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What's new in obstetrics and gynecology

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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2014. | This topic last updated: Apr 21, 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.


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

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) [8,9]. 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'.)

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 [10]. 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 [11]. 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", 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) [12]. In 2013, the ADA had only recommended a one-step approach. (See "Screening for and diagnosis of diabetes mellitus during pregnancy", 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 [13]. 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 [14]. 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'.)

SSRIs during pregnancy and risk of autism spectrum disorder (January 2014)

Previous studies have suggested an association between use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy and an increased risk of autism spectrum disorders in offspring, but a recent national registry study of over 600,000 births provides reassuring data [15]. The study identified nearly 4000 children with autism, including 52 who were exposed in utero to SSRIs. After adjusting for potential confounders, such as maternal parity, age, socioeconomic status, smoking status, psychiatric disorders, and other drugs used during pregnancy, use of SSRIs during pregnancy was not associated with an increased risk of autism. However, there was an increased risk of autism in children of women who received SSRIs before pregnancy but not during pregnancy. The authors concluded that the associations observed between antenatal SSRI exposure and autism in previous studies may have been attributable to the underlying indications for these medications (eg, maternal depression). (See "Infants with antenatal exposure to selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)", section on 'Autism'.)

Fetal iron deficiency inhibits neural myelination (December 2013)

Iron deficiency in infancy has been associated with persistent changes in neural transmission through the auditory and visual systems, suggesting that myelination may be impaired. A new study suggests that the effects of iron deficiency on neural myelination and auditory brainstem responses (ABR) begin during fetal development [16]. The subjects were neonates born in the United States with risk factors for neonatal iron deficiency (eg, maternal diabetes mellitus, pregnancy-induced hypertension, or intrauterine growth restriction). Infants with latent iron deficiency, as measured by ferritin concentrations in cord blood, had significantly prolonged ABR compared with infants without iron deficiency, after controlling for confounders. (See "Iron deficiency in infants and young children: Screening, prevention, clinical manifestations, and diagnosis", section on 'Neurodevelopmental'.)

Risk of venous thromboembolism in women hospitalized during pregnancy (December 2013)

The risk of venous thromboembolism (VTE) in pregnant women who are hospitalized for non-delivery reasons is not well defined, although acute admission to the hospital and pregnancy are both independent risk factors. The risk of first VTE was assessed in an analysis of over 200,000 women who had one or more pregnancies over a 13-year period [17]. Admission to the hospital for non-delivery reasons was associated with an 18-fold higher rate of VTE during hospitalization and 6-fold higher rate during the 28 days after discharge, compared to rates while not hospitalized. The highest rates were observed in those with a BMI >30 kg/m2, maternal age >35 years, admission during the third trimester, and a hospital stay >3 days. Although this level of risk is similar to that of hospitalized patients in the general population for whom thromboprophylaxis is frequently prescribed, further study is needed to define the safety and efficacy of thromboprophylaxis in hospitalized pregnant women before intervention can be routinely recommended. (See "Deep vein thrombosis and pulmonary embolism in pregnancy: Prevention", section on 'Antepartum admission'.)

New diagnostic criteria for preeclampsia (November 2013)

In 2013, the American College of Obstetricians and Gynecologists removed proteinuria as an essential diagnostic criterion for preeclampsia. Preeclampsia can now be diagnosed based on new onset of hypertension with either proteinuria or end-organ dysfunction after 20 weeks of gestation [18]. Massive proteinuria and fetal growth restriction have also been removed as characteristics of severe disease. (See "Preeclampsia: Clinical features and diagnosis", section on 'Definitions of pregnancy-related hypertensive disorders'.)

Pessaries do not prevent preterm delivery in twins (October 2013)

In a randomized trial of over 800 women with twin gestations, use of a cervical pessary inserted between 16 and 20 weeks gestation, compared to no pessary, did not reduce preterm birth or a composite of poor perinatal outcomes [19]. Although a benefit was found in a subgroup of pregnancies whose cervical length was in the lowest quartile (less than 38 mm), methodologic concerns limit the validity of this finding. We do not use pessaries to prevent preterm birth in twin pregnancies. (See "Twin pregnancy: Prenatal issues", section on 'Pessary'.)


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 [20]. 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'.)

Levonorgestrel-releasing intrauterine device for women on anticoagulants (December 2013)

Women on anticoagulants are at increased risk of heavy menstrual bleeding. The levonorgestrel-releasing-intrauterine device (LNg-IUD), which is beneficial in reducing menstrual flow in women with heavy bleeding, also appears to be effective in women who are being treated with anticoagulants. In a prospective study of 33 women with thrombophilia and/or history of thrombosis who initiated LNg-IUD use, oral anticoagulant users had similar bleeding patterns to nonusers during the first 12 months after LNg-IUD insertion [21]. Three-quarters of the women developed amenorrhea or infrequent bleeding and no women experienced frequent or prolonged bleeding. (See "Intrauterine contraception (IUD): Overview", section on 'Anticoagulation/bleeding diathesis'.)

Diagnosis of spontaneous abortion in early gestations (October 2013)

Diagnosis of spontaneous abortion is based upon pelvic ultrasound findings. The criteria had been based mainly on the size of the gestation and presence of appropriate findings. The Society of Radiologists in Ultrasound has added criteria for early gestations (gestational sac <25 mm or embryo <7 mm) based upon lack of development over time [22]. These stipulate that a spontaneous abortion may be diagnosed if the appropriate findings (yolk sac or fetal cardiac activity) are not visualized in a follow-up ultrasound in 11 to 14 days. (See "Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation", section on 'Diagnosis'.)


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 [23]. Alternative techniques for removal of uterine tissue during laparoscopic surgery are being explored. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'FDA statement on power morcellation'.)


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 1) [24]. 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'.)

Cediranib as maintenance treatment for platinum-sensitive recurrent epithelial ovarian cancer (October 2013)

Women with epithelial ovarian cancer (EOC) who relapse more than six months from the end of prior treatment have platinum-sensitive recurrent EOC. Although they usually respond well to chemotherapy, they are at high risk of another recurrence. Cediranib, an oral angiogenesis inhibitor, has been evaluated as maintenance treatment in this setting [25]. As presented at the 2013 European Cancer Congress, maintenance therapy with cediranib for up to 18 months, compared to placebo, improved overall survival but was associated with multiple toxicities, including hypertension, hemorrhage, and fatigue. Pending publication of the ICON6 trial to fully inform the outcomes of cediranib in this setting, we do not currently routinely offer maintenance therapy for these patients, given the associated toxicities. (See "Medical treatment for relapsed epithelial ovarian, fallopian tubal, or peritoneal cancer: Platinum-sensitive disease", section on 'Cediranib'.)


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 [26]. 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'.)

In vitro fertilization with donor oocytes: US trends (November 2013)

Analysis of US data for in vitro fertilization with donor oocytes from 2000 to 2010, reported by the Centers for Disease Control (CDC) and the National Assisted Reproductive Technology (ART) Surveillance System (NASS), found an increase in the annual number of donor oocyte cycles from 10,801 to 18,306, and an increase in good perinatal outcomes, defined as a singleton live-born infant delivered at 37 weeks or later and weighing 2500 g or more (18.5 to 24.4 percent) [27]. Use of frozen rather than fresh embryos, and transfer of single rather than multiple embryo transfers, are increasing. (See "Oocyte donation for assisted reproduction", section on 'Current trends'.)


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 [28]. 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'.)

Urodynamic testing and uncomplicated stress urinary incontinence (December 2013)

The diagnostic value and cost-effectiveness of routine urodynamic testing in women with uncomplicated stress urinary incontinence (SUI) is a subject of debate. A randomized trial evaluated women with urodynamic testing and those with results that were discordant with clinical assessment were assigned to immediate midurethral sling surgery or treatment guided by urodynamic results [29]. In the urodynamic-guided group, surgery was performed in 92 percent of women initially and in 98 percent by 12 months. The immediate surgery and urodynamic-guided groups both had comparable improvement in a validated symptom inventory at 12 months. Thus, urodynamic evaluation does not appear to be useful to guide treatment decisions in women with uncomplicated SUI. (See "Stress urinary incontinence in women: Preoperative evaluation for a primary procedure", section on 'Women with uncomplicated SUI'.)

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