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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 Employee of UpToDate, Inc. Sandy J Falk, MD, FACOG Employee of UpToDate, Inc. Vanessa A Barss, MD, FACOG Employee of UpToDate, Inc.

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.

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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2014. | This topic last updated: Jan 22, 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.


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 [1]. 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 [2]. 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 [3]. 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 [4]. 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 [5]. 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 [6]. 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 [7]. 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 [8]. 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 [9]. 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'.)

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) [10]. 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 [11]. 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 [12]. (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 [13]. 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 [14]. 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'.)


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 [15,16]. 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 [17]. 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 [18]. (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 [19]. 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'.)

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) [20]. 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 it 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 [21]. 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 [22]. 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'.)


Limitations on the use of power morcellation in gynecologic surgery (November 2014)

Power morcellation of tissue in gynecologic surgery may result in dissemination of malignant cells if a malignancy is present. The US Food and Drug Administration (FDA) has published an updated safety communication advising that laparoscopic power morcellation is contraindicated in most hysterectomy or myomectomy procedures for the treatment of uterine leiomyomas [23]. Specifically, the FDA recommends against use when there is a known or suspected uterine malignancy, in peri- or postmenopausal patients, and/or when intact removal of the uterus is possible via a vaginal or minilaparotomy incision. Based upon concerns regarding occult carcinoma in women undergoing uterine surgery, power morcellation has a limited role in current practice. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'Professional society and FDA statements'.)


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 [24]. 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 [25]. 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'.)


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  [26]. 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) [27]. 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 [28].

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'.)


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 [29]. 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'.)


New human papillomavirus (HPV) vaccine targets nine HPV types (December 2014)

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 [30]. In an as-yet-unpublished 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. The 9-valent vaccine is expected to be available in the US in early 2015. (See "Recommendations for the use of human papillomavirus vaccines", section on 'Available vaccines'.)

Circulating influenza A H3N2 viruses in the United States (December 2014)

In December 2014, the 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 [31]. 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. Influenza vaccination is still strongly recommended because it usually provides some cross-protection against drifted viruses and because influenza vaccines protect against other strains. 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'.)

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