Introduction

Endometriosis is a chronic, estrogen-dependent disorder that is defined by the ectopic implantation of endometrial tissue, commonly involving other nearby pelvic organs. This can cause pain, constipation, decreased sexual satisfaction, infertility, and impaired quality of life that varies based on the location and severity of the implants. Clinically, for those who suffer from bowel endometriosis, the most frequent symptoms are pain with defecation and chronic constipation. However, large bowel obstruction as a result of an endometriosis-induced stricture is exceedingly rare. This report highlights a rare case of two separate but simultaneous colonic perforations of the transverse colon as a result of long-term endometriosis-induced constipation.

Case Description

A 30-year-old woman with a history of severe endometriosis presented to rural gynecology for a possible hysterectomy, indicated by extreme dysmenorrhea and cyclic constipation. She had been hospitalized several times, her most recent admission being during her last cycle three weeks prior. Since then, she had not passed stool or flatus. A CT showed a significantly large stool burden (Figure 1). An ultrasound showed a poorly defined complex mass in the right adnexal region. After conservative constipation management failed, she was scheduled for a flexible sigmoidoscopy. However, before the procedure occurred, she developed an acute abdomen. A repeat CT scan suggested large bowel perforation (Figure 2), which was confirmed in emergent exploratory laparotomy. The surgeon noted two perforations in the transverse colon, severe endometrial disease, extensive adhesions in the pelvis, and strictures surrounding the rectosigmoid junction. He performed a double-barrel colostomy and referred her to gynecologic oncology for further management.

Discussion

According to LaPlace’s Law (T = P x r), the cecum is at the greatest risk of ischemic necrosis and perforation in the setting of a closed-loop obstruction, which is created by a clear transition point and a competent ileocecal valve. Therefore, the transverse colon is an atypical site for a perforation, and multiple perforations simultaneously are extraordinarily rare in the literature. Lack of continuity of care potentially played a role in this case, given that this patient was lost to follow-up after her diagnosis of severe endometriosis and a failed trial of combination oral contraceptives. The distance from her gynecologist increased her risk for loss of follow-up and lack of sufficient care, which points to the lack of specialist support in rural areas. Management for bowel endometriosis includes pain control, constipation management, menstrual cycle suppression, and surgical options. This patient received a medroxyprogesterone injection as well as letrozole, which works by reducing estrogen production, causing the endometrial implants to shrink. She was referred to gynecologic oncology for future surgeries with on-site specialist support. To prevent outcomes similar to this case, it is critical to have clinical vigilance to keep an acute abdomen in the differential diagnosis of a woman with a history of endometriosis presenting with severe abdominal pain.

Background

Iron metabolism is a fundamental biochemical process that is tightly regulated by the hepcidin–ferroportin axis, which controls intestinal iron absorption and tissue iron availability, to maintain metabolic and cellular homeostasis. Beyond its role in hemoglobin and oxygen transport, iron is essential for mitochondrial energy production, DNA synthesis, and steroidogenesis, pathways which are essential for normal reproductive function. However, iron deficiency remains one of the most prevalent micronutrient disorders worldwide, disproportionately affecting women of reproductive age. These iron-dependent pathways also regulate follicular development, ovulation, and implantation, suggesting that disturbances in iron homeostasis may may influence ovarian function through altered cellular iron delivery and oxidative stress and adversely affect fertility. Current animal studies show:

Mice fed a low-iron diet developed arrested estrous cycles and impaired follicular growth, both of which normalized following iron repletion.

Loss of the estrogen receptor in mouse ovaries led to iron accumulation and disrupted folliculogenesis, highlighting the hormonal regulation of ovarian iron metabolism.

Excessive iron cause irregular cycles, oxidative damage, and fewer corpora lutea in rodents, indicating impaired ovulation.

High iron exposure also suppressed granulosa cell proliferation via activation of the p38 MAPK–p53–p21 pathway suggesting iron induced cellular stress.

These findings display a relationship in which both iron deficiency and overload can disrupt ovarian physiology. Animal data provides strong mechanistic evidence, the extent to which these processes occur in humans remains uncertain. Clarifying these pathways could identify iron status as a modifiable target for improving ovulatory function and fertility. This review evaluates current evidence linking iron deficiency and iron overload with ovulatory function and fertility in women of reproductive age, emphasizing proposed biological mechanisms and the translational relevance of animal models.

Methods

Human studies published between 2000 and 2025 evaluating iron status and ovulatory function or fertility in women of reproductive age were identified using PubMed, Embase, and the Cochrane Library. Exclusion criteria included Animal or in vitro studies, non-reproductive populations, review articles, case reports, conference abstracts, duplicate studies, and studies not evaluating reproductive outcomes related to iron status.

Results

This review demonstrates evidence of the relationship between iron status and female reproductive health, where both iron deficiency and iron overload can impair fertility. Multiple studies suggest that low ferritin (<30 µg/L) is linked with reduced conception and higher miscarriage rates. One study found significantly lower ferritin levels in women with unexplained infertility, and another showed that IV iron repletion markedly improved conception rates, decreased miscarriage, and increased live births. These findings suggest that iron deficiency may contribute to ovulatory dysfunction and implantation failure, and that correcting this deficiency can help restore fertility potential. In contrast, excessive iron also appears just as detrimental. Another study observed that women taking high-dose iron supplements had reduced antral follicle counts and elevated FSH levels, indicating possible ovarian aging or oxidative stress. In addition, one study further showed that moderate iron intake from supplements was associated with a 40% lower risk of ovulatory infertility, reinforcing the benefits of adequate, but not excessive, iron intake. Overall, maintaining iron and ferritin levels in an optimal range collectively support healthy ovulation, implantation, and eventually, positive fertility and live birth outcomes.

Conclusion

Iron is a critical component to the survival of most organisms, however, when expressed at inappropriately low or high levels it can be detrimental. while animal models provide compelling mechanistic evidence, translating these findings to humans remains challenging because ovarian iron regulation is influenced by additional genetic, hormonal, and environmental factors. This review demonstrates evidence of a potential relationship between iron status and female reproductive health, where both iron deficiency and iron overload can impair fertility.

Multiple studies suggest that iron deficiency is linked with reduced conception and higher miscarriage rates.

One study reported significantly lower serum ferritin concentrations in women with unexplained infertility, whereas another observed improved conception rates, reduced miscarriage, and increased live births following intravenous iron therapy. These findings suggest that iron deficiency may contribute to ovulatory dysfunction and implantation failure, and that its correction can restore fertility potential.

One study observed that women taking high dose iron supplements had reduced antral follicle counts and elevated FSH levels, indicating possible ovarian aging or oxidative stress.

Another study further showed that moderate iron intake from supplements was associated with a 40% lower risk of ovulatory infertility, thus reinforcing the benefit of adequate, but not excessive, iron intake.

Overall, maintaining iron homeostasis within an optimal physiological range may support ovulation, implantation, and healthy pregnancy outcomes. However, prospective clinical trials are needed before routine fertility screening or treatment recommendations can be made.

Background

The placenta functions as a dynamic structure that connects the mother and fetus, facilitating fetal growth and nutrient exchange. Factors present prior to conception not only influence placental development but may also affect subsequent obstetric outcomes. Evidence suggests that paternally expressed genes play an important role in placental development and function. Despite this, the literature has largely focused on maternal factors affecting obstetric outcomes, with comparatively less attention given to paternal factors, particularly paternal age.

This gap is increasingly relevant as parenthood is being delayed in many developed countries, including the United States. The mean paternal age in the United States increased from 27.4 years in 1972 to 30.9 years in 2015, while the proportion of births to fathers older than 40 years doubled during the same period. As men age, age-related changes in sperm have been associated with adverse reproductive outcomes, including preterm birth, low birth weight, and low Apgar scores. However, the independent contribution of advanced paternal age (APA) to placental-mediated perinatal outcomes remains incompletely understood.

The objective of this study was to evaluate whether advanced paternal age is independently associated with placental-mediated adverse perinatal outcomes among U.S. singleton births and to determine whether this association differs across population subgroups.

Methods

We conducted a retrospective population-based cohort study using the National Center for Health Statistics (NCHS) Natality Public-Use Files from 2003 to 2024. Singleton births with documented paternal age were included. Paternal age was analyzed continuously and categorically (≥40, ≥45, and ≥50 years).

The primary outcome was a composite of preterm birth (<37 weeks) and/or low birth weight (<2500 g). Secondary outcomes included placental abruption and hypertensive disorders of pregnancy.

Multivariable logistic regression evaluated associations between paternal age and outcomes. Models were adjusted for maternal age, parity, race/ethnicity, education, marital status, smoking, prenatal care, pre-pregnancy hypertension, prior preterm birth, and birth year. Effect modification by race/ethnicity and maternal age was evaluated.

Results

The study sample included 624,354 singleton live births. Compared with fathers younger than 40 years, fathers aged ≥40 years had 12% higher adjusted odds of the composite placental-mediated outcome (aOR 1.12, 95% CI 1.09–1.15, p<0.001). The magnitude of association increased with advancing paternal age, with adjusted odds ratios of 1.17 (95% CI 1.12–1.21, p<0.001) for fathers aged ≥45 years and 1.21 (95% CI 1.14–1.29, p<0.001) for fathers aged ≥50 years.

In race/ethnicity-stratified analyses, APA (≥40 years) was associated with increased odds of the composite outcome among Non-Hispanic White, Hispanic, and Asian mothers, but not among Non-Hispanic Black or American Indian/Alaska Native mothers. The association between advanced paternal age and adverse outcomes was significantly attenuated among Non-Hispanic Black mothers relative to Non-Hispanic White mothers (interaction p<0.001).

Maternal age and hypertensive disorders of pregnancy did not significantly modify the association between APA and the composite outcome.

Conclusion

Advanced paternal age was associated with increased odds of placental-mediated adverse pregnancy outcomes, with risk becoming apparent at paternal age 40 years and increasing at older age thresholds. However, this association was not uniform across racial and ethnic groups, indicating that paternal age-related risk may vary across populations. These findings suggest that population-level estimates may obscure important subgroup differences and support a more individualized approach to reproductive risk assessment.

Background

Trauma-informed care (TIC) is a patient-centered approach that recognizes the widespread impact of trauma and emphasizes sensitivity to the needs of all patients. Often they suggest using what is called the four “R’s”: recognizing the signs and symptoms, realizing the prevalence and impact of trauma, resisting retraumatization, and responding with policies, procedures, and practices. It aims to prevent retraumatization, promote collaboration and self-efficacy, and support both patients and healthcare providers. Because trauma is common, experts recommend using universal trauma-informed precautions by assuming that any patient may have experienced trauma. Core principles of TIC include creating safety, trust, transparency, collaboration, patient choice, peer support, and reducing inequities caused by systemic oppression. Trauma-informed healthcare also involves educating patients about the effects of trauma, asking about trauma when appropriate, responding with empathy, and connecting patients with community resources. TIC is especially important in reproductive healthcare because exams and procedures can involve vulnerability, pain, loss of bodily autonomy, and invasive physical examinations. These experiences may be traumatizing or retraumatizing for individuals with a history of trauma, making trauma-informed practices essential in reproductive care. This review examines the existing literature on TIC in reproductive healthcare and explores how healthcare providers are educated and trained to apply these principles.

Methods

This scoping review sought to answer the research question: What is the state of the literature on trauma-informed care in reproductive healthcare settings? The objective was to examine and summarize the existing literature addressing trauma-informed care (TIC) within reproductive healthcare settings as it stood when the research was conducted in 2024. A scoping review methodology was used, with literature searched in Google Scholar and PubMed using the terms “trauma,” “trauma-informed,” “reproductive healthcare,” “healthcare education,” “standards of care,” “gynecology,” “sexual trauma,” “medical education,” “pelvic exam,” “sexual assault kits,” and “emergency medicine.” Only recent and relevant articles published were included. The review focused on two overarching areas: the application of trauma-informed care in reproductive healthcare settings and the education and training of healthcare providers in implementing trauma-informed care approaches within these settings.

Results

There were 43 articles located using the aforementioned terms, 10 of which were excluded due to the eligibility criteria, leaving 33 articles or book chapters. The following themes were discussed within the paper pertaining to the state of the literature on that topic: TIC in Healthcare standards and barriers, importance of TIC in reproductive healthcare, PTSD and reproductive healthcare, TIC in prenatal healthcare, importance of TIC in acute care settings, emergency department care and TIC, sexual assault nurse examination, improving patient perception with TIC, recommendations for healthcare education, and training from undergraduate education to medical education to residency training. The literature was explored with the goal of determining the current state of TIC importance and practices in reproductive healthcare settings, as well as implementation into healthcare provider training and education.

Current proposed standards of practice from a TIC perspective include routine trauma screening in annual gynecologic visits as well as obstetrical visits. There are some barriers that may prevent disclosures, for example the patient anticipating a negative response from the provider or fearing re-traumatization. For this reason, TIC literature encourages providers to assume that everyone has a history of trauma and build the environment around that assumption. In searching for TIC education standards in training future OB-GYN providers, it was found that there exists no standard education on TIC practices. This means that TIC is being implemented based on the discretion of each clinical setting, and may differ from clinical trainer to clinical trainer..

Despite the lack of TIC education standardization by governing healthcare organizations, an astounding amount of research supports the importance of TIC, especially in female reproductive healthcare settings. There are limited quantitative studies that characterize the impact of TIC on health outcomes. Trauma-informed care in the context of peripartum and postpartum care is highlighted in the literature as there are increasing rates of postpartum PTSD, which is now recognized by the DSM. In addition, TIC has its place in acute care settings, especially in instances of rape/sexual assault examinations. TIC improves patients’ perception of their care and leads to less healthcare avoidance through provider practices such as acknowledgement of their trauma, asking for permission to begin exams, and patient preference for gender of clinician.

In the context of training providers on TIC, there are articles that address all levels of education from the undergraduate level through residency training and continuing medical education; however, there are gaps aplenty for implementation of TIC into curricula as a standard for at least medical and post-medical-graduate education. Notably, one study found that 20% of OB/GYN residency programs address and assess TIC in their resident education, while 27% did not. Participants reported that barriers to including TIC in their training included a lack of time and lack of dedication to its importance. Some articles discussed the beginnings of truly structured TIC education such as that in nurse practitioners, but there are few articles for OB/GYN residents. These results have implications for both providers and patients across all healthcare settings, highlighting the unique nature and TIC needs of reproductive healthcare.

Conclusion

This scoping review explored the literature on TIC in reproductive healthcare settings, specifically attending to implications for healthcare education, training, and practice. The aims of this exploration were to investigate: 1) TIC relevant to healthcare settings, particularly reproductive healthcare settings, and 2) education and training of healthcare clinicians in TIC approaches in healthcare settings. Overall, the research is dense and comprehensive, but there are still gaps in knowledge surrounding TIC. There appears to be a gap in the amount of quantitative literature that explores the efficacy of trauma-informed healthcare practices, especially in a longitudinal format. In addition, the application of these practices to a gender expansive population has been studied but could use more attention due to higher rates of interpartner violence. The recent emergence of TIC as a more patient-centered culture of care delivery is worth further exploration and consideration by providers, medical schools, graduate schools, and healthcare governing organizations, such as ACOOG, ACOG, and APA.

Background

The 1978 Alma-Ata Declaration was a transformative vision for primary and reproductive health care grounded in social justice, equity, and community participation. It called for “maximum community… participation in the planning, organisation, operation, and control of primary health care” catalyzing a shift from facility-based care toward community health workers (CHWs) and grassroots involvement in health decisions. In the following decade, however, many national programs were discontinued or defunded during the 1980s structural adjustment era, and national strategies reverted back to top-down, externally designed models with limited community engagement. Over time, community-led reproductive health programs changed in scale, raising questions about how they have evolved since the 1970s and what they can teach us about building equitable global health programs today.

Methods

This study used a qualitative historical review to trace the evolution of community-led reproductive health programs from the 1970s to the present. Peer-reviewed literature from PubMed and WHO databases was included if it examined programs in low and middle-income countries serving women of reproductive age in rural or underserved communities. Programs were also compared across two periods: pre-Alma-Ata and post-Alma-Ata to assess shifts in community participation, access and integration of local knowledge and data was thematically analyzed to identify lessons learned from these historical transitions.

Results

Findings show a progression from locally driven, participatory models in the 1970s toward increasingly centralized, technocratic approaches in subsequent decades, followed by a partial re-emergence of community-centered strategies. Early programs emphasized community governance, midwife-led care, women’s collectives, and locally trained CHWs, resulting in improved access, cultural acceptability, and maternal and neonatal outcomes. During the structural adjustment era of the 1980s and 1990s, underfunded and external designed programs undermined community ownership and sustainability and evaluations documented tensions between donor-driven technical models and the original Alma-Ata principles of social participation and empowerment. More recent interventions integrating community mapping, peer-led care groups, culturally adapted birthing centers, and holistic CHWs support, demonstrated substantial improvements in maternal and child health, mortality reductions, increased contraceptive use and cancer screening, and better maternal psychosocial well-being.

Conclusion

The historical trajectory reveals that community participation and CHW support are foundational to equitable reproductive health, and that recentering health “by the people for the people” remains essential for just and sustainable global health systems.

Introduction

Ovarian germ cell tumors are the most common ovarian neoplasm in young females between 10-30 years old and can be subclassified as benign or malignant, although most are benign. Benign ovarian germ cell tumors are also known as dermoid ovarian cysts or mature cystic teratomas. Malignant transformation within a benign dermoid cyst is a relatively rare occurrence, (< 2.0% of neoplasms), most commonly reported to be squamous cell carcinoma.

Case Description

Here we present the case of a 23 year old G0P0 patient with a rare incidental finding of malignant melanocytes within a dermoid ovarian cyst. The patient underwent a prophylactic ipsilateral salpingo-oophorectomy and subsequent excisional biopsy of skin nevi which revealed no evidence of malignant melanoma.

Discussion

This case highlights an extremely rare occurrence of malignant transformation of a primary benign ovarian germ cell tumor which necessitates further research to evaluate best management practices.

Background

Assisted Reproductive Technology (ART) is defined as reproductive assistance

that handles either eggs or embryos to increase fertility rates (CDC, 2019c)

• Infertility is defined as “not being able to get pregnant (conceive) after one year

(or longer) of unprotected sex” (CDC, 2021a)

• Infertility affects approximately 9% of married women between the ages of 15

and 49 within the United States (CDC, 2019b)

• In vitro fertilization (IVF) is and has been the most popular and successful ART

treatment since its first successful embryo transfer in 1978

• Another common example of ART treatments includes intrauterine insemination

(IUI)

• Study Purpose: Through this research project, I conducted a literature review

and interviews with women who have previously been through ART treatments,

with the goal of learning more about the mental health effects of fertility

treatments on women

Methods

Key information regarding the mental health effects of ART was reviewed

through a literature review of published research about mental health and its

relation to ART

• Interviews were conducted with 7 women to gain a better understanding of

their lived experiences undergoing ART treatments

• The interviews were one-on-one and lasted anywhere from 30 minutes or

one hour

• The interviews were all conducted virtually via Webex

• The data were transcribed and analyzed using an array of qualitative tools,

including memoing and identification of key topics

• The key findings were summarized and developed into four main themes

Results

Continued failure with ART or miscarriages increased depressive symptoms and negatively influences women’s pregnancy journey. Cost associated with ART treatments increased stress experienced by the women and their partners. Despite negative emotional and physical experiences with ART treatments, all women declared they would use ART treatment again. The ART treatment journey can be

isolating.

Conclusion

• Change needs to occur in current medical insurance

coverage to include ART treatments to reduce

monetary stress placed on the women and their

partners/spouses

• Failed ART treatments can lead to feelings of fear

and uncertainty with a positive pregnancy test. These

feelings need to be address prior to ART treatment

• When discussing their experience with ART, the

women also included suggestions for those

considering ART treatment such as finding Facebook

support groups and a mental health specialist outside

of their partner/spouse prior to and during treatment

to help with the negative emotions that could arise

during ART treatment

Background

Menopause is the stage in a woman’s life in which she stops menstruating, marking the end of her reproductive years. Menopause is also a normal part of aging and a common health concern encountered by physicians across multiple specialties, including obstetrics and gynecology, family medicine, and internal medicine. As life expectancy increases, women spend a substantial portion of their lives in the postmenopausal period, making menopause management an increasingly important aspect of healthcare.

Beyond common symptoms, menopause is associated with significant long term health considerations, including increased risk of osteoporosis, cardiovascular disease, and reduced quality of life. Effective menopause care requires physicians who are prepared to provide appropriate counseling, evaluation, and evidence based management. Despite its clinical importance, limited research has examined how menopause is taught during medical education, with most studies focusing on postgraduate training.

This review summarizes the available literature on menopause education in medical education and highlights existing gaps in learner exposure, knowledge, and preparedness.

Methods

Peer-reviewed literature was identified through PubMed, Menopause, Embase, and Web of Science and synthesized in a narrative review. Publications evaluating menopause education among medical students, as well as relevant studies involving resident physicians and broader health professions education, were reviewed to summarize the current state of menopause education for future practicing physicians.

Results

Menopause education remains limited within undergraduate medical education. A scoping review by Macpherson and Quinton identified only 12 empirical studies on menopause education among 758 publications, with just two involving undergraduate medical education, highlighting the limited evidence available for medical students. The only national study evaluating menopause education among third-year medical students, conducted by Schnatz and Marakovits, found significantly less educational exposure to menopause compared with other topics, including routine gynecology, preeclampsia, and urinary tract infections. Clinical exposure alone also does not appear to ensure preparedness. O’Hara et al. found that although students commonly cared for menopausal patients, they reported lower confidence in women’s health topics, while Reid et al. demonstrated that many students struggled with appropriate management despite recognizing menopausal symptoms. Notably, students reported increased confidence following dedicated menopause instruction, emphasizing the value of structured education. These gaps extend beyond medical school, with studies of obstetrics and gynecology, family medicine, and internal medicine residents demonstrating limited menopause education and low confidence in managing menopausal patients. One national survey found that 20.3% of residents received no menopause lectures, and fewer than 7% felt adequately prepared to manage menopausal patients. Collectively, these findings suggest that deficiencies in menopause education may begin during medical school and persist throughout postgraduate training.

Conclusion

The current literature demonstrates a persistent gap in menopause education across medical training. Despite the frequency of menopause related care, it receives less curricular emphasis than many other core gynecologic topics. Additionally, Clinical exposure alone does not appear to be sufficient to ensure learner preparedness, as students and residents continue to report limited confidence in menopause evaluation and management.

These findings highlight the need for structured, evidence based menopause education within medical curriculum. Addressing these knowledge gaps earlier in training may improve physician confidence, preparedness, and the quality of care provided to menopausal patients.

Background

Vaginismus is a condition characterized by involuntary vaginal muscle contraction leading to pain and distress that significantly impacts sexual health, psychological well-being, and quality of life. While conventional treatments, including behavioral therapy, physical therapy, and vaginal dilators, remain the cornerstone of management, their efficacy is often limited, and barriers such as stigma and access persist. Advancements such as botulinum toxin injections and topical agents show promise in reducing pain and muscle hypertonicity. Technological innovations, including laser and radiofrequency therapy, as well as neurostimulation techniques, aim to enhance muscle relaxation and modulate nerve activity. Additionally, psychological and integrative interventions, such as virtual reality-based exposure therapy and mind-body practices, address the emotional and psychological dimensions of the condition. Advances in personalized medicine, including biomarker research, offer the potential to tailor treatments to individual patient needs. Despite these developments, challenges remain in ensuring accessibility, overcoming stigma, and conducting robust clinical trials to establish efficacy and safety. Osteopathic physicians may contribute to multidisciplinary management by addressing musculoskeletal dysfunction associated with pelvic floor disorders through osteopathic manipulative medicine (OMM). This review highlights the importance of a multidisciplinary, patient-centered approach to managing vaginismus and underscores the need for further research to refine and expand therapeutic options.

Methods

A comprehensive literature search of the PubMed, JSTOR, and EBSCO databases was conducted between December 2024 and August 2025, and articles were selected based on accessibility and relevance. The majority of studies evaluated multimodal approaches, including pelvic floor physical therapy, cognitive behavioral therapy, pharmacologic interventions, and combined strategies.

Results

Cognitive behavioral therapy reduced fear of intercourse (p=.04) and increased non-coital penetration (p<.01). Pelvic floor physical therapy resulted in 100% of participants tolerating gynecologic examination in retrospective data. Botulinum toxin combined with dilation achieved 71% pain-free intercourse at six months. Transvaginal trigger point injections reduced levator pain (p<.0001), though durability was limited. Topical lidocaine, glyceryl trinitrate, intravaginal diazepam, and oral muscle relaxants showed variable or modest benefit.

Neuromodulation demonstrated physiologic and clinical improvement. Functional electrical stimulation improved Female Sexual Function Index scores more than botulinum toxin in randomized trials. Transcutaneous flat magnetic stimulation increased anorectal angle (p<.001) and levator ani minimal plane distance (p=.001). Photobiomodulation reduced pelvic pain and dyspareunia in observational cohorts. Fractional CO₂ laser and radiofrequency improved dyspareunia and sexual function in related pelvic pain conditions but remain investigational. Osteopathic manipulative medicine showed short-term pain reduction and improved pressure pain thresholds in pelvic pain syndromes. Virtual Reality Exposure Therapy elicited heightened state anxiety in vaginismus-specific studies, supporting its role as a graded exposure modality.

Conclusion

Traditional and emerging interventions improve pain, hypertonicity, anxiety, and sexual function; however, heterogeneity and limited randomized trials preclude standardization. Multidisciplinary, patient-centered care aligned with osteopathic principles remains essential.

Background

Background: Poverty is more than a lack of income, but a multidimensional condition in which one cannot meet their basic needs. Poverty is also a chronic stressor and state of resource deprivation. Globally, poverty affects about 831 million people with women of childbearing age and children being the most vulnerable. Both human and animal studies have shown that chronic stress and resource deprivation (i.e. poverty) increase one’s risk of developing respiratory diseases. Furthermore, alterations in lung nitric oxide (NO) bioavailability and oxidative stress can facilitate this risk. Although multiple epidemiological studies have investigated how resource deprivation and chronic stress affects the lungs in children, very few studies have examined these outcomes in women after birth that experienced poverty during nursing. To study these outcomes, our lab uses the limited bedding and nesting (LBN) rodent model, which simulates chronic stress and resource deprivation in dams and pups by removing ~80 % of bedding and nesting material during weaning. Previous studies from our lab have shown that dams exposed to the LBN model displayed elevated levels of stress, neuro-inflammation, and depression (PMID 39884662). However, no studies have examined any alterations in lung NO bioavailability and oxidative stress in these dams. Thus, the objective of our study is to examine the effects of chronic stress and resource deprivation on lung NO bioavailability and oxidative stress in LBN rat dams at 6 weeks postpartum. We

hypothesize that the LBN dams will demonstrate reduced NO bioavailability and increased oxidative stress in the lungs.

Methods

Methods: Pregnant Sprague-Dawley rats gave birth naturally and were allowed to wean pups for 21 days. During the weaning period, dams and pups were separated into control (CON; n=7) and LBN (n=6) groups. The LBN group received the LBN treatment from post-natal days 2-9 and then was replaced with normal bedding until the end of the weaning period. CON dams and pups were given normal bedding and

nesting materials for the weaning period. After 21 days postnatal, pups were separated from dams, and the dam’s lung tissue was measured for NO bioavailability and oxidative stress via biochemical colorimetric assays at 6 weeks postpartum.

Results

Results: There was no change in NO bioavailability between LBN vs CON dams (10.75±2.47 vs 4.78 ± 1.95 mM Nitrate/ mg of protein; ns). However, lipid per-oxidation was decreased by ~38% (0.80 ± 0.05 vs 1.29 ± 0.11 mM MDA/ mg of protein, p< 0.05) and total antioxidant capacity was increased by ~38%

(13.72 ± 1.43 vs. 9.94 ± 0.86 mM Trolox/ mg of protein) in LBN vs. CON dams.

Conclusion

Conclusion: Post-partum dams exposed to resource scarcity displayed no change in lung NO bioavailability and a decrease in oxidative stress, via decrease in lipid peroxidation and increase in total antioxidant capacity. Therefore, the post-partum dams may have a unique compensatory mechanism to maintain NO bioavailability via an increase in antioxidant capacity to decrease oxidative stress in lungs. Future studies will investigate these mechanisms and lung function in postpartum dams exposed to chronic stress and resource deprivation. This study is clinically and societally relevant because poverty is a major public health concern that disproportionately affects the overall health and well-being of women

of childbearing age and mothers.

Background

Maternal mortality remains a major global health challenge, with nearly 95% of maternal deaths occurring in low- and middle-income countries, many from preventable causes. In rural communities, socioeconomic and cultural factors shape perceptions of childbirth interventions, making it important to understand these views in order to provide culturally responsive care and improve overall maternal outcomes. This study aimed to evaluate and compare attitudes toward and perceptions of childbirth interventions in rural Kenya and rural Guatemala.

Methods

After KCU IRB approval, a cross-sectional, anonymous survey of women aged ≥18 years was conducted in rural Kenya from November-December 2025 and rural Guatemala in February 2026 following completion of a community health clinic visit. The 21-item survey assessed demographics, attitudes toward labor pain control, perceptions of delivery methods and obstetric interventions, and cultural influences on childbirth. Surveys were administered in Spanish in Guatemala and English in Kenya, with translator support available in Kenya. 49 surveys were collected and analyzed in SPSS using descriptive statistics, chi-square tests, and Mann-Whitney U tests, as appropriate.

Results

Guatemala. The groups were broadly comparable at baseline, and both rated pain relief as important during childbirth (p=0.791). Guatemalan respondents reported significantly more favorable attitudes toward cesarean delivery (p=0.002) and forceps- or vacuum- assisted vaginal delivery (p=0.005) and were more likely to consider elective cesarean delivery (p=0.044). In contrast, Kenyan respondents rated non-pharmacologic pain relief methods as safer (p=0.028) and were more likely to have heard of assisted vaginal delivery (p<0.001), despite less favorable attitudes toward its use. Respondents from the two countries did not differ in where they received childbirth information or whether they had felt judged for their childbirth choices.

Conclusion

Although many perceptions were similar between rural Kenya and rural Guatemala, differences in attitudes toward cesarean and assisted vaginal delivery suggest that obstetric interventions may be understood and accepted differently between the two communities. These findings emphasize the importance of incorporating community-specific perspectives into obstetric counseling to support informed decision-making and patient-centered maternal care. This study highlights the importance of understanding how women in different rural communities perceive childbirth interventions, as these perspectives may inform more effective, culturally responsive maternal care.

Introduction

Preeclampsia is a major hypertensive disorder of pregnancy and an important

cause of maternal and perinatal morbidity and mortality worldwide. The

diagnostic criteria for preeclampsia and severe preeclampsia are included in

the tables. These diagnoses require prompt recognition and

management to reduce maternal and fetal complications.

Maternal obesity is associated with an increased risk of hypertensive disorders

of pregnancy and cesarean delivery. Obesity also increases the risk of

postoperative wound complications following cesarean delivery, including surgical-site infection, seroma, hematoma, and wound separation. Negative-

pressure wound therapy (NPWT) has been studied as a strategy to reduce postoperative wound complications in patients with obesity; however, evidence

regarding its routine prophylactic use remains mixed (2,3,4,5,6). This case

highlights the multidisciplinary management of severe preeclampsia in a patient

with class III obesity and the postoperative considerations involved in cesarean

delivery and wound management.

Case Description

A 33-year-old G1P0 at 37 weeks’ gestation presented to labor and delivery for induction of labor due to elevated blood pressures and urine protein-creatinine ratio of 0.4. She reported headaches, visual disturbances with scotomata, and generalized swelling. She denied right upper quadrant pain, cramping, vaginal bleeding, or leakage of fluid and reported good fetal movement. Her pregnancy was complicated by group B Streptococcus positivity, class III obesity (BMI 40), and preeclampsia. On examination, she had 4+ pitting edema and 4+ deep tendon reflexes with one-beat clonus. Her initial blood pressure was 173/98 mmHg. Magnesium sulfate was initiated for seizure prophylaxis. Fetal heart tracing was category I, with a baseline fetal heart rate of 150 beats per minute and no contractions. Cervical examination was 1/40/-3. Urinalysis demonstrated 2+ protein. Laboratory studies showed hemoglobin of 10.9 g/dL, platelets of 121 x 103/μL, AST 24 U/L, ALT 18 U/L, creatinine 0.6 mg/dL, BUN 12 mg/dL, and uric acid 5.4 mg/dL. The repeat urine protein-to-creatinine ratio was 0.6. Labetalol 20 mg IV followed by 40 mg IV was administered for severe-range blood pressure. Twenty-five minutes

after administration, blood pressure remained elevated at 195/122 mmHg, and an additional 80 mg IV labetalol was administered, resulting in improvement to 136/86 mmHg. Magnesium sulfate was continued at 2 g/hr. Blood pressure subsequently increased again to 168/88 mmHg. Given severe preeclampsia and an unfavorable cervix, shared decision-making was undertaken, and the patient proceeded with primary cesarean delivery. A primary low- transverse cesarean delivery was performed with an estimated blood loss of 1,500 mL. Given the patient’s severe preeclampsia, class III obesity, and marked preoperative wound tissue edema, she was considered at increased risk of postoperative wound complications. Prophylactic closed-incision negative-pressure wound therapy (NPWT) was applied over the intact surgical incision following closure to support the postoperative wound environment and reduce the risk of wound complications, including seroma, wound separation, impaired healing, and infection.

Seven hours postpartum, blood pressures remained elevated at 150-172/67-81 mmHg. She received an additional 20 mg IV labetalol and was started on oral labetalol 200 mg three times daily. On postoperative day 2, blood pressure remained elevated at 162/74 but subsequently improved with oral antihypertensive therapy. During the first 24 hours postpartum, the patient had an intake of 2,079 mL and urine output of 4,500 mL, resulting in a net negative fluid balance of 2,421 mL. Despite this substantial net fluid loss, lower-extremity edema persisted during the postpartum period.

Magnesium sulfate was discontinued 24 hours after delivery. Her postpartum course

was additionally notable for persistent lower-extremity edema. She was discharged on labetalol 200 mg three times daily, acetaminophen-hydrocodone, and ibuprofen for pain control. At discharge, she was ambulating, tolerating oral intake, voiding, passing flatus, and had minimal lochia with adequate pain control. The cesarean incision remained well approximated without drainage or other signs of wound complication. The NPWT dressing was planned for removal on postoperative day 7.

Discussion

The decision to proceed with delivery was based on the patient’s severe

preeclampsia, including severe-range blood pressures, headache, visual

disturbances, marked edema, hyperreflexia with clonus, and proteinuria at 37

weeks’ gestation. Magnesium sulfate was initiated for seizure prophylaxis, and

intravenous and oral antihypertensive therapy was used to achieve blood

pressure control. Given the unfavorable cervix and ongoing severe

preeclampsia, cesarean delivery was chosen after shared decision-making

rather than continuing an induction. Following cesarean delivery, prophylactic

closed-incision NPWT was selected because the patient had combined class III

obesity and marked preoperative tissue edema, which were considered

additional risk factors for postoperative wound complications. Although routine

prophylactic NPWT is not universally recommended for obese patients

undergoing cesarean delivery, this case highlights the role of individualized

clinical judgement when multiple wound-risk factors are present. An important

lesson from this case is the value of recognizing and documenting significant

tissue edema before delivery and considering the patient’s overall risk profile

when developing a postoperative wound-management plan. The patient’s

persistent edema despite a net negative fluid balance of 2,421 mL during the first

24 hours postpartum further demonstrates that marked tissue edema may persist despite substantial postpartum fluid loss. The incision remained well-

approximated without drainage or other documented wound complications, although this favorable outcome should be interpreted as an observation rather

than as evidence that NPWT alone prevented complications.

Background

Background: Human papillomavirus (HPV) causes approximately 90% of anal and cervical cancers, 70% of vaginal and vulvar cancers, and 60% of penile cancers, and is associated with approximately 60%-70% of oropharyngeal cancers. Although more than 90% of HPV-related cancers are preventable through vaccinations, HPV vaccine uptake rates in Missouri remain below the national average. Objective: The aim of this systematic review is to critically assess and compare current strategies for improving HPV vaccination uptake rates and reducing vaccination disparities, with consideration of their implementation in Missouri.

Methods

Methods: This systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, Scopus, Scopus AI, and the Cochran Database of Systematic Reviews (CDSR) were searched along with grey literature and government sources, including the CDC. Eligible studies were peer-reviewed, conducted in the United States, published between 2015 and 2025, and evaluated interventions targeting HPV vaccination among individuals aged 9-26 years.

Results

Results: Fifteen studies met the inclusion criteria. Interventions targeted adolescents, young adults, parents, healthcare providers, ethnic minority and low-income populations, and religious communities. Effective strategies included multicomponent interventions, community engagement, HPV and vaccine education, provider recommendations, reminder systems, healthcare system-based policies, environmental messaging, and culturally or demographically tailored communication. Multilevel interventions addressing population-specific barriers demonstrated the most consistent improvements in HPV vaccination uptake.

Conclusion

Discussion & Conclusion: Evidence supports multilevel, population-tailored interventions as promising strategies for increasing HPV vaccination uptake and addressing vaccination inequities. Provider recommendation and reminder systems demonstrated usefulness, particularly in clinical settings. Further research should evaluate the long-term sustainability and cost-effectiveness of these interventions to guide implementation and public health policy.

Background

The pregnancy status checkbox was added to U.S. death certificates in 2003 to improve identification of pregnancy-associated and maternal deaths. Although implementation increased maternal death ascertainment, studies have demonstrated potential misclassification, especially in cases lacking clinical verification. Differences in reporting practices and surveillance infrastructure may disproportionately affect rural communities and ethnic minority populations.

Methods

Objective: To evaluate the impact of pregnancy checkbox surveillance on maternal mortality estimates in Colorado, with emphasis on rural versus urban counties and historically underserved populations, and to assess whether enhanced pregnancy-status ascertainment could improve surveillance accuracy and reduce overestimation.

Methods: This retrospective observational study uses Colorado death certificate data, vital records, and publicly available maternal mortality surveillance data from 2013 to 2024. Maternal deaths identified through the pregnancy checkbox will be compared with verified maternal deaths identified through linked records and Maternal Mortality Review Committee classifications when available. Rural and urban counties will be classified according to Colorado state criteria. A database of maternal deaths with reports of county, race, and cause of death will be created. Statistical significance in the difference between checkbox maternal death classification and enhanced ascertainment will be assessed. Subgroup analyses will examine potential differences across American Indian/Alaska Native and Hispanic women.

Results

Preliminary analysis of publicly available Colorado maternal mortality data identified substantial temporal and geographic variation in pregnancy-associated and pregnancy-related mortality. From 2013–2024, 169 pregnancy-related deaths were identified in the preliminary annual dataset, with annual counts ranging from 3 to 18 deaths. Among cases with currently available county-level information, Denver, Arapahoe, and El Paso Counties accounted for at least 48 deaths.

Colorado’s five-year aggregate surveillance data demonstrated increasing pregnancy-related mortality across overlapping reporting periods. The pregnancy-related mortality ratio increased from 25.1 deaths per 100,000 live births in 2016–2020 (80 deaths) to 36.6 per 100,000 in 2019–2023 (114 deaths), representing a 45.8% increase. Pregnancy-associated mortality similarly increased from 54.7 to 73.6 deaths per 100,000 live births over these reporting periods.

Geographic differences were also observed. During 2019–2023, the pregnancy-related mortality ratio was 61.0 per 100,000 live births among rural residents compared with 34.5 among urban residents, approximately 1.77 times higher in rural populations. Hispanic individuals experienced a pregnancy-related mortality ratio of 39.8 per 100,000 live births during 2019–2023, compared with 24.0 during 2016–2020.

Differences were also observed between publicly available datasets: 63 pregnancy-related deaths were identified in the preliminary annual dataset for 2019–2023 compared with 114 reported in the five-year aggregate surveillance dataset for the same period, warranting further evaluation of differences in case ascertainment, definitions, and reporting methodology.

Conclusion

Improved pregnancy-status verification procedures could enhance the accuracy of maternal mortality surveillance in Colorado. Findings from this study could inform future revisions to death certificate reporting practices and support more accurate identification of maternal deaths, particularly in rural and historically underserved populations.

Background

Social media is prevalent in the lives of female adolescents and serves as a common source of health information. Content is often based on personal experiences and shared by non-medical professionals, potentially influencing perceptions and decision-making regarding hormonal contraceptive use. The purpose of this study is to better understand how social media exposure influences attitudes toward hormonal contraception and its therapeutic use among female adolescent patients. It is hypothesized that increased social media exposure will be associated with negative perceptions of birth control and hesitancy towards its use, consistent with attitudes on social media.

Methods

This cross-sectional survey study will assess demographics, contraceptive history, exposure to hormonal contraceptive content on social media, and Likert-scale measures of perceptions and willingness to use hormonal contraceptives. The survey will be administered to patients in the waiting rooms of various PCP clinics in the Cook Children’s Health Care System in Fort Worth, TX.

Results

IRB submission is pending. The data collection process has not yet been initiated.

Conclusion

This study aims to address an existing gap in the literature regarding how social media may contribute to reproductive health perceptions and health-related decision making. Research in this realm is important to examine how misinformation may be mitigated while leveraging user platforms for promoting positive and accurate health information.

Introduction

Zolpidem is a hypnotic benzodiazepine receptor agonist (HBRA) commonly used for the short-term treatment of insomnia1. Current available data is generally reassuring regarding the risk of congenital malformation with zolpidem use in pregnancy, but prior observational studies have identified a potential association between HBRA use and pyloric stenosis1. We present a case of pyloric stenosis following maternal zolpidem exposure in pregnancy and review the literature available for possible association.

A 34-year-old G1P1001 delivered a 2770 gram neonate via cesarean delivery after arrest of dilation at 8 cm with a pregnancy complicated by gestational hypertension and later development of pre-eclampsia, and occasional tobacco use (estimated 1-2 cigarettes daily). The infant was subsequently diagnosed with pyloric stenosis several months later.

Case Description

Maternal zolpidem exposure, pregnancy and delivery course, and neonatal outcomes were obtained through a retrospective chart review. A focused literature review was conducted through the PubMed database to identify studies evaluating the association between maternal use of zolpidem during pregnancy and congenital malformations, namely pyloric stenosis. Relevant studies evaluating known risk factors for pyloric stenosis were also evaluated. Findings from the case were compared with the available literature to establish any relationship that may be present between zolpidem exposure in pregnancy and pyloric stenosis. Wikner et al. evaluated 1,979 infants in the Swedish Medical Registry who were exposed to benzodiazepines or HBRA medications and identified 7 cases of pyloric stenosis compared with 1.84 expected cases (RR 3.80, 95% CI 1.53-7.84) based on the incidence of pyloric stenosis in the general population at the time. However, overall congenital malformation rates among benzodiazepine and HBRA users compared to non-users were not significantly increased (OR 1.09, 95% CI 0.68-1.75). Fung et al. evaluated 4.2 million pregnancies and found no increased risk of congenital malformations following first-trimester zolpidem exposure (RR 1.01, 95% CI 0.95-1.08). Yu et al. found a small but statistically significant association between second-trimester HBRA exposure and congenital malformations (RR 1.27, 95% CI 1.13-1.43).

Discussion

Available evidence regarding zolpidem exposure during pregnancy and pyloric stenosis is limited. Some studies have identified a small but statistically significant risk of congenital malformations with maternal zolpidem use, especially later in pregnancy1,2,3. However, these studies are observational and limited by confounding variables and limited power due to rarity of congenital malformations in the general population. More recently, larger studies have disputed this relationship, finding no statistically significant association2. Another study found mildly increased but significant risk of congenital malformation with maternal exposure to zolpidem during the second trimester of pregnancy3. Regarding the case presented, it is important to correlate the review of these studies with the pre-existing risk factors such as cesarean delivery and maternal tobacco use4.

Introduction

Cervical ectopic pregnancy is a rare form of ectopic pregnancy, accounting for less than 1% of all ectopic pregnancies, in which the gestational sac implants within the cervical stroma below the internal os. Due to the highly vascular nature of the cervix and the significant risk of life-threatening hemorrhage, prompt diagnosis and management is essential. Termination of the pregnancy is often necessary to minimize maternal morbidity and prevent hemorrhage.

Case Description

A 27-year-old G4P3 presented with a 2-day history of vaginal bleeding that progressed from light spotting to heavier, persistent bleeding, accompanied by severe abdominal cramping and right shoulder pain. The patient reported a recent positive urine pregnancy test. On presentation, vital signs and general examination were within normal limits. Pelvic examination demonstrated active vaginal bleeding from a closed cervical os, with a clot visualized near the cervix. Serum beta-hCG was approximately 3,000 mIU/mL. Transvaginal ultrasonography demonstrated a gestational sac containing a yolk sac and fetal pole withing the cervical region, with a crown-rump length corresponding to 5 weeks and 6 days of gestation. Both ovaries appeared normal, and no free fluid was identified within the posterior cul-de-sac. Based on the clinical presentation and ultrasonographic findings, the differential diagnosis included inevitable abortion versus cervical ectopic pregnancy.

Discussion

Transvaginal ultrasonography is essential for distinguishing cervical ectopic pregnancy from an inevitable or incomplete abortion, as the sonographic appearance of these conditions may overlap. Cervical ectopic pregnancy is characterized by implantation of the gestational sac within the endocervical stroma below the level of the internal os. Diagnositic features include fetal cardiac activity, peritrophoblastic Doppler flow, and an absent sliding sign, reflecting fixation of gestational sac with cervical tissue despite gentle pressure with the transvaginal probe. In contrast, in cases of inevitable or incomplete abortion, the gestational sac may transiently occupy the cervical canal but is not implanted within the cervical stroma. The presence of a sliding sac sign, demonstrated by the mobility of the gestational contents in response to gentle transducer pressure, favors an aborting pregnancy.

Background

The clinical safety of oocyte donation is commonly characterized by rates of recognized complications. These are important measures of medical and procedural safety; however, they capture only one dimension of the donor experience.

Osteopathic medicine’s whole-person approach provides a useful framework for addressing these broader dimensions of donor experience. It recognizes the person as a unit of body, mind, and spirit and emphasizes rational treatment informed by body unity and the relationship between structure and function. Applied to oocyte donation, this perspective supports consideration of donor-reported physical, psychological, and functional outcomes alongside recognized complications.

Background

The Breakthrough

PARP inhibitors (PARPi) exploit tumor-specific DNA repair vulnerabilities through synthetic lethality (1,2). In tumors with BRCA1/2 mutations or homologous recombination deficiency (HRD), impaired DNA repair creates a therapeutic vulnerability that can be selectively targeted by PARP inhibition.

The Clinical Evolution

This biologic principle has translated into clinically meaningful advances across ovarian, fallopian tube, primary peritoneal, and breast malignancies, with PARPi treatment expanding from heavily pretreated disease to maintenance and earlier-stage settings (3-5). Increasingly, BRCA1/2 status, HRD, and other biomarkers inform patient selection and therapeutic strategy.

The Remaining Challenge

Despite these advances, heterogeneous treatment response, acquired resistance, and limitations in biomarker selection continue to restrict the full potential of PARPi therapy. Understanding these challenges is essential for developing more effective and durable treatment strategies.

Review Objective

This review examines the clinical evolution of PARPi in gynecologic and breast malignancies, emphasizing biomarker selection, landmark clinical outcomes, mechanisms of resistance, and emerging therapeutic strategies.

Methods

A focused literature review was conducted to evaluate the clinical development and therapeutic applications of PARPi in gynecologic and breast malignancies. Landmark clinical trials evaluating olaparib, rucaparib, niraparib, talazoparib, and veliparib were reviewed, with emphasis on ovarian, fallopian tube, primary peritoneal, and breast cancers. Studies were examined for treatment setting, biomarker status, therapeutic regimen, and clinical outcomes, including progression-free survival (PFS), hazard ratio (HR), overall survival (OS), and objective response rate (ORR). Key regulatory approvals and emerging combination strategies were also evaluated to characterize the evolution of PARPi therapy and identify remaining challenges and opportunities for clinical advancement.

Results

PARP inhibitor therapy has undergone a substantial clinical evolution, progressing from treatment of heavily pretreated BRCA-mutated disease to maintenance and earlier-line therapy across gynecologic and breast malignancies. In ovarian cancer, landmark trials established PARPi maintenance as an effective strategy following response to platinum-based chemotherapy, with subsequent studies expanding investigation into first-line treatment and broader biomarker-defined populations (5). In breast cancer, trials of olaparib and talazoparib demonstrated the clinical utility of PARP inhibition in patients with germline BRCA mutations, extending the application of synthetic lethality beyond ovarian cancer (5,6). Collectively, these studies established PARP inhibition as an important component of biomarker-directed cancer therapy while highlighting the continued need for improved patient selection and strategies to overcome therapeutic resistance.

Conclusion

Clinical Impact

PARP inhibitors have transformed precision treatment for BRCA-mutated and HRD-associated malignancies. In ovarian cancer, their role has expanded from recurrent disease to maintenance following platinum response and first-line therapy. In breast cancer, PARPi have demonstrated benefit in both metastatic and high-risk early disease, illustrating a broader shift toward biomarker-directed treatment and earlier therapeutic intervention.

Remaining Challenges

The next phase of PARP inhibitor development is defined by selectivity rather than simply expansion. Not all patients with HRD derive the same degree of benefit, and acquired resistance remains a major limitation. Restoration of homologous recombination, replication-fork stabilization, and other mechanisms can allow tumor cells to escape PARP-mediated cytotoxicity.

Future Directions

Future development will focus on expanding the therapeutic window of PARP inhibition while overcoming resistance and improving patient selection. Combination strategies—including PARPi with antiangiogenic therapy and immune checkpoint blockade—seek to exploit complementary vulnerabilities within the tumor microenvironment. At the same time, selective PARP1 inhibitors represent a next-generation approach designed to preserve antitumor activity while potentially reducing effects associated with broader PARP inhibition. Together, these strategies may move PARP-directed therapy beyond its current biomarker-defined boundaries.

Background

Peripheral nerve injuries associated with vaginal delivery are rare but potentially underreported

complications of childbirth that can contribute towards postpartum morbidity and functional impairment.

These injuries may occur following operative or non-operative vaginal delivery and damages the

pudendal, femoral, obturator, lateral femoral cutaneous, and sciatic nerves. Reported risk factors include

lengthened second stage of labor, prolonged lithotomy positioning, fetal macrosomia, and use of regional

anesthesia. Current literature is fragmented on types of peripheral nerve injuries, risk factors, injury

mechanisms, and clinical presentations. Addressing this gap is important for increasing recognition of

such injuries, which can negatively impair quality of life in the postpartum parturients. The aim of this

review was to map literature to portray a holistic picture of both pelvic and lower extremity peripheral

nerve injuries, common mechanisms of injury, associated risk factors, and clinical manifestations with

course of recovery.

Methods

Following JBI scoping review methodology, a Population, Concept, and Context (PCC) framework guided

study selection. Eligible studies included females with postpartum peripheral nerve injury following

operative or non-operative vaginal delivery, without a pre-existing underlying condition or neuropathy.

PubMed, Embase, and Web of Science were searched using terms related to postpartum peripheral

nerve injury and vaginal delivery, yielding approximately 500 articles. After de-duplication, four reviewers

independently screened studies in pairs, with designated reviewers resolving disagreements. Data were

extracted using a standardized Excel sheet, including study characteristics, delivery type, nerve/plexus

involved, risk factors, proposed injury mechanisms, clinical manifestations, symptom onset, and recovery.

Findings were synthesized descriptively.

Results

Thirty-five studies were included. The pudendal nerve was the most commonly injured (45.9%),

followed by the femoral nerve (29.7%) and lumbosacral plexus (21.6%). Instrumental delivery, including

forceps and vacuum extraction, was reported in nearly half of the studies. Other recurring risk factors

include regional anesthesia (67.6%), prolonged second stage, and high fetal weight (>4000g). The most

commonly reported mechanisms of injury were nerve compression, traction related to fetal descent, and

maternal positioning. Clinical presentation varied depending on the nerve involved; most common

manifestations were lower-extremity weakness, including foot drop, and sensory disturbances, such as

hypoesthesia and paresthesias. Pelvic and functional impairment was also observed in several patients.

Conclusion

Obstetric peripheral nerve injuries, although uncommon, can have a significant impact on patient

presentation and functionality postpartum. Following vaginal delivery, the pudendal and femoral nerves

are among the most commonly injured. Proposed mechanisms suggest nerve compression and stretch

associated with fetal descent. Other factors that may increase susceptibility to peripheral nerve injury

include instrumental childbirth, prolonged second stage of labor, and maternal positioning. Clinical

manifestations vary based on the distribution of the affected nerve but often include lower-extremity

weakness in flexion and extension, as well as sensory deficits. The often rapid clinical course and

recovery may contribute to underreporting of these injuries. Greater awareness of peripheral nerve

injuries associated with vaginal delivery may support earlier recognition and encourage more proactive

management of patients during labor.

Background

Breech presentation occurs in 3-4% of term singleton pregnancies and is associated with a high rate of cesarean delivery. External cephalic version (ECV) is an established intervention for converting a breech fetus to cephalic presentation and can increase the likelihood of vaginal birth. However, ECV is unsuccessful in a substantial proportion of patients and remains underutilized. ACOG currently describes ECV as successful in more than half attempts and notes that successful ECV improves the chance of vaginal birth.

Osteopathic manipulative medicine (OMM) may theoretically address maternal musculoskeletal and myofascial restrictions that could influence fetal mobility.

Methods

A structured narrative review was conducted. Searches were performed using EBSCO, PubMed, and Google Scholar within the date range of 08/13/2026 to 08/27/2026. English-language literature addressing term singleton breech presentation, ECV outcomes, predictors of ECV success, and osteopathic manipulative treatment in pregnancy were included. Search terms included "External cephalic version", "Term breech presentation", and "Osteopathic Manipulative Medicine”, Studies involving multifetal gestations were excluded. No publication-date restriction was applied.

Results

ECV Results

ECV is shown to have a 49-72% success rate in resolving breech presentation.

Success is affected by maternal, fetal, and procedural factors.

ECV remains underutilized.

OMM Results

OMM has been investigated for selected pregnancy-related musculoskeletal complaints.

No studies directly evaluating OMM immediately before ECV or its effect on ECV success were identified.

Therefore, no conclusion regarding efficacy can currently be made.

Conclusion

Osteopathic techniques directed at thoracic, lumbar, sacral, pelvic and associated myofascial dysfunction could theoretically optimize maternal biomechanics and reduce somatic restriction before ECV. However, this proposed mechanism remains hypothetical, and no evidence currently demonstrates that OMM improves ECV success.

There is currently insufficient evidence to determine whether OMM could improve ECV success. No studies directly evaluating OMM as an adjunct to ECV were identified in this review. Nevertheless, the biomechanical rationale, clinical importance of successful ECV, and osteopathic emphasis on structure-function relationships support prospective investigation of standardized OMM protocol before ECV

Background

Abortion remains highly stigmatized and criminalized in the Philippines, leading to unsafe abortion procedures and preventable maternal deaths. Governmental norms and standards, alongside conservative religious beliefs, strongly influence how adolescents access contraceptive and abortion care in the Philippines. One study found that Filipinx-American women in Los Angeles internalize cultural stigma surrounding sex and family planning services. Despite being one of the largest subpopulations in the United States today, Filipinx-Americans remain highly underrepresented in reproductive health research, especially surrounding abortion care and access. Limited research has examined how religious, cultural, and social factors influence how Filipinx-Americans make reproductive health decisions, regarding abortion and family planning.

Methods

-This study is approved by Touro University California IRB.

-Qualitative study, recruited participants through convenience sampling

-Performed one-on-one, semi-structured interviews with individuals who met the following criteria:

--Women between the ages 18-55

--Identify as Filipinx or Filipinx-American, either first-generation immigrants from the Philippines or second-generation individuals

--Who currently reside in the Bay Area

--Are able to speak English

-Analyzed using grounded theory-informed thematic analysis

Results

Demographics

Interviewed 13 Filipinx-American women, aged 21-37

31% first-generation, 69% second-generation

Familial & Generational Influence

Participant 10 - “So I felt to protect myself because my mom had me–got pregnant with me at 19. She had me when she was in college with my father…and so I knew I didn’t want to follow the same path. I didn’t want to have an unplanned pregnancy.”

Participant 3 - “[My relatives] were one whole family in one bedroom…I didn’t think that was fair, and my mom didn’t think that was fair either, which is why she always told us to try to become financially stable first.”

Findings:

Family members’ experiences shaped participants’ perspectives of unintended pregnancy and family planning. Family experiences with financial hardships influenced participants to consider financial readiness when it comes to family planning.

Religious Upbringing

Participant 9 - “I think a combination of the way I was brought up, like I was saying, every life is essentially a miracle. I feel like that probably has religious undertones to it, but every life is special and created for a reason, but I also very much strongly feel like everyone should have the choice to do whatever they want with their body.”

Participant 3 - “Catholic guilt really is what gets them when they are first getting into sex or abortion…Catholic guilt is like God is always watching.”

Findings:

Religious identity and reproductive autonomy are not mutually exclusive. Participants may identify as religious themselves, acknowledging it’s a major part of their culture, but resisted allowing institutional religious beliefs dictate their reproductive autonomy. Religious expectations could also be internalized, essentially implicitly influencing how they navigate reproductive decision-making.

Stigma & Judgment

Participant 11 - “Hey doctor, I’m going to be taking this pill, is it okay if I take the antibiotics?...And then the dermatologist asked me, why are you taking that?...because you know, in my school, we don’t do that. We don’t have sex outside of marriage.”

Participant 1 - “Well, when I first got on birth control, I told them it was for my acne, which is true…and then I just never stopped taking it. laughs…In seventh grade, I got a boyfriend…and they were yelling at me right before we went to a family party…anything that would lead them to believe that I’m sexually active, I just really want to not talk about it.”

Participant 9 - “I’ll say that, you know, ever since I got married–and my parents are actually very

good about this–it's more like the aunties and uncles who were like, when are you going to have

babies? And are really kind of annoying about that.”

Findings:

Participants described receiving stigma from other healthcare workers and family members. Participants often concealed purpose of contraceptive use to protect themselves from anticipated judgment from family members. Family planning expectations extended beyond marriage for some participants, involving familial pressure to have kids

Silence & Privacy in Decision-Making

Participant 10 - “I did not feel comfortable telling or talking to [my mom] about it because then…she was very against premarital sex and all that…she was not a safe person to talk to about this.”

Participant 8 - “...that uncertainty of oh okay, maybe I wasn’t allowed to date until I graduate, but I know that because of them being religious and their values. I would think they wouldn’t like the idea of premarital sex and so I was like, that’s just not something I’m going to even try to talk about or touch on.”

Findings:

Anticipated judgment and stigma can prevent patients from discussing abortion or contraceptive care with family members. Participants tend to independently navigate reproductive health decisions due to anticipated stigma.

Conclusion

Reproductive decision-making involved multiple factors, including religion, expected stigma, culture, socioeconomic status, and familial background. Given these factors, many participants were not comfortable sharing their reproductive decision-making with family members, often making decisions independently. Instead, they also depended on other support systems, such as their partners and friends. Clinical providers can individualize their guidance on contraceptive and abortion care by addressing knowledge gaps, creating nonjudgmental environments, and considering cultural, religious, and familial influences on patients’ decisions.

Clinical Implications:

- Ask what a patient’s support systems are

- Directly ask if the patient would like to talk about sexual activity and contraceptives

- Don’t assume religious upbringing and belief in reproductive autonomy are mutually exclusive of each other

Background

Ovarian cancer is the leading cause of death among gynecologic tumors [1]. Surgery plus platinum-based combination chemotherapy is the first-line management for the disease [2]. The treatment of patients with platinum-sensitive or platinum-resistant recurrent or refractory ovarian cancer can be further managed by employing liposomal Doxorubicin. The preparation of liposomes for cancer therapy is impeded by long-duration procedures that include drug loading at low temperature, extended purification steps by dialysis, waste of expensive drugs, generation of large amounts of hazardous waste, and other large associated costs. In this respect, our investigations focused on developing a rapid and effective procedure for loading the anticancer drug Doxorubicin into liposomes. To achieve these goals, we exploited the temperature-induced phase transition of lipids in combination with rapid purification of liposomes by high-speed centrifugation in an Airfuge; the combination enabled completion of liposome preparation and loading in one day.

Methods

Principle of temperature-induced permeability. The key element of the proposed methodology is the phase transition of lipids assembled into artificial membrane systems (Figure 1). At high temperature, the lipids in a lipid membrane transition from a gel/solid crystalline phase to a more fluid phase, characterized by decreased rigidity and increased permeability. Therefore, we anticipated that an increased permeability will significantly speed up the active loading of drugs into liposomes.

Principle of active loading. Active loading exploits the molecules’ ability to toggle between permeant and non-permeant state based on the solution conditions. In the case of the anticancer drug Dox and drug simulator AO, the state of the molecule depends on the solution’s pH. At neutral pH, Dox and AO (weak bases, Figure 2) are electrically neutral and cross the membrane. However, at an acidic pH, the ionized Dox/AO may no longer cross the membrane and becomes trapped inside liposomes (Figure 2). Nonetheless, this process is very slow, and it takes several days at room or low temperature.

Liposome preparation. To demonstrate the central hypothesis of this research project, we prepared by extrusion ~200 nm liposomes (therefore, capable of self accumulating into solid tumors) from lipid mixtures composed of DSPC, DSPE-PEG (to render them invisible to the immune host), and cholesterol. The liposomes were produced by hydrating the lipid cakes with a citrate buffer (pH 4.5). After preparation, the external buffer was exchanged with a neutral one (PBS1x, pH 7.2) by employing four consecutive purification steps in a high-speed Beckman Airfuge (75,000 RPM, 20 minutes). Liposome characterization was further performed by microscopy and Dynamic Light Scattering (DLS) analyses.

Liposomes loading at high temperature. After preparation, purification, and creation of a pH gradient, the liposomes have been exposed for one hour to 100 μM Dox or AO at 65 0C in a thermal block. After loading, the liposomes were cooled down by vial immersion in water at room temperature. The removal of the non-incorporated Dox or AO was performed by replacing the external neutral buffer with a drug-free solution (PBS 1x, pH 7.2) in four purification steps with the Airfuge. Loading verification. The presence of loaded Dox into liposomes was confirmed by fluorescence microscopy. Dox is a low-solubility anticancer drug, which presents fluorescence, thus it may be identified by microscopy. However, Dox also presents strong self-quenching capabilities (seen by a marked decrease in fluorescence as its concentration increases). AO, a drug simulator, is also fluorescent and presents self-quenching. This important feature can be exploited to additionally characterize the loading by monitoring the changes in fluorescence upon drug dilution into bulk after liposome membrane permeabilization with a non-ionic detergent (i.e., Triton X100).

Results

Characterization of unloaded liposomes. Before loading, the undiluted liposomes were characterized by B/W microscopy and DLS (Figure 3). The image revealed the presence of high-density, non aggregated liposomes. DLS determination of size distribution indicated an average hydrodynamic diameter of 205 nm and an excellent Polydispersity Index (PDI) of 0.09, indicative of a very narrow size distribution. Liposomes of this size are suitable for self-accumulation into solid tumors by the Enhanced Permeability and Retention (EPR) effect, and the narrow distribution ensures their clinical applicability for drug delivery purposes.

Characterization of Dox-loaded liposomes by microscopy and DLS. After sustained purification by high-speed centrifugation and washing, the loaded liposomes have been characterized for loading by fluorescence microscopy, DLS, and fluorescence spectroscopy. Fluorescence microscopy imaging of Dox-loaded liposomes was carried out on diluted samples (1:5) to avoid saturation elicited by the high density of liposomes in the samples and revealed the presence of loaded, non-aggregated liposomes (Figure 4). DLS indicated that the loading process did not affect the hydrodynamic size of the Dox loaded liposomes or the dispersity index. Fluorescence spectroscopy analysis of Dox and AO release. Fluorescence spectroscopy analysis of Dox fluorescence dependency on concentration (Figure 5) shows a strong self-quenching effect (i.e. a marked decrease in fluorescence) at concentrations larger than ~30 μM; a similar plot is obtained for AO (data not shown). This self quenching feature is further exploited to assess the effectiveness of DOX and AO loading from the kinetic evolution of the fluorescence signal upon liposome breach by the detergent Triton X100. If the concentration of loaded Dox or AO exceeds the self quenching threshold, membrane solubilization leads to drug dilution into the bulk and an increase in fluorescence. This anticipated behavior was clearly observed in our experimental samples (Figure 5), indicative of significant Dox and AO loading into liposomes.

Conclusion

In conclusion, the thermal transition of lipids can be exploited to facilitate the rapid yet stable loading of liposomes with anticancer drugs and drug simulators by active approaches. In conjunction with fast separation by high-speed centrifugation, the entire loading and characterization procedure may be finalized in one day. This is a major advancement: the proposed procedure is substantially shorter than the traditional approach that implies dialysis and loading at low temperature, which requires at least one week. Future work will focus on protocol optimization for attaining a maximum load for various lipid compositions and distinct drugs. We are also planning on assessing the long-term stability of the thermally-loaded liposomes, together with their ability to self-accumulate into solid tumors.

Background

Approximately 5-10% of U.S. pregnancies are affected by intrauterine growth restriction (IUGR), which is often due to placental ischemia. Adults who were exposed to IUGR have a higher risk of developing cardiovascular diseases (CVD), in which there are sex differences where IUGR males show greater risk of CVD morbidities. One plausible mechanism is cardiac inflammation. Multiple studies have shown that IUGR offspring have increased pro-inflammatory cytokines, such as TNF-α, IL-6, and IFN-γ, that are present in the circulation and heart. However, few studies have explored anti-inflammatory cytokines in the hearts of adult IUGR offspring. Thus, the objective of this study is to investigate alterations in blood pressure (BP) and cardiac IL-4 and IL-10 in adult male and female IUGR offspring. We hypothesize that IUGR males will have higher BP accompanied by decreased cardiac IL-4 and IL-10, while these cytokines will remain unchanged in IUGR females.

Methods

Pregnant Sprague Dawley rats were randomly divided into two groups: normal and placental ischemic (PI) dams. On gestational day 14, the reduced uterine perfusion pressure surgery was performed to induce PI. Our PI dams generated IUGR offspring while the normal pregnant dams generated control (CON) offspring. All pups were born naturally and weaned for 3 weeks. At 16-18 weeks (adulthood), the offsprings’ BP was recorded via a carotid catheterization. Hearts were then collected and homogenized to measure IL-4 and IL-10 levels via ELISAs.

Results

BP increased in IUGR vs CON males (136±2 vs. 120±7mmHg, p<0.05), whereas BP in IUGR vs CON females was unchanged. Cardiac IL-4 was elevated in females compared to males (p<0.05) and in IUGR compared to CON (p=0.0002). IL-4 exhibited a greater increase of ~63% in IUGR vs CON females (306.6±17.1 vs. 188.0±22.6pg/mg, p<0.05) and 45% increase in IUGR vs CON males (216.8±19.2 vs. 149.5±23.4pg/mg, p<0.05). Furthermore, IUGR females showed a 41% increase in IL-4 levels compared to IUGR males (306.6±17.1 vs. 216.8±19.2pg/mg, p<0.05). There were no changes in cardiac IL-10 in all groups

Conclusion

IUGR males displayed elevated BP compared to CON males, while females displayed no differences. Surprisingly, IL-4 concentrations were increased with IUGR status in both sexes, with a greater increase in IUGR vs CON females. Moreover, IL-4 was elevated in females vs males. This increase in IL-4 in females may be a protective mechanism to prevent future cardiac dysfunction. Previous studies have shown IL-4 aids in tissue repair, but chronically elevated IL-4 is linked to adverse cardiac remodeling. More studies are needed to determine the sexually dimorphic role of cardiac IL-4 in this IUGR model. Cardiac IL-10 was unchanged in all groups, suggesting that its role in BP regulation and CVD is not as critical as IL-4. This study is clinically relevant because it highlights the sex differences and the role of cardiac anti-inflammatory cytokines to increase the risk of CVD in adult IUGR offspring.

Background

Introduction: Poverty is a common form of early life stress (ELS), which is a low-resourced environment, that impacts ~333 million children worldwide. The implications of childhood poverty often carry into adulthood, specifically impacting cardiovascular health. Furthermore, childhood poverty increases the risk of developing hypertension (HTN) during adulthood. Studies have explored the link between childhood poverty and HTN development later in life, but less is known about sex-specific changes in the heart. Utilizing the rodent ELS limited bedding and nesting (LBN) model, we investigated sex differences in cardiac oxidative stress, inflammation, and nitric oxide (NO) bioavailability. We hypothesize that LBN male rats will have an elevated cardiac oxidative stress (increase in hydrogen peroxide (H2O2) concentration and decreased antioxidant concentration), along with increased pro-inflammatory cytokines and decreased NO bioavailability compared to control (CON) male rats. Dissimilarly, we predict LBN female rats will express minimal changes, if any, compared to the CON females.

Methods

Methods: The LBN model induces ELS in the LBN pups by reducing bedding and nesting material from postnatal day (PND) 2 to 9. After weaning, the rats were divided into four groups based on sex and condition: LBN male (n=4-5), CON male (n=4), LBN female (n=6), and CON female (n=3-4). At 16-18 weeks of age (young adulthood), we assessed markers of oxidative stress, inflammation, and NO bioavailability. We evaluated oxidative stress in cardiac tissue using H2O2 and total antioxidant capacity biochemical assays. Cardiac tissue was also used to investigate inflammation, interleukin-17 (IL-17) and tumor necrotic factor-alpha (TNF-α), via colorimetric assays.

Results

Results: LBN males exhibited a 2-fold increase in H2O2, a potent reactive oxygen species (101.08 ± 15.95 vs 47.26 ±4.83 pmol/ug protein; p<0.05 vs CON males), while there were no changes in females. Cardiac antioxidant capacity, IL-17 (1410.90 ± 501.73 vs. 1414.14 ± 369.73 pg/mL/mg; p=0.99 vs CON males), and TNF- α (130.72 ± 58.47 vs 141.43 ± 54.61 pg/mL/mg; p=0.73 vs CON males) all demonstrated no significant changes amongst the groups, both male and females (ns). Cardiac NO bioavailability was also unchanged in LBN males (ns); although, LBN females showed an upward trend in NO bioavailability (10.64 ± 0.62 vs 8.61 ± 0.48 mM/ug protein; p=0.14 vs CON female).

Conclusion

Overall, these findings demonstrate that ELS induces oxidative stress in males but not significantly in females, underscoring sex as a critical biological variable in cardiac vulnerability. Specifically, LBN males demonstrated significantly elevated cardiac H₂O₂ concentrations, whereas females appeared protected against this increase. Across all groups, antioxidant capacity, inflammatory cytokines, and NO bioavailability remained unchanged; however, LBN females presented a positive trend toward increased NO bioavailability. Ultimately, these results suggest that males may be more sensitive to the cardiovascular consequences of childhood poverty, whereas females may possess adaptive mechanisms that protect against these negative repercussions. Consequently, these findings provide a vital framework to guide future experiments, refine hypotheses, and advance our understanding of how early life stress impacts sex-specific cardiovascular function.

Background

California’s Family Planning, Access, Care, and Treatment (Family PACT) program provides all forms of contraception free of charge to all uninsured California residents who fall below 200% of the federal poverty line1.

Even with funding, patients may not be able to find a participating provider in an accessible location, obtain accurate information, or receive their desired contraceptive method without additional visits or referrals2,5.

These barriers may be particularly consequential for adolescents and patients in geographically dispersed, medically underserved areas.

San Bernardino and Riverside Counties span more than 27,000 square miles and 52% of the population are eligible reproductive age females2,5.

Although the etongestrel implant is a highly effective, user independent contraceptive method, it does require a face to face meeting with a provider for insertion4.

Little is known about whether Family Pact-listed sites in this region actually offer the implant on-site or facilitate timely placement.

Methods

We gathered all of the Family Pact enrolled sites in the zip codes of San Bernardino and Riverside Counties

The 131 sites were called, and given 3 chances to answer the call

A single caller used a standardized, IRB approved script to simulate a 17-year old Family Pact patient seeking the etongestrel contraceptive implant

We recorded outcomes such as Family Pact acceptance, on-site implant availability, informal referral practices, preliminary visit requirements (2 visit), and telephone access barriers (hold times, transfers, etc).

Results

Among 131 sites listed on the Family Pact website, 8 did not answer after 3 attempts, 21 had incorrect or disconnected phone numbers, and 21 were reached but front desk staff were unable to provide definitive information on Family Pact participation or implant availability.

63 sites confirmed Family Pact participation (48.1%). Of these sites, 48 of them provided the etongestrel implant on site.

Only 10 of the 131 sites reported that the implant could be placed on site in one visit (See Figure 1).

Conclusion

Although Family PACT is designed to reduce financial barriers to contraception, our findings demonstrate that coverage alone does not ensure meaningful access to the etonogestrel implant.

Fewer than 8% of listed sites reported the ability to provide implant placement in a single visit, highlighting a substantial gap between program participation and timely contraceptive care.

Barriers occurred at multiple levels, including inaccurate directory information, uncertainty among clinic staff, referral-dependent care, and requirements for preliminary visits.

Improving access will require more than expanding contraceptive coverage. Maintaining accurate provider directories, improving staff knowledge of Family PACT services, and increasing same-day implant availability may help translate contraceptive coverage into actual, timely access.

Background

Vaginal infections are one of the most presented complaints by female patients. The use of artificial intelligence (AI) in this field has the potential to improve accuracy and subsequently provide more prompt treatment. Caza Health has developed the DayZ™ Vaginal Health Assessment Assay (VHA), which uses artificial intelligence (AI) coupled with immunofluorescence antibody cocktails plus automated scanning microscopy to determine the targets of interest, bacterial vaginosis, candida vaginitis, and trichomonas vaginosis, at the time of the office visit. The aim of this study is to evaluate the effectiveness of the DayZ™ VHA reader training program by comparing newly trained readers’ interpretations with expert-established ground truth (expert reader) to determine reader-to-reader variations.

Methods

As part of the DayZTM development, a multi-reader study was conducted on a subset of samples, with the objective of assessing the ability of a newly trained reader to interpret results of the DayZ™ VHA test as compared to ground truth (expert reader). The effectiveness of the training was evaluated by reader-to-reader variations and by discordant analysis with ground truth. Five individual readers were trained one-on-one using the DayZ ™ System analysis software using the same exemplary image file. The readers then independently read image files in random order as their time allowed. Completed files by each reader were uploaded to Caza Health for analysis, which compared the results of the individual readers within the group for each target species and to the results to the ground truth (expert reader) who trains the AI algorithm.

Results

At present, 200 (out of 400 planned) vaginal swab samples from symptomatic vaginosis participants have been analyzed, and algorithm training has achieved an accuracy of 86% for BV, 83% for CV and, 94% for TV compared to the results obtained by an expert human reader. The trained reader data suggests that human identification of clue cells is still problematic, with a 39% discordance rate compared to the expert reader, where CV and TV discordance was 14% and 12%, respectively. As a result of the analysis, ways to enhance training effectiveness to better reader outcomes were identified including increased one-on-one training time, clearer definitions of clue cell characteristics, how to identify clue cells versus normal epithelial cells more accurately, and recognizing/rejecting non-specific staining, autofluorescence, and cellular debris.

Conclusion

The DayZTM Vaginal Health Assessment System is in development as a near point-of-care instrument to provide physicians with improved vaginal biome data for the assessment and treatment of vaginitis. This study provides key information to enhance training effectiveness for end-point users, including providing clearer definitions of clue cell characteristics and how to identify clue cells more accurately versus normal epithelial cells. Furthermore, this project will develop and improve training modules and methods to enhance easy start-up of the DayZTM VHA System when deployed in a clinician practice.

Background

-Standard of Care: The CDC and American Academy of Pediatrics recommend universal hepatitis B vaccination starting at birth, while intramuscular vitamin K is routinely recommended to prevent vitamin K deficiency bleeding.

-Clinical Concern: Parental refusal of routine newborn prophylaxis has been increasingly reported.

-Knowledge Gap: The influence of healthcare-related mistrust on newborn prophylaxis refusal remains poorly characterized.

Methods

Search Strategy: Systematic review of PubMed, Cochrane Library, CINAHL, Web of Science, and ScienceDirect conducted and reported in accordance with PRISMA guidelines.

Eligibility: U.S.-based studies evaluating parental refusal of intramuscular vitamin K and/or the hepatitis B birth dose were included.

Screening: Three reviewers independently screened records using Rayyan. The disagreements were resolved by consensus.

Quality Appraisal: Included studies were appraised using JBI critical appraisal tools appropriate to study design.

Results

Seven studies met inclusion criteria. Comparisons were made between the themes of the qualitative study (Loyal et al.) and the quantitative studies. The results are displayed in a Table 1.

Conclusion

-Quantitative evidence identified patterns of refusal across demographic and behavioral groups. However, most studies (6 of 7) did not directly measure healthcare-related mistrust.

-Qualitative evidence provided insight into why refusal may occur, identifying medical and pharmaceutical mistrust as influences on peripartum decision-making.

-Conceptual similarities were observed between quantitative refusal patterns and themes identified in the qualitative study (Table 1); however, these associations cannot establish that mistrust caused refusal without direct measurement.

-Refusal was clustered among groups characterized by factors such as exclusive breastfeeding and advanced parity. These factors do not adequately explain why trends are concentrated within these groups and do not explain whether this reflects deeper, systemic skepticism toward the healthcare system.

-Accessible evidence suggests healthcare-related mistrust may contribute to newborn prophylaxis refusal. Direct evidence remains limited because most included studies did not directly measure mistrust.

-Future Direction: Future peripartum studies should move beyond passive demographic tracking and integrate validated methods to conclusively map and address the psychosocial and healthcare-related drivers of peripartum newborn prophylaxis refusal.

Background

The vaginal microbiome shapes reproductive health; bacterial vaginosis (BV), a shift from a Lactobacillus-dominant to a diverse anaerobic community, is linked to adverse reproductive outcomes.1 Psychosocial stress is associated with increased BV prevalence/incidence; trauma and PTSD are independently linked to neuroendocrine dysregulation and altered genital immune/mucosal homeostasis.2–4 Given that 45.1% of United States women report lifetime contact sexual violence and 21.0% report completed/attempted rape, a confirmed pathway linking trauma to BV would have broad reproductive health relevance.5 The goal of this work is to synthesize evidence for a stress-mediated pathway linking sexual trauma to vaginal dysbiosis/BV, given that this pathway remains poorly characterized, and to identify gaps for future investigation.

Methods

A PubMed search was conducted from April through August 2026 using combinations of terms related to sexual violence, PTSD/stress, vaginal dysbiosis/microbiota, cortisol/HPA-axis function, inflammation, and immune markers. Approximately 150 citations were screened by title and abstract, with primary studies most directly addressing the proposed pathway prioritized and review articles used to identify additional relevant sources. Studies with limited relevance to the pathway were excluded. This work represents a narrative synthesis rather than a systematic review.

Results

Evidence across the reviewed literature supported four components of the proposed pathway. Sexual trauma and trauma-related PTSD were associated with persistent HPA-axis dysregulation, including altered ACTH secretion and context-dependent cortisol levels and reactivity. Trauma exposure was also associated with altered genital immune signaling, epithelial changes, and reduced barrier integrity. Vaginal microbiome composition and bacterial load were linked to immune activation, with Lactobacillus-depleted, high-diversity communities showing increased inflammatory signaling and overlap with mediators reported in trauma-associated genital studies. Finally, psychosocial stress and lifetime trauma were consistently associated with BV development, persistence, and impaired recovery toward Lactobacillus-dominant communities.

Conclusion

The reviewed evidence supports a biologically coherent stress-mediated pathway linking sexual trauma with vaginal dysbiosis, but no single study has evaluated the complete pathway or established causality. Important limitations include heterogeneity in trauma exposure, study populations, and measurement methods, as well as potential confounding and alternative pathways such as direct sexual/microbial exposure, genital injury, and behavioral factors. Prospective studies integrating trauma history, stress physiology, genital immune markers, and longitudinal vaginal microbiome outcomes are needed to establish temporality and mediation. If confirmed, this pathway could inform more integrated, trauma-informed approaches to recurrent BV research and clinical evaluation.

Background

Multiple gestation: Remains one of the most significant complications associated with in vitro fertilization (IVF). Compared to singleton gestations, twin pregnancies carry significantly higher rates of severe maternal complications, including preeclampsia, gestational diabetes, preterm labor, placental abruption, and postpartum hemorrhage.

2021 ASRM Guideline Specifications: The 2021 ASRM Practice Committee Opinion (Guidance on the limits to the number of embryos to transfer) explicitly limits the transfer of demonstrated euploid embryos to exactly 1 across all maternal age groups (<35, 35–37, 38–40, and 41–42 years). While the guidelines permit age- and prognosis-based allowances for transferring multiple untested embryos (up to 2–5 depending on age and stage) and require medical record documentation for clinical exceptions, single euploid embryo transfer (SEET) remains the standard for transferring embryos that have been screened for chromosomal abnornmalities.

Guideline non-adherence: Despite these standards aimed at limiting risks of multiple gestation, multiple euploid embryo transfers (MEET) continue to occur in clinical practice in the United States.

Methods

Data Source: Society for Assisted Reproductive Technology (SART) Retrieval and Transfer Outcome Tables (2022–2024).

Study Population: Autologous preimplantation genetic testing for aneuploidy (PGT-A) frozen blastocyst cycles (N = 300,579).

Age Stratification: Data were categorized into four standard clinical age groups: <35 years (n = 124,390), 35–37 years (n = 86,989), 38–40 years (n = 67,335), and 41–42 years (n = 21,865), alongside a pooled overall cohort.

Outcome Measures & Statistical Analysis: Evaluated outcomes included live birth rate (LBR) per transfer cycle and multiple delivery rate among live births. Unadjusted relative risks (RR) with 95% confidence intervals (CI) were calculated to evaluate the multiple delivery risk comparing MEET against SEET across age strata.

Results

Among 300,579 euploid blastocyst transfers, 292,142 (97.2%) were SEET and 8,437 (2.8%) MEET (Table 1).

Live birth rates were 53.4% from SEET and 53.5% from MEET (Table 1, Figure 1).

Multiple delivery rates after MEET ranged from 38.6%–40.7% vs. SEET (0.9%–1.1%) across all age groups (Figure 1).

MEET carried 35- to 42-fold increased multiple delivery risk vs. SEET (Figure 2).

Conclusion

Live birth rates were statistically indistinguishable between SEET (53.4%) and MEET (53.5%), meaning a second euploid embryo added no live-birth benefit.

Multiple delivery rates, however, diverged sharply: 0.9–1.1% with SEET versus 34.5–40.7% with MEET across every age group, for a pooled 38-fold increased risk (RR 38.5; 95% CI 36.2–40.9).

The elevated risk held even at ages 41–42, where guideline exceptions are most often invoked.

Because public SART data cannot identify which MEET cycles met a documented ASRM exception, this analysis cannot confirm whether those transfers were clinically justified, underscoring the need for patient-level follow-up research.

Background

More than 44% of counties in Georgia are designated maternity care deserts, and over 60% of rural Georgia residents live more than 30 minutes from a birthing hospital.¹ In Colquitt County, 23.6% of residents under age 65 are uninsured, and 25.6% live in poverty.⁹ Provider shortages, transportation limitations, insurance gaps, poverty, and language barriers are persistent barriers to timely prenatal care access in rural communities.²,⁸ In Colquitt County, prenatal care resources are concentrated in Moultrie, potentially representing access challenges for obstetric patients in surrounding rural communities. While healthcare and social resources exist throughout the community, information about these services may be fragmented across multiple organizations and difficult for patients to navigate. A centralized, Quick Response (QR) code–accessible platform may provide a low-cost mechanism for connecting pregnant patients with healthcare and social support resources.?

Aim: To characterize geographic and resource-access barriers to prenatal care in Colquitt County and develop a centralized, QR code–accessible maternal health resource platform connecting pregnant patients in Moultrie and surrounding rural communities with healthcare, insurance, education, housing, food, and transportation resources.

Methods

Targeted Literature Review:  PubMed and Google Scholar were searched for peer-reviewed literature published from 2022–2026 using combinations of terms related to QR codes, health information, pregnancy, public health, and rural populations. Six articles met inclusion criteria based on relevance to QR code–based health information delivery, maternal health disparities, prenatal care access, and rural/underserved populations. Findings were synthesized thematically across QR code utilization, barriers to care, and healthcare infrastructure.?

Community Assessment:  A descriptive community assessment used publicly available demographic, socioeconomic, and healthcare access data. Prenatal care sites were identified through local healthcare directories and community healthcare resources and were defined as facilities providing routine prenatal care to pregnant patients. Google Maps was used to calculate driving distance from each of eight ZIP-code locations (31788, 31776, 31768, 31753, 31722, 31771, 31747, 31744) to each site; the shortest distance was recorded for each ZIP code. Mean distances were descriptively compared between Moultrie and non-Moultrie ZIP codes. Measurements were performed in June 2026.

Resource Tool Development: Findings from the literature review and community assessment were used to identify key barriers and resource needs and inform the development of a centralized, QR code–accessible maternal health resource platform.

Results

Geographic & Community Assessment

Geographic Concentration: Identified prenatal care resources were concentrated within Moultrie, with no identified prenatal care sites located in the surrounding rural communities assessed.

Travel Burden: Non-Moultrie ZIP codes had approximately 5.5x the average driving distance to the nearest prenatal care site compared with Moultrie ZIP codes (12.7 vs 2.3 miles).

Fragmented Resource Landscape: Existing healthcare and social support resources were distributed across multiple organizations, requiring users to navigate separate sources to identify available services.

Resource Tool Development & Pilot Interface

A centralized maternal health resource platform was developed across six domains: Healthcare Providers, Insurance Support, Health Education, Housing Support, Food Pantries, and Transportation Options. The platform uses direct-to-source links to connect users with existing community services rather than duplicating information.

Example User Pathway:

Scan → Choose a need → Select a resource → Connect directly

Conclusion

Addressing Rural Disparities: The community assessment demonstrates a substantial geographic travel burden for patients residing outside Moultrie. Greater travel burden may contribute to delayed or more difficult access to prenatal care and warrants further study. Combined with regional baseline metrics such as a 23.6% uninsured rate and 25.6% poverty rate, this physical distance may worsen care entry delays. Longer travel requirements may also create financial and logistical burdens, including transportation costs, time away from work, and challenges coordinating childcare or other responsibilities.

Efficacy of QR-Driven Informational Hubs: Consolidating existing resources into a single digital directory creates an “offline-to-online” pathway through strategically placed physical QR codes. Prior studies support the potential utility of QR codes for connecting individuals with digital health information and public health resources.³,⁴,⁷

Digital Health Access: Hu et al. demonstrated the use of QR codes to facilitate access to digital health resources in a primary care waiting-room setting.⁷

Prenatal Education: Farland's quality improvement project evaluated virtual and mobile prenatal education and reported increased enrollment associated with targeted educational strategies.⁵

Public Health Navigation: Ramsey-Coleman et al. examined QR code strategies for promoting public health programs, supporting their potential as an accessible resource-navigation mechanism.⁴

Women’s Health Information: Fischer-Suárez et al. evaluated QR codes as an eHealth strategy for promoting health among women, supporting their potential for mobile health information delivery.³

Limitations & Future Direction: While the QR-based tool offers a scalable, low-cost approach to resource navigation, implementation may be limited by smartphone access, cellular/Wi-Fi availability, language, health literacy, and accessibility needs. Future phases will include stakeholder-informed usability review and community deployment in food pantries, health departments, and public spaces. Tool utilization will be evaluated through QR scans, click-through rates, resource categories accessed, usability, and whether users successfully locate needed resources. Resources will be reviewed and updated quarterly to maintain accuracy and community relevance.

Background

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting of pregnancy that can result in dehydration, nutritional compromise, and electrolyte abnormalities. Current obstetric guidelines focus appropriately on these complications, but oral health is not routinely incorporated into HG assessment or management. This represents a potential clinical gap given the physiologically plausible pathway between recurrent vomiting, gastric-acid exposure, and oral complications including dental erosion and gingival inflammation.

Although HG typically improves as pregnancy progresses, oral complications associated with repeated acid exposure or difficulty maintaining oral hygiene may persist beyond the acute illness and warrant early attention. Routine HG visits therefore provide a low-burden opportunity for oral-health screening, preventive counseling, and timely dental referral without requiring a separate medical appointment.

This project aims to synthesize existing obstetric and dental guidance, including recommendations from ACOG and the ADA, alongside HG reference literature, pregnancy-based oral-health evidence. The framework prioritizes areas of convergence across available evidence while distinguishing established pregnancy and dental evidence from the still-limited HG-specific literature.

The proposed approach focuses on four areas: (1) the physiologic pathways linking HG to oral-health risk, (2) what current evidence demonstrates, (3) low-cost preventive measures obstetric providers can recommend, and (4) a practical screening and referral pathway for routine HG care.

Methods

A focused literature and guideline review was conducted using the references identified by the authors, including guidance from the American College of Obstetricians and Gynecologists, American Dental Association, Health Resources and Services Administration, and American Academy of Periodontology, as well as peer-reviewed literature addressing hyperemesis gravidarum, pregnancy-related oral health, dental erosion, and periodontal health. Recommendations were synthesized into a risk-stratified clinical framework addressing common oral-health challenges associated with HG. The framework was organized into recommendations for obstetric clinicians and dental professionals to facilitate multidisciplinary care.

Results

The literature review identified several clinically relevant oral-health concerns associated with severe nausea and vomiting, including dental erosion, difficulty maintaining oral hygiene, gingival inflammation, dietary-related caries risk, dehydration and xerostomia, and intolerance of toothpaste or routine oral-care practices. A multidisciplinary framework was developed that stratifies patients according to the severity of oral-health barriers and provides corresponding obstetric and dental actions. Recommendations include maintaining fluoride exposure when tolerated, modifying oral-hygiene techniques during severe gagging, rinsing after vomiting or acidic dietary exposures, supporting hydration and salivary stimulation, assessing for dental erosion and periodontal disease, and coordinating dental evaluation when symptoms or oral findings warrant further care.

Conclusion

Oral health represents an underrecognized component of comprehensive care for patients with hyperemesis gravidarum. Severe vomiting, dietary changes, dehydration, and difficulty tolerating routine oral hygiene may create cumulative risks for dental erosion, caries, xerostomia, and gingival disease. Incorporating brief oral-health counseling into obstetric care and establishing clear referral pathways to dental professionals may help reduce preventable oral morbidity. This framework provides a practical approach for integrating oral-health considerations into multidisciplinary HG management while allowing recommendations to be individualized according to symptom severity and patient tolerance.

Background

Contraceptive counseling is a critical component of comprehensive reproductive health care, yet physician knowledge and communication around this topic remain inconsistent. Counseling is associated with increased contraceptive use among

primary care patients, and high-quality counseling at the initiation of contraceptive use has been shown to reduce discontinuation and lower unintended pregnancy rates.

Misinformation during clinical encounters propagates towards patient understanding and limits access to effective

contraceptive methods. As patients increasingly turn to peers and online platforms for health information, sources that often

perpetuate myths, there is a growing need for future physicians to serve as accurate, evidence-based resources. Osteopathic (D.O.) medical students, 57% of whom go into primary care, are especially well-positioned to improve contraceptive counseling and access.

Yet, primary care trainees often have less formal contraceptive education than their OB/GYN peers. This study will investigate how knowledge, attitudes, and comfort with contraceptive care evolve throughout the years of osteopathic medical training. By tracing the origins and persistence of common myths and misconceptions about contraception, the findings may help inform targeted educational strategies that strengthen clinical preparedness and reduce bias and misinformation.

Methods

IRB-approved, anonymous, voluntary, beta-tested, 16 item survey sent to all osteopathic medical students twice from January 2026 to March 2026 represent 3 different groups.

OMS1= no formal teaching

OMS2= preclinical didactics

OMS3 + OMS4/5= clinical experience added

Survey Structure and Key Measures

Influencing Factors: Questions assessed demographics, personal experience, faith importance, perceived confidence in counseling, primary info sources, referral intentions to provide care in practice, and belief in accuracy of common myths.

Objective Knowledge: Evaluated efficacy, mechanisms of action, and common misinformation. Scored 1 (correct) or 0 (incorrect) for a total composite score (range 0-4). We were testing more controversial aspects surrounding contraception.

Data Analysis: One-tailed two-sample t-test to compare average scores for OMS1 with all other classes.

Results

Our results demonstrated that misinformation exists across all the years, but there was a significant increase in scores after students received curricular lectures and gained clinical experience (p < 0.001).

200 of the 1000 students participated (20% response rate)

183 of 200 respondents completed the survey entirely.

Conclusion

By identifying the sources and timing of barriers to evidence-based contraceptive counseling, we can contribute to the development of early-stage educational interventions. As patients turn to peer and online platforms that perpetuate myths, future physicians must serve as accurate resources.

It appears there is an impact in medical education. OMS1 scored lower than OMS2-5.

Popular sources of information were curriculum and medical websites. First years preferred medical websites and social media/general internet. Professional guidelines were rarely cited. No subject scored 4/4 on these deliberately tested misconceptions. This affirms prior research showing that gaps in contraceptive knowledge exist.

Background

The 2022 Dobbs v. Jackson Women’s Health Organization decision returned abortion regulation to the states, ending federal constitutional protection under Roe v. Wade. In Georgia, this triggered enforcement of the Living Infants Fairness and Equality (LIFE) Act, banning most abortions after fetal cardiac activity is detected, typically around 6 weeks of gestation, often before pregnancy is confirmed. Narrow exceptions exist for medical emergencies, irreversible impairment, documented rape or incest, and fatal anomalies. Since the ban took effect, clinic closures have reduced Georgia’s in-state abortion provider network, raising concerns about geographic access disparities, particularly for rural and low-income patients facing substantial travel burdens. This study quantifies that burden across all 159 Georgia counties, examining how estimated travel time to abortion care varies by rurality, race, and household income in the post-Dobbs landscape.

Methods

Straight-line (geodesic) distance was calculated from each of Georgia's 159 county centroids to the nearest geocoded abortion clinic location. This distance was multiplied by 1.25 to approximate real road-network travel distance, then converted to estimated travel time assuming an average speed of 45 mph. Travel time was modeled under two access scenarios: in-state-only (13 open Georgia clinics) and best-available, which allowed out-of-state clinics when they were closer. Counties were grouped by rurality (Rural-Urban Continuum Code), quartile of percent Black population, and household income relative to the Georgia median, to test whether travel burden differs across these groups.

Results

Median estimated travel time to the nearest abortion provider was 92.0 minutes in-state and 81.9 minutes best-available (regardless of state). Overall, 30.2% of Georgia’s 159 counties exceeded a 2-hour travel threshold in-state, falling to 20.1% best-available. Burden increased sharply with rurality: metro counties (n=74) had a median in-state travel time of 58.7 minutes, nonmetro RUCC 4-6 counties (n=27) faced 101.7 minutes, and nonmetro RUCC 7-9 counties (n=58) faced the greatest and most persistent burden at 109.6 minutes in-state, 101.1 minutes best-available, with 94.8% remaining over 1 hour from care under either scenario. Georgia’s operating clinic count fell from 15 to 13 post-Dobbs (13.3% reduction). Counties with lower Black population share and below-median household income faced longer median travel times than their counterparts (83.3 vs. 75.2 minutes in-state; 106.7 vs. 70.0 minutes in-state, respectively).

Conclusion

Georgia’s post-Dobbs geographic disparities in abortion access are driven primarily by rurality, not race. Nonmetro counties (RUCC 7-9) face a median estimated travel time of 109.6 minutes to an in-state provider, and unlike metro and less rural counties, out-of-state access provides little relief, with 94.8% remaining over one hour from care regardless of scenario. Income compounds this disparity, with counties below Georgia’s median household income facing a median travel time of 106.7 minutes versus 70.0 minutes for higher-income counties. Race shows a more complex pattern: counties with lower Black population share have longer median travel times overall, but this largely reflects the concentration of Georgia’s remaining clinics in metro areas (Atlanta, Columbus, Augusta) that also have large Black populations. When restricted to rural counties specifically, those with higher Black population share still face substantial travel burdens, averaging 86.3 minutes, confirming that rurality, not racial composition, is the primary geographic driver of access burden statewide. Closing this gap will require investment in transportation support, telehealth options, and provider access specifically targeted at rural Georgia, not statewide policy alone.

Introduction

Twin reversed arterial perfusion (TRAP) sequence is a rare complication of monochorionic twin pregnancies in which a malformed acardiac twin depends on a normal “pump” twin for circulation. Prenatal diagnosis typically relies on ultrasonography with Doppler; however, the acardius amorphous subtype may lack classic sonographic features and resemble a placental mass. Distinguishing fetus acardius from placental teratoma may require histopathologic evaluation for features such as umbilical cord attachment and axial organization. We present an atypical case diagnosed postnatally by histopathology after prenatal imaging was inconclusive, with a favorable outcome for the pump twin.

Case Description

A 32-year-old G3P2012 woman was found to have a placental/umbilical cord mass, single umbilical artery, and fetal VSD on ultrasound at approximately 28 weeks’ gestation. Fetal MRI at 30 weeks demonstrated a 4.7 × 3.5 × 4.6 cm complex solid mass attached to the placenta by a vascular stalk without identifiable fetal structures. Placental teratoma and fetus acardius amorphous were considered; however, absent reversed arterial flow made TRAP sequence less likely prenatally. The pregnancy was monitored with twice-weekly fetal testing and remained reassuring. At 37 weeks and 1 day, a viable male infant was delivered by repeat cesarean section and remained hemodynamically stable. Gross placental examination demonstrated an exophytic mass attached by a vascular stalk. Histopathologic examination confirmed fetus acardius amorphous. Maternal and neonatal postpartum courses were uncomplicated.

Discussion

Twin reversed arterial perfusion (TRAP) sequence is a rare complication of monochorionic multifetal gestations in which an acardiac twin receives retrograde perfusion from a structurally normal “pump” twin through abnormal placental vascular anastomoses. The acardius amorphous subtype is the least differentiated form and may appear as a placental mass without recognizable fetal anatomy, making prenatal diagnosis challenging.

Ultrasonography with Doppler is the primary diagnostic modality, with typical findings including absent cardiac activity and reversed arterial blood flow. In this case, a vascular placental mass was identified without reversed arterial perfusion or recognizable fetal structures, raising concern for placental teratoma rather than fetus acardius amorphous. Distinguishing these entities by prenatal imaging alone can be difficult. Histopathology is therefore essential, with umbilical cord attachment, axial organization, or partial fetal development supporting fetus acardius.

TRAP sequence may increase hemodynamic demand on the pump twin, potentially resulting in high-output cardiac failure, hydrops, polyhydramnios, or fetal death. Despite a fetal VSD and single umbilical artery, the pump twin remained hemodynamically stable. This case emphasizes the importance of considering fetus acardius amorphous in the differential diagnosis of atypical placental masses despite absent classic Doppler findings.

Background

Uterine cancers are broadly classified into endometrial carcinomas (UCEC), which arise from the endometrial lining, and uterine carcinosarcomas (UCS), which contain both epithelial and mesenchymal malignant components. Despite advances over the past several decades that have significantly enhanced overall uterine cancer patient survival, outcomes for certain patient populations and specific tumor subtypes remain a significant challenge. MicroRNAs (miRNAs) are small non-coding RNAs that regulate gene expression post-transcriptionally. Mutations and dysfunctions of miRNA are large contributors to cancer development, prognosis, and survival. The impact of miRNAs on uterine cancer outcomes across different populations is not adequately explored.

Methods

Data was obtained from the open data source: The Cancer Genome Atlas (TCGA) accessed via The University of Alabama Cancer Data Analysis portal (UALCAN). After reviewing the available miRNA prognostic markers for uterine cancers on TCGA, only one miRNA-coding gene, hsa-mir-943, was found to have association with patient survival in UCEC and UCS. Survival curves and expression data were extracted and evaluated for UCEC and UCS data. Expression differences between ages, weights, and menopausal statuses were evaluated using Student’s t-test and one-way ANOVA for UCEC data. UCS expression data was significantly limited.

Results

In UCEC, patients with high expression of the miRNA-encoding gene hsa-mir-943 show to have a statistically significantly decreased number of days of survival than patients with low expression of hsa-mir-943 (p=0.015). In UCS, patients with high expression of the miRNA-encoding gene hsa-mir-943 show to have a statistically significantly increased number of days of survival than patients with low expression of hsa-mir-943 (p=0.0096). Patient age categories seen as having a statistically significant increase of hsa-mir-943 expression compared to normal include 41-60 Yrs, 61-80 Yrs, and 81-100 Yrs. Patient weight categories seen as having a statistically significant increase of hsa-mir-943 expression compared to normal include Normal Weight, Extreme Weight, Obese, and Extreme Obese. Patient menopausal Status categories seen as having a statistically significant increase of hsa-mir-943 expression compared to normal include Pre Menopause, Peri Menopause, and Post Menopause.

Conclusion

The miRNA-encoding gene hsa-mir-943 acts as an oncogene in UCEC and a tumor suppressor gene in UCS. Differences in miRNA expression may contribute to disparities in survival outcomes in UCEC and UCS. Expression of hsa-mir-943 is highly variable based on several patient demographic factors which must be considered during treatment planning. It is an emerging area of interest, and the current findings are dependent on limited data accessed through TCGA. Our laboratory is currently engaged in accessing additional data sources and conducting laboratory testing to evaluate the translational potential of miRNAs in improving outcomes for patients with UCEC and UCS.

Background

Preeclampsia affects 5-8% of pregnancies and is characterized by abnormal placentation, endothelial dysfunction, and cardiovascular maladaptation. Early or severe disease is associated with LV hypertrophy, altered filling patterns, and diastolic dysfunction that may persist postpartum. Angiogenic imbalance, including increased sFLt-1 and decreased PlFG, may precede clinical disease and contribute to cardiovascular dysfunction, providing potential opportunities for earlier risk stratification (Shaw et al. 2024).

Preeclampsia is also associated with increased postpartum hypertension and long-term cardiovascular disease (CVD), raising the possibility that pregnancy may identify women at elevated cardiovascular risk years before clinical disease develops (Contouris et al., 2025).

Echocardiography may identify LV remodeling, diastolic dysfunction, and abnormal global longitudinal strain (GLS) despite preserved LVEF. However, the optimal timing and role of cardiac assessment in patients with preeclampsia remain uncertain.

Methods

A structured literature search of PubMed/MEDLINE and Google Scholar was conducted using predefined terms related to preeclampsia/HDP and maternal cardiovascular outcomes

Studies reporting maternal cardiovascular or echocardiographic outcomes were included. Of 34 records screened, 17 met the inclusion criteria for final synthesis.

Results

Preeclampsia is associated with acute cardiovascular maladaptation and persistent postpartum risk

Endothelial dysfunction and angiogenic imbalance may contribute to myocardial remodeling, hypertension, and later CVD

GLS may detect subclinical myocardial dysfunction despite preserved LVEF

Risk is greatest with early-onset, severe, or recurrent preeclampsia and traditional cardiovascular risk factors

Postpartum BP monitoring and risk modification are essential, but evidence is insufficient to define the role of routine echocardiography or intensified cardiac surveillance.

Conclusion

Preeclampsia is not solely a pregnancy complication but an early marker of future maternal cardiovascular risk. Cardiac remodeling and subclinical myocardial dysfunction may persist postpartum, particularly after early, severe, or recurrent disease. Pregnancy and the postpartum period provide an opportunity for earlier cardiovascular risk identification and prevention. Further research is needed to define optimal screening and surveillance strategies.

Background

MicroRNAs, miRNAs, are small non-coding RNAs that function in post-transcriptional gene regulation. Thus, their dysfunction can play a key role in cancer development and progression. MiRNAs can be used to evaluate prognosis in cancer types, including OV (Ovarian Serous Cystadenocarcinoma), UCEC (Uterine Corpus Endometrial Carcinoma) and UCS (Uterine Carcinosarcoma).

Cancer of the uterine corpus represents the most common gynecologic cancer and is the fourth most common malignancy in women worldwide. Endometrial cancer (more precisely, uterine corpus endometrial carcinoma, or UCEC) is associated with unfavorable prognosis with incidence and mortality rates rising quickly.

As of 2025, approximately 420,368 women are diagnosed with an estimated 97,723 deaths each year due to UCEC. Prognostic UCEC biomarkers are needed to improve pre- and postoperative risk stratification and therapeutic targets

MicroRNAs are gaining attention as circulating biomarkers for various malignancies, including ovarian cancer.

Methods

Data was obtained from The Cancer Genome Atlas (TCGA) via UALCAN: a portal for

analyzing tumor genes and survival curves.

A comparison was made between the common miRNA-coding genes in OV vs UCS, OV vs UCEC and UCS vs UCEC. Survival curves were obtained for OV vs UCEC.

Clinical trials were identified using clinicaltrials.gov

All gene data came from UALCAN and statistical significance was determined using student’s t-test (for two-group comparisons) or one-way ANOVA (for multiple-group comparisons), and survival curves were analyzed using Kaplan–Meier method with log-rank test. A p-value of 0.05 was used.

Results

Figure 2: Kaplan-Meier Survival Curve depicts difference in patient survival based on High expression and Low/Medium expression of UCEC hsa-mir-335. High expression of hsa-mir-335 depicts a shorter survival period versus low/medium expression of hsa-mir-335 for UCEC patients.

Figure 3: Box-and-whisker plot shows expression levels of hsa-mir-335 in UCEC dataset (normal versus primary tumor). The plot depicts higher expression of hsa-mir-335 in UCEC primary tumors versus normal UCEC with statistical significance of 1.62714286489063E-12.

Figure 4: Box-and-whisker plot depict differences in expression of hsa-mir-335 in normal uterine corpus endometrial lining versus UCEC Grade 1-4. Expression of hsa-mir-335 increases as tumor grade increases, with the most statistically significant comparison between normal and Grade 3 at 3.18369774987559E-11

Conclusion

Figure 1: Comparative miRNA analysis identifies hsa-miR-335 as a shared prognostic miRNA between Ovarian Serous Cystadenocarcinoma (OV) and Uterine Endometrial Cancers (UCEC). The p-value for OV is 0.0265661 and p-value for UCEC is 7.40E-06. We chose to focus on UCEC hsa-miR-335 as a potential UCEC biomarker due to its strong statistical significance (p-value 7.40E-06) and additional statistically significant UALCAN GEx profile data. Kaplan-Meier Survival Curve, Sample type and Tumor grade were obtained from the UALCAN data set. The lowest P-value, and therefore the most statistically significant miRNA for OV and UCEC was hsa-mir-335 at 7.40E-06.

Figure 2: Effect of UCEC hsa-mir-335 expression on patient survival: High expression of hsa-mir-335 depicts a shorter survival period for UCEC patients compared to low/medium expression. The steeper the curve, the fewer days these patients survive. The p-value of <0.0001 shows the difference in survival timelines are not due to chance. The step-down curve of the Kaplan-Meier curve is a patient event (death or endpoint). The step-down curve of UCEC patient survival shows a bigger visible drop due to smaller sample size (n=100 for high expression) vs a smoother curve due to higher sample size (n=297 for low/medium expression). Therefore, high expression of hsa-mir-335 suggests this miRNA may behave as an oncogenic miRNA in UCEC.

Figure 3: Box-and-whisker plot shows expression levels of hsa-mir-335 in UCEC dataset (normal versus primary tumor). The plot depicts a statistically significant higher expression of hsa-mir-335 in UCEC primary tumors versus normal uterine corpus endometrial tissue (P-value=1.6E-12). These findings suggest hsa-mir-335 is a potential prognostic marker biomarker for UCEC.

Figure 4: Box-and-whisker plot depict differences in expression of hsa-mir-335 in normal uterine corpus endometrial lining versus UCEC Grade 1-4. Expression of hsa-mir-335 increases as tumor grade increases, with the most statistically significant comparison between normal and Grade 3 at 3.2E-11. These findings suggest increasing hsa-mir-335 levels is potentially associated with increasing UCEC tumor aggressiveness.

Overall, the mechanism of hsa-mir-335 suppressing RBM10, which increases tumor-promoting Numb-L, is a potential therapeutic target for UCEC. Continuing to monitor clinical trials and oncology/ laboratory data is important for therapeutic application.

Background

Persistent infection with high-risk human papillomavirus (hrHPV) is the necessary etiologic cause of cervical carcinogenesis and the primary driver of cervical intraepithelial neoplasia (CIN) progression. While HPV oncoproteins E6 and E7 mediate malignant transformation, the contribution of host metabolic and immunological factors to hrHPV persistence and CIN progression remains incompletely characterized. Vitamin D, measured as serum 25-hydroxyvitamin D [25(OH)D], regulates innate and adaptive immune pathways, epithelial differentiation, and inflammatory signaling relevant to HPV immune surveillance. Despite biological plausibility, clinical evidence linking 25(OH)D status to hrHPV persistence and high-grade cervical neoplasia remains inconsistent across study populations and methodologies. This structured narrative review synthesizes current clinical, epidemiological, and mechanistic evidence examining the association between serum 25(OH)D, hrHPV persistence, CIN grade, and progression to high-grade cervical intraepithelial neoplasia (CIN2+).

Methods

A structured narrative review was conducted following a predefined search strategy. PubMed/MEDLINE was searched from database inception through March 2026 using combinations of MeSH terms and keywords related to vitamin D ("vitamin D", "25-hydroxyvitamin D", "25(OH)D", "cholecalciferol") and HPV-associated cervical disease ("human papillomavirus", "HPV persistence", "cervical intraepithelial neoplasia", "CIN2+", "cervical dysplasia", "HSIL"). Studies were eligible if they measured serum 25(OH)D in women aged 18-65 undergoing cervical screening or with confirmed hrHPV infection and reported hrHPV persistence, CIN grade, CIN regression, or progression to CIN2+. hrHPV persistence was defined as detection of the same high-risk HPV genotype at ≥ 2 time points ≥ 6 months apart. Vitamin D status was categorized as deficient (< 20 ng/mL), insufficient (20–29 ng/mL), or sufficient (≥30 ng/mL). Cohort, cross-sectional, and randomized studies were included, with mechanistic studies used to contextualize biological pathways. Study quality was assessed using the Newcastle-Ottawa Scale (NOS) and the RoB2 tool. Due to heterogeneity across study designs, vitamin D assays, and outcome definitions, findings were synthesized narratively.

Results

Across included studies spanning seven countries, a predominant inverse association was observed between serum 25(OH)D levels and hrHPV prevalence, cervical dysplasia severity, and CIN2+ risk. The sole randomized controlled trial reported significantly greater CIN1 regression with vitamin D3 supplementation compared with placebo (84.6% vs 53.8%, p=0.01). Contradictory findings included a paradoxical positive association between higher 25(OH)D and short-term hrHPV persistence, as well as a modifying interaction between HIV status and vitamin D on dysplasia grade.

Conclusion

Current evidence suggests that vitamin D insufficiency may impair immune surveillance of hrHPV infection, potentially contributing to persistent infection and progression toward high-grade cervical neoplasia through immunomodulatory and epithelial regulatory mechanisms. Standardized prospective studies with consistent 25(OH)D thresholds and longitudinal HPV clearance outcomes are needed to determine whether vitamin D optimization could serve as an adjunct strategy in cervical cancer prevention.

Background

Introduction/Background: Postpartum depression (PPD) is a common and potentially persistent complication of the postpartum period, affecting an estimated 10–20% of postpartum women. Despite its prevalence, nearly 60% of women experiencing postpartum depressive symptoms may not receive a clinical diagnosis. Postpartum psychosis (PPP), although rare (approximately 1–2 cases per 1,000 births), represents a psychiatric emergency requiring immediate evaluation and intervention. Current evidence supports routine perinatal mental health screening; however, barriers including limited time, inadequate resources, stigma, and uncertainty regarding management of positive screens can limit effective implementation. This project addresses the need for a standardized screening protocol that extends beyond identification to include assessment, treatment/referral, safety evaluation, and longitudinal follow-up.

Methods

Methods: A focused review of the literature was conducted to identify evidence regarding the prevalence, risk factors, screening tools, clinical recognition, treatment, and follow-up of postpartum depression and postpartum psychosis. Evidence regarding the Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9), and Mood Disorder Questionnaire (MDQ) was reviewed, along with current recommendations from professional organizations. Literature addressing barriers to screening and the effectiveness of screening programs was also examined. Findings were synthesized into a proposed clinical workflow organized as SCREEN → ASSESS → ACT → FOLLOW-UP, emphasizing standardized screening, diagnostic assessment, safety evaluation, evidence-based treatment or referral, and continued monitoring.

Results

Results: The literature supports standardized, repeated screening for perinatal depression and anxiety and demonstrates that screening is most effective when connected to clinical care. The EPDS provides a brief, validated screening method, while the PHQ-9 may provide additional information regarding symptom severity and treatment response. Screening alone, however, does not establish a diagnosis and should be followed by clinical assessment. Positive self-harm responses require immediate safety assessment, while symptoms of postpartum psychosis require urgent psychiatric evaluation. Evidence also identifies important patient- and provider-level barriers to screening and follow-up. These findings support a protocol that explicitly defines responsibilities and next steps following a positive screen rather than relying on screening without a defined care pathway.

Conclusion

Conclusions: Existing evidence demonstrates that validated screening instruments can improve recognition of perinatal depression, but screening is insufficient without a reliable system for subsequent assessment and treatment. A standardized SCREEN → ASSESS → ACT → FOLLOW-UP protocol can address key gaps by establishing clear responses to positive depression screens, incorporating safety assessment and bipolar-risk evaluation, providing defined treatment and referral pathways, and ensuring continued monitoring. Postpartum psychosis requires particular emphasis because it is a medical emergency and cannot be adequately addressed through routine depression screening alone. Implementing a standardized, multidisciplinary screening and follow-up pathway may improve early identification, timely intervention, continuity of care, and patient safety.

Introduction

Endometrial Hyperplasia results from excessive proliferation of endometrial glands, most commonly due to prolonged unopposed estrogen exposure. In addition to increasing the risk of endometrial cancer, abnormal endometrial proliferation may impair endometrial receptivity and fertility. This case highlights the combined impact of PCOS, obesity, and a CHEK2 mutation as hormonal, metabolic, and genetic risk factors for endometrial pathology.

PCOS causes chronic anovulation and unopposed estrogen exposure, while obesity (BMI > 40 kg/m2) increases peripheral estrogen production in adipose tissue. CHEK2 mutations have also been associated with increased endometrial cancer risk, creating a potentially high-risk environment for recurrence and progression.

For patients desiring fertility preservation, progestin therapy provides a conservative treatment option. However, ACOG recommends endometrial biopsy every 3 months until two consecutive negative biopsies are obtained. Inadequate surveillance or loss to follow-up may increase the risk of recurrence, malignancy, and further compromise fertility.

Case Description

37-year-old nulliparous female, BMI 47.55 kg/m2

PMH: PCOS

2017: CHEK2 mutation identified.

2021: Presented with menorrhagia. Transvaginal ultrasound revealed 12-mm endometrial thickening, biopsy demonstrated complex endometrial hyperplasia. Given her desire for future fertility, she underwent hysteroscopy and two rounds medroxyprogesterone therapy, with subsequent biopsy showing a normal endometrial lining. She was referred to REI for fertility treatment.

Following unsuccessful fertility treatment, the patient was lost to follow-up, with no documented surveillance of her endometrial lining after October 2021.

2026: Returned with severe menorrhagia and ongoing concerns regarding fertility. Hemoglobin was 8.6 g/dL, despite a recent transfusion. Transvaginal ultrasound demonstrated marked progression of endometrial thickening to 23-mm.

Repeat biopsy revealed complex endometrial hyperplasia with atypia/endometrial intraepithelial neoplasia (EIN), representing recurrence and progression of her prior hyperplasia.

Discussion

This case demonstrates that regression of EIN/endometrial hyperplasia does not eliminate recurrence risk, especially when underlying risk factors persist. Long-term surveillance with endometrial assessment every 3-6 months until two consecutive negative biopsies is essential.

Fertility preservation requires balancing definitive treatment with reproductive goals. Although AMH suggested preserved ovarian reserve, PCOS and chronic anovulation may impair reproductive function independently.

Effective management should combine continued endometrial surveillance, fertility-sparing therapy, and modification of underlying risk factors, including obesity and chronic anovulation, to reduce recurrence and malignant progression while supporting fertility goals.

Introduction

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome (ACS), primarily affecting young and middle-aged women. Although data on disease prevalence is limited, SCAD is estimated to account for between 1.7 to 4% of ACS cases. Pregnancy-associated SCAD (P-SCAD) represents 30-40% of acute myocardial infarctions related to pregnancy, with more than 70% occurring in the early postpartum period.

Although cardiac biomarkers are almost always elevated in SCAD, 27% of patients have an initially normal troponin at presentation. We describe a case of P-SCAD in a 31-year-old postpartum female who presented with chest pain, ST-elevations in inferior leads on electrocardiogram (ECG), and initially negative troponin. This case demonstrates the importance for obstetric providers to maintain vigilance for cardiac pathology and how a reassuring clinical picture led to the early discontinuation of ACS evaluation. Additionally, it exposes a gap in sex-specific ACS pathways or SCAD-specific guidelines for the timing of angiography.

Case Description

A 31-year-old G2P2 female with a past medical history of asthma and gestational diabetes presented to the emergency department five days postpartum with worsening cough over the past few days and new onset chest heaviness for 3 hours. She denied any palpitations, shortness of breath, orthopnea, family history of heart disease, or connective tissue disease. She denied any medication or substance use.

She was initially hypertensive at 170/80 mmHg, but otherwise her vitals and physical exam were unremarkable. Laboratory testing was notable for B-type natriuretic peptide 373 pg/mL (reference range 0–299 pg/mL), high-sensitivity troponin within normal limits at 14.9 ng/L (reference <34 ng/L), and urine protein/creatinine ratio of 0.9 (reference range < 0.2 mg/mg) on the evening of admission. Chest radiography was unremarkable. ECG on presentation showed ST-elevations in inferior leads with reciprocal depressions in aVL and V2. Hypertension was treated with hydralazine and labetalol as needed.

There were no immediate obstetric complications noted by the OBGYN team and further management was deferred to Cardiology. ACS protocol was initiated, and the patient received a loading dose of aspirin, intravenous heparin, high-intensity statin, and oral nitroglycerin. Cardiology deferred fibrinolytic therapy due to concern for SCAD, which could worsen the hematoma. Left heart catheterization was not feasible at the presenting facility due to a lack of cath lab availability, and the patient was transferred to a nearby facility with percutaneous coronary intervention (PCI) capabilities.

On arrival, there was resolution of ST changes on ECG and symptoms. Cardiology advised against anticoagulants and heparin was discontinued on arrival. The patient had a negative CT Pulmonary Angiography and conventional troponin 1.62 ng/mL (>0.290 ng/mL critical value), as opposed to the high-sensitivity assay at the presenting facility. The emergency department documentation included the diagnosis of NSTEMI and she was transferred back to her original presenting hospital to be under the supervision of her obstetric team. However, the clinical reasoning behind her risk stratification or guidance regarding further evaluation of NSTEMI was not documented.

On arrival back to the presenting hospital, the patient reported recurrent chest pain. Repeat ECG showed ST depressions, and serial troponins rose to 1,110 ng/L and peaked at 15,786 ng/L the following morning before downtrending. This prompted reinitiation of ACS protocol, including aspirin, clopidogrel, intravenous heparin, and statin therapy.

The decision was made to defer cardiac catheterization until hospital day 3 due to the resolution of symptoms and ST changes with low clinical suspicion for ongoing myocardial infarction. Left heart catheterization revealed Type 1 SCAD at the midpoint of the large obtuse marginal 1 (OM1) branch with preserved distal TIMI III flow. There was a visible intimal dissection flap that extended to a small bifurcation branch, without any coronary obstruction noted. Heparin and clopidogrel were discontinued at this time, and the patient recovered with conservative management. Echocardiogram revealed a mildly dilated right ventricle and mildly increased filling pressures with left ventricular ejection fraction of 50-55%. The patient subsequently received carotid and renal imaging to screen for fibromuscular dysplasia due to its high prevalence in the SCAD population, with no abnormal findings.

Discussion

An initially negative troponin, transient ST changes, and a reassuring clinical picture may all lead to premature rule-out of ACS.

The GRACE Score used for ACS risk stratification was developed in an older, male population and has not been validated in SCAD.

This patient had an initially low risk GRACE score despite transient ST changes and subsequent dynamic rise in troponin.

Although these findings would support an early invasive strategy under traditional ACS stratification, current ACS/SCAD guidelines provide limited guidance on the timing of angiography in young women with suspected SCAD.

Diagnosis is important as fibrinolytics and heparin used in traditional ACS may worsen the intramural hematoma that underlies the pathophysiology in SCAD.

The postpartum period is a particularly high-risk window for maternal death. Obstetric providers play a central role in recognizing the warning signs and maintaing a broad differential beyond classic obstetric complications. The severity of these conditions warrants a low threshold for cardiac evaluation of chest pain regardless of traditional cardiovascular risk factors. Our patient’s transient ECG changes and initially negative troponin level, combined with low atherosclerotic risk factors, led to premature discontinuation of the ACS pathway before SCAD was properly evaluated. Future studies should address sex-specific ACS pathways or SCAD-specific risk stratification tools. These could guide the timing of angiography in suspected SCAD and help prevent similar delays in diagnosis.

Background

Background: Every year, over 40% of pregnancies across the US are unintended. Unintended pregnancies are associated with increased maternal and fetal complications, including later entry into prenatal care, decreased breastfeeding rates, and increased rates of smoking during gestation. These risks are greater in rural areas where reproductive care is less accessible. Access to over-the-counter (OTC) contraception, such as emergency contraceptive pills (Plan B) and oral contraceptive pills (Opill), could safely prevent up to 50% of unintended pregnancies.

Objective: The goal of this study was to determine the availability of OTC contraceptive access at pharmacies in the state of Missouri, based on pharmacy location and type.

Methods

Sampling of 1,172 Missouri pharmacies classified as Class A (Community/ Ambulatory) was performed, with selection of 100% of rural pharmacies and 26% of urban pharmacies. Pharmacies were classified by location (rural/urban) and type (independent/corporate). Rural pharmacies were defined as those within counties with < 150 people/square mile outside of a metropolitan statistical area/ MSA. Corporate pharmacies defined as a group authorized as a single entity, otherwise classified as independent. Surveyed 471 pharmacies via 805 phone calls about OTC contraception availability, and collected ad-hoc qualitative data. Analyzed quantitative data using Chi Square and Fisher's Exact tests to compare pharmacy location and type.

Results

Of the 471 pharmacies surveyed, 327 (69.4%) regularly carry Plan B (Table 1). 308 (65.4%) could provide Plan B same day, while 404 (85.8%) could provide Plan B within 24 hours. Only 218 (46.3%) of surveyed pharmacies regularly carry Opill, with 198 (42.0%) having Opill in stock for same-day purchase at the time of the survey call. However, 370 (78.6%) of surveyed pharmacies could provide Opill within 24 hours.

While most urban and rural pharmacies surveyed regularly carry Plan B, urban pharmacies (78.8%) were more likely to carry Plan B compared to rural pharmacies (65.2%) (p-value = 0.005). Similarly, urban pharmacies (74.7%) were more likely to have Plan B in stock at the time of the survey than rural pharmacies (61.2%) (p-value = 0.009). For Plan B availability within 24 hours, rural pharmacies (85.8%) and urban pharmacies (85.6%) had very similar rates (p-value = 0.939). Availability of Opill followed the same pattern as Plan B. Urban pharmacies (56.2%) regularly carried Opill at higher rates than rural pharmacies (41.8%) (p-value = 0.005). Same-day availability of Opill was also higher in urban pharmacies (52.1%) than in rural pharmacies (37.5%) (p-value = 0.003). For Opill availability within 24 hours, urban pharmacies (78.8) and rural pharmacies (78.5) had similar rates (p value = 0.899).

Larger differences in carrying and same-day stocking of both Plan B and Opill were seen between corporate and independent pharmacies (Table 4). Corporate pharmacies (79.9%) were more likely to carry Plan B than independent pharmacies (53.7%) (p value <.001). Corporate pharmacies (76.3%) also had higher same-day availability for Plan B than independent pharmacies (48.9%) (p-value = 2.65 x 10-9). However, availability of Plan B within 24 hours was similar for both corporate (86.9%) and independent (84.0) pharmacies (p-value = 0.94). Corporate pharmacies (66.8%) were more likely to regularly carry Opill than independent pharmacies (15.4%) (p-value = <.001). The rate of same-day availability of Opill was higher for corporate pharmacies (62.2%) than for independent pharmacies (11.7%) (p-value <.001). Availability of Opill within 24 hours was higher for corporate pharmacies (81.3%) than for independent (74.5%) pharmacies (p-value = 0.01).

Key Takeaways:

Urban and corporate pharmacies were more likely to have same-day access to both forms of OTC contraception.

Corporate pharmacies were more likely to have 24-hour access to Opill.

Barriers reported by pharmacies include medication costs, patient privacy concerns, expiring inventory, and awareness of medications.

Conclusion

Majority Availability Overall for Plan B: A majority of pharmacies carried and had Plan B available at the time of survey, and rates of 24-hour access were similar across all pharmacy types and locations.

Low same-day availability for Opill: Same-day availability was overall much lower for Opill than for Plan B. While a slight majority of urban and corporate pharmacies offered same-day access to Opill, rural and independent pharmacy access was very low.

Pharmacy type impacted 24-hour access to Opill: While the majority of pharmacies could provide access to Opill within 24 hours, corporate pharmacies were more likely to provide this access than independent pharmacies.

Anecdotal Data: Pharmacy staff cited abortion restrictions, privacy concerns, and expiring inventory as the primary barriers to providing access to OTC contraceptives.

Strengths: Our study showed a robust 82.9% response rate representing 93.9% of MO counties. Our sample had excellent rural representation and benefitted from collection of qualitative data.

Limitations: To ensure adequate sampling of rural pharmacies, our study performed an undersampling of urban pharmacies. We collected limited follow-up data due to the nature of the self-reported phone survey.

Implications: Improved access to over-the-counter contraceptives, as well as education and awareness of these methods, is paramount. This need is especially great in rural areas. Further exploration of the relationship between medication access and pharmacy type/location is necessary.

Introduction

Pelvic girdle and pubic bone pain frequently occur in the third trimester of pregnancy and significantly impair function, mobility, and quality of life. Treatment options are limited due to medication restrictions, creating a need for safe, non-pharmacologic interventions. Osteopathic manipulative treatment (OMT) may offer benefits in managing pregnancy-related pelvic and pubic pain. This case demonstrates functional and symptomatic changes following OMT using objective outcome measures.

Case Description

Methods: A G1P0 patient at 33 5/7 weeks’ gestation presented with worsening pelvic girdle, pubic bone, and low back pain, with severity ranging from 2-9/10 and current pain rated at 4/10, limiting ambulation and daily activities. Osteopathic structural examination identified pelvic asymmetries, pubic bone dysfunctions, sacral torsions, and dysfunctions of the abdominal fascia, pelvic diaphragm, and broad ligament Chapman’s point. The patient received a total of five weekly serial OMT sessions using pregnancy-appropriate techniques including myofascial release, balanced ligamentous tension, muscle energy, and articulation. Patient informed consent was obtained for submission of this case report.

Results: Functional disability measured by the Pelvic Girdle Questionnaire (75 possible points) improved from scores of 52-53 (69.3-70.7% disability) to 37 (49.3% disability) by week 5 of treatment. The patient reported decreased pain severity and frequency, improved gait, and increased tolerance for daily activities. No adverse maternal or fetal outcomes occurred.

Discussion

This case demonstrates clinically meaningful improvement in pain and function following OMT in the third trimester. Addressing pelvic, pubic, and sacral somatic dysfunctions may improve biomechanics and maternal comfort. These findings suggest OMT may be a valuable non-pharmacologic option for managing pregnancy-related pelvic pain and support further investigation.