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What's new in obstetrics and gynecology
Official reprint from UpToDate® ©2017 UpToDate®
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
What's new in obstetrics and gynecology
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2017. | This topic last updated: Aug 17, 2017.

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.


Sugar-sweetened beverage consumption in pregnancy (August 2017)

A growing body of data suggest that prenatal exposures influence susceptibility to obesity. In a prospective cohort study, higher maternal consumption of sugar-sweetened beverages during pregnancy was associated with increasing adiposity among in utero-exposed school-aged offspring [1]. The association persisted after adjustment for multiple confounding variables and was independent of the offspring's beverage intake. We advise pregnant women to avoid or limit intake of sugar-sweetened beverages because they tend to be high in calories, low in nutritive value, and may impact offspring adiposity. (See "Nutrition in pregnancy", section on 'Sugar-sweetened beverages'.)

Intrapartum fluid administration (August 2017)

We provide maintenance intravenous fluids with glucose when intrapartum oral intake is restricted or otherwise inadequate to avoid volume depletion and ketosis. Some studies have suggested that a rapid intravenous fluid infusion rate or glucose supplementation are also associated with a shorter length of labor in such women. However, in one of the only trials to evaluate both interventions together, the length of labor was similar for women randomly assigned to 250 mL/hour of normal saline, 125 mL/hour of normal saline with dextrose, or 250 mL/hour of normal saline with dextrose [2]. We do not adjust intravenous fluid administration to try to reduce labor duration. (See "Management of normal labor and delivery", section on 'Fluids and oral intake'.)

Updated guidance on diagnosis of Zika virus infection in pregnancy (July 2017)

The Centers for Disease Control and Prevention have updated their guidance for diagnosis of Zika virus infection in asymptomatic pregnant women (algorithm 1) [3]. Two major changes are: (1) for asymptomatic women with possible Zika virus exposure but no ongoing exposure, nucleic acid testing (NAT) is no longer recommended; and (2) for asymptomatic women with ongoing Zika virus exposure, first and second trimester IgM antibody testing is no longer recommended, but NAT should be performed three times during pregnancy. (See "Zika virus infection: Evaluation and management of pregnant women", section on 'Asymptomatic women with limited or ongoing risk of Zika virus exposure'.)

Dose of aspirin for prevention of preeclampsia (July 2017)

In women at high risk for developing preeclampsia, increasing evidence suggests that low-dose aspirin prophylaxis should be started early in gestation and at a dose higher than 81 mg/day. In a multicenter trial in nearly 1800 women at high risk for preterm preeclampsia, use of aspirin 150 mg from the end of the first trimester (12 to 13 weeks) until 36 weeks of gestation reduced the frequency of preterm preeclampsia by over 60 percent compared with placebo [4]. Based on these and other data, we now suggest a dose of 100 to 150 mg of aspirin rather than a lower dose. In the US, this can be achieved by taking one and one-half 81 mg tablets; however, taking one 81 mg tablet is also reasonable since this is the commercially available dose and has proven efficacy. (See "Preeclampsia: Prevention", section on 'Results from large trials of at risk women'.)

Left uterine displacement for cesarean delivery (July 2017)

Left uterine displacement is routinely used to avoid aortocaval compression during cesarean delivery, but the supporting evidence for this practice is not robust. In a trial that randomly assigned 100 healthy parturients having elective cesarean delivery to supine positioning or 15 degree lateral tilt, there was no difference in fetal acid base status [5]. Blood pressure was maintained at baseline with intravenous fluid co-loading and phenylephrine in both groups. While these results raise a question of the need for left uterine displacement in healthy parturients, they may not apply to patients with uteroplacental insufficiency or to emergency procedures, and we continue to advise left uterine displacement for most women. (See "Anesthesia for cesarean delivery", section on 'Intraoperative positioning'.)

Cesarean delivery and future preterm birth (July 2017)

A retrospective cohort study observed that a second stage cesarean delivery more than doubled the odds of spontaneous preterm birth at the next birth compared with a prior spontaneous vaginal birth [6]. The risk did not appear to be related to a prolonged second stage. Future studies should further evaluate this possible association and possible causative factors (eg, incision placement, method of delivering fetus from a low station, previous attempt at operative vaginal delivery). (See "Cesarean delivery: Postoperative issues", section on 'Preterm birth'.)

In utero exposure to beta-blockers and congenital heart disease (June 2017)

Although several previous studies have suggested an association between in utero exposure to beta-blockers and congenital heart disease, the most recent study found no association after adjusting for maternal age, maternal body mass index, and maternal comorbidities [7]. Further research is required given the limitations of available studies, including inability to analyze data by type of beta-blocker, variability in timing of exposure within the first trimester, differences in indications for beta-blocker therapy, and recall, recording, publication, and survivor biases. When first trimester antihypertensive therapy is indicated, we suggest using either methyldopa or labetalol. (See "Management of hypertension in pregnant and postpartum women", section on 'Beta-blockers'.)

Neuraxial anesthesia in parturients with thrombocytopenia (June 2017)

The risk of spinal epidural hematoma (SEH) associated with neuraxial anesthesia (NA) techniques in patients with thrombocytopenia is poorly defined because SEH is rare. In a systematic review of over 1500 NA procedures in parturients with platelet counts less than 100,000 /microL, no cases of epidural hematoma requiring decompressive laminectomy were identified [8]. A statistical analysis based on data from this cohort suggests that the incidence of epidural hematoma may range from 0.2 percent (for platelet counts 70 to 100,000/microL) to 11 percent (for platelet counts <49,000/microL). These estimates may inform clinical decision-making regarding performance of NA in parturients with thrombocytopenia. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Neuraxial analgesia and low platelets'.)

Risk of congenital Zika virus syndrome (June 2017)

The magnitude of risk of birth defects resulting from in utero exposure to Zika virus is uncertain. The Centers for Disease Control and Prevention identified over 2500 pregnant women in US territories with Zika virus infection in early 2017 [9]. Maternal Zika virus infection in the first trimester was associated with an 8 percent incidence of offspring with birth defects, but fell to 4 to 5 percent with infection in the second and third trimesters. Because of study limitations, these figures likely understate the true risk of any congenital adverse outcome. Importantly, structural birth defects were seen with similar frequency in infants born to women with and without clinical signs and symptoms of Zika virus infection during pregnancy. (See "Zika virus infection: Evaluation and management of pregnant women", section on 'Risk of vertical transmission and anomalies'.)

IVF-conceived pregnancy and Down syndrome screening (June 2017)

In vitro fertilization (IVF) (with or without intracytoplasmic sperm injection) can affect maternal serum marker levels to mimic the pattern associated with Down syndrome. In a meta-analysis of studies that compared free β-human chorionic gonadotropin (hCG) levels, pregnancy-associated plasma protein A (PAPP-A) levels, and nuchal translucency measurements in IVF pregnancies with those in spontaneously-conceived pregnancies, PAPP-A was reduced by 15 percent, free beta-hCG was slightly increased, and nuchal translucency was unaffected by IVF [10]. Based on these and other data, we recommend that clinicians inform the laboratory when specimens are taken from patients with IVF-conceived pregnancies, so that the laboratory can make appropriate adjustments in reported multiples of median (MoM), to reduce the need for follow-up invasive testing or secondary cell-free-DNA screening. (See "Laboratory issues related to maternal serum screening for Down syndrome", section on 'Assisted reproduction techniques'.)

Antenatal exposure to lithium and congenital cardiac defects (June 2017)

Fetal lithium exposure may increase the risk of cardiac malformations, although the data are conflicting. In a retrospective study examining cardiac defects in infants exposed to lithium or lamotrigine during the first trimester, cardiac malformations occurred more frequently in infants exposed to lithium (2.4 versus 1.4 percent) [11]. There was a dose-response relationship between the lithium dose and the risk of cardiac malformations. These results support using lamotrigine for euthymic patients with bipolar disorder who are pregnant or planning a pregnancy and are receiving maintenance pharmacotherapy. (See "Teratogenicity, pregnancy complications, and postnatal risks of antipsychotics, benzodiazepines, lithium, and electroconvulsive therapy", section on 'Cardiac'.)

Rising rates of HCV infection in young women in the United States (May 2017)

In parallel with the opioid and injection drug use epidemic in the United States, rates of hepatitis C virus (HCV) infection have been increasing over the past decade. In particular, the annual number of acute HCV cases among women aged 15 to 44 years rose 3.6-fold from 2006 to 2014 [12]. An estimated 29,000 women with HCV infection gave birth each year between 2011 and 2014; since the risk of vertical transmission is approximately 5.8 percent, this implies that an estimated 1700 infants were infected annually during this time. These numbers highlight the importance of screening at-risk individuals and arranging follow-up for those with HCV infection. (See "Vertical transmission of hepatitis C virus", section on 'Incidence' and "Hepatitis C virus infection in children", section on 'Epidemiology'.)

Tranexamic acid for management of postpartum hemorrhage (May 2017)

Tranexamic acid, an antifibrinolytic drug, reduces bleeding in surgical and trauma patients. In a pragmatic randomized trial involving over 20,000 women with postpartum hemorrhage in over 20 countries (the World Maternal Antifibrinolytic Randomized Trial [WOMAN]), tranexamic acid, compared with placebo, reduced the relative risk of death due to bleeding by 20 to 30 percent, reduced the incidence of laparotomy to control bleeding, and was not associated with an increase in adverse effects [13]. Overall mortality was not reduced. We now recommend administration of tranexamic acid as a component of the treatment for postpartum hemorrhage. (See "Postpartum hemorrhage: Medical and minimally invasive management".)

USPSTF guidelines on screening for preeclampsia (May 2017)

The US Preventive Services Task Force (USPSTF) affirmed the long-standing practice of screening pregnant women for preeclampsia with blood pressure measurements throughout pregnancy [14]. In contrast to traditional practice, they concluded that evidence does not support point-of-care urine testing to screen for preeclampsia. We suggest testing for proteinuria at the first prenatal visit to establish a baseline and, given the possibility for false-positives and false-negatives, repeating the test in asymptomatic normotensive patients on at least one subsequent prenatal visit. (See "Preeclampsia: Clinical features and diagnosis", section on 'Screening'.)

Maternal Tdap vaccination and prevention of infant pertussis (May 2017)

Immunization with the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is recommended for women during each pregnancy in order to provide passive protection against pertussis to their infants. Although passive transfer of maternal antibodies can blunt the infant's own immune response to infant doses of the diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine, it does not appear to interfere with clinical vaccine efficacy. In a retrospective study of nearly 150,000 infants at every level of DTaP vaccine exposure, infants exposed in utero to Tdap vaccine were better protected against pertussis during the first year of life than infants not exposed in utero [15]. (See "Immunizations during pregnancy", section on 'Rationale, efficacy, and safety'.)

Persistence of neurotoxicity of childhood lead poisoning into adulthood (May 2017)

Detectable blood lead levels (BLLs) are associated with irreversible neurocognitive deficits in children and a BLL lower limit for this toxicity has not been established. Previous studies had shown that this effect persists into adolescence. In a longitudinal cohort study of over 1000 patients, lead exposure, based upon BLLs obtained at 11 years of age, was associated in a dose-dependent fashion with lower intelligence quotient (IQ) and lower socioeconomic status at age 38 years after adjustment for maternal IQ, child IQ, and childhood socioeconomic status [16]. Thus, childhood lead exposure causes neurotoxicity that persists into adulthood. Primary prevention of lead exposure, including in pregnant women, can prevent these effects. (See "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Neurologic'.)

Safety warnings issued for codeine and tramadol in breastfeeding women and children under age 12 years (April 2017)

The US Food and Drug Administration (FDA) issued a strong warning to restrict use of codeine and tramadol in breastfeeding women and children <12 years old because of increasing reports of life-threatening respiratory depression in young children exposed to these drugs [17]. Children who are ultra-rapid metabolizers metabolize these drugs faster than normal, leading to dangerously high levels of active drug. We suggest avoiding codeine and tramadol in breastfeeding women and children <12 years old. (See "Evaluation and management of pain in children", section on 'Agents not recommended'.)

Neonatal mortality in US planned home births (April 2017)

The American College of Obstetricians and Gynecologists considers fetal malpresentation, multiple gestation, and prior cesarean delivery absolute contraindications to planned home birth. In a retrospective United States cohort study, the neonatal mortality rate (NMR) among women who planned home birth was similar for nulliparous women and women with a prior cesarean delivery (approximately 2 neonatal deaths per 1000 births), with the highest NMR among nulliparas ≥35 years of age or ≥41 weeks of gestation (4 to 5 neonatal deaths per 1000 births) [18]. These risks should be discussed with women planning home birth. (See "Planned home birth", section on 'Patient selection'.)

Computerized interpretation and alerts for intrapartum fetal monitoring not beneficial (April 2017)

Two randomized trials (FM-ALERT [19] and INFANT [20]) have evaluated the use of continuous intrapartum fetal monitoring with computerized interpretation and real-time alerts versus usual care (continuous intrapartum fetal monitoring with clinician interpretation). In both trials, use of the intervention did not improve any maternal or neonatal outcome. In the larger INFANT trial, which included over 47,000 pregnancies at or near term, developmental assessment at age two years was similar for both groups [20]. Thus, a change in the standard clinical approach to intrapartum fetal heart rate monitoring is unwarranted. (See "Intrapartum fetal heart rate assessment", section on 'Use of decision aids'.)

Expulsion following immediate postpartum intrauterine device insertion (March 2017)

Women may choose to have a copper or levonorgestrel-releasing intrauterine device (IUD) inserted immediately postpartum. In a prospective study, the expulsion rate for the levonorgestrel-releasing IUD was higher than that for the copper IUD at six months postpartum (17 versus 4 percent) [21]. Although further data from a large trial are required to confirm this finding, we counsel women that the risk of expulsion may be higher with the levonorgestrel-releasing device and discuss the need to check for the IUD thread intermittently. (See "Postpartum contraception", section on 'Device selection'.)

Sensitivity of short cervix and fetal fibronectin for preterm birth (March 2017)

Cervical length is measured sonographically in the midtrimester because a short cervix is predictive of preterm birth, and the risk may be reduced by administration of progesterone. A new large prospective study reported the sensitivity for preterm birth among nulliparous women with singleton gestations and cervical length ≤25 mm was 8 percent at 16 to 22 weeks of gestation and 23 percent at 22 to 30 weeks [22]. Although these values are lower than previously reported in nonintervention studies, a major limitation of the study was unblinding when the cervix was very short (<15 mm), and probable intervention in these patients. The study also confirmed previous data that midtrimester measurement of fetal fibronectin in asymptomatic nulliparous women performs poorly for prediction of preterm birth. We continue to obtain a cervical length measurement in nulliparous women during ultrasound examinations at 18 to 24 weeks of gestation and treat those with a short cervix with vaginal progesterone. (See "Second-trimester evaluation of cervical length for prediction of spontaneous preterm birth in singleton gestations", section on 'Universal versus selective screening' and "Preterm birth: Risk factors and interventions for risk reduction", section on 'Biomarkers'.)

Pregnancy outcomes with HPV vaccination (March 2017)

Human papillomavirus (HPV) vaccination during pregnancy is not recommended, but mounting evidence suggests that it is safe. In a large cohort study from Denmark, the risks of spontaneous abortion, major birth defects, preterm birth, and low birth weight were comparable among women who received quadrivalent HPV vaccine during pregnancy (mostly during the first trimester) and matched controls who did not [23]. Women who inadvertently receive HPV vaccine during pregnancy can be reassured that it does not increase their risk of adverse pregnancy or fetal outcomes. (See "Immunizations during pregnancy", section on 'Human papillomavirus'.)

Maternal obesity and risk of cerebral palsy (March 2017)

Maternal obesity has been associated with several adverse pregnancy outcomes. Now, a population-based cohort study from Sweden has reported an increasing risk of cerebral palsy in offspring delivered at term as maternal body mass index (BMI) increases [24]. Although this observation requires confirmation, we continue to advise overweight and obese women to try to achieve a normal BMI before becoming pregnant because of established pregnancy and general health benefits. (See "Obesity in pregnancy: Complications and maternal management", section on 'Neurodevelopment'.)

Guidelines on women's health in systemic lupus erythematosus and antiphospholipid syndrome (March 2017)

Both systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) affect women of child-bearing age, and the management of these diseases in the setting of pregnancy can pose unique challenges. These include the effect of pregnancy on maternal disease, the impact of disease activity on fetal health, and the safety of medications during pregnancy and breastfeeding. The European League Against Rheumatism (EULAR) has published new recommendations for the management of women's health in patients with SLE and APS, which provide guidance for family planning, assisted reproduction, pregnancy monitoring, treatment during pregnancy, hormone replacement therapy and menopause, and malignancy screening [25]. (See "Pregnancy in women with systemic lupus erythematosus", section on 'Pregnancy planning'.)

New classification and guidance regarding suboptimally dated pregnancy (March 2017)

The American College of Obstetricians and Gynecologists now classifies pregnancies as "suboptimally dated" in the absence of an ultrasound examination before 22+0 weeks of gestation [26]. Because fetal biometry after 22 weeks is not sufficiently accurate to change menstrual dating without correlative sonographic follow-up, serial examinations three to four weeks apart are advised in these cases to assess growth over time. Normal interval growth supports the sonographic estimate of gestational age, while suboptimal or accelerated interval growth suggests that the gestational age may be further along or less advanced than predicted by ultrasound. (See "Prenatal assessment of gestational age and estimated date of delivery".)

Treatment of subclinical hypothyroidism and maternal hypothyroxinemia during pregnancy (March 2017)

In parallel multicenter trials, over 600 pregnant women with subclinical hypothyroidism (median thyroid-stimulating hormone [TSH] 4.4 mU/L, normal free T4) or isolated maternal hypothyroxinemia (low free T4, normal TSH) were randomly assigned to levothyroxine or placebo [27]. There was no significant effect of treatment on adverse pregnancy outcomes or on neurodevelopmental outcomes in the children at five years of age. The main limitation of the study is the late initiation of treatment at a mean gestational age of almost 17 weeks, at which time fetal thyroid tissue is beginning to function. We suggest levothyroxine (with earlier initiation when possible) for pregnant women with subclinical hypothyroidism, defined as a TSH above a trimester-specific normal reference range (or above 4.0 mU/L if trimester-specific range unavailable) with normal free T4. (See "Hypothyroidism during pregnancy: Clinical manifestations, diagnosis, and treatment", section on 'Effect of thyroid hormone replacement'.)

Recommended immunization schedule—United States, 2017 (March 2017)

The Advisory Committee on Immunization Practices has released the 2017 recommended immunization schedule for children and adolescents in the United States [28,29]. New recommendations include the following:

All infants should now receive monovalent hepatitis B vaccine within 24 hours of birth; earlier recommendations allowed some infants born to hepatitis B surface antigen-negative mothers to receive the vaccine after discharge. (See "Hepatitis B virus immunization in infants, children, and adolescents", section on 'Mother's HBsAg status unknown, birth weight ≥2 kg'.)

When administered during pregnancy, the tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine should be given as early as possible between 27 and 36 weeks of gestation. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

For individuals receiving the meningococcal serogroup B vaccine MenBFHbp (Trumenba), two doses are recommended for healthy adolescents and young adults who are not at increased risk for meningococcal disease. Three doses are recommended for individuals ≥10 years of age at increased risk for meningococcal disease and for use during serogroup B meningococcal disease outbreaks (table 1). Previously, three doses were recommended for all recipients. The dosing frequency and interval for the other serogroup B vaccine, MenB-4C (Bexsero), have not changed. (See "Meningococcal vaccines", section on 'Serogroup B meningococcus vaccines'.)

Aspirin for prevention of preeclampsia (February 2017)

Low-dose aspirin therapy during pregnancy reduces the occurrence of preeclampsia in high-risk women, but questions remain about optimum dosing and timing. In one recent meta-analysis, the optimum aspirin dose appeared to be 100 to 150 mg, with favorable effects limited to initiation before 16 weeks of gestation [30]. In another recent meta-analysis with a different design, aspirin was similarly effective whether initiated before or after 16 weeks of gestation; optimum dosing was not assessed [31]. For women at high risk of developing preeclampsia, we continue to suggest initiating aspirin 81 mg daily at the end of the first trimester because this dose is readily available and early initiation is both safe and effective. If aspirin is not initiated at this time, initiation after 16 weeks, but before symptoms develop, also appears to be effective. (See "Preeclampsia: Prevention", section on 'Meta-analysis'.)

Maternal fish oil supplementation and asthma in offspring (February 2017)

Maternal supplementation with fish oil, which consists of two n-3 long chain polyunsaturated fatty acids (docosahexaenoic acid [DHA]) and eicosapentaenoic acid [EPA]), has been proposed to improve a variety of pregnancy outcomes. In a placebo-controlled randomized trial of third-trimester maternal supplementation with fish oil 2.4 grams daily (55 percent EPA and 37 percent DHA), supplementation resulted in a 7 percent reduction in the absolute risk of persistent wheeze or asthma in offspring followed to age three to five years [32]. Because of limitations in the design of this trial, UpToDate does not advise routine supplementation with this dose of fish oil, but continues to recommend that all pregnant women achieve DHA intake of at least 200 to 300 mg/day. (See "Fish consumption and docosahexaenoic acid (DHA) supplementation in pregnancy".)

Folic acid supplementation for prevention of neural tube defects (February 2017)

Folic acid supplementation and food fortification have reduced the incidence of neural tube defects (NTDs). A 2017 systematic review by the US Preventive Services Task Force (USPSTF) noted that post-food fortification studies of folic acid supplementation have not demonstrated a protective association [33], suggesting that current levels of food fortification may be sufficient to prevent most folate-sensitive NTDs. However, the USPSTF also reaffirmed its 2009 recommendation that all women of reproductive age planning or capable of pregnancy take a supplement containing 0.4 to 0.8 mg of folic acid daily to reduce their risk of having a child with a NTD [34]. Given the limitations of the post-food fortification studies, we agree with this recommendation. (See "Folic acid supplementation in pregnancy".)

United States guidelines for fish consumption during pregnancy and lactation (February 2017)

Fish may be contaminated by environmental pollutants, such as methylmercury, which can cause fetal neurologic problems. The US Food and Drug Administration and Environmental Protection Agency released updated recommendations about fish consumption for women who are pregnant or nursing, or who might become pregnant [35]. Revisions include guidance on many more types of fish and recommendations for best choices versus good choices (table 2). (See "Nutrition in pregnancy", section on 'Fish consumption'.)


Overweight and risk of pelvic organ prolapse (June 2017)

Studies assessing the impact of body weight on risk of pelvic organ prolapse (POP) have reported conflicting results. A meta-analysis of 22 studies now reports that the risk of POP is increased by at least 36 percent in overweight and obese women compared with normal-weight peers [36]. This finding is noteworthy because body weight is one of the few modifiable risk factors for POP. (See "Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management", section on 'Obesity'.)

HSG with oil-based versus water-soluble contrast (May 2017)

For infertile women undergoing a hysterosalpingogram (HSG) to assess tubal patency, the impact of oil-based versus water-soluble contrast on pregnancy and live birth rates has been debated. In the largest trial comparing these contrast agents in women at low risk for tubal disease, oil-based contrast resulted in higher rates of ongoing pregnancy and live birth [37]. We will continue to use water-soluble contrast for HSG as water-soluble contrast provides higher-quality images, is safer, and this trial is not generalizable to our patient population, which is typically at high risk for tubal disease. (See "Hysterosalpingography", section on 'Contrast'.)

IUD use does not impact human papillomavirus infection (March 2017)

A reduction in cervical cancer rates among intrauterine device (IUD) users has been observed and attributed to favorable effects of the device on human papillomavirus (HPV) clearance. However, a prospective cohort study that controlled for sexual and behavioral confounders reported no difference in HPV acquisition or clearance among women and girls with or without an IUD [38]. Thus, IUD use does not appear to impact HPV infection. (See "Intrauterine contraception: Devices, candidates, and selection", section on 'IUDs cause infection'.)

USPSTF statement on routine pelvic examination (March 2017)

Routine pelvic examination in asymptomatic women is controversial. The US Preventive Services Task Force (USPSTF) recently published a statement that evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women [39]. In 2014, the American College of Physicians (ACP) recommended against such examinations. In 2012, the American College of Obstetricians and Gynecologists (ACOG) recommended annual pelvic examination in nonpregnant women age 21 years or older and is now reviewing its policy in response to the USPSTF statement. As few data about the benefit and harms of routine pelvic examinations are available, we suggest shared decision-making between the patient and clinician. (See "The gynecologic history and pelvic examination", section on 'Indications and frequency for examination'.)


Negative pressure dressing for closed abdominal wounds (May 2017)

Negative pressure dressings have been widely used to manage open wounds but are less commonly used for closed wounds. In a randomized trial of 50 patients with closed laparotomy incisions, the use of a negative pressure dressing, as opposed to a standard dressing, resulted in fewer wound infections and a shorter mean hospital stay [40]. If these findings are validated by other studies, negative pressure dressings could be used for closed abdominal wounds, particularly when the risk of wound complications is high, such as in obese patients or with a contaminated field. (See "Principles of abdominal wall closure", section on 'Negative pressure dressings'.)

Choice of antibiotic prophylaxis before hysterectomy (April 2017)

Preoperative cephalosporins are recommended for the prevention of surgical site infections (SSI) following hysterectomy. However, a retrospective cohort study of women undergoing hysterectomy (by any route) reported that women receiving cefazolin plus metronidazole had lower rates of SSI compared with women who received a cephalosporin alone [41]. The efficacy of this approach needs to be confirmed and the long-term consequences fully evaluated. We continue to use preoperative cefazolin or a second-generation cephalosporin for SSI prevention before hysterectomy because of concern for increasing antibiotic resistance with more broad-spectrum coverage. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Antibiotic prophylaxis'.)

Safety of transvaginal mesh for stress urinary incontinence (February 2017)

Although relatively high complication rates have been reported when transvaginal mesh is used in pelvic organ prolapse surgery, this is not the case for female stress urinary incontinence (SUI) surgery. In a large cohort study comparing outcomes of mesh with non-mesh SUI procedures, the risk of immediate complications was approximately 50 percent lower in mesh-based procedures, with similar five-year efficacy and complication rates [42]. Transvaginal mesh continues to be the preferred surgical treatment for women with SUI. (See "Overview of transvaginal placement of mesh for prolapse and stress urinary incontinence", section on 'Choice of synthetic mesh or native tissue'.)


Oral contraceptives and ovarian cancer risk (June 2017)

Use of oral estrogen-progestin contraceptives is associated with a reduction in risk of ovarian cancer. In the largest and longest duration study of oral contraceptive use, the Royal College of General Practitioners’ Oral Contraception Study followed over 46,000 women for up to 44 years and found that ever-use of oral contraceptives was associated with a 33 percent reduction in ovarian cancer risk [43]. This finding supports previous data and our recommendation for use of oral contraceptives in women who desire ovarian cancer risk reduction who have not undergone risk reduction surgery and who are not trying to conceive. (See "Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer" and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Epidemiology and risk factors", section on 'Oral contraceptives'.)

Breastfeeding and risk of endometrial cancer (June 2017)

Breastfeeding has many maternal and infant benefits. In a meta-analysis of epidemiologic studies of women with endometrial cancer, ever-breastfeeding was associated with an 11 percent reduction in risk compared with never breastfeeding, and the greatest reduction was among those who breastfed for at least three months per child [44]. A decreased risk of endometrial cancer appears to be an additional maternal benefit of breastfeeding. (See "Endometrial carcinoma: Epidemiology and risk factors", section on 'Breastfeeding'.)

Sentinel lymph node biopsy in endometrial cancer (May 2017)

Sentinel lymph node biopsy for staging endometrial carcinoma is increasingly performed instead of selective or extended nodal dissection. In the largest multicenter prospective study of the procedure in over 300 women with clinical stage I endometrial carcinoma, successful mapping of at least one sentinel lymph node was achieved in 86 percent and the sensitivity of the sentinel lymph node was 97 percent [45]. Nevertheless, we believe further study is needed before sentinel lymph node biopsy is established as a reasonable alternative to full pelvic lymphadenectomy in endometrial carcinoma. (See "Endometrial carcinoma: Pretreatment evaluation, staging, and surgical treatment", section on 'Sentinel node biopsy'.)

Laparoscopic interval debulking after neoadjuvant chemotherapy for ovarian cancer (May 2017)

Women with stage IIIC or IV ovarian cancer and unresectable disease may be candidates for neoadjuvant chemotherapy (NACT) followed by interval debulking, typically performed with laparotomy. Results of a large retrospective study suggest that laparoscopy could be a minimally invasive option for such debulking. Compared with laparotomy, laparoscopy was associated with similar three-year overall survival rates (47.5 versus 52.6 percent), similar suboptimal debulking rates (20.0 versus 22.6 percent), a shorter hospital stay by one day, and similar 30-day readmission rates [46]. Further study is needed to evaluate whether short-term morbidity is reduced with use of laparoscopy. (See "Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management", section on 'Role of laparoscopy'.)

Survival with laparoscopic staging for early endometrial carcinoma (May 2017)

The second largest randomized trial of total laparoscopic hysterectomy versus total abdominal hysterectomy for treatment of apparent stage I endometrial carcinoma reported similar disease-free survival at 4.5 years and overall survival for the two techniques [47]. Based on these and previous data, laparoscopic hysterectomy appears to be a reasonable approach for initial management of women with apparent stage I endometrial cancer and may be preferable to open surgery because of lower perioperative morbidity. (See "Endometrial carcinoma: Pretreatment evaluation, staging, and surgical treatment", section on 'Laparoscopy'.)

Niraparib maintenance therapy in platinum-sensitive, recurrent ovarian cancer (March 2017)

In a phase III trial, enrolling approximately 550 patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who have responded to platinum-based chemotherapy, niraparib maintenance improved progression-free survival relative to placebo, although over a third experienced severe hematologic toxicity [48]. Based on these results, the US Food and Drug Administration (FDA) has approved niraparib for the maintenance treatment of such patients [49]. However, overall survival data are still immature and niraparib has not been compared with bevacizumab, which is better studied in the maintenance setting. Pending further data, we reserve use of niraparib maintenance for patients with relapsed ovarian cancer who are not candidates for bevacizumab and who are in a complete or partial response to platinum-based chemotherapy. (See "Medical treatment for relapsed epithelial ovarian, fallopian tubal, or peritoneal cancer: Platinum-sensitive disease".)

Hysterectomy-corrected cervical cancer mortality rates and racial variation (February 2017)

Cervical cancer incidence and mortality rates are known to vary across racial groups in the United States but can be underestimated if data are not adjusted for prior hysterectomy. In a population-based study that corrected for the prevalence of hysterectomy, cervical cancer mortality in black women was more than twice that of white women from 2000 to 2012 (10.1 versus 4.7 per 100,000) [50]. These data add to the body of evidence showing a racial disparity in cervical cancer mortality and support the need for research to identify and overcome the factors that account for this disparity. (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Incidence and mortality'.)


Gene editing in human embryos to prevent disease (August 2017)

In vitro fertilization with preimplantation genetic diagnosis (IVF/PGD) is an established strategy for avoiding implantation of embryos with specific pathogenic gene mutations. In a landmark study of the correction of a pathogenic gene mutation, a mutant paternal allele in human embryos was repaired using the homologous wild-type maternal gene instead of a synthetic DNA template [51]. The embryos were not transferred or allowed to mature beyond the blastocyst stage. This technology is experimental and the efficacy, safety, and clinical utility of gene editing remain unknown. (See "In vitro fertilization", section on 'Other uses'.)

Fertility preservation with cryopreserved ovarian tissue transplantation (July 2017)

For women at risk of ovarian failure due to planned gonadotoxic therapy and who desire fertility preservation, increasing evidence supports use of ovarian tissue cryopreservation followed by autotransplantation (OTT) after completion of therapy. In a 2017 meta-analysis, endocrine function was restored for at least four months after OTT in over 60 percent of women [52]. OTT was associated with similar live birth rates as conventional frozen embryo transfer, and over 60 percent of women who conceived after an orthotopic transplant conceived naturally. (See "Fertility preservation in patients undergoing gonadotoxic treatment or gonadal resection", section on 'Outcomes'.)

Oral GnRH antagonist for endometriosis-related pain (May 2017)

Endometriosis can cause chronic debilitating dysmenorrhea and pelvic pain. In phase 3 trials, elagolix (a novel oral gonadotropin-releasing [GnRH] antagonist) reduced endometriosis-related dysmenorrhea and noncyclic pelvic pain compared with placebo at three months of treatment, and these reductions were sustained at six months of treatment [53]. Oral GnRH antagonists, such as elagolix, provide a treatment option for women who do not respond to standard oral therapies and are more convenient than intramuscular GnRH agonists. However, they are associated with hypoestrogenic side effects. (See "Endometriosis: Treatment of pelvic pain", section on 'Gonadotropin-releasing hormone (GnRH) antagonists'.)

HSG with oil-based versus water-soluble contrast (May 2017)

For infertile women undergoing a hysterosalpingogram (HSG) to assess tubal patency, the impact of oil-based versus water-soluble contrast on pregnancy and live birth rates has been debated. In the largest trial comparing these contrast agents in women at low risk for tubal disease, oil-based contrast resulted in higher rates of ongoing pregnancy and live birth [37]. We will continue to use water-soluble contrast for HSG as water-soluble contrast provides higher-quality images, is safer, and this trial is not generalizable to our patient population, which is typically at high risk for tubal disease. (See "Hysterosalpingography", section on 'Contrast'.)

Reproductive hormones in women conceived by ICSI (April 2017)

The reproductive potential of children conceived with intracytoplasmic sperm injection (ICSI) for male factor infertility is not known. In the first study comparing the reproductive function of young women conceived by ICSI with peers conceived spontaneously, no differences in reproductive hormone levels or mean follicle count were observed [54]. These data are reassuring regarding the reproductive potential of female ICSI offspring. (See "Intracytoplasmic sperm injection", section on 'Reproductive function'.)


Safety of transvaginal mesh for stress urinary incontinence (February 2017)

Although relatively high complication rates have been reported when transvaginal mesh is used in pelvic organ prolapse surgery, this is not the case for female stress urinary incontinence (SUI) surgery. In a large cohort study comparing outcomes of mesh with non-mesh SUI procedures, the risk of immediate complications was approximately 50 percent lower in mesh-based procedures, with similar five-year efficacy and complication rates [42]. Transvaginal mesh continues to be the preferred surgical treatment for women with SUI. (See "Overview of transvaginal placement of mesh for prolapse and stress urinary incontinence", section on 'Choice of synthetic mesh or native tissue'.)

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