Gynecologists Recommends Research Articles

Quantifying the additional maternal morbidity in women with preeclampsia with severe features in whom immediate delivery is recommended

Preeclampsia with severe features when diagnosed at less than 34 weeks is associated with maternal morbidity and is managed by immediate delivery or inpatient expectant management. This study aimed to compare maternal morbidity in women with preeclampsia with severe features in whom the American College of Obstetricians and Gynecologists recommends immediate delivery versus those eligible for expectant management. This was a retrospective cohort study of women with preeclampsia with severe features delivered between 23 to 34 weeks of gestation from 2013 to 2017 at a single tertiary center. Women were categorized into 2 groups: (1) those recommended by the American College of Obstetricians and Gynecologists for immediate delivery, that is, ineligible for expectant management, and (2) those eligible for expectant management. The primary outcome was composite postpartum maternal morbidity, which included maternal intensive care unit admission, stroke, death, and other severe morbidities. The secondary outcomes included select adverse perinatal outcomes. Groups were compared and adjusted odds ratios (95% confidence intervals) calculated. Of the 1172 women with preeclampsia identified during the study period, 543 with preeclampsia with severe features were included for analysis: 211 (39%) were ineligible for expectant management and 332 (61%) were eligible for expectant management. Baseline characteristics, including age, body mass index, race and ethnicity, parity, marital status, and gestational age at preeclampsia diagnosis, were similar between the 2 groups. Women ineligible for expectant management had significantly higher composite postpartum maternal morbidity (adjusted odds ratio, 5.02 [95% confidence interval, 1.35-18.69]). In addition, those ineligible for expectant management were more likely to have postpartum intensive care unit admission (adjusted odds ratio, 4.19 [95% confidence interval, 1.09-16.16]) and postpartum hemoglobin level of <7 g/dL (adjusted odds ratio, 5.07 [95% confidence interval, 1.35-19.08]). There was no demonstrable difference in neonatal outcomes between the 2 groups. Women with preeclampsia with severe features who were ineligible for expectant management per the American College of Obstetricians and Gynecologists guidelines had a 5-fold increased risk of maternal morbidity, confirming the need for escalation of care and delivery without delay.

Marijuana use inPregnant Women with Disabilities in the United States.

While perinatal marijuana use is increasing, limited research exists related to its use during pregnancy among vulnerable subpopulations of women with disabilities. The purpose of this study is to assess marijuana use in pregnant U.S. women with disabilities. The analytic sample using 2015-2019 National Survey on Drug Use and Health (NSDUH) data included 3657 pregnant women. Descriptive statistics were performed and adjusted logistic regression models estimated the size and direction of the association between the type of disabilityand marijuana use. Approximately 13.0% of pregnant women with disabilities used marijuana in the past month, which was higher than pregnant women without disabilities (4.4%). The highest prevalence of past month marijuana use was observed among pregnant women with sensory disabilities (17.2%) followed by women with cognitive disabilities (14.6%) and daily living limitations (11.7%). Marijuana use was also associated with younger age (≤ 25years old), Black non-Hispanic, high school education or less, non-married, and past month alcohol/tobacco use. Overall, pregnant women with any disability, and particularly those with sensory disabilities (AOR 2.32, 95% CI 1.21, 4.47), were significantly more likely (AOR 1.65, 95% CI 1.02, 2.69) to use marijuana than their counterparts without disabilities. The higher prevalence of marijuana use among pregnant women with disabilities in this study supports the American College of Obstetricians and Gynecologists recommendations for universal screening of maternal substance use. Screening for marijuana use in vulnerable populations is crucial and it may require training of health care providers to administer such screenings to women with disabilities.

Implementing a combined instruction model on pregnancy options counseling for pre-clinical medical students: Expert physician panel, case-based learning, and pre-recorded lectures

Introduction: The Association of Professors of Gynecology and Obstetrics (APGO) recommends that pre-clinical medical students learn how to counsel on pregnancy options as a standard learning topic during undergraduate medical curriculum. Materials and Methods: Second-year medical students viewed pre-recorded lectures and attended a panel on pregnancy options counseling covering adoption, abortion, and pregnancy continuation. Students were then surveyed about their experiences. Results: Participants (n = 57) were primarily female (74%), non-Hispanic (89%), and Caucasian (77%). Students determined that most (80–100%) of the APGO Student Learning Objectives were adequately covered by the panel and pre-recorded lectures. Students reported on a 5-point Likert-type scale a statistically significant increase (P < 0.0001) in their perceived preparedness to counsel across each pregnancy option category: abortion (2.17 ± 0.94 before vs. 3.5 ± 0.94 after), adoption (1.81 ± 0.86 before vs. 2.56 ± 1.04 after), and continuation of pregnancy (2.52 ± 1 before vs. 3.38 ± 0.95 after). Eighty-seven percent of the respondents felt that the panel was inclusive of diverse viewpoints. Discussion: Students appreciated the pre-recorded lectures and case-based panel as providing important exposure to pregnancy options counseling. Students noted a significantly increased preparedness to counsel a newly diagnosed pregnant patient on abortion, adoption, and pregnancy continuation, most notably with abortion counseling. The overwhelmingly positive reception of the panel highlights the desire of medical students to learn about these issues. Conclusion: This study demonstrates the efficacy of combined instruction modalities, including traditional didactics, case-based learning, and an expert provider panel, in educating students on pregnancy options counseling.

Assessment of compliance with aspirin for preeclampsia prophylaxis and reasons for non-compliance

The American College of Obstetricians and Gynecologists (ACOG) recommends daily aspirin (ASA) initiation by 16 weeks gestation in at-risk patients for preeclampsia risk reduction. This study examined whether patients at high-risk for preeclampsia recalled ASA counseling and treatment compliance.

Rectovaginal Group B streptococcus and urinary tract infections: Lessons from over one million urine cultures

The American College of Obstetricians and Gynecologists recommends performing universal antenatal GBS screening, however, recommendations are still a matter of debate and in some countries GBS screening is based on an antenatal risk-assessment strategy. Rectovaginal GBS typically is caused by contamination of the pathogen residing in the gut, similarly to urinary tract infection (UTI) which starts with periurethral colonization by gut pathogens. We sought to investigate possible association between maternal history of UTI and GBS colonization.

Demographic and Clinical Predictors of Postpartum Blood Pressure Screening Attendance.

Background: Hypertensive disorders of pregnancy (HDP) cause substantial preventable maternal morbidity and mortality. Postpartum hypertension that worsens after women are discharged is particularly dangerous, as it can go undiagnosed and cause complications. The American College of Obstetricians and Gynecologists recommends women with HDP undergo blood pressure (BP) screening 7-10 days after delivery to detect postpartum hypertension. This study aimed to describe predictors of postpartum BP screening attendance among a high-risk safety-net population in Atlanta, Georgia. Materials and Methods: We conducted a population-based cohort study of pregnant women who delivered at a large public hospital in Atlanta between July 1, 2016, and June 30, 2018. We manually abstracted demographic and clinical data from electronic medical records and used multivariable log binomial regression to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs) for associations with BP screening attendance. Results: Of 1260 women diagnosed with HDP, 13.7% attended a BP screening visit within 10 days of delivery. Women with preeclampsia with severe features were more likely to attend a BP visit than women with gestational hypertension (aRR 2.10, 95% CI 1.35-3.27). Rates of BP screening attendance were lower for women with inadequate (aRR 0.42, 95% CI 0.26-0.67) and intermediate (aRR 0.40, 95% CI 0.21-0.74) prenatal care utilization relative to women with adequate utilization. Conclusions: Among a high-risk safety-net population with HDP, most women did not attend a BP screening visit within 10 days of delivery. Addressing this gap requires further research and creative solutions to address barriers at the individual, provider, and system levels.

Iron Deficiency Anemia in Pregnancy.

Anemia is defined as a low red blood cell count, a low hematocrit, or a low hemoglobin concentration. In pregnancy, a hemoglobin concentration of less than 11.0 g/dL in the first trimester and less than 10.5 or 11.0 g/dL in the second or third trimester (depending on the guideline used) is considered anemia. Anemia is the most common hematologic abnormality in pregnancy. Maternal anemia is associated with adverse fetal, neonatal and childhood outcomes, but causality is not established. Maternal anemia increases the likelihood of transfusion at delivery. Besides hemodilution, iron deficiency is the most common cause of anemia in pregnancy. The American College of Obstetricians and Gynecologists recommends screening for anemia with a complete blood count in the first trimester and again at 24 0/7 to 28 6/7 weeks of gestation. Mild anemia, with a hemoglobin of 10.0 g/dL or higher and a mildly low or normal mean corpuscular volume (MCV) is likely iron deficiency anemia. A trial of oral iron can be both diagnostic and therapeutic. Mild anemia with a very low MCV, macrocytic anemia, moderate anemia (hemoglobin 7.0-9.9 g/dL) or severe anemia (hemoglobin 4.0-6.9 g/dL) requires further investigation. Once a diagnosis of iron deficiency anemia is confirmed, first-line treatment is oral iron. New evidence suggests that intermittent dosing is as effective as daily or twice-daily dosing with fewer side effects. For patients with iron deficiency anemia who cannot tolerate, cannot absorb, or do not respond to oral iron, intravenous iron is preferred. With contemporary formulations, allergic reactions are rare.

Identification of Factors Associated With Delayed Treatment of Obstetric Hypertensive Emergencies

(Am J Obstet Gynecol. 2020;223:250.e1–11) Approximately 10% of all pregnancies worldwide are complicated by hypertensive disorders. The most serious of the hypertensive spectrum includes hypertensive emergencies, which can be fatal. Criteria of a hypertensive emergency includes persistent (&gt;15 min duration), acute-onset, with systolic blood pressure of greater than or equal to 160 mm Hg, and diastolic blood pressure of greater than or equal to 110 mm Hg. Obstetric hypertensive emergencies must be treated expeditiously to reduce risks of maternal morbidity or death. The American College of Obstetricians and Gynecologists recommends treatment of hypertensive emergencies within 30-60 minutes of symptom onset in order to reduce risk of maternal stroke. The objective of this study was to identify factors associated with delayed treatments and to determine the timely treatment rate for hypertensive emergencies.

Keberhasilan Pelaksanaan Senam Hamil terhadap Proses Persalinan

The American College of Obstetricians and Gynecologists (ACOG) recommends exercise as a preventive measure for mothers so that the process of pregnancy and childbirth runs naturally and reduces the crisis caused by childbirth. This study aims to determine the analysis of the success rate of the implementation of pregnant exercise on the delivery process at the Puskesmas Lubuk Buaya Padang in 2018. This type of research is an analytical study with a cross-sectional approach that has been carried out in the Work Area of ??the Lubuk Buaya Puskesmas in Padang in October 2017 - June. 2018. The population of all mothers who have experienced childbirth in the Lubuk Buaya Padang Public Health Center is 2,042 people. Samples were taken by simple random sampling with a total sample of 48 people. Data collection using a questionnaire. Then the data were analyzed by univariate and bivariate with the chi-square statistical test. The results showed that 31.3% of mothers did not carry out pregnancy exercise correctly. As much as 37.5% of mothers gave birth with action and based on bivariate analysis there was a significant relationship between the success rate of implementing pregnancy exercise and the delivery process (p = 0.000). The results of the study, it can be concluded that there is a relationship between the success rate of implementing pregnancy exercise with the delivery process, it is hoped that health workers will continue to provide health education and counseling and disseminate information about pregnancy exercise and empower other health workers to conduct pregnancy exercise counseling for pregnant women. how to demonstrate every pregnancy exercise movement in various pregnancy class activities so that mothers can understand it. Key words: pregnancy exercise, childbirth process, class of pregnant women

The Collision of Mental Health, Substance Use Disorder, and Suicide.

Suicide is the 10th leading cause of death, and, in women, nearly half of all suicide deaths occur during their reproductive years. Suicide is associated with psychiatric illness, especially mood and anxiety disorders. Childhood adversities, such as physical, emotional, and sexual abuse, and intimate partner violence increase the risk of suicide. Having more than one psychiatric disorder or comorbid substance use disorder also increases the risk of suicide. Substance use disorders can be the triggering factor for a suicide attempt among those who have a psychiatric condition and suicidal thoughts. Women attempt suicide three times more often than men, although they are less likely to complete suicide. Although the rate of suicide decreases in the perinatal period, pregnant women are more likely to use violent means. Women who complete suicide in the perinatal period are also more likely to be younger, married, and experiencing a depressive episode. For many women, the only encounter with the medical system they have might be in reproductive health care clinics. This means that their obstetrician-gynecologist has a unique opportunity to address women's mental health and enhance suicide prevention. The American College of Obstetricians and Gynecologists recommends screening for depression among perinatal women. Clinicians need to be aware that women with severe perinatal depression are at increased risk of suicide and that women with suicidal thoughts need careful monitoring, evaluation, and treatment.

Pregnancy outcomes among women with class III obesity with normal early glucola

Background Because obese women are at increased risk for insulin resistance and development gestational diabetes (GDM), the American College of Obstetricians and Gynecologists (ACOG) recommends early GDM screening in this population. For obese women with a normal early 1-hour 50 g oral glucose challenge test (eGCT), the risk of developing GDM later in the pregnancy is unknown. Thus, we aimed to assess the risk of developing gestational diabetes based on the value of a normal eGCT. Study Design Retrospective cohort of non-anomalous singleton pregnancies with maternal body mass index (BMI) ≥40 at the time of entry to prenatal care at a single institution from 2013 to 2017. Pregnancies with abnormal early 1-hour 50 g glucose challenge test (eGCT), multiple gestation, late entry to care, type 1 or 2 diabetes, and missing diabetes-screening information are excluded. Primary outcome was development of GDM. Secondary outcomes include fetal growth restriction, macrosomia, gestational age at delivery, large for gestational age, delivery BMI, total weight gain in pregnancy, induction of labor, shoulder dystocia, and cesarean delivery. Bivariate statistics compare demographics, pregnancy complications and delivery characteristics of women who had an eGCT≤ 100 mg/dL (low-normal eGCT) and women who had an eGCT of 101–134 mg/dL (high-normal eGCT). Regression models used to estimate odds of primary outcome. Results Of 169 women, 66(39%) had a low-normal eGCT, and 103(61%) had a high-normal eGCT. Women in the low-normal eGCT group were more likely to use recreational drugs (p = 0.03), other baseline demographics did not differ. The rate of GDM was low in this population (5.3%), with no difference in the rate of GDM between with a low-normal eGCT (1.5%) and high-normal eGCT (7.7%) (p = 0.09). The median neonatal birthweight was higher in the high-normal GCT group (3405 g) as compared to the low-no GCT (3285 g) (p = 0.03). Conclusions Among women with class 3 obesity, the specific value of an early normal GCT was not associated with developing gestational diabetes mellitus later in the pregnancy. Larger studies are needed confirm these findings.

Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions

Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions

Medication-Assisted Treatment vs. Detoxification for Women Who Misuse Opioids in Pregnancy: Associations With Dropout, Relapse, Neonatal Opioid Withdrawal Syndrome (NOWS), and Childhood Sexual Abuse

(Abstracted from Addict Behav Rep 2020;12:100315) The American College of Obstetrics and Gynecology recommends medically assisted treatment (MAT) for the management of women who misuse opioids during pregnancy. Medically assisted treatment allows pregnant women to use opioids at doses that lessen the euphoric effect, minimize withdrawal symptoms, and curb cravings.

Evaluation of the Maternal-Fetal Triage Index in a tertiary care labor and delivery unit

The Maternal-Fetal Triage Index is a 5-level system to facilitate the care of pregnant women seeking care in an obstetrical triage unit (priority 1 being the highest acuity and priority 5 being the lowest acuity). Although the American College of Obstetricians and Gynecologists recommends implementing labor and delivery triage tools, it remains unclear whether the Maternal-Fetal Triage Index facilitates the timely evaluation of high-acuity pregnant women. We sought to examine the duration of a labor and delivery triage evaluation before and after the implementation of the Maternal-Fetal Triage Index. We also sought to examine the duration of a labor and delivery triage evaluation according to priority levels by the Maternal-Fetal Triage Index. This was a retrospective quality improvement study of all women presenting to an urban, tertiary labor and delivery triage unit at 16 weeks' gestation or later from December 2017 to February 2018 (historical cohort) and December 2018 to February 2019 (study cohort). As part of a quality improvement initiative, the Maternal-Fetal Triage Index was implemented in the labor and delivery unit in May 2018. All registered nurses who worked in the labor and delivery unit completed a formal education course and assigned the priority levels at the time of triage presentation. The primary outcome was the duration of a labor and delivery triage evaluation, which was defined as the time interval from triage presentation to the completion of history and physical examination in the electronic medical record. Secondary outcomes included the rates of labor and delivery unit admissions. There were 1305 and 1374 women in the historical cohort and study cohort, respectively. The duration of labor and delivery triage evaluation was longer for the study cohort than for the historical cohort (64 minutes vs 61 minutes; P=.02). Of the 1374 women in the study cohort, there were 28 (2%), 290 (21%), 459 (33%), 462 (34%), and 135 (10%) women with priority levels 1, 2, 3, 4, and 5 assigned, respectively. Women with a higher priority according to the Maternal-Fetal Triage Index had a shorter labor and delivery triage evaluation (priority 1, 57 minutes; priority 2, 66 minutes; priority 3, 63 minutes; priority 4, 62 minutes; and priority 5, 83 minutes; P<.001). The rates of admission were higher in the priority 1 and 5 groups (priority 1, 89.3%; priority 2, 41.4%; priority 3, 57.3%; priority 4, 53.3%; and priority 5, 92.6%; P<.001). Compared with the historical cohort, the duration of labor and delivery triage evaluation was longer in the study cohort. However, in the study cohort, women classified as higher priority according to the Maternal-Fetal Triage Index had a shorter labor and delivery triage evaluation. Our study supports the American College of Obstetricians and Gynecologists' recommendation on the implementation and utilization of labor and delivery triage tools such as the Maternal-Fetal Triage Index.

Successful Implementation of a Medical Student Postpartum Follow-up Phone Call Project.

IntroductionThe American College of Obstetricians and Gynecologists recommends prompt postpartum follow-up. However, 40% of women do not attend postpartum visits. These rates are lower in populations with limited resources. In response, the Department of Obstetrics, Gynecology, and Reproductive Science in the Mount Sinai Health System created a postpartum follow-up phone call project that utilized medical students and was conducted at three health system hospitals from April 6 to May 30, 2020.MethodsThe number of patients contacted by medical students within 72 hours of hospital discharge was recorded. Students at two of the three sites also recorded the number of patients who needed (1) urgent evaluation and subsequent hospital readmission, (2) medications prescribed, and (3) referral for social work services. Students completed questionnaires at the project beginning and end regarding confidence in rendering of postpartum care. Confidence level was based on a 5-point Likert scale (1 = not confident at all, 5 = very confident).ResultsNine students participated. Overall, confidence on providing postpartum care significantly increased from 2.2 to 3.7 (p < .001). Three hundred eighty-seven patients were contacted. Four patients were advised to return to the hospital emergently; two were readmitted. Forty-seven patients needed medication prescribed. Two patients were referred for social work services.DiscussionOur medical student–driven postpartum follow-up phone call project was associated with a high number of patients called and management of significant postpartum issues. Students’ confidence in managing postpartum issues was significantly higher after versus before project participation.

National Trends in Cervical Cancer Screening in Adolescents.

To characterize patterns of cervical cancer screening among adolescents ages 14-20 years before and after the 2009 American College of Obstetrics and Gynecology recommendations. Retrospective cohort study. National Ambulatory Medical Care Survey 2005-2016 data. Female adolescents and young women ages 14-26 years. Multivariable logistic regression models identified independent predictors of unindicated cervical cancer screening at office-based visits among adolescents ages 14-20 years. Cervical cancer screening in women ages 14-20 and 21-26 years in 2 time periods: 2005-2008 and 2009-2016. Between 2005 and 2016, 11,768 office visits were among adolescents ages 14-20 years. Overall, the cervical cancer screening rate for young women ages 14-20 years was 4.0%, which decreased from 4.5% to 0.4% (P = .008) during the study period. Adolescents who received cervical cancer screening during an office visit were older (18-20 years: 24.1% vs 14-17 years: 8.2%; P < .001), had a preventive care visit (preventive care: 79.7% vs other visit types: 20.3%; P < .001), and saw an obstetrician/gynecologist (obstetrician/gynecologist: 74.81% vs other specialties: 25.1%; P < .001). After adjusting for age, year, period, insurance status, region, and provider type, screening for cervical cancer was associated with living in the Southern region of the United States (adjusted odds ratio, 1.88; 95% confidence interval, 1.09-3.25; P = .02) and public insurance (adjusted odds ratio, 0.47, 95% confidence interval, 0.34-0.64; P < .001). Despite recommendations, cervical cancer screening continued to occur in the adolescent population-especially older adolescents-creating unnecessary costs and potential harms. These findings show a slow uptake of guidelines nationally and the need for initiatives that encourage implementation of performance measures for providers, including ongoing provider and patient education.

Safety and Outcomes for Penicillin Skin Testing in Pregnancy

Penicillin allergy in pregnant women is associated with increased morbidity and use of less effective antibiotics to treat group B streptococcus infections. Although the American College of Obstetrics and Gynecology recommends evaluation of women with penicillin allergy prior to delivery, testing in pregnancy remains infrequent. We studied the largest known cohort to date of pregnant women who underwent penicillin allergy evaluation to assess the effectiveness and safety of penicillin skin test and oral drug challenge in pregnancy. A retrospective review was conducted of pregnant women with penicillin allergy referred by obstetrics/gynecology to the University of Pennsylvania allergy clinic. We evaluated the index drug reaction, penicillin skin prick and intradermal testing, oral challenge outcomes, and antibiotic use after testing. Eighty-three pregnant women were identified with average gestational age of twenty-six weeks. The culprit drugs included penicillin (33%), amoxicillin (40%), and unknown (36%). Index reaction occurred greater than five years ago in 91% of women. 95% of index reactions were cutaneous or unknown. Skin testing was negative in seventy-six (92%) patients, positive in one (1%) patient, and inadequate or equivocal in six (7%) patients. Eighty women underwent graded challenge to penicillin V or amoxicillin. Seventy-nine tolerated the challenge. One developed isolated itching. Thirty-five patients used intrapartum antibiotics. Penicillin was used in 43% of deliveries. Two patients subsequently had drug reactions. Penicillin allergy evaluation, including drug challenge, can be safely conducted in pregnant women. Similar to the general population, most pregnant women with penicillin allergy have negative testing, and can receive penicillin intrapartum.

Perceived barriers to and suggested interventions for physical activity during pregnancy among participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Southern California

BackgroundThe American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women engage in at least 20 to 30 min of moderate-intensity physical activity on most days of the week. Regular exercise during pregnancy is associated with many benefits for the mother and the developing fetus; yet, a large number of pregnant women do not engage in the recommended amounts. This study aimed to investigate barriers to and interventions for physical activity among pregnant WIC participants in Southern California.MethodsWe conducted four focus groups (FGs) with pregnant low-income women aged 18 years or older in either their second or third trimester. FGs were conducted at a WIC center in Southern California. The FGs were held according to language (English vs. Spanish-speaking) and BMI category (normal weight vs. overweight and obese). A total of 28 women participated. We used ATLAS. ti. to analyze the focus group transcripts. The study adhered to the Consolidated Criteria for Reporting Qualitative Research.ResultsThe mean age of focus group participants was 28.9 years (SD = 6.6), and the majority were Latina. Intrapersonal barriers to physical activity were fatigue and lack of energy, pain and swelling, lack of childcare, medical restrictions and safety concerns, lack of knowledge about exercise safety, and lack of time. Interpersonal barriers included concerns and lack of support from partners and families, conflicting advice from friends and neighbors, and lack of advice on safe exercise from physicians. Women in all four groups suggested a community-based intervention where they can mingle with each other and share their challenges and concerns. Other suggestions to interventions differed among groups and reflected the women’s experiences and backgrounds. Specifically, to promote education, English-speaking women preferred a brochure while Spanish-speaking women preferred a video. Overweight women emphasized including children in their exercise activities to promote healthy behavior in youth.ConclusionsInterventions should be tailored to pregnant women’s needs. Primary care providers should provide reassurance and information to pregnant women and their partners on the type and frequency of safe exercise.

Advanced cervical cancer in young women: imaging study of late and very late radiation-related side effects after successful treatment by combined radiotherapy

Radical combined radiotherapy (RT) is a standard treatment for advanced cervical cancer. The aim of our study was to identify morphological late (≥6 months) and very late (≥5 years) radiation-related comorbidities on computed tomography (CT), positron emission tomography/computerized tomography (PET/CT) or magnetic resonance imaging (MRI) scans in young females who survived ≥5 years since RT and were considered as successfully treated. Secondly, we studied a rate of clinically silent radiation-related toxicities apparent on imaging scans that might influenced on future well-being of survived females. Thirdly, we analyzed reasons why patients underwent imaging scans. We included 41 subjects aged under 50 years (mean 41.8±7.2 years, median 41 years), who survived ≥5 years since RT, with at least one available imaging scan ≥3 years since RT. The mean time between RT and the last available scan was 12.3±7.9 years (median 9 years); the mean time of clinical follow-up was 15.4±7.1 years (median 14 years). Fourteen (34.1%) females underwent the first imaging scan in emergency situation and 27 (65.9%) patients due to variable chronic complaints. Grade III-V radiation-related comorbidities occurred in 19 (46.3%) females including one case of death due to radiation-induced osteosarcoma. In 14 of 19 patients, comorbidities were multiple. Four (9.8%) females suffered from life-threatening complications (grade IV): one from an uretero-arterial fistula with massive hematuria and 3 from bowel perforations. Eleven (26.8%) subjects suffered from bowel strictures with ileus development, they underwent mean 1.7±0.8 surgery (median 1.5). The mean time since RT to the first surgery for intestinal complications was 5.4±6.0 years (median 3 years), to the second 12.0±9.6 years (median 11.5 years) and to the third surgery 9.0±4.2 years (median 9 years). Late fistulas formations (vesico-recto-vaginal) were seen in 6 (14.6%) patients. Bone complications were diagnosed in 9 (22.0%) of treated females, one case of osteosarcoma included, 4 of 9 bone complications were clinically silent. In 5 (12.2%) subjects, toxicities grade III-IV first time manifested >5 years since RT, majority of them were multiple. The bowel perforation and fistulas formations were the earliest manifested grade III-IV toxicities, with median time 3 years since RT, the bone complications were the latest manifested with median time 16 years since RT. Our study is not able to bring information about the incidence of late and very late radiation related comorbidities, according to International Federation of Gynecology and Obstetrics (FIGO) recommendations patients are clinically followed only for 5 years and imaging cross-sectional scans are not recommended. However, our study shows that if females successfully treated for advanced cervical cancer report abdominal/pelvic clinical problems, it is highly probable their imaging scans will reveal late radiation related side-effects that may affect the rest of their life. It puts forward question whether females after radical RT should been regularly followed by cross-sectional imaging methods.

Screening for Aneuploidy in the Patient With Diabesity: Pearls and Pitfalls

The American College of Obstetrics & Gynecology (ACOG) recommends offering aneuploidy screening to all pregnant women. Obesity and diabetes are not associated with an increased risk of aneuploidy; however, they can complicate and compromise testing options. As the prevalence of obesity and diabetes, or "diabesity" increases, counseling women regarding potential limitations in testing performance of aneuploidy screening is of paramount importance. This chapter reviews options for aneuploidy screening for women with diabesity including sonography/nuchal translucency, serum analyte screening, and cell-free DNA. Potential challenges associated with diagnostic testing with amniocentesis and chorionic villus sampling in women with obesity are also discussed.