SASGOG's Pearls of Exxcellence

Medication Abortion

Editor’s Note: This article is accurate and current as of the publication and review date. Practitioners need to be aware of the laws concerning this subject, and the variability of...

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Management of Malpositioned Intrauterine Devices

As the rate of intrauterine device (IUD) insertion increases, IUD malposition has become more common, with some studies citing an incidence as high as 10.4%. Most nonfundal IUDs are located...

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Female Sexual Interest/Arousal Disorder and Female Orgasmic Disorder

Sexual function is a complex interaction among biological, medical, psychosocial, interpersonal, and sociocultural factors. Almost half of women (43%) experience sexual dysfunction and 12% of women report related personal distress...

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Recurrent Pregnancy Loss

Pregnancy loss occurs in 15% to 25% of pregnancies, while recurrent pregnancy loss affects up to 2% of pregnancies. Recurrent pregnancy loss is defined by the loss of 2 or...

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Management of Lactational Mastitis

Mastitis spectrum conditions are common disorders of lactation that can contribute to early cessation of lactation. Prompt recognition and consistent treatment recommendations can prevent worsening complications and assist patients with...

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Essential Concepts in Perioperative Huddles and Time Outs

Patient safety in the surgical setting continues to be an area of focus because of the significant patient harm resulting from surgical errors. Many of these preventable errors result...

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Blood Transfusion in Obstetric Patients

Most blood transfusions in pregnancy and the postpartum period are performed to address acute blood loss. In the first and second trimesters, this mostly results from ruptured ectopic pregnancies or...

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Just culture: Balanced Accountability for Systems and Individuals During Safety Event Reviews

In 1999, the Institute of Medicine (now known as the National Academy of Medicine) estimated that preventable medical errors caused 98,000 hospital deaths annually and called on health care organizations...

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Evaluating Pelvic Floor Dysfunction in Chronic Pelvic Pain or Dyspareunia

Pelvic floor dysfunction is a broad term used to describe the abnormal activity or function of the pelvic floor musculature. Pelvic floor relaxation can lead to pelvic organ prolapse or...

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Addressing Microaggression in Women's Health Care Settings

Microaggressions are subtle, often recurrent, verbal and nonverbal interactions that are demeaning or engender hostility toward marginalized communities and nondominant groups. Microaggressions may be conscious or unconscious and include several...

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Acute Cardiovascular Disease in Pregnancy

Cardiovascular disease is the leading cause of mortality during pregnancy and the postpartum period, accounting for 35% of maternal deaths worldwide. Nearly 4% of pregnancies in the United States are...

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Physician Guide to Promoting Equitable and Socially Just Obstetric Care

Significant inequities in obstetric clinical outcomes persist despite advancement in technology and social protections such as higher education and income. The disproportionate burden of premature death and morbidity affects historically...

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Cesarean Delivery with Deeply Impacted Fetal Head

While various definitions have been proposed for impacted fetal head (IFH), all include the fetal head becoming deeply engaged within the maternal pelvis resulting in a difficult extraction. IFH complicates...

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Intrauterine Device in Place During Pregnancy

The risk of becoming pregnant with an intrauterine device (IUD) in place is very low, similar to the risk of pregnancy occurring with tubal sterilization, about 2% over 10 years....

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Management of Lost Subdermal Contraceptive Implant

When an etonogestrel contraceptive implant cannot be palpated, pregnancy must first be excluded, and the patient should use an alternative method of contraception until the presence of the implant can...

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Recurrent Bacterial Vaginosis

Bacterial vaginosis occurs when there is a shift in the vaginal microbiota from Lactobacillus dominant species to Gardnerella vaginalis and anaerobic bacteria, which may be difficult to culture. Bacterial vaginosis...

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Management of Cesarean Scar Pregnancy

Cesarean scar pregnancy (CSP), also referred to as cesarean scar ectopic pregnancy, was first reported in 1978. CSP is rare, occurring in 1 in 1800 to 2656 pregnancies, and it...

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Best Practices for Morbidity and Mortality Conferences for Obstetrics and Gynecology Departments

Morbidity and mortality (M&M) conferences provide a unique opportunity to deconstruct patient care and gain insight into systems-based challenges contributing to adverse outcomes. Although nearly all institutions hold regular M&M...

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Best Practices for Simulation: Planning a Meaningful Simulation

Effective medical simulations are critical to enabling optimal responses to emergencies. Simulations provide necessary experiential learning to all health care team members and promote team functioning. Meaningful simulations require extensive...

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Understanding the Peer-Review Process

The best peer-review processes facilitate continuous evaluation of a provider’s professional performance by other providers using the 6 core competencies endorsed by the Accreditation Council for Graduate Medical Education: patient...

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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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Transgender Care

The terms transgender male or transgender man describe individuals who were sex-assigned female at birth who identify on the more masculine spectrum of gender identity. The transgender and gender-diverse experience...

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Stillbirth Evaluation

Stillbirth affects nearly 1 in 160 pregnancies in the United States and is defined as fetal death at 20 or more weeks of gestation. In developed countries, risk factors include...

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Urodynamics: Indications for the Procedure and Systematic Interpretation

Urinary incontinence is a common concern for women. Initial evaluation should include a detailed history, physical examination, demonstration of stress incontinence, assessment of urethral mobility, determination of symptom severity, and...

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Medical Management of Menopausal Symptoms

Menopausal symptoms vary for each woman. Symptoms can arise in the perimenopausal period and last throughout the rest of a woman’s lifetime. Vasomotor symptoms occur in 75% of women...

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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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Persistent Postpartum Endometritis

When patients with postpartum endometritis do not respond to initial broad-spectrum antibiotic therapy and either demonstrate persistent temperatures over 38° Celsius after 48 hours or who are critically...

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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 lasting...

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Migraine, Cluster, and Tension Headaches

Headaches 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, emotional, and potentially physical symptoms. According to the American Psychiatric Association Diagnostic and Statistical...

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Endometrial Ablation

Endometrial ablation can be performed by several different minimally invasive procedures which cause surgical destruction of the endometrium to treat abnormal uterine bleeding (AUB). First generation technique involves...

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Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-specific liver disease. The incidence is between 0.2%-2% and is higher in South American and Northern European populations. Risk...

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Management of Prolonged Latent Phase

Labor is divided into three stages. The first stage of labor is divided into two phases – the latent phase and the active phase. In the latent phase,...

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Laparoscopic Sterilization

Female permanent sterilization is the most common form of contraception in the United States and is used by nearly half of all married couples. Laparoscopic sterilization is performed under general...

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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 post-term...

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Evaluation and Management of Bleeding in Perimenopausal Women

The perimenopause is defined as the onset of intermenstrual cycle variability (±7 days) and/or classic menopausal symptoms through two years after the final menstrual period. Menopause is achieved after 12...

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Laparoscopic Port Site Hernias

Trocar site hernias occur in approximately 1% of laparoscopies. While rare, trocar site hernias are preventable. Risk factors for trocar site hernia include increasing age and BMI. ...

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Diagnosis of non-endometriosis pelvic pain after negative diagnostic laparoscopy

Although considered the gold standard in investigating acute or chronic pelvic pain, diagnostic laparoscopy may be noncontributory in 30-50% of patients, While this can be quite a disappointment to the...

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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...

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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 papillomavirus (HPV). High-risk HPV (hrHPV)...

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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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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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Surgery in Morbidly Obese Patients

Surgical complications such as infection, venous thromboembolism (VTE), and wound complications are a major source of morbidity in obese women, but may be reduced with attention to preoperative, intraoperative and...

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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/worsening hypertension or symptoms suggesting end organ effects, such as persistent headache, visual changes, right upper quadrant or epigastric pain, should be evaluated for...

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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 affecting one in 11 persons worldwide. Approximately half of these cases are undiagnosed. Routine screening for...

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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 a number of indications including pelvic organ prolapse, urinary incontinence, preterm labor, and cervical insufficiency. They are considered a safe and reasonable long-term option...

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Pertussis Prophylaxis 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

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

Placenta accreta spectrum (PAS) describes the pathologic adherence of the placentaand includes placenta increta, percreta, and accreta. The PAS incidence has increased in parallel with increasing cesarean...

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Infertility in patients with PCOS

Polycystic ovarian syndrome (PCOS) is the leading cause of infertility in reproductive-age women. Anovulation is typically the cause of infertility in PCOS. However, evaluating anatomic reasons using an...

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Lynch Syndrome

Lynch syndrome is an autosomal dominant hereditary cancer syndrome which commonly presents with colon cancer, endometrial cancer, or ovarian cancer. It is also associated with cancers of the stomach,...

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Postpartum Hemorrhage from Atony Unresponsive to First Line Uterotonics

Primary postpartum hemorrhage (PPH), a leading cause of severe maternal morbidity in the US, is defined as cumulative blood loss of ≥1000 ml and signs of hypovolemia during the 24...

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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), and is estimated...

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Contraception for Patients with Migraines

Migraine headache is a common condition that affects up to 24% of females aged 18-39. A migraine is a headache lasting 4 to 72 hours and must have nausea,...

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Overactive Bladder

Overactive bladder (OAB) is defined by the International Continence Society (ICS) as “urinary urgency, typically accompanied by frequency and nocturia, with and without urge urinary incontinence, in the absence of...

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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. Clinicians should use the USMEC to guide their counseling and...

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Contraception in Patients 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 Patients 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 the most common cause...

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Clostridioides Difficile Colitis

Clostridioides difficile infection should be suspected as a cause of acute diarrhea, defined as 3 or more loose or watery stools in a 24-hour period, in patients who have had...

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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

The risk for fetal and neonatal mortality and long-term morbidity in monochorionic twins is higher than dichorionic twins, with a 3- fold to 4-fold increase in intrauterine demise. Placental vascular...

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Hyperthyroidism in Pregnancy

During pregnancy, physiological adaptations of the thyroid include increased thyroid volume (up to 30%) and a 40-100% increase in thyroid hormone production. Cross-reactivity between human chorionic gonadotropin and thyroid-stimulating...

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Antepartum Management of Dichorionic/Diamniotic Twins

Chorionicity in twins is determined by ultrasonography in the late first or early second trimester, with sensitivity of 90% or better. The twin peak sign (lambda or delta sign)...

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Management of the Breech Presenting at the Introitus

Breech presentation occurs in 3-4 % of pregnancies at term. Frank breech accounts for over 50% of breech presentations. Factors predisposing to persistent breech presentation at term include anything that...

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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

Vaginal cysts occur in 1% of all women. Most are benign, asymptomatic, discovered incidentally, and should be managed expectantly. Common benign causes of vaginal cysts include remnants of the embryonic...

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Management of Second Trimester Fetal Loss

Second trimester fetal loss complicates 1% to 2% of pregnancies and occurs between 14 and 27 weeks gestation and may encompass spontaneous abortion, stillbirth, and early preterm labor. Risk factors...

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Management of Large Rectoceles in Geriatric Patients

Patients with rectoceles may be asymptomatic or have symptoms such as splinting, pelvic pressure, dyspareunia, constipation, fecal incontinence, and defecatory dysfunction. Rectocele extent does not necessarily correlate with the severity...

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Management of Fetal Demise caused by Abruption at Term

Placental abruption complicates 0.5 to 1% of pregnancies, but very rarely results in fetal demise. Fetuses that survive are at increased risk of significant morbidity. Management must address maternal...

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Post-pill Amenorrhea

Combined hormonal contraceptives (CHC), including combined oral contraceptives (COC), inhibit ovulation through hypothalamic-pituitary inhibition of gonadotropin secretion. While no casual relationship has been established between CHC and subsequent amenorrhea, historically,...

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Evaluation of Stress Urinary Incontinence

Stress urinary incontinence is an involuntary urinary loss from physical exertion related to increased abdominal pressure, resulting in a reduced quality of life. Of the 16% of adult women...

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Surgical Management of Stress Urinary Incontinence

Stress urinary incontinence (SUI), defined as involuntary leakage of urine during coughing, laughing, sneezing, or physical activity, affects greater than 16% of all women. Bothersome SUI can be managed...

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Non-surgical Management of Stress Urinary Incontinence

Treatments options for stress urinary incontinence (SUI) include conservative therapies (pelvic floor exercises, behavioral modifications, continence support devices, and urethral inserts) and surgical treatments options (retropubic urethropexies, autologous, fascial slings,...

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Management of Postoperative Ileus

Postoperative ileus is an absent or abnormal peristalsis after surgery causing a functional obstruction without mechanical blockage. A physiologic ileus can occur up to 72 hours after surgery. When...

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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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Evaluation and Management of Postmenopausal Bleeding in a Woman with a Stenotic Cervix

Postmenopausal bleeding (PMB), defined as any bleeding which occurs greater than 12 months after the final menstrual period, requires evaluation because of the 1-14% risk of endometrial cancer. More than...

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Sepsis

Sepsis is a systemic, dysregulated, inflammatory response with an identified source of infection. Septic shock and multiorgan dysfunction are subtypes of severe sepsis and are associated with increased mortality. Many...

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Complications of TVT and TOT

Tension-free transvaginal tape (TVT) and transobturator tape (TOT) are polypropylene mesh “slings” placed in a midurethral position to treat stress incontinence. TVT incorporates a retropubic approach with the tape exiting...

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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 patients < 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

The metabolic syndrome encompasses a cluster of risk factors including central obesity, dyslipidemia, elevated blood pressure, and raised fasting glucose. Together these factors increase the risk of atherosclerotic cardiovascular disease,...

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Anal 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 Patient

The evaluation and management of an adnexal mass in an older patient is an important clinical challenge. Primary ovarian lesions include functional cysts, neoplastic cysts and solid masses (benign, borderline,...

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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 Trichomoniasis

Trichomonas vaginalis (T. vaginalis) is a protozoan parasite, and is the most common nonviral sexually transmitted infection (STI), with 3-5 million cases annually, in the United States. Health disparities...

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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 oral estrogen plus progesterone therapy are twice as likely to...

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Postmenopausal Vulvar Disorders

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 variety of conditions. The most...

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Non-proliferative Breast Masses in Young Women

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

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Neonatal Encephalopathy and Cerebral Palsy

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

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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 after gynecologic surgery includes atelectasis, pneumonia, and pulmonary thromboembolism (PTE). Atelectasis, the most common cause, occurs in 15-20% of patients after abdominal surgery. ...

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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

Postmenopausal bleeding (PMB) is defined as any staining, spotting, or bleeding that occurs more than 12 months after a woman’s last menstrual period. PMB most commonly results from vaginal or...

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Management of Wound Complications of Cesarean Delivery

Preoperative measures that reduce wound infection include weight-based prophylactic antibiotics given within one hour before the incision, the addition of azithromycin when indicated, hair removal with clippers rather than shaving,...

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Management of Dehiscence of the Vaginal Cuff

Vaginal cuff dehiscence, a rare complication of hysterectomy, is the full or partial separation of the edges of the vaginal cuff. Evisceration is dehiscence with prolapse of abdominal contents....

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Management of Women with Multiple Fibroids who are Attempting Pregnancy

Although the presence of fibroids does not usually impair fertility or affect an ongoing pregnancy, some patients with fibroids may face several pregnancy-related risks. Fibroid location plays an important role...

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

Uterine perforation is one of the more common complications of cervical dilation and uterine curettage. The incidence is 0.3% in premenopausal, nonpregnant patients, and increases in pregnant or recently...

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Diagnosis and Management of Cervical Ectopic Pregnancy

Cervical ectopic pregnancy is the rare implantation of a pregnancy in the endocervical canal and accounts for less than 1% of all ectopic pregnancies. Patients usually present with vaginal bleeding,...

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Proximal Tubal Occlusion

Proximal tubal occlusion is a common finding on hysterosalpingogram, occurring in up to 15% of studies. The occlusion is seen at the utero-tubal junction, where radiographic contrast fails to enter...

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

Breast cancer is the second leading cause of cancer death among women in the United States. Seventy five percent of breast cancers are estrogen receptor (ER) or progesterone receptor (PR)...

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Management of Broad Ligament Extension and Hematoma during a Cesarean Delivery

The broad ligaments consist of anterior and posterior leaflets of peritoneum which cover the lateral uterine corpus and upper cervix and extend from the lateral walls of the uterus to...

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Amniotic Fluid Embolism

Amniotic Fluid Embolism (AFE) is an uncommon, catastrophic obstetric emergency. The frequency of AFE is 2-7 cases per 100,000 births. It is responsible for approximately 10-15% of maternal deaths in...

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Management of Bilateral Tubo-Ovarian Abscesses

Tubo-ovarian abscess (TOA) occurs in 15% of cases of pelvic inflammatory disease (PID), and in 33% of patients with PID requiring admission. PID and TOAs are polymicrobial infections of anaerobic...

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

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 include an enlarged uterus, lack...

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Management of Atypical Glandular Cells

Though atypical glandular cells (AGC) are uncommon, occurring in approximately 3 per 1000 specimens, the associated risk of invasive malignancy is as high as 2-5%. All patients with...

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Hematoma after Delivery

Puerperal hematomas occur commonly and may pose life-threatening morbidity. Risk factors include lacerations from operative vaginal delivery/episiotomy and injury to pelvic vasculature from a variety of mechanical events, including uterine...

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Management of Breakdown of Obstetrical Anal Sphincter Repairs

Obstetric anal sphincter injuries (OASIS) include 3rd and 4th degree lacerations. Risk factors include forceps or vacuum delivery, midline episiotomy, first vaginal delivery, higher infant birth weight (> 3500gms), vertex...

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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 a protein mainly synthesized and secreted by the lactotroph cells in the pituitary gland. Hyperprolactinemia is defined by a high level of serum prolactin above the standard limit...

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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 however laparoscopy remains the gold standard for diagnosis. In patients with pain that is not improved with medical management, surgery affords...

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Singleton Breech Presentation

Approximately 3-4% of pregnancies at term are breech presentations. All pregnancies should undergo assessment of presentation beginning at 36 weeks, and confirmatory ultrasound should occur for all suspected breech presentations....

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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 cervical os. Two types of...

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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) with an occurrence of 0.5-1% of newborns. ABO...

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Management of Placenta Accreta Spectrum Diagnosed Antenatally

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 women, with approximately 0.3-0.5% being overt and 0.7% subclinical. Hypothyroidism is more...

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Primary Amenorrhea in a Teenager

Primary amenorrhea (PA) is defined absence of menarche by 15 years old. Secondary amenorrhea is defined as the cessation of regular menses for 3 months or the cessation of irregular...

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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 (AFP) is produced by the fetal yolk sac and liver. Levels rise during the second trimester. Values are expressed as MoMs (multiples of the median) for each specific week...

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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

The two most common causes of anemia in pregnancy and the puerperium are iron deficiency and acute blood loss. Pregnancy results in a physiologic anemia due to expanded plasma volume....

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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. Approximately one-third to one-half of complications occur during initial access. Evidence is insufficient to support the use...

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Adnexal Masses in Adolescents

The prevalence of adnexal masses in adolescents is unknown. Of those adnexal masses requiring surgical intervention in specialty care centers, 7-25% are malignant in pediatric and adolescent ages combined,...

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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

Nonimmune hydrops fetalis (NHF) is the presence of excessive fluid in two or more fetal compartments (for example, skin edema, pleural effusion, pericardial effusion, or ascites), in the absence of...

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Toxoplasmosis in Pregnancy

Toxoplasma gondii is a protozoan which can lead to human infection termed Toxoplasmosis. Transmission occurs via fecal-oral exposure of uncooked meat, contaminated soil or water, contaminated fruits or vegetables, or...

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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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