Endometrial Ablation Versus Hysterectomy

This article reviews study methodology, results, limitations, and utility of the Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding (STOP-DUB). Criticisms and limitations of the study are proposed. Relevant information from other studies or guidelines are reviewed. The key findings from this study are then applied to a clinical case scenario. The results of this study, particularly those related to reoperation, were in line with other studies. While follow-up of enrolled patients was lengthy, the study was limited by slow recruitment leading to small sample sizes. Generalizability of this study is limited by the lack of randomized with regards to surgical technique and hysterectomy route, as well as use of resectoscopic ablation techniques. Both endometrial ablation and hysterectomy were found to be effective treatments for premenopausal women with DUB. Hysterectomy was more effective at treating bleeding symptoms but was associated with more adverse events and higher rates of infection. A small but significant proportion of women initially treated with ablation subsequently underwent reoperation with either repeat ablation or hysterectomy. The information from this study when used in context with similar studies is useful in guiding patient counseling for treatment of premenopausal DUB; however, treatment plans should ultimately be individualized based on patient-specific factors to maximize the likelihood of success with initial treatment.

Human Papillomavirus Infection of the Cervix

In 1992 Lorincz et al. were the first to evaluate the clinicopathologic correlation with 11 recently identified human papillomavirus (HPV) genotypes: 31, 33, 35, 42, 43, 44, 45, 51, 52, 56, and 58. Using cervical samples from 8 studies that included specimens from 2627 women, HPV genotypes were categorized by the likelihood of association with grades of cervical neoplasia (from normal to cancer). These findings were the basis of the determination that (a) HPV causes cervical cancer, (b) detection of the cancer associated HPV genotypes could identify women at risk for cervical pre-cancer and cancer, and (c) a prophylactic HPV vaccine should include protection against (at least) HPV 16 and 18.

Outcomes Associated With Trial of Labor After Cesarean Delivery

This article provides a summary of a prominent study in obstetrics. What are the risks of adverse maternal and neonatal outcomes associated with trial of labor after cesarean delivery? With this question, the article presents the basics of the study, including funding, location, patient population, study design, endpoints, results, and criticism and limitations. It then briefly reviews other relevant studies in the field and information and the main recommendations of the most recent practice bulletin provided by the American College of Obstetricians and Gynecologists and concludes with a relevant clinical scenario.

A Randomized Clinical Trial to Evaluate Optimal Treatment for Unexplained Infertility

The treatment of unexplained infertility has traditionally been comprised of a stepwise treatment approach, first with ovulation induction combined with intrauterine insemination (IUI) and then with in vitro fertilization (IVF). Ovulation induction is first attempted with clomiphene citrate, and, if unsuccessful, injectable gonadotropins are used. The value of ovulation induction with injectable gonadotropins in couples with unexplained infertility has been questioned, however, given the high risk of multiple gestation and the increasing efficacy of IVF. To address this, the FASTT trial randomized couples with unexplained infertility to a treatment arm that either included or omitted gonadotropin/IUI. They found that an accelerated treatment approach that involved 3 cycles of clomiphene citrate/IUI and then progressed immediately to IVF resulted in a decreased time to pregnancy compared to the group who underwent gonadotropin/IUI for 3 cycles, as well as decreased cost per live birth. Therefore, it was concluded that treatment of couples with unexplained infertility with gonadotropin/IUI was of no additional benefit.

Low-Dose Aspirin for the Prevention and Treatment of Preeclampsia

“CLASP: A Randomized Trial of Low-Dose Aspirin for the Prevention and Treatment of Preeclampsia Among 9364 Pregnant Women” was a double-blinded, placebo-controlled trial that evaluated the impact of antenatal aspirin administration on development of preeclampsia and intrauterine growth restriction (IUGR). A total of 9364 women either at risk for preeclampsia or currently experiencing preeclampsia or IUGR were enrolled between 12 and 32 weeks and randomized to receive 60mg aspirin daily or placebo. While a nonsignificant 12% reduction in the odds of preeclampsia was found among the entire cohort, the reduction in preeclampsia with aspirin use was more pronounced for those who began prophylaxis prior to 20 weeks (22% reduction, p = 0.06). There was also a lower risk of preterm birth before 37 weeks in those who received aspirin at any time (19.7% vs. 22.2%, p = 0.003) but no difference in IUGR infants. In conclusion, 60mg aspirin daily did not significantly reduce the risk of preeclampsia or IUGR among the women included in this study.

Cell-Free DNA Screening for Fetal Aneuploidy

In a prospective, multicenter blinded study at 35 international centers, the Noninvasive Examination of Trisomy (NEXT) study evaluated the performance of cell-free DNA screening for fetal trisomy compared to standard first trimester screening with nuchal translucency and serum analytes in a routine prenatal population. Among the 15,841 women who had standard screening and cell-free DNA analysis with neonatal outcome data, there were 68 chromosomal abnormalities (1 in 236). Of these, 38 were Trisomy 21 (1 in 417). Cell-free DNA analysis had a higher area under the curve (AUC) for trisomy 21, compared to standard screening (0.999 vs. 0.958, p = 0.001). Cell-free DNA analysis also had greater sensitivity, specificity, and positive predictive value compared to standard screening for trisomy 21, 18, and 13. While cell-free DNA analysis cannot detect all chromosome abnormalities, it performed better than standard screening for detection of trisomies 21, 18, and 13 in a routine population including low- and high-risk women.

Predictors of Success of Methotrexate Treatment for Tubal Ectopic Pregnancies

This study reviewed the use of a single dose of intramuscular methotrexate as therapy in women with an ectopic pregnancy. Therapy failure was more likely in women with higher hCG level and presence of cardiac activity at time of treatment. Age, parity, size of pregnancy, and the presence of intraperitoneal fluid were not found to correlate with treatment failures.

Racial and Ethnic Disparities in Maternal Morbidity and Obstetric Care

This article provides a summary of a landmark study describing racial and ethnic disparities in maternal morbidity and obstetric care practices. The article describes the basics of the study, including funding, study location, who was studied, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The article briefly reviews other relevant studies and information, and discusses implications. The article concludes with a relevant clinical case highlighting unconscious bias and how it affects the care providers deliver to their patients. Racial disparities are rampant in medicine, this article highlights the role of race in maternal outcomes.

Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes

This article provides a summary of a landmark study in obstetrics. The article provides insight on a pivotal question; Is delivery before 39 weeks among patients undergoing elective repeat cesarean delivery associated with increased risk of adverse neonatal outcomes? The authors describe the basics of the study, including study location, study population, number of patients, study design, endpoints, results, and limitations. The article briefly reviews other relevant studies and information, discusses implications, and concludes with a relevant clinical case. The article places these finding in contemporary context and highlights its impact on obstetric care. In addition, the author reference updated national guidelines developed as a result of this study.

Clomiphene, Metformin, or Both for Infertility With Polycystic Ovarian Syndrome

The PPCOS trial examines and compares ovulation induction treatments for infertile women with a diagnosis of polycystic ovarian syndrome (PCOS). Both clomiphene and metformin are pharmacologic therapies that have been utilized to promote ovulation and subsequent fertility in women with PCOS. However, it is uncertain if clomiphene, metformin, or a combination of both should be the first-line ovulation induction treatment option for women with PCOS. This study examines fertility and pregnancy outcomes for PCOS women by performing a double-blind, randomized study utilizing 3 different study arms: clomiphene, metformin, and clomiphene plus metformin. This study not only reviews differences in ovulation, pregnancy loss, live birth, and multiple gestation rates between the 3 different study arms, but it also concludes which treatment option is superior for infertile PCOS women seeking treatment.