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Ovarian clear cell carcinoma

Clinical case Forty-year-old G1P1 presented to her local emergency department with back pain. A CT scan showed a 14 cm right ovarian cyst, and CA-125 was elevated at 49 U She underwent a robotic-assisted laparoscopic right salpingo-oophorectomy, with surgical findings of adhesions in the posterior cul-de-sac ( Fig. 4.1 ). Final pathology was consistent with clear cell carcinoma of the ovary with evidence of endometriosis. She…

Ovarian carcinosarcoma

Clinical case A 76-year-old female presents with vague abdominal pain, increased abdominal girth, and early satiety over the past 3 months. On physical exam, she was noted to have abdominal distension, right lower quadrant tenderness on palpation, and a fixed approximately 10 cm adnexal mass. CT of the chest, abdomen, and pelvis with contrast reveals a right-sided 10 cm mass, ascites, carcinomatosis, and no pleural effusions…

Sex cord stromal tumors of the ovary

Clinical case A 58-year-old G2P2 female presents with a 10 cm complex adnexal mass and postmenopausal bleeding. CT imaging also demonstrates a 4 cm perihepatic tumor implant ( Fig. 2.1 ). Image-guided biopsy of this implant demonstrates an adult granulosa cell tumor (AGCT), and preoperative inhibin A was elevated at 22 pg/mL and inhibin B was elevated at 751 pg How do you treat this patient?…

Malignant ovarian germ cell tumors

Clinical case A 22-year-old G0 presents to an emergency department with pain and vomiting. CT scan of the abdomen/pelvis reveals a complex mass with cystic and solid components, including scattered calcifications, which occupies a large portion of the abdomen and pelvis and measuring up to 24 cm ( Fig. 1.1 ). There is also a small amount of pelvic fluid and an enlarged paraaortic lymph node…

Neonatal Morbidities of Prenatal and Perinatal Origin

Obstetrical Decisions and Neonatal Outcomes The nature of obstetrical practice requires consideration of two patients: mother and fetus. Their intrinsic biological interdependence creates unique challenges not typically encountered in other realms of medical practice. Often there is a paucity of objective data to support the evaluation of risks and benefits associated with a given clinical situation, forcing obstetricians to rely on their clinical acumen and experience.…

Pregnancy as a Window to Future Health

Cardiovascular disease (CVD) is the leading cause of mortality among women in the United States and developed countries. Women on average experience CVD mortality about 10 years later than men. However, women experience a higher fatality rate following a first myocardial infarction, and despite an overall decline in the CVD death rate in the United States, the rate of decline has been slower for women compared…

Intensive Care Considerations in Obstetrics

Critical care, as a branch of medicine, is a young specialty. Specialized intensive care units (ICUs) date only from the 1950s, having arisen either in response to polio epidemics, in which patients needed respiratory care up to and including mechanical ventilation, or as “shock” units to deal with the aftermath of trauma. , Development and refinement of positive-pressure ventilators, originating from anesthesia machines, allowed survival after…

Anesthesia Considerations for Complicated Pregnancies

An estimated 1% to 3% (40,000 to 120,000) of pregnant women require critical care services in the United States each year. Most admissions are related to hemorrhage, hypertension, or cardiac disease. , When a woman requires any of the following procedures, she should be admitted to an intensive care unit (ICU): (1) respiratory support such as endotracheal intubation or treatment of pneumothorax, (2) cardiovascular support with…

The Skin and Pregnancy

The physical and hormonal alterations induced by pregnancy, childbirth, and the puerperium are associated with numerous cutaneous changes. Some occur so frequently that they are not considered abnormal and vary only in degree. This chapter discusses these physiologic changes, the rashes of pregnancy, and the effects of pregnancy on preexisting dermatologic diseases. Common Skin Changes Induced by Pregnancy Pigmentary Changes Hyperpigmentation occurs in at least 90%…

Substance Use and Addiction in Pregnancy and the Postpartum Period

Substance use, substance misuse, and substance use disorder (SUD) or addiction are among the most complex clinical and public health challenges that affect individuals, families, and society. Most people in the United States have used a substance, but only some individuals develop an addiction. It is incredibly rare for someone to initiate substance use in pregnancy. Almost everyone who uses a substance during pregnancy is someone…

Management of Depression and Psychoses in Pregnancy and in the Puerperium

Epidemiology Approximately one in five women experiences a major depressive episode (MDE) over the course of her lifetime. Chronic psychotic disorders are less common, affecting about 1% of women. The risk for developing any type of depressive, bipolar, or chronic psychotic disorder such as schizoaffective disorder or schizophrenia peaks when women are in their early 20s. Mood Disorders in Pregnant and Postpartum Women Mood disorders are…

Neurologic Disorders

Women are as susceptible to neurologic disorders during gestation as at other times, and certain disorders may be aggravated or influenced by pregnancy. Investigation and management of many neurologic disorders may be complicated by the pregnancy and by concern about the safety of the developing fetus. This chapter describes some of the special problems posed by neurologic disorders during pregnancy as well as problems posed by…

Pregnancy and Rheumatic Diseases

Systemic Lupus Erythematosus Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with multiorgan involvement characterized by periods of remission and relapse. The clinical presentation varies considerably, but the disease tends to affect the joints, skin, kidneys, serous membranes, hematologic system, and nervous system. The prevalence of SLE among women is approximately 5 to 100 per 100,000 in the United States, and it is two- to…

Diseases of the Liver, Biliary System, and Pancreas

Acknowledgment This chapter is based on a similar chapter by Richard H. Lee, MD, Raymond T. Chung, MD, and Patricia Pringle, MD in the eighth edition. Liver Function in Normal Pregnancy Normal pregnancy often elevates the liver superiorly, particularly as gestation progresses in the second through third trimesters as a result of the expanding uterus. Physiologically, proportional hepatic blood flow remains relatively constant in pregnancy (approximately…

Gastrointestinal Disease in Pregnancy

Anatomic and physiologic alterations of the gastrointestinal tract result in significant maternal symptoms that are experienced even in uncomplicated gestations. Difficulty arises in differentiating normal pregnancy complaints from those associated with pathology. The workup of suspected gastrointestinal disease is hampered by the potential risks of radiation or endoscopy to the fetus. Similarly, management may be altered because of the adverse or unknown effects of medical or…

Other Endocrine Disorders of Pregnancy

Acknowledgments We gratefully acknowledge the contributions in this chapter of Dr. Dalal Al-Ali and Dr. Karel Dandurand, fellows in Metabolic Bone Disease at McMaster University. Hypothalamic-Pituitary Disorders Hypothalamic-pituitary disorders present in one or more of the following ways: an incidental finding on an MRI or CT scan, evidence of a space-occupying mass (headache, bitemporal hemianopsia, cranial nerve palsy), hyposecretion of one or more pituitary hormones, or…

Thyroid Disease and Pregnancy

Thyroid disorders are among the most common endocrinopathies in women of childbearing age, yet diagnosis and management are often confusing during pregnancy. In large areas of the world, iodine deficiency is the predominant cause of these disorders affecting both maternal and fetal production of thyroid hormones. In the Western Hemisphere, these disorders are most often due to autoimmunity. The hormonal and immunologic perturbations during and after…

Pregnancy in Women With Obesity

Acknowledgment The authors would like to acknowledge Dr. Thomas Kelly, MD, for his work on the previous edition of this chapter. Epidemiology Since the 1960s a stunning increase in obesity has plagued the United States. Overall rates of overweight and obesity—defined as body mass index (BMI, in kg/m 2 ) of 25–29.9 and greater than or equal to 30, respectively—have continued to rise. Women with obesity…

Diabetes in Pregnancy

Global Prevalence of Diabetes An epidemic of diabetes continues to sweep the globe in parallel with an epidemic of obesity. In 2019 it was estimated that there were 463 million people with diabetes worldwide, over 4 million deaths attributable to diabetes, and $760 billion in diabetes-associated global health expenditures. Three-quarters (75%) of those with diabetes live in low- and middle-income countries. Further, the global burden of…