OBG Management

EASIER COLORECTAL CANCER SCREENING
Cologuard^® from Exact Sciences is a new, FDA-approved, noninvasive stool DNA screening test for colorectal cancer. Cologuard has been proven to find 92% of colorectal cancers in average risk patients with 87% specificity. Available by prescription for people aged 50 years and older who are at average risk for colorectal cancer, Cologuard does not require medication, dietary restrictions, or prior bowel preparation.
FOR MORE INFORMATION, VISIT www.exactsciences.com

FRONT-CLOSURE SURGICAL BRA
Elizabeth Pink Surgical Bra™ from BFFL Co allows for mild compression and stretch, with a Velcro front closure and adjustable, padded shoulder straps. The pink bra has patent-pending side-drain openings to accommodate JP drain exit placement. JP drain bulbs can be attached to a loop and ring, eliminating the need for wearing a pouch or fanny pack during recovery.
FOR MORE INFORMATION, VISIT http://bfflco.com/

16-POCKET LAB COATS FOR MEN AND WOMEN
SCOTTeVEST has a new line of SeV lab coats styled for men and women with 16 pockets to carry medical devices and personal electronics. Some pockets are hidden for added security. The exterior white fabric is stain- and water-resistant and can be laundered and sanitized.
FOR MORE INFORMATION, VISIT www.scottevest.com

LAPAROSCOPIC SMOKE EVACUATION SYSTEM
The Plume-Away^® Smoke Evacuation System is now available to clinical users, reports CooperSurgical. The passive, disposable, multi-stage system traps smoke, particulates, and aerosolized pathogens while an activated charcoal membrane absorbs odors and chemical toxins. CooperSurgical claims the system removes 99.999% of 0.01 μm particles from surgical procedure sites, while the air-flow rate remains steady.
FOR MORE INFORMATION, VISIT www.CooperSurgical.com

NEW BABY BOTTLE DESIGN PREVENTS COLIC
Difrax claims the design of its S-Bottles allows the baby to swallow less air and therefore have less trouble with burping, vomiting, colic, and earache. When the bottle is being used, the teat is constantly filled with liquid and a valve in the bottle’s base prevents vacuum suction. A bottle warmer is available.
FOR MORE INFORMATION, VISIT www.difraxusa.com

HOME-USE CONCEPTION ASSISTANCE DEVICE
Rinovum Women’s Health announced that The Stork^® OTC, a conception-assistance device, is now available without a prescription in stores and online. Rinovum claims that The Stork OTC is a safe, easy way to perform cervical cap insemination at home, without drugs or invasive procedures.
FOR MORE INFORMATION, VISIT www.storkotc.com

MEASURE LIPIDS & GLUCOSE IN 2 MINUTES
The LipidPlus^® Lipid Profile and Glucose Measuring System from JANT Pharmacal Corporation uses a single test strip to measure total cholesterol, high-density lipoprotein (HDL), triglycerides, and to calculate low-density lipoprotein (LDL) with results in 2 minutes. Lipid and glucose test strips do not require refrigeration, and require a small blood sample. The system includes an analyzer that can store up to 200 results.
FOR MORE INFORMATION, VISIT www.lipidplus.com

ENCOURAGING BREAST SELF-EXAM
Circuelle™ Breast Ritual Crème is intended for use during twice-monthly breast self-examinations in the shower or bath. Circuelle claims that the lotion’s texture enables a woman’s fingertips to glide across her breast and underarm areas so she will notice something different, such as thickened skin, a lump, or change in the nipple. The moisturizing cream is paraben-, phthalate-, and petroleum-free, with organically derived ingredients including evening primrose oil, green tea extract, vitamins D and E, and essential oils. Circuelle also offers a Guide to Breast Self-Examination and tips to reduce the risk of breast cancer on its Web site.
FOR MORE INFORMATION, VISIT www.circuelle.com

RF DETECTION SYSTEM FOR L&D UNITS
RF Surgical Systems says it designed the RF Assure Delivery System for the labor and delivery (L&D) environment to locate and prevent the loss of sponges, towels, and gauze during vaginal delivery. After birth, a clinician uses the Verisphere sensor to scan the mother’s pelvic area and L&D room to obtain an accurate count of radio-frequency (RF) tag-embedded items.
FOR MORE INFORMATION, VISIT www.rfsurg.com

NEW WEB SITE FOR FERTILITY RESOURCES
Advanced Reproductive Care Inc. offers a full suite of products, services, and resources for infertility through its new Web site. There, patients can access a nationwide network of fertility services, from fertility treatment package options and payment plans to articles, newsletters, and informational videos addressing common questions and treatment options.
FOR MORE INFORMATION, VISIT www.arcfertility.com

EXCHANGE DATA USING PATIENTGRAPH
CareConnectors™ says that its PatientGraph™ software enables patients and health-care providers and enterprises to exchange traditional and nontraditional health-care data in a secure, HIPAA-compliant system. The 3-component platform allows trusted parties (including patients) to share information with authorized providers, devices, and services; provides programming interfaces to aid workflow; and offers software development kits to allow customization.
FOR MORE INFORMATION, VISIT www.careconnectors.com

EASIER COLORECTAL CANCER SCREENING
Cologuard^® from Exact Sciences is a new, FDA-approved, noninvasive stool DNA screening test for colorectal cancer. Cologuard has been proven to find 92% of colorectal cancers in average risk patients with 87% specificity. Available by prescription for people aged 50 years and older who are at average risk for colorectal cancer, Cologuard does not require medication, dietary restrictions, or prior bowel preparation.
FOR MORE INFORMATION, VISIT www.exactsciences.com

FRONT-CLOSURE SURGICAL BRA
Elizabeth Pink Surgical Bra™ from BFFL Co allows for mild compression and stretch, with a Velcro front closure and adjustable, padded shoulder straps. The pink bra has patent-pending side-drain openings to accommodate JP drain exit placement. JP drain bulbs can be attached to a loop and ring, eliminating the need for wearing a pouch or fanny pack during recovery.
FOR MORE INFORMATION, VISIT http://bfflco.com/

16-POCKET LAB COATS FOR MEN AND WOMEN
SCOTTeVEST has a new line of SeV lab coats styled for men and women with 16 pockets to carry medical devices and personal electronics. Some pockets are hidden for added security. The exterior white fabric is stain- and water-resistant and can be laundered and sanitized.
FOR MORE INFORMATION, VISIT www.scottevest.com

LAPAROSCOPIC SMOKE EVACUATION SYSTEM
The Plume-Away^® Smoke Evacuation System is now available to clinical users, reports CooperSurgical. The passive, disposable, multi-stage system traps smoke, particulates, and aerosolized pathogens while an activated charcoal membrane absorbs odors and chemical toxins. CooperSurgical claims the system removes 99.999% of 0.01 μm particles from surgical procedure sites, while the air-flow rate remains steady.
FOR MORE INFORMATION, VISIT www.CooperSurgical.com

NEW BABY BOTTLE DESIGN PREVENTS COLIC
Difrax claims the design of its S-Bottles allows the baby to swallow less air and therefore have less trouble with burping, vomiting, colic, and earache. When the bottle is being used, the teat is constantly filled with liquid and a valve in the bottle’s base prevents vacuum suction. A bottle warmer is available.
FOR MORE INFORMATION, VISIT www.difraxusa.com

HOME-USE CONCEPTION ASSISTANCE DEVICE
Rinovum Women’s Health announced that The Stork^® OTC, a conception-assistance device, is now available without a prescription in stores and online. Rinovum claims that The Stork OTC is a safe, easy way to perform cervical cap insemination at home, without drugs or invasive procedures.
FOR MORE INFORMATION, VISIT www.storkotc.com

MEASURE LIPIDS & GLUCOSE IN 2 MINUTES
The LipidPlus^® Lipid Profile and Glucose Measuring System from JANT Pharmacal Corporation uses a single test strip to measure total cholesterol, high-density lipoprotein (HDL), triglycerides, and to calculate low-density lipoprotein (LDL) with results in 2 minutes. Lipid and glucose test strips do not require refrigeration, and require a small blood sample. The system includes an analyzer that can store up to 200 results.
FOR MORE INFORMATION, VISIT www.lipidplus.com

ENCOURAGING BREAST SELF-EXAM
Circuelle™ Breast Ritual Crème is intended for use during twice-monthly breast self-examinations in the shower or bath. Circuelle claims that the lotion’s texture enables a woman’s fingertips to glide across her breast and underarm areas so she will notice something different, such as thickened skin, a lump, or change in the nipple. The moisturizing cream is paraben-, phthalate-, and petroleum-free, with organically derived ingredients including evening primrose oil, green tea extract, vitamins D and E, and essential oils. Circuelle also offers a Guide to Breast Self-Examination and tips to reduce the risk of breast cancer on its Web site.
FOR MORE INFORMATION, VISIT www.circuelle.com

RF DETECTION SYSTEM FOR L&D UNITS
RF Surgical Systems says it designed the RF Assure Delivery System for the labor and delivery (L&D) environment to locate and prevent the loss of sponges, towels, and gauze during vaginal delivery. After birth, a clinician uses the Verisphere sensor to scan the mother’s pelvic area and L&D room to obtain an accurate count of radio-frequency (RF) tag-embedded items.
FOR MORE INFORMATION, VISIT www.rfsurg.com

NEW WEB SITE FOR FERTILITY RESOURCES
Advanced Reproductive Care Inc. offers a full suite of products, services, and resources for infertility through its new Web site. There, patients can access a nationwide network of fertility services, from fertility treatment package options and payment plans to articles, newsletters, and informational videos addressing common questions and treatment options.
FOR MORE INFORMATION, VISIT www.arcfertility.com

EXCHANGE DATA USING PATIENTGRAPH
CareConnectors™ says that its PatientGraph™ software enables patients and health-care providers and enterprises to exchange traditional and nontraditional health-care data in a secure, HIPAA-compliant system. The 3-component platform allows trusted parties (including patients) to share information with authorized providers, devices, and services; provides programming interfaces to aid workflow; and offers software development kits to allow customization.
FOR MORE INFORMATION, VISIT www.careconnectors.com

EASIER COLORECTAL CANCER SCREENING
Cologuard^® from Exact Sciences is a new, FDA-approved, noninvasive stool DNA screening test for colorectal cancer. Cologuard has been proven to find 92% of colorectal cancers in average risk patients with 87% specificity. Available by prescription for people aged 50 years and older who are at average risk for colorectal cancer, Cologuard does not require medication, dietary restrictions, or prior bowel preparation.
FOR MORE INFORMATION, VISIT www.exactsciences.com

FRONT-CLOSURE SURGICAL BRA
Elizabeth Pink Surgical Bra™ from BFFL Co allows for mild compression and stretch, with a Velcro front closure and adjustable, padded shoulder straps. The pink bra has patent-pending side-drain openings to accommodate JP drain exit placement. JP drain bulbs can be attached to a loop and ring, eliminating the need for wearing a pouch or fanny pack during recovery.
FOR MORE INFORMATION, VISIT http://bfflco.com/

16-POCKET LAB COATS FOR MEN AND WOMEN
SCOTTeVEST has a new line of SeV lab coats styled for men and women with 16 pockets to carry medical devices and personal electronics. Some pockets are hidden for added security. The exterior white fabric is stain- and water-resistant and can be laundered and sanitized.
FOR MORE INFORMATION, VISIT www.scottevest.com

LAPAROSCOPIC SMOKE EVACUATION SYSTEM
The Plume-Away^® Smoke Evacuation System is now available to clinical users, reports CooperSurgical. The passive, disposable, multi-stage system traps smoke, particulates, and aerosolized pathogens while an activated charcoal membrane absorbs odors and chemical toxins. CooperSurgical claims the system removes 99.999% of 0.01 μm particles from surgical procedure sites, while the air-flow rate remains steady.
FOR MORE INFORMATION, VISIT www.CooperSurgical.com

NEW BABY BOTTLE DESIGN PREVENTS COLIC
Difrax claims the design of its S-Bottles allows the baby to swallow less air and therefore have less trouble with burping, vomiting, colic, and earache. When the bottle is being used, the teat is constantly filled with liquid and a valve in the bottle’s base prevents vacuum suction. A bottle warmer is available.
FOR MORE INFORMATION, VISIT www.difraxusa.com

HOME-USE CONCEPTION ASSISTANCE DEVICE
Rinovum Women’s Health announced that The Stork^® OTC, a conception-assistance device, is now available without a prescription in stores and online. Rinovum claims that The Stork OTC is a safe, easy way to perform cervical cap insemination at home, without drugs or invasive procedures.
FOR MORE INFORMATION, VISIT www.storkotc.com

MEASURE LIPIDS & GLUCOSE IN 2 MINUTES
The LipidPlus^® Lipid Profile and Glucose Measuring System from JANT Pharmacal Corporation uses a single test strip to measure total cholesterol, high-density lipoprotein (HDL), triglycerides, and to calculate low-density lipoprotein (LDL) with results in 2 minutes. Lipid and glucose test strips do not require refrigeration, and require a small blood sample. The system includes an analyzer that can store up to 200 results.
FOR MORE INFORMATION, VISIT www.lipidplus.com

ENCOURAGING BREAST SELF-EXAM
Circuelle™ Breast Ritual Crème is intended for use during twice-monthly breast self-examinations in the shower or bath. Circuelle claims that the lotion’s texture enables a woman’s fingertips to glide across her breast and underarm areas so she will notice something different, such as thickened skin, a lump, or change in the nipple. The moisturizing cream is paraben-, phthalate-, and petroleum-free, with organically derived ingredients including evening primrose oil, green tea extract, vitamins D and E, and essential oils. Circuelle also offers a Guide to Breast Self-Examination and tips to reduce the risk of breast cancer on its Web site.
FOR MORE INFORMATION, VISIT www.circuelle.com

RF DETECTION SYSTEM FOR L&D UNITS
RF Surgical Systems says it designed the RF Assure Delivery System for the labor and delivery (L&D) environment to locate and prevent the loss of sponges, towels, and gauze during vaginal delivery. After birth, a clinician uses the Verisphere sensor to scan the mother’s pelvic area and L&D room to obtain an accurate count of radio-frequency (RF) tag-embedded items.
FOR MORE INFORMATION, VISIT www.rfsurg.com

NEW WEB SITE FOR FERTILITY RESOURCES
Advanced Reproductive Care Inc. offers a full suite of products, services, and resources for infertility through its new Web site. There, patients can access a nationwide network of fertility services, from fertility treatment package options and payment plans to articles, newsletters, and informational videos addressing common questions and treatment options.
FOR MORE INFORMATION, VISIT www.arcfertility.com

EXCHANGE DATA USING PATIENTGRAPH
CareConnectors™ says that its PatientGraph™ software enables patients and health-care providers and enterprises to exchange traditional and nontraditional health-care data in a secure, HIPAA-compliant system. The 3-component platform allows trusted parties (including patients) to share information with authorized providers, devices, and services; provides programming interfaces to aid workflow; and offers software development kits to allow customization.
FOR MORE INFORMATION, VISIT www.careconnectors.com

With no consensus regarding the normal endometrial thickness in postmenopausal women without vaginal bleeding, there are no guidelines for clinicians to follow on when to biopsy, if at all, in an older patient presenting with pelvic pain but no bleeding.

To determine at what endometrial thickness biopsy would be optimal, Michelle Louie, MD, and colleagues from Magee Women’s Hospital in Pittsburgh, Pennsylvania, performed a retrospective cohort analysis of postmenopausal women aged 50 or older who underwent transvaginal ultrasound (TVUS) for indications other than vaginal bleeding. They presented their findings in an abstract at the 43rd AAGL Global Congress in Vancouver, Canada.

Details of the study

Patients were included if they had an endometrial lining of 4 mm or greater and excluded if they had a history of tamoxifen use, hormone replacement, endometrial ablation, hereditary cancer syndrome, or no available pathology results.

Of 462 biopsies, 435 (94.2%) had benign pathology, nine (2.0%) had carcinoma, and seven (1.5%) had atypical hyperplasia.

Endometrial thickness of 14 mm or greater was associated with atypical hyperplasia (odds ratio [OR], 4.29; P = .02), with a negative predictive value of 98.3%. A thickness of 15 mm or greater was associated with carcinoma (OR, 4.53; P = .03), with a negative predictive value of 98.5%.

Under 14 mm, the risk of hyperplasia was low, the authors found, at 0.08%. Below 15 mm, the risk of cancer was 0.06%.

They found no significant associations between endometrial lining TVUS appearance, age, parity, body mass index, diabetes, hypertension, hyperlipidemia, and carcinoma or atypical hyperplasia.

When biopsy might not be necessary

Therefore, regardless of conventional risk factors for endometrial cancer, if a postmenopausal woman reports pelvic pain without vaginal bleeding, and is found to have a thickened endometrial lining of less than 14 mm on TVUS, biopsy might not be warranted, conclude the study authors.  

With no consensus regarding the normal endometrial thickness in postmenopausal women without vaginal bleeding, there are no guidelines for clinicians to follow on when to biopsy, if at all, in an older patient presenting with pelvic pain but no bleeding.

To determine at what endometrial thickness biopsy would be optimal, Michelle Louie, MD, and colleagues from Magee Women’s Hospital in Pittsburgh, Pennsylvania, performed a retrospective cohort analysis of postmenopausal women aged 50 or older who underwent transvaginal ultrasound (TVUS) for indications other than vaginal bleeding. They presented their findings in an abstract at the 43rd AAGL Global Congress in Vancouver, Canada.

Details of the study

Patients were included if they had an endometrial lining of 4 mm or greater and excluded if they had a history of tamoxifen use, hormone replacement, endometrial ablation, hereditary cancer syndrome, or no available pathology results.

Of 462 biopsies, 435 (94.2%) had benign pathology, nine (2.0%) had carcinoma, and seven (1.5%) had atypical hyperplasia.

Endometrial thickness of 14 mm or greater was associated with atypical hyperplasia (odds ratio [OR], 4.29; P = .02), with a negative predictive value of 98.3%. A thickness of 15 mm or greater was associated with carcinoma (OR, 4.53; P = .03), with a negative predictive value of 98.5%.

Under 14 mm, the risk of hyperplasia was low, the authors found, at 0.08%. Below 15 mm, the risk of cancer was 0.06%.

They found no significant associations between endometrial lining TVUS appearance, age, parity, body mass index, diabetes, hypertension, hyperlipidemia, and carcinoma or atypical hyperplasia.

When biopsy might not be necessary

Therefore, regardless of conventional risk factors for endometrial cancer, if a postmenopausal woman reports pelvic pain without vaginal bleeding, and is found to have a thickened endometrial lining of less than 14 mm on TVUS, biopsy might not be warranted, conclude the study authors.  

With no consensus regarding the normal endometrial thickness in postmenopausal women without vaginal bleeding, there are no guidelines for clinicians to follow on when to biopsy, if at all, in an older patient presenting with pelvic pain but no bleeding.

To determine at what endometrial thickness biopsy would be optimal, Michelle Louie, MD, and colleagues from Magee Women’s Hospital in Pittsburgh, Pennsylvania, performed a retrospective cohort analysis of postmenopausal women aged 50 or older who underwent transvaginal ultrasound (TVUS) for indications other than vaginal bleeding. They presented their findings in an abstract at the 43rd AAGL Global Congress in Vancouver, Canada.

Details of the study

Patients were included if they had an endometrial lining of 4 mm or greater and excluded if they had a history of tamoxifen use, hormone replacement, endometrial ablation, hereditary cancer syndrome, or no available pathology results.

Of 462 biopsies, 435 (94.2%) had benign pathology, nine (2.0%) had carcinoma, and seven (1.5%) had atypical hyperplasia.

Endometrial thickness of 14 mm or greater was associated with atypical hyperplasia (odds ratio [OR], 4.29; P = .02), with a negative predictive value of 98.3%. A thickness of 15 mm or greater was associated with carcinoma (OR, 4.53; P = .03), with a negative predictive value of 98.5%.

Under 14 mm, the risk of hyperplasia was low, the authors found, at 0.08%. Below 15 mm, the risk of cancer was 0.06%.

They found no significant associations between endometrial lining TVUS appearance, age, parity, body mass index, diabetes, hypertension, hyperlipidemia, and carcinoma or atypical hyperplasia.

When biopsy might not be necessary

Therefore, regardless of conventional risk factors for endometrial cancer, if a postmenopausal woman reports pelvic pain without vaginal bleeding, and is found to have a thickened endometrial lining of less than 14 mm on TVUS, biopsy might not be warranted, conclude the study authors.  

During the 43rd AAGL Global Congress, held November 17–21 in Vancouver, British Columbia, Sarah L. Cohen, MD, MPH, of Brigham and Women’s Hospital in Boston, Massachusetts, stepped attendees through diagnosis and surgical management of adnexal masses in pregnancy, noting the approaches backed by the highest-quality data.

The incidence of adnexal masses in pregnancy is 1 in every 600 live births. A mass can be benign or malignant. Among benign masses found in pregnancy are functional cysts, teratomas, and the corpus luteum.

Work-up
Ultrasound imaging is a valuable component of the work-up, owing to its risk-free nature. Magnetic resonance imaging may be appropriate in selected cases, but gadolinium contrast should be avoided.

In pregnancy, the aim is to limit ionizing radiation to less than 5 to 10 rads to minimize the risk of childhood malignancy/leukemia, with no single imaging study exceeding 5 rads.

Tumor markers may be helpful, but careful interpretation is critical, taking into account the effects of pregnancy itself on CA-125 (which peaks in the first trimester), human chorionic gonadotropin, alpha fetoprotein, inhibin A, and lactate dehydrogenase.

When expectant management may be appropriate
Watchful waiting may be considered for simple cysts less than 6 cm in size, provided the patient is asymptomatic with no signs of malignancy.

Surgery is indicated when the patient is symptomatic, when there is a concern for malignancy, and when a persistent mass exceeds 10 cm in size.

As always, elective surgery is preferable, as emergent surgery in pregnancy is associated with a risk of preterm labor of 22% to 35%.

Optimal timing of surgery
Surgery can be performed safely in any trimester, provided the gynecologist is aware of special concerns. For example, in the first trimester, organogenesis is under way and the corpus luteum is still present. If the corpus luteum is removed, progesterone supplementation is necessary.

When surgery can be postponed to the second trimester, it allows time for possible resolution of the mass.

Mode of surgery
Laparoscopy allows for faster recovery, less pain (and, therefore, lower narcotic exposure to the fetus), and improved maternal ventilation.

Prophylaxis for venous thromboembolism is indicated through the use of pneumatic compression devices and, when appropriate, heparin.

Initial port placement can be performed using a Hassan technique, Veress needle, or optical trocar.

Insufflation pressures of 10 to 15 mm Hg are safe, with intraoperative monitoring of carbon dioxide. 

Availability of guidelines
Surgeons should make use of guidelines, when feasible, to guide surgery. For example, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) publishes guidelines on surgery during pregnancy. The American College of Obstetricians and Gynecologists also offers guidelines.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

During the 43rd AAGL Global Congress, held November 17–21 in Vancouver, British Columbia, Sarah L. Cohen, MD, MPH, of Brigham and Women’s Hospital in Boston, Massachusetts, stepped attendees through diagnosis and surgical management of adnexal masses in pregnancy, noting the approaches backed by the highest-quality data.

The incidence of adnexal masses in pregnancy is 1 in every 600 live births. A mass can be benign or malignant. Among benign masses found in pregnancy are functional cysts, teratomas, and the corpus luteum.

Work-up
Ultrasound imaging is a valuable component of the work-up, owing to its risk-free nature. Magnetic resonance imaging may be appropriate in selected cases, but gadolinium contrast should be avoided.

In pregnancy, the aim is to limit ionizing radiation to less than 5 to 10 rads to minimize the risk of childhood malignancy/leukemia, with no single imaging study exceeding 5 rads.

Tumor markers may be helpful, but careful interpretation is critical, taking into account the effects of pregnancy itself on CA-125 (which peaks in the first trimester), human chorionic gonadotropin, alpha fetoprotein, inhibin A, and lactate dehydrogenase.

When expectant management may be appropriate
Watchful waiting may be considered for simple cysts less than 6 cm in size, provided the patient is asymptomatic with no signs of malignancy.

Surgery is indicated when the patient is symptomatic, when there is a concern for malignancy, and when a persistent mass exceeds 10 cm in size.

As always, elective surgery is preferable, as emergent surgery in pregnancy is associated with a risk of preterm labor of 22% to 35%.

Optimal timing of surgery
Surgery can be performed safely in any trimester, provided the gynecologist is aware of special concerns. For example, in the first trimester, organogenesis is under way and the corpus luteum is still present. If the corpus luteum is removed, progesterone supplementation is necessary.

When surgery can be postponed to the second trimester, it allows time for possible resolution of the mass.

Mode of surgery
Laparoscopy allows for faster recovery, less pain (and, therefore, lower narcotic exposure to the fetus), and improved maternal ventilation.

Prophylaxis for venous thromboembolism is indicated through the use of pneumatic compression devices and, when appropriate, heparin.

Initial port placement can be performed using a Hassan technique, Veress needle, or optical trocar.

Insufflation pressures of 10 to 15 mm Hg are safe, with intraoperative monitoring of carbon dioxide. 

Availability of guidelines
Surgeons should make use of guidelines, when feasible, to guide surgery. For example, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) publishes guidelines on surgery during pregnancy. The American College of Obstetricians and Gynecologists also offers guidelines.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

During the 43rd AAGL Global Congress, held November 17–21 in Vancouver, British Columbia, Sarah L. Cohen, MD, MPH, of Brigham and Women’s Hospital in Boston, Massachusetts, stepped attendees through diagnosis and surgical management of adnexal masses in pregnancy, noting the approaches backed by the highest-quality data.

The incidence of adnexal masses in pregnancy is 1 in every 600 live births. A mass can be benign or malignant. Among benign masses found in pregnancy are functional cysts, teratomas, and the corpus luteum.

Work-up
Ultrasound imaging is a valuable component of the work-up, owing to its risk-free nature. Magnetic resonance imaging may be appropriate in selected cases, but gadolinium contrast should be avoided.

In pregnancy, the aim is to limit ionizing radiation to less than 5 to 10 rads to minimize the risk of childhood malignancy/leukemia, with no single imaging study exceeding 5 rads.

Tumor markers may be helpful, but careful interpretation is critical, taking into account the effects of pregnancy itself on CA-125 (which peaks in the first trimester), human chorionic gonadotropin, alpha fetoprotein, inhibin A, and lactate dehydrogenase.

When expectant management may be appropriate
Watchful waiting may be considered for simple cysts less than 6 cm in size, provided the patient is asymptomatic with no signs of malignancy.

Surgery is indicated when the patient is symptomatic, when there is a concern for malignancy, and when a persistent mass exceeds 10 cm in size.

As always, elective surgery is preferable, as emergent surgery in pregnancy is associated with a risk of preterm labor of 22% to 35%.

Optimal timing of surgery
Surgery can be performed safely in any trimester, provided the gynecologist is aware of special concerns. For example, in the first trimester, organogenesis is under way and the corpus luteum is still present. If the corpus luteum is removed, progesterone supplementation is necessary.

When surgery can be postponed to the second trimester, it allows time for possible resolution of the mass.

Mode of surgery
Laparoscopy allows for faster recovery, less pain (and, therefore, lower narcotic exposure to the fetus), and improved maternal ventilation.

Prophylaxis for venous thromboembolism is indicated through the use of pneumatic compression devices and, when appropriate, heparin.

Initial port placement can be performed using a Hassan technique, Veress needle, or optical trocar.

Insufflation pressures of 10 to 15 mm Hg are safe, with intraoperative monitoring of carbon dioxide. 

Availability of guidelines
Surgeons should make use of guidelines, when feasible, to guide surgery. For example, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) publishes guidelines on surgery during pregnancy. The American College of Obstetricians and Gynecologists also offers guidelines.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Editor in Chief Robert L. Barbieri, MD, provides an overview of three articles appearing in OBG Management’s November 2014 issue. Listen to his take on why these articles are of particular importance to women’s health professionals.

Access all of the articles in the November 2014 issue here.

Editor in Chief Robert L. Barbieri, MD, provides an overview of three articles appearing in OBG Management’s November 2014 issue. Listen to his take on why these articles are of particular importance to women’s health professionals.

Access all of the articles in the November 2014 issue here.

Editor in Chief Robert L. Barbieri, MD, provides an overview of three articles appearing in OBG Management’s November 2014 issue. Listen to his take on why these articles are of particular importance to women’s health professionals.

Access all of the articles in the November 2014 issue here.

When the cause of infertility is unexplained, what is the best first-choice treatment option? Could letrozole, an oral nonsteroidal aromatase inhibitor, result in fewer multiple gestations than current standard therapy—gonadotropins or selective estrogen receptor modulators (clomiphene citrate)—without worsening the live birth rate?

Researchers from the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) trial investigated this question and presented data at the recent annual meeting of the American Society of Reproductive Medicine. The research was supported by the National Institutes of Health (NIH)/Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

Study details

This prospective, randomized, multicenter clinical trial involved 900 women aged 18 to 40 with at least one patent fallopian tube and regular menses. Patients underwent ovarian stimulation for up to four cycles with an injectable gonadotropin (Gn; n = 300), clomiphene citrate (n = 301), or letrozole (n = 299), followed by intrauterine insemination (IUI).

Birth rate. Conception occurred in 46.8%, 35.7%, and 28.4% of women receiving Gn, clomiphene, and letrozole, respectively, with a live birth occurring in 32.2%, 23.3%, and 18.7% of respective cases. Pregnancy rates with letrozole were significantly less than with Gn (P<.001) and less than with clomiphene (P<.015).

Multiple gestations. The rate of multiple gestations was highest among women treated with Gn (10.3%). But the multiple gestation rate for letrozole was higher than that for clomiphene (2.7% vs 1.3%, respectively). All multiples treated with letrozole and clomiphene were twins; in the Gn group, there were 24 twin and 10 triplet gestations.

No significant difference was found in the rates of infants with congenital anomalies or other fetal or neonatal complications.¹

Clomiphene plus IUI remains first-line therapy for unexplained infertility

Although ovarian stimulation with letrozole was safe overall, the number of live births was reduced when treatment with letrozole was compared with clomiphene or Gn, and the multiple pregnancy rate for letrozole fell between clomiphene and Gn.

“CC [clomiphene citrate] /IUI remains first-line therapy for women with unexplained infertility,” concludes Michael P. Diamond, Chair and Professor of the Department of Obstetrics and Gynecology at Georgia Regents University in Augusta, Georgia.

Share your thoughts on this article. Send your Letter to the Editor to: [email protected]

When the cause of infertility is unexplained, what is the best first-choice treatment option? Could letrozole, an oral nonsteroidal aromatase inhibitor, result in fewer multiple gestations than current standard therapy—gonadotropins or selective estrogen receptor modulators (clomiphene citrate)—without worsening the live birth rate?

Researchers from the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) trial investigated this question and presented data at the recent annual meeting of the American Society of Reproductive Medicine. The research was supported by the National Institutes of Health (NIH)/Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

Study details

This prospective, randomized, multicenter clinical trial involved 900 women aged 18 to 40 with at least one patent fallopian tube and regular menses. Patients underwent ovarian stimulation for up to four cycles with an injectable gonadotropin (Gn; n = 300), clomiphene citrate (n = 301), or letrozole (n = 299), followed by intrauterine insemination (IUI).

Birth rate. Conception occurred in 46.8%, 35.7%, and 28.4% of women receiving Gn, clomiphene, and letrozole, respectively, with a live birth occurring in 32.2%, 23.3%, and 18.7% of respective cases. Pregnancy rates with letrozole were significantly less than with Gn (P<.001) and less than with clomiphene (P<.015).

Multiple gestations. The rate of multiple gestations was highest among women treated with Gn (10.3%). But the multiple gestation rate for letrozole was higher than that for clomiphene (2.7% vs 1.3%, respectively). All multiples treated with letrozole and clomiphene were twins; in the Gn group, there were 24 twin and 10 triplet gestations.

No significant difference was found in the rates of infants with congenital anomalies or other fetal or neonatal complications.¹

Clomiphene plus IUI remains first-line therapy for unexplained infertility

Although ovarian stimulation with letrozole was safe overall, the number of live births was reduced when treatment with letrozole was compared with clomiphene or Gn, and the multiple pregnancy rate for letrozole fell between clomiphene and Gn.

“CC [clomiphene citrate] /IUI remains first-line therapy for women with unexplained infertility,” concludes Michael P. Diamond, Chair and Professor of the Department of Obstetrics and Gynecology at Georgia Regents University in Augusta, Georgia.

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When the cause of infertility is unexplained, what is the best first-choice treatment option? Could letrozole, an oral nonsteroidal aromatase inhibitor, result in fewer multiple gestations than current standard therapy—gonadotropins or selective estrogen receptor modulators (clomiphene citrate)—without worsening the live birth rate?

Researchers from the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) trial investigated this question and presented data at the recent annual meeting of the American Society of Reproductive Medicine. The research was supported by the National Institutes of Health (NIH)/Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

Study details

This prospective, randomized, multicenter clinical trial involved 900 women aged 18 to 40 with at least one patent fallopian tube and regular menses. Patients underwent ovarian stimulation for up to four cycles with an injectable gonadotropin (Gn; n = 300), clomiphene citrate (n = 301), or letrozole (n = 299), followed by intrauterine insemination (IUI).

Birth rate. Conception occurred in 46.8%, 35.7%, and 28.4% of women receiving Gn, clomiphene, and letrozole, respectively, with a live birth occurring in 32.2%, 23.3%, and 18.7% of respective cases. Pregnancy rates with letrozole were significantly less than with Gn (P<.001) and less than with clomiphene (P<.015).

Multiple gestations. The rate of multiple gestations was highest among women treated with Gn (10.3%). But the multiple gestation rate for letrozole was higher than that for clomiphene (2.7% vs 1.3%, respectively). All multiples treated with letrozole and clomiphene were twins; in the Gn group, there were 24 twin and 10 triplet gestations.

No significant difference was found in the rates of infants with congenital anomalies or other fetal or neonatal complications.¹

Clomiphene plus IUI remains first-line therapy for unexplained infertility

Although ovarian stimulation with letrozole was safe overall, the number of live births was reduced when treatment with letrozole was compared with clomiphene or Gn, and the multiple pregnancy rate for letrozole fell between clomiphene and Gn.

“CC [clomiphene citrate] /IUI remains first-line therapy for women with unexplained infertility,” concludes Michael P. Diamond, Chair and Professor of the Department of Obstetrics and Gynecology at Georgia Regents University in Augusta, Georgia.

Share your thoughts on this article. Send your Letter to the Editor to: [email protected]