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Screening for Gestational Diabetes: US Preventive Services Task Force Recommendation Statement

Author/s: 
US Preventive Services Task Force, Davidson, K. W., Barry, M. J., Mangione, C. M., Cabana, M., Caughey, A. B., Davis, E. M., Donahue, K. E., Doubeni, C. A., Kubik, M., Li, L., Ogedegbe, G., Pbert, L., Silberstein, M., Stevermer, J., Tseng, C., Wong, J. B.

Importance: Gestational diabetes is diabetes that develops during pregnancy. Prevalence of gestational diabetes in the US has been estimated at 5.8% to 9.2%, based on traditional diagnostic criteria, although it may be higher if more inclusive criteria are used. Pregnant persons with gestational diabetes are at increased risk for maternal and fetal complications, including preeclampsia, fetal macrosomia (which can cause shoulder dystocia and birth injury), and neonatal hypoglycemia. Gestational diabetes has also been associated with an increased risk of several long-term health outcomes in pregnant persons and intermediate outcomes in their offspring.

Objective: The USPSTF commissioned a systematic review to evaluate the accuracy, benefits, and harms of screening for gestational diabetes and the benefits and harms of treatment for the pregnant person and infant.

Population: Pregnant persons who have not been previously diagnosed with type 1 or type 2 diabetes.

Evidence assessment: The USPSTF concludes with moderate certainty that there is a moderate net benefit to screening for gestational diabetes at 24 weeks of gestation or after to improve maternal and fetal outcomes. The USPSTF concludes that the evidence on screening for gestational diabetes before 24 weeks of gestation is insufficient, and the balance of benefits and harms of screening cannot be determined.

Recommendation: The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes in asymptomatic pregnant persons before 24 weeks of gestation. (I statement).

Keywords 
Gestational Diabetes US Preventative Task Force Infancy Pregnancy Diagnostic Criteria

Treatment-induced neuropathy of diabetes related to abrupt glycemic control

Author/s: 
Stainforth-Dubois, M., Mcdonald, E. G.

KEY POINTS
Rapid correction of glycemic control (i.e., > 2 percentage points of hemoglobin A1c) over 3 months may lead to treatment-induced neuropathy of diabetes.

Symptoms include painful neuropathy, autonomic dysfunction, gastroparesis, early worsening of retinopathy and microalbuminuria.

Women and people with type 1 diabetes are at elevated risk of treatment-induced neuropathy of diabetes.

Management of the condition may include involvement of a dietitian, adjustment of insulin dose and use of medications to improve symptoms such as painful neuropathy, postural hypotension and gastroparesis.

Stress Incontinence in Women

Author/s: 
Wu, J. M.

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.

A 43-year-old woman with a history of obesity (body-mass index [the weight in kilograms divided by the square of the height in meters] of 32.0) reports urinary leakage with coughing, sneezing, and exercise. She first noticed these symptoms after delivering her third child 6 years ago. Since then, her symptoms have worsened, and she now soaks through pads when she runs. She is frustrated by her situation because she would like to exercise to lose weight, but exercise exacerbates her urinary leakage. How should this case be evaluated and managed?

Rethinking mechanisms, diagnosis and management of endometriosis

Author/s: 
Chapton, Charles, Marcellin, Louis, Borghese, Bruno, Santulli, Pietro

Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. This disease should be viewed as a public health problem with a major effect on the quality of life of women as well as being a substantial economic burden. In light of the considerable progress with diagnostic imaging (for example, transvaginal ultrasound and MRI), exploratory laparoscopy should no longer be used to diagnose endometriotic lesions. Instead, diagnosis of endometriosis should be based on a structured process involving the combination of patient interviews, clinical examination and imaging. Notably, a diagnosis of endometriosis often leads to immediate surgery. Therefore, rethinking the diagnosis and management of endometriosis is warranted. Instead of assessing endometriosis on the day of the diagnosis, gynaecologists should consider the patient's 'endometriosis life'. Medical treatment is the first-line therapeutic option for patients with pelvic pain and no desire for immediate pregnancy. In women with infertility, careful consideration should be made regarding whether to provide assisted reproductive technologies prior to performing endometriosis surgery. Modern endometriosis management should be individualized with a patient-centred, multi-modal and interdisciplinary integrated approach.

Keywords 
Pregnancy women Endometriosis Infertility Uterus Pain

Diagnosis and treatment of adenomyosis

Author/s: 
Dason, Ebernella Shirin, Chan, Crystal, Sobel, Mara

Adenomyosis is a benign gynecological disorder characterized by aberrant development of endometrial glands and stroma within the myometrium, causing inflammation and neuroangiogenesis. Adenomyosis often coexists with other gynecological conditions and may cloud the clinical presentation.

Keywords 
Adenomyosis Endometrium Genital Diseases female gynecology women menstruation

A Review of the Pathophysiology and Management of Diabetes in Pregnancy

Author/s: 
Egan, A.M., Dow, M.L., Vella, A.

Diabetes is a common metabolic complication of pregnancy and affected women fall into two subgroups: women with pre-existing diabetes and those with gestational diabetes mellitus (GDM). When pregnancy is affected by diabetes, both mother and infant are at increased risk for multiple adverse outcomes. A multidisciplinary approach to care before, during, and after pregnancy is effective in reducing these risks. The PubMed database was searched for English language studies and guidelines relating to diabetes in pregnancy. The following search terms were used alone and in combination: diabetes, pregnancy, gestational diabetes, GDM, prepregnancy, and preconception. A date restriction was not applied. Results were reviewed by the authors and selected for inclusion based on relevance to the topic. Additional articles were identified by manually searching reference lists of included articles. Using data from this search we herein summarize the evidence relating to pathophysiology and management of diabetes in pregnancy. We discuss areas of controversy including the method and timing of diagnosis of GDM, and choice of pharmacologic agents to treat hyperglycemia during pregnancy. Therefore, this review is intended to serve as a practical guide for clinicians who are caring for women with diabetes and their infants.

Contraceptive Challenges in Women With Common Medical Conditions

Author/s: 
Gave, C.J., Marnach, M.L., Casey, P.M.

Women have the opportunity to meet personal contraceptive goals with convenient, highly reliable, and easily reversible methods. Long-acting reversible contraception represents an increasingly popular option for most women throughout the reproductive lifespan. Nonetheless, many women and their health care providers are challenged by coexisting medical issues. We aim to help clinicians individualize contraception and use shared decision-making to enhance patient satisfaction and continuation with their method.

Copyright © 2020. Published by Elsevier Inc.

Association of Menopausal Hormone Therapy With Breast Cancer Incidence and Mortality During Long-term Follow-up of the Women's Health Initiative Randomized Clinical Trials

Author/s: 
Chlebowski, R.T., Anderson, G.L., Aragaki, A.K., Manson, J.E., Stefanick, M.L., Pan, K., Barrington, W., Kuller, K.H., Simon, M.S., Lane, D., Johnson, K.C., Rohan, T.E., Gass, M.L.S., Cauler, C.A., Paskett, E.D., Sattari, M., Prentice, M.L.

Abstract

Importance: The influence of menopausal hormone therapy on breast cancer remains unsettled with discordant findings from observational studies and randomized clinical trials.

Objective: To assess the association of prior randomized use of estrogen plus progestin or prior randomized use of estrogen alone with breast cancer incidence and mortality in the Women's Health Initiative clinical trials.

Design, setting, and participants: Long-term follow-up of 2 placebo-controlled randomized clinical trials that involved 27 347 postmenopausal women aged 50 through 79 years with no prior breast cancer and negative baseline screening mammogram. Women were enrolled at 40 US centers from 1993 to 1998 with follow-up through December 31, 2017.

Interventions: In the trial involving 16 608 women with a uterus, 8506 were randomized to receive 0.625 mg/d of conjugated equine estrogen (CEE) plus 2.5 mg/d of medroxyprogesterone acetate (MPA) and 8102, placebo. In the trial involving 10 739 women with prior hysterectomy, 5310 were randomized to receive 0.625 mg/d of CEE alone and 5429, placebo. The CEE-plus-MPA trial was stopped in 2002 after 5.6 years' median intervention duration, and the CEE-only trial was stopped in 2004 after 7.2 years' median intervention duration.

Main outcomes and measures: The primary outcome was breast cancer incidence (protocol prespecified primary monitoring outcome for harm) and secondary outcomes were deaths from breast cancer and deaths after breast cancer.

Results: Among 27 347 postmenopausal women who were randomized in both trials (baseline mean [SD] age, 63.4 years [7.2 years]), after more than 20 years of median cumulative follow-up, mortality information was available for more than 98%. CEE alone compared with placebo among 10 739 women with a prior hysterectomy was associated with statistically significantly lower breast cancer incidence with 238 cases (annualized rate, 0.30%) vs 296 cases (annualized rate, 0.37%; hazard ratio [HR], 0.78; 95% CI, 0.65-0.93; P = .005) and was associated with statistically significantly lower breast cancer mortality with 30 deaths (annualized mortality rate, 0.031%) vs 46 deaths (annualized mortality rate, 0.046%; HR, 0.60; 95% CI, 0.37-0.97; P = .04). In contrast, CEE plus MPA compared with placebo among 16 608 women with a uterus was associated with statistically significantly higher breast cancer incidence with 584 cases (annualized rate, 0.45%) vs 447 cases (annualized rate, 0.36%; HR, 1.28; 95% CI, 1.13-1.45; P < .001) and no significant difference in breast cancer mortality with 71 deaths (annualized mortality rate, 0.045%) vs 53 deaths (annualized mortality rate, 0.035%; HR, 1.35; 95% CI, 0.94-1.95; P= .11).

Conclusions and relevance: 

In this long-term follow-up study of 2 randomized trials, prior randomized use of CEE alone, compared with placebo, among women who had a previous hysterectomy, was significantly associated with lower breast cancer incidence and lower breast cancer mortality, whereas prior randomized use of CEE plus MPA, compared with placebo, among women who had an intact uterus, was significantly associated with a higher breast cancer incidence but no significant difference in breast cancer mortality.

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