The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
What's new in obstetrics and gynecology

Disclosures: Sandy J Falk, MD Employee of UpToDate, Inc. Vanessa A Barss, MD Employee of UpToDate, Inc. Equity Ownership/Stock Options: Merck; Pfizer; Abbvie.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2014. | This topic last updated: Sep 16, 2014.

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

Maternal mortality among women with epilepsy (August 2014)

Individuals with chronic epilepsy are at increased risk for sudden death, and a new study suggests that this risk may contribute to increased maternal mortality among women with epilepsy. A study that examined all epilepsy-related deaths in a United Kingdom population-based registry of over two million pregnancies found 14 deaths in women with epilepsy over a two-year period; 80 percent of these were attributed to sudden unexpected death in epilepsy (SUDEP) [1]. The estimated maternal death rate, 1 in 1000 among women with epilepsy, was 10-fold higher than the rate in the general population of pregnant women but similar to estimates of SUDEP risk in the chronic epilepsy population. Additional studies are needed to confirm this finding and to determine whether there are modifiable risk factors for SUDEP during pregnancy. (See "Risks associated with epilepsy and pregnancy", section on 'Maternal mortality'.)

Antidepressants and risk of congenital cardiac defects (August 2014)

A large population-based study has provided reassuring results suggesting that treatment with antidepressants during pregnancy is not associated with congenital cardiac defects [2]. The study used an administrative claims database to compare infants of depressed mothers who were either treated with antidepressants during the first trimester or not treated with antidepressants. After adjusting for confounding, there was no significant difference in risk of congenital cardiac malformations among exposed versus unexposed infants. Seven other analyses examined specific exposure to selective serotonin reuptake inhibitors (as a class), fluoxetine, paroxetine, sertraline, serotonin-norepinephrine reuptake inhibitors, tricyclics, and bupropion; in each analysis, exposure was not associated with an increased risk of cardiac defects. (See "Risks of antidepressants during pregnancy", section on 'Antidepressant composite data'.)

Additional benefits of delayed cord clamping (August 2014)

Delayed cord clamping raises neonatal hemoglobin levels. In addition, delaying cord clamping until spontaneous respirations are established appears to improve cardiopulmonary hemodynamics during the fetal to neonatal transition. In an observational study performed in a hospital in rural Tanzania, healthy self-breathing neonates were more likely to die or be admitted to a neonatal care unit if cord clamping occurred before or immediately after onset of spontaneous respirations, but not when cord clamping was delayed [3]. (See "Management of normal labor and delivery", section on 'Cord clamping'.)

Value of placental examination in stillbirth (August 2014)

In a 2014 systematic review that investigated the likelihood of diagnosing a cause of stillbirth from placental examination, histopathological examination provided useful information about the cause of death or contributing factors in 11 to 84 percent of cases [4]. Although certain placental abnormalities are more common in stillbirths, determination of causality in an individual case is difficult because the same abnormalities also occur in uncomplicated pregnancies. Nevertheless, microscopic examination of the placenta is commonly performed as part of the perinatal autopsy. (See "Evaluation of stillbirth", section on 'Components of the perinatal autopsy'.)

Physical activity reduces risk of type 2 diabetes after gestational diabetes (July 2014)

Increasing evidence suggests that an active lifestyle reduces the risk of developing type 2 diabetes in women with gestational diabetes. In a 16-year prospective observational study, 14 percent of women with a history of gestational diabetes self-reported the development of type 2 diabetes [5]. Women with a total physical activity level equivalent to 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity had a 30 to 50 percent lower risk of developing type 2 diabetes than women with lower levels of physical activity. (See "Gestational diabetes mellitus: Glycemic control and maternal prognosis", section on 'Follow-up and prevention of type 2 diabetes'.)

Benefits of controlled cord traction (June 2014)

We suggest controlled cord traction to facilitate separation and delivery of the placenta. In a 2014 meta-analysis of randomized trials comparing controlled cord traction with a hands-off approach, controlled cord traction resulted in a 30 percent reduction in need for manual removal of the placenta, as well as small reductions in the duration of the third stage (three minutes), mean blood loss (10 mL), and incidence of postpartum hemorrhage (11.8 versus 12.7 percent); the rates of severe postpartum hemorrhage, need for additional uterotonics, and blood transfusion were similar [6]. Although the benefits of controlled cord traction are small, there are no significant harms from the maneuver if performed without excessive traction. (See "Management of normal labor and delivery", section on 'Delivery of the placenta'.)

Fish consumption advisory (June 2014)

Because of the potential fetal benefits of maternal docosahexaenoic acid (DHA) intake, the US Food and Drug Administration and the US Environmental Protection Agency now advise women who might become pregnant, pregnant women, and breastfeeding women to consume 8 to 12 ounces of a variety of fish lower in mercury each week (table 1), rather than "up to 12 ounces" as previously recommended [7]. This is consistent with two to three servings of fish per week. We suggest that pregnant and breastfeeding women try to achieve fish consumption resulting in at least 200 mg/day DHA intake instead of relying on the number of servings of fish, since fish vary widely in DHA content. (See "Fish consumption during pregnancy", section on 'Diet and supplements'.)

Risk of perinatal transmission of HBV in the United States (June 2014)

Administration of hepatitis B virus (HBV) vaccination and hepatitis B immune globulin (HBIG) to newborns of women with chronic HBV infection significantly reduces the risk of perinatal HBV transmission but does not eradicate it. In an observational study of over 4000 infants born to HBV-infected mothers in the United States between 1997 and 2010, over 95 percent received HBV vaccination and HBIG [8]. Perinatal transmission occurred in 3.40 percent of births to hepatitis B e antigen (HBeAg) positive mothers and 0.04 percent of births to HBeAg negative mothers. Among women whose HBV DNA results and HBeAg status were known, no HBV transmission occurred with a viral load less than 5 x107 IU/mL, regardless of the HBeAg status. (See "Hepatitis B and pregnancy", section on 'HBV DNA level'.)

Antidepressants and risk of preterm delivery (May 2014)

Use of antidepressants during pregnancy may be associated with preterm delivery, and a new study suggests that this effect may be related to the timing of exposure. In a meta-analysis of 41 observational studies, third trimester exposure to antidepressants was associated with an approximately twofold higher risk of preterm birth compared with no exposure, whereas first trimester exposure was not associated with increased risk [9]. Management of depression during pregnancy requires that these and other potential risks of medications be weighed against the maternal and fetal risks of untreated illness. (See "Risks of antidepressants during pregnancy", section on 'Antidepressant composite data'.)

Effect of gravity on placental transfusion (April 2014)

The length of time a mother can safely hold her newborn before the umbilical cord is clamped is controversial because of concerns that gravity may decrease the volume of placental transfusion. In the first randomized trial evaluating this issue, the location of the newborn above or below the level of the placenta for two minutes before cord clamping did not affect the volume of placental transfusion (as assessed by change in newborn weight) [10]. This finding suggests that placing the newborn on the maternal abdomen or chest before cord clamping does not adversely affect the volume of placental transfusion. (See "Management of normal labor and delivery", section on 'Cord clamping'.)

Hyperimmune globulin does not prevent congenital CMV infection (April 2014)

Although prospective observational studies have reported that administration of hyperimmune globulin to pregnant women with primary cytomegalovirus (CMV) infection reduced maternal-to-fetal transmission and the severity of congenital infection, a recent randomized trial did not demonstrate a significant benefit. The Congenital Human CMV Infection Prevention (CHIP) trial randomly assigned pregnant women at 5 to 26 weeks of gestation with recent onset primary CMV infection to receive hyperimmune globulin or placebo every four weeks [11]. The overall rate of congenital infection and the proportion of infected infants symptomatic at birth was similar for both groups. (See "Cytomegalovirus infection in pregnancy", section on 'Hyperimmunoglobulin'.)

Vancomycin dose for intrapartum GBS chemoprophylaxis (April 2014)

A study has found that vancomycin dosing recommendations from a 2010 guideline from the US Centers for Disease Control (CDC) regarding intrapartum chemoprophylaxis of neonatal early-onset Group B Streptococcus may provide subtherapeutic levels in neonates. The CDC guidelines recommend vancomycin 1 gram every 12 hours for penicillin allergic women if GBS isolates are resistant to clindamycin or susceptibility results are not available. However, a 2014 study of vancomycin levels in neonatal cord blood noted that therapeutic levels were infrequently achieved in neonates whose mothers received this dose, but usually were achieved with maternal weight-based dosing (20 mg/kg every 8 hours; maximum dose 2 grams) [12]. We now suggest weight-based dosing for vancomycin intrapartum GBS chemoprophylaxis. (See "Neonatal group B streptococcal disease: Prevention", section on 'Patients with penicillin allergy'.)

Possible adverse effect of in utero exposure to acetaminophen (April 2014)

An epidemiologic study noted a small but statistically significant (OR 1.13) association between in utero exposure to acetaminophen and attention-deficit/hyperactivity disorder–like behavioral problems in offspring at age seven years [13]. These findings are subject to the many limitations of observational studies and should not change current practice. (See "Initial prenatal assessment and first trimester prenatal care", section on 'Acetaminophen'.)

Maternal intake of highly allergenic foods during pregnancy (March 2014)

To date, most studies have found that maternal avoidance of highly allergenic foods during pregnancy does not reduce the incidence of allergic disease in infants and children at risk for these disorders. However, participants in such studies are often from "high risk" atopic families and thus may not be representative of the general population. A new cohort study in over 1200 unselected mother-child pairs examined the association between maternal intake of common allergenic foods during pregnancy and the development of allergic disorders in the offspring [14]. Data from mid-childhood visits found that diets lower in allergenic foods were not associated with reduction in the incidence of food allergy, asthma, allergic rhinitis, or atopic dermatitis, and in some situations, higher intake in early pregnancy appeared to have a protective effect. These findings support our current suggestion that women not restrict their diets during pregnancy for the purpose of reducing allergic disease in their children. (See "Primary prevention of allergic disease: Maternal avoidance diets in pregnancy and lactation", section on 'Definitions'.)

Noninvasive prenatal screening in low-risk women (March 2014)

Noninvasive prenatal screening using cell-free DNA is an option for screening women at high risk of fetal aneuploidy (trisomy 21, 18, 13), but test performance is unclear in low-risk women. A recent study compared the performance of cell-free DNA sequencing with standard maternal aneuploidy screening (maternal analyte assay with or without nuchal translucency measurement) in a general obstetrical population of over 1900 women who underwent both screening tests; results of DNA sequencing were concealed [15]. Both screening tests detected all cases of trisomy 21 and trisomy 18. DNA sequencing had a lower false-positive rate (trisomy 21: 0.3 versus 3.6 percent; trisomy 18: 0.2 versus 0.6 percent). Thus, far fewer women would need to be offered invasive diagnostic testing because of a positive screen. However, additional issues need to be addressed before noninvasive prenatal screening using cell-free DNA can be recommended as a primary screening tool in the general obstetrical population. (See "Down syndrome: Prenatal screening overview", section on 'Screening performance of tests used for primary screening'.)

Contraception and postpartum risk of thrombosis (March 2014)

Because the risk of thrombotic events is elevated in postpartum women, estrogen-progestin contraceptives are not initiated until at least three weeks after delivery. In a large retrospective study, the risk of a thrombotic event was highest in the first three weeks postpartum (odds ratio 18), fell to relatively low levels by seven weeks (odds ratio 2), but did not reach baseline levels until 16 weeks after delivery [16]. This study does not change our approach to postpartum contraception, which allows women without additional risk factors for thrombosis to begin estrogen-progestin contraception after the period of highest risk (first three weeks postpartum) but before ovulation resumes. Although the risk of a thrombotic event remains increased three to six weeks postpartum, there is no direct evidence that initiation of contraception during this period further increases the risk of thrombosis, which continues to fall over time. (See "Postpartum and postabortion contraception", section on 'Estrogen-progestin contraceptives'.)

OFFICE GYNECOLOGY

KEEPS hormone therapy trial in newly menopausal women (September 2014)

The Women's Health Initiative (WHI), a set of menopausal hormone therapy (MHT) trials in older postmenopausal women (average age 63 years) reported an excess risk of coronary heart disease (CHD) with MHT. Emerging data, including secondary analyses from the WHI, now suggest that use of MHT in the early menopausal years is not associated with excess CHD risk. The Kronos Early Estrogen Prevention Study (KEEPS) is the first randomized trial of MHT in younger menopausal women (727 women ages 45 to 54 years) [17]. When combined with cyclical monthly oral progesterone, low dose oral conjugated estrogen (0.45 mg daily) or transdermal estradiol (50 mcg daily) for four years relieved menopausal symptoms. While several markers of cardiovascular risk improved in the MHT group, there was no significant effect on surrogate markers of atherosclerosis progression (coronary artery calcium and carotid intima-medial thickness) when compared to placebo. This trial provides additional reassurance that early use of MHT is safe for the treatment of menopausal symptoms, though does not support a role for MHT in prevention. (See "Menopausal hormone therapy and cardiovascular risk", section on 'Timing of exposure'.)

Injectable progestins and risk of venous thrombosis (September 2014)

In contrast to other progestin-only contraceptives, depot medroxyprogesterone acetate (DMPA) use may be associated with an increased risk of venous thrombosis and embolism (VTE). In a case-control study, women with a first episode of VTE were twice as likely to be DMPA users than were controls in the general population [18]. In this study, VTE was not associated with use of progestin-only pills, the levonorgestrel-releasing intrauterine device, or the progestin-only contraceptive implant. However, in the absence of data about absolute risk of VTE in DMPA users, we continue to think that the advantages of using DMPA generally outweigh the risks for women with a history of VTE. (See "Depot medroxyprogesterone acetate for contraception", section on 'Cardiovascular risk'.)

Oral emergency contraception in overweight women (August 2014)

In Europe, product labeling for levonorgestrel-based emergency contraception (NorLevo) was updated in February 2014 to indicate that it may be less effective in women ≥75 kg (165 pounds). In July 2014, the European Medicines Association concluded that the available data were not robust enough to be certain the contraceptive efficacy of levonorgestrel emergency contraception is reduced with increased bodyweight and that the benefits of taking the medication outweighed any risks [19]. We counsel overweight and obese women of potentially reduced efficacy of levonorgestrel emergency contraception as BMI increases above the normal range (25 kg/m2) or at weights ≥75 kg (165 pounds), and offer them a copper-releasing IUD as first-line therapy to prevent pregnancy. If the IUD is not an option, ulipristal is more likely to be effective than levonorgestrel. (See "Emergency contraception", section on 'Overweight and obese women'.)

Pelvic examination in asymptomatic women (July 2014)

Routine pelvic examinations in asymptomatic women are controversial. The American College of Physicians has issued guidelines that advise against performing screening pelvic examinations in asymptomatic, nonpregnant, adult women [20]. The American College of Obstetricians and Gynecologists continues to recommend annual pelvic examination for nonpregnant women age 21 years and older, but suggests that asymptomatic women participate in the decision [21]. We believe the decision whether or not to perform a complete pelvic examination at the time of the periodic health examination for the asymptomatic patient should be a shared decision after a discussion between the patient and her healthcare provider. (See "The gynecologic history and pelvic examination", section on 'Indications and frequency for examination'.)

Topical lidocaine for dyspareunia after treatment for breast cancer (May 2014)

Dyspareunia is a frequent issue for women after treatment for breast cancer. For women with dyspareunia isolated to tenderness in the vulvar vestibule, topical lidocaine appears to provide effective relief. This was shown in a small trial that included 49 women randomly assigned to local treatment with topical lidocaine or normal saline [22]. Compared with normal saline, topical lidocaine resulted in a significant reduction in coital pain scores. While these data suggest that topical lidocaine can effectively treat dyspareunia in women with vulvar vestibule discomfort, its effectiveness for women who have findings of intravaginal or pelvic floor pain is not known. (See "Approach to the patient following treatment for breast cancer", section on 'Sexual health'.)

Cobas HPV test and cervical cancer screening (May 2014)

The cobas HPV test for cervical cancer screening detects the presence of HPV types 16 and 18 with a pooled result for 12 additional high-risk types. HPV types 16 and 18 confer the highest risk for cervical cancer among HPV types. The cobas HPV test was approved by the US Food and Drug Administration (FDA) in April 2014 for use alone as primary screening in women 25 years of age and older [23]. Evidence regarding use of the cobas HPV test as stand-alone testing is not yet publicly available. Awaiting review of this evidence, we continue to recommend cytological (Pap smear) screening for cervical cancer in women 21 to 30 years of age, and either Pap smear alone or co-testing with Pap and HPV testing in women age 30 and older. (See "Screening for cervical cancer: Rationale and recommendations", section on 'HPV testing'.)

HPV vaccine dosing and genital warts (March 2014)

Three doses of HPV vaccine are recommended in the United States, but missed doses and suboptimal adherence to the schedule are frequent. In a Swedish cohort study of over one million females, aged 10 to 24 years, followed for four years, receipt of two quadrivalent HPV vaccine doses was associated with substantial protection against genital warts, although completion of three doses was slightly superior [24]. The study did not assess other important outcomes such as cervical intraepithelial neoplasia or cervical cancer. (See "Recommendations for the use of human papillomavirus vaccines", section on 'Missed doses/alternate schedules'.)

GYNECOLOGIC SURGERY

Risk of dissemination of gynecologic tumors with power morcellation (April 2014, MODIFIED August 2014)

Unsuspected gynecologic malignancy is detected postoperatively in a small proportion of women who undergo laparoscopic hysterectomy or myomectomy with power morcellation (cutting the uterus into small pieces to facilitate removal). In such cases, power morcellation may disseminate malignant cells and potentially worsen the survival outcome. In April 2014, the US Food and Drug Association (FDA) issued a safety communication that discouraged power morcellation during laparoscopic hysterectomy or myomectomy in women with uterine fibroids and stated that morcellation should not be used in women with known or suspected uterine cancer [25]. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'Professional society and FDA statements'.)

Accurate estimates of the prevalence of malignancy at the time of laparoscopic hysterectomy with power morcellation are lacking. In the largest study to date, among 36,370 women who underwent laparoscopic or robotic hysterectomy with power morcellation, there were 99 cases of uterine cancer (0.27 percent) and 26 cases of other gynecologic malignancies (0.07 percent) [26]. The prevalence of gynecologic malignancy increased with age. Compared with women younger than 40 years, the prevalence of gynecologic malignancy was approximately 5-fold higher for women 50 to 54 and 19-fold higher for women 55 to 59 years. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'Prevalence of sarcoma after surgery for presumed leiomyomas'.) 

Power morcellation should be avoided in women with known or suspected uterine or other gynecologic cancer or significant risk factors for uterine sarcoma (eg, postmenopausal status; ≥2 years of tamoxifen therapy; history of pelvic radiation, childhood retinoblastoma, or hereditary leiomyomatosis and renal cell carcinoma syndrome). Patients should be counseled about the risk of tumor dissemination if an unsuspected malignancy is present. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'Do morcellation, myomectomy, or supracervical hysterectomy worsen prognosis?'.)

Salpingostomy versus salpingectomy for tubal ectopic pregnancy (May 2014, MODIFIED July 2014)

Tubal pregnancy may be treated surgically with salpingostomy or salpingectomy. A randomized trial comparing salpingostomy and salpingectomy in 446 women found similar rates of spontaneous intrauterine pregnancy at 36 months (61 and 56 percent) [27]. The rate of repeat ectopic pregnancy in the ipsilateral tube was also similar (3 versus 1 percent). Based on the comparable reproductive outcomes in this and other studies, salpingostomy is preferred for most women because the fallopian tube is conserved. Salpingectomy is required for women with or at high risk of tubal rupture or with severe tubal damage. (See "Surgical treatment of ectopic pregnancy", section on 'Salpingostomy versus salpingectomy'.)

GYNECOLOGIC ONCOLOGY

FDA approval for bevacizumab for cervical cancer (August 2014)

For women with advanced, recurrent, or metastatic cervical cancer, a Gynecologic Oncology Group randomized trial (GOG 240) showed that chemotherapy plus bevacizumab significantly improved outcomes, including a prolongation of overall survival, compared with the administration of chemotherapy alone. Based on these results, the US Food and Drug Administration approved the use of bevacizumab in combination with chemotherapy for these patients in August 2104 [28]. Despite these developments, issues related to costs of therapy may need to be considered, especially in underdeveloped areas. (See "Management of recurrent or metastatic cervical cancer", section on 'Chemotherapy plus bevacizumab as first-line treatment'.)

Opportunistic salpingectomy and operative outcomes (August 2014)

Opportunistic salpingectomy (the removal of the fallopian tubes in a woman undergoing pelvic surgery for another indication) is a new strategy for the primary prevention of ovarian, fallopian tube, or peritoneal carcinoma in average-risk women. Adoption rates are high in Canada, where it was first proposed, and the first large study found no increase in operative morbidity. This retrospective population-based cohort study found an increase in the rate of salpingectomy performed at the time of hysterectomy (from 5 to 35 percent) or sterilization (from <1 to 33 percent) between 2008 and 2011 [29]. Opportunistic salpingectomy was associated with a modest increase in operative duration (10 to 16 minutes), but no increase in the rate of blood transfusion or readmission. Although opportunistic salpingectomy appears to be safe, further study is necessary to determine the impact on gynecologic cancer risk. (See "Opportunistic salpingectomy for ovarian, fallopian tubal, and peritoneal carcinoma risk reduction", section on 'Outcome'.)

Tubal ligation and risk of ovarian cancer (June 2014)

Tubal ligation is associated with a decreased risk of ovarian cancer. The Nurses’ Health Study and Nurses’ Health Study II, two large prospective cohort studies, found that tubal ligation was associated with a 24 percent decrease in the risk of ovarian cancer [30]. The effect was stronger for endometrioid, clear cell, and mucinous carcinomas than for serous carcinomas. This finding provides support for the role of the fallopian tube in the pathogenesis of ovarian cancer. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Epidemiology and risk factors", section on 'Tubal ligation'.)

New staging system for ovarian, fallopian tubal, and peritoneal carcinomas (March 2014)

The International Federation of Gynecology and Obstetrics (FIGO)/Tumor Nodes Metastases (TNM) classification system for carcinoma of the ovary, fallopian tube, or peritoneum has been revised. A major change is the combining of staging for the three sites (tubal carcinoma previously had a separate system) (table 2) [31]. Biologic behavior varies by histology and grade, and these are recorded as part of staging in the new system. Other changes include dividing several stages into substages to improve reporting of: etiology of malignant cells in peritoneal fluid (stage IC); site of microscopic peritoneal metastases (IIIA); and site of distant metastases (IV). (See "Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management", section on 'Staging system'.)

Potential role of aspirin in ovarian cancer prevention (March 2014)

Systematic reviews regarding a potentially protective effect against ovarian cancer of nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen have yielded conflicting results. A meta-analysis of 12 population-based case-control studies found a significant association between reduced risk of ovarian cancer and use of aspirin but not non-aspirin NSAIDs or acetaminophen [32]. Although these observational data suggest a protective role for aspirin in ovarian cancer, further study is needed. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Epidemiology and risk factors", section on 'NSAIDs and acetaminophen'.)

UROGYNECOLOGY

Transobturator versus retropubic slings for stress urinary incontinence (July 2014)

Midurethral slings are the most common surgical treatment for stress urinary incontinence in women. The two techniques for this procedure are the retropubic and the newer transobturator sling routes. Growing data have suggested that they are comparably effective treatments for stress urinary incontinence. A meta-analysis of 21 randomized trials found no significant difference between these two techniques in subjective and objective cure rates [33]. The distinct perioperative complications associated with each technique are important factors in deciding between the two. (See "Stress urinary incontinence in women: Choosing a type of midurethral sling", section on 'Transobturator versus retropubic midurethral slings'.)

Comparing transvaginal approaches to apical prolapse repair (April 2014, MODIFIED June 2014)

There are several surgical approaches for the repair of prolapse of the vaginal apex (cervix or post-hysterectomy vaginal vault). The first randomized trial to compare the two most common transvaginal repair procedures, uterosacral ligament suspension (ULS) and sacrospinous ligament suspension (SSLS), found no overall difference in symptoms, anatomic outcomes, or retreatment rates at two years. However, there was a higher rate of neurologic pain for SSLS and a higher rate of ureteral obstruction for ULS [34]. Counseling regarding these procedures should include the comparable efficacy and differing complication risks of each procedure. (See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Comparing among vaginal procedures'.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

  1. Edey S, Moran N, Nashef L. SUDEP and epilepsy-related mortality in pregnancy. Epilepsia 2014; 55:e72.
  2. Huybrechts KF, Palmsten K, Avorn J, et al. Antidepressant use in pregnancy and the risk of cardiac defects. N Engl J Med 2014; 370:2397.
  3. Ersdal HL, Linde J, Mduma E, et al. Neonatal outcome following cord clamping after onset of spontaneous respiration. Pediatrics 2014; 134:265.
  4. Ptacek I, Sebire NJ, Man JA, et al. Systematic review of placental pathology reported in association with stillbirth. Placenta 2014; 35:552.
  5. Bao W, Tobias DK, Bowers K, et al. Physical activity and sedentary behaviors associated with risk of progression from gestational diabetes mellitus to type 2 diabetes mellitus: a prospective cohort study. JAMA Intern Med 2014; 174:1047.
  6. Du Y, Ye M, Zheng F. Active management of the third stage of labor with and without controlled cord traction: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2014; 93:626.
  7. Fish: What Pregnant Women and Parents Should Know. Draft Updated Advice by FDA and EPA http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm393070.htm (Accessed on June 13, 2014).
  8. Kubo A, Shlager L, Marks AR, et al. Prevention of vertical transmission of hepatitis B: an observational study. Ann Intern Med 2014; 160:828.
  9. Huybrechts KF, Sanghani RS, Avorn J, Urato AC. Preterm birth and antidepressant medication use during pregnancy: a systematic review and meta-analysis. PLoS One 2014; 9:e92778.
  10. Vain NE, Satragno DS, Gorenstein AN, et al. Effect of gravity on volume of placental transfusion: a multicentre, randomised, non-inferiority trial. Lancet 2014; 384:235.
  11. Revello MG, Lazzarotto T, Guerra B, et al. A randomized trial of hyperimmune globulin to prevent congenital cytomegalovirus. N Engl J Med 2014; 370:1316.
  12. Onwuchuruba CN, Towers CV, Howard BC, et al. Transplacental passage of vancomycin from mother to neonate. Am J Obstet Gynecol 2014; 210:352.e1.
  13. Liew Z, Ritz B, Rebordosa C, et al. Acetaminophen use during pregnancy, behavioral problems, and hyperkinetic disorders. JAMA Pediatr 2014; 168:313.
  14. Bunyavanich S, Rifas-Shiman SL, Platts-Mills TA, et al. Peanut, milk, and wheat intake during pregnancy is associated with reduced allergy and asthma in children. J Allergy Clin Immunol 2014; 133:1373.
  15. Bianchi DW, Parker RL, Wentworth J, et al. DNA sequencing versus standard prenatal aneuploidy screening. N Engl J Med 2014; 370:799.
  16. Kamel H, Navi BB, Sriram N, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014; 370:1307.
  17. Harman SM, Black DM, Naftolin F, et al. Arterial imaging outcomes and cardiovascular risk factors in recently menopausal women: a randomized trial. Ann Intern Med 2014; 161:249.
  18. Bergendal A, Persson I, Odeberg J, et al. Association of venous thromboembolism with hormonal contraception and thrombophilic genotypes. Obstet Gynecol 2014; 124:600.
  19. Levonorgestrel and ulipristal remain suitable emergency contraceptives for all women, regardless of bodyweight http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2014/07/news_detail_002145.jsp&mid=WC0b01ac058004d5c1 (Accessed on August 04, 2014).
  20. Qaseem A, Humphrey LL, Harris R, et al. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161:67.
  21. http://www.acog.org/About-ACOG/News-Room/College-Statements-and-Advisories/2014/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations (Accessed on July 01, 2014).
  22. Goetsch MF, Lim JY, Caughey AB. Locating pain in breast cancer survivors experiencing dyspareunia: a randomized controlled trial. Obstet Gynecol 2014; 123:1231.
  23. FDA approves first human papillomavirus test for primary cervical cancer screening http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm394773.htm (Accessed on April 25, 2014).
  24. Herweijer E, Leval A, Ploner A, et al. Association of varying number of doses of quadrivalent human papillomavirus vaccine with incidence of condyloma. JAMA 2014; 311:597.
  25. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm (Accessed on April 18, 2014).
  26. Wright JD, Tergas AI, Burke WM, et al. Uterine Pathology in Women Undergoing Minimally Invasive Hysterectomy Using Morcellation. JAMA 2014.
  27. Mol F, van Mello NM, Strandell A, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet 2014; 383:1483.
  28. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm410121.htm.
  29. McAlpine JN, Hanley GE, Woo MM, et al. Opportunistic salpingectomy: uptake, risks, and complications of a regional initiative for ovarian cancer prevention. Am J Obstet Gynecol 2014; 210:471.e1.
  30. Rice MS, Hankinson SE, Tworoger SS. Tubal ligation, hysterectomy, unilateral oophorectomy, and risk of ovarian cancer in the Nurses' Health Studies. Fertil Steril 2014; 102:192.
  31. Prat J, FIGO Committee on Gynecologic Oncology. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet 2014; 124:1.
  32. Trabert B, Ness RB, Lo-Ciganic WH, et al. Aspirin, nonaspirin nonsteroidal anti-inflammatory drug, and acetaminophen use and risk of invasive epithelial ovarian cancer: a pooled analysis in the Ovarian Cancer Association Consortium. J Natl Cancer Inst 2014; 106:djt431.
  33. Schimpf MO, Rahn DD, Wheeler TL, et al. Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis. Am J Obstet Gynecol 2014; 211:71.e1.
  34. Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014; 311:1023.
Topic 8350 Version 3827.0

Topic Outline

GRAPHICS

RELATED TOPICS

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.