Miranda Hester

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

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	Women who develop menarche early in life may be at an increased risk of developing gestational diabetes mellitus (GDM), according to a new study in the 

	Researchers used data from 4749 women who participated in the Australian Longitudinal Study on Women’s Health between 2000 and 2012. The women were aged 22 to 27 years at the start of the study when they reported their age at start of menstruation. During the 12 years of the study, information on GDM diagnosis was obtained for every live birth. Log-binomial analysis was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) and analyses were adjusted for body mass index, polycystic ovary syndrome, mother’s highest educational qualification, nulliparity, and physical activity.

	The mean age at start of menstruation was 12.9 years (standard deviation, 1.4) and a first diagnosis of GDM was reported by 357 women (7.5%). When compared to women who started menstruation at 13 years, women who started menstruation at age ≤ 11 years had a 51% higher risk of developing GDM (95% confidence interval: 1.10 - 2.07) following adjustment for known GDM risk factors.

	The investigators believe their findings illustrate that young age at the start of menarche may be a way of identifying women who are higher risk of developing GDM. They say that further studies are needed to confirm these initial results and to illuminate the role of early start of menarche and later risk of GDM.

NEXT: USPSTF issues final recommendation on pelvic exam

USPSTF issues final recommendation on pelvic exam

	Evidence is insufficient to assess balance versus risk of screening pelvic examination for asymptomatic, nonpregnant adult women, according to a Recommendation Statement issued by the US Preventive Services Task Force (USPSTF). Published in 

, the findings are based on a review of abstracts and full-text articles on screening pelvic examination published from 1946 to January 13, 2016.

	The report also took into consideration comments from the public received after release of a 

, which was posted from June 28, 2016 to July 25, 2016.

	The literature review was designed to answer 3 questions:

What is the direct evidence for the effectiveness of the pelvic examination in reducing all-cause mortality, cancer- and disease-specific morbidity and mortality, and improving quality of life?;

What are the test performance characteristics of the pelvic examination in screening for gynecologic cancers and other gynecologic conditions?; and

What are the adverse effects of screening using the pelvic examination?

	The investigators found inadequate evidence on the accuracy or benefits of pelvic examination for detection of a range of gynecologic conditions. Evidence was similarly inadequate on harms of screening for a variety of gynecologic conditions. No studies were found that looked at pelvic examination’s benefit on all-cause mortality, disease-specific morbidity or quality of life.

	The USPSTF acknowledged the difficulty of performing studies on the effectiveness of screening pelvic examination. The panel said that their findings do not apply to screening for cervical cancer, gonorrhea, or chlamydia, although some public comments mentioned that misperception. The authors also clarified, in response to public comments, that costs of preventive service are not considered when determining a recommendation grade.

	“In the absence of clear evidence on the balance of benefits and harm of using pelvic examination to screen for asymptomatic gynecologic conditions,” USPSTF said in summary, “clinicians are encouraged to consider the patient’s risk factors for various gynecologic conditions and the patient’s values and preferences, and engage in shared decision making with the patient to determine whether to perform pelvic examination.”

	The American College of Obstetricians and Gynecologists recommends performing pelvic examinations annually in all patients age 21 and older. 

NEXT: Can vaginal progesterone reduce PTB in women with twins?

	Can vaginal progesterone reduce PTB in women with twins?

	According to a meta-analysis published in 

, using vaginal progesterone may reduce the risk of preterm birth.

	Researchers searched Google Scholar, research registers of ongoing trials, MEDLINE, EMBASE, POPLINE, CINAHL, LILACS, and the Cochrane Central Register to look for randomized controlled trials (RCTs) which compared vaginal progesterone with placebo/no treatment in women with a twin gestation and a mid-trimester sonographic cervical length ≤ 25mm and that had individual patient data. Primary measured outcome was preterm birth < 33 weeks’ gestation. Two reviewers selected the studies independently, assessed the risk of bias and extracted the data. They found data for 303 women (159 assigned to vaginal progesterone and 144 assigned to placebo/no treatment) and their 606 fetuses/infants from 6 RCTs. One study provided 74% of the total sample size.

	When compared with placebo or no treatment, vaginal progesterone was linked with a statistically significant reduction in the risk of preterm birth at < 33 weeks’ gestation (31.4% vs 43.1%; relative risk [RR], 0.69 [95% confidence interval {CI}, 0.51–0.93]; moderate-quality evidence). It was also linked with significant decrease in birth weight < 1500 g (RR, 0.53 [95% CI, 0.35–0.80]), neonatal death (RR, 0.53 [95% CI, 0.35–0.81]), preterm birth < 35, < 34, < 32 and < 30 weeks' gestation (RRs ranging from 0.47 to 0.83), composite neonatal morbidity and mortality (RR, 0.61 [95% CI, 0.34–0.98]), use of mechanical ventilation (RR, 0.54 [95% CI, 0.36–0.81]), and respiratory distress syndrome (RR, 0.70 [95% CI, 0.56–0.89]), all moderate evidence. Additionally, no significant difference was seen between vaginal progesterone and placebo groups in the neurodevelopmental outcomes for the children at 4 to 5 years of age.

	The researchers concluded that administering vaginal progesterone to mothers with twin gestation and a short cervix mid-trimester will reduce the risk of preterm vaginal birth, neonatal mortality, and some neonatal morbidities. The use of progesterone also appears to show no negative effects on the neurodevelopment of offspring.

Articles

A new study looks at whether who begin menarche early in life are more likely to develop GDM. Plus: USPSTF issues their final recommendations on pelvic exams. Also, a look at the efficacy of vaginal progesterone in preventing preterm birth in twin pregnancy.

Does early menstruation increase risk of GDM?

	Preterm delivery may put women at increased risk of cardiovascular disease (CVD) later in lifem according to a study in 

	Researchers looked at the 70,182 parous women in Nurses’ Health Study II to examine the link between delivering an infant preterm (< 37 weeks) and CVD. They used multivariable Cox proportional-hazards to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for cardiovascular events (myocardial infarction and stroke, n = 949).

	Following adjustment for age, race, parental education, and prepregnancy lifestyle and cardiovascular risk factors, a preterm delivery in a woman’s first pregnancy was linked with an increased risk of CVD (HR, 1.42; 95% CI, 1.16–1.72) when compared to women who had a term delivery (≥ 37 weeks) in their first pregnancy. When split into moderate preterm (≥ 32 to < 37 weeks) and very preterm (< 32 weeks), the HRs were 1.22 (95% CI, 0.96–1.54) and 2.01 (95% CI, 1.47–2.75), respectively.

Recommended: Can a patient safety bundle prevent deaths from PE?

	Even among women who had first pregnancies uncomplicated by hypertensive disorders of pregnancy, the increased rate of CVD persisted in the very preterm group (HR, 2.01; 95% CI, 1.38–2.93). When compared to women with at least 2 pregnancies all delivered at term, women with a preterm first birth and at least 1 more later preterm birth had an HR for CVD of 1.65 (95% CI, 1.20–2.28). The link between moderate preterm first birth and CVD was accounted for in part by the development of changes in body mass index, type 2 diabetes, postpartum chronic hypertension, and hypercholesterolemia (proportion accounted for, 14.5%; 95% CI, 4.0–41.1), as was the very-preterm-CVD relationship (13.1%; 95% CI, 9.0–18.7).

	The researchers concluded that preterm delivery was independently predictive of CVD and could prove useful in CVD efforts. Because only a relatively modest proportion of the association between preterm birth and CVD was accounted for with development of convention CVD risk factors, the researchers say that further research could help identify other pathways.

NEXT: Night shifts, physical labor, and fecundity

	Night shifts, physical labor, and fecundity

	Women who work at night and perform physically demanding jobs may have lower fecundity, according to researchers from Harvard University. Their findings, published in 

, are from a first-of-its-kind study that looked at the association between occupational factors and markers of ovarian response in women of reproductive age.

	Participants in the prospective cohort were 786 women aged 18 to 45 with mean body mass index (BMI) 23 who planned to use their own gametes and were being treated at an academic fertility center between 2004 and 2015. Unexplained infertility was the primary diagnosis for most of the patients and 80% had undergone examination for infertility but only 48% had previously been treated for the condition.

	A questionnaire was used to collect information on the women’s occupational factors and electronic medical records were used to identify reproductive outcomes in the cohort. Compared with women who worked only day shifts, those who worked evening/night/rotating shifts had 2.3 fewer mature oocytes, on average (

<0.001). Moving heavy objects at work was associated with trends toward fewer total oocytes, mature oocytes, and antral follicles (

	The inverse association between heavy lifting and oocyte yield was stronger in women older than age 37 and with a BMI of at least 25 and when evening/night shift workers were considered as separate category (3.2 fewer mature oocytes in evening/night shift workers versus 8 in women working days). None of the occupational exposures were associated with Day 3 follicle-stimulating hormone or peak estradiol levels. Adjustment for total leisure time physical activity and smoking status did not affect the results.

	Their results, the authors said, “suggest that occupational factors may be more specifically affecting oocyte production and quality, rather than accelerating ovarian ageing, in this study population of women attending a fertility centre.” They cautioned that it may not be possible to generalize the findings to couples conceiving without medical intervention and note that they were not able to control for other work factors that might have been correlated with shift and physically demanding work. “Future work in other studies is needed,” the researchers said, “to further disentangle the effects of rotating shift work with and without nights and current versus lifetime exposure to shift work on fecundity.”

NEXT: Does a false-positive mammogram lead to delay in future screenings?

	Does a false-positive mammogram lead to delay in future screenings?

	Following a false-positive result from a screening mammogram, women may be more likely to delay or even forgo subsequent screenings, according to a new study published in 

Cancer Epidemiology, Biomarkers & Prevention

	The researchers used data from women who had mammogram screenings through a large healthcare organization with multiple facilities in the greater Chicago metropolitan area, which covered 741,150 screening mammograms for 261,767 women.

	Of the mammograms included, 650,232 produced true-negative results and 90,918 produced false-positive results. The likelihood of undergoing a subsequent mammogram was higher among women who had true-negative than those who had a false-positive result (85.0% vs 77.9%, 

 < 0.001). Median delay in being screened again was higher among women who had a false-positive result than a true-negative (13 months vs 3 months, 

 < 0.001). Additionally, women with a true-negative screening were 36% more likely to have a screening in the next 36 months than women who had a false-positive (hazard ratio = 1.36; 95% confidence interval, 1.35-1.37). Also women who have a false-positive mammogram are at increased risk of late-stage disease at time of diagnosis compared to those who have a true-negative mammogram (

Next: Are you in compliance with breast density laws?

	The investigators concluded that a false-positive mammogram is likely to cause a woman to delay subsequent screening, which could increase the 4-year cumulative risk of late-stage disease at time of diagnosis.

A study looks at the impact of a preterm birth on the mother's future risk of cardiovascular disease. Plus: Do shift work and physical labor negatively impact a woman's fertility? Also, are women who get a false-positive mammogram more likely to delay their future screenings?

Is there a link between CVD and preterm birth?

 underscore the correlation between decreased brain volume on fetal magnetic resonance imaging (MRI) and ultrasound-detected microcephaly in Zika-exposed fetuses. The findings were presented at the 37

 Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine, held in Las Vegas.

	The goal of the prospective cohort study was to assess fetal brain findings and volumetric composition with MRI in fetuses with confirmed Zika virus from the current outbreak in Barranquilla, Colombia. Among 214 pregnant women with Zika exposure, 13 fetuses were found on ultrasound to have abnormal brain findings such as microcephaly, ventriculomegaly, callosal dysgenesis, calcifications, and cortical anomalies. Seven women who were Zika-positive received fetal MRI at 29±4.4 weeks and were gestational age matched to 7 healthy controls at 29.87±4.61 weeks.

	Total brain volume in the Zika-infected fetuses differed significantly from that in controls (9422.42±2169.11 versus 20529.7±7049.95; 

<0.001) as did total intracranial volume (16390.42±3690.41 versus 35593.42±12281.71; 

<0.01. No significant difference was seen in ventricular volume, brainstem volume, or cerebellar volume. The ratio of cerebrospinal fluid to supratentorial brain parenchyma was higher in Zika-affected fetuses (1.36±0.20 versus 0.99±0.16; 

	Sanz-Cortes M, Zarutskie AJ, Yepez M, et al. Characterization of brain malformations and volume assessment in fetuses with Zika virus infection using MRI. Abstract 73. Presented Friday, January 27 at the 37

 Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in Las Vegas, Nevada.

NEXT: Cervical pessaries and preterm birth prevention

	Cervical pessaries and preterm birth prevention

	Placing a cervical pessary may not be enough to prevent preterm birth (PTB), according to results of a multicenter randomized controlled trial presented at the 37

 annual Pregnancy Meeting for the Society for Maternal-Fetal Medicine, in Las Vegas, Nevada.

	The researchers included asymptomatic women with singleton gestations with a transvaginal ultrasound (TVU) cervical length (CL) ≤ 25 mm at 18

 weeks and no prior PTB. The women were randomly assigned to receive the Bioteque cup pessary or no pessary and the pessaries were inserted by maternal-fetal medicine staff trained in proper placement. Randomization was stratified by CL (≤ 20 mm or >20-25 mm) and study site. Any women with a TV CL ≤ 20 mm were recommended for treatment with vaginal progesterone. Analysis was by intention-to-treat and the researchers required a total sample size of 242.

Recommended: Preterm birth - A pulic health concern

	Of a total of 17,388 screened for TVU CL, 446 (2.6%) were found to have a TVI CL ≤ 25 mm. Three hundred ninety-four (88.3%) met the eligibility criteria and 122 (31.0%) agreed to be randomized. When the study was submitted for the meeting, 111 of the women had delivered: 56 in the pessary and 55 in the no pessary group. Demographic characteristics were similar across both groups and no significant differences were seen between the pessary and no pessary group in the rates of PTB < 37 weeks, PTB < 34 weeks, PTB < 28 weeks, gestational age at delivery, birth weight, and composite neonatal outcome.

	The investigators concluded that treatment with a cervical pessary did not appear to prevent PTB in women with a singleton gestation and a TVU CL ≤ 25 mm at 18

weeks. The study recruitment was halted before the researchers were able to meeting their enrollment, but they state that the findings are similar to other recent studies that have also found pessaries to be ineffective.

NEXT: Is inadvertent HPV vaccination in pregnancy safe?

	Is inadvertent HPV vaccination in pregnancy safe?

	Inadvertently receiving a dose of the quadrivalent human papillomavirus vaccine (4vHPV) may not be a cause for adverse pregnancy outcomes, according to a retrospective, observational cohort study presented at the 37

	The researchers used administrative and healthcare data from the Vaccine Safety Datalink to look at a cohort of insured women aged 11 to 27 with singleton pregnancies that ended in a live birth between January 2007 and September 2013. Women who received the 4vHPV either during pregnancy or in the peri-conception period were classified as exposed. Controls were women with singleton pregnancies and a live birth during the same period who had received the 4vHPV vaccine in the 4 to 18 months prior to the start of pregnancy.

	Risks of major structural birth defects, chorioamnionitis, small for gestational age birth, hypertensive disorders of pregnancy, gestational diabetes, and preterm birth (< 37 weeks’ gestation) were evaluated. Adjusted relative risk tied to receiving the 4vHPV vaccine pregnancy, the peri-conception period, and the risks for both periods combined were evaluated using a generalized estimating equation method.

	The researchers found 720 women who received the 4vHPV vaccine peri-conception and 638 who had received the vaccine during pregnancy with 8166 women with distal 4vHPV exposures. Overall, vaccination with 4vHPV during the peri-conception period and pregnancy was not associated with an increased risk of adverse obstetrical events such as gestational diabetes (peri-conception adjusted risk ratio [aRR]1.06, 95% confidence interval [CI] [1.02]; during pregnancy aRR .98 [.67 – 1.4]; combined period aRR 1.0 [.77 – 1.3]); birth outcomes like preterm birth (peri-conception aRR .93 [.69 – 1.2]; during pregnancy aRR .97 [.72 – 1.3]; combined period aRR .97 [.79 – 1.2]); and major structural birth defects (peri-conception aRR .94 [.49 – 1.8]; during pregnancy aRR .91 [.46 – 1.8]; combined period aRR .96 [.59 – 1.6]).

	The researchers concluded that inadvertent 4vHPV vaccine administration is not linked to adverse outcomes for either mother or infant. 

Research looks at the science showing associations between microcephaly and Zika virus. Plus: Can cervical pessaries help prevent preterm birth? Also, a study examines whether inadvertent HPV vaccination during pregnancy leads to adverse outcomes for mother and baby.

Brain volume, microcephaly on US associated with Zika

	A history of at least 1 major depressive episode and a diagnosis of posttraumatic stress disorder (PTSD) may increase the risk of preterm birth (PTB) 4-fold, according to a recent study in 

	Researchers at Yale School of Medicine and University of Pennsylvania did a prospective study of 2654 women who been recruited from 137 practices in Connecticut and Western Massachusetts before 17 weeks of pregnancy. Psychiatric diagnoses were identified by administering the Complete International Diagnostic Interview and the Modified PTSD Symptom Scale and medication use data were gathered at participant reviews.

	Elevated rates of PTB among women with PTSD were identified with recursive partitioning analysis and splitting the PTSD node further suggested an interaction between PTSD and major depression. Logistic regression analysis confirmed an increased risk of PTB in women who likely had both PTSD and a major depressive episode (odds ratio [OR], 4.08, 95% confidence interval [CI], 1.27-13.15). PTB risk increased by 1% to 2% for each point increase on the Modified PTSD Symptom Scale, which has a range of 0 to 110. It was also high in women who took a serotonin reuptake inhibitor (OR, 1.55, 95% CI, 1.02-2.36) or a benzodiazepine medication (OR, 1.99, 95% CI, 0.98-4.03).

	The study authors concluded that women with likely diagnoses of PTSD and a major depressive episode are at a 4-fold increased risk of PTB. This risk is independent of antidepressant and benzodiazepine use.

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A history of at least 1 major depressive episode and a diagnosis of posttraumatic stress disorder (PTSD) may increase the risk of preterm birth (PTB) 4-fold, according to a recent study in JAMA Psychiatry.

Author | Miranda Hester

Articles

Does early menstruation increase risk of GDM?

Is there a link between CVD and preterm birth?

Brain volume, microcephaly on US associated with Zika

Is PTSD another risk factor for preterm birth?