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What's new in obstetrics and gynecology
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What's new in obstetrics and gynecology

Disclosures: Kristen Eckler, MD, FACOG Nothing to disclose. Sandy J Falk, MD, FACOG Nothing to disclose. Vanessa A Barss, MD, FACOG Nothing to disclose.

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: Feb 2015. | This topic last updated: Mar 30, 2015.

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

Induction after previous cesarean delivery (March 2015)

The risks and benefits of labor induction in women with a previous cesarean delivery are best understood when compared with the outcome of expectant management in a similar population, rather than a population of women in spontaneous labor. In one such study of over 12,000 women with singleton gestations ≥39 weeks and one low transverse cesarean delivery, women undergoing induction at 39 weeks without an acute obstetric medical indication were more likely to deliver vaginally than those managed expectantly (74 versus 61 percent), but they also experienced a higher rate of uterine rupture (1.4 versus 0.5 percent) [1]. Uterine rupture was defined as a disruption or tear of the uterine muscle and visceral peritoneum or a separation of the uterine muscle with extension to the bladder or broad ligament. These findings affirm previous findings of the high probability of vaginal delivery with induction after a previous cesarean delivery at the cost of an increased risk of uterine rupture. (See "Cervical ripening and induction of labor in women with a prior cesarean delivery", section on 'Likelihood of successful induction'.)

Exercise reduces risk of gestational diabetes (March 2015)

Regular moderate exercise may lower the risk of developing gestational diabetes. In a 2015 meta-analysis of 10 randomized trials, initiating an exercise program during pregnancy reduced the risk of developing gestational diabetes compared with routine care (RR 0.74, 95% CI 0.57-0.97), although the confidence interval was wide [2]. (See "Diabetes mellitus in pregnancy: Screening and diagnosis", section on 'Approaches for risk reduction'.)

Chronic hypertension may increase risk of congenital anomalies (March 2015)

Children of women with chronic hypertension, either treated or untreated, appear to be at increased risk of congenital malformations, particularly cardiac malformations. In a recent study, the risk of congenital heart disease was increased by 50 percent in offspring of women with untreated hypertension compared with offspring of normotensive controls, which corresponds to 1.4 additional cases of congenital heart disease per 100 pregnancies in women with hypertension [3]. This suggests that factors associated with hypertension or hypertension itself increases the risk for congenital malformations independent of antihypertensive drug therapy. (See "Management of hypertension in pregnant and postpartum women", section on 'Antihypertensive therapy'.)

Pregnancy outcomes after bariatric surgery (March 2015)

Bariatric surgery prior to pregnancy appears to reduce the risk of certain adverse pregnancy outcomes associated with maternal obesity. In the largest study to date evaluating this issue, women who had bariatric surgery prior to pregnancy were less likely to have gestational diabetes and large-for-gestational-age infants compared with women matched for age and presurgical body mass index (BMI) who had not undergone bariatric surgery [4]. However, they were more likely to have small-for-gestational-age infants. The risks of preterm birth, stillbirth or neonatal death, and congenital malformations were not statistically different between the two groups. (See "Fertility and pregnancy after bariatric surgery", section on 'Pregnancy outcomes'.)

Safety of inhaled long-acting beta agonist/glucocorticoid for asthma during pregnancy (February 2015)

An important clinical question for pregnant women with asthma is whether using a combination long-acting beta-agonist (LABA) plus inhaled glucocorticoid confers an increased risk for adverse fetal outcomes, compared with monotherapy using a higher dose of the inhaled glucocorticoid. In a study of 1302 pregnant women with asthma, the risk for a major congenital malformation was not increased when a LABA plus low dose inhaled glucocorticoid was compared with a medium dose inhaled glucocorticoid, or when a LABA plus medium-dose inhaled glucocorticoid was compared with a high-dose inhaled glucocorticoid [5]. (See "Management of asthma during pregnancy", section on 'Long-acting beta-adrenergic agents'.)

Oral anti-hyperglycemic drugs for treatment of gestational diabetes mellitus (February 2015)

Prevention of macrosomia is a major goal of treatment of gestational diabetes mellitus (GDM), but the best approach is controversial. In a 2015 systematic review and meta-analysis of randomized trials comparing neonatal outcomes in women with GDM treated with glyburide, metformin, or insulin therapy, women assigned to glyburide had a higher rate of macrosomia than those assigned to metformin or insulin therapy [6]. Metformin therapy and insulin therapy resulted in similar rates of macrosomia. We prefer insulin therapy for women with GDM who fail nutritional therapy because it is effective and safe, while there is no information about the long-term effects of transplacental passage of oral anti-hyperglycemic drugs. However, oral anti-hyperglycemic agents are a reasonable alternative for women who refuse to take, or are unable to comply with, insulin therapy. (See "Gestational diabetes mellitus: Glycemic control and maternal prognosis", section on 'Glyburide'.)

Target diastolic blood pressure in pregnancy (February 2015)

In pregnant women with chronic (preexistent) or gestational hypertension, the effect of less-tight versus tight control of hypertension on pregnancy complications is unclear. A randomized trial that assigned pregnant women with gestational or chronic hypertension to diastolic blood pressure treatment targets of 85 or 100 mmHg reported similar maternal, fetal, and neonatal outcomes in both groups [7]. More women in the 100 mmHg target group developed severe hypertension, although this was not associated with an increase in transient ischemic attack or stroke. The trial was not powered to exclude a clinically important increase in fetal growth restriction in the 85 mmHg target group. For these reasons, we continue to suggest a diastolic pressure target of 90 to 100 mmHg for pregnant women with hypertension without end-organ damage. (See "Management of hypertension in pregnant and postpartum women", section on 'Blood pressure goal'.)

Risk of depression among pregnant women with epilepsy (February 2015)

Individuals with epilepsy have an increased prevalence of depression compared with individuals without epilepsy, and this appears to be true during pregnancy and the postpartum period as well. In a population-based study that included 706 pregnancies in women with epilepsy and over 100,000 pregnancies in those without epilepsy, peripartum depression affected 27 percent of women with epilepsy compared with 23 percent of women with other chronic diseases and 19 percent of the entire non-epilepsy population [8]. Risk factors for depression included high seizure frequency, antiepileptic drug use, and prepregnancy depression or anxiety. Detection of depression during pregnancy is important because both pharmacologic and nonpharmacologic treatments are available, and untreated illness may have consequences for both mother and child. (See "Risks associated with epilepsy and pregnancy", section on 'Other risks'.)

Mortality decreasing for extremely preterm infants (January 2015)

Although infants born extremely premature have the highest mortality rate, mortality has decreased with advances in prenatal and neonatal care. This was illustrated in a large prospective study of 22,248 extremely premature infants (defined as gestational age between 22 and 28 6/7 weeks) conducted by the National Institute of Child Health and Human Development Neonatal Research Network that compared mortality across three time periods (2000 to 2003, 2004 to 2007, and 2008 to 2011) [9]. In this analysis, mortality was lowest in the third time period (2008 to 2011) due to decreased rates of deaths related to pulmonary causes (neonatal respiratory distress syndrome and bronchopulmonary dysplasia), immaturity, infection, and central nervous system injury. The study also documented improved prenatal care among mothers of these preterm infants, as the percentage of women who received prenatal care increased throughout the three study periods including higher rates of prenatal glucocorticoid administration. (See "Incidence and mortality of the premature infant", section on 'Extremely preterm infants'.)

Timing of antiretroviral initiation during pregnancy (January 2015)

The risk of HIV transmission from an infected mother to her infant is proportional to the level of maternal viremia at delivery. Among women not already taking an antiretroviral regimen, viral suppression at delivery is more likely when a regimen is initiated earlier during gestation. In a large US cohort of antiretroviral-naïve HIV-infected women who initiated a combination antiretroviral regimen during pregnancy, a detectable viral load at delivery was documented in 13 percent overall, but in 24 percent of those who initiated the regimen during the third trimester [10]. This supports our recommendation to initiate antiretroviral therapy promptly in treatment-naïve pregnant women with advanced HIV disease or CD4 cell count th week of gestation for HIV-infected pregnant women with higher CD4 cell counts. (See "Use of antiretroviral medications in pregnant HIV-infected patients and their infants in resource-rich settings", section on 'When to initiate antiretroviral medications during pregnancy'.)

Risk of congenital anomalies in offspring of consanguineous couples (January 2015)

There is increasing evidence that the prevalence of congenital and genetic disorders among offspring of consanguineous couples is about double that compared to non-consanguineous couples. In a retrospective study of a multiethnic population referred to a specialist center in Berlin, Germany, the prevalence of major anomalies among fetuses with consanguineous and non-consanguineous parents was 6.1 and 2.8 percent, respectively [11]. This information is useful for managing pregnancy in a consanguineous couple or counseling consanguineous couples who are contemplating pregnancy. (See "Genetic and environmental causes of birth defects", section on 'Consanguinity'.)

No change to recommendations for pain medicine use in pregnancy (January 2015)

Studies of pain medicine use by pregnant women have suggested associations between prescription nonsteroidal antiinflammatory drugs (NSAIDs) and the risk of miscarriage, the use of acetaminophen and subsequent childhood attention deficit hyperactivity disorder (ADHD), and the use of opioids and the development of fetal neural tube defects. A 2015 US Food and Drug Administration (FDA) Drug Safety Communication has found methodologic limitations to these studies and inconclusive results regarding NSAIDs and acetaminophen use [12]. Further investigation is needed regarding maternal opioid use and the risk of fetal neural tube defects. It is always advisable for pregnant women to avoid medications that are not clearly needed. However, specific recommendations regarding analgesic use need not change based on this current analysis. (See "Initial prenatal assessment and first trimester prenatal care", section on 'Treatment of pain and fever'.)

Success of preterm labor induction (January 2015)

Induction of labor is less likely to be successful in very preterm pregnancies, but reliable estimates of success rates have not been published. In a study of data from the National Institute of Child Health and Human Development Consortium on Safe Labor, 57 percent of pregnancies induced at 24 to 28 weeks, and 54 percent of those at 28 to 31 weeks had a successful vaginal delivery [13]. Success rates were highest in multiparous women and pregnancies ≥34 weeks. (See "Induction of labor", section on 'Predicting a successful induction'.)

Congenital anomalies associated with increased nuchal translucency on prenatal ultrasonography (December 2014)

Measurement of fetal nuchal translucency on prenatal ultrasonography is a first trimester screening test for Down syndrome. Increased nuchal translucency is associated with Down syndrome, but also with an increased risk of congenital cardiac and noncardiac anomalies. In a large population-based study of euploid liveborn infants without critical congenital heart defects, the risk of hydrocephalus, osteodystrophy, and anomalies of the lung, diaphragm, and small intestine was increased approximately threefold in infants with first trimester nuchal translucency measurement ≥95th percentile compared with those <95th percentile [14]. These findings highlight the importance of a thorough fetal anatomic survey when increased fetal nuchal translucency is identified. (See "First trimester cystic hygroma and increased nuchal translucency", section on 'Noncardiac'.)

Blunt versus sharp uterine incision expansion (December 2014)

The uterine incision at cesarean delivery can be expanded using a blunt or sharp technique. In a 2014 meta-analysis of randomized trials of blunt versus sharp incision expansion, blunt expansion resulted in a 50 percent reduction in the rate of unintended extensions and a lower drop in postpartum hemoglobin and hematocrit, and reduced operative time by two minutes [15]. These data support our recommendation for blunt incision expansion. (See "Cesarean delivery: Technique", section on 'Procedure'.)

Low Apgar scores: Predictors of neonatal and infant deaths (November 2014)

Although not used to guide resuscitation, Apgar scores, first introduced in 1953, have been used as a measure of the newborn's overall clinical status and response to resuscitation during the first minutes after delivery. The accurate predictability of low Apgar scores for mortality was confirmed by a study that reviewed discharge and mortality data for all births in Scotland between 1992 and 2010 [16]. Linear regression analysis showed Apgar scores ≤3 at five minutes, compared with normal scores (between 7 and 10), were associated with 300-fold increased risk of early neonatal death (birth to seven days of life), 30-fold increased risk of late neonatal death (7 to 28 days of life), and 50-fold increased infant death (up to one year of age). (See "Neonatal resuscitation in the delivery room", section on 'Apgar scores'.)

Risk of gestational hypertension or preeclampsia in kidney donors (November 2014)

The assessment of risk conferred by living kidney donation is critically important in determining the suitability of individual donor candidates. A retrospective cohort study demonstrated an increased risk of gestational hypertension or preeclampsia compared with well-matched nondonors [17]. Women of childbearing age who wish to donate a kidney should be advised of this increased risk. (See "Evaluation of the living kidney donor and risk of donor nephrectomy", section on 'Maternal and fetal outcomes'.)

Anticoagulation and placenta-mediated complications (October 2014)

Placenta-mediated pregnancy complications include pregnancy loss, severe/early-onset preeclampsia, and birth of small for gestational age infant. Anticoagulation has been recommended to prevent placenta-mediated pregnancy complications in women with thrombophilia, but the effectiveness of this approach is controversial. In a multinational randomized trial (TIPPS), prophylactic use of dalteparin in women with thrombophilia and a history of previous placenta-mediated pregnancy complications did not reduce the occurrence of the composite outcome (pregnancy loss, severe/early-onset preeclampsia, birth of small for gestational age infant, major venous thromboembolism) compared with women who did not receive dalteparin [18]. We believe the available evidence supports not prescribing anticoagulants to prevent adverse obstetrical outcomes in pregnant women with thrombophilia. (See "Inherited thrombophilias in pregnancy", section on 'Prevention of pregnancy complications'.)

Aspirin for preventing preeclampsia (September 2014)

For women at high risk of developing preeclampsia, the US Preventive Services Task Force (USPSTF) now recommends use of low dose aspirin after 12 weeks of gestation to reduce the risk of preeclampsia, preterm birth, and fetal growth restriction [19]. Low dose aspirin prophylaxis results in potentially substantial benefit and no more than minimally harmful effects. This recommendation is consistent with recommendations of other professional organizations. The USPSTF also offered a pragmatic approach for selecting a high risk population, while acknowledging that there are no validated methods for identifying these women. (See "Preeclampsia: Prevention", section on 'Approach to therapy'.)

OFFICE GYNECOLOGY

Long duration of hot flashes (March 2015)

For many if not most menopausal women, hot flashes last considerably longer than the duration currently recommended for treatment of symptoms (maximum 4 to 5 years to minimize excess breast cancer risk). Among 1449 women with hot flashes followed longitudinally in the Study of Women Across the Nation (SWAN), the median total hot flash duration was 7.4 years, with symptoms persisting for a median of 4.5 years after the final menstrual period (FMP) [20]. Women who were premenopausal or early perimenopausal when they first experienced hot flashes had the longest total duration (>11.8 years, post-FMP median duration 9.4 years). The long duration of hot flashes raises important treatment challenges for many women, particularly those with early onset symptoms. (See "Menopausal hot flashes", section on 'Duration'.)

Menopausal hormone therapy and risk of ovarian cancer (March 2015)

There have been concerns that menopausal hormone therapy (MHT) may be associated with an increase in ovarian cancer risk, but data are conflicting. A meta-analysis of 52 epidemiologic studies including 21,488 postmenopausal women with ovarian cancer now suggests that there is a small excess risk of ovarian cancer with MHT [21]. While the relative risk of ovarian cancer was greater in ever-users than never-users of MHT (RR 1.14), the calculated absolute excess risk associated with MHT was very low: five years of MHT use in women ages 50 to 54 years would result in about one additional ovarian cancer case per 1000 users and one ovarian cancer death per 1700 users. Given these low absolute risks, we do not consider ovarian cancer to be a major consideration when deciding to take MHT for symptomatic relief. (See "Menopausal hormone therapy: Benefits and risks", section on 'Ovarian cancer'.)

Interim guidelines for cervical cancer screening with primary HPV testing (February 2015)

Interim guidelines from the Society of Gynecologic Oncology and the American Society for Colposcopy and Cervical Pathology are the first US guidelines to suggest primary human papillomavirus (HPV) testing as an option for cervical cancer screening in women starting at age 25 years (table 1) [22]. This option is provided based on a randomized trial comparing primary HPV testing with cytology (Pap test) or co-testing (Pap test and HPV testing) [23]. Among women ≥25 years, primary HPV testing was more sensitive for the detection of cervical intraepithelial neoplasia (CIN) 3 or greater. However, the study is limited by having only three years of follow-up, use of a surrogate outcome (CIN3 rather than cancer), and highly structured follow up protocols that may not be feasible in practice. Given these limitations, we continue to suggest that women age <30 years not be screened for cervical cancer with primary HPV testing. (See "Screening for cervical cancer", section on 'Primary HPV testing'.)

Urine testing for human papillomavirus (November 2014)

Urine tests for human papillomavirus (HPV) DNA have been developed for detecting cervical HPV infection in women, although this testing is not clinically available. The efficacy of urine testing for different genotypes of HPV was evaluated in a meta-analysis of 14 studies including 1443 women [24,25]. For detection of high-risk HPV, the sensitivity was 77 percent and specificity was 88 percent. For detection of HPV 16 and 18 specifically, sensitivity was 73 percent and specificity was 98 percent. This method of testing may have potential in large research studies or as an alternative test where routine cervico-vaginal exams are not economically feasible or less likely to be performed due to cultural barriers. (See "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing", section on 'Other methods'.)

Long-acting reversible contraception for adolescents (October 2014)

The intrauterine device and etonogestrel implant are two types of long-acting reversible contraception (LARC). Although LARC is more effective than other methods, few adolescents choose LARC. Lack of access to services, lack of information, and increased cost may be barriers to LARC for adolescents. Removal of these barriers appears to be associated with increased use of LARC and decreased rates of pregnancy. In a prospective study, 1404 urban adolescents 15 to 19 years of age were educated about reversible contraception (emphasizing the benefits of LARC), provided with their choice of reversible contraception at no cost, and followed for two to three years [26]. Nearly three-quarters of participants chose LARC. The pregnancy rate among participants was nearly five times less than that in a contemporaneous cohort of sexually active teenagers in the United States (34.0 versus 158.5 per 1000). The American Academy of Pediatrics now recommends the etonogestrel implant and intrauterine device as first-line contraceptive options for adolescents [27]. (See "Contraception: Overview of issues specific to adolescents", section on 'Overcoming barriers'.)

Levonorgestrel IUD in endometrial carcinoma prevention (September 2014)

The levonorgestrel-releasing intrauterine device (LNg-IUD) is a popular option for both contraception and treatment of abnormal uterine bleeding (AUB). It also appears to have a preventive effect on endometrial carcinoma, at least in women with AUB. One of the largest studies of this issue was a national registry study from Finland that reported that women using the LNg-IUD for treatment of menorrhagia had one-half the expected incidence of endometrial carcinoma [28]. The results of this study support a potential preventive, as well as therapeutic, role of the LNg-IUD in women with AUB. (See "Endometrial carcinoma: Epidemiology and risk factors", section on 'Hormonal contraceptives'.)

GYNECOLOGIC SURGERY

Efficacy of surgical treatment for ovarian remnant syndrome (February 2015)

Ovarian remnant syndrome is the presence of residual ovarian tissue after oophorectomy, which may cause pelvic pain. Most studies have reported high success rates with surgical treatment. In a retrospective series of women with ovarian remnant syndrome or the related disorder ovarian retention syndrome (when the ovaries are purposefully left intact), rates of success with surgical treatment were lower than described in previous studies [29]. Only 10 of 20 women with ovarian remnant syndrome experienced improvements in pain scores. Endometriosis was a significant risk factor for lack of treatment success. (See "Ovarian remnant syndrome", section on 'Choice of treatment method'.)

GYNECOLOGIC ONCOLOGY

Morcellation associated with worse prognosis in uterine sarcoma (February 2015)

Uterine sarcoma prognosis appears to be worsened if morcellation is used on uterine tissue, typically in cases in which the malignancy was unsuspected at time of surgery. A meta-analysis of observational studies in women with uterine sarcoma found that morcellation (scalpel or power methods) compared with no morcellation was associated with a 3.2-fold higher recurrence rate and 2.4-fold higher mortality rate [30]. This analysis provides the first set of pooled data regarding the adverse impact of uterine morcellation in uterine sarcoma. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'Do morcellation, myomectomy, or supracervical hysterectomy worsen prognosis?'.)

REPRODUCTIVE ENDOCRINOLOGY

Modified IVF to prevent transmission of mitochondrial DNA disorders (February 2015)

Modified in vitro fertilization (IVF) techniques, including donor spindle cell transfer and pronuclear transfer, have been developed to prevent the transmission of inherited mitochondrial DNA (mtDNA) mutations from affected mothers to offspring. These techniques are controversial because the resultant offspring carry DNA from three different individuals- the mother, the father, and the mitochondrial donor, although only 0.05 percent of the individual's total DNA would originate from the mitochondrial donor. In January 2015, the United Kingdom House of Commons approved two techniques, making the UK the first country to offer these therapies [31]. Within the UK, an estimated 150 women a year could benefit from this technology [32]. (See "In vitro fertilization", section on 'Other uses of IVF'.) 

First live birth after uterine transplantation (October 2014)

Uterine transplantation is an investigational procedure performed in a few centers worldwide. The first live birth after uterine transplantation was recently reported  [33]. The donor was a 61-year-old unrelated family friend. The recipient was a 35-year-old woman with congenital Müllerian agenesis who delivered a healthy, appropriately grown infant via cesarean section at 32 weeks because of preeclampsia. The mother and baby were doing well two weeks postdelivery. This report supports the feasibility of uterine transplantation as a potential treatment for uterus-associated infertility. (See "Surgical management of congenital uterine anomalies", section on 'Uterine transplantation'.)

Letrozole versus clomiphene citrate for ovulation induction in PCOS (October 2014)

Clomiphene citrate (CC) has been the first line ovulation induction drug for women with polycystic ovary syndrome (PCOS) for many years. However, a multicenter trial in 750 women with PCOS suggests that letrozole results in higher cumulative birth rates (over five cycles) when compared to CC (27.5 percent and 19.1 percent, respectively) [34]. Body mass index (BMI) had a significant impact on live birth rates. For women with a BMI ≤30.3, the cumulative live birth rate (approximately 30 percent) was similar in the CC and letrozole groups. For women with a BMI ≥30.3, the cumulative live birth rates were significantly higher with letrozole when compared to CC (20 versus 10 percent). The possible advantage of letrozole was supported by a meta-analysis of six trials, including this multicenter trial, comparing letrozole and CC, which found higher birth rates with letrozole although BMI data were not provided [35].

Safety data suggest that letrozole is not associated with an increased risk of congenital malformations, but the evidence is based upon a relatively small number of pregnancies. Unlike CC, letrozole is not approved in any country for ovulation induction. However, based upon available data, for women with PCOS pursuing ovulation induction, we now suggest letrozole for those with a BMI >30 kg/m2, while we still suggest CC for those with a BMI ≤30 kg/m2.

(See "Ovulation induction with letrozole", section on 'Ovulation induction in PCOS'.)

UROGYNECOLOGY

Transobturator versus retropubic slings for stress urinary incontinence in women (December 2014)

Five-year follow-up data from the Trial of Midurethral Slings (TOMUS), which randomized women to either a retropubic sling or a transobturator sling, demonstrated decreasing continence rates for women in both treatment groups [36]. The continence rate was higher in retropubic sling patients as compared with transobturator sling patients, but not statistically different (51.3 percent versus 43.4 percent). A greater proportion of women who underwent a transobturator sling procedure reported a "much better or very much better" urinary status. The overall mesh erosion rate was low, but new mesh exposures developed remote from surgery. Both retropubic slings and transobturator slings are reasonable choices for the surgical management of stress urinary incontinence in women, but the continence rates of both procedures decrease with time. (See "Surgical management of stress urinary incontinence in women: Choosing a type of midurethral sling", section on 'Transobturator versus retropubic midurethral slings'.)

OTHER GYNECOLOGY

Circulating influenza A H3N2 viruses and influenza vaccine effectiveness in the United States (December 2014, MODIFIED March 2015)

In December 2014, the United States Centers for Disease Control and Prevention (CDC) released a health advisory stating that more than half of influenza A H3N2 viruses collected and analyzed in the United States in October and November 2014 were antigenically different (drifted) from the H3N2 antigen included in this season's influenza vaccines [37]. Most isolated influenza viruses to date have been H3N2 strains. During previous seasons in which influenza A H3N2 viruses have predominated, higher hospitalization and mortality rates have been reported among older people, very young children, and individuals with certain medical conditions. In seasons where predominant circulating influenza viruses have antigenically drifted, decreased vaccine effectiveness has been observed. Nevertheless, vaccination typically provides some cross-protection against drifted viruses and should still reduce hospitalization and death. As of late February 2015, overall vaccine effectiveness was only 19 percent and vaccine effectiveness against influenza A H3N2 was only 18 percent [38]. Influenza vaccination is still highly recommended [37]. The CDC health advisory was issued to reemphasize the importance of the use of neuraminidase inhibitors (eg, oseltamivir, zanamivir) when indicated for the treatment and prevention of influenza infection as an adjunct to vaccination. (See "Seasonal influenza vaccination in adults", section on 'Drifted H3N2 viruses during the 2014 to 2015 influenza season' and "Seasonal influenza in children: Prevention with vaccines", section on 'Drifted H3N2 viruses during the 2014 to 2015 influenza season'.)

New human papillomavirus (HPV) vaccine targets nine HPV types (February 2015)

Infection with human papillomavirus (HPV) types 16, 18, 31, 33, 45, 52, and 58 is implicated in approximately 90 percent of invasive cervical cancers. The US Food and Drug Administration has approved Gardasil 9, a 9-valent HPV vaccine that targets those seven HPV types in addition to the two types associated with genital warts (6 and 11), for the prevention of HPV-related disease [39]. In a trial that included approximately 14,000 females randomly assigned to receive the 9-valent or quadrivalent HPV vaccine, immune responses with the two vaccines were comparable for the HPV types targeted by both (6, 11, 16, and 18). Additionally, the 9-valent HPV vaccine was 97 percent effective for preventing precancerous and cancerous lesions of the cervix, vagina, and vulva associated with the other targeted HPV types (31, 33, 45, 52, and 58). Safety profiles were overall similar. We favor the 9-valent HPV vaccine for its broader HPV type coverage.

Routine immunization should be offered to boys and girls aged 11 to 12, but can be administered as early as nine years of age. Catch-up vaccination should be offered for males between the ages of 13 to 21 and females between 13 to 26 years who have not been previously vaccinated. Repeat vaccination with the 9-valent vaccine is likely not warranted for individuals who have completed a series with a different HPV vaccine.

(See "Recommendations for the use of human papillomavirus vaccines", section on 'Available vaccines'.)

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