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What's new in obstetrics and gynecology
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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: Sep 2017. | This topic last updated: Oct 19, 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.


pH1N1-containing influenza vaccine and miscarriage (October 2017)

Multiple studies have reported that administration of inactivated influenza vaccines to pregnant women is not associated with an increased risk of maternal, fetal, or neonatal complications. One exception is a case-control study of a possible increase in spontaneous abortion among the subgroup of women vaccinated with two consecutive pH1N1-containing vaccines during the 2010-2011 and 2011-2012 seasons [1]. This study had several limitations that might have influenced the findings, and further confirmation is needed. We continue to strongly recommend routine influenza vaccination with trivalent or quadrivalent inactivated influenza vaccine, as the benefits outweigh any risks. (See "Influenza and pregnancy", section on 'Safety'.)

Safety of tenofovir disoproxil fumarate during pregnancy (September 2017)

For HIV-infected pregnant women, tenofovir disoproxil fumarate (TDF) is a preferred agent to use as part of combination antiretroviral therapy (ART) in both resource-rich and limited settings. A recent meta-analysis reported that TDF increased neonatal mortality, and an accompanying British Medical Journal clinical practice guideline thus suggested zidovudine rather than TDF for HIV-infected pregnant women [2,3]. This conclusion was based on a single trial from Africa in which TDF-based ART resulted in higher rates of very preterm birth (<34 weeks) and neonatal mortality compared with zidovudine-based ART (each given with lopinavir-ritonavir), but not compared with zidovudine alone [4]. Given uncertainties regarding the trial results, potential interactions between TDF and lopinavir-ritonavir, and observational data suggesting safety of other TDF-containing regimens in pregnancy, we do not believe the evidence is clear enough to stop using TDF as a preferred agent (although we do not initiate TDF and lopinavir-ritonavir containing regimens during pregnancy). The British HIV Association also released a statement consistent with our position [5]. (See "Safety and dosing of antiretroviral medications in pregnancy", section on 'Very preterm birth/neonatal mortality'.)

2017-2018 influenza immunization recommendations for the United States (September 2017)

The Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) have released recommendations for influenza immunization for the 2017-2018 season in the United States [6,7]. Routine influenza immunization with a licensed, age-appropriate vaccine (table 1) is recommended for all persons ≥6 months of age. Live attenuated influenza vaccine is not recommended for the 2017-2018 season. Pregnant women and persons with egg allergy of any severity can receive any licensed, age-appropriate inactivated influenza vaccine with standard immunization precautions. Although neither the ACIP nor the AAP provide a preference for a particular formulation, we favor a quadrivalent vaccine when available for adults <65 years and we recommend the high-dose vaccine for those ≥65 years. (See "Seasonal influenza in children: Prevention with vaccines", section on 'Types of vaccine' and "Seasonal influenza vaccination in adults", section on 'Choice of vaccine formulation' and "Influenza and pregnancy", section on 'Vaccination' and "Influenza vaccination in individuals with egg allergy", section on 'Safety of vaccines in patients with egg allergy'.)

Severity of maternal Zika virus infection and birth outcome (September 2017)

Maternal-to-fetal transmission of Zika virus can occur with either symptomatic or asymptomatic maternal infection; the risk factors for transmission are unknown. In a prospective study from Rio de Janeiro of women with confirmed Zika virus infection during pregnancy, no association was observed between maternal disease severity (signs, symptoms, virus load) or prior dengue virus infection and adverse birth outcome defined as fetal loss or birth of a live infant with grossly abnormal clinical or brain imaging findings [8]. This finding supports the Centers for Disease Control and Prevention (CDC) recommendation for serial fetal ultrasound examinations in pregnant women with laboratory evidence of Zika virus infection, regardless of maternal disease severity. (See "Zika virus infection: Evaluation and management of pregnant women", section on 'Risk of vertical transmission and anomalies'.)

Revised ACOG diagnostic criteria for gestational diabetes mellitus (August 2017)

The American College of Obstetricians and Gynecologists updated practice bulletin on gestational diabetes mellitus (GDM) now states that some clinicians may choose to make this diagnosis in patients with one elevated glucose value on a glucose tolerance test (GTT), although the diagnosis generally requires that two or more glucose thresholds must be met or exceeded [9]. This change was based on a 2016 systematic review that concluded that women with one abnormal value on the three-hour, 100-gram GTT were at increased risk for the same poor outcomes as women with two abnormal values [10]. (See "Diabetes mellitus in pregnancy: Screening and diagnosis", section on '100-gram three-hour oral glucose tolerance test'.)

Increased nuchal translucency and Noonan syndrome (August 2017)

Increased nuchal translucency on first trimester ultrasound screening has been associated with over 100 developmental and genetic syndromes. In a retrospective study in which a Noonan syndrome gene sequencing panel was obtained in 39 euploid fetuses with nuchal translucency ≥3.0 mm (median thickness 4.0 mm), 10 percent had variants consistent with Noonan syndrome [11]. It may be reasonable to offer screening for genetic mutations associated with Noonan syndrome in euploid fetuses with nuchal translucency ≥3.0 mm, but prospective studies are still needed to validate this result. (See "Cystic hygroma and increased nuchal translucency", section on 'Targeted genetic studies'.)

Genomic sequencing to identify inherited pathogenic genes in families of individuals with multiple congenital malformations (August 2017)

Next-generation sequencing, such as whole exome or whole genome sequencing, is used to aid in diagnosis of complex diseases such as severe intellectual disability or developmental delay. A study that used these techniques to evaluate patients with multiple congenital malformations and their family members identified four families with loss-of-function variants in two genes leading to nicotinamide adenine dinucleotide (NAD) deficiency (HAAO, encoding 3-hydroxyanthranilic acid 3,4-dioxygenase, and KYNU, encoding kynureninase) [12]. In a mouse model of these defects, niacin supplementation during gestation corrected the NAD deficiency and prevented abnormal embryogenesis and fetal death. (See "Birth defects: Causes", section on 'Disorders due to single gene defects' and "Principles and clinical applications of next-generation DNA sequencing", section on 'Diagnosis of complex diseases'.)

Sugar-sweetened beverage consumption in pregnancy (August 2017)

A growing body of data suggests 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 [13]. 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'.)

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) [14]. 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 [15]. 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'.)

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 [16]. 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'.)

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 [17]. 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 [18]. 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) [19]. 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 [20]. 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'.)

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 [21]. 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 [22]. (See "Immunizations during pregnancy", section on 'Rationale, efficacy, and safety'.)


Postpartum antibiotic prophylaxis for cesarean delivery in obese women (October 2017)

Traditionally, antibiotic prophylaxis has not been continued postpartum because trials in general surgical populations showed no benefit. Now, a randomized trial of oral cephalexin plus metronidazole for 48 hours following cesarean delivery found a 60 percent reduction in surgical site infections compared with placebo [23]. All of the participants were obese and received preoperative prophylaxis. This trial should prompt further study to confirm or refute these findings, determine whether specific populations are more likely to experience clinically meaningful benefits, and evaluate both short- and long-term risks of extending the period of prophylaxis. (See "Cesarean delivery of the obese woman", section on 'Antibiotic prophylaxis'.)

Vaginal cleansing before cesarean delivery (August 2017)

Whether vaginal cleansing before cesarean delivery further reduces infection-related morbidity in patients already receiving parenteral antibiotic prophylaxis has been unclear. In a 2017 meta-analysis of randomized trials of this issue, vaginal cleansing reduced the incidence of endometritis whether or not preoperative antibiotics were administered, but the reduction appeared to be limited to women in labor or with ruptured membranes [24]. Based on these data, we perform a povidone-iodine vaginal scrub with a sponge stick for 30 seconds before cesarean delivery in women in labor or with ruptured membranes. (See "Cesarean delivery: Preoperative planning and patient preparation", section on 'Vaginal preparation'.)

Long-term risk of hypertension in women with pregnancy-associated hypertension (August 2017)

For women with a history of gestational hypertension, preeclampsia, eclampsia, or HELLP syndrome, at least annual lifelong measurement of blood pressure is important due to their increased risk for chronic hypertension. In a long-term population-based study, the rate of hypertension in the first decade postpartum for primiparous women in their 20s with pregnancy-associated hypertension was 14 percent, compared with 4 percent for those without pregnancy-associated hypertension [25]. For primiparous women in their 40s, the rates were 32 and 11 percent, respectively. The risk of chronic hypertension in this population may be reduced by adherence to a beneficial lifestyle (eg, achieving/maintaining a healthy weight, salt restriction, exercise, limited alcohol intake) [26]. (See "Management of hypertension in pregnant and postpartum women", section on 'Long-term prognosis of women with hypertension during pregnancy'.)

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 [27]. 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'.)

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 [28]. 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 [29]. 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'.)

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 [30]. 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".)

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 [31]. 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".)

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 [32]. 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'.)

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

Two randomized trials (FM-ALERT [33] and INFANT [34]) 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 [34]. 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'.)


Single-dose secnidazole for bacterial vaginosis (September 2017)

Metronidazole is a preferred treatment for bacterial vaginosis (BV) and is given topically or orally as a multi-day course. In September 2017, the US Food and Drug Administration approved secnidazole, a related oral antibiotic with a longer half-life, for the treatment of BV [35]. In an earlier study, a single dose of secnidazole was as effective as, but not superior to, metronidazole for seven days. Secnidazole is an option for BV when a single dose is desired (eg, to enhance adherence), but it is more expensive than other regimens. (See "Bacterial vaginosis: Treatment", section on 'Secnidazole'.)

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'.)


Risk of endometrial cancer after endometrial ablation (September 2017)

Endometrial ablation is a common treatment for heavy menstrual bleeding but introduces obstacles to the detection and diagnosis of endometrial neoplasia. Whether this delays diagnosis of endometrial cancer is unclear. In a retrospective cohort study from Finland of over 5400 women who underwent endometrial ablation and were followed for a mean of seven years, only three women developed endometrial cancer after ablation (ratio of observed to expected cases: 0.56 [95% CI 0.12-1.64]); two cancers were at an early stage and one at an unknown stage [38]. Endometrial hyperplasia, a precursor to cancer, was found in 1.8 percent of the subset of women who underwent post-ablation hysterectomy. This study found no evidence of a delay in diagnosis of endometrial cancer after ablation, but with so few events, further study is needed. (See "An overview of endometrial ablation", section on 'Risk factors for endometrial cancer'.)

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 [39]. 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 [40]. 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'.)


PARP inhibitor maintenance therapy in platinum-sensitive, recurrent ovarian cancer (March 2017, Modified September 2017)

Inhibitors of poly-ADP ribose polymerase (PARP) are being actively evaluated as maintenance therapy in platinum-sensitive relapsed ovarian cancer. In phase III trials of women with recurrent ovarian cancer who achieved a response to their most recent platinum-based treatment, the PARP inhibitors niraparib, olaparib, and rucaparib have each demonstrated progression-free survival benefits as maintenance therapy compared with placebo [41-44]. These data have led to approvals by the US Food and Drug Administration of both niraparib and olaparib in this setting [45,46]. However, overall survival data for PARP inhibitors as maintenance therapy are immature, and these agents have not been compared with bevacizumab, which is better established in the maintenance setting. Pending further data, we reserve use of PARP inhibition as maintenance therapy 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".)

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 [47]. 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 [48]. 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 [49]. 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 [50]. 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 [51]. 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'.)


Polycystic ovary syndrome: No role for metformin in ovulation induction (September 2017)

Metformin was widely used in the past for women with polycystic ovary syndrome (PCOS) for ovulation induction and prevention of miscarriage, multiple gestations, and pregnancy complications. However, the American Society for Reproductive Medicine now suggests that there is insufficient evidence to recommend metformin for any of these indications [52]. Unlike the first-line ovulation induction agents letrozole and clomiphene, which improve live birth rates, metformin increases ovulatory rates and pregnancy rates, but not live birth rates. (See "Metformin for treatment of the polycystic ovary syndrome", section on 'Anovulatory infertility'.)

Investigational gene editing in human embryos to prevent disease (August 2017)

In vitro fertilization with preimplantation genetic diagnosis (IVF/PGD) is an established strategy for selecting embryos for implantation that lack specific pathogenic gene mutations. In a landmark study of the use of gene editing to correct a pathogenic gene mutation in human embryos, a mutant paternal allele was repaired using the homologous wild-type maternal gene [53]. The embryos were not transferred or allowed to mature beyond the blastocyst stage. This technology is experimental; 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 [54]. 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 [55]. 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 [56]. These data are reassuring regarding the reproductive potential of female ICSI offspring. (See "Intracytoplasmic sperm injection", section on 'Reproductive function'.)


Electroacupuncture for stress urinary incontinence in women (August 2017)

Treatment options for stress urinary incontinence (SUI) in women include lifestyle modifications, bladder training, medications, devices, and surgery. The use of electroacupuncture for SUI has been reported in a multicenter randomized trial in China [57]. Compared with sham treatments, electroacupuncture reduced the volume of urine leaked and number of leakage episodes. Availability of this therapy may limit this option. Additionally, confirmation of these results in other trial settings is needed before its general use can be widely recommended.[57]"Treatment of urinary incontinence in women".)

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  1. Donahue JG, Kieke BA, King JP, et al. Association of spontaneous abortion with receipt of inactivated influenza vaccine containing H1N1pdm09 in 2010-11 and 2011-12. Vaccine 2017; 35:5314.
  2. Siemieniuk RA, Foroutan F, Mirza R, et al. Antiretroviral therapy for pregnant women living with HIV or hepatitis B: a systematic review and meta-analysis. BMJ Open 2017; 7:e019022.
  3. Siemieniuk RAC, Lytvyn L, Mah Ming J, et al. Antiretroviral therapy in pregnant women living with HIV: a clinical practice guideline. BMJ 2017; 358:j3961.
  4. Fowler MG, Qin M, Fiscus SA, et al. Benefits and Risks of Antiretroviral Therapy for Perinatal HIV Prevention. N Engl J Med 2016; 375:1726.
  5. British HIV Association (BHIVA). Response to BMJ article published 11 September 2017. (Accessed on September 21, 2017).
  6. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2017-18 Influenza Season. MMWR Recomm Rep 2017; 66:1.
  7. COMMITTEE ON INFECTIOUS DISEASES. Recommendations for Prevention and Control of Influenza in Children, 2017 - 2018. Pediatrics 2017; 140.
  8. Halai UA, Nielsen-Saines K, Moreira ML, et al. Maternal Zika Virus Disease Severity, Virus Load, Prior Dengue Antibodies, and Their Relationship to Birth Outcomes. Clin Infect Dis 2017; 65:877.
  9. Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 180: Gestational Diabetes Mellitus. Obstet Gynecol 2017; 130:e17.
  10. Roeckner JT, Sanchez-Ramos L, Jijon-Knupp R, Kaunitz AM. Single abnormal value on 3-hour oral glucose tolerance test during pregnancy is associated with adverse maternal and neonatal outcomes: a systematic review and metaanalysis. Am J Obstet Gynecol 2016; 215:287.
  11. Ali MM, Chasen ST, Norton ME. Testing for Noonan syndrome after increased nuchal translucency. Prenat Diagn 2017; 37:750.
  12. Shi H, Enriquez A, Rapadas M, et al. NAD Deficiency, Congenital Malformations, and Niacin Supplementation. N Engl J Med 2017; 377:544.
  13. Gillman MW, Rifas-Shiman SL, Fernandez-Barres S, et al. Beverage Intake During Pregnancy and Childhood Adiposity. Pediatrics 2017; 140.
  14. (Accessed on July 25, 2017).
  15. Rolnik DL, Wright D, Poon LC, et al. Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia. N Engl J Med 2017; 377:613.
  16. Duan L, Ng A, Chen W, et al. β-Blocker Exposure in Pregnancy and Risk of Fetal Cardiac Anomalies. JAMA Intern Med 2017; 177:885.
  17. Shapiro-Mendoza CK, Rice ME, Galang RR, et al. Pregnancy Outcomes After Maternal Zika Virus Infection During Pregnancy - U.S. Territories, January 1, 2016-April 25, 2017. MMWR Morb Mortal Wkly Rep 2017; 66:615.
  18. Cavoretto P, Giorgione V, Cipriani S, et al. Nuchal translucency measurement, free β-hCG and PAPP-A concentrations in IVF/ICSI pregnancies: systematic review and meta-analysis. Prenat Diagn 2017; 37:540.
  19. Patorno E, Huybrechts KF, Bateman BT, et al. Lithium Use in Pregnancy and the Risk of Cardiac Malformations. N Engl J Med 2017; 376:2245.
  20. Ly KN, Jiles RB, Teshale EH, et al. Hepatitis C Virus Infection Among Reproductive-Aged Women and Children in the United States, 2006 to 2014. Ann Intern Med 2017; 166:775.
  21. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for Preeclampsia: US Preventive Services Task Force Recommendation Statement. JAMA 2017; 317:1661.
  22. Baxter R, Bartlett J, Fireman B, et al. Effectiveness of Vaccination During Pregnancy to Prevent Infant Pertussis. Pediatrics 2017; 139.
  23. Valent AM, DeArmond C, Houston JM, et al. Effect of Post-Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial. JAMA 2017; 318:1026.
  24. Caissutti C, Saccone G, Zullo F, et al. Vaginal Cleansing Before Cesarean Delivery: A Systematic Review and Meta-analysis. Obstet Gynecol 2017; 130:527.
  25. Behrens I, Basit S, Melbye M, et al. Risk of post-pregnancy hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study. BMJ 2017; 358:j3078.
  26. Timpka S, Stuart JJ, Tanz LJ, et al. Lifestyle in progression from hypertensive disorders of pregnancy to chronic hypertension in Nurses' Health Study II: observational cohort study. BMJ 2017; 358:j3024.
  27. Fong A, Serra AE, Caballero D, et al. A randomized, double-blinded, controlled trial of the effects of fluid rate and/or presence of dextrose in intravenous fluids on the labor course of nulliparas. Am J Obstet Gynecol 2017; 217:208.e1.
  28. Lee AJ, Landau R, Mattingly JL, et al. Left Lateral Table Tilt for Elective Cesarean Delivery under Spinal Anesthesia Has No Effect on Neonatal Acid-Base Status: A Randomized Controlled Trial. Anesthesiology 2017; 127:241.
  29. Wood SL, Tang S, Crawford S. Cesarean delivery in the second stage of labor and the risk of subsequent premature birth. Am J Obstet Gynecol 2017; 217:63.e1.
  30. Lee LO, Bateman BT, Kheterpal S, et al. Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group. Anesthesiology 2017; 126:1053.
  31. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017.
  32. FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. Available at: (Accessed on April 24, 2017).
  33. Nunes I, Ayres-de-Campos D, Ugwumadu A, et al. Central Fetal Monitoring With and Without Computer Analysis: A Randomized Controlled Trial. Obstet Gynecol 2017; 129:83.
  34. INFANT Collaborative Group. Computerised interpretation of fetal heart rate during labour (INFANT): a randomised controlled trial. Lancet 2017; 389:1719.
  35. Secnidasole oral granules. US Food and Drug Administration (FDA) approved product information. Revised September 2017. US National Library of Medicine. (Accessed on September 19, 2017).
  36. Giri A, Hartmann KE, Hellwege JN, et al. Obesity and pelvic organ prolapse: a systematic review and meta-analysis of observational studies. Am J Obstet Gynecol 2017.
  37. Dreyer K, van Rijswijk J, Mijatovic V, et al. Oil-Based or Water-Based Contrast for Hysterosalpingography in Infertile Women. N Engl J Med 2017; 376:2043.
  38. Soini T, Rantanen M, Paavonen J, et al. Long-term Follow-up After Endometrial Ablation in Finland: Cancer Risks and Later Hysterectomies. Obstet Gynecol 2017; 130:554.
  39. O'Leary DP, Peirce C, Anglim B, et al. Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations: A Randomized, Controlled, Open-label Trial: The P.I.C.O. Trial. Ann Surg 2017; 265:1082.
  40. Till SR, Morgan DM, Bazzi AA, et al. Reducing surgical site infections after hysterectomy: metronidazole plus cefazolin compared with cephalosporin alone. Am J Obstet Gynecol 2017.
  41. Mirza MR, Monk BJ, Herrstedt J, et al. Niraparib Maintenance Therapy in Platinum-Sensitive, Recurrent Ovarian Cancer. N Engl J Med 2016; 375:2154.
  42. Ledermann J, Harter P, Gourley C, et al. Olaparib maintenance therapy in platinum-sensitive relapsed ovarian cancer. N Engl J Med 2012; 366:1382.
  43. Pujade-Lauraine E, Ledermann JA, Selle F, et al. Olaparib tablets as maintenance therapy in patients with platinum-sensitive, relapsed ovarian cancer and a BRCA1/2 mutation (SOLO2/ENGOT-Ov21): a double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Oncol 2017; 18:1274.
  44. Coleman RL, Oza AM, Lorusso D, et al. Rucaparib maintenance treatment for recurrent ovarian carcinoma after response to platinum therapy (ARIEL3): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2017.
  45. (Accessed on March 29, 2017).
  46. (Accessed on September 12, 2017).
  47. Iversen L, Sivasubramaniam S, Lee AJ, et al. Lifetime cancer risk and combined oral contraceptives: the Royal College of General Practitioners' Oral Contraception Study. Am J Obstet Gynecol 2017; 216:580.e1.
  48. Jordan SJ, Na R, Johnatty SE, et al. Breastfeeding and Endometrial Cancer Risk: An Analysis From the Epidemiology of Endometrial Cancer Consortium. Obstet Gynecol 2017; 129:1059.
  49. Rossi EC, Kowalski LD, Scalici J, et al. A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study. Lancet Oncol 2017; 18:384.
  50. Melamed A, Nitecki R, Boruta DM 2nd, et al. Laparoscopy Compared With Laparotomy for Debulking Ovarian Cancer After Neoadjuvant Chemotherapy. Obstet Gynecol 2017; 129:861.
  51. Janda M, Gebski V, Davies LC, et al. Effect of Total Laparoscopic Hysterectomy vs Total Abdominal Hysterectomy on Disease-Free Survival Among Women With Stage I Endometrial Cancer: A Randomized Clinical Trial. JAMA 2017; 317:1224.
  52. Practice Committee of the American Society for Reproductive Medicine. Electronic address:, Practice Committee of the American Society for Reproductive Medicine. Role of metformin for ovulation induction in infertile patients with polycystic ovary syndrome (PCOS): a guideline. Fertil Steril 2017; 108:426.
  53. Ma H, Marti-Gutierrez N, Park SW, et al. Correction of a pathogenic gene mutation in human embryos. Nature 2017; 548:413.
  54. Pacheco F, Oktay K. Current Success and Efficiency of Autologous Ovarian Transplantation: A Meta-Analysis. Reprod Sci 2017; 24:1111.
  55. Taylor HS, Giudice LC, Lessey BA, et al. Treatment of Endometriosis-Associated Pain with Elagolix, an Oral GnRH Antagonist. N Engl J Med 2017; 377:28.
  56. Belva F, Roelants M, Vloeberghs V, et al. Serum reproductive hormone levels and ultrasound findings in female offspring after intracytoplasmic sperm injection: first results. Fertil Steril 2017; 107:934.
  57. Liu Z, Liu Y, Xu H, et al. Effect of Electroacupuncture on Urinary Leakage Among Women With Stress Urinary Incontinence: A Randomized Clinical Trial. JAMA 2017; 317:2493.
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