Infertility affects 1 in 6 reproductive-aged couples, and declining ovarian function is a common cause of infertility among women in their late 30s to early 40s.
Women in their late 30s to early 40s who have difficulty conceiving are often unaware that success rates of fertility treatment decline with age, most commonly due to declining ovarian function. Counseling about the high prevalence of infertility and miscarriage may be met with surprise and sadness. Reports of children born to high-profile women older than 50 years may contribute to misconceptions, but these births highlighted in the media were likely achieved with donor oocytes from a younger woman or with oocytes or embryos that were previously cryopreserved. Consistent with declining fertility rates worldwide,1 the fertility rate in the US has declined from 70.9 births per 1000 women in 1990 to 56.1 per 1000 in 2022.2 Simultaneously, the 2019 US Census reported that age at first birth had risen from 27 years in 1990 to 30 years in 2019 as more women postponed first birth.
Reasons for these trends may include lack of a partner, economic insecurity, career aspirations, and long work hours. Concerns about childbearing discrimination, including lack of pregnancy and postpartum support, and childcare challenges also likely influence decisions to delay pregnancy. Results of a questionnaire completed by 5692 US general surgery residents reported that more female than male residents delayed pregnancy because of training (46.8% vs 32.7%; P < .001) and experienced pregnancy/parenthood-based mistreatment (58.1% vs 30.5%; P < .001).3
Perinatal depression can occur during pregnancy and the first 12 months after childbirth.
Perinatal depression, also called postpartum depression, affects about 1 in 7 perinatal individuals. More than 75% of these individuals receive no treatment for perinatal depression. Onset of perinatal depression may occur prepregnancy or may develop over the course of pregnancy and the postpartum period. Untreated perinatal depression is associated with an increased risk of suicide and has additional negative effects on the perinatal individual, the fetus (preterm birth, low birth weight), and the child (impaired attachment, which may affect neurodevelopment) and may negatively affect relationships with partners and other family members.
Introduction: Existing guidelines for primary care clinicians (PCCs) on the detection and management of perinatal depression (PD) contain important gaps. This review aims to provide PCCs with a summary of clinically relevant evidence in the field.
Methods: A narrative literature review was conducted by searching PubMed and PsycINFO for articles published between 2010 to 2023. Guidelines, systematic reviews, clinical trials, and/or observational studies were all examined.
Results: Screening with the Edinburgh Postnatal Depression Scale or Patient Health Questionnaire-9 followed by a diagnostic evaluation for major depressive disorder in probable cases can enhance PD detection. At-risk individuals and mild to moderate PD should be referred for cognitive behavioral therapy or interpersonal psychotherapy when available. Selective serotonin reuptake inhibitors should be used for moderate to severe PD, with sertraline, escitalopram, or citalopram being preferred first. Using paroxetine or clomipramine in pregnancy, and fluoxetine or doxepin during lactation is generally not preferred. Gestational antidepressant use is associated with a small increase in risk of reduced gestational age at birth, low birth weight, and lower APGAR scores, though whether these links are causal is unclear. Sertraline and paroxetine have the lowest rate of adverse events during lactation. Consequences of untreated PD can include maternal and offspring mortality, perinatal complications, poor maternal-infant attachment, child morbidity and maltreatment, less breastfeeding, and offspring developmental problems.
Conclusions: These clinically relevant data can support the delivery of high-quality care by PCCs. Risks and benefits of PD treatments and the consequences of untreated PD should be discussed with patients to support informed decision making.
Perinatal mental health conditions are those that occur during pregnancy and the year following childbirth, whether onset of the condition(s) predates pregnancy or occurs in the perinatal period. Perinatal mental health conditions are the leading cause of overall and preventable maternal mortality and include a wide array of mental health conditions including anxiety, depression, and substance use disorders. Perinatal depression specifically affects 1 in 7 perinatal individuals. While commonly referred to as postpartum depression, it is more accurately called perinatal depression because its onset corresponds with prepregnancy (27%), pregnancy (33%), and postpartum (40%) time frames.
Importance: Anxiety disorders are commonly occurring mental health conditions. They are often unrecognized in primary care settings and substantial delays in treatment initiation occur.
Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for anxiety disorders in asymptomatic adults.
Population: Asymptomatic adults 19 years or older, including pregnant and postpartum persons. Older adults are defined as those 65 years or older.
Evidence assessment: The USPSTF concludes with moderate certainty that screening for anxiety disorders in adults, including pregnant and postpartum persons, has a moderate net benefit. The USPSTF concludes that the evidence is insufficient on screening for anxiety disorders in older adults.
Recommendation: The USPSTF recommends screening for anxiety disorders in adults, including pregnant and postpartum persons. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety disorders in older adults. (I statement).
Pregnant and recently pregnant individuals who become infected with the COVID-19 virus
are at high risk of requiring extra medical care.
According to the Centers for Disease Control and Prevention (CDC),
between January 22, 2020, and November 29, 2021, 148 327
pregnant individuals had documented infection with SARS-CoV-2
(the virus that causes COVID-19) and 241 had died of COVID-19.
Of the 121 973 pregnant people with information on hospitalization
available, 20.6% were hospitalized with COVID-19 or pregnancyrelated conditions.
Importance: Gestational diabetes is diabetes that develops during pregnancy. Prevalence of gestational diabetes in the US has been estimated at 5.8% to 9.2%, based on traditional diagnostic criteria, although it may be higher if more inclusive criteria are used. Pregnant persons with gestational diabetes are at increased risk for maternal and fetal complications, including preeclampsia, fetal macrosomia (which can cause shoulder dystocia and birth injury), and neonatal hypoglycemia. Gestational diabetes has also been associated with an increased risk of several long-term health outcomes in pregnant persons and intermediate outcomes in their offspring.
Objective: The USPSTF commissioned a systematic review to evaluate the accuracy, benefits, and harms of screening for gestational diabetes and the benefits and harms of treatment for the pregnant person and infant.
Population: Pregnant persons who have not been previously diagnosed with type 1 or type 2 diabetes.
Evidence assessment: The USPSTF concludes with moderate certainty that there is a moderate net benefit to screening for gestational diabetes at 24 weeks of gestation or after to improve maternal and fetal outcomes. The USPSTF concludes that the evidence on screening for gestational diabetes before 24 weeks of gestation is insufficient, and the balance of benefits and harms of screening cannot be determined.
Recommendation: The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes in asymptomatic pregnant persons before 24 weeks of gestation. (I statement).
Background: Environmental microbial exposure plays a role in immune system development and susceptibility to food allergy.
Objective: We sought to investigate whether infant pacifier use during the first postnatal year, with further consideration of sanitization, alters the risk of food allergy by age 1 year.
Methods: The birth cohort recruited pregnant mothers at under 28 weeks' gestation in southeast Australia, with 894 families followed up when infants turned 1 year. Infants were excluded if born under 32 weeks, with a serious illness, major congenital malformation, or genetic disease. Questionnaire data, collected at recruitment and infant ages 1, 6, and 12 months, included pacifier use and pacifier sanitization (defined as the joint exposure of a pacifier and cleaning methods). Challenge-proven food allergy was assessed at 12 months.
Results: Any pacifier use at 6 months was associated with food allergy (adjusted odds ratio, 1.94; 95% CI, 1.04-3.61), but not pacifier use at other ages. This overall association was driven by the joint exposure of pacifier-antiseptic use (adjusted odds ratio, 4.83; 95% CI, 1.10-21.18) compared with no pacifier use. Using pacifiers without antiseptic at 6 months was not associated with food allergy. Among pacifier users, antiseptic cleaning was still associated with food allergy (adjusted odds ratio, 3.56; 95% CI, 1.18-10.77) compared with no antiseptic use. Furthermore, persistent and repeated antiseptic use over the first 6 months was associated with higher food allergy risk (P = .029).
Conclusions: This is the first report of a pacifier-antiseptic combination being associated with a higher risk of subsequent food allergy. Future work should investigate underlying biological pathways.
Keywords: Pacifier; antiseptic; birth cohort; dummy; food allergy; microbial exposure; sanitization.
Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.
