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خرید پکیج
تعداد ایتم قابل مشاهده باقیمانده : 4 مورد

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: Mar 2021. | This topic last updated: Apr 01, 2021.

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

Progesterone supplementation of pregnancies at high risk for spontaneous preterm birth (March 2021)

The efficacy of progesterone supplementation (PS) for reducing spontaneous preterm birth (PTB) in high risk pregnancies is controversial because of discordant data from randomized trials. Now, in a meta-analysis of individual participant data from 30 trials (>11,600 participants), compared with no PS, PS reduced PTB <34 weeks by approximately 20 percent in singleton gestations with a short midtrimester cervical length or a previous history of PTB, but not in unselected multiple gestations [1]. There were no clear differences in effect between vaginal progesterone and intramuscular hydroxyprogesterone caproate (17-OHPC) and no significant safety concerns. We continue to suggest 17-OHPC for patients with a previous PTB and vaginal progesterone for those with a short cervix. (See "Progesterone supplementation to reduce the risk of spontaneous preterm birth", section on 'Patients with singleton pregnancy and a short cervix or previous spontaneous preterm birth'.)

Immunogenicity of COVID-19 vaccination in pregnant and lactating people (March 2021)

The first data on the immune response of pregnant and lactating women to COVID-19 vaccination are now available. In this prospective study of 84 pregnant, 31 lactating, and 16 nonpregnant women who received an mRNA COVID-19 vaccine, the three cohorts had equivalent vaccine-induced immune responses, antibody titers were higher than those induced by SARS-CoV-2 infection during pregnancy, and vaccine-generated antibodies were present in umbilical cord blood and breast milk samples [2]. Although a small study, these data are reassuring and support our recommendation for COVID-19 vaccination of pregnant and lactating women. (See "COVID-19: Pregnancy issues and antenatal care", section on 'Vaccines'.)

One-step versus two-step diagnosis of gestational diabetes mellitus (March 2021)

A previous meta-analysis of four small trials found that one-step diagnosis of gestational diabetes (GDM) resulted in better perinatal outcomes than the traditional two-step diagnosis (table 1) in patients who were subsequently treated according to standard guidelines. Now, in the largest randomized trial comparing pregnancy outcomes of the two diagnostic approaches (>23,000 pregnancies), the one-step approach resulted in more patients diagnosed with GDM (16.5 versus 8.5 percent), but no additional improvement in pregnancy outcomes (eg, rates of large for gestational age newborn and preeclampsia were similar for both approaches) [3]. These findings support our preference for the two-step approach for diagnosis of GDM, with standard treatment of affected patients. (See "Diabetes mellitus in pregnancy: Screening and diagnosis", section on 'One-step and two-step approaches'.)

Cardiovascular risk profiles in pregnant people and adolescent offspring (March 2021)

In a multinational cohort study including over 2300 mother-child pairs, poorer maternal cardiovascular metrics (as defined by body mass index, blood pressure, total cholesterol level, glucose level, and smoking) at approximately 28 weeks of gestation were associated with poorer cardiovascular metrics in offspring examined at 10 to 14 years of age [4]. Optimizing cardiovascular health in pregnant people may benefit cardiovascular health in offspring, possibly in part by avoiding adverse epigenetic modifications in utero. (See "The preconception office visit", section on 'Maternal medical problems'.)

Fetal abdominal circumference <10th percentile for diagnosis of growth restriction (March 2021)

An ultrasound estimate of fetal weight <10th percentile for gestational age has been the most common threshold for suspecting fetal growth restriction (FGR). Updated guidance from the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists now considers abdominal circumference <10th percentile for gestational age another acceptable threshold for suspecting FGR [5]. We agree with these thresholds and note that the lower the percentile, the more likely the diagnosis of FGR rather than a constitutionally small fetus. (See "Fetal growth restriction: Screening and diagnosis", section on 'Diagnosis'.)

COVID-19 vaccination and pregnancy/breastfeeding (February 2021)

Pregnant/breastfeeding people have been excluded from trials evaluating COVID-19 vaccines, thus there are minimal safety and efficacy data in these populations. Some guidance recommends not withholding these vaccines based on pregnancy/lactation alone [6-8]; other guidance suggests offering vaccination with individualized decision-making [9-11]. We suggest COVID-19 vaccination for pregnant people rather than deferring vaccination until after delivery/breastfeeding, particularly for those at higher risk of COVID-19 exposure or severe disease. Although pregnancy itself is associated with an increased risk of severe infection, some patients may reasonably defer vaccination until after delivery/breastfeeding based upon shared decision-making with their health care provider that weighs their personal risk related to COVID-19 against the very limited data regarding the safety and efficacy of COVID-19 vaccines during pregnancy/breastfeeding. (See "COVID-19: Pregnancy issues and antenatal care", section on 'Vaccines' and "COVID-19: Labor, delivery, and postpartum issues and care", section on 'SARS-CoV-2 vaccines'.)

Fetal effects of maternal anesthesia during pregnancy (February 2021)

Whether anesthetics administered to the mother increase the fetus’ risk for adverse neurodevelopment is uncertain, and clinical data are lacking. An observational study including over 2000 mother/child pairs reported an association between in utero exposure to general anesthesia during maternal antenatal surgical procedures and behavioral problems at age 10 years [12]. However, these results must be interpreted with caution due to the small number of exposed children (n = 22), and the possible effects of factors other than general anesthesia. This and other evidence is inadequate to guide anesthetic practice, and necessary surgery should not be avoided or delayed during pregnancy. (See "Neurotoxic effects of anesthetics on the developing brain", section on 'Prenatal exposure to anesthesia' and "Anesthesia for nonobstetric surgery during pregnancy", section on 'Effects of anesthetics on the fetus and the pregnancy'.)

Tobacco cessation in pregnancy (January 2021)

Pregnancy presents a unique opportunity to assist individuals who use tobacco or related products in quitting. The 2021 United States Preventive Services Task Force (USPSTF) statement continues to advise asking all pregnant persons about use of tobacco and related products and offering users behavioral interventions aimed at cessation [13]. While USPSTF concluded that the balance of benefits and harms of pharmacotherapy and e-cigarettes for tobacco cessation could not be determined in pregnant persons, UpToDate suggests offering nicotine replacement therapy, in addition to behavioral interventions, to those who desire it once adequate counseling has taken place. (See "Tobacco and nicotine use in pregnancy: Cessation strategies and treatment options", section on 'Society guidelines'.)

Screening for perinatal depression (January 2021)

Practice guidelines recommend screening all pregnant and postpartum women for depression; the most widely used instrument is the self-reported 10-item Edinburgh Postnatal Depression Scale (figure 1A-B), which can be completed in less than five minutes. A cutoff score of 11 appears to maximize sensitivity plus specificity for detecting major depression. In a recent meta-analysis of 36 studies that included participant level data from over 9000 pregnant and postpartum women, this threshold optimally balanced sensitivity (0.81) and specificity (0.88) [14]. Screening for depression during pregnancy and the puerperium should be implemented with services in place to ensure follow-up for diagnosis and treatment. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Screening'.)

Effect of antenatal corticosteroids on neonatal mortality in low-resource countries (January 2021)

Administration of antenatal corticosteroids (ACS) to patients at risk for preterm birth reduces neonatal mortality when delivery occurs within seven days. In contrast to trials in high-income countries, the Antenatal Corticosteroids Trial (ACT) reported increased neonatal mortality (relative risk [RR] 1.12) in ACS-exposed infants born in low- and middle-income countries. Now, a larger randomized trial conducted by the World Health Organization (WHO) in low-resource countries found that ACS administered at 260/7ths to 336/7ths weeks reduced neonatal death (RR 0.84) and stillbirth or neonatal death (RR 0.88) compared with placebo [15]. The difference between these results and those of ACT may relate to better selection of patients for whom ACS is warranted. In the WHO trial, 90 percent of the infants who were exposed to ACS were born preterm, compared with only 16 percent of those in ACT. (See "Antenatal corticosteroid therapy for reduction of neonatal respiratory morbidity and mortality from preterm delivery", section on 'Short-term harms'.)

Nonsteroidal anti-inflammatory drugs and oligohydramnios (November 2020)

Nonsteroidal anti-inflammatory drugs (NSAIDs) carry well known risks to the fetus during the third trimester of pregnancy but also have rare risks when used earlier in pregnancy. The FDA recently issued a warning that use of NSAIDs around 20 weeks gestation or later in pregnancy may rarely cause fetal renal dysfunction leading to oligohydramnios and, in some cases, neonatal renal impairment [16]. These outcomes could be seen within 48 hours of NSAID use but typically occurred after days to weeks of treatment. The FDA suggests that if NSAID treatment is necessary between 20 to 30 weeks of pregnancy that it be at the lowest effective dose and shortest duration possible, that monitoring by ultrasound be considered for those treated for more than 48 hours, and that the drug be discontinued if oligohydramnios occurs. (See "Safety of rheumatic disease medication use during pregnancy and lactation", section on 'NSAIDs'.)

Metformin treatment of diabetes in pregnancy (November 2020)

Data continue to accrue regarding the potential benefits and adverse effects of metformin use during pregnancy. In a trial in which pregnant women with type 2 diabetes were randomly assigned to receive insulin alone or both insulin and metformin, combined treatment improved maternal glycemic control, reduced total gestational weight gain, and reduced the frequency of large for gestational age and macrosomic newborns; however, the rate of small for gestational age newborns was higher [17]. In most patients with preexisting diabetes on metformin, we recommend not continuing metformin beyond the transition to insulin before or in early pregnancy, given concerns about the increased risks for small for gestational age newborns and previous data showing an increased risk for childhood adiposity. (See "Pregestational (preexisting) diabetes mellitus: Antenatal glycemic control", section on 'Specific drugs'.)

COVID-19 course in pregnancy (November 2020)

Pregnant women should be counseled to adhere closely to public health precautions designed to avoid exposure to SARS-CoV-2, given increasing evidence that they are at higher risk for severe illness from COVID-19. In a report from the US Centers for Disease Control and Prevention (CDC) that included over 23,000 pregnant women and over 386,000 nonpregnant women of reproductive age with symptomatic laboratory-confirmed SARS-CoV-2 infection, pregnant patients had higher rates of intensive care unit admission (10.5 versus 3.9 per 1000 cases), invasive ventilation (2.9 versus 1.1 per 1000 cases), and death (1.5 versus 1.2 cases per 1000) [18]. In another CDC report, hospitalized pregnant women with COVID-19 had slightly higher rates of preterm birth (PTB) and cesarean delivery (CD) compared with national averages (PTB: 12.9 versus 10.2 percent; CD: 34 versus 31.9 percent) [19]. (See "COVID-19: Pregnancy issues and antenatal care", section on 'Maternal course'.)

Exome sequencing in nonimmune hydrops fetalis (October 2020)

The etiology of nonimmune hydrops fetalis (NIHF) is determined in 60 to 85 percent of cases, and this rate can be increased with use of advanced genomic testing. In a study of 127 consecutive cases of unexplained NIHF defined by the presence of ≥1 rather than 2 abnormal fluid collections in fetal compartments, exome sequencing identified a diagnostic genetic variant in 29 percent and a variant of potential clinical significance in another 9 percent of cases [20]. Disorders affecting the RAS-MAPK cell-signaling pathway (eg, Noonan syndrome) were most common, accounting for 30 percent of the genetic diagnoses. Information from exome sequencing was clinically important as it influenced counseling and clinical care. When a genetic etiology for NIHF is suspected but standard testing is nondiagnostic, we suggest consultation with a genetics professional to help direct advanced testing. (See "Nonimmune hydrops fetalis", section on 'General approach'.)

New guideline for hereditary hemorrhagic telangiectasia (October 2020)

The second International Consensus Guideline for hereditary hemorrhagic telangiectasia (HHT) has been published. Six areas were addressed, including therapies for epistaxis and gastrointestinal bleeding, evaluation and treatment of anemia, use of anticoagulation, screening for hepatic arteriovenous malformations, and recommendations for children and pregnant women [21]. Preconception and prenatal diagnostic options were discussed. As emphasized in UpToDate, shared decision-making regarding surveillance strategies is an especially important component of HHT management. (See "Hereditary hemorrhagic telangiectasia (HHT): Routine care including screening for asymptomatic arteriovenous malformations (AVMs)", section on 'Overview of screening strategy'.)

INTRAPARTUM AND POSTPARTUM OBSTETRICS

Intrapartum maternal oxygen supplementation does not improve umbilical artery pH (February 2021)

Intrapartum maternal oxygen administration has been a standard component among interventions for fetal resuscitation, but increasing evidence suggests that it has no clinical benefit. In a meta-analysis of randomized trials comparing oxygen supplementation versus room air for patients in labor or undergoing scheduled cesarean, administering oxygen did not reduce the incidence of umbilical artery pH<7.2 or improve other neonatal outcomes (Apgar scores, neonatal intensive care unit admissions) in laboring patients [22]. A limitation of the analysis is that it did not specifically assess use of oxygen for management of abnormal fetal heart rate (FHR) tracings. Based on the body of data on the lack of fetal benefit from maternal oxygen supplementation, we no longer administer oxygen to laboring patients with FHR abnormalities. (See "Intrapartum category I, II, and III fetal heart rate tracings: Management", section on 'Interventions of no or uncertain benefit'.)

Elective induction versus expectant management at 39 weeks gestation (February 2021)

Evidence of the benefits of induction rather than expectant management at 39 weeks of gestation continue to accrue. In a secondary analysis of the ARRIVE trial of elective induction versus expectant management, composite perinatal adverse outcome in expectantly managed patients increased with increasing gestational age (39 weeks: 5.1 percent, 40 weeks: 5.9 percent, 41 to 42 weeks: 8.2 percent); cesarean rates also increased (17, 22, and 38 percent, respectively) [23]. We advise shared decision-making regarding elective induction at 39 weeks, taking into account the values and preferences of the patient as well as the availability of labor unit beds and staffing. (See "Induction of labor with oxytocin", section on 'Evidence'.)

Pregnancy and seizure control in patients with epilepsy (January 2021)

Meticulous dosing and monitoring of antiseizure drugs during pregnancy in patients with epilepsy is important to prevent worsened seizure control. In a recent prospective cohort study that included nearly 300 pregnant patients with epilepsy, seizure frequency was higher during pregnancy than during the nongravid baseline in approximately one-quarter of patients and in a similar proportion of matched, nonpregnant controls with epilepsy during corresponding periods of time [24]. However, more pregnant patients required at least one change in antiseizure drug dosing (74 versus 31 percent), in many cases to anticipate alterations in drug clearance during and after pregnancy. These findings will help to counsel patients with epilepsy on expectations for seizure control during pregnancy. (See "Risks associated with epilepsy during pregnancy and postpartum period", section on 'Seizure control'.)

Lung function decline during pregnancy in lymphangioleiomyomatosis (November 2020)

Small retrospective case series suggest that pregnancy in women with lymphangioleiomyomatosis (LAM) results in disease progression. A prospective study that compared pre- and post-pregnancy lung function in 16 pregnant women with LAM confirmed a significant decline in the forced expiratory volume in one second and diffusing capacity for carbon monoxide during pregnancy [25]. Five women developed pneumothorax. Lung function continued to decline in many patients after delivery and 10 patients required initiation of sirolimus. We continue to inform women with LAM about the increased risks associated with pregnancy. (See "Sporadic lymphangioleiomyomatosis: Treatment and prognosis", section on 'Pregnancy and birth control'.)

Updated neonatal resuscitative guidelines (November 2020)

The 2020 updated neonatal resuscitative guidelines from the American Heart Association/American Academy of Pediatrics/International Liaison Committee on Resuscitation (AHA/AAP/ILCOR) are available [26,27]. Unlike the pediatric update, which includes notable changes and new algorithms, the neonatal guidelines remain largely unchanged with no changes to the previously published neonatal resuscitative algorithm (algorithm 1). However, additional modifications based on new evidence include delay of cord clamping in uncomplicated deliveries while the infant is placed with the mother for skin-to-skin contact, confirmation of recommended initial oxygen concentration at the onset of resuscitation, and an increase in time before discontinuing resuscitative efforts from 10 to 20 minutes. (See "Neonatal resuscitation in the delivery room", section on 'Overview'.)

Labor epidurals and autism (November 2020)

Whether any aspect of labor affects the risk of autism spectrum disorders (ASD) in offspring is an active area of investigation. In a retrospective birth cohort study including 148,000 vaginal deliveries, the frequency of ASD was higher in children of mothers who had labor epidural analgesia (LEA) than in children of mothers who did not have LEA (1.9 versus 1.3 percent) [28]. However, there were significant methodologic problems with the study, such as important demographic differences between the study groups and lack of details regarding the course of labor and delivery. After review of all available data, we believe that there is no convincing evidence that LEA causes ASD and no evidence that choosing another form of labor analgesia reduces the risk of ASD. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Epidural analgesia and childhood autism'.)

New device for treating postpartum hemorrhage due to atony (September 2020)

A novel device has been developed that applies low-level intrauterine vacuum (70 to 90 mmHg) to rapidly evacuate blood and facilitate physiologic uterine contraction in patients with postpartum hemorrhage (PPH) due to atony unresponsive to uterotonic drugs and uterine massage. In a prospective multicenter single-arm treatment study of such patients, the device controlled bleeding in 100 of 106 participants (94 percent), typically within 2 to 5 minutes of beginning the vacuum [29]. Based on this study, the US Food and Drug Administration granted premarket approval of the device in August 2020 [30]. This device may become the preferred intervention for patients who do not respond to oxytocin alone, given that it is rapidly effective and not associated with serious procedure-related adverse events. (See "Postpartum hemorrhage: Medical and minimally invasive management", section on 'Vacuum-induced uterine tamponade'.)

OFFICE GYNECOLOGY

Anaerobic coverage for treatment of pelvic inflammatory disease (January 2021)

Anaerobic bacteria are frequently recovered from the upper genital tract of women with acute pelvic inflammatory disease (PID), but whether antibiotic regimens for PID should include anaerobic coverage has been controversial. In a trial of 233 women with mild to moderate PID who were treated with ceftriaxone and doxycycline and randomly assigned to additionally receive either metronidazole (500 mg twice daily) or placebo for 14 days, clinical improvement rates at three days were similar in the two groups [31]. However, at 30 days, women in the metronidazole group had a lower rate of pelvic tenderness (9 versus 20 percent) and a nonsignificant trend towards a higher 30-day clinical cure rate (96 versus 90 percent). Adherence was similar in both groups. Given the potential additional benefits of anaerobic coverage, we now add metronidazole to standard outpatient therapy for PID. (See "Pelvic inflammatory disease: Treatment in adults and adolescents", section on 'Anaerobic bacteria'.)

Single-dose ceftriaxone for treatment of gonococcal infections (January 2021)

In the United States, the Centers for Disease Control and Prevention updated its guidance on treatment of gonococcal infections to recommend ceftriaxone as the preferred regimen, given as a single intramuscular dose of 500 mg for individuals who weigh <150 kg or 1 g for individuals who weigh ≥150 kg [32]. Previous recommendations were for combination therapy with a lower dose of ceftriaxone plus azithromycin. However, the previous preference for combination therapy was based on a theoretical benefit, which is now outweighed by decreasing susceptibility to azithromycin in Neisseria gonorrhoeae. A higher dose of ceftriaxone is recommended because of concern that lower doses are unlikely to be effective against isolates with higher minimum inhibitory concentrations to ceftriaxone, which have increased in prevalence. Presumptive treatment of chlamydia with doxycycline is warranted if chlamydia coinfection has not been ruled out. We agree with these updated guidelines. (See "Treatment of uncomplicated Neisseria gonorrhoeae infections", section on '"High" dose intramuscular ceftriaxone'.)

HPV vaccination and cervical cancer (October 2020)

Most clinical trial data on the impact of human papillomavirus (HPV) vaccination on cervical disease demonstrate reductions in cervical intraepithelial neoplasia and adenocarcinoma in situ. In a nationwide study from Sweden that included over 1.6 million females aged 10 to 30 years, HPV vaccine receipt was associated with a reduction in the incidence of invasive cervical cancer (47 versus 94 cases per 100,000 among those who had not been vaccinated; adjusted incidence rate ratio 0.37, 95% CI 0.21-0.57) [33]. The lowest incidence was among those who were vaccinated before 17 years of age. These findings lend further support for routine HPV vaccination in individuals in the appropriate age range, ideally prior to sexual debut. (See "Human papillomavirus vaccination", section on 'Cervical, vaginal, and vulvar disease'.)

Gabapentin for chronic pelvic pain in females (October 2020)

Similar to other chronic pain syndromes, gabapentin has become widely used for the treatment of female chronic pelvic pain (CPP). In a multisite United Kingdom trial that randomly assigned 306 females with CPP of at least three months duration and no identifiable pathology to gabapentin or placebo, worst and average pain scores were similar for both groups, while dizziness was more common in the active treatment group (54 versus 26 percent) at 13 to 16 weeks after randomization [34]. Study limitations included the short follow-up, likely inclusion of patients with overlapping pain conditions, and inability to control for variation of individual pain response. As such, UpToDate continues to offer gabapentin to females with CPP as part of a multimodal, interdisciplinary treatment approach that includes counseling on potential side effects. (See "Chronic pelvic pain in adult females: Treatment", section on 'Review of data'.)

GYNECOLOGIC SURGERY

Oophorectomy at hysterectomy and breast cancer risk (February 2021)

Oophorectomy at the time of hysterectomy may reduce the risk of breast cancer, although the age at which this benefit occurs is uncertain. In a retrospective study including over 49,000 patients undergoing hysterectomy for benign disease, bilateral salpingo-oophorectomy (BSO) was associated with a lower risk of developing breast cancer in patients <60 but not ≥60 years [35]. BSO was also associated with increased all-cause mortality. When counseling patients under age 60 about BSO at the time of hysterectomy, we include a reduction in risk of breast cancer as a potential benefit and increased all-cause mortality as a potential harm, especially in the absence of estrogen therapy. (See "Elective oophorectomy or ovarian conservation at the time of hysterectomy", section on 'Breast cancer risk reduction'.)

Preoperative estrogen management in transgender women (February 2021)

As estrogen therapy is associated with increased risk of venous thromboembolism (VTE), the optimal preoperative management of estrogen for transgender women undergoing major surgery has been debated. A retrospective review of 407 transfeminine individuals undergoing labiaplasty with and without preoperative estrogen cessation reported one VTE, which occurred in a patient whose hormones had been stopped [36]. While the absence of increased VTE risk in this small series is reassuring, UpToDate advises transgender women to reduce their estrogen dose, typically to 1 mg of oral estradiol starting three weeks prior to surgery, until high quality data regarding VTE risk are available. (See "Transgender surgery: Male to female", section on 'Perioperative management of estrogen therapy'.)

GYNECOLOGIC ONCOLOGY

Secondary gynecologic malignancies after radiotherapy for rectal cancer (February 2021)

Radiation-induced secondary malignancies are a known complication of pelvic irradiation, but the incidence of a second gynecological malignancy has not been well studied. In a cohort study including over 20,000 female patients surgically treated for rectal cancer, neoadjuvant radiation therapy was associated with a higher cumulative incidence of uterine corpus and ovarian cancers at 30 years compared with no radiotherapy (4.5 versus 1.5 percent) [37]. Patients treated for rectal cancer undergo periodic follow-up that includes posttreatment computed tomography surveillance; we do not perform additional testing (eg, ultrasound, tumor markers) to identify secondary gynecologic cancers. (See "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Uncertain risk factors' and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Incidence and risk factors", section on 'Pelvic radiation' and "Approach to the long-term survivor of colorectal cancer", section on 'Second malignancies'.)

Cervical cancer and vertical transmission (January 2021)

Vaginal delivery in the setting of cervical cancer has unclear risks to the fetus. In one report, pediatric lung cancer was diagnosed in two children, both delivered vaginally, whose mothers were diagnosed with cervical carcinoma within 12 weeks of delivery [38]. The peribronchial pattern of tumor growth suggested aspiration of tumor-contaminated vaginal fluids during birth, and the pediatric and maternal tumor specimens revealed histologic and genetic similarities. However, as vertical transmission is rare, we reserve cesarean delivery for standard obstetrical indications in most patients with early-stage cervical cancer. (See "Cervical cancer in pregnancy", section on 'Vertical transmission'.)

Health care workers at risk for human papillomavirus (HPV) exposure (September 2020)

Smoke or vapor generated from ablative and excisional procedures (eg, loop electrosurgical excision procedure [LEEP]) for cervical intraepithelial neoplasia can expose health care workers to human papillomavirus (HPV) [39]. This exposure may increase the risk of developing HPV-associated upper aerodigestive tract diseases such as oropharyngeal cancer and laryngeal papillomatosis. To decrease this risk, personal protection equipment (N-95 masks) and smoke evacuation systems should be used during these procedures. In addition, we agree with guidance from the American Society for Colposcopy and Cervical Pathology (ASCCP) and others that the entire operative team, including physicians, nurses, and operating room staff, receive the HPV vaccine, if not already vaccinated [40]. (See "Cervical intraepithelial neoplasia: Diagnostic excisional procedures", section on 'Health care workers at risk for occupational exposure'.)

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  34. Horne AW, Vincent K, Hewitt CA, et al. Gabapentin for chronic pelvic pain in women (GaPP2): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2020; 396:909.
  35. Chow S, Raine-Bennett T, Samant ND, et al. Breast cancer risk after hysterectomy with and without salpingo-oophorectomy for benign indications. Am J Obstet Gynecol 2020; 223:900.e1.
  36. Kozato A, Fox GWC, Yong PC, et al. No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery. J Clin Endocrinol Metab 2021; 106:e1586.
  37. Guan X, Wei R, Yang R, et al. Association of Radiotherapy for Rectal Cancer and Second Gynecological Malignant Neoplasms. JAMA Netw Open 2021; 4:e2031661.
  38. Arakawa A, Ichikawa H, Kubo T, et al. Vaginal Transmission of Cancer from Mothers with Cervical Cancer to Infants. N Engl J Med 2021; 384:42.
  39. Harrison R, Huh W. Occupational Exposure to Human Papillomavirus and Vaccination for Health Care Workers. Obstet Gynecol 2020; 136:663.
  40. https://www.asccp.org/Assets/d3abdb05-25c5-4e58-9cec-05c11fb2b920/637177876310030000/hpv-vaccine-member-announcment-02-19-20-pdf (Accessed on September 28, 2020).
Topic 8350 Version 10221.0

References

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5 : Fetal Growth Restriction: ACOG Practice Bulletin, Number 227.

6 : Fetal Growth Restriction: ACOG Practice Bulletin, Number 227.

7 : Fetal Growth Restriction: ACOG Practice Bulletin, Number 227.

8 : The Advisory Committee on Immunization Practices' Interim Recommendation for Allocating Initial Supplies of COVID-19 Vaccine - United States, 2020.

9 : The Advisory Committee on Immunization Practices' Interim Recommendation for Allocating Initial Supplies of COVID-19 Vaccine - United States, 2020.

10 : The Advisory Committee on Immunization Practices' Interim Recommendation for Allocating Initial Supplies of COVID-19 Vaccine - United States, 2020.

11 : The Advisory Committee on Immunization Practices' Interim Recommendation for Allocating Initial Supplies of COVID-19 Vaccine - United States, 2020.

12 : Prenatal Exposure to General Anesthesia and Childhood Behavioral Deficit.

13 : Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: US Preventive Services Task Force Recommendation Statement.

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16 : Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries.

17 : Metformin in women with type 2 diabetes in pregnancy (MiTy): a multicentre, international, randomised, placebo-controlled trial.

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19 : Birth and Infant Outcomes Following Laboratory-Confirmed SARS-CoV-2 Infection in Pregnancy - SET-NET, 16 Jurisdictions, March 29-October 14, 2020.

20 : Exome Sequencing for Prenatal Diagnosis in Nonimmune Hydrops Fetalis.

21 : Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia.

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23 : Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients.

24 : Changes in Seizure Frequency and Antiepileptic Therapy during Pregnancy.

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30 : Intrauterine Vacuum-Induced Hemorrhage-Control Device for Rapid Treatment of Postpartum Hemorrhage.

31 : A Randomized Controlled Trial of Ceftriaxone and Doxycycline, with or Without Metronidazole, for the Treatment of Acute Pelvic Inflammatory Disease.

32 : Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020.

33 : HPV Vaccination and the Risk of Invasive Cervical Cancer.

34 : Gabapentin for chronic pelvic pain in women (GaPP2): a multicentre, randomised, double-blind, placebo-controlled trial.

35 : Breast cancer risk after hysterectomy with and without salpingo-oophorectomy for benign indications.

36 : No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery.

37 : Association of Radiotherapy for Rectal Cancer and Second Gynecological Malignant Neoplasms.

38 : Vaginal Transmission of Cancer from Mothers with Cervical Cancer to Infants.

39 : Occupational Exposure to Human Papillomavirus and Vaccination for Health Care Workers.