechanical prosthetic valves, and significant aortopathy remain the highest-risk phenotypes, whereas chronic regurgitant lesions are often better tolerated but may still be associated with adverse outcomes when symptoms, ventricular dysfunction, or multivalve disease are present. Contemporary registries and cohort studies have refined estimates of maternal, fetal, and neonatal risk and have highlighted the importance of Pregnancy Heart Team pathways, serial imaging surveillance, careful peripartum planning, and selective use of transcatheter interventions. Optimal outcomes in pregnant patients with VHD depend on early risk assessment, lesion-specific counselling, coordinated Cardio-Obstetric multidisciplinary care at an experienced center, and vigilant postpartum follow-up. Future priorities include safer anticoagulation strategies, improved lesion-specific risk prediction, standardized surveillance pathways, and stronger evidence to guide intervention and delivery planning.
Monochorionic monoamniotic (MCMA) twin gestation represents the highest-risk form of twin pregnancy and remains a challenging entity in maternal-fetal medicine. Despite substantial advances in prenatal diagnosis, fetal surveillance, and neonatal care, management strategies continue to rely heavily on observational data and expert consensus. This review aims to synthesize contemporary evidence, address misconceptions, and highlight evolving strategies in the management of MCMA twin pregnancies. Improved prenatal detection and standardized delivery planning have significantly reduced perinatal mortality in MCMA gestations over the past few decades. Umbilical cord entanglement is now understood to be nearly universal and poorly predictive of outcome. Contemporary studies suggest that inpatient surveillance may reduce fetal death compared with outpatient management, though definitive evidence is lacking. Planned preterm delivery between 32 and 34 weeks’ gestation has emerged as standard practice, balancing the competing risks of sudden intrauterine demise and neonatal morbidity from prematurity. Optimal management of MCMA twin pregnancy requires early and accurate diagnosis, individualized surveillance strategies, multidisciplinary coordination, and shared decision-making. While consensus supports intensive fetal monitoring and planned preterm cesarean delivery, knowledge gaps remain. Future research should focus on refining risk stratification and identifying which patients derive the greatest benefit from intensive surveillance strategies.
Microplastic pollution is a growing environmental concern with an unknown impact on health, particularly as it relates to maternal, neonatal and offspring development. This scoping review maps the available evidence on the effects of microplastics on pregnancy, neonatal, offspring and tissue outcomes. Microplastics (MPs) and nanoplastics (NPs) have been identified in various human tissues, from amniotic fluid to uterine and placental tissue. Emerging evidence shows that MPs and NPs can cause inflammatory changes and dysfunction in multiple organs, including the intestines, liver, and gonads. A total of 806 studies were identified and imported for screening, of which 348 were eliminated after deduplication. Out of 458 abstracts, 122 abstracts moved forward into full-text review. Following the application of exclusion criteria, 53 studies underwent extraction. These studies were extracted for the following outcomes: pregnancy (5), placental (13), embryogenesis (5), fetal tissue (19), offspring (14) and neonatal outcomes (9). Broadly, the most common outcomes included changes in fetal development and birth weight, disturbances in metabolism and signaling pathways, and differences in gene expression in MP-NP exposed groups compared to control groups. Further research amongst human participants should be conducted to determine if MP-NP exposure has significant clinical effects on pregnancy and fetal outcomes.
The goal of this paper is to examine the pathophysiology, diagnostic challenges, and maternal-fetal implications of postprandial (reactive) hypoglycemia in pregnant women following bariatric surgery. It seeks to explain how altered gastrointestinal anatomy and pregnancy-associated metabolic shifts converge to increase the risk of postprandial glycemic excursions. Furthermore, the review identifies current management strategies and highlights significant gaps in standardized screening and treatment protocols. Observational studies and continuous glucose monitoring (CGM) reports reveal a high prevalence of hypoglycemia in post-bariatric pregnancies, ranging from 50
To synthesize current evidence on immediate postpartum (delivery hospitalization) oral glucose tolerance testing (OGTT) following gestational diabetes mellitus (GDM), with a focus on underlying physiology, diagnostic performance, implementation outcomes, and evolving diagnostic criteria, in order to clarify its role in postpartum diabetes screening. Emerging physiologic data demonstrate that insulin sensitivity improves rapidly within days of delivery, supporting the feasibility of early postpartum glucose testing. Observational and prospective studies show that immediate postpartum OGTT has high negative predictive value for overt diabetes, suggesting utility as a rule-out test. However, specificity and positive predictive value are limited, and sensitivity is modest, raising concern for overclassification due to transient metabolic changes. A 2023 meta-analysis reported pooled sensitivity of 81
This report will evaluate the current evidence on physical exam-indicated cerclage, a procedure performed for painless cervical dilation in the second trimester. We aim to clarify its indications, terminology and its clinical role in modern obstetrics. Physical exam-indicated cerclage is performed in patients presenting with painless cervical dilation during the second trimester. Historically referred to as “rescue” or “salvage” cerclage, contemporary terminology favors the term physical exam-indicated cerclage to more accurately describe the indication for intervention. Growing evidence indicate that cerclage placement in appropriately selected patients can prolong pregnancy and improve neonatal outcomes. Systematic reviews and meta-analysis show increased pregnancy latency and neonatal survival compared with expectant management. Emerging data also suggest potential benefit in carefully selected twin pregnancies. Physical exam-indicated cerclage is a valuable intervention in select patients with second trimester cervical dilation. Current evidence supports its role in improving perinatal outcomes, through careful patient selection remains essential. Future research should prioritize well-designed, adequately powered prospective trials to refine candidate selection criteria, standardize adjunctive therapies, and better define the role of cerclage at gestational ages beyond traditional thresholds of viability.
To examine global gaps in Pediatric and Adolescent Gynecology (PAG) education and assess how limited curricular exposure contributes to disparities in care. This review also explores emerging educational strategies, including simulation, virtual learning, and artificial intelligence, to strengthen PAG training. Despite its clinical importance, PAG remains underrepresented across undergraduate and residency programs. Professional societies have expanded teaching resources, yet formal subspecialty recognition is limited. Innovations such as simulation-based education, digital platforms, and AI enhanced tools increasingly support competency development where clinical exposure is scarce. Significant educational gaps continue to hinder the PAG workforce. Modern educational approaches offer promising solutions to improve competency-based training and expand access to high-quality care. Strengthening international collaboration and standardizing curricula will be essential to advancing PAG education and guiding future research. PAG is an under-recognized specialty globally: Despite its importance, Pediatric and Adolescent Gynecology is not widely acknowledged as a distinct subspecialty in most countries, leading to gaps in specialized training and care. Educational gaps persist: Fellowship programs are expanding, but medical and residency-level exposure remains limited, leaving many clinicians ill-equipped to manage PAG conditions. Modern educational strategies are essential: Simulation-based education, virtual learning platforms, and emerging technologies such as AI can bridge gaps in clinical exposure and improve competency. Global collaboration is critical: Professional societies (NASPAG, EURAPAG, FIGIJ, etc.) play a key role in standardizing curricula and advocating for subspecialty recognition. Competency-based assessment is the future: Tools like Entrustable Professional Activities (EPAs) and technology-driven evaluations will ensure measurable proficiency and standardization of skills.
Given the proliferation of direct-to-consumer marketing of vulvar hygiene products, this review addresses best practices influenced by new understanding of the vulvar biome. It also provides new understanding of the how alterations in the vulvar biome can adversely affect health. The vulvar microbiome represents a distinct ecological niche that differs fundamentally from the vaginal microbiome in composition, function, and hormonal responsiveness. Unlike the vagina, the vulva is a keratinized cutaneous surface characterized by higher microbial diversity and lower biomass, rendering it particularly vulnerable to mechanical, chemical, and antibiotic-induced disruption. The vulvar biome evolves with the hormonal and structural changes of puberty. Emerging evidence suggests that many recurrent vulvar conditions, including folliculitis, methicillin-resistant Staphylococcus aureus (MRSA) abscesses, and early-onset hidradenitis suppurativa, may represent manifestations of microbiome dysbiosis rather than primary infection. Current evidence suggests that to effectively restore health, it is important to assess the ecosystem, normalize the physiologic pH, restore protective barriers, and rebalance the flora.
The goal of this review is to provide an updated overview of the evaluation, diagnosis, and non-surgical management of stress urinary incontinence (SUI) in women, a prevalent chronic condition. We aim to highlight current best practices for diagnosing SUI, describe the latest evidence around non-surgical treatment modalities for SUI, and strategies for clinicians in optimizing care for women experiencing SUI. Recent literature emphasizes the importance of thorough history-taking and physical examination, including the use of validated questionnaires and bladder diaries, to accurately diagnose SUI. Urodynamic testing is now reserved for complex or unclear cases. Weight loss in obese and overweight patients results in significant improvement in SUI. Pelvic floor muscle training (PFMT) is offered as first-line therapy, with evidence supporting its efficacy across age groups and severity levels. Digital health tools and supervised physical therapy may enhance adherence and outcomes. Additionally, devices such as vaginal pessaries and inserts provide symptom relief, particularly in women seeking non-invasive options and have not completed child-bearing. Behavioral interventions, including weight loss and smoking cessation, complement physical therapies. In-office urethral bulking is a procedure with moderate/good efficacy and tolerability. The evaluation and non-surgical management of SUI should be individualized and guided by a comprehensive clinical assessment. PFMT remains the most effective first-line intervention, with adjunctive therapies offering further benefit in selected patients. With proper diagnosis and conservative management, many women experience significant symptom improvement without the need for surgical intervention.
Adolescent endometriosis and chronic pelvic pain frequently overlap but represent distinct clinical entities requiring thoughtful diagnostic and management approach. This review summarizes recent advances in understanding adolescent endometriosis and its role in chronic pelvic pain, a condition frequently underrecognized and associated with significant diagnostic delay. We discuss emerging evidence regarding symptom patterns, mechanisms of pain, and treatment approaches. Increasing evidence supports a shift towards a noninvasive clinical diagnosis of endometriosis in adolescents rather than delaying treatment for surgical confirmation. Specialized imaging and biomarkers show promise for identifying later stage disease; they currently lack the sensitivity to definitively rule out endometriosis and are not yet validated in this population. Emerging data highlights the role of central sensitization and biopsychosocial factors in pain persistence, explaining why symptoms of endometriosis and chronic pelvic pain coexist and warrant multimodal management. Chronic pelvic pain and endometriosis require comprehensive evaluation and management approaches that combine hormonal therapy, specialized surgery, and adjunctive treatments like pelvic floor physical therapy. Early intervention optimizes care and may mitigate long-term consequences on reproductive health and psychological well-being.
This review summarizes the pathophysiology, clinical presentation, and evidence-based management of pelvic floor disorders (PFDs) during pregnancy, birth, and the postpartum period. It highlights current knowledge on prevention, diagnosis, treatment, and long-term outcomes, with particular focus on urinary incontinence, fecal incontinence, pelvic organ prolapse, and perineal wound-related complications. Pregnancy induces hormonal and mechanical changes that predispose to PFDs, including urinary incontinence, fecal incontinence, and pelvic organ prolapse. Vaginal birth, especially with operative assistance and/or resulting in obstetric anal sphincter injury (OASI), significantly increases the risk of long-term pelvic floor dysfunction. Preventative strategies—such as antenatal perineal massage, pelvic floor muscle training (PFMT), perineal application of warm compresses in labor, manual perineal protection during birth, and restricted use of episiotomy—can reduce severe lacerations and future PFDs. Conservative postpartum management of PFDs includes PFMT, biofeedback, pessaries; and newer digital tools may improve adherence and outcomes. Although surgical interventions are typically delayed until after childbearing, emerging evidence supports select procedures even if future childbearing is desired. Myofascial pain and wound complications require tailored management with physical therapy and, in some cases, local injections. Counseling on subsequent mode of birth after prior OASI remains individualized. Pelvic floor disorders are common and often underrecognized sequelae of pregnancy and childbirth. Optimizing prevention and early postpartum care can reduce symptom burden and improve quality of life. Individualized counseling, shared decision-making, and multidisciplinary management are essential to address the complex interplay of delivery-related injury, pelvic floor dysfunction, and patient goals.
This review provides an update for clinicians on: (1) person-centered contraceptive counseling; (2) 2024 updates to the Centers for Disease Control and Prevention (CDC) U.S. Medical Eligibility Criteria and Selected Practice Recommendations; (3) emerging and updated contraceptive methods, and (4) innovative models for contraceptive access and service delivery relevant to adolescents. Adolescent-serving clinicians are encouraged to move beyond a focus on pregnancy prevention toward autonomy-centered, developmentally appropriate contraceptive care that recognizes adolescents as emerging decision-makers. The 2024 CDC contraceptive guidelines support more equitable and affirming care through gender-inclusive language and an emphasis on shared decision-making and personal autonomy. Adolescent-relevant evidence-based updates include guidance on depot medroxyprogesterone acetate and venous thromboembolism risk, self-administration of subcutaneous depot medroxyprogesterone acetate, pain management during intrauterine device insertion, management of bleeding irregularities with implant use, and contraceptive counseling for adolescents using testosterone. In parallel, newer contraceptive options expand opportunities to align method selection with adolescents’ preferences. Innovations in contraceptive access, such as telehealth, pharmacist-prescribed and over-the-counter oral contraceptives, mobile health applications, and integration into acute care settings, have expanded in recent years. However, few models have been implemented at scale for adolescents, and barriers to equitable, confidential, and convenient access persist. Clinicians should provide person-centered contraceptive counseling, integrate updated CDC guidance into practice, and offer a broad range of contraceptive methods and access pathways aligned with adolescents’ diverse needs and values. Prioritizing autonomy, flexibility, and responsiveness may advance a more equitable and empowering adolescent contraceptive care landscape.
