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What's new in obstetrics and gynecology
Official reprint from UpToDate® ©2015 UpToDate®
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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: Oct 2015. | This topic last updated: Nov 20, 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.


Universal versus selective ultrasound screening for fetal growth restriction (November 2015)

Early identification of fetal growth restriction allows for closer surveillance and earlier intervention in case of fetal decompensation. However, the value of universal rather than selective ultrasound examination in late pregnancy to screen for fetal growth restriction is unclear. A recent prospective cohort study (Pregnancy Outcome Prediction study) addressed this issue in unselected nulliparous women with singleton gestations who underwent routine early ultrasonography for pregnancy dating [1]. These women were scheduled to undergo serial ultrasound examinations at about 20, 28, and 36 weeks of gestation, but findings were masked from the women and their providers. Universal sonography in the third trimester almost tripled the detection of infants subsequently born small for gestational age compared with clinically indicated sonography, but also misdiagnosed many normal infants as small. Among fetuses with estimated fetal weight <10th percentile, only those with abdominal circumference growth velocity at the lowest decile were at increased risk for neonatal morbidity. UpToDate continues to recommend selective use of ultrasound in patients with risk factors for growth restriction rather than universal third trimester screening. (See "Routine prenatal ultrasonography as a screening tool", section on 'Better diagnosis of deficient growth and improvement in perinatal outcome'.)

Timing of delivery in late preterm membrane rupture (November 2015)

Optimum timing of delivery for pregnancies with late preterm premature rupture of membranes (PPROM) is unclear. This issue was recently addressed by a multicenter, international, randomized trial (PPROMT) that randomly assigned over 1800 women with PPROM between 34 and 366/7ths weeks of gestation to immediate delivery or expectant management [2]. The rate of neonatal sepsis (primary outcome) did not differ significantly between the two groups, but infants in the immediate delivery group were more likely to develop respiratory distress syndrome, require mechanical ventilation, and spend more time in the neonatal intensive care unit. Mothers assigned to expectant management were more likely to develop antepartum or intrapartum bleeding and intrapartum fever and had a longer hospital stay, but they also had a lower cesarean delivery rate.

Several limitations of this trial preclude extrapolating the findings to women in the United States. International facilities had different levels of resources; some patients were managed as outpatients; there were no clear criteria for determining the timing of delivery in the expectantly managed group; protocols for administration of prophylactic antibiotics were variable and use of corticosteroids was inconsistent. We continue to recommend delivery rather than expectant management for late preterm PPROM (algorithm 1). (See "Preterm premature (prelabor) rupture of membranes", section on 'Initial approach'.)

Adverse pregnancy effects of improved control of malaria (November 2015)

Improvements in malaria control in some endemic areas have led to declines in malaria transmission and, in turn, immunity. A recent study from Mozambique illustrated an adverse consequence of a less immune population. In this study, a large reduction in malaria transmission in recent years was associated with a large reduction in maternal levels of antimalarial IgG antibodies against both pregnancy-specific parasite lines and more general parasite lines [3]. In addition, women who developed a malaria infection during pregnancy in recent years had greater reductions in hemoglobin level and newborn birth weight compared with pregnant women infected prior to the overall decline in malaria prevalence and reduced immunity. (See "Overview of malaria in pregnancy", section on 'Immunity'.)

n-3 LCPUFA supplementation in pregnancy and allergies in offspring (November 2015)

It has been hypothesized that maternal intake of long chain polyunsaturated fatty acids (n-3 LCPUFA) during pregnancy may prevent development of allergies in offspring. However, a recent systematic review of randomized trials assessing the effect of n-3 LCPUFA supplementation during pregnancy and/or breastfeeding on allergy outcomes in offspring found supplementation did not significantly reduce childhood allergic disease (food allergy, atopic dermatitis, allergic rhinitis, asthma) at 36 months of age compared with no treatment/placebo [4]. (See "Fish consumption during pregnancy", section on 'Other outcomes'.)

Endotracheal suctioning does not benefit nonvigorous neonates with meconium-stained amniotic fluid (May 2015, Modified November 2015)

New American Heart Association, American Academy of Pediatrics, and International Liaison Committee on Resuscitation guidelines no longer recommend routine endotracheal suction for nonvigorous (depressed) newborns with meconium-stained amniotic fluid in the delivery room (ie, newborns with absent or depressed respirations, decreased muscle tone, or heart rate less than 100 beats/minute) [5,6]. This change was prompted by findings from a recent randomized clinical trial of endotracheal suctioning versus no suctioning in 122 nonvigorous term newborns with meconium-stained amniotic fluid [7]. No differences were observed between groups in meconium aspiration syndrome, need for mechanical ventilation, survival at nine months of age, and mental and motor developmental status at nine months of age. Our criteria for intervention for newborns with meconium-stained amniotic fluid are the same as those used for intervention in all neonates (algorithm 1). (See "Prevention and management of meconium aspiration syndrome", section on 'Neonatal care' and "Neonatal resuscitation in the delivery room", section on 'Next steps'.)

Maternal cancer during pregnancy and child development (October 2015)

Little is known about the effect of maternal cancer during pregnancy on subsequent child development. In a study of 129 children born to mothers diagnosed with cancer during pregnancy (over half of whom had breast cancer), cardiac, cognitive, and general development after a median of 22 months was equivalent to that in controls matched for gestational age at birth [8]. In a subgroup analysis, similar outcomes were also reported for children exposed to chemotherapy or radiation after the first trimester compared with gestational age-matched controls. Although these results are generally reassuring regarding early developmental outcomes among children born to mothers with cancer, the heterogeneity of cancers and treatments represented in this study should be taken into account when counseling individual patients. (See "Gestational breast cancer: Treatment", section on 'Pregnancy and infant outcome'.)

Increased maternal mortality and morbidity among women with epilepsy (October 2015)

Women with epilepsy are known to be at increased risk for a range of adverse outcomes during pregnancy compared with women without epilepsy. While the magnitude of the risk is relatively small for most outcomes, the risk of maternal death at the time of delivery may be higher than previously recognized. In a population-based study of delivery hospitalizations in >20 million pregnant women in the United States, including >69,000 women with epilepsy, the risk of maternal mortality was 10-fold higher among women with epilepsy (80 versus 6 deaths per 100,000 pregnancies) [9]. Most other adverse outcomes, including hemorrhage, preterm labor, and poor fetal growth, were increased by a factor less than two. Specific causes of death could not be determined by the study. These results emphasize the importance of close intrapartum care in women with epilepsy and the need for a better understanding of the causes of death in these patients. (See "Management of epilepsy and pregnancy" and "Risks associated with epilepsy and pregnancy", section on 'Perinatal morbidity and mortality'.)

Uterine exteriorization at cesarean delivery (October 2015)

A 2015 meta-analysis of randomized trials of extraabdominal (exteriorized) versus intraabdominal (in situ) hysterotomy repair at cesarean delivery found no clinically significant differences in blood loss, intraoperative nausea, vomiting, or pain between the two approaches [10]. Both personal preference and individual clinical circumstances should guide the choice of technique. (See "Cesarean delivery: Technique", section on 'Exteriorizing the uterus'.)

Chest compressions for cardiac arrest in pregnancy (October 2015)

Chest compressions are the cornerstone of resuscitation after cardiac arrest. The 2015 American Heart Association guideline on cardiac arrest in pregnancy recommends the same hand position for chest compressions in pregnant women and nonpregnant adults [11]. Previous guidelines suggested a more cephalad hand position in pregnancy to adjust for elevation of the diaphragm by the gravid uterus; however, a recent imaging study showed no significant vertical displacement of the heart in the third trimester relative to the nonpregnant state [12]. (See "Cardiopulmonary arrest in pregnancy", section on 'Chest compressions'.)

Preterm external cephalic version (October 2015)

The optimal gestational age to perform external cephalic version (ECV) of the breech fetus is unclear. A recent meta-analysis of randomized trials reported that ECV at 34 to 36 weeks was more likely than ECV at ≥37 weeks to decrease the rate of noncephalic presentation at the time of delivery (risk ratio [RR] 0.81); however, the decrease was not accompanied by a statistical reduction in the cesarean delivery rate [13]. The higher success rate when ECV is attempted at 34 to 36 weeks of gestation needs to be balanced with the possibility of rare complications necessitating preterm delivery and lack of convincing evidence of a substantial reduction in cesarean delivery. Women should be informed of the relative advantages and disadvantages of early initiation of ECV attempts to make an informed choice. (See "External cephalic version", section on 'Timing and outcome'.)

Dihydroartemisinin-piperaquine for intermittent preventive treatment of malaria during pregnancy (October 2015)

For pregnant women who live in areas with medium and high malaria transmission, we agree with the World Health Organization (WHO) strategy to provide intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP). The optimal approach to IPTp is uncertain in areas of high SP resistance and malaria transmission, such as Kenya. In a recent trial including over 1500 Kenyan women randomly assigned to receive IPT with SP or dihydroartemisinin-piperaquine (DP), IPT with DP resulted in a lower prevalence of malaria infection at delivery (3 versus 10 percent) and fewer episodes of clinical malaria during pregnancy (38 versus 6 episodes) compared with IPT with SP [14]. The trial was not powered to detect small differences in neonatal outcomes. Before changing to IPT with DP, more data are needed to compare the effects of the two therapies on these outcomes. (See "Prevention and treatment of malaria in pregnant women", section on 'Intermittent preventive treatment during pregnancy'.)

Prescription medications during pregnancy (August 2015)

Concerns have been raised regarding the frequency with which medication is prescribed during pregnancy, especially for those drugs that may have adverse outcomes for the mother or her fetus. In a study of over one million pregnant women in the United States Medicaid program, nearly 40 percent were prescribed a potentially harmful medication (category D, most commonly codeine and hydrocodone) and 5 percent were prescribed a medication contraindicated during pregnancy (category X, most commonly hormonal contraceptives that were prescribed prior to the diagnosis of pregnancy) [15]. Overall, 83 percent were dispensed at least one medication of any kind (most commonly antibiotic or antifungal agents). While medication can be safely used in pregnancy, the lowest risk option is to avoid drug exposure if possible. When medication is to be taken, the risks and benefits must be discussed, particularly for medications with harmful potential, such as addiction. (See "Initial prenatal assessment and first trimester prenatal care", section on 'Medications commonly used in pregnancy'.)

Limited value of fetal ST-segment analysis (August 2015)

The STAN S31 fetal heart monitor is a relatively new device used to monitor the fetal electrocardiogram during labor. Fetal ST-segment changes have been associated with hypoxemia and acidosis necessitating prompt delivery. The largest randomized trial of this approach to intrapartum fetal assessment assigned over 11,000 women to "open" or "masked" fetal ST-segment analysis and reported no significant between-group differences in the rate of cesarean delivery, any operative delivery, or the primary composite outcome (stillbirth, neonatal death, five-minute Apgar score ≤3, cord artery pH ≤7.05 and base deficit in extracellular fluid ≥12, intubation in the delivery room, seizures, neonatal encephalopathy) [16]. The results of this large, well-designed trial are important because previous small trials had suggested ST-segment analysis reduced the frequency of fetal scalp sampling, operative vaginal delivery, and neonatal metabolic acidosis. We do not perform fetal ST-segment analysis as there is no convincing evidence that it improves maternal or neonatal outcome. (See "Intrapartum fetal heart rate assessment", section on 'ST analysis'.)

Pregnancy and surgical outcomes (July 2015)

There has been increasing evidence that pregnancy does not appear to increase the risk of poor surgical outcomes. In a retrospective cohort study of over 2500 pregnant women undergoing non-elective general surgery procedures, 30-day morbidity and mortality rates were comparable to those among procedure-matched non-pregnant controls [17]. Non-elective surgical intervention should not be delayed because of pregnancy. (See "Management of the pregnant patient undergoing nonobstetric surgery", section on 'Outcome of surgery'.)

Use of venlafaxine during early pregnancy and risk of birth defects (June 2015)

Venlafaxine is often used as an alternative to selective serotonin reuptake inhibitors for treating antenatal depression, but the risk of birth defects with venlafaxine is not clear due to inconsistent findings across small observational studies. A study of national registries from multiple countries identified infants who were exposed to venlafaxine during the first trimester (n>2700) and infants who were not exposed (n>2,100,000); the analyses controlled for several potential confounding factors, such as maternal age, smoking, diabetes, and use of other medications (eg, antiepileptics) [18]. The risk of major birth defects was comparable for the two groups, as was the specific risk for cardiac defects. However, this study did not address other perinatal risks, such as preterm birth or hypertension, which have been associated with venlafaxine in other studies. (See "Risks of antidepressants during pregnancy: Drugs other than selective serotonin reuptake inhibitors", section on 'Teratogenicity'.)

Expectant management of mild preeclampsia near term (June 2015)

The optimum time for delivery of women with preeclampsia without features of severe disease and stable maternal and fetal conditions at 34 to 36 weeks of gestation is uncertain. The recent randomized HYPITAT-II trial confirmed findings from observational studies showing that most patients with late-onset mild preeclampsia managed expectantly will reach term without progressing to severe disease or developing an adverse outcome [19]. Newborns benefited from the extra time in utero: the rate of respiratory distress syndrome was 70 percent less with expectant management compared with immediate delivery. Mild preeclampsia with onset at 34 to 36 weeks can be managed expectantly to enable further fetal growth and maturation. Delivery is indicated at 37 weeks. (See "Preeclampsia: Management and prognosis", section on 'Preeclampsia without features of severe disease'.)

Gestational age apps (June 2015)

Electronic techniques, such as apps available for download to smart phones, are generally more accurate for determining gestational age than mechanical wheels. However, a high proportion of gestational age apps are also inaccurate [20]. Clinicians and patients should be aware of this possibility when using a gestational age app, and clinicians should test the accuracy of the app they use. UpToDate provides calculators that determine the estimated date of delivery and current gestational age. (See "Prenatal assessment of gestational age and estimated date of delivery", section on 'Calculator'.)

Skin closure at cesarean delivery (June 2015)

The best method for skin closure at cesarean delivery is controversial. In a recent meta-analysis of staples versus subcuticular sutures for skin closure, stapled closure increased the rate of wound complications (infection and/or separation), while shortening operating time by only a few minutes [21]. Cosmetic appearance, pain perception at discharge, and patient satisfaction were similar for both approaches. Although stapled closure took seven minutes less than sutured closure, the time involved to remove staples also needs to be considered. We suggest reapproximation of the skin with subcuticular sutures rather than staples. (See "Cesarean delivery: Technique", section on 'Skin'.)

Vitamin D supplementation during pregnancy (May 2015)

Several observational studies suggest an association between poor maternal vitamin D status and adverse pregnancy outcomes. A meta-analysis of 13 trials showed that, compared with a control group, vitamin D administration (in varied dosing, types, and schedules) resulted in higher serum 25(OH)D levels at delivery but no difference in the incidence rates of preeclampsia or gestational diabetes [22]. There was also no difference in the incidence rates of small for gestational age, low birth weight, and preterm birth in the neonates. Although routine prenatal vitamin D supplementation does not appear to prevent low birthweight, preterm birth, or preeclampsia, the earliest interventions in the published trials were made in the late first trimester. Initiation of therapy with vitamin D prior to conception has not been evaluated. (See "Vitamin D and extraskeletal health", section on 'Pregnancy outcomes'.)

Effectiveness of pertussis vaccine in infants (May 2015)

Infants younger than 12 months have the highest incidence of pertussis and pertussis-related complications, including death. In a large case control study, having received ≥1 dose of pertussis vaccine was associated with a 72 percent reduction in the risk of death and a 31 percent reduction in the risk of hospitalization in infants ≥6 weeks of age (the minimum age for the first dose of pertussis vaccine) [23]. However, 64 percent of the deaths occurred in infants younger than six weeks. These findings highlight the importance of timely pertussis immunization for infants, as well as maternal immunization during pregnancy and immunization of the infant's close contacts, as recommended by the Global Pertussis Initiative [24]. (See "Diphtheria, tetanus, and pertussis immunization in infants and children 0 through 6 years of age", section on 'Efficacy and effectiveness' and "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination' and "Bordetella pertussis infection in adolescents and adults: Treatment and prevention", section on 'Tdap booster'.)


Medication approved for low sexual desire in women (August 2015)

Flibanserin is the first and currently only drug approved by the US Food and Drug Administration (FDA) for female sexual dysfunction [25]. Daily use results in modest increases in the frequency of sexually satisfying events and sexual desire. The clinical role of flibanserin may be limited by the need for daily dosing, common adverse effects (eg, somnolence, dizziness), and by safety concerns or lack of safety data regarding combining flibanserin with alcohol or certain medications (eg, fluconazole, CYP3A4 inhibitors, antidepressants). (See "Sexual dysfunction in women: Management", section on 'Flibanserin'.)

Improving uptake of long-acting reversible contraceptives (July 2015)

Long-acting reversible contraceptives (LARC), which include implants and intrauterine devices, are the most effective reversible methods to prevent pregnancy. Interventions that increase LARC use lower the rate of unintended pregnancy. In a trial of 1500 women who were randomly assigned to receive either standardized counseling for LARC or routine contraceptive counseling, standardized counseling resulted in increased LARC use and a reduction in unintended pregnancies (8 versus 15 percent) [26]. Introduction of affordable LARC methods in the state of Colorado from 2009 to 2013 was associated with an approximately 40 percent reduction in teen birth and abortion rates compared with previous years [27]. These data add further support to our suggestion to use LARC for women who desire reversible contraception. (See "Overview of contraception", section on 'Effectiveness'.)

Repeat testing for women treated for trichomoniasis (July 2015)

The risk of repeat infection following treatment for a sexually transmitted infection (STI) is high. In the United States, reinfection with Trichomonas vaginalis has been reported to occur in up to 17 percent of women following treatment for an initial infection. The 2015 Centers for Disease Control and Prevention (CDC) guidelines on the management of STIs recommend that women treated for confirmed T. vaginalis infection undergo repeat testing within three months of treatment, regardless of partner treatment status [28]. Prior guidelines had only listed retesting as a consideration. The preferred diagnostic test for repeat testing is a nucleic acid amplification test (NAAT) on a vaginal swab, which can be performed as soon as two weeks after treatment. Data are insufficient to support retesting men. (See "Trichomoniasis", section on 'Follow-up'.)

Bethesda 2014 guidelines published for cervical cytology specimens (July 2015)

The Bethesda 2014 guidelines (table 1) for the reporting of cervical cytology specimens include two changes from Bethesda 2001 [29-31]. Low-grade squamous intraepithelial lesion specimens that contain a few cells that are suspicious for but not diagnostic of high-grade squamous intraepithelial lesion are reported as ASC-H; previously there was no guidance on how to classify these specimens. Benign-appearing endometrial cells (BEC) are reported only in women ≥45 years. At the previous age threshold of ≥40 years, a finding of BEC was not found to be effective for predicting endometrial hyperplasia or carcinoma. (See "Cervical and vaginal cytology: Interpretation of results", section on 'Changes in the Bethesda 2014 guidelines'.)

Updated CDC guidelines on the management of sexually transmitted infections (June 2015)

The US Centers for Disease Control and Prevention (CDC) updated its guidelines on the management of sexually transmitted infections in June 2015 [32]. Major revisions include a lower threshold for the diagnosis of urethritis based on microscopy of a urethral specimen, a new emphasis on the role of Mycoplasma genitalium in persistent urethritis and cervicitis, preference for nucleic acid amplification-based testing for the diagnosis of Trichomonas vaginalis, and a recommendation to retest women after treatment for T. vaginalis to evaluate for reinfection. New screening recommendations include annual hepatitis C virus (HCV) testing for HIV-infected men who have sex with men and T. vaginalis testing for HIV-infected women annually and when pregnant. (See "Urethritis in adult men", section on 'Diagnostic criteria' and "Mycoplasma genitalium infection in men and women", section on 'Nongonococcal urethritis' and "Trichomoniasis", section on 'Follow-up' and "Primary care of the HIV-infected adult", section on 'Sexually transmitted infections'.)

Menopausal hormone therapy and cardiovascular risk: Timing of exposure (June 2015)

Current evidence suggests that the use of menopausal hormone therapy (MHT) in the early menopausal years (<10 years from menopause) may not be associated with excess cardiovascular risk when compared with use in the later menopausal years. This has been referred to as the "timing hypothesis." Additional support for this hypothesis comes from a 2015 meta-analysis of 19 trials of oral (including the Womens Health Initiative), but not transdermal, MHT in over 40,000 postmenopausal women [33]. A subgroup analysis in women who started MHT less than 10 years after menopause showed a lower risk of coronary heart disease (CHD) compared with placebo (RR 0.52; 8 fewer cases of heart disease per 1000 women treated/year) and a lower mortality rate (RR 0.70; 6 fewer deaths per 1000 women treated/year). However, there were important limitations in this analysis; when one methodologically flawed trial was removed, the beneficial effects on CHD and mortality were no longer significant (but no adverse effects were seen). These data provide additional evidence that oral MHT use in younger postmenopausal women is not associated with excess CHD risk. (See "Menopausal hormone therapy: Benefits and risks", section on 'Younger postmenopausal women'.)

Benefit of long-term management on risk for vulvar carcinoma in women with vulvar lichen sclerosus (June 2015)

Vulvar lichen sclerosus is a chronic disease associated with an increased risk for vulvar carcinoma. The findings of a prospective cohort study of 507 women with vulvar lichen sclerosus suggest that topical corticosteroid therapy, used both to achieve disease control and for long-term maintenance treatment, may reduce cancer risk [34]. Women who reported consistent adherence to treatment instructions had a lower incidence of vulvar carcinoma or vulvar intraepithelial neoplasia than women who reported less consistent adherence (0 versus 4.7 percent). In addition, patients who adhered to treatment had better symptom control and reduced risk for vulvar scarring. These findings suggest that consistent treatment rather than an "as needed" approach to the long-term management of vulvar lichen sclerosus may improve patient outcomes. (See "Vulvar lichen sclerosus", section on 'Topical corticosteroids'.)

Reduced HPV vaccination rate among women who have sex with women (May 2015)

Prior research has suggested that women who have sex with women (WSW) may be less likely to initiate human papillomavirus (HPV) vaccination than their age-matched heterosexual peers. One possible reason for this discrepancy is that both WSW and their healthcare providers may erroneously believe that WSW are not at risk for HPV infection or cervical cancer. In one study of over 12,000 United States women from 2006 to 2010, of women who were aware of the HPV vaccine, only 8 percent of lesbian women had initiated vaccination compared with 28 percent of heterosexual women and 32 percent of bisexual women [35]. This study highlights the need for healthcare providers to discuss HPV vaccination with all patients. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend vaccination for females and males ages 11 or 12 years of age, up to age 26. (See "Medical care of women who have sex with women", section on 'Prevention of sexually transmitted diseases'.)


Short versus long suture width in the closure of abdominal incisions (October 2015)

When abdominal incisions are closed with a running suture, the needle is typically inserted at a distance of 10 mm from the fascia edge (ie, suture width). A reduction of that distance to 5 mm has been proposed in Europe based upon the result of a randomized trial [36]. In that trial, patients whose incisions were closed with a suture width of 5 mm developed significantly fewer incisional hernias at one year compared with patients whose incisions were closed with a 10 mm suture width (13 versus 21 percent). Further studies with longer follow-up periods are required before a suture width of less than 10 mm can be recommended for routine closure of all abdominal incisions. (See "Principles of abdominal wall closure", section on 'Technique'.)

Long-term mesh complication rates after anti-incontinence surgery (September 2015)

The risk of complications from transvaginal mesh used for urinary incontinence in women accumulates over time. In a cohort study that included nearly 60,000 women who underwent transvaginal mesh-based procedures for stress-urinary incontinence, the risk of a complication warranting surgical reintervention was 1.2 percent at one year and increased to a cumulative rate of 3.3 percent at 10 years [37]. This study highlights the need for a detailed preoperative discussion of the risks and benefits associated with transvaginal mesh and the importance of evaluation for mesh-related complications in any woman with a history of transvaginal mesh placement who develops a new urogynecologic complaint, regardless of the time elapsed since the original procedure. (See "Overview of transvaginal placement of mesh for prolapse and stress urinary incontinence", section on 'Complications'.)

Safety concerns and FDA panel meeting regarding hysteroscopic sterilization (July 2015, Modified September 2015)

Safety concerns have been raised about female sterilization via hysteroscopic placement of micro-inserts into the fallopian tubes. A prospective study of this procedure reported that, at five years, up to 38 percent of women reported recurrent menstrual irregularities and up to 5 percent reported recurrent pelvic pain [38]. Between 2002 and 2015, the US Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database received 5093 adverse event reports related to this device, including over 4700 related to menstrual abnormalities or pelvic pain [39]. In September 2015, the FDA convened a meeting of the Obstetrics and Gynecology Devices Panel to review the safety and effectiveness of hysteroscopic sterilization [40]. The panel discussed and made suggestions regarding: a need for better patient information materials; a need for a review of existing and future data on adverse effects; and a need to better select candidates for the procedure. Less suitable candidates include those with hypersensitivity to metal or a history of pelvic inflammatory disease. (See "Hysteroscopic sterilization".)

Pretreatment with misoprostol in women undergoing hysteroscopy (June 2015)

Adequate cervical dilation is an important step in hysteroscopy, as nearly 50 percent of hysteroscopic complications are associated with difficult passage of the hysteroscope through the cervical canal. Preoperative dilation with cervical ripening agents is generally preferred to mechanical dilation at the time of the procedure, which is associated with pain, uterine perforation, and false track creation. In a 2015 systematic review and meta-analysis of 19 trials, pre- and postmenopausal women treated with preoperative misoprostol were much less likely to require additional mechanical dilation and had fewer complications than women treated with placebo or no intervention prior to hysteroscopy [41]. These data support our suggestion to use preoperative misoprostol in women undergoing hysteroscopy. (See "Overview of hysteroscopy", section on 'Cervical preparation and dilation'.)


Hormonal risk factors for endometrial cancer in women with Lynch syndrome (July 2015)

For women with Lynch syndrome, hormonal risk factors for the development of endometrial cancer appear to be the same as those in the general population. A multicenter international retrospective cohort study of a registry of 1128 women with a mismatch repair gene mutation included 133 women who developed endometrial cancer [42]. Later age at menarche (≥13 years), higher parity (≥1 live birth), and longer use of hormonal contraceptives (≥1 year) were associated with a decrease in the risk of endometrial cancer. The biologic behavior of endometrial cancer in Lynch syndrome in terms of hormonal risk factors appears similar to sporadic cases. (See "Endometrial and ovarian cancer screening and prevention in women with Lynch syndrome (hereditary nonpolyposis colorectal cancer)", section on 'Endometrial cancer'.)


Frozen donor oocyte use impacts live birth rate (August 2015)

Use of donor oocytes (eggs) in assisted reproductive technology has allowed women unable to conceive with their own eggs the opportunity to achieve pregnancy. The use of frozen oocytes is more convenient and less costly compared with fresh oocytes because the donor and recipient don't have to be hormonally synchronized and frozen eggs can be shipped anywhere. Although initial studies reported equivalent pregnancy and live birth rates for donor egg transfers, a study of over 11,000 oocyte donation cycles, including 20 percent using frozen eggs, reported the live birth rate per transfer for frozen donor oocytes was lower than the live birth rate for fresh donor oocytes (47 versus 56 percent) [43]. Despite the possible discrepancy in live birth rate, the improved efficiency and lower cost of cryopreserved donor oocytes makes their use a reasonable and attractive option. (See "Management of infertility and pregnancy in women of advanced age", section on 'Oocyte or embryo donation'.)


New breast cancer screening guidelines from the American Cancer Society (October 2015)

The American Cancer Society (ACS) has issued revised guidelines for screening women for breast cancer [44]. Significant changes from previous ACS guidelines include recommendations to initiate mammographic screening in average risk women at age 45, to screen women aged 45 to 54 years annually and to screen women 55 years and older biennially as long as they are healthy and have a life expectancy of at least 10 years. Additionally, the guidelines recommend not performing a clinical breast examination. Multiple societies and agencies have developed guidelines with varying recommendations for age and frequency of mammogram screening (table 2). (See "Screening for breast cancer: Strategies and recommendations", section on 'Age to initiate'.)

Frequency of screening mammograms (October 2015)

An analysis of data from the Breast Cancer Surveillance Consortium compared annual and biennial mammogram screening among 15,440 women with breast cancer who were stratified by menopausal status and, if postmenopausal, use of menopausal hormone therapy (MHT) [45]. The proportion of cancers that were less favorable (stage IIB or higher) was higher for women who had biennial screening than for those who had annual screening. This was also the case for women taking MHT, but not for other postmenopausal women in whom tumor characteristics were similar for those screened annually or biennially. Although these data may suggest some benefit for more frequent (eg, annual) screening for premenopausal women, this benefit needs to be weighed against the increased risk of false positive mammogram findings in younger women. In general, for women aged 40 and older at average risk who opt to be screened for breast cancer after counseling and shared decision making, we suggest biennial screening. (See "Screening for breast cancer: Strategies and recommendations", section on 'Frequency of mammography'.)

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