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What's new in obstetrics and gynecology
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What's new in obstetrics and gynecology
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2017. | This topic last updated: Apr 24, 2017.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

OBSTETRICS

Computerized interpretation and alerts for intrapartum fetal monitoring not beneficial (April 2017)

Two randomized trials (FM-ALERT [1] and INFANT [2]) have evaluated the use of continuous intrapartum fetal monitoring with computerized interpretation and real-time alerts versus usual care (continuous intrapartum fetal monitoring with clinician interpretation). In both trials, use of the intervention did not improve any maternal or neonatal outcome. In the larger INFANT trial, which included over 47,000 pregnancies at or near term, developmental assessment at age two years was similar for both groups [2]. Thus, a change in the standard clinical approach to intrapartum fetal heart rate monitoring is unwarranted. (See "Intrapartum fetal heart rate assessment", section on 'Use of decision aids'.)

Expulsion following immediate postpartum intrauterine device insertion (March 2017)

Women may choose to have a copper or levonorgestrel-releasing intrauterine device (IUD) inserted immediately postpartum. In a prospective study, the expulsion rate for the levonorgestrel-releasing IUD was higher than that for the copper IUD at six months postpartum (17 versus 4 percent) [3]. Although further data from a large trial are required to confirm this finding, we counsel women that the risk of expulsion may be higher with the levonorgestrel-releasing device and discuss the need to check for the IUD thread intermittently. (See "Postpartum contraception", section on 'Device selection'.)

Sensitivity of short cervix and fetal fibronectin for preterm birth (March 2017)

Cervical length is measured sonographically in the midtrimester because a short cervix is predictive of preterm birth, and the risk may be reduced by administration of progesterone. A new large prospective study reported the sensitivity for preterm birth among nulliparous women with singleton gestations and cervical length ≤25 mm was 8 percent at 16 to 22 weeks of gestation and 23 percent at 22 to 30 weeks [4]. Although these values are lower than previously reported in nonintervention studies, a major limitation of the study was unblinding when the cervix was very short (<15 mm), and probable intervention in these patients. The study also confirmed previous data that midtrimester measurement of fetal fibronectin in asymptomatic nulliparous women performs poorly for prediction of preterm birth. We continue to obtain a cervical length measurement in nulliparous women during ultrasound examinations at 18 to 24 weeks of gestation and treat those with a short cervix with vaginal progesterone. (See "Second-trimester evaluation of cervical length for prediction of spontaneous preterm birth in singleton gestations", section on 'Universal versus selective screening' and "Preterm birth: Risk factors and interventions for risk reduction", section on 'Biomarkers'.)

Pregnancy outcomes with HPV vaccination (March 2017)

Human papillomavirus (HPV) vaccination during pregnancy is not recommended, but mounting evidence suggests that it is safe. In a large cohort study from Denmark, the risks of spontaneous abortion, major birth defects, preterm birth, and low birth weight were comparable among women who received quadrivalent HPV vaccine during pregnancy (mostly during the first trimester) and matched controls who did not [5]. Women who inadvertently receive HPV vaccine during pregnancy can be reassured that it does not increase their risk of adverse pregnancy or fetal outcomes. (See "Immunizations during pregnancy", section on 'Human papillomavirus'.)

Maternal obesity and risk of cerebral palsy (March 2017)

Maternal obesity has been associated with several adverse pregnancy outcomes. Now, a population-based cohort study from Sweden has reported an increasing risk of cerebral palsy in offspring delivered at term as maternal body mass index (BMI) increases [6]. Although this observation requires confirmation, we continue to advise overweight and obese women to try to achieve a normal BMI before becoming pregnant because of established pregnancy and general health benefits. (See "Obesity in pregnancy: Complications and maternal management", section on 'Neurodevelopment'.)

Guidelines on women's health in systemic lupus erythematosus and antiphospholipid syndrome (March 2017)

Both systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) affect women of child-bearing age, and the management of these diseases in the setting of pregnancy can pose unique challenges. These include the effect of pregnancy on maternal disease, the impact of disease activity on fetal health, and the safety of medications during pregnancy and breastfeeding. The European League Against Rheumatism (EULAR) has published new recommendations for the management of women's health in patients with SLE and APS, which provide guidance for family planning, assisted reproduction, pregnancy monitoring, treatment during pregnancy, hormone replacement therapy and menopause, and malignancy screening [7]. (See "Pregnancy in women with systemic lupus erythematosus", section on 'Pregnancy planning'.)

New classification and guidance regarding suboptimally dated pregnancy (March 2017)

The American College of Obstetricians and Gynecologists now classifies pregnancies as "suboptimally dated" in the absence of an ultrasound examination before 220/7ths weeks of gestation [8]. Because fetal biometry after 22 weeks is not sufficiently accurate to change menstrual dating without correlative sonographic follow-up, serial examinations three to four weeks apart are advised in these cases to assess growth over time. Normal interval growth supports the sonographic estimate of gestational age, while suboptimal or accelerated interval growth suggests that the gestational age may be further along or less advanced than predicted by ultrasound. (See "Prenatal assessment of gestational age and estimated date of delivery", section on 'Assigning the estimated date of delivery'.)

Treatment of subclinical hypothyroidism and maternal hypothyroxinemia during pregnancy (March 2017)

In parallel multicenter trials, over 600 pregnant women with subclinical hypothyroidism (median thyroid-stimulating hormone [TSH] 4.4 mU/L, normal free T4) or isolated maternal hypothyroxinemia (low free T4, normal TSH) were randomly assigned to levothyroxine or placebo [9]. There was no significant effect of treatment on adverse pregnancy outcomes or on neurodevelopmental outcomes in the children at five years of age. The main limitation of the study is the late initiation of treatment at a mean gestational age of almost 17 weeks, at which time fetal thyroid tissue is beginning to function. We suggest levothyroxine (with earlier initiation when possible) for pregnant women with subclinical hypothyroidism, defined as a TSH above a trimester-specific normal reference range (or above 4.0 mU/L if trimester-specific range unavailable) with normal free T4. (See "Hypothyroidism during pregnancy: Clinical manifestations, diagnosis, and treatment", section on 'Effect of thyroid hormone replacement'.)

Recommended immunization schedule—United States, 2017 (March 2017)

The Advisory Committee on Immunization Practices has released the 2017 recommended immunization schedule for children and adolescents in the United States [10,11]. New recommendations include the following:

All infants should now receive monovalent hepatitis B vaccine within 24 hours of birth; earlier recommendations allowed some infants born to hepatitis B surface antigen-negative mothers to receive the vaccine after discharge. (See "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Mother's HBsAg status unknown, birth weight ≥2 kg'.)

When administered during pregnancy, the tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine should be given as early as possible between 27 and 36 weeks of gestation. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

For individuals receiving the meningococcal serogroup B vaccine MenBFHbp (Trumenba), two doses are recommended for healthy adolescents and young adults who are not at increased risk for meningococcal disease. Three doses are recommended for individuals ≥10 years of age at increased risk for meningococcal disease and for use during serogroup B meningococcal disease outbreaks (table 1). Previously, three doses were recommended for all recipients. The dosing frequency and interval for the other serogroup B vaccine, MenB-4C (Bexsero), have not changed. (See "Meningococcal vaccines", section on 'Serogroup B meningococcus vaccines'.)

Aspirin for prevention of preeclampsia (February 2017)

Low-dose aspirin therapy during pregnancy reduces the occurrence of preeclampsia in high-risk women, but questions remain about optimum dosing and timing. In one recent meta-analysis, the optimum aspirin dose appeared to be 100 to 150 mg, with favorable effects limited to initiation before 16 weeks of gestation [12]. In another recent meta-analysis with a different design, aspirin was similarly effective whether initiated before or after 16 weeks of gestation; optimum dosing was not assessed [13]. For women at high risk of developing preeclampsia, we continue to suggest initiating aspirin 81 mg daily at the end of the first trimester because this dose is readily available and early initiation is both safe and effective. If aspirin is not initiated at this time, initiation after 16 weeks, but before symptoms develop, also appears to be effective. (See "Preeclampsia: Prevention", section on 'Meta-analysis'.)

Maternal fish oil supplementation and asthma in offspring (February 2017)

Maternal supplementation with fish oil, which consists of two n-3 long chain polyunsaturated fatty acids (docosahexaenoic acid [DHA]) and eicosapentaenoic acid [EPA]), has been proposed to improve a variety of pregnancy outcomes. In a placebo-controlled randomized trial of third-trimester maternal supplementation with fish oil 2.4 grams daily (55 percent EPA and 37 percent DHA), supplementation resulted in a 7 percent reduction in the absolute risk of persistent wheeze or asthma in offspring followed to age three to five years [14]. Because of limitations in the design of this trial, UpToDate does not advise routine supplementation with this dose of fish oil, but continues to recommend that all pregnant women achieve DHA intake of at least 200 to 300 mg/day. (See "Fish consumption and docosahexaenoic acid (DHA) supplementation in pregnancy".)

Folic acid supplementation for prevention of neural tube defects (February 2017)

Folic acid supplementation and food fortification have reduced the incidence of neural tube defects (NTDs). A 2017 systematic review by the US Preventive Services Task Force (USPSTF) noted that post-food fortification studies of folic acid supplementation have not demonstrated a protective association [15], suggesting that current levels of food fortification may be sufficient to prevent most folate-sensitive NTDs. However, the USPSTF also reaffirmed its 2009 recommendation that all women of reproductive age planning or capable of pregnancy take a supplement containing 0.4 to 0.8 mg of folic acid daily to reduce their risk of having a child with a NTD [16]. Given the limitations of the post-food fortification studies, we agree with this recommendation. (See "Folic acid supplementation in pregnancy" and "Folic acid supplementation in pregnancy".)

United States guidelines for fish consumption during pregnancy and lactation (February 2017)

Fish may be contaminated by environmental pollutants, such as methylmercury, which can cause fetal neurologic problems. The US Food and Drug Administration and Environmental Protection Agency released updated recommendations about fish consumption for women who are pregnant or nursing, or who might become pregnant [17]. Revisions include guidance on many more types of fish and recommendations for best choices versus good choices (table 2). (See "Nutrition in pregnancy", section on 'Fish consumption'.)

Delayed cord clamping (January 2017)

Delaying umbilical cord clamping for at least 30 to 60 seconds after birth in both term and preterm vigorous infants is the recommendation of an updated committee opinion by the American College of Obstetricians and Gynecologists (ACOG) [18]. Previously, ACOG had recommended individualizing the timing of cord clamping in term infants. Although the optimal amount of time before cord clamping has not been studied extensively, we believe data support a minimum duration of delay of at least one minute in term births and 30 seconds in preterm births. (See "Management of normal labor and delivery", section on 'Cord clamping'.)

Risk of birth defects with Zika virus infection during pregnancy (January 2017)

The risk of birth defects resulting from in utero exposure to Zika virus was 6 and 42 percent in two recent reports [19,20]. The wide range likely reflects differences in study design, populations studied, maternal Zika case definition, and the range of clinical abnormalities included. The most common fetal/newborn findings in these reports were abnormal brain imaging, microcephaly, small size for gestational age, and abnormal neurologic examination. The greatest risk of serious sequelae in offspring appeared to be with first or second trimester infection, but serious sequelae also occurred with third trimester infection. (See "Zika virus infection: Evaluation and management of pregnant women", section on 'Risk of vertical transmission and anomalies' and "Congenital Zika virus infection: Clinical features, evaluation, and management of the neonate", section on 'Clinical findings'.)

Trends in marijuana use during pregnancy (December 2016)

The impact of recent laws legalizing marijuana for medical and recreational use on use by pregnant women is unknown. In a survey of marijuana use among reproductive-aged women, use of marijuana in the past month by pregnant women increased 62 percent between 2002 and 2014 (from 2.4 to 3.9 percent) and was highest among women aged 18 to 25 years [21]. As there are multiple concerns about the neurodevelopmental impact of marijuana on the developing fetus, abstinence during pregnancy is advised. (See "Overview of substance misuse in pregnant women", section on 'Marijuana'.)

FDA issues warning about anesthesia for pregnant patients and children under three years of age (December 2016)

The US Food and Drug Administration has warned about potential negative effects on the developing brain from administration of anesthetics and sedatives to pregnant women and children under age three, especially for repeated exposures or procedures lasting more than three hours [22]. However, the degree of risk remains unclear. A single, brief exposure to anesthesia probably does not cause neurotoxicity in healthy young children. Further study is required to determine the effects of prolonged or repeated anesthetics, variability among anesthetic agents and combinations of drugs, and patient factors that may confer vulnerability to anesthetic neurotoxicity. At present, there is no compelling evidence that any specific anesthetic agent should be avoided during pregnancy or in young children, or that necessary surgery should be delayed because of concerns about neurotoxicity. (See "Management of the pregnant patient undergoing nonobstetric surgery", section on 'Fetal brain development'.)

Pattern of anomalies in congenital Zika syndrome (November 2016)

The clinical spectrum of congenital Zika syndrome (CZS) is evolving as more cases are described. A comprehensive review of the available published data identified five unique features of CZS that are rarely seen with other congenital infections: (1) severe microcephaly with partially collapsed skull, (2) thin cerebral cortices with subcortical calcifications, (3) macular scarring and focal pigmentary retinal mottling, (4) congenital contractures (arthrogryposis), and (5) marked early hypertonia [23]. Recognition of this distinctive phenotype can help clinicians identify infants with CZS and ensure appropriate etiologic evaluation and comprehensive clinical investigation. (See "Congenital Zika virus infection: Clinical features, evaluation, and management of the neonate", section on 'Clinical findings'.)

Extended versus narrow spectrum antibiotic prophylaxis for cesarean delivery (November 2016)

Use of extended versus narrow spectrum antibiotic prophylaxis for cesarean delivery is controversial. In the largest randomized trial, which was limited to women in labor or with ruptured membranes for at least four hours, the combination of azithromycin and cefazolin resulted in a 50 percent reduction in postcesarean infection compared with cefazolin alone [24]. This trial had a high proportion of obese patients and lacked comparative data on the efficacy of weight-based cefazolin dosing, which may have accounted, at least in part, for the findings. We continue to use single-dose narrow-spectrum antibiotic prophylaxis for all patients before cesarean delivery; however, others may reasonably choose to use an extended spectrum regimen in the high-risk patient population targeted by the trial. (See "Cesarean delivery: Preoperative issues".)

OFFICE GYNECOLOGY

IUD use does not impact human papillomavirus infection (March 2017)

A reduction in cervical cancer rates among intrauterine device (IUD) users has been observed and attributed to favorable effects of the device on human papillomavirus (HPV) clearance. However, a prospective cohort study that controlled for sexual and behavioral confounders reported no difference in HPV acquisition or clearance among women and girls with or without an IUD [25]. Thus, IUD use does not appear to impact HPV infection. (See "Intrauterine contraception: Devices, candidates, and selection", section on 'IUDs cause infection'.)

USPSTF statement on routine pelvic examination (March 2017)

Routine pelvic examination in asymptomatic women is controversial. The US Preventive Services Task Force (USPSTF) recently published a statement that evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women [26]. In 2014, the American College of Physicians (ACP) recommended against such examinations. In 2012, the American College of Obstetricians and Gynecologists (ACOG) recommended annual pelvic examination in nonpregnant women age 21 years or older and is now reviewing its policy in response to the USPSTF statement. As few data about the benefit and harms of routine pelvic examinations are available, we suggest shared decision-making between the patient and clinician. (See "The gynecologic history and pelvic examination", section on 'Indications and frequency for examination'.)

No role for routine serologic screening for genital herpes infection (December 2016)

Genital herpes, which can be caused by herpes simplex virus type 1 or 2 (HSV-1 or HSV-2), is one of the most common sexually transmitted infections, and sexual transmission can occur even in the absence of symptoms. Despite this, routine serologic screening for herpes simplex is not recommended in asymptomatic adolescents and adults due to significant limitations of available tests, as highlighted in a recent US Preventive Services Task Force statement [27]. Limitations include the low specificity and high false positive rate of serologic tests for HSV-2 and the inability of serologic tests for HSV-1 to differentiate oral from genital infection. Furthermore, there are no specific treatment interventions for asymptomatic patients, so the anxiety and disruption of personal relationships associated with a positive test outweigh any potential benefits. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Screening'.)

Vaginal prasterone for dyspareunia in postmenopausal women (November 2016)

In November 2016, the US Food and Drug Administration approved the use of prasterone (also known as dehydroepiandrosterone [DHEA]) for treatment of dyspareunia in women with vulvovaginal atrophy (VVA) due to menopause [28]. In an earlier randomized trial of women with VVA and moderate to severe dyspareunia, 12 weeks of daily intravaginal DHEA resulted in improved scores for pain during sexual activity and other key domains of female sexual function (desire, arousal, lubrication, orgasm, satisfaction) compared with placebo [29]. However, patients may find daily dosing more cumbersome than twice-weekly dosing with vaginal estrogen preparations. (See "Treatment of genitourinary syndrome of menopause (vulvovaginal atrophy)", section on 'Dehydroepiandrosterone (prasterone)'.)

Combination antiretroviral treatment in pregnancy (November 2016)

Combination antiretroviral treatment (ART) has become the worldwide standard of care for HIV-infected pregnant women, both for their own health and for prevention of HIV transmission to their infants. In a large randomized trial of HIV-infected pregnant women in Africa and India, antepartum ART (with one of two different protease inhibitor-based regimens) resulted in lower transmission rates compared with zidovudine plus single-dose nevirapine (0.5 versus 1.8 percent) [30]. Rates of preterm birth at <37 weeks were higher with the ART regimens than with zidovudine, but more significant prematurity (<34 weeks) and neonatal deaths were not increased. Clinicians should discuss with patients the potential risk for adverse pregnancy outcome with certain ART regimens. (See "Safety and dosing of antiretroviral medications in pregnancy", section on 'Preterm birth'.)

Long-acting reversible contraception and teenage pregnancy rates (November 2016)

In a systematic review of nine studies including nearly 27,000 adolescent and young adult women (≤25 years), the 12-month continuation rate was nearly twice as high with the intrauterine device or contraceptive implant as with other contraceptive methods (approximately 85 percent versus 40 to 50 percent) [31]. Increased contraceptive use, particularly increased use of these highly effective long-acting reversible contraceptive (LARC) methods, contributed to the historically low teenage pregnancy rate in 2015 [32]. These observations support our recommendations to highlight LARC methods when discussing contraception with adolescents and young adults. (See "Pregnancy in adolescents", section on 'Epidemiology' and "Contraception: Overview of issues specific to adolescents", section on 'Long-acting reversible methods'.)

Updated US guidelines on HIV infection and pregnancy (November 2016)

The Department of Health and Human Services in the United States recently published updated guidelines on the evaluation and management of HIV-infected pregnant women to reduce the risk of perinatal transmission [33]. Preferred antiretroviral agents for initiation in pregnant women are now tenofovir-disoproxil-fumarate plus emtricitabine or lamivudine, abacavir-lamivudine, ritonavir-boosted atazanavir, ritonavir-boosted darunavir, and raltegravir. Other agents are not recommended for routine initiation in pregnant women because of limited data during pregnancy, but women who become pregnant while taking other commonly used agents can continue their regimen if they have achieved viral suppression. (See "Antiretroviral and intrapartum management of pregnant HIV-infected women and their infants in resource-rich settings", section on 'Antiretroviral selection and management'.)

Incidence of sexually transmitted infections in the United States (November 2016)

The total number of cases of chlamydia (over 1.5 million), gonorrhea (nearly 400,000), and syphilis (nearly 24,000) reported to the Centers for Disease Control and Prevention in the United States in 2015 was the highest ever recorded in a given year [34]. Chlamydia and gonorrhea continued to occur most commonly among 15 to 24 year olds, and men who have sex with men accounted for the majority of gonorrhea and primary/secondary syphilis cases. These surveillance data highlight the importance of sexually transmitted infection prevention efforts, screening, and treatment among at-risk individuals. (See "Epidemiology of Chlamydia trachomatis infections", section on 'Incidence' and "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection", section on 'Incidence' and "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients", section on 'Epidemiology' and "Screening for sexually transmitted infections".)

GYNECOLOGIC SURGERY

Safety of transvaginal mesh for stress urinary incontinence (February 2017)

Although relatively high complication rates have been reported when transvaginal mesh is used in pelvic organ prolapse surgery, this is not the case for female stress urinary incontinence (SUI) surgery. In a large cohort study comparing outcomes of mesh with non-mesh SUI procedures, the risk of immediate complications was approximately 50 percent lower in mesh-based procedures, with similar five-year efficacy and complication rates [35]. Transvaginal mesh continues to be the preferred surgical treatment for women with SUI. (See "Overview of transvaginal placement of mesh for prolapse and stress urinary incontinence", section on 'Choice of synthetic mesh or native tissue'.)

Guidance on hysteroscopic sterilization from the US FDA (November 2016)

Hysteroscopic placement of micro-inserts into the fallopian tubes is a minimally invasive approach to female sterilization; however, long-term complications are a concern. In October 2016 the US Food and Drug Administration (FDA) issued final guidance related to this procedure, recommending a boxed warning regarding potential adverse effects and the potential need for surgical removal to manage these effects [36]. The FDA also recommended a checklist highlighting key risk and benefit information to be reviewed and signed by the patient and physician and provided an example of a procedural consent form. (See "Hysteroscopic sterilization", section on 'Statements from regulatory organizations'.)

GYNECOLOGIC ONCOLOGY

Niraparib maintenance therapy in platinum-sensitive, recurrent ovarian cancer (March 2017)

In a phase III trial, enrolling approximately 550 patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who have responded to platinum-based chemotherapy, niraparib maintenance improved progression-free survival relative to placebo, although over a third experienced severe hematologic toxicity [37]. Based on these results, the US Food and Drug Administration (FDA) has approved niraparib for the maintenance treatment of such patients [38]. However, overall survival data are still immature and niraparib has not been compared with bevacizumab, which is better studied in the maintenance setting. Pending further data, we reserve use of niraparib maintenance for patients with relapsed ovarian cancer who are not candidates for bevacizumab and who are in a complete or partial response to platinum-based chemotherapy. (See "Medical treatment for relapsed epithelial ovarian, fallopian tubal, or peritoneal cancer: Platinum-sensitive disease".)

Hysterectomy-corrected cervical cancer mortality rates and racial variation (February 2017)

Cervical cancer incidence and mortality rates are known to vary across racial groups in the United States but can be underestimated if data are not adjusted for prior hysterectomy. In a population-based study that corrected for the prevalence of hysterectomy, cervical cancer mortality in black women was more than twice that of white women from 2000 to 2012 (10.1 versus 4.7 per 100,000) [39]. These data add to the body of evidence showing a racial disparity in cervical cancer mortality and support the need for research to identify and overcome the factors that account for this disparity. (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Incidence and mortality'.)

Risk of preterm delivery following loop electrosurgical excision procedure (LEEP) (November 2016)

Studies have consistently found an increased risk for preterm delivery in pregnancies conceived after cold knife conization, but data are mixed regarding the risk with laser conization and loop electrosurgical excision procedure (LEEP). In the largest study of pregnancy outcomes after treatment for cervical intraepithelial neoplasia (CIN), a Norwegian registry study of almost 10,000 births confirmed that prior treatment for CIN was associated with an increased risk of preterm birth compared with no prior treatment [40]. The strongest associations were for cold knife and laser conization, but a small increase in risk was also observed for LEEP. Women with CIN 2,3 who plan future childbearing should be counseled about the risks and benefits of both treatment and observation. (See "Cervical intraepithelial neoplasia: Reproductive effects of treatment", section on 'Risks of individual treatment methods'.)

UROGYNECOLOGY

Safety of transvaginal mesh for stress urinary incontinence (February 2017)

Although relatively high complication rates have been reported when transvaginal mesh is used in pelvic organ prolapse surgery, this is not the case for female stress urinary incontinence (SUI) surgery. In a large cohort study comparing outcomes of mesh with non-mesh SUI procedures, the risk of immediate complications was approximately 50 percent lower in mesh-based procedures, with similar five-year efficacy and complication rates [35]. Transvaginal mesh continues to be the preferred surgical treatment for women with SUI. (See "Overview of transvaginal placement of mesh for prolapse and stress urinary incontinence", section on 'Choice of synthetic mesh or native tissue'.)

Cranberry products and urinary tract infection in women (October 2016)

Numerous clinical studies on the effects of cranberry products on recurrent urinary tract infection (UTI) in women have failed to clearly demonstrate a preventive benefit. In a year-long randomized trial among female nursing home residents, cranberry capsules similarly did not reduce adjusted rates of bacteriuria plus pyuria or symptomatic UTI compared with placebo [41]. While we do not suggest cranberry products to reduce the risk of recurrent UTI, there is likely little harmful effect. (See "Recurrent urinary tract infection in women", section on 'Cranberry products'.)

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