Medical Specialties Commons^™

Management Of Bilateral Ectopic Pregnancies After Ovulation Induction Using Unilateral Salpingectomy And Methotrexate For The Remaining Ectopic With Subsequent Intrauterine Pregnancy, Quinton Katler, Lindsay Pflugner, Anjali Martinez

Obstetrics and Gynecology Faculty Publications

Bilateral ectopic pregnancy is a rare phenomenon which is found with increased frequency when using assisted reproductive technology (ART). This diagnosis is most often made incidentally and intraoperatively, as ultrasound and serial β-hCG trends have shown poor efficacy for accurate diagnosis. Management of bilateral ectopic pregnancies is most commonly reported using bilateral surgical removal of the ectopic pregnancy (salpingostomy and/or salpingectomy). We present a case of an ART patient with incidentally found bilateral tubal ectopic pregnancies, where multiple management strategies including medical and surgical techniques were used concurrently which resulted in a subsequent spontaneous intrauterine pregnancy. While the standard …

Evolution Of Knowledge, Awareness, And Practices Regarding Zika Virus From 2016 To 2017, Quinton Katler, Prachi Godiwala, Charles J. Macri, Beth Pineles, Gary Simon, Aileen Chang, Homa Ahmadzia

Obstetrics and Gynecology Faculty Publications

Objective. Our team created a knowledge, attitudes, and practice (KAP) survey in order to assess changes over time in healthcare provider and community member awareness of Zika virus symptoms, transmission, treatment, and current and future concerns.

Study Design. The cross-sectional survey was issued at an academic medical center in Washington, DC, and via an online link to healthcare providers and community members between June and August 2016. Survey distribution was then repeated the following year, from March to April 2017. Outcomes were compared by survey year and healthcare provider versus community member status using SAS Program Version 9.4.

Results. Significant …

Geographic Disparities In The Distribution Of The U.S. Gynecologic Oncology Workforce: A Society Of Gynecologic Oncology Study, Stephanie Ricci, Ana Tergas, Kara Roche, Melissa Fairbairn, Kimberly Levinson, Micael Lopez-Acevedo, +Several Additional Authors

Obstetrics and Gynecology Faculty Publications

A recent ASCO workforce study projects a significant shortage of oncologists in the U.S. by 2020, especially in rural/underserved (R/US) areas. The current study aim was to determine the patterns of distribution of U.S. gynecologic oncologists (GO) and to identify provider-based attitudes and barriers that may prevent GOs from practicing in R/US regions. U.S. GOs (n = 743) were electronically solicited to participate in an on-line survey regarding geographic distribution and participation in outreach care. A total of 320 GOs (43%) responded; median age range was 35–45 years and 57% were male. Most practiced in an urban setting (72%) at …

Projecting The Potential Impact Of The Cap-Score™ On Clinical Pregnancy, Live Births, And Medical Costs In Couples With Unexplained Infertility., Joseph B Babigumira, Fady I Sharara, Louis P Garrison

Obstetrics and Gynecology Faculty Publications

Purpose

The Cap-Score™ was developed to assess the capacitation status of men, thereby enabling personalized management of unexplained infertility by choosing timed intrauterine insemination (IUI), versus immediate in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in individuals with a low Cap-Score™. The objective of this study was to estimate the differences in outcomes and costs comparing the use of the Cap-Score™ with timed IUI (CS-TI) and the standard of care (SOC), which was assumed to be three IUI cycles followed by three IVF-ICSI cycles.

Methods

We developed and parameterized a decision-analytic model of management of unexplained infertility for women …

Results Of A Pilot Study In The U.S. And Vietnam To Assess The Utility And Acceptability Of A Multi-Level Pregnancy Test (Mlpt) For Home Monitoring Of Hcg Trends After Assisted Reproduction., Tara Shochet, Ioanna A Comstock, Nguyen Thi Nhu Ngoc, Lynn M Westphal, Wendy R Sheldon, Ly Thai Loc, Jennifer Blum, Beverly Winikoff, Paul D Blumenthal

Obstetrics and Gynecology Faculty Publications

Background

To evaluate the utility and acceptability of using multi-level pregnancy tests (MLPTs) at home to monitor hCG trends following assisted reproductive technology (ART).

Methods

One hundred and four women presenting for ART at either Stanford Medicine Fertility and Reproductive Health Clinic (Stanford, CA) or Hung Vuong Hospital (Ho Chi Minh City, Vietnam) participated in this pilot study. Women were asked to perform the MLPT at home, primarily on days when they were also scheduled to receive standard clinic-based serum hCG testing. These tests were administered up to 6 times over the 6-week period following embryo transfer or intrauterine insemination …

Effect Of Flibanserin Treatment On Body Weight In Premenopausal And Postmenopausal Women With Hypoactive Sexual Desire Disorder: A Post Hoc Analysis., Susan G Kornstein, James A Simon, Stuart C Apfel, James Yuan, Krista A Barbour, Robert Kissling

Obstetrics and Gynecology Faculty Publications

Background: Flibanserin, a 5-HT_1A agonist and 5-HT_2A antagonist, is indicated for the treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. This post hoc analysis evaluated the effect of flibanserin treatment on body weight in premenopausal and postmenopausal women with HSDD.

Materials and Methods: This analysis included three 24-week, double-blind, placebo-controlled studies of flibanserin 100 mg each bedtime (qhs) in premenopausal women, a similarly designed study in postmenopausal women, and a 52-week, open-label extension study in premenopausal women.

Results: In a pooled analysis of premenopausal women, mean baseline body mass index (BMI) was 27.0 kg/m …

Cervical Ectropion May Be A Cause Of Desquamative Inflammatory Vaginitis., Leia Mitchell, Michelle King, Heather Brillhart, Andrew Goldstein

Obstetrics and Gynecology Faculty Publications

Desquamative inflammatory vaginitis is a poorly understood chronic vaginitis with an unknown etiology. Symptoms of desquamative inflammatory vaginitis include copious yellowish discharge, vulvovaginal discomfort, and dyspareunia. Cervical ectropion, the presence of glandular columnar cells on the ectocervix, has not been reported as a cause of desquamative inflammatory vaginitis. Although cervical ectropion can be a normal clinical finding, it has been reported to cause leukorrhea, metrorrhagia, dyspareunia, and vulvovaginal irritation. Patients with cervical ectropion and desquamative inflammatory vaginitis are frequently misdiagnosed with candidiasis or bacterial vaginosis and repeatedly treated without resolution of symptoms. We report the case of a 34-year-old woman …

The Rejoice Trial: A Phase 3 Randomized, Controlled Trial Evaluating The Safety And Efficacy Of A Novel Vaginal Estradiol Soft-Gel Capsule For Symptomatic Vulvar And Vaginal Atrophy., Ginger D Constantine, James A Simon, James H Pickar, David F Archer, Harvey Kushner, Brian Bernick, Gina Gasper, Shelli Graham, Sebastian Mirkin

Obstetrics and Gynecology Faculty Publications

OBJECTIVE: To evaluate the safety and efficacy of TX-004HR vaginal estradiol soft-gel capsules for moderate-to-severe dyspareunia associated with postmenopausal vulvar and vaginal atrophy.

METHODS: In this randomized, double-blind, placebo-controlled, phase 3 study, postmenopausal women with a self-identified most bothersome symptom of dyspareunia received 4, 10, or 25 μg TX-004HR or placebo for 12 weeks. Four co-primary efficacy endpoints were change from baseline to week 12 in percentages of superficial and parabasal cells, vaginal pH, and severity of dyspareunia. Secondary endpoints included severity of vaginal dryness and vulvar and/or vaginal itching or irritation. Endometrial histology and adverse events (AEs) were included …

Hypoactive Sexual Desire Disorder: International Society For The Study Of Women's Sexual Health (Isswsh) Expert Consensus Panel Review., Irwin Goldstein, Noel N Kim, Anita H Clayton, Leonard R Derogatis, Annamaria Giraldi, Sharon J Parish, James Pfaus, James A Simon, Sheryl A Kingsberg, Cindy Meston, Stephen M Stahl, Kim Wallen, Roisin Worsley

Obstetrics and Gynecology Faculty Publications

The objective of the International Society for the Study of Women's Sexual Health expert consensus panel was to develop a concise, clinically relevant, evidence-based review of the epidemiology, physiology, pathogenesis, diagnosis, and treatment of hypoactive sexual desire disorder (HSDD), a sexual dysfunction affecting approximately 10% of adult women. Etiologic factors include conditions or drugs that decrease brain dopamine, melanocortin, oxytocin, and norepinephrine levels and augment brain serotonin, endocannabinoid, prolactin, and opioid levels. Symptoms include lack or loss of motivation to participate in sexual activity due to absent or decreased spontaneous desire, sexual desire in response to erotic cues or stimulation, …

Movement To Outpatient Hysterectomy For Benign Indications In The United States, 2008-2014., Gaby Moawad, Emelline Liu, Chao Song, Alex Z Fu

Obstetrics and Gynecology Faculty Publications

Introduction

The past decade has witnessed adoption of conservative gynecologic treatments, including minimally invasive surgery (MIS), alongside steady declines in inpatient hysterectomies. It remains unclear what factors have contributed to trends in outpatient benign hysterectomy (BH), as well as whether these trends exacerbate disparities.

Materials and methods

Retrospective cohort of 527,964 women ≥18 years old who underwent BH from 2008 to 2014. BH surgical approaches included: open/abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and robotic-assisted hysterectomy (RH). Quarterly frequencies were calculated by care setting and surgical approach. We used multilevel logistic regression (MLR) using the most recent year …

Tx-004hr Vaginal Estradiol Has Negligible To Very Low Systemic Absorption Of Estradiol., David F Archer, Ginger D Constantine, James A Simon, Harvey Kushner, Philip Mayer, Brian Bernick, Shelli Graham, Sebastian Mirkin, Rejoice Study Group.

Obstetrics and Gynecology Faculty Publications

OBJECTIVE: To evaluate the pharmacokinetics of TX-004HR vaginal estradiol softgel capsules when used for treating moderate-to-severe dyspareunia in postmenopausal women with vulvar and vaginal atrophy.

METHODS: A substudy of the REJOICE trial (multicenter, double-blind, placebo-controlled, phase 3) evaluated the pharmacokinetics of 4, 10, and 25-μg TX-004HR doses once/d for 2 weeks, followed by twice/wk for 10 weeks. Serum samples obtained at 2, 4, 6, 10, and 24 hours postdose on days 1 and 14, and once on day 84, were analyzed for area under the serum concentration-time curve, tmax, Cmin, Cavg, and Cmax for estradiol, estrone, and estrone conjugates.

RESULTS: …

Tx-004hr Improves Sexual Function As Measured By The Female Sexual Function Index In Postmenopausal Women With Vulvar And Vaginal Atrophy: The Rejoice Trial., Sheryl A Kingsberg, Leonard Derogatis, James A Simon, Ginger D Constantine, Shelli Graham, Brian Bernick, Gina Gasper, Sebastian Mirkin

Obstetrics and Gynecology Faculty Publications

INTRODUCTION: TX-004HR is an investigational, applicator-free, vaginal soft gel capsule containing low-dose solubilized 17β-estradiol. The phase 3, randomized, double-blinded, placebo-controlled, multicenter REJOICE trial has shown TX-004HR to be safe and effective for the treatment of moderate to severe dyspareunia in postmenopausal women with vulvar and vaginal atrophy (VVA).

AIM: To evaluate the effect of TX-004HR on female sexual dysfunction in postmenopausal women with VVA.

METHODS: The REJOICE study compared the effects of 12-week treatment with TX-004HR (4, 10, or 25 μg) with placebo in postmenopausal women (40-75 years old) with VVA and a most bothersome symptom of moderate to severe …

Performance Of Sentinel Lymph Node Biopsy In High-Risk Endometrial Cancer, Jessie Ehrisman, Angeles Alvarez Secord, Andrew Berchuck, Paula S. Lee, Nicola Di Santo, Micael Lopez-Acevedo, Gloria Broadwater, Fidel A. Valdea, Laura J. Havrilesky

Obstetrics and Gynecology Faculty Publications

Objective

To determine the rate and performance of sentinel lymph node (SLN) mapping among women with high-risk endometrial cancers.

Methods

Patients diagnosed between 2012 and 2015 with uterine cancer of grade 3 endometrioid, clear cell, serous or carcinosarcoma histology and who underwent SLN mapping prior to full pelvic lymph node dissection were included. Subjects underwent methylene blue or ICG injection for laparoscopic (N = 16) or robotic-assisted laparoscopic (N = 20) staging. Outcomes included SLN mapping rates, SLN and non-SLN positive rates, false negative SLN algorithm rate, and the negative predictive value (NPV) of the SLN algorithm. Fisher's exact test …

Urethral Solitary Fibrous Tumor: A Rare Pathologic Diagnosis Of A Periurethral Mass, Gaby N. Moawad, Elias Abi Khalil, Cheryl Silverbrook, Stephanie Barak, Alice Semerjian, Michael Phillips

Obstetrics and Gynecology Faculty Publications

Solitary fibrous tumors (SFTs) may occur at any site in the body. SFTs can only be conclusively diagnosed based on histopathologic and immunohistochemical characteristics of the tumor. The presence of SFTs in the abdomen and pelvis is extremely rare. To our knowledge no cases of urethral solitary fibrous tumor in the literature have been reported so far. We present a case of a solitary fibrous tumor arising from the urethra in a twenty-three-year-old female presenting with vaginal mass.

Flibanserin Approval: Facts Or Feelings?, James A. Simon, Irwin Goldstein, Noel Kim, Murray Freedman, Sharon Parish

Obstetrics and Gynecology Faculty Publications

No abstract provided.

Performance Of Sentinel Lymph Node Biopsy In High-Risk Endometrial Cancer., Jessie Ehrisman, Angeles Alvarez Secord, Andrew Berchuck, Paula S Lee, Nicola Di Santo, Micael Lopez-Acevedo, Gloria Broadwater, Fidel A Valea, Laura J Havrilesky

Obstetrics and Gynecology Faculty Publications

OBJECTIVE: To determine the rate and performance of sentinel lymph node (SLN) mapping among women with high-risk endometrial cancers.

METHODS: Patients diagnosed between 2012 and 2015 with uterine cancer of grade 3 endometrioid, clear cell, serous or carcinosarcoma histology and who underwent SLN mapping prior to full pelvic lymph node dissection were included. Subjects underwent methylene blue or ICG injection for laparoscopic (N = 16) or robotic-assisted laparoscopic (N = 20) staging. Outcomes included SLN mapping rates, SLN and non-SLN positive rates, false negative SLN algorithm rate, and the negative predictive value (NPV) of the SLN algorithm. Fisher's exact test …

Effect Of Ospemifene On Moderate Or Severe Symptoms Of Vulvar And Vaginal Atrophy., N. Bruyniks, R. E. Nappi, C. Castelo-Branco, T. J. De Villiers, James A. Simon

Obstetrics and Gynecology Faculty Publications

Objectives To determine whether assessment of all moderate-to-severe symptoms at baseline gives a more accurate evaluation of the treatment effect of ospemifene in vulvovaginal atrophy (VVA) than the most bothersome symptom (MBS) approach. Methods Data were pooled from two pivotal phase-III clinical trials evaluating the efficacy and safety of oral ospemifene 60 mg/day for the treatment of symptoms of VVA (n = 1463 subjects). Symptoms of vaginal dryness, dyspareunia, and vaginal and/or vulvar irritation/itching reported as moderate or severe at baseline were evaluated. Clinically relevant differences between ospemifene and placebo were analyzed using a four-point severity scoring system and presented …

A Case Of Recurrent Rudimentary Horn Ectopic Pregnancies Managed By Methotrexate Therapy And Laparoscopic Excision Of The Rudimentary Horn, Gaby N. Moawad, Elias D. Abi Khalil

Obstetrics and Gynecology Faculty Publications

This report presents a case of a 31-year-old woman successfully treated medically for a noncommunicating rudimentary horn ectopic pregnancy who presented with a second, successive rudimentary horn pregnancy. Patient underwent laparoscopic excision of right rudimentary horn and right salpingectomy after failed methotrexate therapy. Given the potential for rupture and recurrence, serious efforts should be made to excise a uterine rudimentary horn.

First Described Case Of Group B Streptococcus Pelvic Abscess In A Patient With No Medical Comorbidities, Paul Tyan, Elias Abi-Khalil, Karthik Dwarki, Gaby N. Moawad

Obstetrics and Gynecology Faculty Publications

Background. Group B Streptococcus is an organism that commonly infects a wide range of hosts including infants in the first week of life, pregnant women, and older age adults as well as adults with underlying medical comorbidities.

Case. Large pelvic abscess in a nonpregnant patient found to be caused by Group B Streptococcuswas treated successfully with IR guided drainage and antibiotics.

Conclusion. Though rare, GBS can still be a cause of invasive infection even in individuals who are nonpregnant and have no underlying comorbidities. Empiric antibiotic coverage for this organism should be kept in mind when treating an abscess.

Testing The Feasibility Of Remote Patient Monitoring In Prenatal Care Using A Mobile App And Connected Devices: A Prospective Observational Trial, Kathryn Marko, Jill M. Krapf, Andrew C. Meltzer, Julia Oh, Nihar Ganju, Anjali Martinez, Sheetal Sheth, Nancy D. Gaba

Obstetrics and Gynecology Faculty Publications

BACKGROUND:

Excessive weight gain and elevated blood pressure are significant risk factors for adverse pregnancy outcomes such as gestational diabetes, premature birth, and preeclampsia. More effective strategies to facilitate adherence to gestational weight gain goals and monitor blood pressure may have a positive health benefit for pregnant women and their babies. The impact of utilizing a remote patient monitoring system to monitor blood pressure and weight gain as a component of prenatal care has not been previously assessed.

OBJECTIVE:

The objective of this study is to determine the feasibility of monitoring patients remotely in prenatal care using a mobile phone …

Promoting The Use Of Elective Single Embryo Transfer In Clinical Practice., Tamara Tobias, Fady I Sharara, Jason M Franasiak, Patrick W Heiser, Emily Pinckney-Clark

Obstetrics and Gynecology Faculty Publications

BACKGROUND: The transfer of multiple embryos after in vitro fertilization (IVF) increases the risk of twins and higher-order births. Multiple births are associated with significant health risks and maternal and neonatal complications, as well as physical, emotional, and financial stresses that can strain families and increase the incidence of depression and anxiety disorders in parents. Elective single embryo transfer (eSET) is among the most effective methods to reduce the risk of multiple births with IVF.

MAIN BODY: Current societal guidelines recommend eSET for patientsprognosis, yet even this approach is not widely applied. Many patients and clinicians have been reluctant to …

Patient Satisfaction Of Surgical Treatment Of Clitoral Phimosis And Labial Adhesions Caused By Lichen Sclerosus, Anne N. Flynn, Michelle King, Mollie Rieff, Jill A. Krapf, Andrew T. Goldstein

Obstetrics and Gynecology Faculty Publications

Introduction

Lichen sclerosus (LS) is a chronic inflammatory dermatosis, usually affecting the anogenital skin in women. This chronic inflammation can cause scarring of genitalia including narrowing of the introitus and phimosis of the clitoris. These architectural changes can lead to recurrent tearing during intercourse (vulvar granuloma fissuratum) and decreased clitoral sensation. Surgical correction of vulvar granuloma fissuratum (VGF) and clitoral phimosis can be performed, but there is little data on the patient satisfaction and complications following these surgical procedures.

Aim

To evaluate patient experience and outcomes in women undergoing surgical correction of scarring caused by anogenital LS.

Methods

A retrospective …

Cervical Varices Presenting As Vaginal Bleeding: A Description Of Two Cases And A Management Plan, Kathy Chyjek, Catherine Hutz, Charles Macri, Jeffrey S. Berger, Anthony C. Venbrux, Nadia Juliet Khati, Dorothy I. Bulas, John W. Larsen

Obstetrics and Gynecology Faculty Publications

Background: Varicose veins are common in pregnancy. However, potentially life-threatening uterine cervical varices have rarely been reported and there are currently no guidelines for their management. Cases: We present two cases of cervical varices found in the setting of second and third trimester bleeding, report on the clinical outcomes and propose a management plan. Both of our patients were delivered between 38-39 weeks gestation and required interdisciplinary meetings between Obstetrics and Gynecology, Anesthesiology, Neonatology and Interventional Radiology to prepare for delivery. Conclusion: For patients in which varices are found inside the cervix, we recommend consideration of second trimester cerclage followed …

Long-Term Safety Of Ospemifene (52-Week Extension) In The Treatment Of Vulvar And Vaginal Atrophy In Hysterectomized Postmenopausal Women, James A. Simon, David J. Portman, R. Garn Mabey, The Ospemifene Study Group

Obstetrics and Gynecology Faculty Publications

Objective

To examine the long-term safety of oral ospemifene, a non-estrogen tissue-selective estrogen agonist/antagonist, for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy (VVA) due to menopause.

Study design

This multicenter, long-term, open-label, safety extension study was conducted in women without a uterus aged 40–80 years (N = 301) who received oral ospemifene 60 mg/day for 52 weeks. Participants either continued their 60-mg/day ospemifene dose from the initial 12-week pivotal efficacy study or switched from blinded placebo or ospemifene 30 mg/day to open-label ospemifene 60 mg/day. The 52-week open-label extension period plus initial …

Minor Gynecologic Surgery: A Review Of The Training Experience And Skill Building Opportunities For Providers In Low And Middle Income Countries, Rachel Marie Clark, Leslie Siriya Bradford, Jessica Opoku-Anane, Joseph Ngonzi, Ferdous Islam, Mithila Faruque, Annekathryn Goodman

Obstetrics and Gynecology Faculty Publications

Purpose: Minor gynecologic surgery is the cornerstone of gynecologic evaluation and intervention in countries with a well-established medical infrastructure. Surgical training and exposure to minor procedures are not available in low and middle-income countries due to the complex challenges of patient delay and lack of access to healthcare, physician shortages, and the lack of ancillary services such as pathology and radiology. This paper reviews current training statistics, the international literature on minor gynecologic surgery and training strategies.

Methods: PubMed searches using MESH terms cone biopsy, dilation and curettage, and loop electrosurgical excision procedure were performed. Statistics of minor …

Impact Of Vulvovaginal Health On Postmenopausal Women: A Review Of Surveys On Symptoms Of Vulvovaginal Atrophy, Sharon J. Parish, Rossella E. Nappi, Michael L. Krychman, Susan Kellogg-Spadt, James A. Simon, Jeffrey A. Goldstein, Sheryl A. Kingsberg

Obstetrics and Gynecology Faculty Publications

Several recent, large-scale studies have provided valuable insights into patient perspectives on postmenopausal vulvovaginal health. Symptoms of vulvovaginal atrophy, which include dryness, irritation, itching, dysuria, and dyspareunia, can adversely affect interpersonal relationships, quality of life, and sexual function. While approximately half of postmenopausal women report these symptoms, far fewer seek treatment, often because they are uninformed about hypoestrogenic postmenopausal vulvovaginal changes and the availability of safe, effective, and well-tolerated treatments, particularly local vaginal estrogen therapy. Because women hesitate to seek help for symptoms, a proactive approach to conversations about vulvovaginal discomfort would improve diagnosis and treatment.

Coccygeal Fracture Pain Cured By Sacral Neuromodulation: A Case Report, Erica R. Hope, Daniel Gruber

Obstetrics and Gynecology Faculty Publications

No abstract provided.

Moyamoya Disease In Pregnancy: Management After Intracranial Bypass Grafting, Alexis C. Gimovsky, Charles Macri, Susanne L. Bathgate, D. E. Ross

Obstetrics and Gynecology Faculty Publications

Moyamoya disease (MD) is a chronic, progressive cerebrovascular disease distinguished by bilateral stenosis or occlusion of the arteries around the circle of Willis with resulting prominent arterial collateral circulation. We describe a pregnant woman in whom this diagnosis was confirmed by cerebral angiogram and treated with bilateral superficial temporal artery-middle cerebral artery (STA-MCA) bypass grafting prior to conception. The patient was managed with strict blood pressure monitoring and low-dose aspirin antepartum, intrapartum, and postpartum. The patient presented in spontaneous labor at term and underwent a spontaneous vaginal delivery without complications.