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What's new in obstetrics and gynecology

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

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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2014. | This topic last updated: Jul 30, 2014.

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

OBSTETRICS

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 [1]. Women with a total physical activity level equivalent to 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity had a 30 to 50 percent lower risk of developing type 2 diabetes than women with lower levels of physical activity. (See "Gestational diabetes mellitus: Glycemic control and maternal prognosis", section on 'Follow-up and prevention of type 2 diabetes'.)

Benefits of controlled cord traction (June 2014)

We suggest controlled cord traction to facilitate separation and delivery of the placenta. In a 2014 meta-analysis of randomized trials comparing controlled cord traction with a hands-off approach, controlled cord traction resulted in a 30 percent reduction in need for manual removal of the placenta, as well as small reductions in the duration of the third stage (three minutes), mean blood loss (10 mL), and incidence of postpartum hemorrhage (11.8 versus 12.7 percent); the rates of severe postpartum hemorrhage, need for additional uterotonics, and blood transfusion were similar [2]. Although the benefits of controlled cord traction are small, there are no significant harms from the maneuver if performed without excessive traction. (See "Management of normal labor and delivery", section on 'Delivery of the placenta'.)

Fish consumption advisory (June 2014)

Because of the potential fetal benefits of maternal docosahexaenoic acid (DHA) intake, the US Food and Drug Administration and the US Environmental Protection Agency now advise women who might become pregnant, pregnant women, and breastfeeding women to consume 8 to 12 ounces of a variety of fish lower in mercury each week (table 1), rather than "up to 12 ounces" as previously recommended [3]. This is consistent with two to three servings of fish per week. We suggest that pregnant and breastfeeding women try to achieve fish consumption resulting in at least 200 mg/day DHA intake instead of relying on the number of servings of fish, since fish vary widely in DHA content. (See "Fish consumption during pregnancy", section on 'Diet and supplements'.)

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

Administration of hepatitis B virus (HBV) vaccination and hepatitis B immune globulin (HBIG) to newborns of women with chronic HBV infection significantly reduces the risk of perinatal HBV transmission but does not eradicate it. In an observational study of over 4000 infants born to HBV-infected mothers in the United States between 1997 and 2010, over 95 percent received HBV vaccination and HBIG [4]. Perinatal transmission occurred in 3.40 percent of births to hepatitis B e antigen (HBeAg) positive mothers and 0.04 percent of births to HBeAg negative mothers. Among women whose HBV DNA results and HBeAg status were known, no HBV transmission occurred with a viral load less than 5 x107 IU/mL, regardless of the HBeAg status. (See "Hepatitis B and pregnancy", section on 'HBV DNA level'.)

Antidepressants and risk of preterm delivery (May 2014)

Use of antidepressants during pregnancy may be associated with preterm delivery, and a new study suggests that this effect may be related to the timing of exposure. In a meta-analysis of 41 observational studies, third trimester exposure to antidepressants was associated with an approximately twofold higher risk of preterm birth compared with no exposure, whereas first trimester exposure was not associated with increased risk [5]. Management of depression during pregnancy requires that these and other potential risks of medications be weighed against the maternal and fetal risks of untreated illness. (See "Risks of antidepressants during pregnancy", section on 'Antidepressant composite data'.)

Effect of gravity on placental transfusion (April 2014)

The length of time a mother can safely hold her newborn before the umbilical cord is clamped is controversial because of concerns that gravity may decrease the volume of placental transfusion. In the first randomized trial evaluating this issue, the location of the newborn above or below the level of the placenta for two minutes before cord clamping did not affect the volume of placental transfusion (as assessed by change in newborn weight) [6]. This finding suggests that placing the newborn on the maternal abdomen or chest before cord clamping does not adversely affect the volume of placental transfusion. (See "Management of normal labor and delivery", section on 'Cord clamping'.)

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

Although prospective observational studies have reported that administration of hyperimmune globulin to pregnant women with primary cytomegalovirus (CMV) infection reduced maternal-to-fetal transmission and the severity of congenital infection, a recent randomized trial did not demonstrate a significant benefit. The Congenital Human CMV Infection Prevention (CHIP) trial randomly assigned pregnant women at 5 to 26 weeks of gestation with recent onset primary CMV infection to receive hyperimmune globulin or placebo every four weeks [7]. The overall rate of congenital infection and the proportion of infected infants symptomatic at birth was similar for both groups. (See "Cytomegalovirus infection in pregnancy", section on 'Hyperimmunoglobulin'.)

Vancomycin dose for intrapartum GBS chemoprophylaxis (April 2014)

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

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

An epidemiologic study noted a small but statistically significant (OR 1.13) association between in utero exposure to acetaminophen and attention-deficit/hyperactivity disorder–like behavioral problems in offspring at age seven years [9]. These findings are subject to the many limitations of observational studies and should not change current practice. (See "Initial prenatal assessment and first trimester prenatal care", section on 'Acetaminophen'.)

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

To date, most studies have found that maternal avoidance of highly allergenic foods during pregnancy does not reduce the incidence of allergic disease in infants and children at risk for these disorders. However, participants in such studies are often from "high risk" atopic families and thus may not be representative of the general population. A new cohort study in over 1200 unselected mother-child pairs examined the association between maternal intake of common allergenic foods during pregnancy and the development of allergic disorders in the offspring [10]. Data from mid-childhood visits found that diets lower in allergenic foods were not associated with reduction in the incidence of food allergy, asthma, allergic rhinitis, or atopic dermatitis, and in some situations, higher intake in early pregnancy appeared to have a protective effect. These findings support our current suggestion that women not restrict their diets during pregnancy for the purpose of reducing allergic disease in their children. (See "Primary prevention of allergic disease: Maternal avoidance diets in pregnancy and lactation", section on 'Definitions'.)

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

Noninvasive prenatal screening using cell-free DNA is an option for screening women at high risk of fetal aneuploidy (trisomy 21, 18, 13), but test performance is unclear in low-risk women. A recent study compared the performance of cell-free DNA sequencing with standard maternal aneuploidy screening (maternal analyte assay with or without nuchal translucency measurement) in a general obstetrical population of over 1900 women who underwent both screening tests; results of DNA sequencing were concealed [11]. Both screening tests detected all cases of trisomy 21 and trisomy 18. DNA sequencing had a lower false-positive rate (trisomy 21: 0.3 versus 3.6 percent; trisomy 18: 0.2 versus 0.6 percent). Thus, far fewer women would need to be offered invasive diagnostic testing because of a positive screen. However, additional issues need to be addressed before noninvasive prenatal screening using cell-free DNA can be recommended as a primary screening tool in the general obstetrical population. (See "Down syndrome: Prenatal screening overview", section on 'Screening performance of tests used for primary screening'.)

Risk of spontaneous abortion from exposure to NSAIDs (March 2014)

There is uncertainty regarding the risk of spontaneous abortion (SAB) following exposure to nonsteroidal antiinflammatory drugs (NSAIDs) during pregnancy. A recent cohort study linked data from medication dispensing records to information on obstetric outcomes for over 65,000 pregnancies, including about 6500 women with SAB and 4500 pregnant women exposed to NSAIDs [12]. There was no significant increase in the risk of SAB following NSAID exposure up to 20 weeks of pregnancy, after controlling for multiple variables. This was most conclusive for nonselective NSAIDs but appeared true for COX-2-selective NSAIDs as well, although data on the latter agents were limited. These results are reassuring, although some experts continue to advise caution. In addition, NSAIDs should still be avoided in the third trimester due to risk of premature closure of the fetal ductus arteriosus, an issue that was not addressed in this study. (See "Use of antiinflammatory and immunosuppressive drugs in rheumatic diseases during pregnancy and lactation", section on 'NSAIDs and aspirin'.)

Contraception and postpartum risk of thrombosis (March 2014)

Because the risk of thrombotic events is elevated in postpartum women, estrogen-progestin contraceptives are not initiated until at least three weeks after delivery. In a large retrospective study, the risk of a thrombotic event was highest in the first three weeks postpartum (odds ratio 18), fell to relatively low levels by seven weeks (odds ratio 2), but did not reach baseline levels until 16 weeks after delivery [13]. This study does not change our approach to postpartum contraception, which allows women without additional risk factors for thrombosis to begin estrogen-progestin contraception after the period of highest risk (first three weeks postpartum) but before ovulation resumes. Although the risk of a thrombotic event remains increased three to six weeks postpartum, there is no direct evidence that initiation of contraception during this period further increases the risk of thrombosis, which continues to fall over time. (See "Postpartum and postabortion contraception", section on 'Estrogen-progestin contraceptives'.)

Epidural anesthesia and second stage of labor (February 2014)

Epidural anesthesia is known to be associated with a longer second stage of labor. A large retrospective cohort study reported that, compared with no epidural anesthesia, the 95th percentile for the second stage of labor was increased by about 2.3 hours in nulliparous women and 3.0 hours in multiparous women who had epidural anesthesia [14]. These times are significantly longer than reported in previous studies and may reflect specific obstetric and anesthesia practices at a single institution. The results of this study do not change our recommendations for managing the second stage of labor. (See "Overview of normal labor and protraction and arrest disorders", section on 'Neuraxial anesthesia'.)

Tools for estimating delivery date (February 2014)

Calculators for the estimated delivery date (EDD) of a pregnancy and current gestational age are widely available (calculator 1 and calculator 2) and should be used instead of traditional mechanical gestational wheels. Electronic techniques, such as APPs, appear to be more accurate than these wheels. In a study comparing 31 paper gestational wheels from a variety of sources and 20 electronic gestational age calculators, there was significant variation in the EDD determined by the paper wheels [15]. The largest discrepancy was four days short of the EDD predicted by Naegele’s rule (the most common method of pregnancy dating) and two wheels yielded EDDs that differed by seven days. All 20 APPs gave an EDD consistent with Naegele’s rule and all corrected for a leap year, while none of the paper gestational wheels made this adjustment. (See "Prenatal assessment of gestational age and estimated date of delivery", section on 'Calculator'.)

New recommendations for detection of gestational diabetes (February 2014)

The diagnosis of gestational diabetes mellitus is based on the glucose tolerance test. The American College of Obstetricians and Gynecologists (ACOG) recommends a two-step approach for diagnosis (perform a screening 50 gram glucose challenge test followed by a three hour, 100 gram glucose tolerance test in screen-positive patients). In the American Diabetes Association (ADA) 2014 guidelines for Diagnosis and Classification of Diabetes Mellitus, the ADA supports use of this approach or a one-step approach (omit the screening glucose challenge test and perform a two hour, 75 gram glucose tolerance test in all patients) [16]. In 2013, the ADA had only recommended a one-step approach. (See "Diabetes mellitus in pregnancy: Screening and diagnosis", section on 'Recommendations of national organizations'.)

In utero exposure to topiramate or zonisamide and risk of low birth weight (January 2014)

Weight loss is a well-known side effect of the antiepileptic drugs topiramate and zonisamide. In utero exposure to topiramate has been associated with an increased risk of oral clefts, but effects on birth weight have not been previously described. In a recent study from the North American Antiepileptic Drug Pregnancy Registry that included over 2000 singleton pregnancies, the risk of small for gestational age was significantly higher in neonates exposed to topiramate or zonisamide compared with those exposed to lamotrigine and controls [17]. The effect was significant even after controlling for multiple factors that can affect birth weight, including maternal age, parity, and smoking status. (See "Risks associated with epilepsy and pregnancy", section on 'Topiramate'.)

Pregnancy outcomes in women with primary sclerosing cholangitis (January 2014)

Data are limited with regard to pregnancy in women with primary sclerosing cholangitis (PSC). In a population-based study from Sweden, 229 singleton births from women with PSC were compared with over two million births from mothers without PSC [18]. PSC was associated with increases in the risks of preterm birth and need for cesarian delivery, but not with small for gestational age, congenital anomalies, stillbirth, or neonatal death. This study suggests that pregnancy should not be discouraged in women with PSC. (See "Pregnancy in women with pre-existing chronic liver disease", section on 'Primary sclerosing cholangitis'.)

OFFICE GYNECOLOGY

Pelvic examination in asymptomatic women (July 2014)

Routine pelvic examinations in asymptomatic women are controversial. The American College of Physicians has issued guidelines that advise against performing screening pelvic examinations in asymptomatic, nonpregnant, adult women [19]. The American College of Obstetricians and Gynecologists continues to recommend annual pelvic examination for nonpregnant women age 21 years and older, but suggests that asymptomatic women participate in the decision [20]. We believe the decision whether or not to perform a complete pelvic examination at the time of the periodic health examination for the asymptomatic patient should be a shared decision after a discussion between the patient and her healthcare provider. (See "The gynecologic history and pelvic examination", section on 'Indications and frequency for examination'.)

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

Dyspareunia is a frequent issue for women after treatment for breast cancer. For women with dyspareunia isolated to tenderness in the vulvar vestibule, topical lidocaine appears to provide effective relief. This was shown in a small trial that included 49 women randomly assigned to local treatment with topical lidocaine or normal saline [21]. Compared with normal saline, topical lidocaine resulted in a significant reduction in coital pain scores. While these data suggest that topical lidocaine can effectively treat dyspareunia in women with vulvar vestibule discomfort, its effectiveness for women who have findings of intravaginal or pelvic floor pain is not known. (See "Approach to the patient following treatment for breast cancer", section on 'Sexual health'.)

Cobas HPV test and cervical cancer screening (May 2014)

The cobas HPV test for cervical cancer screening detects the presence of HPV types 16 and 18 with a pooled result for 12 additional high-risk types. HPV types 16 and 18 confer the highest risk for cervical cancer among HPV types. The cobas HPV test was approved by the US Food and Drug Administration (FDA) in April 2014 for use alone as primary screening in women 25 years of age and older [22]. Evidence regarding use of the cobas HPV test as stand-alone testing is not yet publicly available. Awaiting review of this evidence, we continue to recommend cytological (Pap smear) screening for cervical cancer in women 21 to 30 years of age, and either Pap smear alone or co-testing with Pap and HPV testing in women age 30 and older. (See "Screening for cervical cancer: Rationale and recommendations", section on 'HPV testing'.)

HPV vaccine dosing and genital warts (March 2014)

Three doses of HPV vaccine are recommended in the United States, but missed doses and suboptimal adherence to the schedule are frequent. In a Swedish cohort study of over one million females, aged 10 to 24 years, followed for four years, receipt of two quadrivalent HPV vaccine doses was associated with substantial protection against genital warts, although completion of three doses was slightly superior [23]. The study did not assess other important outcomes such as cervical intraepithelial neoplasia or cervical cancer. (See "Recommendations for the use of human papillomavirus vaccines", section on 'Missed doses/alternate schedules'.)

Oral emergency contraception in overweight women (February 2014)

In Europe, product labeling for levonorgestrel-based emergency contraception (NorLevo) was recently updated to indicate that it may be less effective in women ≥75 kg (165 pounds) and not effective in women >80 kg (176 pounds) [24,25]. We counsel overweight and obese women about potentially reduced or absent efficacy of levonorgestrel emergency contraception as body mass index increases above the normal range (25) or at weights ≥75 kg (165 pounds). (See "Emergency contraception", section on 'Overweight and obese women'.)

GYNECOLOGIC SURGERY

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

Tubal pregnancy may be treated surgically with salpingostomy or salpingectomy. A randomized trial comparing salpingostomy and salpingectomy in 446 women found similar rates of spontaneous intrauterine pregnancy at 36 months (61 and 56 percent) [26]. The rate of repeat ectopic pregnancy in the ipsilateral tube was also similar (3 versus 1 percent). Based on the comparable reproductive outcomes in this and other studies, salpingostomy is preferred for most women because the fallopian tube is conserved. Salpingectomy is required for women with or at high risk of tubal rupture or with severe tubal damage. (See "Surgical treatment of ectopic pregnancy", section on 'Salpingostomy versus salpingectomy'.)

Power morcellation for fibroids and risk of sarcoma dissemination (April 2014)

Unsuspected uterine sarcoma is detected postoperatively in a small proportion of women who undergo surgery for presumed benign uterine leiomyomas. Power morcellation of uterine tissue may disseminate malignant cells and potentially worsen the survival outcome of uterine sarcoma. The US Food and Drug Association (FDA) has issued a safety communication that discourages use of power morcellation during laparoscopic hysterectomy or myomectomy in women with uterine fibroids and states that morcellation should not be used in women with known or suspected uterine cancer [27]. Power morcellation should be avoided in women with known or suspected uterine cancer or significant risk factors for uterine sarcoma (eg, postmenopausal status; ≥2 years of tamoxifen therapy; history of pelvic radiation, childhood retinoblastoma, or hereditary leiomyomatosis and renal cell carcinoma syndrome). Patients should be counseled about the risk of tumor dissemination if an unsuspected malignancy is present. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'Professional society and FDA statements'.)

GYNECOLOGIC ONCOLOGY

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

The International Federation of Gynecology and Obstetrics (FIGO)/Tumor Nodes Metastases (TNM) classification system for carcinoma of the ovary, fallopian tube, or peritoneum has been revised. A major change is the combining of staging for the three sites (tubal carcinoma previously had a separate system) (table 2) [28]. Biologic behavior varies by histology and grade, and these are recorded as part of staging in the new system. Other changes include dividing several stages into substages to improve reporting of: etiology of malignant cells in peritoneal fluid (stage IC); site of microscopic peritoneal metastases (IIIA); and site of distant metastases (IV). (See "Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management", section on 'Staging system'.)

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

Systematic reviews regarding a potentially protective effect against ovarian cancer of nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen have yielded conflicting results. A meta-analysis of 12 population-based case-control studies found a significant association between reduced risk of ovarian cancer and use of aspirin but not non-aspirin NSAIDs or acetaminophen [29]. Although these observational data suggest a protective role for aspirin in ovarian cancer, further study is needed. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Epidemiology and risk factors", section on 'NSAIDs and acetaminophen'.)

REPRODUCTIVE ENDOCRINOLOGY

Obesity and outcomes of IVF with donor oocytes (January 2014)

Obesity is associated with infertility, an increased risk of miscarriage, and a decreased conception rate when undergoing in vitro fertilization (IVF) with autologous oocytes. However, a meta-analysis of six studies that included 4758 women undergoing IVF with donor oocytes suggests that obesity may not have a negative impact on outcomes of this procedure [30]. Similar rates of pregnancy, miscarriage, and live birth were observed for obese (BMI >30 kg/m2) and normal weight (BMI 20 to 24.9 kg/m2) women. Since the vast majority of studies report adverse reproductive outcomes in obese women compared to normal weight women, however, women should be counseled about the benefits of weight loss prior to pursuing fertility. (See "Oocyte donation for assisted reproduction", section on 'Obese women'.)

UROGYNECOLOGY

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

There are several surgical approaches for the repair of prolapse of the vaginal apex (cervix or post-hysterectomy vaginal vault). The first randomized trial to compare the two most common transvaginal repair procedures, uterosacral ligament suspension (ULS) and sacrospinous ligament suspension (SSLS), found no overall difference in symptoms, anatomic outcomes, or retreatment rates at two years. However, there was a higher rate of neurologic pain for SSLS and a higher rate of ureteral obstruction for ULS [31]. Counseling regarding these procedures should include the comparable efficacy and differing complication risks of each procedure. (See "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Comparing among vaginal procedures'.)

Mesh-related complications in pelvic organ prolapse repair (February 2014)

Complications related to reconstructive materials for treatment of pelvic organ prolapse may require nonsurgical or surgical management, and some women may require multiple interventions. In a multicenter retrospective study, 60 percent of women seeking treatment of mesh-related complications at tertiary referral centers required two or more interventions; 59 percent of women initially treated nonsurgically went on to require surgery [32]. The burden of treatment of mesh-related complications in prolapse repair procedures is an important factor in deciding whether to use these materials. (See "Overview of transvaginal placement of reconstructive materials (surgical mesh or biografts) for treatment of pelvic organ prolapse or stress urinary incontinence", section on 'Complications'.)

Predicting stress incontinence following pelvic organ prolapse repair (February 2014)

Women who undergo surgery for pelvic organ prolapse have a high risk of developing de novo stress urinary incontinence (SUI) postoperatively. A calculator, based upon data from a randomized trial in stress-continent women that compared transvaginal prolapse repair with or without a concomitant midurethral sling placement, has been developed to predict this risk [33]. The calculator predicted postoperative SUI better than preoperative urinary stress testing or expert surgeons. The calculator may be useful in guiding decisions regarding prophylactic continence surgery at the time of prolapse repair. (See "Pelvic organ prolapse and stress urinary incontinence in women: Combined surgical treatment", section on 'POP with no symptoms of SUI'.)

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REFERENCES

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