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Clinical Obstetrics and Gynecology

Janelle K Moulder, Jonathan D Boone, Jason M Buehler, Michelle Louie
Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain...
November 6, 2018: Clinical Obstetrics and Gynecology
Tarek Toubia, Tarek Khalife
The endogenous opioid system is comprised of a wide array of receptors and ligands that are present throughout the central and peripheral nervous system, the gastrointestinal tract, and the immune system. This explains the multitude of physiological functions it is responsible for including analgesia, mood regulation, and modulation of the stress response. It also plays a pivotal role in modulating the brain's reward center with behavioral and social implications on mood disorders and addiction. Exogenous opioid therapy hijacks the endogenous system and alters its functions contributing to an imbalance that is responsible for the pathogenesis of several disease states...
November 5, 2018: Clinical Obstetrics and Gynecology
Sara R Till, Sawsan As-Sanie, Andrew Schrepf
Patients with pelvic pain suffer from psychological conditions at a disproportionately high rate compared with their peers. We review environmental, genetic, inflammatory, and neurobiological factors that increase vulnerability to developing both of these conditions. We review treatment strategies for chronic pelvic pain in patients who have comorbid psychological conditions, including both nonpharmacologic and pharmacologic options.
October 31, 2018: Clinical Obstetrics and Gynecology
Eliza M Berkley, Alfred Abuhamad
Placenta accreta spectrum (PAS) refers to an abnormally invasive implantation of the placenta into the uterine myometrium. The resultant risk is that of severe maternal hemorrhage and significant maternal morbidity and even mortality. The 2 strongest risk factors for the development of PAS are a history of a prior cesarean section and a placenta previa in the current pregnancy. Clinically, most patients are asymptomatic but some will present with vaginal bleeding and abdominal cramping. The goal of this article is to discuss the common clinical presentation and risk factors for placenta accreta spectrum, and to review in detail the ultrasound features/markers of PAS in each trimester...
December 2018: Clinical Obstetrics and Gynecology
(no author information available yet)
No abstract text is available yet for this article.
December 2018: Clinical Obstetrics and Gynecology
Nicole L Nisly, Katherine L Imborek, Michelle L Miller, Susan D Kaliszewski, Rachel M Williams, Matthew D Krasowski
It is important for the practicing primary care provider to become familiar with the unique health care needs for people who identify as transgender men, transgender women, and non-binary people, who are all within the scope of practice of a general obstetrician-gynecologist and other primary care providers. A review of the unique health needs and essential terminology is presented. This knowledge is a basic foundation to develop a welcoming and inclusive practice for people who are gender nonconforming. This fund of knowledge is essential the practicing primary care providers and support staff...
December 2018: Clinical Obstetrics and Gynecology
(no author information available yet)
No abstract text is available yet for this article.
December 2018: Clinical Obstetrics and Gynecology
Robert M Silver
No abstract text is available yet for this article.
December 2018: Clinical Obstetrics and Gynecology
Halley Crissman, John F Randolph
Many transgender and gender nonconforming individuals have undergone, or plan to pursue, gender-affirming surgery as part of their transition. While not all gender-affirming surgeries are provided by Obstetricians and Gynecologists (OBGYNs), OBGYNs are uniquely skilled to perform certain gender-affirming surgeries such as hysterectomies, bilateral oophorectomies, and vaginectomies. OBGYNs are also well positioned to provide anatomy-specific cancer screening as dictated by patient's hormonal and surgical status, and to address postsurgical or natal vulvovaginal concerns...
December 2018: Clinical Obstetrics and Gynecology
Christine M Warrick, Mark D Rollins
Placenta accreta spectrum is becoming more common and is the most frequent indication for peripartum hysterectomy. Management of cesarean delivery in the setting of a morbidly adherent placenta has potential for massive hemorrhage, coagulopathies, and other morbidities. Anesthetic management of placenta accreta spectrum presents many challenges including optimizing surgical conditions, providing a safe and satisfying maternal delivery experience, preparing for massive hemorrhage and transfusion, preventing coagulopathies, and optimizing postoperative pain control...
December 2018: Clinical Obstetrics and Gynecology
Nicole L Nisly, Katherine L Imborek, Michelle L Miller, Nancy Dole, Jacob B Priest, Leonard Sandler, Matthew D Krasowski, Maia Hightower
People who identify as lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) are underserved and face barriers to knowledgeable health care. Most health systems are ill prepared to provide care that addresses the needs of the LGBTQ community. Basic steps to developing an LGBTQ welcoming health care program are presented. It can be adapted to diverse health care models, from obstetrics and gynecology and other primary care services whether public or private and to hospitals and specialty clinics...
December 2018: Clinical Obstetrics and Gynecology
Eric Jauniaux, Graham J Burton
Current findings continue to support the concept of a biologically defective decidua rather than a primarily abnormally invasive trophoblast. Prior cesarean sections increase the risk of placenta previa and both adherent and invasive placenta accreta, suggesting that the endometrial/decidual defect following the iatrogenic creation of a uterine myometrium scar has an adverse effect on early implantation. Preferential attachment of the blastocyst to scar tissue facilitates abnormally deep invasion of trophoblastic cells and interactions with the radial and arcuate arteries...
December 2018: Clinical Obstetrics and Gynecology
Brett D Einerson, D Ware Branch
This is a discussion of the standard surgical treatment of placenta accreta spectrum disorders including preoperative considerations, diagnostic imaging, surgical steps for cesarean hysterectomy, and postoperative management.
December 2018: Clinical Obstetrics and Gynecology
Vineet K Shrivastava, Michael P Nageotte
The role of Interventional radiologic procedures for the management of suspected placenta accreta spectrum (PAS) has evolved considerably over last 3 decades. In this article, the authors describe the various techniques of vascular occlusion for the management of PAS and provide a brief review of the literature examining the pros and cons in the use of these devices.
December 2018: Clinical Obstetrics and Gynecology
Kaitlyn C McCUNE, Katherine L Imborek
Sexual minority women are more likely to delay care, less likely to have a usual place of care, and more likely to exhibit higher risk behaviors such as smoking, obesity, heavy drinking resulting in a disproportionate number of chronic conditions. It is imperative for obstetrician-gynecologists to be at the forefront of providing comprehensive health care to all women, no matter their sexual orientation. This article seeks to discuss health care disparities as well as health behaviors and outcomes in this population...
December 2018: Clinical Obstetrics and Gynecology
Susan R Johnson
No abstract text is available yet for this article.
December 2018: Clinical Obstetrics and Gynecology
Molly B Moravek
There are an estimated 1.4 million transgender adults in the United States, and lack of providers knowledgeable in transgender care is a barrier to health care. Obstetricians and Gynecologists can help increase access in part by becoming competent in gender-affirming hormone therapy. For transgender men, testosterone protocols can be extrapolated from those used for hypogonadal cisgender men. Unfortunately, there are not any high-quality, long-term prospective studies on the effectiveness and safety of different testosterone regimens specifically in transgender men, but the available data suggest that gender-affirming testosterone therapy is safe and effective with proper screening and monitoring...
December 2018: Clinical Obstetrics and Gynecology
Luke A Gatta, Evelyn L Lockhart, Andra H James
A critical tool in the successful management of patients with abnormal placentation is an established massive transfusion protocol designed to rapidly deliver blood products in obstetrical and surgical hemorrhage. Spurred by trauma research and an understanding of consumptive coagulopathy, the past 2 decades have seen a shift in volume resuscitation from an empiric, crystalloid-based method to balanced, targeted transfusion therapy. The present article reviews patient blood management in abnormal placentation, beginning with optimizing the patient's status in the antenatal period to the laboratory assessment and transfusion strategy for blood products at the time of hemorrhage...
December 2018: Clinical Obstetrics and Gynecology
John F Randolph
The provision of hormone therapy, both estrogens and antiandrogens, to adult transgender females is well within the scope of practice of the obstetrician gynecologist. The goal is to induce feminizing changes and suppress previously developed masculinization. Estrogens in sufficient doses will usually achieve both goals with augmentation by antiandrogens. The primary short-term risk of estrogens is thrombosis, but long-term risk in transgender females is unclear. Optimal care requires pretreatment education and assessment, individualized dosing, ongoing routine monitoring, and standard breast and prostate cancer screening...
December 2018: Clinical Obstetrics and Gynecology
Loïc Sentilhes, Gilles Kayem, Robert M Silver
The purpose of this review was to assist obstetricians and gynecologists in considering the most appropriate conservative treatment option to manage women with placenta accreta spectrum according to their individual need and local expertise of the heath care team. The issue is challenging, as the quality of evidence with regard to efficacy is poor, and is mainly based on retrospective studies with limited sample size.
December 2018: Clinical Obstetrics and Gynecology
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