SASGOG's Pearls of Exxcellence

Interpretation of benign endometrial biopsy report when evaluating abnormal uterine bleeding

The primary role of endometrial sampling is to ascertain existence of premalignant or malignant intrauterine pathology; however, further information can be gained from reviewing pathology results in the clinical setting...

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Evaluation and Management of Urinary Retention Caused by Pelvic Organ Prolapse (POP)

Pelvic organ prolapse (POP) is a common gynecologic condition causing symptoms in 4-8% of women. Women with prolapse beyond the hymen are more likely to present with obstructive voiding symptoms...

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Severe Postpartum Endometritis

Patients with postpartum endometritis who have failed initial broad-spectrum antibiotic therapy (including persistent temperatures over 38° Celsius after 48 hours) or who are critically ill, have severe postpartum endometritis. ...

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Ovarian Conservation at the Time of Hysterectomy

With hysterectomy representing a common opportunity for removal of the ovaries, a general approach to conservation or removal should focus on risk stratification. Placing aside known pathology of the ovary...

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Management of Active Phase Arrest

In order to manage active phase arrest, the active phase must be correctly defined, and arrest properly diagnosed. The active phase begins when there is an acceleration in the rate...

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Evaluation of Sexual Dysfunction

Female sexual dysfunction is defined as any sexual complaint or problem that results from disorders of desire, arousal, orgasm, or sexual pain and causes marked distress or interpersonal difficulty. ...

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Migraine, Cluster, and Tension Headaches

Headache may be classified as primary or secondary. Primary headaches have no associated underlying pathologic abnormalities. The principal primary headaches include cluster, migraine, and tension-type headaches. These syndromes...

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Management of Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder (PMDD) is a severe form of Premenstrual syndrome (PMS) associated with marked behavioral and emotional symptoms, in addition to physical symptoms According to the American Psychiatric Association...

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Endometrial Ablation

Mentor: Meg Autry, MDEditor: Daniel Breitkopf, MD Endometrial ablation can be performed by several different minimally invasive procedures which cause surgical destruction of the endometrium to treat abnormal uterine...

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Intrahepatic Cholestasis of Pregnancy

Mentor: Eric Strand, MD Editor: Elizabeth Ferris-Rowe, MD Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-specific liver disease. The incidence is between...

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Management of Prolonged Latent Phase

Mentor: Marygrace Elson, MD, MME, FACOG Editor: Tiffany A. Moore Simas, MD, MPH, MEd, FACOG Labor is divided into three stages. The first...

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Laparoscopic Sterilization

Mentor: Todd Jenkins, MD Editor: Abimbola Famuyide, MBBS Female permanent sterilization is the most common form of contraception in the United States and is used by nearly half...

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Management of Late Term Pregnancy

Late term pregnancy refers to pregnancies from 41 0/7 through 41 6/7 weeks gestation. Compared to full term pregnancy (39 0/7 - 40 6/7 weeks), late term and postterm...

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Evaluation and Management of Bleeding in Perimenopausal Women

Mentor: Sireesha Reddy Editor: Daniel M. Breitkopf The perimenopause is defined as the onset of intermenstrual cycle variability (±7 days) through two years after the final menstrual period....

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Laparoscopic Port Site Hernias

Elizabeth Ferries-Rowe, MD, FACOG Trocar site hernias occur in approximately 1% of laparoscopies. While rare, trocar site hernias are preventable. Risk factors for trocar site hernia include...

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Management of pelvic pain after negative diagnostic laparoscopy

Although considered gold standard in investigating acute or chronic pelvic pain, diagnostic laparoscopy may not demonstrate any causative factors in 30-50% of patients, leading to considerable disappointment. When endometriosis...

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Fluid Management at Hysteroscopy

During hysteroscopy, systemic absorption of uterine distension fluid occurs largely through disrupted endometrial and myometrial venous sinuses as a result of the pressure gradient between the uterine cavity and open...

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Management of Preeclampsia at Term

Management of preeclampsia at term (≥ 37 0/7 weeks) involves assessing the maternal-fetal status, preparing for delivery, and monitoring for disease severity and progression. Delivery is indicated when preeclampsia...

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Evaluation and Management of an Ovarian Mass in a Patient with a Family History of Ovarian Cancer

Increasing age is the most important risk factor for ovarian cancer in the general population, but a strong family history of breast or ovarian cancer is the most important personal...

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Management of Brow, Face, and Compound Malpresentations

Five percent of fetuses present in brow, face, or compound presentations, many of which result in vaginal delivery. Patients should be counseled about increased risk for cesarean delivery due to...

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Vaginal Squamous Intraepithelial Lesions

Vaginal intraepithelial neoplasia (VaIN) affects 0.2 per 100,000 women in the United States. VaIN, like cervical intraepithelial neoplasia (CIN), is caused by Human Papilloma Virus (HPV). High-risk HPV...

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Management of Hirsutism in a PCOS Patient

Hirsutism is often a primary complaint in women with PCOS. The most effective treatment includes a long-term approach that reduces androgen receptor activity, thus decreasing new terminal hair development, and...

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Evaluation and Management of Ruptured Membranes with Amnionitis at Term

Intraamniotic infection (IAI), or amnionitis, is an inflammatory or infectious disorder involving any combination of amniotic fluid, placenta, fetus, fetal membranes, or decidua. IAI Complicates approximately 2-5% of...

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Ultrasound Markers for Down Syndrome

Down Syndrome (trisomy 21) is the most common chromosomal disorder in live born infants. About 6,000 babies are born with Down Syndrome each year in the United States, or about...

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Glycemic Control in Diabetic Patients Undergoing Gynecologic Surgery

Patients with diabetes undergoing surgery are at increased risk of morbidity and mortality from their hypermetabolic stress response, preoperative catabolic state, altered nutritional status, changes in circulation, immobility, and glucose...

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Prevention of Complications in Women with Diabetes Undergoing Surgery

Diabetes mellitus (DM) is a common and increasingly prevalent chronic medical condition with an incidence of one in 11 persons worldwide. Approximately half of these cases are undiagnosed. ...

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Surgery in Morbidly Obese Patients

Preoperative preparation for obese patients requires attention to health conditions more common with obesity, including coronary artery disease (CAD), hypertension, diabetes mellitus, and obstructive sleep apnea (OSA). Anesthesia consultation is...

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Hysteroscopic Bowel Injury

Although hysteroscopic complications are rare, uterine perforation can cause serious injury to adjacent structures. Compared to diagnostic procedures, operative hysteroscopy elevates the risk of uterine corpus perforation 16-fold, and increases...

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Evaluation of Preeclampsia at Term

Gravidas at term (≥37 weeks) with new-onset hypertension or symptoms suggesting potential end organ effects such as headache, visual changes, or right upper quadrant or epigastric pain, should be evaluated...

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Abnormal Uterine Bleeding in Adolescents

Abnormal uterine bleeding (AUB) in adolescents is defined as excessive bleeding occurring between menarche and 19 years of age. During the first 12–18 months after the onset of menstruation, immaturity...

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Complications of Pessary Use

Pessary devices have been used for centuries for a number of indications including pelvic organ prolapse, urinary incontinence, and cervical insufficiency. They are considered a safe and reasonable long-term option...

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Pertussis in Pregnancy

Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. Infection causes paroxysms of coughing which can lead to dyspnea, hypoxia,...

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The Management of Borderline Ovarian Tumors in Young Nulliparous Women

Borderline ovarian tumors, previously known as low-malignant potential (LMP) tumors, make up nearly 20% of ovarian epithelial cancers and have an excellent prognosis regardless of stage at diagnosis. Borderline ovarian...

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Perioperative Management of Women with Chronic Obstructive Airway Disease and Asthma

The overall incidence of postoperative pulmonary complications is 5-10%, but patients with poorly controlled chronic obstructive airway disease (COPD) and asthma are at increased risk with up to 40% risk...

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Management of Placenta Accreta at Delivery

Mentor: Nancy Gaba, MD Editor: Christine Isaacs, MD and Tiffany Moore-Simas, MD Placenta accreta occurs when all or part of the placenta invades and is...

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Infertility in patients with PCOS

Editors: Julie Decesare, MD and Eduardo Lara-Torre, MD Polycystic ovarian syndrome (PCOS) is the leading cause of infertility in reproductive age women. Anovulation is generally assumed to be the...

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Lynch Syndrome

Mentor: Todd Jenkins MD Editor: Elizabeth Ferries-Rowe Lynch syndrome is an autosomal dominant hereditary cancer syndrome which commonly presents with colon cancer, endometrial cancer, or ovarian cancer. ...

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Postpartum Hemorrhage from Atony Unresponsive to First Line Uterotonics

Mentor: Tiffany A. Moore-Simas, MD Editor: Christine R. Isaacs, MD Primary postpartum hemorrhage (PPH), a leading cause of severe maternal morbidity in the US, is defined...

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Contraception for Women with Diabetes

The prevalence of diabetes mellitus is increasing worldwide, including among women of childbearing age, with an additional 150 million adult cases projected by 2030. Diabetes poses significant...

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Trial of Labor after Cesarean (TOLAC)

Options following a cesarean delivery include elective repeat cesarean delivery and trial of labor after cesarean (TOLAC). Successful TOLAC results in vaginal birth after cesarean (VBAC). No large...

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Contraception for Women with Migraines

Migraine headache is a common condition that affects approximately 12% of the population, and is more common in women than men. It affects 17.3-24.4% of women 18-39 years old. ...

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Overactive Bladder

Overactive bladder (OAB) is defined as “urinary urgency, typically accompanied by frequency and nocturia, with and without urge urinary incontinence, in the absence of urinary tract infection or other obvious...

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Contraception in Women with Cardiovascular Risk Factors

Cardiovascular risk factors include hypertension, diabetes, obesity, smoking and increasing age, and may limit options for contraception, particularly hormonal methods. Hypertension: Implants, intrauterine systems, and progestin-only pills do not...

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Contraception in Women with Lupus

Systemic Lupus Erythematosus (SLE) is an autoimmune disease with a highly variable presentation that occurs more commonly in females than males (10:1 ratio) and is most common in women of...

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Hormonal Contraception in Women Taking Medications with Potential Drug Interactions

Interactions between hormonal contraceptives and other medications can cause alteration of therapeutic medication level, increased toxicity, and decreased contraceptive efficacy. Combined hormonal contraceptives (CHCs) include products with estrogen and progestin,...

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Surgical Management of Women with Hypertension

Approximately one in three adults in the United States has a diagnosis of systemic hypertension and almost half of them have uncontrolled blood pressure. Hypertension is a risk factor for...

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Clostridium Difficile Colitis

Editor: Ronald T. Burkman, MD Clostridium difficile should be suspected as a cause of acute diarrhea in patients with recent surgery or antibiotic use. Acute diarrhea is usually...

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Management of Symptomatic Polyhydramnios

Polyhydramnios (or hydramnios) is an excessive amount of amniotic fluid relative to gestational age. It is thought to result from either increased production or decreased clearance of...

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Minor Red Cell Antigens and Fetal Hemolytic Anemia

There are more than 300 recognized blood-group antigens, of which the Rhesus (Rh) blood-group system is the most common cause of maternal alloimmunization. It is comprised of the c, C,...

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Cytomegalovirus Infection in Pregnancy

Cytomegalovirus (CMV) is the most common congenital viral infection, occurring in 0.2 – 2.2% of neonates. Up to 4% of women have a primary CMV infection during pregnancy. CMV may...

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Monochorionic Twins

In the United States, twin gestation is no longer a rare event due to the increase in maternal age at conception and the increase in use of assisted reproductive technology....

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Hyperthyroidism in Pregnancy

Mentor: Laurie S. Swaim, MD Editor: Eduardo Lara-Torre, MD Thyroid diseases in pregnancy must be differentiated from normal physiologic adaptations including increased thyroid volume (up to 30%)...

Antepartum Management of Dichorionic/Diamniotic Twins

Editor: Tiffany A. Moore Simas, MD, MPH, Med Chorionicity in twins is best determined by ultrasonography in the late first or early second trimester, with sensitivity of 90% or...

Management of the Breech Presenting at the Introitus

Mentor: Julie DeCesare, MD Editor: David Chelmow, MD Breech presentation occurs in 3-4 % of pregnancies at term. Frank breech accounts for over 50% of breech presentations....

Management of Twin Delivery

Important factors in determining the route of delivery for a twin gestation include: Chorionicity Fetal presentations Gestational age Estimated fetal weights and discordance ...

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Management of Vaginal Cysts

Mentor: Thomas Gellhaus, MD Editor: Eduardo Lara-Torre, MD Vaginal cysts occur in 1% of all women. Most are benign, asymptomatic, discovered incidentally, and should be...

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Management of Second Trimester Fetal Loss

Mentor: Abimbola Famuyide, MD Editor: Regan Theiler, MD Second trimester fetal loss occurs between 14 and 27 weeks and may encompass...

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Management of Large Rectoceles in Geriatric Patients

Mentor: Tiffany Moore-Simas, MD Editor: Julie Decesare, MD Patients with rectoceles may be asymptomatic or have symptoms such as splinting, pelvic pressure, dyspareunia, constipation,...

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Management of Fetal Demise caused by Abruption at Term

Mentor: Nancy D. Gaba, MD Editor: Daniel Breitkopf, MD Placental abruption complicates 0.5 to 1% of pregnancies, but very rarely results in fetal demise. Fetuses that survive...

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Post-pill Amenorrhea

Editor: Eduardo Lara-Torre, MD Combined hormonal contraceptives (CHC), including combined oral contraceptives (COC), inhibit ovulation through hypothalamic-pituitary inhibition of gonadotropin secretion. Historically, it was believed that...

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Evaluation of Stress Urinary Incontinence

Mentor: Christopher M. Zahn, MD Editor: Vanessa Gregg, MD There are several different types of urinary incontinence: stress, urge, chronic urinary retention (overflow), mixed, and...

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Surgical Management of Stress Urinary Incontinence

Mentor: Laurie S. Swaim MD Editor: Christopher M. Zahn, MD Stress urinary incontinence (SUI), defined as involuntary leakage of urine during coughing, laughing, sneezing, or...

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Non-surgical Management of Stress Urinary Incontinence

Mentor: Christine R. Isaacs, MD Editor: Tiffany Moore Simas, MD Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine with cough, sneeze,...

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Management of Postoperative Ileus

Mentor: L. Chesney Thompson, MD Editor: Martin E. Olsen, MD Postoperative ileus is a absent or abnormal peristalsis after surgery causing a functional obstruction without mechanical blockage. A...

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Perioperative Management of Anticoagulation in Gynecologic Patients

Editor: Eduardo Lara-Torre, MD For patients using chronic antithrombotic therapy undergoing gynecologic surgery, interruption of therapy to reduce bleeding risk must be balanced against risk of...

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Postmenopausal Bleeding in a Woman with a Stenotic Cervix

Mentor: Sandra Dayaratna, MD Editor: Eduardo Lara-Torre, MD Postmenopausal bleeding (PMB), defined as any bleeding which occurs greater than 12 months after the final menstrual period, requires evaluation...

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Sepsis

Mentor: Rajiv Gala, MD Editor: Chris Zahn, MD Sepsis is a systemic, dysregulated, inflammatory response with an identified source of infection. Septic shock and multiorgan dysfunction are subtypes...

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Complications of TVT and TOT

Mentor: Ellen Brock, MD Editor: Eduardo Lara-Torre, MD Tension-free transvaginal tape (TVT) and transobturator tape (TOT) are polypropylene mesh “slings” placed in a midurethral...

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Trichomonas, Gonorrhea, and Chlamydia in Pregnancy

Chlamydia trachomatis Most infections are asymptomatic, but may manifest with urethritis, Bartholin gland infection, or mucopurulent cervicitis. Upper tract infection is uncommon. All pregnant women < 25 years of...

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Postpartum Eclampsia

Eclampsia is defined as preeclampsia related new onset generalized tonic-clonic seizures and can result in significant morbidity and death. Postpartum eclampsia accounts for 10 to 44% of all cases of...

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Management of Primary and Recurrent HSV 2 Vulvar Infections

Serologic surveys show 26% of women 12 years and older have antibodies to HSV-2. While the initial presentation is similar for HSV-1 and HSV-2, most recurrences are caused by HSV-2....

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Contraception in Women with Thromboembolism and Thrombophilia

Estrogen administration increases the risk of venous thromboembolism (VTE) in women with a history of prior thromboembolism or known thrombogenic mutation by increasing hepatic production of coagulant factors. Additive risk...

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Metabolic Syndrome

Mentor: Laurie S. Swaim, MD Editor: Paula J. Hillard, MD The metabolic syndrome encompasses a cluster of risk factors including central obesity, dyslipidemia, elevated blood pressure, and hyperglycemia....

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Fecal Incontinence

Fecal incontinence is defined as the involuntary loss of liquid or solid stool, whereas anal incontinence, commonly termed “accidental bowel leakage” (ABL), also includes the loss of flatus. The prevalence...

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Evaluation of the Adnexal Mass in an Older Woman

The evaluation and management of an adnexal mass in an older woman is an important clinical challenge. Adnexal masses arise in gynecologic and non-gynecologic sites. Primary ovarian lesions include functional...

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Management of Adnexal Masses in Pregnancy

The overall prevalence of adnexal pathology in pregnancy is 1-6%, depending on the gestational age at presentation. The most common pathologic diagnoses include mature cystic teratomas, paraovarian cysts and corpus...

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Management of Persistent and Recurrent Trichomonas

Trichomonas vaginalis (T. vaginalis) is a protozoan parasite. It is one of the most common sexually transmitted infections, with an estimated 3.1% prevalence in the United States. Risks for infection...

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Management of Women on Hormonal Therapy or Contraception in Women Undergoing Surgery

Hormone therapy and use of combination hormonal contraceptives are associated with an increased risk of venous thromboembolism. Menopausal women taking estrogen plus progesterone therapy are twice as likely to experience...

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Postmenopausal Vulvar Disorders

Editor: Rebecca McAlister, MD The postmenopausal vulva is characterized by a decline in skin barrier function associated with aging and estrogen deficiency that contributes to increased susceptibility to a...

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Cystic Breast Masses in Young Women

The differential diagnosis of a cystic breast mass in a young woman includes benign cyst, fibrocystic changes, fibroadenoma, breast abscess, galactocele, fat necrosis, and malignancy. Evaluation should include history, exam,...

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Neonatal Encephalopathy and Cerebral Palsy

Neonatal encephalopathy is a clinical syndrome of neurologic dysfunction noted in the first days of life of a neonate born at or beyond 35 weeks gestation. It is characterized by...

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Management of a Patient who has Suffered Intimate Partner Violence

Domestic violence, or intimate partner violence (IPV), is threatening or controlling behavior inflicted on a person by another person in the context of an intimate relationship. Intimate partner violence...

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Evaluation and Management of Obstetric Anal Sphincter Injuries (OASIS)

All women having vaginal delivery should be closely examined for vaginal and perineal injuries and those with perineal laceration should have rectal examination to determine the extent of their injury...

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Evaluation of Dyspnea and Management of Pulmonary Embolism after Surgery

The differential diagnosis for dyspnea in a patient after gynecologic surgery or cesarean delivery should include atelectasis, pneumonia, and pulmonary thromboembolism (PTE). Atelectasis is the most common cause, occurring...

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Management of Grade 1 Adenocarcinoma of the Endometrium

Surgery is the cornerstone of treatment for endometrial carcinoma except for select premenopausal patients desiring fertility, and patients with significant medical comorbidities. In patients with known grade 1 adenocarcinoma,...

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Evaluation of Postmenopausal Vaginal Bleeding

Mentor: Rebecca McAlister, MD Editor: Daniel Breitkopf, MD Postmenopausal bleeding (PMB) is defined as any staining, spotting, or bleeding that occurs more than 12 months...

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Management of Wound Complications of Cesarean Delivery

Mentor: Christopher M. Zahn, MD Editor: Tiffany A. Moore Simas, MD, MPH, Med Preoperative measures that reduce wound infection include prophylactic antibiotics given within one...

Management of Evisceration of the Vaginal Cuff

Mentor: David Chelmow, MD Editor: Abimbola Famuyide, MD, MBBS Vaginal cuff dehiscence, a rare complication of vaginal hysterectomy, is the full or partial separation of the edges...

Management of Women with Multiple Fibroids who are Attempting Pregnancy

Although the presence of fibroids in most women will not impair their fertility or affect an ongoing pregnancy, some women with fibroids may face several pregnancy-related risks. Submucosal fibroids increase...

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Fetal Heart Rate Baseline Abnormalities: Bradycardia

Editor: Paul Wendel, MD Editor: Elizabeth Ferries-Rowe, MD Fetal bradycardia is defined as a baseline fetal heart rate less than 110 beats per minute...

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Perforation with Uterine Sound and Suction Cannula during a D&C

Editor: Eduardo Lara-Torre, MD Uterine perforation is one of the more common complications of cervical dilation and uterine curettage. The incidence is increased for a pregnant...

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Diagnosis and Management of Cervical Ectopic Pregnancy

Editor: Vanessa Gregg. MD Cervical ectopic pregnancy is the rare implantation of a pregnancy in the endocervical canal and accounts for less than 1% of...

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Proximal Tubal Occlusion

Editor: Rebecca McAlister, MD Proximal tubal occlusion is a common finding on hysterosalpingogram, occurring in up to 15% of studies. The occlusion is seen at the...

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Evaluation of Anemia in Pregnancy

Editor: Ronald T. Burkman, MD Anemia is common in pregnancy because blood volume expands by approximately 50% in a singleton gestation while total red blood cell mass only...

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Ongoing Care of a Woman with Breast Cancer on an Aromatase Inhibitor

Editor: Daniel Breitkopf, MD Breast cancer is the second leading cause of cancer death among women in the United States. Seventy five percent of breast cancers are estrogen...

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Management of Broad Ligament Extension and Hematoma during a Cesarean Delivery

Editor: Regan Theiler, MD The broad ligaments consist of anterior and posterior leaflets of peritoneum which cover the lateral uterine corpus and upper cervix and...

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Amniotic Fluid Embolism

Editor: Elizabeth Ferris-Rowe, MD Amniotic Fluid Embolism (AFE) is an uncommon, catastrophic obstetric emergency. The frequency of AFE is 2-7 cases per 100,000 births. It is...

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Management of Bilateral Tubo-Ovarian Abscesses in Young Nulligravida

Editor: Eduardo Lara-Torre, MD Tubo-ovarian abscess (TOA) occurs in 15% of cases of pelvic inflammatory disease (PID), and 33% of patients with PID requiring admission....

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Management of a Lost Pedicle At the Time of a Vaginal Hysterectomy

Editor: Rebecca McAlister, MD Clinically significant bleeding occurs in 1-2% of vaginal hysterectomies; subclinical hematomas, identified by sonography, may be seen in up to 15% of cases. Risk factors...

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Management of Atypical Glandular Cells

Editor: Paula J. Hillard, MD Atypical glandular cells (AGC) are uncommon, occurring in approximately 3 per 1000 specimens, but are a significant cervical cytology finding. Several retrospective studies...

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Hematoma after Delivery

Editor: Roger Smith, MD Puerperal hematomas can occur after spontaneous or operative vaginal delivery. Frequently cited risk factors include the use of vacuum or forceps, nulliparity,...

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Management of Breakdown of Obstetrical Anal Sphincter Repairs

Editor: Pamela D. Berens, MD Obstetric anal sphincter injuries (OASIS) include 3rd and 4th degree lacerations. Risk factors include forceps or vacuum delivery, episiotomy, first vaginal delivery, higher...

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Complications of Varicella Infection in the Third Trimester

Varicella, a herpes virus, is highly contagious and associated with significant maternal and neonatal morbidity during pregnancy. Clinical features of maternal infection include a prodrome of fever, headache, and malaise,...

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Management of Lateral Uterine Perforation at the Time of Hysteroscopy

Lateral uterine perforation at the time hysteroscopy is a rare, but potentially dangerous complication. The overall rate of hysteroscopic complications is low and diagnostic procedures have a lower rate than...

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Management of Ureteral Injuries

Ureteral injuries are relatively uncommon, and may be more common with gynecologic than other types of abdominopelvic surgery. The incidence of ureteral injury ranges from < 0.1% to over 1%...

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Hyperprolactinemia

Prolactin is mainly synthesized and secreted by the lactotroph cells in the pituitary gland. Elevations in serum prolactin usually result from conditions that cause hypersecretion of prolactin by the lactotrophs....

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Avoiding Trocar Injuries Associated with Laparoscopic Surgery

Up to half of major intraoperative complications associated with laparoscopy, including major vascular injury, occur at the time of surgical entry. Half of all bowel injuries occur during entry, with...

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Surgical Management of Endometriosis

Endometriosis may be strongly suspected based on clinical presentation, but laparoscopy remains the gold standard for a definitive diagnosis. In patients with pain that is not improved with medical management,...

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Singleton Breech Presentation

Approximately 3-4% of pregnancies at term are breech presentations. Presentation should be assessed in all pregnancies 36 weeks and beyond and suspected breech presentation confirmed by ultrasound. Eighty-five percent of...

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Antepartum Management of Vasa Previa

Vasa previa occurs when fetal blood vessels, that are unprotected by the umbilical cord or placenta, run through the amniotic membranes and traverse the cervix. Two types of vasa...

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Management of Pregnancy with ABO Incompatibility

ABO incompatibility is the most common maternal-fetal blood group incompatibility and the most common cause of hemolytic disease of the newborn (HDN). ABO incompatibility is more often seen in newborns...

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Desired Pregnancy after Essure Placement

While permanent methods of sterilization should be considered just that, permanent, patients and their partners can and do change their minds. Pregnancies after permanent sterilization procedures can occur spontaneously. In...

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Management of Placenta Accreta Spectrum Diagnosed at 20 Weeks

The degree of invasion of the myometrium by the chorionic villi defines placenta accreta (adherent to the myometrium), increta (invading the myometrium) and percreta (perforating through the myometrium). A...

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Hypothyroidism

ETIOLOGY Hypothyroidism is much more common in women than men. It occurs in up to 5% of the population, with approximately 0.1-2% being overt and 4.3% subclinical. Hypothyroidism is...

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Primary Amenorrhea in a Teenager

Primary amenorrhea (PA) has traditionally been defined as failure to menstruate by age 16. However, an evaluation should be initiated if a 15-year-old with normal secondary sexual characteristics or a...

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Management of Urethral Diverticula

Suburethral diverticula usually originate from the middle or distal portion of the posterior aspect of the urethra. The majority of urethral diverticula are thought to begin as an infection in...

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Management of Adnexal Cysts

Adnexal cysts may be identified based on gynecologic symptoms or may be incidentally noted during pelvic exam or imaging for other reasons. Further actions depend on imaging characteristics and symptoms....

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Elevated Maternal Serum AFP (MSAFP) During the Second Trimester

Alpha-fetoprotein is produced by the fetal liver. Levels rise during the second trimester. Values are expressed as MoMs (multiples of the median) for each specific week of gestation, and values...

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Management of Paget Disease of the Vulva

Extramammary Paget Disease (EMPD) of the vulva is a rare intra-epithelial adenocarcinoma of the vulvar skin presenting most commonly with pruritus. Unfortunately, diagnosis is often delayed as both patients and...

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Anemia in Pregnancy with Normal Iron Studies

Pregnancy results in a physiologic anemia due to expanded plasma volume. The red cell mass also expands, but to a lesser degree. Lack of iron supplementation results in a smaller...

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Management of a Thyroid Nodule

The prevalence of thyroid nodules varies with the level of iodine sufficiency. Because iodine deficiency is relatively rare in the United States, only about 5% of US women will have...

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Postoperative Urinary Fistulae

Although it has been estimated that the risk of injury to the urinary tract is 0.3% during pelvic surgery, particularly hysterectomy, many of these injuries are occult. When routine cystoscopy...

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Postpartum Perineal Pain

The diagnosis and management of postpartum perineal pain depends on history and physical examination. Because pain is rarely an isolated symptom, additional symptoms by history may also include bleeding,...

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Complications of Gynecologic Laparoscopic Surgery

Complications of gynecologic laparoscopy occur in 3 to 6 per 1000 cases, proportional to the complexity of the case. Approximately one-third to one-half occurs during initial access. There...

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Adnexal Masses in Adolescents

The prevalence of adnexal masses in adolescents is unknown. While the diagnosis of a “ruptured ovarian cyst” is common for adolescents presenting with abdominal and pelvic pain, often this...

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Fetal Ventral Abdominal Wall Defects

Gastroschisis and omphalocele are the most common fetal ventral abdominal wall defects. Omphalocele is a midline ventral abdominal wall defect through which abdominal contents herniate. The defect generally...

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Nonimmune Hydrops Fetalis

Hydrops fetalis is the presence of excessive fluid in two or more fetal compartments including skin edema, pleural effusion, pericardial effusion, ascites, and polyhydramnios. Fetal hydrops can be immune or...

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Toxoplasmosis in Pregnancy

Toxoplasma gondii is a protozoan which can lead to human infection through infected uncooked meat, exposure to contaminated soil or water, eating soil contaminated fruits or vegetables, or exposure to...

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Parvovirus in Pregnancy

Parvovirus B19 is a single stranded DNA virus which causes erythema infectiosum, also known as fifth disease. Clinical manifestations include flu-like signs and symptoms, low-grade fever, malaise, arthralgia, and a...

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