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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

Perinatal depression and mortality (March 2024)

Perinatal depression is associated with an increased risk of death. An analysis of a national register from Sweden compared outcomes among individuals with and without a diagnosis of depression during pregnancy or postpartum, matched by age and year of delivery [ 1 ]. After controlling for potential confounding factors, all-cause mortality was greater in those with perinatal depression over 18 years of follow-up; the increased risk was largely driven by suicide. These results confirm previous data on the risks of perinatal depression and support our practice of screening for depression during pregnancy and postpartum. Services to ensure follow-up for diagnosis and treatment should accompany screening efforts. (See "Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and diagnosis", section on 'All cause' .)

Noninsulin antidiabetic medications and pregnancy (February 2024)

Noninsulin antidiabetic medications such as glucagon-like peptide 1 (GLP-1) agonists, sodium-glucose cotransporter 2 (SGLT-2) inhibitors, and dipeptidyl peptidase 4 (DPP-4) inhibitors are commonly used in nonpregnant individuals but avoided in pregnancy because of lack of safety data in humans and harms observed in animal studies. However, in a multinational population-based cohort study including nearly 2000 individuals with preconception/first trimester exposure to these medications, the frequency of congenital anomalies was not increased compared with insulin [ 2 ]. A limitation of the study is that it did not adjust for potential differences in A1C, diabetes severity, or diabetes duration, which could obscure true effects on risk for congenital anomalies. We continue to avoid use of GLP-1 agonists, SGLT-2 inhibitors, and DPP-4 inhibitors in females planning to conceive and in pregnancy. (See "Pregestational (preexisting) diabetes: Preconception counseling, evaluation, and management", section on 'Patients on preconception noninsulin antihyperglycemic agents' .)

Updates to the United States perinatal HIV clinical guidelines (February 2024)

The United States Department of Health and Human Services has released updates to the perinatal HIV clinical guidelines [ 3 ]. Ritonavir-boosted darunavir is now a preferred agent only for treatment-naïve pregnant individuals who have used cabotegravir-based pre-exposure prophylaxis, because of the concern for integrase inhibitor-resistant mutations; for other pregnant individuals, it is now an alternative rather than preferred agent. Additionally, bictegravir, which was previously not recommended for initial therapy in pregnant individuals, is now an alternative agent based on new pharmacokinetic data that support its use during pregnancy. Our approach to treating HIV during pregnancy is consistent with these updated guidelines. (See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings", section on 'Selecting the third drug' .)

Combined use of metformin and insulin for treating diabetes in pregnancy (February 2024)

In patients with type 2 diabetes, insulin is the mainstay for managing hyperglycemia in pregnancy. The addition of metformin improves maternal glucose control and reduces the chances of a large for gestational age newborn, but a prior randomized trial reported an increased risk for birth of a small for gestational age (SGA) infant. A recent randomized trial comparing use of insulin alone with insulin plus metformin in nearly 800 adult pregnant patients with either preexisting type 2 diabetes or diabetes diagnosed in early pregnancy confirmed the previously reported benefits but found that both treatment groups had low and similar rates of SGA [ 4 ]. The discordancy in SGA risk needs to be explored further, as metformin cotreatment would be undesirable if this risk is real. (See "Pregestational (preexisting) diabetes mellitus: Antenatal glycemic control", section on 'Metformin' .)

Fetoplacental GDF15 linked to nausea and vomiting of pregnancy (February 2024)

Almost all pregnant people experience nausea with or without vomiting in early pregnancy; however, the pathogenesis of the disorder has been unclear. Previous studies have shown that GDF15 is expressed in a wide variety of cells, with the highest expression in placental trophoblast, and that its protein (GDF15) appears to regulate appetite. A recent study confirmed the fetoplacental unit as a major source of GDF15 and also found that higher GDF15 levels correlated with more severe nausea and vomiting of pregnancy [ 5 ]. In the future, drugs targeting the production or action of GDF15 are a potential novel pathway for treating nausea and vomiting of pregnancy, if safety and efficacy are established. (See "Nausea and vomiting of pregnancy: Clinical findings and evaluation", section on 'Pathogenesis' .)

Use of cerebroplacental ratio at term does not reduce perinatal mortality (February 2024)

Cerebral blood flow may increase in chronically hypoxemic fetuses to compensate for the decrease in available oxygen and can be assessed by the cerebroplacental ratio (CPR; middle cerebral artery pulsatility index divided by the umbilical artery pulsatility index). However, increasing evidence indicates that use of the CPR does not reduce perinatal mortality in low-risk pregnancies. In a randomized trial comparing fetal growth assessment plus revealed versus concealed CPR in over 11,000 low-risk pregnancies at term, knowledge of CPR combined with a recommendation for delivery if the CPR was <5th percentile did not reduce perinatal mortality compared with usual care (concealed group) [ 6 ]. We do not perform umbilical artery Doppler surveillance, including the CPR, in low-risk pregnancies. (See "Doppler ultrasound of the umbilical artery for fetal surveillance in singleton pregnancies", section on 'Low-risk and unselected pregnancies' .)

Low- versus high-dose calcium supplements and risk of preeclampsia (January 2024)

In populations with low baseline dietary calcium intake, the World Health Organization recommends 1500 to 2000 mg/day calcium supplementation for pregnant individuals to reduce their risk of developing preeclampsia. However, a recent randomized trial that evaluated low (500 mg) versus high (1500 mg) calcium supplementation in over 20,000 nulliparous pregnant people residing in two countries with low dietary calcium intake found low and similar rates of preeclampsia in both groups [ 7 ]. These findings suggest that a 500 mg supplement is sufficient for preeclampsia prophylaxis in these populations. For pregnant adults in the United States, we prescribe 1000 mg/day calcium supplementation, which is the recommended daily allowance to support maternal calcium demands without bone resorption. (See "Preeclampsia: Prevention", section on 'Calcium supplementation' .)

Respectful maternity care (January 2024)

Respectful maternity care is variably defined but broadly involves both absence of disrespectful conduct and promotion of respectful conduct toward pregnant individuals. A systematic review found that validated tools to measure respectful maternity care were available, but the optimal tool was unclear and high quality studies were lacking on the effectiveness of respectful maternity care for improving any maternal or infant health outcome [ 8 ]. Respectful maternal care is a basic human right, but how to best implement and monitor it and assess outcomes requires further study. (See "Prenatal care: Initial assessment", section on 'Effectiveness' .)

Outcome of a multifaceted intervention in patients with a prior cesarean birth (January 2024)

Patients with a pregnancy after a previous cesarean birth must choose between a trial of labor (TOLAC) and a planned repeat cesarean. The optimal care of such patients is unclear. In a multicenter, cluster-randomized trial including over 20,000 patients with one prior cesarean birth, a multifaceted intervention (patient decision support, use of a calculator to assess chances of a vaginal birth after cesarean [VBAC], sonographic measurement of myometrial thickness, clinician training in best intrapartum practices during TOLAC) reduced perinatal and major maternal morbidity composite outcomes compared with usual care [ 9 ]. VBAC and uterine rupture rates were similar for both groups. Further study is needed to identify the most useful component(s) of the intervention for reducing morbidity. (See "Choosing the route of delivery after cesarean birth", section on 'Person-centered decision-making model' .)

Serial amnioinfusions for bilateral renal agenesis (January 2024)

Bilateral renal agenesis (BRA) is incompatible with extrauterine life because prolonged oligohydramnios results in pulmonary hypoplasia, leading to postnatal respiratory failure. A prospective study (RAFT) assessed use of serial amnioinfusions to treat 18 cases of BRA diagnosed at <26 weeks of gestation [ 10 ]. Of the 17 live births, 14 survived ≥14 days and had placement of dialysis access, but only 6 survived to hospital discharge. Of the 4 children alive at 9 to 24 months of age, 3 had experienced a stroke and none had undergone transplant. These findings show that serial amnioinfusions for BRA mitigates pulmonary hypoplasia and increases short-term survival and access to dialysis; however, long-term outcome remains poor with no survival to transplantation. Serial amnioinfusions remain investigational and should be offered only as institutional review board-approved research. (See "Renal agenesis: Prenatal diagnosis", section on 'Investigative role of therapeutic amnioinfusion' .)

Prenatal genetic testing for monogenic diabetes due to glucokinase deficiency (December 2023)

In pregnant individuals with monogenic diabetes due to glucokinase (GCK) deficiency, management depends on the fetal genotype. If the fetus inherits the maternal GCK variant, maternal hyperglycemia will not cause fetal hyperinsulinemia and excessive growth, and maternal hyperglycemia does not require treatment. However, if the fetus does not inherit the pathogenic variant, maternal insulin therapy is indicated to prevent excessive fetal growth. Fetal ultrasound has been used to predict fetal genotype but has limited diagnostic utility. In a cohort of 38 pregnant individuals with GCK deficiency, fetal genetic testing using cell-free DNA in maternal blood had higher sensitivity (100 versus 53 percent) and specificity (96 versus 61 percent) for prenatal diagnosis of GCK deficiency compared with ultrasound measurement of fetal abdominal circumference [ 11 ]. When available, noninvasive prenatal genotyping should be used to guide management of GCK deficiency during pregnancy. (See "Classification of diabetes mellitus and genetic diabetic syndromes", section on 'Glucokinase' .)

Early metformin treatment of gestational diabetes mellitus (November 2023)

Usual initial gestational diabetes mellitus (GDM) care (ie, medical nutritional therapy, exercise) may result in a few weeks of hyperglycemia before a need for pharmacotherapy is established. In a randomized trial evaluating whether initiating metformin at the time of GDM diagnosis regardless of glycemic control improves clinical outcomes compared with usual care, the metformin group had a lower rate of insulin initiation and favorable trends in mean fasting glucose, gestational weight gain, and excessive fetal growth, but more births <2500 grams [ 12 ]. Rates of preeclampsia, neonatal intensive care unit admission, and neonatal hypoglycemia were similar for both groups. Given these mixed results, we recommend not initiating metformin at the time of GDM diagnosis except in a research setting. (See "Gestational diabetes mellitus: Glucose management and maternal prognosis", section on 'Does early metformin initiation improve glycemic control and reduce need for insulin?' .)

Automated insulin delivery in pregnant patients with type 1 diabetes (October 2023)

Hybrid closed-loop insulin therapy is associated with improved glucose control in nonpregnant adults and in children, but little information is available in pregnant people. In the first randomized trial in this population, hybrid closed-loop insulin delivery beginning at 11 weeks gestation improved glycemic control compared with standard insulin therapy in 124 patients with type 1 diabetes, without increasing their risk of severe hypoglycemia [ 13 ]. The system allowed customization of glycemic targets appropriate to pregnancy, in contrast to other commercially available systems in the United States. Additional study is needed to confirm these findings, evaluate the effects on obstetric and neonatal outcomes, and identify optimal candidates. (See "Pregestational (preexisting) diabetes mellitus: Antenatal glycemic control", section on 'Continuous subcutaneous insulin infusion (insulin pump)' .)

Valacyclovir for prevention of congenital cytomegalovirus infection (October 2023)

Emerging evidence suggests that maternal administration of valacyclovir for primary cytomegalovirus (CMV) infection substantially reduces the risk of congenital CMV infection, especially if begun prior to 14 weeks of gestation and within 8 weeks of the maternal infection. In a 2023 individual patient data meta-analysis (one randomized trial, two observational studies), maternal valacyclovir administration upon diagnosis of periconception or first-trimester primary CMV infection was associated with a 66 percent reduction in congenital CMV (11 versus 25 percent) [ 14 ]. We suggest high-dose oral valacyclovir (8g per day) for patients with a primary CMV infection in early pregnancy after a comprehensive discussion of the potential benefits and risks (eg, 2 percent risk of reversible maternal kidney failure). (See "Cytomegalovirus infection in pregnancy", section on 'Antiviral medication' .)

Respiratory syncytial virus vaccination in pregnancy (April 2023, Modified October 2023)

Respiratory syncytial virus (RSV) is a major cause of morbidity and mortality in infants. In October 2023, the United States Centers for Disease Control and Prevention, along with guidelines from other expert groups, endorsed RSV vaccination of pregnant individuals to reduce severe RSV infections in their infants [ 15-18 ]. Nirsevimab , a monoclonal antibody that can be given to infants postnatally to reduce the risk of severe RSV, has also been recently approved and endorsed by expert guidance panels. In settings where nirsevimab is not available, we suggest vaccination of pregnant individuals between 32 0/6 and 36 6/7 weeks of gestation in September through January (in the northern hemisphere) with inactivated nonadjuvanted recombinant RSV vaccine (RSVPreF; Abrysvo). In settings where both maternal vaccination and nirsevimab are available, the optimal preventive strategy remains uncertain, and, in most cases, it will not be possible to use both. For such patients, both options should be discussed and shared decision-making undertaken. (See "Immunizations during pregnancy", section on 'Choosing the optimal strategy' .)

INTRAPARTUM AND POSTPARTUM OBSTETRICS

Intrauterine postpartum hemorrhage control devices for managing postpartum hemorrhage (February 2024)

Intrauterine balloon tamponade and vacuum-induced uterine compression are the most common devices used for intrauterine postpartum hemorrhage (PPH) control in patients with atony, but it is unclear which device is superior as few comparative studies have been performed. In a retrospective study including nearly 380 patients with PPH, quantitative blood loss after placement, rate of blood transfusion, and discharge hematocrit were similar for both devices [ 19 ]. Based on these and other data, in the setting of ongoing uterine bleeding, rapid use of one of these devices is likely to be more important than the choice of device when both devices are available. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Choice of method' .)

Labor epidural analgesia and risk of emergency delivery (December 2023)

It is well established that contemporary neuraxial labor analgesia does not increase the overall risk of cesarean or instrument-assisted vaginal delivery. However, a new retrospective database study of over 600,000 deliveries in the Netherlands reported that epidural labor analgesia was associated with an increased risk of emergency delivery (cesarean or instrument-assisted vaginal) compared with alternative analgesia (13 versus 7 percent) [ 20 ]. Because of potential confounders and lack of detail on epidural and obstetric management, we consider these data insufficient to avoid neuraxial analgesia or change the practice of early labor epidural placement to reduce the potential need for general anesthesia in patients at high risk for cesarean delivery. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the progress and outcome of labor' .)

Delayed cord clamping in preterm births (December 2023)

Increasing evidence supports delaying cord clamping in preterm births. In an individual participant data meta-analysis of randomized trials of delayed versus immediate cord clamping at births <37 weeks (over 3200 infants), delaying cord clamping for >30 seconds reduced infant death before discharge (6 versus 8 percent) [ 21 ]. In a companion network meta-analysis evaluating the optimal duration of delay, a long delay (≥120 seconds) significantly reduced death before discharge compared with immediate clamping; reductions also occurred with delays of 15 to <120 seconds but were not statistically significant [ 22 ]. For preterm births that do not require resuscitation, we recommend delayed rather than immediate cord clamping. We delay cord clamping for at least 30 to 60 seconds as approximately 75 percent of blood available for placenta-to-fetus transfusion is transfused in the first minute after birth. (See "Labor and delivery: Management of the normal third stage after vaginal birth", section on 'Preterm infants' .)

Vacuum-induced intrauterine tamponade for postpartum hemorrhage (November 2023)

Intrauterine tamponade (with a balloon, packing, or vacuum) may be used to manage patients with postpartum hemorrhage (PPH) resulting from uterine atony that is not controlled by uterotonic medications and uterine massage. However, outcome data regarding vacuum-induced tamponade are limited. A study of data from a postmarketing registry of over 500 patients with PPH and isolated atony treated with vacuum-induced tamponade reported that the device controlled bleeding without treatment escalation or bleeding recurrence in 88 percent following cesarean birth and 96 percent following vaginal birth, typically within five minutes [ 23 ]. These data are consistent with previously published outcomes. Given its efficacy and ease of use, vacuum-induced tamponade is an important option for managing PPH in centers where this device is available. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Vacuum-induced tamponade' .)

Risk of pregnancy-associated venous and arterial thrombosis in sickle cell disease (November 2023)

Sickle cell disease (SCD) and pregnancy both confer an increased risk of venous thromboembolism (VTE), but the magnitude of the risk is unclear. In a new administrative claims data study involving >6000 people with SCD and >17,000 age- and race-matched controls who were followed for one year postpartum, the risk of VTE was 11.3 percent in the patients with SCD, versus 1.2 percent in controls [ 24 ]. Arterial thromboembolism was also increased (5.2 percent, versus 0.6 percent in controls). This study emphasizes the value of postpartum VTE prophylaxis in people with SCD and the need for vigilance in evaluating suggestive symptoms. (See "Sickle cell disease: Obstetric considerations", section on 'Maternal risks' .)

Racial disparities in anemia during pregnancy (October 2023)

A new study has found that racial disparities in anemia during pregnancy persist and may be increasing. This analysis involved nearly four million births in the state of California from 2011 to 2020 [ 25 ]. Antepartum anemia was most common in Black individuals (22 percent), followed by Pacific Islanders (18 percent), Native American and Alaska Native peoples (14 percent), multiracial individuals (14 percent), Hispanic individuals (13 percent), Asian individuals (11 percent), and White individuals (10 percent). Antepartum anemia is associated with an increase in severe maternal morbidity. The reasons for disparities are multifactorial. (See "Anemia in pregnancy", section on 'Racial disparities' .)

Intrapartum magnesium sulfate before preterm birth and cerebral palsy (October 2023)

Magnesium sulfate is typically administered to pregnant women with impending preterm birth <32 weeks of gestation to decrease the incidence and severity of cerebral palsy in offspring. However, the recent MAGENTA trial comparing the effects of magnesium sulfate versus placebo administered before impending preterm birth between 30 and 34 weeks of gestation found that it did not prevent cerebral palsy among surviving infants [ 26 ]. These findings do not change our current practice because the trial used a single 4 g bolus of magnesium sulfate alone, whereas we also provide an ongoing 1 g/hour infusion until delivery and do not use the medication after 32 weeks; the trial was likely underpowered to find a significant difference. (See "Neuroprotective effects of in utero exposure to magnesium sulfate", section on 'Lower and upper gestational age' .)

OFFICE GYNECOLOGY

Infertility and autism spectrum disorder (December 2023)

Patients with infertility often ask about the impact of the disorder and its treatment on risk of autism spectrum disorder (ASD) in offspring. In a large population-based cohort study comparing ASD risk among children whose parents had subfertility (an infertility consultation without treatment), infertility treatment, or neither (unassisted conception), children in the subfertility and infertility treatment groups had a small increased risk of ASD compared with unassisted conception but the absolute risk was low (2.5 to 2.7 per 1000 person-years versus 1.9 per 1000 person-years with unassisted conception) [ 27 ]. The increased risk was similar in the subfertile and infertility treatment groups, suggesting that infertility treatment was not a major risk factor. Obstetrical and neonatal factors (eg, preterm birth) appeared to mediate a sizeable proportion of the increased risk for ASD. (See "Assisted reproductive technology: Infant and child outcomes", section on 'Confounders' .)

Macular changes related to pentosan polysulfate sodium (November 2023)

Macular eye disease has been reported in patients who have taken pentosan polysulfate sodium (PPS), which is used for the treatment of interstitial cystitis. In a prospective cohort study of 26 eyes with PPS maculopathy and >3000 g cumulative PPS exposure, progression of macular changes continued 13 to 30 months after drug cessation [ 28 ]. Median visual acuity decreased slightly; most patients reported progression of symptoms, including difficulty in low-light environments and blurry vision. These results indicate that PPS maculopathy progresses despite drug discontinuation, underscoring the importance of regular screening for maculopathy in patients with current or prior PPS exposure. (See "Interstitial cystitis/bladder pain syndrome: Management", section on 'Pentosan polysulfate sodium as alternative' .)

Vaginal laser therapy not effective for genitourinary syndrome of menopause (November 2023)

Laser devices, including the fractional microablative CO 2 laser, have been marketed for treatment of patients with genitourinary syndrome of menopause (GSM), but data regarding their safety and efficacy are limited. In a randomized trial including nearly 50 postmenopausal patients with GSM, treatment with CO 2 laser did not improve symptom severity compared with sham therapy [ 29 ]. Change in vaginal histology, which is a common surrogate determinant of treatment success, was similar in both groups at six months postprocedure. In addition, histologic features associated with a hypoestrogenic state correlated poorly with the severity of vaginal symptoms. Although the trial had limitations, these findings are consistent with other data and support our practice of not using laser treatment for patients with GSM. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Laser or radiofrequency devices' .)

Use of vaginal estrogen in breast cancer patients taking aromatase inhibitors (October 2023)

Use of vaginal estrogen to manage symptoms of genitourinary syndrome of menopause (GSM) may be harmful in patients with breast cancer on aromatase inhibitors (AIs). In a subgroup analysis of a claims-based analysis, vaginal estrogen therapy was associated with a higher rate of breast cancer recurrence in patients taking versus not taking an AI [ 30 ]. Time to recurrence in the AI group was approximately 140 days. While this study had many limitations, these data support our general practice of avoiding vaginal estrogen for the management of GSM in most patients with breast cancer taking AIs. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Patients with breast cancer' .)

GYNECOLOGIC SURGERY

Risk of unplanned hysterectomy at time of myomectomy (February 2024)

Myomectomy is an option for patients with bothersome fibroid symptoms (eg, bleeding, bulk); however, data are limited regarding the risk of unplanned hysterectomy at the time of myomectomy. In a retrospective study of the American College of Surgeons' National Surgical Quality Improvement Program database from 2010 to 2021 including over 13,000 patients undergoing myomectomy, the risk of unplanned hysterectomy was higher in those undergoing laparoscopic myomectomy compared with an open abdominal or hysteroscopic approach (7.1, 3.2, and 1.9 percent respectively) [ 31 ]. While much lower risks have been reported (<0.4 percent), and expert surgeons at high-volume centers may have fewer conversions to hysterectomy, this study highlights the importance of discussing the risk of unplanned hysterectomy during the informed consent process. (See "Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments", section on 'Unplanned hysterectomy' and "Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure", section on 'Unplanned hysterectomy' and "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy", section on 'Unplanned hysterectomy' .)

Risk of subsequent hysterectomy after endometrial ablation (January 2024)

Endometrial ablation is an alternative to hysterectomy in selected premenopausal patients with heavy menstrual bleeding. Most ablations are performed using a non-resectoscopic technique; however, the long-term efficacy of this approach is unclear. In a meta-analysis of 53 studies including over 48,000 patients managed with non-resectoscopic endometrial ablation (NREA), the rates of subsequent hysterectomy were 4 percent at 12 months, 8 to 12 percent at 18 to 60 months, and 21 percent at 120 months [ 32 ]. Hysterectomy rates were similar for the different NREA devices (eg, thermal balloon, microwave, radiofrequency). These findings are useful for counseling patients about the long-term risk for hysterectomy after NREA. (See "Endometrial ablation: Non-resectoscopic techniques", section on 'Efficacy' .)

Pregnancy and childbirth after urinary incontinence surgery (January 2024)

Patients with stress urinary incontinence (SUI) have historically been advised to delay midurethral sling (MUS) surgery until after childbearing because of concerns for worsening SUI symptoms following delivery. In a meta-analysis of patients with MUS surgery who were followed for a mean of nearly 10 years, similar low SUI recurrence and reoperation rates were reported for the 381 patients with and the 860 patients without subsequent childbirth [ 33 ]. Birth route did not affect the findings. Although the total number of recurrences and reoperations was small, this study adds to the body of evidence suggesting that subsequent childbirth does not worsen SUI outcomes for patients who have undergone MUS. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Subsequent pregnancy' .)

GYNECOLOGIC ONCOLOGY

Types of hysterectomy in patients with stage IB1 cervical cancer (March 2024)

Patients with stage IB1 cervical cancer (ie, >5 mm depth of stromal invasion and ≤2 cm in greatest dimension) are typically treated with radical hysterectomy; however, less extensive surgery is being evaluated. In a randomized trial including over 640 patients with stage IB1 cervical cancer, radical hysterectomy and simple hysterectomy plus lymph node assessment resulted in similar rates of recurrence at three years (2.2 and 2.5 percent, respectively) [ 34 ]. Although the study has limitations, including a short follow-up period, simple hysterectomy with lymph node assessment may be an acceptable alternative to radical hysterectomy in patients with IB1 cervical cancer. (See "Management of early-stage cervical cancer", section on 'Type of surgery' .)

Increasing incidence of cervical and uterine corpus cancer in the United States (February 2024)

In January 2024, the American Cancer Society published their annual report of cancer statistics in the United States [ 35 ]. Notable trends in regard to gynecologic cancers include a 1.7 percent increase in the annual incidence of cervical cancer from 2012 to 2019 in individuals aged 30 to 44 years, after decades of decline. Cancer of the uterine corpus (all ages) continued to increase by approximately 1 percent annually and was the only cancer in the report in which survival decreased. These and other data emphasize the continued importance of both early detection and prevention (eg, for cervical cancer: human papillomavirus vaccination and screening for precursor lesions; for endometrial cancer: achieving and maintaining a normal body mass index). (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis", section on 'Incidence and mortality' and "Endometrial carcinoma: Epidemiology, risk factors, and prevention", section on 'Epidemiology' and "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening", section on 'Prognosis' .)

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• Li FG, Fuchs T, Deans R, et al. Vaginal epithelial histology before and after fractional CO2 laser in postmenopausal women: a double-blind, sham-controlled randomized trial. Am J Obstet Gynecol 2023; 229:278.e1.
• Agrawal P, Singh SM, Able C, et al. Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol 2023; 142:660.
• Coyne K, Purdy MP, Bews KA, et al. Risk of hysterectomy at the time of myomectomy: an underestimated surgical risk. Fertil Steril 2024; 121:107.
• Oderkerk TJ, Beelen P, Bukkems ALA, et al. Risk of Hysterectomy After Endometrial Ablation: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 142:51.
• Nahshon C, Abramov Y, Kugelman N, et al. The effect of subsequent pregnancy and childbirth on stress urinary incontinence recurrence following midurethral sling procedure: a meta-analysis. Am J Obstet Gynecol 2024; 230:308.
• Plante M, Kwon JS, Ferguson S, et al. Simple versus Radical Hysterectomy in Women with Low-Risk Cervical Cancer. N Engl J Med 2024; 390:819.
• Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin 2024; 74:12.

• Introduction
• Article Information

The shaded area represents the initial months of the COVID-19 pandemic. The dotted line represents the month immediately following the Dobbs v Jackson Women’s Health Organization decision. Includes visits and new contraception prescriptions for all clinicians regardless of specialty. IUD indicates intrauterine device.

Source: IQVIA LRx (prescription claims) and DxHx (medical and institutional claims), 2019 to 2022. Extracted June 15, 2022, and April 28, 2023.

Pill, patch, and ring clinicians prescribed at least 1 new prescription in the calendar year. Physicians include obstetricians and gynecologists, family medicine, internal medicine, pediatrics, and other physicians (eg, emergency medicine). Advanced practice clinicians include advanced practice nurses (eg, nurse practitioners, nurse midwives) and physician assistants. IUD indicates intrauterine device.

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Strasser J , Schenk E , Luo Q , Bodas M , Murray M , Chen C. Contraception Usage and Workforce Trends Through 2022. JAMA Netw Open. 2024;7(4):e246044. doi:10.1001/jamanetworkopen.2024.6044

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Contraception Usage and Workforce Trends Through 2022

• 1 Fitzhugh Mullan Institute for Health Workforce Equity, Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
• 2 IQVIA Government Solutions, IQVIA, Falls Church, Virginia

In 2022, Dobbs v Jackson Women’s Health Organization dramatically changed the landscape of reproductive health, causing ripple effects that will extend beyond abortion care. Contraception may be especially vulnerable to further restrictions and barriers, both to those seeking care and those providing it. 1 Using a national data set of medical and prescription claims, this study examines contraception service and workforce changes from January 2019 through December 2022.

This cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline. It was approved by the George Washington University institutional review board, which waived informed consent because this study uses secondary data. We used IQVIA prescription and preadjudicated medical claims to identify clinicians providing contraception services in 2019 to 2022. IQVIA captures approximately 93% of retail pharmacy prescriptions and medical claims for approximately 191 million patients. We measured 2 outcomes: (1) the monthly volume of contraceptive service visits by type and (2) the annual number and type of clinicians. Contraception methods include new prescriptions for pills, patches, and rings and visits for intrauterine devices (IUDs), implants, injectable (depo-medroxyprogesterone acetate), vasectomy, and tubal sterilization. Data analyses occurred from August 15 to October 6, 2023, and used Stata version 18.0 (StataCorp).

From 2019 to 2022, 731 447 unique clinicians provided contraceptive services in our sample. Most contraception services showed steady downward trends, except for sharp declines during the early COVID-19 months and temporary increases in the month following the Dobbs v Jackson Women’s Health Organization decision ( Figure 1 ).

The volume of IUD services decreased from 650 043 in 2019 to 591 509 in 2022, and the volume of tubal sterilization services decreased from 103 547 in 2019 to 74 537 in 2022. The volume of vasectomy services steadily increased, from 146 796 in 2019 to 198 212 in 2022. New contraceptive prescriptions (pill, patch, and/or ring) dropped from more than 25 000 000 in 2019 to less than 22 000 000 in 2022. Prescription duration increased with 44 237 865 prescriptions (68%) in 2019 limited to 1 month compared with 27 925 732 (46%) in 2022. The workforce providing contraception shifted during this period, with increases in the number of advanced practice clinicians (APCs) providing IUD, implant, and prescriptions ( Figure 2 ) and decreases in physicians providing prescriptions.

While contraceptive usage increased initially in the month after Dobbs v Jackson Women’s Health Organization , all contraception types except vasectomy returned to overall downward trends through the end of 2022. The decreases we found in contraceptive services and the workforce providing these methods may indicate growing challenges for contraception access. News reports suggest increased interest but persistent barriers for obtaining IUDs and tubal sterilization following Dobbs v Jackson Women’s Health Organization , 2 and emerging research finds some differences in post- Dobbs v Jackson Women’s Health Organization sterilizations by state policy climate. 3 State-level shifts in the contraception workforce may continue, as clinicians may leave states with abortion restrictions or exit the workforce entirely. 4

APCs are a growing segment of the contraception workforce, consistent with previous research by our team. 5 However, the decrease in the number of physicians, coupled with state-level policies that restrict many APCs from full scope of practice, is a cause for concern.

The decreases we saw in certain contraception services may be driven by shifts in the workforce as well as patient preferences and changing markets (eg, growing presence of online pharmacies). Some of the decrease in contraception prescriptions may be due to increases in extended supply prescribing, and the growing use of vasectomy may indicate shifts in gendered approaches to reproductive decision-making.

This study has limitations. These data have limited coverage of online-only and health maintenance organization (eg, Kaiser Permanente) pharmacies. Additionally, medical claims comprehensiveness varies by individual clinician, as discussed elsewhere. 6 As 2023 data become available, future research should continue to track changes in contraception workforce composition and access to the full range of contraceptive methods.

Accepted for Publication: February 13, 2024.

Published: April 15, 2024. doi:10.1001/jamanetworkopen.2024.6044

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Strasser J et al. JAMA Network Open .

Corresponding Author: Julia Strasser, DrPH, MPH, The George Washington University, 2175 K St NW, Ste 250, Washington, DC 20037 ( [email protected] ).

Author Contributions: Dr Luo and Ms Schenk had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Strasser, Schenk, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Strasser, Schenk, Bodas.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Schenk, Luo, Bodas.

Obtained funding: Strasser, Chen.

Administrative, technical, or material support: Schenk, Murray, Chen.

Supervision: Strasser, Luo.

Conflict of Interest Disclosures: Ms Schenk and Drs Strasser, Luo, Bodas, and Chen reported receiving grants from the Susan T. Buffett Foundation during the conduct of the study. Dr Luo reported receiving grants from the National Institutes of Health, the Agency of Healthcare Research and Quality, and Substance Abuse and Mental Health Service Administration, and consulting for Motive Medical Intelligence outside the submitted work. No other disclosures were reported.

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Scientific research in obstetrics and gynecology: changes in the trends over three decades

Gamal a kassem.

Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

The aim of this work was to assess scientific research of master’s and doctoral theses and essays in the Department of Obstetrics and Gynecology, Zagazig University, Egypt.

Materials and methods

All master’s and doctoral theses and essays since the foundation of Department of Obstetrics and Gynecology, Zagazig University, Egypt, in 1975 till end of 2012 were reviewed.

A total of 703 theses and essays were reviewed. The important topics in the specialty of obstetrics and gynecology were covered and updated. Infertility, in vitro fertilization–embryo transfer (IVF-ET) and related techniques, and polycystic ovarian disease were the most common gynecologic topics (27.2%), followed by gynecologic oncology (18.5%). Preeclampsia was the most common obstetrics topic (18.8%), followed by issues of high-risk pregnancy, fetal growth restriction, and fetal well-being (11.6%). The number of researches that allow the candidates to learn skills was 183 and it was increased from 4.4% of all research in the period 1979–1988 to 33.2% in period 1989–2000 then slightly decreased to 31.2% in period 2001–2012. Ultrasonography was on the top and was present in 99 out of 183 (54.1%) followed by laparoscopy (30, 16.4%), hysteroscopy (25, 13.7%), IVF-ET and related techniques (16, 8.7%) and colposcopy (13, 7.1%) researches. Multi-disciplinary research was decreased by 61.7% in the period 2001–2012. Researches in academic fields were abandoned and in some clinically important areas like preeclampsia were decreased.

Scientific research of master’s and doctoral theses and essays was comprehensive, updated, and had some autonomy independent of plans. Research which enable the candidate to learn skills were increased on the expense of academic, clinical and multidisciplinary research. It could be recommended that plans for scientific research should be flexible and should leave a space for local departmental views. Proper training of residents during their rotation in these subspecialties may help to revive the lost interest in clinically important areas.

Introduction

Active participation or submission of a scientific research is an essential step in residency or scholarship programs. 1 Studies have noted that research improves analytical and communication skills of the candidates as well as lifelong learning. 2 It was also observed that residents interested in research and publications have greater academic success. 3 , 4

According to the rules of Supreme Council of Universities, Egypt, submitting a scientific research in the form of a thesis or an essay is one of the requirements to gain a master’s or doctoral degree. Selection of the topic of the research is related to many factors such as availability of cases, instruments, subspecialty, and personal view of the supervising professor. The interest of the candidate is also important. In 2013, discussions started within the faculty to develop a plan for scientific research for the next 5 years. There was a need to review all research to get an impression about previous work. The aim of this study was to assess scientific research of theses and essays accepted in the Department of Obstetrics and Gynecology, Zagazig University, since its foundation in 1975 till end of 2012.

This retrospective observational study was conducted at the Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt, from January to March 2013.

All accepted theses and essays since the foundation of the department in 1975 till end of 2012 were reviewed. The review included title of research, year of acceptance, and supervision from another department. Methodology and skills that the candidate should learn, such as ultrasonography, endoscopy, in vitro fertilization–embryo transfer (IVF-ET), and colposcopy, were checked. Assessment also included the influence of establishment of new specialized units on scientific research. For the sake of convenience, the term “research” will be used to refer to essays and theses in this study.

The Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, was founded in 1975 as a small department under the supervision of Ain-Shams University (the mother university). Then the department became separate and also grew larger. There was an increase in the number of beds, the number of undergraduate and postgraduate candidates, staff, and subsequently the number of research activities. The formation of specialized units of laparoscopy, hysteroscopy, IVF-ET, and ultrasound started in the first half of the 1990s. Colposcopy was present since 1980. A Gynecologic Oncology Unit was founded officially in the first half of 2000s. We have no gynecologic urology unit, although there are some preparations for it.

One of the requirements for a master’s degree is to submit either a thesis or an essay. An essay is review article. For a doctoral degree, a thesis should be submitted. Each thesis or essay should have a supervising committee comprising a professor, assistant professor or lecturer(s), a system similar to mentorship. 5 If part of the work will be done in another department, a supervisor from that department will also be part of the committee. According to rules in the university, supervision from another department is recommended, but is not obligatory. Candidates are encouraged to gain training and supervision from national and international experts in the field of the research.

The study was approved by the Obstetrics and Gynecology Council of the faculty. Data were represented as mean and standard deviation.

A total of 703 theses and essays were reviewed. There were 575 (81.8%) and 128 (18.2%) theses and essays, respectively. The first thesis accepted was in 1977. Because the overall study included 36 years, this period was classified into three parts, each part comprising 12 years ( Figure 1 ). The number of topics in gynecology and obstetrics were 367 and 336, respectively ( Tables 1 and ​ and2). 2 ). Infertility was the most common topic in gynecology. Topics were updated from basic investigations like hysterosalpingography to different techniques of artificial insemination (AI) and IVF-ET. Research also evaluated different parameters of ovarian reserve and its relation to the outcome of IVF. As regards to polycystic ovarian disease (PCOD), research included diagnostic, biochemical, ultrasonographic criteria, and role of insulin sensitizers. Research in gynecologic oncology included recent aspects of diagnosis and treatment of different gynecologic tumors. Role of laparoscopy in characterization of adnexal masses, management of large ovarian cysts, hysterectomy, and pelvic lymphadenectomy in early cancer cervix are examples. Research also covered new tumor markers like human epididymis protein 4. The relation between human papilloma virus and genital tract malignancy was also studied. Ultrasound and color Doppler were used to predict depth of myometrial invasion in cancer endometrium.

Number of research that contain skills in relation to total research in obstetrics and gynecology over 36 years in Zagazig University (N=703).

Gynecological topics involved in theses and essays in relation to year of acceptance (N=367)

Abbreviations: IVF-ET, in vitro fertilization–embryo transfer; PCOD, polycystic ovarian disease; HRT, hormone replacement therapy.

Obstetrical topics involved in the theses and essays in relation to the year of acceptance (N=336)

Abbreviations: FGR, fetal growth restriction; RPL, recurrent pregnancy loss; PROM, prelabor rupture of membranes; CS, cesarean section; VBAC, vaginal birth after cesarean; IOL, induction of labor; APH, antepartum hemorrhage.

Preeclampsia was the first topic in obstetrics, and research included prediction, pathogenesis, clinical criteria, and laboratory investigations. Use of ultrasound and color Doppler was extensive.

Theses including skills were 183, which represented 31.8% of theses and 26% of all research. As shown in Figure 1 , the numbers increased from 8 of 163 (4.4%) in the period 1979–1989 to 91 of 274 (33.2%) in the period 1989–2000, and then slightly decreased to 84 of 266 (31.2%) in the period 2001–2012. Ultrasonography was the most common topic (99 theses, 54.1%) followed by laparoscopy (30, 16.4%), hysteroscopy (25, 13.7%), AI, IVF-ET, and related techniques (16, 8.7%), and lastly colposcopy (13 theses, 7.1%) ( Figure 2 ). Ultrasonography and color Doppler research included prediction, pathogenesis of preeclampsia as well as prediction, diagnosis, and monitoring of fetal growth restrictions. In preterm labor, ultrasonography was used in the prediction of preterm labor by measuring cervical length. Theses also included diagnostic criteria of placenta accreta. In abnormal uterine bleeding, ultrasound was used in evaluation of uterine cavity. In addition hydrosonography was also used in comparison to hysteroscopy. Techniques involved transabdominal, transvaginal, and transperineal examinations.

Number of theses that contain skills in obstetrics and gynecology over 36 years in Zagazig University (N=183).

Abbreviations: AI, artificial insemination; IVF-ET, in vitro fertilization–embryo transfer.

Research in laparoscopy included infertility, ovarian drilling for PCOD, and different techniques of laparoscopic hysterectomy. In hysteroscopy, theses included comparison between hysteroscopy and hysterosalpingography, as well as comparison between CO 2 and normal saline as distending medium. Hysteroscopy also used before and after failed IVF-ET. Operative hysteroscopy included monopolar and bipolar resectoscopic surgery. Research also included salpingoscopy and fallopian tube catheterizations.

Supervisions from another department in our faculty were present in 297 theses ( Table 3 ). Supervision from other universities (national experts) was noted in 10 theses, and international experts in 7 theses. The total supervisions beyond our department were present in 314 cases, which represent 54.7% of theses ( Tables 3 – 5 ).

Supervision from other departments (same university) (N=297)

Supervision from outside Egypt (international experts), (N=7)

Abbreviations: CIN, cervical intraepithelial neoplasia; HPV, human papilloma virus; IVF-ET, in vitro fertilization–embryo transfer.

This study shows that scientific research included in theses and essays for the master’s and doctoral degrees was comprehensive. Important topics in the specialty of obstetrics and gynecology were covered. Infertility was the most common topic in gynecology, followed by gynecologic oncology. Both topics represented about half of all theses and essays in gynecology. Preeclampsia was the most common obstetrics topic (18.8%), followed by issues of high-risk pregnancy, fetal growth restriction, and fetal well-being (11.6%). The study also shows that scientific research was updated. This was more evident regarding infertility research. We observed that not only the number of researches in infertility was steadily increased but also the topics were updated. Issues of AI, IVF-ET and related techniques, ovarian reserve, and role of endoscopy were covered. Recent research areas on PCOD were also studied. Actually, infertility became a well-established subspecialty mainly due to marked advancement in IVF-ET and related techniques in last three decades. 6 , 7

We observed that there was a marked increase in the number of researches after establishment of specialized units of ultrasonography, endoscopy and IVF-ET ( Figure 1 ). This was more evident for research using ultrasound. As shown in Figure 2 , theses including ultrasound jumped from five in the period 1977–1988 to 49 in the period 1989–2000. Actually, advances in technology have expanded the field of obstetrics and gynecology and made training and developing skills in different subspecialties a great challenge. 8 , 9 It seems that candidates preferred scientific research that enabled them to gain skills, and ultrasonography represented the first choice. Ultrasonography is relatively easy to learn, with great application in clinical practice. 10 Similar increase, but to a lesser extent, occurred in research in field of laparoscopy and hysteroscopy. The least number of researches were observed in the field of colposcopy. This could be explained by the absence of any national program for screening of cervical cancer. Actually, cervical cancer is not a great health problem in Egypt. 11 Similar findings were observed regarding research in gynecologic oncology which was increased by 1.5 times in the last 12 years with the establishment of the Gynecologic Oncology Unit.

Multidisciplinary collaboration in research is important. It improves research quality, increases research output, and also improves the communication skills of the researchers. 12 , 13 In the present study, more than half of the theses had supervision from another department, either academic or clinical. However, as shown in Table 3 , there was a reduction in the number of supervisions from 141 to 45 (61.7%) in the last 12 years. This may be explained by a decreased interest in academic research such as anatomy, physiology, and experimental work. The interest in ultrasound, laparoscopy, and hysteroscopy is clear, even though research in some clinically important areas like preeclampsia was also decreased ( Tables 1 and ​ and2). 2 ). Therefore, proper training of residents during their rotation in these subspecialties may help to revive the lost interest in clinically important areas.

The strength of this study is that it reviewed all master and doctoral theses and essays conducted through 36 years. This long period makes the results about changes in trends in research reliable and makes study beneficial for planning of scientific research and training of residents in obstetrics and gynecology. However, the study did not include other research published by staff members for promotion to the posts of professors. Actually, some staff members research are based on these master and doctoral theses. Therefore the study is typically concerned with research done by masters and doctoral candidates but still represents the scientific research in obstetrics and gynecology.

In conclusion, scientific research of master’s and doctoral theses and essays was comprehensive, updated, and had some autonomy independent of plans. Research which enable the candidate to learn skills were increased on the expense of academic, clinical and multidisciplinary research. It could be recommended that plans for scientific research should be flexible and should leave a space for local departmental views. Proper training of residents during their rotation in these subspecialties may help to revive the lost interest in clinically important areas.

Supervision from another university (national experts) (N=10)

Abbreviation: IVF-ET, in vitro fertilization–embryo transfer.

Acknowledgments

The author thanks Professor Mohammed M Al-bakry, ex-Head of Department of Obstetrics and Gynecology, and Professor Monqez Motea, Vice Dean and Head of Scientific Research Council, Faculty of Medicine, Zagazig University, for their great support and encouragement. The author also thanks Dr Reem Abbas, Professor in Community Medicine, for her advice regarding the statistics used for the study.

The author reports no conflict of interest in this work.

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Yale School of Medicine, Department of Obstetrics and Gynecology, 1988

Medical Historical Library, Cushing/Whitney Medical Library > Yale School of Medicine, Department of Obstetrics and Gynecology, 1988

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