Current Opinion in Obstetrics and Gynecology - Most Popular Articles

A new algorithm for the evaluation of recurrent pregnancy loss redefining unexplained miscarriage: review of current guidelines

imagePurpose of review
Couples with recurrent pregnancy loss (RPL) are often referred to reproductive specialists to help determine the reason for their repeated losses. This review will help to develop a strategy that is effective in providing a diagnosis, efficient to administer, and cost-effective to the healthcare system.
Recent findings
International societies have published different recommendations for the evaluation of RPL, they consider it appropriate to initiate an evaluation after two (or three) clinical miscarriages. On the contrary, the clinician who follows these guidelines will only be able to offer a possible explanation to fewer than half of the couples being evaluated. Recently, genetic testing of miscarriage tissue using 24-chromosome microarray (CMA) analysis at the time of the second pregnancy loss coupled with testing based on society guidelines has been shown provide an explanation in more than 90% of cases.
Summary
New guidelines for the complete evaluation of RPL should consider adding 24-CMA testing on the miscarriage tissue. Providing couples with an explanation for recurrent loss assists them in dealing with the loss and discourages the clinician from instituting unproven therapies. Truly unexplained pregnancy loss can be reduced to less than 10% with this new algorithm. Incorporation of these strategies will result in significant cost savings to the healthcare system.

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https://journals.lww.com/co-obgyn/Fulltext/2020/10000/A_new_algorithm_for_the_evaluation_of_recurrent.10.aspx

Vitamin D supplementation during pregnancy: an overview

imagePurpose of review
Examine recent evidence of randomized controlled trials and meta-analyses regarding the effect of maternal vitamin D status and supplementation over obstetrical and offspring outcomes.
Recent findings
Maternal serum 25-hydroxyvitamin [25(OH)D] progressively declines during pregnancy because of fetal physiological demands and adjustments. Vitamin D supplementation during pregnancy in women with low vitamin D status may improve fetal growth and reduce the risks for small-for-gestational-age, preeclampsia, preterm birth, and gestational diabetes. Mothers with sufficient vitamin D levels have offsprings with less enamel defects and less attention deficit and hyperactive disorders and autism. All pregnant women should be supplemented with 600 IU/day of vitamin D3. We discuss evidence indicating that higher vitamin D doses (1000–4000 IU/day) may be convenient to achieve better maternal and infant outcomes. Low maternal vitamin D status during pregnancy may be associated in infants with a higher risk for lower bone mineral content, enamel defects and attention deficit hyperactive disorder.
Summary
Recent evidence from vitamin D intervention studies and meta-analyses of a large number of studies support vitamin D supplementation during pregnancy to improve maternal, fetal and, immediate and later offspring health.

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https://journals.lww.com/co-obgyn/Fulltext/2020/10000/Vitamin_D_supplementation_during_pregnancy__an.3.aspx

Editorial introductions

imageNo abstract available

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The accuracy of haemoglobin A1c as a screening and diagnostic test for gestational diabetes: a systematic review and meta-analysis of test accuracy studies

imagePurpose of review
Gestational diabetes mellitus (GDM) is associated with adverse pregnancy complications. Accurate screening and diagnosis of gestational diabetes are critical to treatment, and in a pandemic scenario like coronavirus disease 2019 needing a simple test that minimises prolonged hospital stay. We undertook a meta-analysis on the screening and diagnostic accuracy of the haemoglobin A1c (HbA1c) test in women with and without risk factors for gestational diabetes.
Recent findings
Unlike the oral glucose tolerance test, the HbA1c test is simple, quick and more acceptable. There is a growing body of evidence on the accuracy of HbA1c as a screening and diagnostic test for GDM. We searched Medline, Embase and Cochrane Library and selected relevant studies. Accuracy data for different thresholds within the final 23 included studies (16 921 women) were pooled using a multiple thresholds model. Summary accuracy indices were estimated by selecting an optimal threshold that optimises either sensitivity or specificity according to different scenarios.
Summary
HbA1c is more useful as a specific test at a cut-off of 5.7% (39 mmol/mol) with a false positive rate of 10%, but should be supplemented by a more sensitive test to detect women with GDM.

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https://journals.lww.com/co-obgyn/Fulltext/2020/10000/The_accuracy_of_haemoglobin_A1c_as_a_screening_and.4.aspx

New evidence on prognostic features, prevention and treatment of congenital Cytomegalovirus infection

imagePurpose of review
Congenital Cytomegalovirus (CMV) infection remains a major cause of lifelong disability, with no systematic screening implemented in pregnancy or the postnatal period. In this review article, we outline the preventive strategies, antenatal prognostic features and experimental therapies as well as evidence of efficacy from recent trials.
Recent findings
A recent randomized, double blinded, placebo-controlled study investigated the efficacy of Valaciclovir in women contracting primary CMV in the periconception period or first trimester. They concluded that Valaciclovir at a dose of 8 g/day is effective in reducing the rate of foetal CMV infection following early maternal primary infection. Administration of CMV hyperimmune globulin (HIG) was investigated in a recent randomized double-masked controlled trial. This study concluded that CMV HIG was ineffective at reducing the risk of congenital CMV among women with primary CMV in early pregnancy.
Summary
Congenital CMV infection remains a significant cause of disability. There is currently no vaccine available, with the best preventive strategy being patient education on transmission as well as hygiene measures to reduce risk of exposure. Experimental therapies have been investigated in recent years and there is evidence supporting the use of Valaciclovir. Data for the efficacy of CMV HIG remains inconsistent and administration is currently limited to clinical trial settings.

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https://journals.lww.com/co-obgyn/Fulltext/2020/10000/New_evidence_on_prognostic_features,_prevention.6.aspx

Non-hormonal mediators of uterine fibroid growth

imagePurpose of review
Uterine fibroids are the most common benign neoplasms of the female reproductive tract and one of the major public health concerns. Although most women with uterine fibroids are asymptomatic, over 30% of them will present with varying symptoms. This review focuses on the role of non-hormonal mediators and pathways in uterine fibroid biology. Furthermore, it provides data regarding the most recent findings in the field of compounds, which use those non-hormonal pathways in the medical therapy of uterine fibroids.
Recent findings
Complex signaling pathway alterations are crucial for uterine fibroid development. The topic of the pathophysiology of uterine fibroids focuses mostly on steroids and other hormones. However, other very important pathways exist, and some of them are independent of hormones. Some of the most important pathways, which are non-hormonal, but in some cases still hormone-depended, include growth factors, cytokines and inflammation, Smad proteins, wingless type/β-catenin and others.
Summary
Much more is known about hormonal than about non-hormonal signaling in uterine fibroids. Growth factors, early life exposure and inflammation are key factors in uterine fibroid biology. Numerous agents depend on those pathways and may find their place in the current and future therapy of uterine fibroids.

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https://journals.lww.com/co-obgyn/Fulltext/2020/10000/Non_hormonal_mediators_of_uterine_fibroid_growth.9.aspx