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What's new in obstetrics and gynecology

What's new in obstetrics and gynecology
Authors:
Kristen Eckler, MD, FACOG
Vanessa A Barss, MD, FACOG
Alana Chakrabarti, MD
Literature review current through: Feb 2022. | This topic last updated: Feb 21, 2022.

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.

PRENATAL OBSTETRICS

Tenofovir alafenamide now a preferred NRTI agent for pregnant individuals with HIV (February 2022)

Recommended antiretroviral regimens for individuals with HIV initiating treatment during pregnancy include two nucleoside reverse transcriptase inhibitor (NRTI) agents in conjunction with either an integrase inhibitor or a booster protease inhibitor. Based on accumulating safety and efficacy data in this population, the United States Department of Health and Human Services has added tenofovir alafenamide (TAF) to the list of preferred NRTIs to use for pregnant individuals with HIV [1]. In a recent trial, regimens containing TAF versus tenofovir disoproxil fumarate (TDF) resulted in similar virologic suppression rates, but TAF was associated with fewer adverse pregnancy outcomes. We generally initiate the NRTI combination of TAF-emtricitabine in this patient population unless there is significant concern for excessive gestational weight gain, in which case a TAF-containing regimen can be used. (See "Antiretroviral selection and management in pregnant women with HIV in resource-rich settings", section on 'Selecting the NRTI backbone'.)

COVID-19 vaccination in pregnancy improves infant outcomes (February 2022)

COVID-19 vaccination of pregnant women reduces serious maternal and pregnancy morbidity from infection. In an analysis of data from 20 pediatric hospitals in the United States during a period of Delta and Omicron variant circulation, infants <6 months of age were 61 percent less likely to be hospitalized with COVID-19 if their mothers became fully vaccinated with an mRNA COVID-19 vaccine during pregnancy [2]. Furthermore, 88 percent of the intensive care unit admissions for COVID-19 and the only death occurred among infants of unvaccinated mothers. Thus, maternal vaccination also appears to protect infants in the first six months of life. (See "COVID-19: Overview of pregnancy issues", section on 'Safety and efficacy'.)

Injectable cabotegravir-rilpivirine not recommended during pregnancy (February 2022)

The injectable cabotegravir-rilpivirine regimen is a useful option for individuals with HIV who prefer to avoid oral antiretroviral therapy (ART). However, there are insufficient data on cabotegravir-rilpivirine use during pregnancy. We agree with updated United States Department of Health and Human Services recommendations to transition individuals who become pregnant while taking cabotegravir-rilpivirine to a preferred oral ART regimen for the duration of their pregnancy [1]. Initiation of the oral regimen should occur within four weeks of the last cabotegravir and rilpivirine intramuscular doses. (See "Antiretroviral selection and management in pregnant women with HIV in resource-rich settings", section on 'On ART with viral suppression'.)

TORCH screening not useful in isolated fetal growth restriction (February 2022)

Maternal TORCH (toxoplasmosis, other, rubella, cytomegalovirus [CMV], herpes) serology does not appear to be useful in the work-up of isolated fetal growth restriction (FGR). In a systematic review including nearly 500 maternal TORCH screens in pregnancies with FGR <10th percentile, 10 congenital infections were ultimately detected (8 CMV, 2 parvovirus B19), but only 2 of the 10 fetuses had isolated FGR (both had CMV) [3]. Given this low yield, we agree with the Society for Maternal-Fetal Medicine recommendation against routine TORCH serology for isolated FGR. We limit serology studies to cases with both FGR plus ultrasound findings suggestive of fetal infection and cases in which maternal history and physical examination suggest an acute infection. (See "Fetal growth restriction: Evaluation and management", section on 'Work-up for infection'.)

COVID-19 vaccination improves outcomes of infected pregnant patients (February 2022, Modified February 2022)

A recent population-based study of over 18,000 pregnant patients in Scotland provides the first evidence of more favorable pregnancy outcomes among those who have received COVID-19 vaccination [4]. In pregnant patients with COVID-19, unvaccinated individuals represented a significantly higher proportion of COVID-19-associated hospital admissions (77 percent), COVID-19-associated critical care admissions (98 percent), and perinatal deaths (100 percent of stillbirths and neonatal deaths). The perinatal death rate in the vaccinated cohort was similar to historical background rates and the rates in pregnant people without COVID-19. These findings further support universal recommendations for pregnant people to be up-to-date with COVID-19 vaccination. (See "COVID-19: Overview of pregnancy issues", section on 'Safety and efficacy'.)

Dental problems associated with oral dissolving buprenorphine (January 2022)

There are >300 reports of dental problems associated with use of buprenorphine formulations dissolved in the mouth, including the buccal formulation and sublingual tablets [5,6]. Reported problems include dental caries, abscesses, and damaged teeth, many of which have required tooth removal. The incidence of dental problems with buprenorphine is unknown. Patients who use orally dissolving buprenorphine should swish and swallow water after the drug has dissolved, see a dentist soon after starting the drug, and make sure the dentist knows they are taking the drug. The US Food and Drug Administration (FDA) has issued a related safety advisory and will mandate a label change. (See "Use of opioids in the management of chronic non-cancer pain", section on 'Buprenorphine for chronic pain'.)

Maternal hydroxyprogesterone caproate exposure and cancer risk in offspring (January 2022)

Few studies have evaluated long-term outcomes of fetuses exposed to maternal progesterone supplementation for prevention of preterm birth. A retrospective population-based study including >18,000 mother-child dyads now reports that offspring of mothers who received hydroxyprogesterone caproate (17-OHPC) during pregnancy between 1959 and 1966 were at increased risk of any cancer (incidence: 30 versus 14 per 100,000 persons; adjusted hazard ratio 2.6) [7]. Most exposures were in the first trimester in patients with threatened abortion. Whether this association is germane to the current use of 17-OHPC beginning at 16 to 20 weeks to prevent preterm birth is not known. (See "Progesterone supplementation to reduce the risk of spontaneous preterm labor and birth", section on 'Safety, side effects, and adverse effects'.)

Impact of cannabis use on pregnancy outcomes (January 2022)

As cannabis use continues to increase, more information regarding its impact on pregnancy outcomes has become available. A retrospective cohort study of over 32,500 pregnant individuals reported that prenatal cannabis use was associated with an approximately 30 percent increase in risk of low birth weight and small for gestational age infants compared with non-use [8]. The study controlled for cigarette use, but ascertainment of cannabis use by self-report was a limitation. We and several medical societies continue to advise against cannabis use in pregnancy because of potential adverse pregnancy and childhood neurodevelopmental outcomes. (See "Substance use during pregnancy: Overview of selected drugs", section on 'Obstetric outcomes'.)

Placental abruption and future risk of cardiovascular disease (January 2022)

Accumulating data support the hypothesis that abnormalities of placental development are a harbinger of future maternal cardiovascular disease (CVD). In a meta-analysis of 11 cohort studies including over 6 million pregnancies, nearly 70,000 abruptions, and nearly 50,000 cases of CVD (including stroke), the risk of future morbidity/mortality from CVD was significantly higher among patients with abruption (17 versus 9 per 1000 births) and positively correlated with the number of abruptions [9]. Based on these and other findings, patients who have had an abruption may benefit from postpartum counseling and interventions to mitigate future CVD risk. (See "Placental abruption: Management and long-term prognosis", section on 'Long-term maternal prognosis'.)

Behavioral interventions and SGA (December 2021)

Small for gestational age (SGA) infants are at increased risk for morbidity and mortality and tend to recur in subsequent pregnancies. In a trial of over 1200 pregnancies at high risk for birth of an SGA infant, participants were randomly assigned to a structured Mediterranean diet, mindfulness-based stress reduction, or usual care from 20 weeks of gestation to delivery. The rate of SGA births was significantly lower for both structured diet (14 percent) and stress reduction (16 percent) compared with usual care (22 percent) [10]. These findings should be interpreted with caution since the trial had several limitations, including a higher proportion of SGA risk factors in the usual care group. However, both interventions are considered healthy behavioral changes that are reasonable in any pregnancy. (See "Fetal growth restriction: Evaluation and management", section on 'Prevention in subsequent pregnancies'.)

Prevalence of iron deficiency during pregnancy (December 2021)

A new retrospective study involving over 44,000 pregnant individuals suggests that a large proportion have iron deficiency, many in the absence of anemia [11]. Ferritin was low in over half (<15 ng/mL in 24 percent, <30 ng/mL in 53 percent) and borderline (30 to 44 ng/mL) in another 25 percent. Individuals with lower household income were less likely to be screened. These data support having a high level of suspicion for iron deficiency during pregnancy, being aware of possible health care disparities, testing individuals at high risk, and evaluating the cause in all patients with anemia. Iron deficiency is correlated with adverse maternal and fetal outcomes. (See "Anemia in pregnancy", section on 'Whether to screen for iron deficiency'.)

COVID-19 is associated with increased maternal death and stillbirth rates (November 2021)

Data continue to accumulate regarding the risks of SARS-CoV-2 infection in pregnancy:

In a report of COVID-19-related deaths in Mississippi, pregnant patients had a higher case fatality rate than nonpregnant females of reproductive age (9 versus 2.5 deaths per 1000 SARS-CoV-2 infections) [12]. Fourteen of the 15 maternal deaths were in patients with comorbidities and none of the 15 patients were fully vaccinated. (See "COVID-19: Overview of pregnancy issues".)

In an analysis of over 8000 stillbirths among 1.2 million delivery hospitalizations in the United States during the pandemic, pregnant COVID-19 patients had a higher stillbirth rate than those without COVID-19 (1.26 versus 0.64 percent of deliveries) [13]. (See "COVID-19: Overview of pregnancy issues", section on 'Pregnancy and newborn outcomes'.)

Although incomplete information and ascertainment bias limit interpretation, these findings provide further support for vaccinating pregnant patients and those planning pregnancy to reduce maternal and fetal death.

Pandemic impacts cannabis use during pregnancy (October 2021)

Increased stress experienced during the COVID-19 pandemic caused many people to increase their use of cannabis, including pregnant individuals. A northern California health care system that performs universal toxicology testing in early pregnancy reported a 25 percent increase in maternal cannabis use during the first eight months of the pandemic compared with the 15 months prior (absolute use increased from 6.8 to 8.1 percent) [14]. This increase is concerning because approximately 50 percent of female marijuana users continue use across gestation. We advise pregnant individuals to avoid marijuana use because of concerns over fetal neurodevelopment. (See "Substance use during pregnancy: Overview of selected drugs", section on 'Prevalence of use'.)

Gestational age at time of COVID-19 and outcome (September 2021)

In an international retrospective cohort study evaluating obstetric and neonatal outcomes of nearly 400 SARS-CoV-2-positive patients according to their gestational age at the time of infection, infection after 20 weeks increased the risk for adverse obstetric outcomes, and infection after 26 weeks increased the risk for adverse neonatal outcomes [15]. Given these findings, the increased severity of COVID-19 in pregnant women, the good safety profile of SARS-CoV-2 vaccines in pregnancy, and the time it takes to become fully vaccinated, we recommend vaccination as soon as possible for women planning to conceive and pregnant women. (See "COVID-19: Overview of pregnancy issues", section on 'Pregnancy and newborn outcomes'.)

Statins not effective for preventing preeclampsia (September 2021)

Statins are generally discontinued in pregnancy; however, data from animal studies and a small pilot trial in humans suggested statins may reduce the risk for preeclampsia. A multicenter randomized trial including over 1100 singleton pregnancies at high risk for term preeclampsia now reports that pravastatin 20 mg daily beginning at 35+0/7ths to 36+6/7ths weeks and continuing until birth did not reduce the incidence of preeclampsia or other adverse pregnancy outcomes compared with placebo [16]. A limitation of the trial is the late initiation and short duration of therapy. Appropriately powered randomized trials are needed to determine whether earlier initiation of therapy, use of higher doses, or use of more potent statins might be effective. (See "Preeclampsia: Prevention", section on 'Statins'.)

COVID-19 vaccination does not increase risk for miscarriage (September 2021)

Evidence of the safety of COVID-19 vaccination in pregnancy continues to accrue. In one study involving nearly 2500 pregnancies, the age-standardized cumulative risk of miscarriage was 12.8 percent individuals who received a mRNA COVID-19 vaccine preconception or prior to 20 weeks of gestation, which is similar to the expected miscarriage rate in the general obstetric population [17]. In another study including over 105,000 pregnancies, individuals who experienced miscarriage had similar odds of exposure to a COVID-19 vaccine in the prior 28 days as those with ongoing pregnancies [18]. Results were consistent with either mRNA-1273 or BNT162b2 vaccine exposure; risks specific to Ad26.COV.2.S vaccine could not be assessed due to a small number of exposures. We recommend COVID-19 vaccination regardless of pregnancy status. (See "COVID-19: Overview of pregnancy issues", section on 'Vaccination in people planning pregnancy and pregnant or recently pregnant people'.)

Timing of delivery in fetal growth restriction (August 2021)

There is little consensus about the optimum time to deliver the fetus with growth restriction (FGR). In a retrospective cohort study, infants who were severely small for gestational age (SGA, birth weight <3rd percentile) and delivered early for suspected FGR had poorer school outcomes in grades 3, 5, and 7 compared with infants with the same degree of SGA who were not suspected of having FGR (mean gestational age at birth: 37.9 versus 39.4 weeks) [19]. Although these findings suggest that avoiding early delivery of suspected FGR when safe to do so may improve school performance of SGA infants, other differences between the two groups may account for the better outcome. (See "Fetal growth restriction: Evaluation and management", section on 'Timing of delivery'.)

Maternal CMV immune globulin not effective for preventing congenital infection (August 2021)

Maternal hyperimmune globulin treatment of primary cytomegalovirus (CMV) infection in early pregnancy is an investigational approach for preventing symptomatic infection in offspring. In the largest trial of this therapy to date, which randomly assigned nearly 400 pregnant women with primary CMV infection before 24 weeks to a monthly infusion of CMV immune globulin or placebo until delivery, the composite outcome (congenital CMV infection or fetal/neonatal death if no CMV testing) was similar in both groups (23 versus 19 percent) [20]. There were no clear differences in individual outcomes (eg, death, preterm birth, birth weight <5th percentile). Given these and previous findings, practitioners should emphasize preventive behavioral measures against maternal CMV acquisition and limit use of hyperimmune globulin therapy to research studies. (See "Cytomegalovirus infection in pregnancy", section on 'CMV immune globulin'.)

INTRAPARTUM AND POSTPARTUM OBSTETRICS

Alternative birthing practices to avoid (February 2022)

The American Academy of Pediatrics recently advised avoiding the following alternative birthing practices because they have been (or may be) associated with increased risks of neonatal morbidity and mortality and have no clear benefits: water birth, vaginal seeding, umbilical cord nonseverance, placentophagy, nonmedical deferral of hepatitis B vaccination and ocular prophylaxis, and delayed bathing of newborns exposed to active genital herpes simplex virus lesions or maternal history of bloodborne pathogens (eg, HIV, hepatitis B or C virus) [21]. Supporting evidence linking each of these practices with increased risk is reviewed in the guideline. We agree with this advice. (See "Management of normal labor and delivery", section on 'Alternative birthing practices that should be avoided'.)

New consensus for managing alpha thalassemia major (January 2022)

Alpha thalassemia major (ATM; deletion of all four alpha globin genes) was once considered incompatible with life, but advances in prenatal and postnatal care have resulted in viability and good quality of life for an increasing number of individuals. A new consensus document outlines management principles for ATM, which include prenatal screening, confirmation of the diagnosis early in the pregnancy, nondirective counseling, and, for those who choose to continue the pregnancy with fetal therapy, intrauterine transfusions (IUTs) started as early as technically possible [22]. Delivery should occur in a facility that can provide high-level critical care. Some neonates may need aggressive resuscitation at birth, although this is generally unnecessary after serial IUTs. Education about options for future pregnancy should be provided. (See "Alpha thalassemia major: Prenatal and postnatal management".)

Mode of delivery and pregnancy outcomes in kidney transplant recipients (January 2022)

Most pregnant kidney transplant recipients will undergo a cesarean delivery, but there is no clear evidence to support its routine use. In a registry study of over 1400 female kidney transplant recipients with live births, approximately two-thirds underwent a trial of labor (most with a vaginal delivery) and one-third had a scheduled cesarean birth [23]. Compared with scheduled cesarean birth, a trial of labor was not associated with an increase in severe maternal morbidity and was associated with lower odds of neonatal morbidity. Among kidney transplant recipients, vaginal birth is the preferred mode of delivery, and cesarean birth should be reserved for patients with obstetric indications only. (See "Kidney transplantation in adults: Sexual and reproductive health after kidney transplantation", section on 'Mode of delivery'.)

Prophylactic negative pressure wound therapy after cesarean birth (December 2021)

The value of prophylactic negative pressure wound therapy (pNPWT) after cesarean birth is under investigation. In a meta-analysis of trials comparing pNPWT with standard wound care in patients with obesity undergoing cesarean birth, the intervention reduced the risk of surgical site infection (SSI) (1.7 versus 8.3 percent; RR 0.79, 95% CI 0.65-0.95) but not other wound complications (eg, dehiscence, seroma), readmission, or reoperation, and it increased skin blistering [24]. Limitations of the analysis included practice variations in surgical care, inconsistent definitions, lack of blinding, and industry sponsorship of some trials. Additional rigorous research is needed before pNPWT can be recommended for patients with obesity undergoing cesarean birth. (See "Cesarean birth: Patients with obesity", section on 'Negative pressure wound therapy'.)

Neuraxial anesthesia and delivery in individuals with VWD (November 2021)

In a retrospective review of 106 deliveries among 71 individuals with von Willebrand disease (VWD) seen by a high-risk anesthesia consult service, neuroaxial anesthesia was used in 89 percent without complications [25]. Treatment with desmopressin (DDAVP) or a von Willebrand factor (VWF) concentrate was used in approximately one-third. Postpartum hemorrhage occurred in approximately 10 percent, mostly following cesarean delivery. We believe that most individuals with type I and mild-to-moderate type II VWD may receive neuraxial anesthesia, especially with good antepartum planning and as long as their VWF levels can be maintained at 50 to 100 international units (IU)/dL. VWF levels decline rapidly following delivery, and close monitoring is needed postpartum. (See "von Willebrand disease (VWD): Treatment of minor bleeding and routine care", section on 'Delivery and postpartum care'.)

OFFICE GYNECOLOGY

Lack of impact of assisted reproductive technology on offspring depressive disorders (February 2022)

Increasing use of assisted reproductive technology (ART), including in vitro fertilization and intracytoplasmic sperm injection, has raised questions about the technology's possible impact on offspring mental health. In the largest study to date, including over 1.2 million individuals aged 12 to 25 years followed for a median of 18 years, the risks of depression, anxiety, or suicide were similar for those conceived with ART compared with all others in adjusted analysis [26]. Although the study used billing codes as proxy for clinical diagnoses, the results are consistent with prior studies and reassuring that use of ART does not increase the risk of depressive disorders in offspring. (See "Assisted reproductive technology: Infant and child outcomes", section on 'General health'.)

COVID-19 vaccination does not affect fertility (January 2022)

Possible cross-reactivity between antibodies to the SARS-CoV-2 virus's spike protein and a protein involved in embryo development raised concerns for impaired fertility following either viral infection or vaccination. In the largest retrospective cohort study comparing 222 vaccinated with 983 unvaccinated females undergoing in vitro fertilization (IVF) between February and September 2021, outcomes of ovarian stimulation and embryo transfer were similar for both groups, including similar fertilization and clinical pregnancy rates [27]. These data add to the body of evidence supporting lack of negative effects of vaccination on fertility or IVF cycles. (See "In vitro fertilization: Overview of clinical issues and questions", section on 'No proven effect'.)

Mifepristone access and abortion safety (January 2022)

Mifepristone, a progesterone receptor antagonist often used in medical and surgical abortions, is only available in some countries with Risk Evaluation and Mitigation Strategy (REMS) restrictions. However, such restrictions may not reduce adverse events or abortion rates. In a retrospective study of >300,000 abortions performed in Canada, rates of severe adverse events and other complications from abortion were low and stable before and after mifepristone availability and before and after REMS-like restrictions [28]. The rate of medication abortion increased after REMS-like restrictions were lifted, but the overall rate of abortion remained stable. These findings are consistent with other studies that suggest abortion remains safe when access to mifepristone is unrestricted. (See "Overview of pregnancy termination", section on 'Legal issues'.)

Updated sexually transmitted infections guidelines from CDC (October 2021)

In 2021, the United States Centers for Disease Control and Prevention (CDC) updated its guidelines on management of sexually transmitted infections [29]. Important changes include preferences for doxycycline over azithromycin for Chlamydia trachomatis infections and nongonococcal urethritis, routine anaerobic coverage for pelvic inflammatory disease, and a moxifloxacin-based regimen for Mycoplasma genitalium. The guidelines also affirmed previous recommendations to use a 500 mg dose of intramuscular ceftriaxone for gonococcal infections. Our approaches to sexually transmitted infections are largely consistent with these updated guidelines. (See "Pelvic inflammatory disease: Treatment in adults and adolescents" and "Mycoplasma genitalium infection in males and females" and "Treatment of uncomplicated Neisseria gonorrhoeae infections" and "Treatment of Chlamydia trachomatis infection", section on 'Doxycycline as preferred agent'.)

Expedited versus expectant management of nonviable pregnancies of unknown location (August 2021)

Patients with a pregnancy of unknown location (PUL) that is nonviable (based on an abnormal trend in serum human chorionic gonadotropin [hCG] levels) can be managed expectantly or with uterine aspiration and/or systemic methotrexate therapy. In a randomized trial including over 250 patients with a persisting PUL, more patients receiving expedited management (uterine evacuation and/or methotrexate) compared with expectant management experienced successful resolution of their pregnancy without change in their initial management strategy (52 versus 36 percent); ectopic pregnancy rupture occurred in a total of five patients [30]. Success rates were similar for methotrexate versus uterine aspiration followed by methotrexate if needed. In our practice, we counsel patients that expedited management may result in faster resolution of the pregnancy and reduce the number of required follow-up tests (eg, ultrasound, serum hCG levels). (See "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Undesired or nonviable pregnancies'.)

Updated guidelines for cervical cancer screening in patients with HIV (August 2021)

In August 2021, the United States Department of Health and Human Services along with the National Institutes of Health published updated guidelines for the screening of cervical cancer in patients with HIV. In contrast to the previous guideline, cervical cancer screening at the time of HIV diagnosis is now limited to patients age 21 years or older [31]. We also follow these updated guidelines for patients without HIV who are on long-term immunosuppressive therapy (eg, solid organ transplant, allogeneic hematopoietic stem cell transplant, systemic lupus erythematous, and those with inflammatory bowel disease or rheumatologic disease requiring current immunosuppressive treatments). (See "Screening for cervical cancer in patients with HIV infection and other immunocompromised states", section on 'Initial screening' and "Screening for cervical cancer in patients with HIV infection and other immunocompromised states", section on 'HIV-negative immunosuppressed patients'.)

GYNECOLOGIC SURGERY

Timing of elective surgery after COVID-19 (January 2022)

The appropriate time to schedule elective surgery after COVID-19 is unclear. In a multicenter database study of >5000 patients in the United States with COVID-19 who underwent major elective surgery, surgery in the first four weeks after COVID-19 diagnosis was associated with higher risks of postoperative pneumonia, respiratory failure, sepsis, and pulmonary embolism [32]. These findings are consistent with a prior international study that found increased 30-day mortality after surgery performed within seven weeks of COVID-19 diagnosis. Risks were higher in patients with symptomatic COVID-19 and highest in those symptomatic at the time of surgery. The decision to schedule elective surgery should consider the severity of COVID-19, the risks of complications, and the risks of delaying surgery. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including airway management and infection control", section on 'Risk related to timing after infection'.)

GYNECOLOGIC ONCOLOGY

Role of HPV on cervical cancer prognosis (February 2022)

In almost all cases, cervical cancer is the result of human papillomavirus (HPV) infection; however, it is unclear if HPV-positive cancer confers a better prognosis than HPV-negative cancer. In a prospective study including over 2800 patients with invasive cervical cancer, HPV-positive compared with HPV-negative cancer was associated with 43 percent relative decrease in mortality [33]. These findings are consistent with patients with head and neck cancer, in whom HPV-related disease is also associated with improved prognosis. Thus, HPV-positive disease may be used along with other factors (eg, disease stage, lymph node status) to counsel patients with cervical cancer about disease prognosis. (See "Management of early-stage cervical cancer", section on 'Prognosis'.)

Pafolacianine in surgical cytoreduction of ovarian cancer (December 2021)

For patients with epithelial ovarian cancer undergoing surgical cytoreduction, the use of pafolacianine (Cytalux; an optical imaging agent used alongside near-infrared fluorescence imaging) to improve intraoperative identification of metastatic lesions is unclear. While pafolacianine increased detection of such lesions in phase II/III trials, drug-related adverse events (eg, nausea/vomiting, abdominal pain) and false positive lesions occurred in up to one-third of patients. Thus, while it was approved by the US Food and Drug Administration in November 2021 for this indication [34], we do not anticipate using pafolacianine in our practice given the high false positive rate and potential for increased morbidity. (See "Cancer of the ovary, fallopian tube, and peritoneum: Surgical cytoreduction", section on 'Role of pafolacianine'.)

Role of secondary cytoreduction in patients with recurrent ovarian carcinoma (December 2021)

Patients with recurrent epithelial ovarian carcinoma (EOC) can be managed with chemotherapy alone or in combination with secondary cytoreductive surgery; the optimal management is unclear. In Germany's DESKTOP III trial including 407 patients with recurrent platinum-sensitive EOC who had a first relapse after a platinum-free interval of at least six months and a high likelihood of complete surgical resection, patients undergoing secondary cytoreductive surgery plus chemotherapy compared with chemotherapy alone had better overall survival (median 54 versus 46 months) [35]. Complete compared with incomplete surgical resection also predicted a better survival outcome. In our practice, we suggest that patients with EOC, limited sites of recurrence, and a disease-free interval of at least six months undergo surgery plus chemotherapy rather than chemotherapy alone. (See "Cancer of the ovary, fallopian tube, and peritoneum: Surgical options for recurrent cancer", section on 'Overall survival'.)

Updated version of the AJCC TNM staging for cervical cancer (August 2021)

An updated version of the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging for cervical cancer was published in March 2021 and is available separately [36]. This version is now in alignment with the 2018 International Federation of Gynecology and Obstetrics cervical cancer staging system (table 1). Both systems are acceptable staging systems and widely used. (See "Invasive cervical cancer: Staging and evaluation of lymph nodes", section on 'Staging system'.)

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  28. Schummers L, Darling EK, Dunn S, et al. Abortion Safety and Use with Normally Prescribed Mifepristone in Canada. N Engl J Med 2022; 386:57.
  29. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1.
  30. Barnhart KT, Hansen KR, Stephenson MD, et al. Effect of an Active vs Expectant Management Strategy on Successful Resolution of Pregnancy Among Patients With a Persisting Pregnancy of Unknown Location: The ACT or NOT Randomized Clinical Trial. JAMA 2021; 326:390.
  31. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/Adult_OI.pdf (Accessed on August 19, 2021).
  32. Deng JZ, Chan JS, Potter AL, et al. The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States. Ann Surg 2022; 275:242.
  33. Lei J, Arroyo-Mühr LS, Lagheden C, et al. Human Papillomavirus Infection Determines Prognosis in Cervical Cancer. J Clin Oncol 2022; :JCO2101930.
  34. https://www.fda.gov/news-events/press-announcements/fda-approves-new-imaging-drug-help-identify-ovarian-cancer-lesions (Accessed on December 06, 2021).
  35. Harter P, Sehouli J, Vergote I, et al. Randomized Trial of Cytoreductive Surgery for Relapsed Ovarian Cancer. N Engl J Med 2021; 385:2123.
  36. Olawaiye AB, Baker TP, Washington MK, Mutch DG. The new (Version 9) American Joint Committee on Cancer tumor, node, metastasis staging for cervical cancer. CA Cancer J Clin 2021; 71:287.
Topic 8350 Version 10977.0

References

1 : Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission. Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States. https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new-guidelines (Accessed on January 18, 2022).

2 : Effectiveness of Maternal Vaccination with mRNA COVID-19 Vaccine During Pregnancy Against COVID-19-Associated Hospitalization in Infants Aged<6 Months - 17 States, July 2021-January 2022.

3 : A systematic review of maternal TORCH serology as a screen for suspected fetal infection.

4 : SARS-CoV-2 infection and COVID-19 vaccination rates in pregnant women in Scotland.

5 : Sublingual buprenorphine and dental problems: a case series.

6 : Sublingual buprenorphine and dental problems: a case series.

7 : In utero exposure to 17a-hydroxyprogesterone caproate and risk of cancer in offspring

8 : Prenatal Cannabis Use and Infant Birth Outcomes in the Pregnancy Risk Assessment Monitoring System.

9 : Maternal Cardiovascular and Cerebrovascular Health After Placental Abruption: A Systematic Review and Meta-Analysis (CHAP-SR).

10 : Effects of Mediterranean Diet or Mindfulness-Based Stress Reduction on Prevention of Small-for-Gestational Age Birth Weights in Newborns Born to At-Risk Pregnant Individuals: The IMPACT BCN Randomized Clinical Trial.

11 : Suboptimal iron deficiency screening in pregnancy and the impact of socioeconomic status in a high-resource setting.

12 : COVID-19–Associated Deaths After SARS-CoV-2 Infection During Pregnancy—Mississippi, March 1, 2020–October 6, 2021

13 : Risk for Stillbirth Among Women With and Without COVID-19 at Delivery Hospitalization - United States, March 2020-September 2021.

14 : Rates of Prenatal Cannabis Use Among Pregnant Women Before and During the COVID-19 Pandemic.

15 : Severe Acute Respiratory Syndrome Coronavirus 2 and Pregnancy Outcomes According to Gestational Age at Time of Infection.

16 : Pravastatin Versus Placebo in Pregnancies at High Risk of Term Preeclampsia.

17 : Receipt of mRNA Covid-19 Vaccines and Risk of Spontaneous Abortion.

18 : Spontaneous Abortion Following COVID-19 Vaccination During Pregnancy.

19 : Association Between Iatrogenic Delivery for Suspected Fetal Growth Restriction and Childhood School Outcomes.

20 : A Trial of Hyperimmune Globulin to Prevent Congenital Cytomegalovirus Infection.

21 : Risks of Infectious Diseases in Newborns Exposed to Alternative Perinatal Practices

22 : Consensus statement for the perinatal management of patients withαthalassemia major.

23 : Mode of Obstetric Delivery in Kidney and Liver Transplant Recipients and Associated Maternal, Neonatal, and Graft Morbidity During 5 Decades of Clinical Practice.

24 : Effect of negative-pressure wound therapy on wound complications in obese women after caesarean birth: a systematic review and meta-analysis.

25 : Anesthetic Management of Von Willebrand Disease in Pregnancy: A Retrospective Analysis of a Large Case Series.

26 : Long-term Follow-up of Psychiatric Disorders in Children and Adolescents Conceived by Assisted Reproductive Techniques in Sweden.

27 : In Vitro Fertilization and Early Pregnancy Outcomes After Coronavirus Disease 2019 (COVID-19) Vaccination.

28 : Abortion Safety and Use with Normally Prescribed Mifepristone in Canada.

29 : Sexually Transmitted Infections Treatment Guidelines, 2021.

30 : Effect of an Active vs Expectant Management Strategy on Successful Resolution of Pregnancy Among Patients With a Persisting Pregnancy of Unknown Location: The ACT or NOT Randomized Clinical Trial.

31 : Effect of an Active vs Expectant Management Strategy on Successful Resolution of Pregnancy Among Patients With a Persisting Pregnancy of Unknown Location: The ACT or NOT Randomized Clinical Trial.

32 : The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States.

33 : Human Papillomavirus Infection Determines Prognosis in Cervical Cancer.

34 : Human Papillomavirus Infection Determines Prognosis in Cervical Cancer.

35 : Randomized Trial of Cytoreductive Surgery for Relapsed Ovarian Cancer.

36 : The new (Version 9) American Joint Committee on Cancer tumor, node, metastasis staging for cervical cancer.