Ob/Gyn News

Sublingual misoprostol versus intramuscular oxytocin for prevention of postpartum hemorrhage in low-risk women
The authors of this article compared sublingual misoprostol with intramuscular oxytocin for prevention of postpartum hemorrhage (PPH) in low-risk vaginal birth. Overall it was shown that The efficacy of 400μg of misoprostol administered sublingually was equivalent to that of 10 units of oxytocin given intramuscularly for prevention of PPH in low-risk vaginal delivery.

HPV Screen Detects Lesions Earlier than Pap Test
DNA testing for human papillomavirus (HPV) picks up precancerous lesions earlier and prevents more cervical cancer than standard cytology screening alone, researchers found.

Coffee drinkers show lower uterine cancer risk
Women who drink four or more cups of coffee a day may have a reduced risk of developing cancer in the lining of their uterus, according to a U.S. study. Researchers who looked at more than 67,000 U.S. nurses found that women who drank that much coffee were one-quarter less likely to develop endometrial cancer than women who averaged less than a cup a day, said the study, published in the journal Cancer Epidemiology, Biomarkers & Prevention. The absolute risk that any one woman, coffee drinker or not, would develop the cancer was fairly small, with only 672 women -- or one percent of the study group -- being diagnosed with it over 26 years.

Older age, BMI, and Race increase risk for Gestational Diabetes
The authors of this study examined the individual association between advancing maternal age, body mass index (BMI) and racial origin with the development of gestational diabetes mellitus (GDM) and the interaction between these factors. There was a strong positive association between advancing maternal age and increasing BMI, individually, and the development of GDM. Compared with White Europeans aged 20–24 years, the odds ratios for GDM development were significantly higher in women older than 30 years if they were White Europeans, older than 25 years if they were Black Africans and older than 20 years if they were South Asians. The odds ratios for GDM development were significantly higher in Black Africans and South Asian irrespective of BMI, compared with White Europeans with normal BMI.

Oxidative stress markers in first trimester for assessment of preeclampsia risk
The aim of this study is to determine the predictive values of oxidative stress markers and antioxidants in the development of preeclampsia between 10–14 and also at 20–24 weeks of gestation, after the completion of vascular transformation. It was found that in preeclamptic women, both between 10–14 and also at 20–24 weeks of gestation the levels of oxLDL, MDA and PGF2α were significantly higher while PON1, SOD and TAC were significantly lower compared to healthy pregnant women; yet there was no significant difference in LHP levels. These results show that iIncreased levels of serum MDA and PGF2α, low levels of SOD and PON1 activity, in 10–14 GW may have been associated with preeclampsia etiology. High levels of MDA and PGF2α indicate that the oxidative damage is present well before the clinical symptoms occur. A panel of oxidative stress markers such as MDA and PGF2α in maternal blood can predict the development of preeclampsia long before clinical onset.

Pregnant Women Added in Updated Recommendations for Tdap
The ACIP of the US Centers for Disease Control and Prevention is taking measures to fill a gap in the protection of infants from pertussis, by vaccinating pregnant women and people in contact with infants younger than 1 year. On June 22, 2011, the ACIP issued recommendations for use of Tdap in unvaccinated pregnant women and updated recommendations regarding cocooning and special situations. Abundant evidence indicates that tetanus and diphtheria vaccines are safe during pregnancy. Although the possible teratogenicity of the vaccine was not initially studied, data from patient registries maintained by the vaccine manufacturers (Sanofi Pasteur and GlaxoSmithKline Biologicals) indicate that Tdap is safe.

No First Trimester Pregnancy Risk for ACE Inhibitors
It is likely that any teratogenic effects previously attributed to ACE inhibitors taken during the first trimester of pregnancy are the result of the underlying hypertension and not the medications themselves, researchers found. Compared with women who did not have hypertension, use of either ACE inhibitors or other anti-hypertensives in the first trimester was associated with greater odds of any malformation when the child was born (ORs 1.20 and 1.22, respectively), according to De-Kun Li, MD, PhD, of Kaiser Permanente's Division of Research in Oakland, Calif., and colleagues.

IUDs Can Lower Risk of Cervical Cancer
Cervical cancer kills over 300,000 worldwide each year and is now the second leading cause of cancer deaths among women. But new research has found that use of an intrauterine device (IUD) can reduce the risk of cervical cancer by 50 percent. Reviewing 26 studies that included approximately 20,000 women, researchers were able to determine that IUD users had only half the risk of cervical cancer. While the link between a lower risk of the human papillomavirus (HPV)—the primary cause of cervical cancer—and the IUD was unknown, the explanation most likely lies in the actions of the IUD itself.

Consequences of hyperemesis gravidarum for offspring
There is evidence that hyperemesis gravidarum (HG) is associated with a predominance of female fetuses, lower birthweights and shorter gestational ages at birth. As the adverse effects of prematurity and low birthweight on disease risk in later life have become increasingly clear, the repercussions of HG might not be limited to adverse perinatal outcomes. This article sought to summarise the evidence on short- and long-term outcomes of pregnancies with HG. The authors found that there is evidence that HG is associated with a higher female/male ratio of offspring and a higher incidence of LBW, SGA and premature babies. Little is known about the long-term health effects of babies born to mothers whose pregnancies were complicated by HG.

Impact of placenta previa on obstetric outcome
The authors of this article attempted to determine the maternal and perinatal outcome for different types of placenta previa (PP). A retrospective review of 132 singleton pregnancies with PP. Outcome measures, including the incidence of obstetric hysterectomy, the neonatal Apgar score, and the neonatal weight, were evaluated by logistic regression analysis. The incidence of PP was 1.0%. Of the women with PP, 51.5% had complete PP, 20.5% had incomplete PP, 5.3% had marginal PP, and 22.7% had a low-lying placenta. Most (93.9%) women were delivered by cesarean delivery. In total, 19.7% women underwent obstetric hysterectomy; of these, 92.3% had complete PP.  The gestational age at delivery was a significant linear predictor of the 5-minute Apgar score. Mothers with incomplete PP delivered neonates with lower Apgar scores than did mothers with complete PP. Overall it was found that A history of multiple cesarean deliveries increased the risk for obstetric hysterectomy in women with PP. The type of PP had no effect on maternal and neonatal outcome, with exception of the fact that neonates in the incomplete PP group had lower Apgar scores than neonates in the complete PP group.

New CDC Advice on Postpartum Contraception
The CDC has recommended further restrictions on the use of combined hormonal contraceptives -- those that contain both estrogen and progestin -- in the postpartum period among women who are not breast feeding. Recommendations published last year had advised that combined hormonal contraceptives should not be used in the first three weeks after delivery, with no restrictions after that, according to Naomi Tepper, MD, of the CDC's Division of Reproductive Health in Atlanta, and colleagues.

Neonatal and delivery outcomes in women with multiple sclerosis
This article sought to determine (1) whether the risk of adverse neonatal and delivery outcomes differs between mothers with and without multiple sclerosis (MS) and (2) whether risk is differentially associated with clinical factors of MS. It was found that babies born to MS mothers did not have a significantly different mean gestational age or birth weight compared to babies born to mothers without MS. MS was not significantly associated with assisted vaginal delivery or Caesarean section. There was a slightly elevated risk of adverse delivery outcomes among MS mothers with greater levels of disability, although findings were not statistically significant. Disease duration and age at MS onset were not significantly associated with adverse outcomes. This study provides reassurance to MS patients that maternal MS is generally not associated with adverse neonatal and delivery outcomes. However, the suggestion of an increased risk with greater disability warrants further investigation; these women may require closer monitoring during pregnancy.

Intravaginal administration of isosorbide mononitrate and misoprostol for cervical ripening and induction of labour
Labor induction in the presence of unfavorable cervix is a common indication for the use of prostaglandins. However, in the last years, there has been a considerable interest in the use of nitrous oxide donors for cervical ripening and labor induction. This article evaluated the efficacy and safety of intravaginal administration of NOD isosorbide mononitrate (IMN) plus misoprostol versus misoprostol alone for cervical ripening and induction of labor. Two hundred and ninety women scheduled for labor induction were recruited and assigned randomly to IMN or placebo followed by misoprostol 50 μg. The efficacy of the medication was evaluated by predetermined outcome variables for cervical ripening and induction of labor and delivery. This article showed that using a combination of IMN and misoprostol is more efficient than misoprostol alone in terms of fast cervical ripening and shortening of induction–labour interval.

Low-Dose Lamotrigine Safest Anti-Epileptic Drug in Pregnancy
Dose selection is as critical as is the choice of antiepileptic drug for avoiding birth defects in women with epilepsy, according to a large observational cohort study published online June 6 in The Lancet Neurology. In a comparison of the four most commonly prescribed antiepileptic drugs, lamotrigine at a dose of less than 300 mg/day at the time of conception was the least likely to be associated with birth defects. Valproic acid at 1,500 mg/day or more was 16 times more likely to be associated with birth defects, according to the results of the multivariate analysis. Carbamazepine and phenobarbital carried intermediate levels of risk, depending on the dose.

Maternal dietary pattern characterised by fish and seafood is associated with a lower risk of congenital heart defects in the offspring
The authors sought to  identify maternal dietary patterns related to biomarkers of methylation and to investigate associations between these dietary patterns and the risk of congenital heart defects (CHDs) in the offspring. This was a case control study of One hundred and seventy-nine mothers of children with CHD and 231 mothers of children without a congenital malformation. Food intake was obtained by food frequency questionnaires. The reduced rank regression method was used to identify dietary patterns related to the biomarker concentrations of methylation in blood. It was found that the one-carbon-rich dietary pattern, characterised by the high intake of fish and seafood, is associated with a reduced risk of CHD. This finding warrants further investigation in a randomised intervention trial.

Benefit Seen for Ovary Removal at Hysterectomy
Removing the ovaries at the same time as the uterus made a small risk of subsequent ovarian cancer even smaller without significantly increasing other risks, results of a large observational study showed. Among more than 25,000 women without a family history of ovarian cancer who had a hysterectomy, those keeping their ovaries were later diagnosed with ovarian cancer at a rate of 0.33%, compared with 0.02% in the women who also had elective bilateral salpingo-oophorectomy (BSO), reported Vanessa L. Jacoby, MD, MAS, of the University of California San Francisco, and colleagues.

Progesterone Gel Lowers Preterm Birth Risk Significantly
Progesterone gel was found to reduce the risk of giving birth before the 33rd week of pregnancy by 45% for women with a short cervix, a NIH (National Institutes of Health) study found. The cervix, part of the uterus, opens and gets shorter during labor. Women with a short cervix have a much higher risk of giving birth prematurely. The study has been published in Ultrasound in Obstetrics and Gynecology.

Oral naproxen versus oral tramadol for analgesia after cesarean delivery
The authors sought to compare the efficacies of oral naproxen and oral tramadol for pain relief after cesarean delivery, and to evaluate administration at fixed intervals versus on request. In a prospective study, 120 women were randomized into 4 groups receiving either oral naproxen or oral tramadol at fixed intervals or on request. Pain was assessed at 6, 12, 24, and 48hours after delivery, and adverse effects, mobility, breastfeeding, and the need for additional drugs for breakthrough pain were recorded. Although similar in terms of pain scores, oral naproxen might be more effective than oral tramadol for pain relief after cesarean delivery. Naproxen seemed to have a better adverse-effects profile, and therefore might be more suitable for mothers. Administration at fixed intervals might be more efficacious than administration on request.

Recurrent miscarriage is associated with a family history of ischaemic heart disease
This was a Retrospective cohort study to determine whether women experiencing recurrent miscarriage were more likely to have a family history of cardiovascular disease. A total of 74 730 first births were linked to the hospital admission and death certification data for the women’s parents through the women’s birth certificates. Overall, the parents of women who experience recurrent miscarriage are more likely to experience IHD. Recurrent miscarriage and IHD may have common patho-physiological pathways and genetic predispositions.

Passive smoke exposure and abnormal cervical cytology in a predominantly Hispanic population
The authors sought to evaluate the association between passive cigarette smoke exposure and cervical cytological abnormalities in a predominantly Hispanic sample. Passive smoke exposure was positively associated with having an abnormal Pap smear (odds ratio, 1.70; 95% confidence interval, 1.14–2.52) as was current active smoking (odds ratio 1.45; 95% confidence interval, 1.03–2.04). Neither effect was modified by ethnicity. Increasing hours per week of passive smoke exposure was associated with low-grade squamous intraepithelial lesion.

Noninvasive uterine electromyography for prediction of preterm delivery
Power spectrum (PS) of uterine electromyography (EMG) can identify true labor. EMG propagation velocity (PV) to diagnose labor has not been reported. The objective was to compare uterine EMG against current methods to predict preterm delivery. PV was found to be higher in preterm and term labor compared with nonlabor (P < .001). Combined PV and PS peak frequency predicted preterm delivery within 7 days. Uterine EMG PV and PS peak frequency more accurately identify true preterm labor than clinical methods.

Cervical polyps: evaluation of routine removal and need for accompanying D&C
This article estimated the prevalence of malignancy and dysplasia in cervical polyps and to judge whether cervical polyps need to be removed routinely. Also to investigate if a cervical polyp is an indicator of endometrial pathology and to assess the necessity of performing dilatation and curettage (D&C). Through retrospectively reviewing hospital records of 4,063 cervical polyp cases it was found that Routine removal of cervical polyps, although not mandatory, seems clinically prudent because pathological evaluation is needed to confirm the diagnosis and to rule out other possibilities. 10.9% of postmenopausal patients and 7.8% of premenopausal patients were diagnosed with any endometrial pathology accompanying cervical polyp. Therefore, cervical polyps can be a sign of endometrial disease, especially in postmenopausal women with cervical polyp endometrium should be evaluated more carefully.

Nifedipine in the management of preterm labor: a systematic review and metaanalysis
This article investigated the efficacy and safety of nifedipine as a tocolytic agent in women with preterm labor. Nifedipine was associated with a significant reduction in the risk of delivery within 7 days of initiation of treatment and before 34 weeks' gestation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, neonatal jaundice, and admission to the neonatal intensive care unit when compared with β2-adrenergic-receptor agonists. There was no difference between nifedipine and magnesium sulfate in tocolytic efficacy. Nifedipine was associated with significantly fewer maternal adverse events than β2-adrenergic-receptor agonists and magnesium sulfate. It was found that Nifedipine is superior to β2-adrenergic-receptor agonists and magnesium sulfate for tocolysis in women with preterm labor.

Efficacy of Escitalopram for Hot Flashes in Healthy Menopausal Women
Concerns regarding the risks associated with estrogen and progesterone to manage menopausal symptoms have resulted in its declining use and increased interest in nonhormonal treatments with demonstrated efficacy for hot flashes. To determine the efficacy and tolerability of 10 to 20 mg/d escitalopram, a selective serotonin reuptake inhibitor, in alleviating the frequency, severity, and bother of menopausal hot flashes. The results of this article show that among healthy women, the use of escitalopram (10-20 mg/d) compared with placebo resulted in fewer and less severe menopausal hot flashes at 8 weeks of follow-up.

Does midtrimester Nugent score or high vaginal pH predict gestational age at delivery in women at risk for recurrent preterm birth?
This article sought to estimate whether bacterial vaginosis, as defined by either Nugent score or vaginal pH, predicts gestational age at delivery in women at risk for recurrent preterm birth. It found the presence of bacterial vaginosis at 16-216/7 weeks does not predict gestational age at birth in women at risk for recurrent preterm birth.

Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery
This article sought to prospectively assess the diagnostic performance of simple ultrasound rules to predict benignity/malignancy in an adnexal mass and to test the performance of the risk of malignancy index, two logistic regression models, and subjective assessment of ultrasonic findings by an experienced ultrasound examiner in adnexal masses for which the simple rules yield an inconclusive result. This article found that the use of the simple rules has the potential to improve the management of women with adnexal masses. In adnexal masses for which the rules yielded an inconclusive result, subjective assessment of ultrasonic findings by an experienced ultrasound examiner was the most accurate diagnostic test; the risk of malignancy index and the two regression models were not useful.

Childbirth deaths from spinal anesthesia rising
The number of U.S. women who die from anesthesia complications during childbirth has fallen sharply in recent decades. But deaths specifically related to so-called regional anesthesia, which includes epidurals and spinal blocks, have crept upward since the mid-1990s, a new study finds.

Effect of subsequent pregnancies on the risk of developing diabetes following a first pregnancy complicated by gestational diabetes
Women with gestational diabetes mellitus have a high risk of developing Type 2 diabetes, secondary to post-partum progression of the chronic pancreatic ß-cell defect that underlies their presenting with dysglycaemia in pregnancy. Insulin-sensitizing therapy can decrease this risk of Type 2 diabetes, partly by offloading the secretory demand placed on the ß-cells. Conversely, however, it is not known whether the considerable secretory demands posed by the physiologic insulin resistance of a subsequent pregnancy could accelerate the progression to Type 2 diabetes. Thus, we sought to determine whether subsequent pregnancies are associated with the risk of developing diabetes following gestational diabetes. This article found that a subsequent pregnancy is not necessarily associated with an increased risk of Type 2 diabetes following gestational diabetes. Instead, the absence of recurrent gestational diabetes in a subsequent pregnancy may identify a lessened risk of developing Type 2 diabetes in this high-risk patient population.

Mechanism of hot flashes revealed
Study results indicate that the increases in skin blood flow during postmenopausal hot flashes are mediated by neural pathways and can be eased with an injection of botulinium toxin A (BTX). Introduction of BTX before a hot flash blocked or substantially inhibited the usual increase in cutaneous vascular conductance, reports the research team. "These findings strongly indicate that increases in skin blood flow during the postmenopausal hot flash are neurally mediated via the same, or related, mechanisms as cutaneous vasodilation and sweating, necessary for thermoregulation in heat-stressed individuals," say Craig Crandall (Presbyterian Hospital of Dallas, Texas, USA) and colleagues.

Chemo Affirmed Safe in Pregnancy
Women whose breast cancers were discovered during pregnancy don't need to delay treatment, according to a German registry study reported here showing that chemotherapy had no major effects on fetal outcomes. The study of 260 patients found that babies born to women who started chemotherapy during pregnancy were not significantly more likely to have reduced birth weights or adverse events, such as birth defects or neutropenia, when compared with those not exposed during gestation, said Sibylle Loibl, MD, of the German Breast Group in Neu-Isenburg, Germany, and colleagues.

Risk of Renal Cell Carcinoma After Hysterectomy
Hysterectomy is the most common gynecologic operation among women; study findings indicate that hysterectomy is associated with renal cell carcinoma. To assess the effects of hysterectomy on the incidence and risk of renal cell carcinoma, we performed a population-based cohort study using data from 184 945 women who had undergone hysterectomy (hereafter referred to as women with hysterectomy) and from 657 288 matched women who had not undergone hysterectomy. The crude incidence rates of renal cell carcinoma were 17.4 cases per 100 000 person-years among women with hysterectomy and 13.1 cases per 100 000 person-years among women without hysterectomy. This corresponded to an adjusted overall HR of 1.50 (95% CI, 1.33-1.69) for renal cell carcinomaamong women with hysterectomy vs women without hysterectomy. The risk of renal cell carcinoma was age dependent, and the highest risk was found within 10 years of surgery among women who underwent hysterectomy at age 44 years or younger.

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