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Managing Vesico-vaginal Fistula

Of the various uro-genital fistulas previously described, the vesico-vaginal fistula (VVF) is the most common due to its relationship to various obstetric and gynecologic risk factors. However, presentation and prognosis can be variable depending on the location, size, and coexisting factors associated with fistula formation. Fortunately, the diagnosis and surgical management of vesico-vaginal fistulas is associated with high cure rates if performed by trained gynecologic surgeons.

Psychosocial Impact Of Breast Cancer

Breast cancer treatments present significant challenges and distress; most patients learn to live with the disease and to incorporate it into day-to-day living. The purpose of this document is to stress upon the factors such as psychologic state, level of optimism, spirituality and support from sources such as family, friends and healthcare team in the recovery of the patients with breast cancer. The psychological distress remains constant over the disease continuum as patients move from diagnosis and treatment to recovery and survivorship. These factors present unique challenges to the healthcare team, and if undetected and untreated psychological distress can jeopardize treatment outcomes and actually increase healthcare costs.

Asthma In Pregnancy

Acute asthma attacks render both the mother and fetus vulnerable to progressive hypoxia and potentially disastrous results. Early studies of pregnant women with asthma revealed high rates of perinatal complications, including perinatal loss, prematurity, preeclampsia, and low birth-weight. Prospective studies performed in the last decade demonstrate essentially normal perinatal outcomes with modern management of asthma. Poor outcomes with some evidence of increased perinatal mortality and morbidity are also seen if the intensity of asthma therapy is decreased. Pregnant patients with asthma should be managed proactively to achieve a good perinatal outcome. Initial and ongoing assessment of the severity of an asthmatic woman’s condition facilitates the stepwise addition of medication to optimize control of symptoms and prevent acute attacks. Educating patients is the key to their ability to use medication appropriately and initiate treatment before an acute disease process becomes critical.

Gestational Trophoblastic Disease: A Comprehensive Review

Gestational Trophoblastic disease comprises a spectrum of interrelated conditions originating from the placenta. Approximately 20% of patients will develop malignant sequelae requiring administration of chemotherapy after evacuation of hydatidiform moles. Most patients with post-molar gestational trophoblastic disease will have non-metastatic molar proliferation or invasive moles, but gestational choriocarcinomas and metastatic disease can develop in this setting. The purpose of this document is to address current evidence regarding the diagnosis, staging, and management of gestational trophoblastic disease. Other terms often used to refer to these conditions include gestational trophoblastic neoplasia and gestational trophoblastic tumor. At present, with sensitive quantitative assays for beta-hCG and current approaches to chemotherapy, most women with malignant gestational trophoblastic disease can be cured and their reproductive function preserved. Histologically distinct disease entities encompassed by this general terminology include complete and partial hydatidiform moles, invasive moles, gestational choriocarcinomas, and placental site trophoblastic tumors.

Toxoplasmosis: Perinatal Parasitic Infection

Toxoplasmosis is caused by the intracellular parasite Toxoplasma gondii. The purpose of this document is to describe the mode of transmission of toxoplasmosis, the maternal and fetal effects, and to offer guidelines for counseling and management during pregnancy. Parasitic infections are associated with significant maternal and fetal consequences if acquired during pregnancy. Congenital toxoplasmosis and prevention are also discussed in this review. Pregnant women who acquire toxoplasmosis should be treated. Treatment of the pregnant women with acute toxoplasmosis reduces but does not eliminate the risk of congenital infection.

Ovarian GermCell Tumors: Benign & Malignant

Germ cell tumors represent a relatively small proportion (~20%) of all ovarian tumors, but are becoming increasingly important in the clinical practice of obstetrics and gynecology. Malignant germ cell tumors of the ovary account for <5% of ovarian cancers in the United States. Most of these neoplasms occur in young women, and extirpation of the disease involves decisions concerning childbearing and probabilities of recurrence. Reproductive function following the treatment of ovarian germ cell tumors is also reviewed. Intraoperative decision making is crucial in preserving reproductive function in girls and young women with malignant ovarian germ cell tumors. The development of effective combination chemotherapy for girls and young women with malignant ovarian germ cell tumors has been one of the true success stories in medicine.

Ovulation Induction Strategies for Infertility Management

Approximately 20% of infertile women have ovulatory disorders. When anovulation is the only infertility factor, the prognosis for pregnancy is very good because modern ovulation induction strategies are highly effective. When anovulation can be attributed to a specific treatable cause, ovulation induction can achieve pregnancy rates comparable to those observed in the normal population. The purpose of this document is to understand various modalities of ovulation induction. Anovulation is among the most common causes of infertility, and clinicians caring for infertile couples must have a thorough understanding of the many treatment options, their indications, and their risks. With these goals in mind, this article reviews the principles that guide both the traditional therapies and more recently described treatment strategies.

Epidural & Spinal Anesthesia: Understanding the Facts

Epidural & spinal anesthesia (regional anesthesia) has become more popular recently, because they are well suited to pain management during labor. It offers the most effective form of pain relief and is used by most women in the United States. In obstetric patients, regional analgesia refers to a partial to complete loss of pain sensation below the T8 to T10 level. In addition, a varying degree of motor blockade may be present, depending on the agents used. The spine consists of 33 vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 fused coccygeal). The vertebral bodies are stabilized by five ligaments that increase in size between the cervical and lumbar vertebrae. In most obstetric patients, the primary indication for epidural analgesia is the patient’s desire for pain relief. The American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG) recommend that third-party payers should not deny reimbursement for regional analgesia and anesthesia because of an absence of other medical indications.

Elder Abuse

Incorporating screening related to elder abuse and neglect into these encounters will increase identification of abuse. Health care providers should assess patients for elder abuse and respond to patients who are victims of elder abuse as they would to domestic violence in general.

Human Papillomavirus (HPV) And Testing

The early successes in cervical cancer screening were based on the development of morphologic criteria for recognizing cells shed from cervical cancer and its precursors. However, our ability to manage cervical diseases more effectively has been limited by an incomplete understanding of the pathogenesis and biology of cervical neoplasia. Recognition that human papillomavirus (HPV) causes most cervical neoplasia suggests that improved screening and management strategies that reflect the biology and behavior of HPV infections may be possible. The purpose of this document is to review the structure and biology of HPVs and summarize the clinical applications of HPV testing and areas of ongoing research will be discussed.