Obstentrics_Williams

Obstentrics_Williams. Cystic breast lesions are simple, complicated, or complex (Berg, 2003). Simple cysts do not require special management or monitoring, but they may be aspirated if symptomatic. Complicated cysts show internal echoes during sonography, and they sometimes are indistinguishable from solid masses. These are typically aspirated, and if the sonographic abnormality does not resolve completely, a core-needle biopsy is usually performed. Complex cysts have septa or intracystic masses seen sonographically. Because some breast cancer may form complex cysts, excision is usually recommended.


Obstentrics_Williams

Obstentrics_Williams. For solid breast masses, evaluation is with the triple test, that is, clinical examination, imaging, and core needle biopsy. If all three suggest a benign lesion or if all three suggest a breast cancer, the test is said to be concordant. A concordant benign triple test is �99-percent accurate, and breast lumps in this category can be followed by clinical examination alone. Fortunately, most masses in pregnancy have these three reassuring features. In contrast, if any of the three assessments suggests malignancy, the mass should be excised. Once breast cancer is diagnosed, a limited search of the most common metastatic sites is completed. For most women, this includes a chest radiograph, liver sonography, and skeletal MR imaging (Becker, 2016; Krishna, 2013).


Obstentrics_Williams

Obstentrics_Williams. Treatment of breast cancer is multidisciplinary and includes an obstetrician, breast surgeon, and medical oncologist. Ini tially, desires for pregnancy continuation are addressed, and data indicate that pregnancy interruption does not influence the course or prognosis of breast cancer (Cardonick, 2010). With pregnancy continuation, treatment in general mirrors that for nonpregnant women. Important caveats are that chemotherapy and surgery are postponed to the second trimester, and adjuvant radiotherapy is withheld until after delivery (Brewer, 2011).


Obstentrics_Williams

Obstentrics_Williams. Surgical treatment may be definitive. In the absence of metastatic disease, either a wide excision or a modified or total mastectomy-each with axillary node staging-can be performed (Rosenkranz, 2006). Staging by sentinel lymph node biopsy and lymphoscintigraphy with technetium-99m is safe. Breast reconstruction, if desired, is typically delayed until after delivery (Viswanathan, 2011). hat said, Caragacianu and coworkers (2016) described good results in 10 pregnant women who underwent immediate reconstruction after mastectomy.


Obstentrics_Williams

Obstentrics_Williams. Chemotherapy is usually given with both positive-and negative-node breast cancers. In premenopausal women, survival rates with this approach are improved, even if lymph nodes are cancer free. For node-positive disease, multiagent chemotherapy is begun if delivery is not anticipated within several weeks. Cyclophosphamide, doxorubicin, and cisplatin are currently used (Euhus, 2016). If an anthracycline-based agent such as doxorubicin is used, pretherapy maternal echocardiography is performed because of associated cardiotoxicity (Brewer, 2011). Good maternal and perinatal results have been reported (Berry, 1999; Hahn, 2006). Immunotherapy for breast cancers is now commonplace.


Obstentrics_Williams

Obstentrics_Williams. Immunotherapy for breast cancers is now commonplace. T rastuzumab (Herceptin) is a monoclonal antibody to the HER2/neu receptor, which is found in approximately a third of invasive breast cancers (Hudis, 2007). The drug is not recommended in pregnancy. This is because HER21 neu is strongly expressed in fetal renal epithelium, and trastuzumab has been linked with miscarriage, fetal renal failure and related oligohydramnios, and preterm birth (Amant, 2010; Azim, 2010). he efects of pregnancy on the course of breast cancer and its prognosis are complex. Breast cancer is more aggressive in younger women, but whether it is more aggressive during pregnancy in these same women is debatable (Azim, 2014). Clinically, most studies indicate little diference in overall survival rates with pregnancy-associated breast cancer compared with similarly aged and staged nonpregnant women (Beadle, 2009).


Obstentrics_Williams

Obstentrics_Williams. Other reports note worse overall survival rates with pregnancy associated breast cancer (Rodriguez, 2008). hese investigators do conclude, however, that later disease stages are more preva lent in pregnant women. Indeed, breast cancer is usually found at a more advanced stage in pregnant women, and thus overall prognosis is dimin ished (Andersson, 2015). The aggregate of studies published after 1990 indicate that up to 60 percent of pregnant women have concomitant axillary node involvement at diagnosis. And although, stage for stage, the 5-year survival rate is compara ble in pregnant and nonpregnant women, the more advanced stages that are typical of pregnant women worsen their progno sis (Kuo, 2017; Zemlickis, 1992).


Obstentrics_Williams

Obstentrics_Williams. After breast cancer treatment, chemotherapy will render some women infertile, and options for childbearing are limited (Kim, 2011). For those who become pregnant, long-term maternal survival rates are not adversely afected (Averette, 1999; Velentgas, 1999). One metaanalysis of 10 studies found that for women with early breast cancer, pregnancy that occurs 10 months after diagnosis may, in fact, confer a survival benefit (Valachis, 2010). Data do not indicate that breastfeeding adversely the course.


Obstentrics_Williams

Obstentrics_Williams. In women successfully treated for breast cancer, recurrence is a concern. Because recurrences are more common soon after treatment, it seems reasonable to delay conception for 2 to 3 years. Hormonal contraceptive methods are contraindicated, and a copper-containing intrauterine device is an excellent long-acting reversible method for many. That said, women who conceive do not appear to have diminished survival rates (Ives, 2006). Notably, women treated with tamoxifen are at risk for several months after its discontinuation to have a newborn with congenital anomalies. This drug has an extremely long half-life, and thus delaying conception is recommended for at least 2 months after tamoxifen completion (Braems, 2011).


Obstentrics_Williams

Obstentrics_Williams. Palpable thyroid nodules are detected in 4 to 7 percent of the population, and approximately 10 percent are malignant (Burman, 2015). Clinical nodules are typically evaluated with sonography and measurement of serum thyroid-stimulating hormone (TSH) and free thyroxine levels. Fine-needle aspiration is indicated for a suspicious nodule (lexander, 2017; Gharib, 2016). With a diagnosis of thyroid malignancy, pregnancy termination is not necessary. Primary therapy is thyroidectomy performed ideally during the second trimester. Postoperatively, replacement thyroxine is given. Most thyroid cancers are well diferentiated and follow an indolent course. Thus, delayed surgical treatment does not usually alter outcome (Yazbeck, 2012; Yu, 2016).


Obstentrics_Williams

Obstentrics_Williams. In some types of thyroid cancer, radioiodine is used for primary or postoperative treatment. This is contraindicated in both pregnancy and lactation for several reasons. First, transplacental 1311 is avidly trapped by the fetal thyroid gland to cause hypothyroidism. Second, during lactation, the breast also concentrates a substantial amount of iodide. This may pose neonatal risk due to radioiodine-contaminated milk ingestion and maternal risk from significant breast irradiation. To limit maternal exposure, a delay of 3 months between lactation and thyroid ablation will more reliably ensure complete breast involution (Sisson, 2011). In women with thyroid cancer who ultimately receive 131 I doses, pregnancy should be avoided for 6 months to 1 year. This time ensures thyroid function stability and permits confirmation of cancer remission (Abalovich, 2007).


Obstentrics_Williams

Obstentrics_Williams. This lymphoma is probably B-cell derived and is cytologically distinguished from other lymphomas by Reed-Sternberg cells. Of cancers in pregnancy, lymphomas are common, and gestational rates are rising because of delayed childbearing (Horowitz, 2016). In pregnant women, Hodgkin lymphomas are more frequent than non-Hodgkin lymphomas. In one populationbased review of 7.9 million births from the Nationwide Inpatient Sample, El-Messidi and colleagues (2015) reported its incidence to be 1 in 12,400. In more than 70 percent of Hodgkin disease cases, lymph nodes painlessly enlarge at sites above the diaphragm, that is, in the axillary, cervical, or submandibular chains. Approximately one third of patients have symptoms such as fever, night sweats, malaise, weight loss, and pruritus. Diagnosis is by histological examination of involved nodes (Longo, 2015).


Obstentrics_Williams

Obstentrics_Williams. The Ann Arbor staging system, shown in Table 63-2, is applied to Hodgkin and other lymphomas. For staging, pregnancy limits the use of some radiographic studies, but at minimum, chest radiography, abdominal imaging with sonography or MR imaging, and bone marrow biopsy are completed (Williams, 2001). MR imaging is excellent for evaluating thoracic and abdominal paraaortic lymph nodes (Brenner, 2012). Staging laparotomy is seldom done today (Longo, 2015). The current trend for nonpregnant individuals is to administer chemotherapy for all stages of Hodgkin disease. In pregnancy, for early-stage disease in the first trimester, options include observation until after 12 weeks' gestation, single-agent vinblastine until the second trimester, pregnancy termination followed by multiagent chemotherapy, or radiotherapy alone for isolated neck or axillary sites (EI-Hemaidi, 2012; Eyre, 2015).


Obstentrics_Williams

Obstentrics_Williams. For advanced-stage disease, chemotherapy is recommended regardless of gestational age. Before 20 weeks, therapeutic abortion is a consideration, but if termination is unacceptable, then treatment with vinblastine followed by multi agent therapy in the second trimester can be used (Eyre, 2015). For most advancedstage disease after the irst trimester, cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine are given, and radiotherapy can be added postpartum (Cohen, 2011). In general, postponement of therapy until fetal maturity is achieved seems justiiable only when the diagnosis is made late in pregnancy. Women with Hodgkin lymphoma have a higher incidence of VTE (El-Messidi, 2015; Horowitz, 2016). lso, in our experiences, pregnant women with Hodgkin disease-even after they arer" cured" -are inordinately susceptible to infection and sepsis. Active antineoplastic therapy only increases this vulnerability.


Obstentrics_Williams

Obstentrics_Williams. The overall prognosis with Hodgkin lymphoma is good, and survival rates exceed 70 percent. Pregnancy does not adversely afect the cancer course or pregnancy outcomes in women with this lymphoma. Speciically, neither chemotherapy after the first trimester nor mediastinal and neck irradiation has adverse fetal efects (Brenner, 2012; El-v1essidi, 2015; Pinnix, 2016). For women with disease in remission, pregnancy does not stimulate a relapse (Weibull, 2016).


Obstentrics_Williams

Obstentrics_Williams. lthough usually B-cell tumors, non-Hodgkin lymphomas can also be T-cell or natural-killer-cell neoplasms. heir biology, classification, and treatment are complex (Longo, 2015; O'Gara, 2009). hey are associated with viral infections, and indeed, their incidence has risen sharply at least pardy because 5 to 10 percent of HIV-infected persons develop lymphoma. Other associated viruses include Epstein-Barr virus, hepatitis C virus, and human herpes virus 8. Some of these lymphomas are aggressive, and survival rates vary with the type of cell line involved (Longo, 2015).


Obstentrics_Williams

Obstentrics_Williams. Non-Hodgkin lymphomas are infrequent during pregnancy (Brenner, 2012; Pinnix, 2016). They are also staged according to the Ann Arbor system. If diagnosed in the irst trimester, pregnancy termination followed by multiagent chemotherapy is recommended for all but indolent or very early disease. These less aggressive forms may either be observed or be temporized with focal supradiaphragmatic radiotherapy and then full treatment in the second trimester. If one of these lymphomas is diagnosed after the irst trimester, chemotherapy and immunotherapy TABLE 63-2. Ann Arbor Staging System for Hodgkin and Other Lymphomas I Involvement in a single lymph node region or lymphoid site-e.g., spleen or thymus II Involvement of two or more lymph node groups on the same side of the diaphragm-the mediastinum is a single site III Involvement of lymph nodes on both sides of the diaphragm 1. Limited to spleen or splenic hilar, celiac, or portal nodes 2.


Obstentrics_Williams

Obstentrics_Williams. III Involvement of lymph nodes on both sides of the diaphragm 1. Limited to spleen or splenic hilar, celiac, or portal nodes 2. Includes paraaortic, iliac, or nodes plus those in III IV Extralymphatic involvement-e.g., liver or bone marrow Substage A = no symptoms; substage B = fever, sweats, or weight loss; substage E = extralymphatic involvement excluding liver and bone marrow. with rituximab are given (Cohen, 2011; Rizack, 2009). In one follow-up of 55 individuals at 6 to 29 years after exposure to chemotherapy in utero during maternal lymphoma treatment, no congenital, neurological, or psychological abnormalities were noted (Aviles, 2001). Burkitt lymphoma is an aggressive B-cell tumor associ ated with Epstein-Barr virus infection. Prognosis is poor, and treatment is given with multiagent chemotherapy. In a review of 19 women whose pregnancies were complicated by this lymphoma, 17 died within a year of diagnosis (Barnes, 1998).


Obstentrics_Williams

Obstentrics_Williams. In general, these malignancies arise either from lymphoid tissues-lymphoblastic or lymphocytic leukemias, or from bone marrow-myeloid leukemias. hey can be acute or chronic. Although adult leukemias are more prevalent after age 40, they still are among the most common malignancies of young women (see Fig. 63-1). Leukemia was diagnosed in 1 in 40,000 pregnancies reported to the California Cancer Registry (Smith, 2003). In a review of 72 pregnancies complicated by leukemia from 1975 until 1988, 44 had acute myelogenous leukemia; 20 had acute lymphocytic leukemia; and eight had one of the chronic leukemias (Caligiuri, 1989). Acute leukemias almost always cause marked peripheral blood count abnormalities, and often the white blood cell count is elevated with readily recognizable circulating blast cells. The diagnosis is made from bone marrow biopsy.


Obstentrics_Williams

Obstentrics_Williams. With current multiagent chemotherapy, remission during pregnancy is common, compared with an almost 100-percent mortality rate before 1970. Pregnancy termination does not further improve the prognosis, however, abortion is a consideration in early pregnancy to avoid potential chemotherapy teratogenesis. One example of the latter is treatment of acute promyelocytic leukemia with all-trans-retinoic acid, also known as tretinoin (Carradice, 2002; Sanz, 2015). This potent teratogen causes retinoic acid syndrome (Chap. 12, p. 245). In another example, acute myeloid leukemia is treated with tyrosine kinase inhibitors, another teratogen group (Palani, 2015). In other cases, pregnancy termination before viability may simpliY management of an acutely ill woman.


Obstentrics_Williams

Obstentrics_Williams. Other than these caveats, treatment of gravidas with leukemia is similar to that for nonpregnant women. Acute myeloid leukemia is treated without delay (Ali, 2015). After induction chemotherapy, postremission maintenance therapy is mandatory to prevent a relapse, which is then usually treated with stem-cell transplantation. If allogeneic stem-cell transplantation is indicated, early delivery is considered. With some chronic leukemias, it may be possible to delay therapy until after delivery (Fey, 2008). As with lymphoma, infection and hemorrhage are signiicant complications that should be anticipated in women with active disease.


Obstentrics_Williams

Obstentrics_Williams. Most descriptions of leukemia treatment in pregnancy are single cases or small series (Routledge, 2016; Sanz, 2015). In an earlier review of 58 cases, 75 percent were diagnosed after the irst trimester (Reynoso, 1987). Half were acute myelogenous leukemia, which had a remission rate of 75 percent with chemotherapy. Only 40 percent of these pregnancies resulted in liveborn neonates (Caligiuri, 1989). and its pigment-producing melanocytes. Melanomas should be suspected in pigmented lesions that show changes in contour, surface elevation, discoloration, bleeding, or ulceration, which should prompt biopsy (Richtig, 2017). They are most com in women of childbearing age.


Obstentrics_Williams

Obstentrics_Williams. In some population studies, melanoma is the most frequent malignancy complicating pregnancy (Andersson, 2015; Ban nister-Tyrrell, 2015). Still, the reported incidence ranges widely from 0.03 to 2.8 per 1000 live births (Eibye, 2013; Smith, 2003). One explanation is that many are treated as outpatients and thus are not entered into tumor registries. As noted earlier (p. 1192), malignant melanoma is one of the tumors that is known to metastasize to the placenta and fetus. Placental evaluation for metastases should be performed after delivery. Staging is clinical. Stage I is a melanoma with no palpable lymph nodes; in stage II, lymph nodes are palpable; and in stage III, there are distant metastases. For patients with stage


Obstentrics_Williams

Obstentrics_Williams. Staging is clinical. Stage I is a melanoma with no palpable lymph nodes; in stage II, lymph nodes are palpable; and in stage III, there are distant metastases. For patients with stage I, tumor thickness is the single most important predictor of survival. he Clark classiication includes ive levels of involve ment by depth into the epidermis, dermis, and subcutaneous fat. he Breslow scale measures tumor thickness and size, in addition to depth of invasion.


Obstentrics_Williams

Obstentrics_Williams. Primary surgical treatment for melanoma is determined by the stage and includes wide local resection, sometimes with extensive regional lymph node dissection. Schwartz and associates (2003) recommend sentinel lymph node mapping and biopsy using 99mT c-sulfur colloid, which has a calculated fetal dose of 0.014 mSv or 0.014 mGy. Routine regional node dissection reportedly improves survival rates in nonpregnant patients with microscopic metastases (Cascinelli, 1998). For pregnant patients, an algorithm has been proposed that begins with resection of the primary tumor under local anesthesia but postpones sentinel lymph node biopsy until after delivery (Broer, 2012). lthough prophylactic chemotherapy or immunotherapy is usually avoided during pregnancy, it may be given if indicated by tumor stage and maternal prognosis. In most cases of distant metastatic melanoma, treatment is at best palliative. Currently, the role of estrogen receptor-� in melanoma progression is under investigation,


Obstentrics_Williams

Obstentrics_Williams. stage and maternal prognosis. In most cases of distant metastatic melanoma, treatment is at best palliative. Currently, the role of estrogen receptor-� in melanoma progression is under investigation, and it may be a target for future therapeutic intervention (de Giorgi, 2011).


Obstentrics_Williams

Obstentrics_Williams. Stage-for-stage, survival is equivalent between pregnant and nonpregnant women (Driscoll, 2016; Johansson, 2014). In one study, half of pregnant women had stage III or IV lesions (de Haan, 2017). Therapeutic abortion does not improve maternal survival rates. Clinical stage is the strongest determinant of survival, and women with deep cutaneous invasion or regional node involvement have the worst prognosis. Approximately 60 percent of recurrences will manifest within 2 years, and 90 percent by 5 years. Thus, most recommend that pregnancy be avoided for 3 to 5 years after surgical resection. Interim contraception can include combination oral contraceptives, as they do not appear to have adverse cancer efects (Gandini, 2011). Related, subsequent pregnancies in women with localized melanoma do not lower cancer survival rates (Driscoll, 2009).


Obstentrics_Williams

Obstentrics_Williams. Carcinomas of the colon and rectum are the third most frequent in women of all age groups in the United States (American Cancer Society, 2016). heir incidence in pregnancy is rising because of delayed childbearing (Rogers, 2016) . Even so, colorectal tumors are uncommon before age 40. Smith and colleagues (2003) reported an approximate incidence of 1 per 150,000 deliveries in the California Cancer Registry. he incidence approximated 1 per 35,000 births in a Danish Registry (Eibye, 2013). Most-80 percent-of colorectal carcinomas in pregnant women arise from the rectum. In one review, only 41 cases in pregnancy were colon cancers above the peritoneal reflection (Chan, 1999).


Obstentrics_Williams

Obstentrics_Williams. he most frequent symptoms of colorectal cancer are abdominal pain, distention, nausea, constipation, and rectal bleeding. If symptoms of colon disease persist, digital rectal examination, stool tests for occult blood, and lexible sigmoidoscopy or colonoscopy are done. Some malignancies of the gastrointestinal tract are discovered because of metastases to the ovary. Kruckenberg tumors are tumor-laden ovaries from another primary, often gastrointestinal, and have a bleak prognosis (GliSic, 2006; Kodama, 2016).


Obstentrics_Williams

Obstentrics_Williams. Treatment of colon cancer in pregnant women mirrors the same general guidelines as for nonpregnant women. Without evidence of metastatic disease, surgical resection is preferred, but most gravidas have advanced lesions (AI-Ibrahim, 2014). During the first half of pregnancy, hysterectomy is not necessary to perform colon or rectal resection, and thus, therapeutic abortion is not mandated. During later pregnancy, therapy may be delayed until fetal maturation, however, bowel hemorrhage, obstruction, or perforation may force surgical intervention (Minter, 2005).


Obstentrics_Williams

Obstentrics_Williams. Gastric cancer is rarely associated with pregnancy, and most reported cases are from Japan. Hirabayashi and coworkers (1987) reviewed outcomes in 60 pregnant women during a 70-year period from 1916 to 1985. Delayed diagnosis during pregnancy is common, and the prognosis is consistently poor (Lee, 2009). Esophageal cancer has similar symptoms, but it is rare (Sahin, 2015). It is axiomatic that persistent unexplained upper gastrointestinal symptoms should be evaluated by endoscopy.


Obstentrics_Williams

Obstentrics_Williams. Various other neoplasms have been reported in pregnancy and are usually the subject of case reports. Examples include carcinoid tumors, which are usually of gastrointestinal origin (Durkin, 1983). Both pancreatic and hepatocellular cancer are rare during pregnancy (Kakoza, 2009; Marinoni, 2006; Papoutsis, 2012; Perera, 2011). Another report described a massive intrahepatic cholangiocarcinoma masquerading as HELLP syndrome (Bladerston, 1998). Except for thyroid cancer, malignant tumors of the head and neck are rare (Cheng, 2015). Lung cancer is also uncommon (Boussios, 2013). Central nervous system neoplasms had a reported frequency of 1 in 10,000 to 28,000 births (Eibye, 2013; Smith, 2003). Bladder and urachal duct carcinoma are rarely coincident with pregnancy (McNally, 2013; Yeaton-Massey, 2013). Last, bone tumors have been described (Kathiresan, 2011).


Obstentrics_Williams

Obstentrics_Williams. Abalovich M, Amino N, Barbour A, et al: 2007 management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 92:S 1, 2007 Abdel-Hady ES, Hemida A, Gamal A, et al: Cancer during pregnancy: perinatal outcome after in utero exposure to chemotherapy. Arch Gynecol Obstet 286(2):283,t2012 Ackermann S, Gehrsitz C, Mehihorn G, et al: Management and course of histologically verified cervical carcinoma in situ during pregnancy. Acta Obstet Gynecol Scand 85: 1134,t2006 AI-Adnani M, Kiho L, Scheimberg 1: Maternal pancreatic carcinoma metastatic to the placenta: a case report and literature review. Pediatr Dev Pathol 10:61,t2007 AI-Ibrahim A, Parrish J, Dunn E, et al: Pregnancy and maternal outcomes in women with prior or current gastrointestinal malignancies. J Obstet Gynaecol Can 36(1):34, 2014


Obstentrics_Williams

Obstentrics_Williams. AI-Ibrahim A, Parrish J, Dunn E, et al: Pregnancy and maternal outcomes in women with prior or current gastrointestinal malignancies. J Obstet Gynaecol Can 36(1):34, 2014 Alexander A, Harris M, Grossman D, et al: Vulvar melanoma: difuse melanosis and metastases to the placenta. J Am Acad Dermatol 50(20):293, 2004 Alexander EK, Pearce EN, Brent GA, et al: 20t16 guidelines of the American hyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid 27(3):315,t2017 Ali S, Jones GL, Culligan DJ, et al: Guidelines for the diagnosis and management of acute myeloid leukaemia in pregnancy. Br J HaematoIt170(4):487, 20t15 Alouini S, Rida K, Mathevet P: Cervical cancer complicating pregnancy: impli cations oflaparoscopic lymphadenectomy. Gynecol Oncolt108(3):472, 2008 Amant F, Deckers S, Van Calsteren K, et al: Breast cancer in pregnancy: recommendations of an international consensus meeting. Eur J Cancer 46(18):3158,t2010


Obstentrics_Williams

Obstentrics_Williams. Amant F, Han SN, Gziri MM, et al: Management of cancer in pregnancy. Best Pract Res Clin Obstet GynaecoIt29(5):741, 2015a Amant F, Uzan C, Han SN, et al: Matched cohort study on patients with cervical cancer diagnosed during pregnancy. Ann OncoI25(suppI4):iv320, 2014 Amant F, Vandenbroucke T, Verheecke M, et al: Pediatric outcome ater maternal cancer diagnosed during pregnancy. N Engl J Med 373: 1824, 20t15b American Cancer Society: Leading sites of new cancer cases and deaths-20t16 estimates. 2016. Available at: https://www.cancer.org/content/dam/ cancer-org/ research/ cancer-facts-and -statistics/ ann ual-cancer-facts-andfigures/20 1t6/leading-sites-of-new-cancer-cases-and-deaths-20 1t6-estimate. Accessed June 11, 2017 American Cancer Society: What are the key statistics about ovarian cancer? 2017. Available at: https://www.cancer.org/cancerlovarian-cancerlabout/ key-statistics.html. Accessed June 11, 2017 American College of Obstetricians and Gynecologists: Alternatives to


Obstentrics_Williams

Obstentrics_Williams. cancer? 2017. Available at: https://www.cancer.org/cancerlovarian-cancerlabout/ key-statistics.html. Accessed June 11, 2017 American College of Obstetricians and Gynecologists: Alternatives to hysterectomy in the management of leiomyomas. Practice Bulletin No. 96, August 2008, Reairmed 2016a American College of Obstetricians and Gynecologists: Cervical cancer screening and prevention. Practice Bulletin No. 168, October 2016b American College of Obstetricians and Gynecologists: Guidelines for diagnostic imaging during pregnancy and lactation. Committee Opinion No. 723, October 2017a American College of Obstetricians and Gynecologists: he role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer in women at average risk. Committee Opinion No. 716, September 2017b American College of Radiology: ACR manual on contrast media. Version 10.2. Reston, American College of Radiology, 20t16 American Society for Reproductive Medicine: Fertility preservation and


Obstentrics_Williams

Obstentrics_Williams. 2017b American College of Radiology: ACR manual on contrast media. Version 10.2. Reston, American College of Radiology, 20t16 American Society for Reproductive Medicine: Fertility preservation and reproduction in patients facing gonadotoxic therapies: a committee opinion. Fertil Sterilt100(5):1224, 2013a American Society for Reproductive Medicine: Prevention and treatment of moderate and severe ovarian hyperstimulation syndrome: a guideline. Fertil Steril 106(7):1634,t2016 American Society for Reproductive Medicine, Society for Assisted Reproductive Technology: Mature oocyte cryopreservation: a guideline. Fertil Steril ,2013b merican Society for Reproductive Medicine, Society for Assisted Reproductive Technology: Recommendations for gamete and embryo donation: a committee opinion. Fertil Steril 99(1):47, 2013c


Obstentrics_Williams

Obstentrics_Williams. Anderson ML, Mari G, Schwartz PE: Gynecologic malignancies in pregnancy. In Barnea ER, Jauniaux E, Schwartz PE (eds): Cancer and Pregnancy. London, Springer, 2001 Andersson TM, Johansson AL, Fredriksson 1, et al: Cancer during pregnancy and the postpartum period: a population-based study. Cancer 121 (12):20 2, 2015 Andrieu N, Goldgar DE, Easton OF, et al: Pregnancies, breast-feeding, and breast cancer risk in the International BRCA1I2 Carrier Cohort Study (IBCCS). J Natl Cancer Inst 98:535,t2006 Antoniou AC, Shenton A, Maher ER, et al: Parity and breast cancer risk among BRCA1 and BRCA2. Breast Cancer Res 2, 2006 Aslam N, Ong C, Woelfer B, et al: Serum CA125 at 11-14 weeks of gestation in women with morphologically normal ovaries. BJOG 107:689,t2000 Averette HE, Mirhashemi R, Mofat FL: Pregnancy after breast carcinoma: the ultimate medical challenge. Cancer 85:2301, 1999


Obstentrics_Williams

Obstentrics_Williams. Averette HE, Nasser N, Yankow SL, et al: Cervical conization in pregnancy: analysis of 180 operations. m J Obstet Gynecol 106:543, 1970 Aviles A, Neri N: Hematological malignancies and pregnancy: a inal report of 84 children who received chemotherapy in utero. Clin Lymphoma 2(3):173,t2001 Azim HA Jr, Azim H, Peccatori FA: Treatment of cancer during pregnancy with monoclonal antibodies: a real challenge. Expert Rev Clin Immunol 6(6):821,t2010 zim HA Jr, Partridge AH: Biology of breast cancer in young women. Breast Cancer Res 16(4):427,t2014 Bannister-Tyrell M, Roberts CL, Hasovits C, et al: Incidence and outcomes of pregnancy-associated melanoma in New South Wales 1994-2008. Aust N Z J Obstet Gynaecol 55(2):116, 2015 Barnes MN, Barrett JC, Kimberlin OF, et al: Burkitt lymphoma in pregnancy. Obstet Gynecol 92:675, 1998 Baxi LV, Grossman LC, Abellar R: Hyperreactio luteinalis in pregnancy and hyperandrogenism: a case report. J Reprod Med 59(9-10):509,2014


Obstentrics_Williams

Obstentrics_Williams. Obstet Gynecol 92:675, 1998 Baxi LV, Grossman LC, Abellar R: Hyperreactio luteinalis in pregnancy and hyperandrogenism: a case report. J Reprod Med 59(9-10):509,2014 Beadle BM, Woodward W A, vliddleton LP, et al: The impact of pregnancy on breast cancer outcomes in women < or = 35 years. Cancer 115 (6): 4, 2009 Becker S: Breast cancer in pregnancy: a brief clinical review. Best Pract Res Clin Obstet Gynaecol 33:79, 2016 Berg WA, Campassi C1, Lofe OB: Cystic lesions of the breast: sonographicpathologic correlation. Radiology 227: 183, 2003 Berry DL, heriault L, Holmes FA, et al: Management of breast cancer during pregnancy using a standardized protocol. J Clin Oncol 17:855, 1999 Bigelow CA, Horowitz NS, Goodman A, et al: Management and outcome of cervical cancer diagnosed in pregnancy. Am J Obstet Gynecol 216(3):276. el-276.e6,t2017 Bishop A, Patel S, Fries fH: A case of recurrent hyperreactio luteinalis in three spontaneous pregnancies. J Clin Ultrasound 44(8):502,t2016


Obstentrics_Williams

Obstentrics_Williams. Bishop A, Patel S, Fries fH: A case of recurrent hyperreactio luteinalis in three spontaneous pregnancies. J Clin Ultrasound 44(8):502,t2016 Bladerston KD, Tewari K, Azizi F, et al: Intrahepatic cholangiocarcinoma masquerading as the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) in pregnancy: case report. Am J Obstet Gynecol 9:823, 1998 Bleau N, Patenaude V, Abenhaim HA: Risk of venous thromboembolic events in pregnant patients with cancer. J Matern Fetal Neonatal Med 29(3):380, 2016 Boulay R, Podczaski E: Ovarian cancer complicating pregnancy. Obstet Gynecol Clin North Am 25:3856, 1998 Boussios S, Han SN, Fruscio R, et al: Lung cancer in pregnancy: report of nine cases from an international collaborative study. Lung Cancer 82(3):499, 2013 Boxer A, Bolyard A, Kelley ML, et al: Use of granulocyte colony-stimulating factor during pregnancy in women with chronic neutropenia. Obstet Gynecol 125(1):197, 2015


Obstentrics_Williams

Obstentrics_Williams. Boxer A, Bolyard A, Kelley ML, et al: Use of granulocyte colony-stimulating factor during pregnancy in women with chronic neutropenia. Obstet Gynecol 125(1):197, 2015 Braems G, Denys H, DeWever 0, et al: Use of tamoxifen before and during pregnancy. Oncologist 16(11):1547,t2011 Brenner B, Avivi 1, Lishner M: Haematological cancers in pregnancy. Lancet 379:580,t2012 Brent L: Utilization of developmental basic science principles in the evaluation of reproductive risks from pre-and postconception environmental radiation exposures. Teratology 59:t182,t1999 Brewer M, Kueck An, Runowicz CD: Chemotherapy in pregnancy. Clin Obstet Gynecol 54:602, 2011 Broer N, Buonocore S, Goldberg C: A proposal for the timing of management of patients with melanoma presenting during pregnancy. J Surg Oncol 106(1):36,t2012 Bulun SE, Moravek MB, Yin P, et al: Uterine leiomyoma stem cells: linking progesterone to growth. Semin Reprod Med ,t2015


Obstentrics_Williams

Obstentrics_Williams. Bulun SE, Moravek MB, Yin P, et al: Uterine leiomyoma stem cells: linking progesterone to growth. Semin Reprod Med ,t2015 Bumpers HL, Butler L, Best 1M: Endometrioma of the abdominal wall. Am J Obstet Gynecol 187:t1709,t2002 Burman KD, Wartofsky L: hyroid nodules. N Engl J Med ,t2015 Caligiuri MA, .Mayer ]: Pregnancy and leukemia. Semin OncoIt16:388, 1989 Caragacianu DL, Mayer EL, Chun YS, et al: Immediate breast reconstruction following mastectomy in pregnant women with breast cancer. J Surg Oncol 114(2):140,t2016 Cardonick E, Dougherty R, Grana G et al: Breast cancer during pregnancy: maternal and fetal outcomes. Cancer 16:76, 2010 Cardonick EH, Gringlas MB, Hunter K, et al: Development of children born to mothers with cancer during pregnancy comparing in utero chemotherapy-exposed children with non exposed controls. m J Obstet Gynecol 212(5):658.e1,t2015


Obstentrics_Williams

Obstentrics_Williams. Carradice 0, Austin N, Bayston K, et al: Successful treatment of acute promyelocytic leukaemia during pregnancy. Clin Lab Haematol 2002 Cascinelli N, Morabito A, Santinami M, et al: Immediate or delayed dissection of regional nodes in patients with melanoma of the trunk: a randomized trial. Lancet 351:793,t1998 Caspi B, Levi R, Appelman Z, et al: Conservative management of ovarian cystic teratoma during pregnancy and labor. Am J Obstet Gynecol 182:503, 2000 Castanon A, Brocklehurst P, Evans H, et al: Risk of preterm birth after treatment for cervical intraepithelial neoplasia among women attending colposcopy in England: retrospective-prospective cohort study. BM] 345:e5174, 2012 Celik C, Acar A, Cicek N, et al: Can myomectomy be performed during pregnancy? Gynecol Obstet Invest 53:79, 2002 Chan YM, Ngai SW, Lao TT: Colon cancer in pregnancy. A case report. ] Reprod Med 44:733, 1999


Obstentrics_Williams

Obstentrics_Williams. Chan YM, Ngai SW, Lao TT: Colon cancer in pregnancy. A case report. ] Reprod Med 44:733, 1999 Cheng K, Zhang F, Tang LL, et al: Pregnancy associated nasopharyngeal carcinoma: a retrospective case-control analysis of maternal survival outcomes. Radiother OncoIt116(1):125, 2015 Choi JR, Levine 0, Finberg H: Luteoma of pregnancy: sonographic indings in two cases. J Ultrasound Med 19(12):877, 2000 Ciavarrini A, Clemente N, Delli Carpini G, et al: Number and size of uterine ibroids and obstetric outcomes. J Maten Fetal Neonatal Med 28(4):484, 2015 Cohen JB, Blum A: Evaluation and management of lymphoma and leukemia in pregnancy. Clin Obstet Gynecol 54:556, 2011 Conner SN, Frey A, Cahill AG, et al: Loop electrosurgical excision procedure and risk of preterm birth. A systematic review and meta-analysis. Obstet Gynecol 123:752,t2014


Obstentrics_Williams

Obstentrics_Williams. Conner SN, Frey A, Cahill AG, et al: Loop electrosurgical excision procedure and risk of preterm birth. A systematic review and meta-analysis. Obstet Gynecol 123:752,t2014 Coronado GO, Marshall LM, Schwartz SM: Complications in pregnancy, labor, and delivery with uterine leiomyomas: a population-based study. Obstet Gynecol 95:764, 2000 Critchley HOD, Wallace WHB, Shalet SM, et al: Abdominal irradiation in childhood: the potential for pregnancy. BJOG 99(5):392, 1992 Curtis KM, Hillis SO, Marchbanks PA, et al: Disruption of the endometrialmyometrial border during pregnancy as a risk factor for adenomyosis. Am J Obstet Gynecol 187(3):543, 2002


Obstentrics_Williams

Obstentrics_Williams. Curtis KM, Hillis SO, Marchbanks PA, et al: Disruption of the endometrialmyometrial border during pregnancy as a risk factor for adenomyosis. Am J Obstet Gynecol 187(3):543, 2002 Dahl SK, Thomas A, Williams DB, et al: Maternal virilization due to luteoma associated with delayed lactation. Fertil Steril 90(5):2006.e1 ,t2008 De Carolis S, Fatigante G, Ferrazzani S, et al: Uterine myomectomy in preg nant women. Fetal Diagn Ther 16: 116, 2001 de Giorgi V, Gori A, Grazzini M, et al: Estrogens, estrogen receptors and melanoma. Expert Rev Anticancer her 11t:739, 2011 de Haan J, Lok CA, de Groot CJ, et al: Melanoma during pregnancy: a report of 60 pregnancies complicated by melanoma. Melanoma Res . Djavadian 0, Braendle W, Jaenicke F: Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review. Ferril Steril 82(4):933, 2004


Obstentrics_Williams

Obstentrics_Williams. Djavadian 0, Braendle W, Jaenicke F: Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review. Ferril Steril 82(4):933, 2004 Dogan S, Gzyuncu G, Atak Z: Fibroids during pregnancy: efects on pregnancy and neonatal outcomes. J Reprod Med 61(1-2):52, 2016 Dorum A, Blom GP, Ekerhovd E, et al: Prevalence and histologic diagnosis of adnexal cysts in postmenopausal women: an autopsy study. Am J Obstet Gynecol 192(1):48,t2005 Driscoll MS, Grant-Kels ].1: Nevi and melanoma in the pregnant woman. Clin Dermatol 27(1): 116, 2009 MS, Martires K, Bieber AK, et al: Pregnancy and melanoma. J m Acad 5(4):669,t2016 Dunton CJ: Management of arypical glandular cells and adenocarcinoma in situ. Obstet Gynecol Clin North Am 35(4):623, 2008 Durkin JW Jr: Carcinoid tumor and pregnancy. Am J Obstet Gynecol 145: 57, 1983


Obstentrics_Williams

Obstentrics_Williams. Durkin JW Jr: Carcinoid tumor and pregnancy. Am J Obstet Gynecol 145: 57, 1983 Eibye S, Kjaer SK, Mellemkjaer L: Incidence of pregnancy-associated cancer in Denmark, 1977-2006. Obstet Gynecol 122:608,t2013 Elgindy E, Sibai H, Abdelghani A, et al: Protecting ovaries during chemotherapy through gonad suppression. A systematic review and meta-analysis. Obstet GynecoIt126:187, 2015 EI-Hemaidi I, Robinson SE: Management of haematological malignancy in pregnancy. Best Pract Res Clin Obstet Gynaecol 26(1):149, 2012 EI-Messidi A, Patenaude V, Hakeem G, et al: Incidence and outcomes of women with Hodgkin's lymphoma in pregnancy: a population-based study on 7.9 million births. J Perinat vIed 43(6):683,2015 Erkanli S, Ayhan A: Fertiliry-sparing therapy in young women with endometrial cancer: 2010 update. Int J Gyn Cancer 20: 1170, 2010


Obstentrics_Williams

Obstentrics_Williams. Erkanli S, Ayhan A: Fertiliry-sparing therapy in young women with endometrial cancer: 2010 update. Int J Gyn Cancer 20: 1170, 2010 Esim Buyukbayrak E, Karageyim Karsidag AY, Kars B, et al: Cervical polyps: evaluation of routine removal and need for accompanying O&C. Arch Gynecol Obstet 283(3):581,t2011 Euhus OM: Breast disease. In Hofman BL, Schorge JO, Bradshaw KO, et al (eds): Williams Gynecology, 3rd ed. McGraw-Hill Education, New York, 2016 Eyre T A, Lau IJ, Mackillop L, et al: Management and controversies of classical Hodgkin lymphoma in pregnancy. Br J Haematol 169(5):613,t2015 Fader AN, lward EK, Niederhauser A, et al: Cervical dysplasia in pregnancy: a multi-institutional evaluation. Am J Obstet Gynecol 203: 113, 2010 Favero G, Chiantera V, Oleszczuk A, et al: Invasive cervical cancer during pregnancy: laparoscopic nodal evaluation before oncologic treatment delay. Gynecol OncoIt118:123, 2010


Obstentrics_Williams

Obstentrics_Williams. Favero G, Chiantera V, Oleszczuk A, et al: Invasive cervical cancer during pregnancy: laparoscopic nodal evaluation before oncologic treatment delay. Gynecol OncoIt118:123, 2010 Fey MF, Surbek 0: Leukaemia and pregnancy. Recent Results Cancer Res 178:97,t2008 FIGO Committee on Gynecologic Oncology: Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet 105:103,t2009 Friedman E, Kotsopoulos J, Lubinski J, et al: Spontaneous and therapeutic abortions and the risk of breast cancer among BRCA mutation carriers. Breast Cancer Res 8:R15, 2006 Fuchs N, Smorgick N, Tovbin Y, et al: Oophoropexy to prevent adnexal torsion: how, when, and for whom? J Minim Invasive GynecoIt17(2):205, 2010 Gandini S, Iodice S, Koomen E, et al: Hormonal and reproductive factors in relation to melanoma in women: current review and meta-analysis. Eur J Cancer 47(1 ):2607,t2011


Obstentrics_Williams

Obstentrics_Williams. Gandini S, Iodice S, Koomen E, et al: Hormonal and reproductive factors in relation to melanoma in women: current review and meta-analysis. Eur J Cancer 47(1 ):2607,t2011 Genta PR, Oias ML, Janiszewski TA, et al: Streptococcus agalactiae endocarditis and giant pyomyoma simulating ovarian cancer. South Med J 94:508, 2001 Germain M, Rarick T, Robins E: Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol 88(4 Pt 2):715, 1996 Gharib H, Papini E, Garber JR, et al: American Association of Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for diagnosis and management of thyroid nodules-2016 update. Endocr Pract 22(5):622,t2016 Giuntoli RL Jr, Yang RS, Bristow RE: Evaluation and management of adnexal masses during pregnancy. Clin Obstet Gynecol 49(3):492, 2006 Glisic A, Atanackovic J: Krukenberg tumor in pregnancy. he lethal outcome. Pathol Oncol Res 12(2): 108, 2006


Obstentrics_Williams

Obstentrics_Williams. Glisic A, Atanackovic J: Krukenberg tumor in pregnancy. he lethal outcome. Pathol Oncol Res 12(2): 108, 2006 Goldman NA, Goldberg GL: Late recurrence of squamous cell cervical cancer in an episiotomy site after vaginal delivery. Obstet Gynecol 101: 1127, 2003 Got!ieb WH, Beiner ME, Shalmon B, et al: Outcome of fertiliry-sparing treatment with progestins in young patients with endometrial cancer. Obstet Gynecol 102:718,t2003 Greer BE, Easterling TR, McLennan OA, et al: Fetal and maternal considerations in the management of stage I-B cervical cancer during pregnancy. Gynecol Oncol 34:61, 1989 Gubbala K, Laios A, Gallos I, et al: Outcomes of ovarian transposition in gynaecological cancers: a systematic review and meta-analysis. J Ovarian Res 7:69,t2014 Haas JF: Pregnancy in association with newly diagnosed cancer: a populationbased epidemiologic assessment. Int J Cancer 34:229, 1984


Obstentrics_Williams

Obstentrics_Williams. Haas JF: Pregnancy in association with newly diagnosed cancer: a populationbased epidemiologic assessment. Int J Cancer 34:229, 1984 Hacker NF, Berek JS, Lagasse LO, et al: Carcinoma of the cervix associated with pregnancy. Obstet Gynecol 59:735, 1982 Haggar FA, Pereira G, Preen 0, et al: Adverse obstetric and perinatal outcomes following treatment of adolescent and young adult cancer: a population based cohort study. PLoS One 9(12):el13292, 2014 Hahn KM, Johnson PH, Gordon N, et al: Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero. Cancer :1219,t2006 Hakim C, Padmanabhan V, Vyas AK: Gestational hyperandrogenism in developmental programming. Endocrinology 14:en20161801, 2016 Hannuna Y, Putignani L, Silvestri E, et al: Incidental endometrial adenocarcinoma in early pregnancy: a case report and review of the literature. Int J Gynecol Cancer 19(9):1580,t2009


Obstentrics_Williams

Obstentrics_Williams. Hannuna Y, Putignani L, Silvestri E, et al: Incidental endometrial adenocarcinoma in early pregnancy: a case report and review of the literature. Int J Gynecol Cancer 19(9):1580,t2009 Hashimoto A, Iriyama T, Sayama S, et al: Adenomyosis and adverse perinatal outcomes: increased risk of second trimester miscarriage, preeclampsia, and placental malposition. J Matern Fetal Neonatal Med 23: 1, 201 Heller OS, Cracchiolo B, Hameed M, et al: Pregnancy-associated invasive squa mous cell carcinoma of the vulva in a 28-year-old, HIV-negative woman: a case report. J Reprod Med 45:659, 2000 Hirabayashi M, Ueo H, Okudaira Y, et al: Early gastric cancer and a concomitant pregnancy. Am Surg 30, 198 Hofman MS, Sayer A: A guide to management: adnexal masses in pregnancy. OBG Management ,2007 Hognas E, KauppilatA, Pukkala E, et al: Cancer risk in women with 10 or more deliveries. Obstet GynecoIt123(4):811, 2014


Obstentrics_Williams

Obstentrics_Williams. A guide to management: adnexal masses in pregnancy. OBG Management ,2007 Hognas E, KauppilatA, Pukkala E, et al: Cancer risk in women with 10 or more deliveries. Obstet GynecoIt123(4):811, 2014 Homer H, Saridogan E: Uterine artery embolization for ibroids is associated with an increased risk of miscarriage. Fertil Steril 94(1):324, 2010 Hong Y, Li SQ, Hu L, et al: Survey of human papillomavirus rypes and their vertical transmission in pregnant women. BMC Infect Dis 13:109,t2013 Hoover N, Hyer M, Pfeifer M, et al: Adverse health outcomes in women exposed in utero to diethylstilbestrol. N Engl J Med 365: 1304, 2011 Horowitz NA, Lavi N, Nadir Y, et al: Haematological malignancies in pregnancy: an overview with an emphasis on thrombotic risks. Thromb Haemost 116(4):613,t2016 Hudis CA: Trastuzumab-mechanism of action and use in clinical practice. N Engl J Med 357:39, 2007


Obstentrics_Williams

Obstentrics_Williams. Hudis CA: Trastuzumab-mechanism of action and use in clinical practice. N Engl J Med 357:39, 2007 Huh K, Ault A, Chelmow 0, et al: Use of high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. Obstet Gynecol 125(2):330,t2015 Irving JA, Clement PB: Nonneoplastic lesions of the ovary. In Kurman J, Ellenson LH, Ronnett BM (eds): Blaustein's Pathology of the Female Genital Tract, 6th ed. New York, Springer, 201t1 Ives A, Saunders C, Bulsara M, et al: Pregnancy after breast cancer: population based study. BMJ 334(7586): 194,t2006 Jenabi E, Khazaei S: The efect of uterine leiomyoma on the risk of malpresentation and cesarean: a meta-analysis. J Matern Fetal Neonatal Med 31 (1):87, 2018 Jernstrom H, Lubinski J, Lynch HT, et al: Breast-feeding and the risk of breast cancer in BRCAI and BRCA2 mutation carriers. J Nat! Cancer Inst 96(14):1094,t2004


Obstentrics_Williams

Obstentrics_Williams. Jernstrom H, Lubinski J, Lynch HT, et al: Breast-feeding and the risk of breast cancer in BRCAI and BRCA2 mutation carriers. J Nat! Cancer Inst 96(14):1094,t2004 Johansson AL, ndersson TM, Plym A, et al: Mortaliry in women with pregnancyassociated malignant melanoma. J Am Acad Oermatol 71(6):1093, 2014 Kakoza RM, Vollmer CM Jr, Stuart E, et al: Pancreatic adenocarcinoma in the pregnant patient: a case report and literature review. J Gastrointest Surg 13(3):535,t2009 Kal HB, Struikmans H: Radiotherapy during pregnancy: fact and iction. Lancet Oncol 6(5):328, 2005 Kanal E, Barkovich AJ, Bell C, et al: Expert panel on MR safery. ACR practice guideline for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. J Magn Reson Imaging 37:501, 2013 Kanova N, BiCikova M: Hyperandrogenic states in pregnancy. Physiol Res 60(2):243,t2011


Obstentrics_Williams

Obstentrics_Williams. Kanova N, BiCikova M: Hyperandrogenic states in pregnancy. Physiol Res 60(2):243,t2011 Kao HW, Wu CJ, Chung KT, et al: MR imaging of pregnancy luteoma: a case report and correlation with the clinical features. Korean J Radiol 6(1):44, 2005 Karaman E, Karaman Y, Alkis I, et al: Maternal serum CA-125 level is elevated in severe preeclampsia. Pregnancy Hypertens 4(1):29,t2014 Kathiresan AS, Johnson IN, Hood BJ, et al: Giant cell bone tumor of the thoracic spine presenting in late pregnancy. Obstet Gynecol 118(2 Pt 2):428,2011 Kim CH, Abu-Rustum NR, Chi OS, et al: Reproductive outcomes of patients undergoing radical trachelectomy for early-stage cervical cancer. Gynecol Oncol 125(3):585,t2012 Kim SS, Klemp J, Fabian C: Breast cancer and fertiliry preservation. Fertil Steril 95(5): 1535, 2011 Knight JC, Elliott JO, Amburgey OL: Efect of maternal retroplacental leiomyomas on fetal growth. J Obstet Gynaecol Can 38(12):1100, 2016


Obstentrics_Williams

Obstentrics_Williams. Knight JC, Elliott JO, Amburgey OL: Efect of maternal retroplacental leiomyomas on fetal growth. J Obstet Gynaecol Can 38(12):1100, 2016 Ko EM, Van Le L: Chemotherapy for gynecologic cancers occurring during pregnancy. Obstet Gynecol Surv 66(5):291,t2011 Kodama M, Moeini A, Machida H, et al: Feto-matenal outcomes of pregnancy complicated by Krukenberg tumor: a systematic review of literature. rch Gynecol Obstet 294(3):589,t2016 Korbin CD, Brown OL, Welch WR: Paraovarian cystadenomas and cystadenoibromas: sonographic characteristics in 14 cases. Radiology 208(2):459, 1998 Krishna I, Lindsay M: Breast cancer in pregnancy. Obstet Gynecol Clin N Am 40:559,t2013 Kuller JA, Zucker PK, Peng TC: Vulvar leiomyosarcoma in pregnancy. Am J Obstet Gynecol 162:164, 1990 Kuo K, Caughey AB: Optimal timing of delivery for women with breast cancer, according to cancer stage and hormone status: a decision-analytic model. J Matern Fetal Neonatal Med September 27,t2017 [Epub ahead of print]


Obstentrics_Williams

Obstentrics_Williams. Lam SJ, Best S, Kumar S: The impact of ibroid characteristics on pregnancy outcome. Am J Obstet Gynecol 211(4):395.e1, 2014 Lambertini M, Del Mastro L, Pescio MC, et al: Cancer and fertility preservation: international recommendations from an expert meeting. BMC Med 14:1,t2016 Lambertini M, Peccatori FA, Azim HAJr: Targeted agents for cancer treatment during pregnancy. Cancer Treat Rev 41(4):301,t2015 Larsen EC, Schmiegelow K, Rechnitzer C, et al: Radiotherapy at a young age reduces uterine volume of childhood cancer survivors. Acta Obstet Gynecol Scand 83:96, 2004 Laughlin SK, Baird DO, Savitz DA, et al: Prevalence of uterine leiomyomas in the first trimester of pregnancy: an ultrasound-screening study. Obstet Gynecol 113(3):630, 2009 Lee HJ, Lee IK, Kim JW, et a1: Clinical characteristics of gastric cancer associated with pregnancy. Dig Sutg 26(1):31,t2009


Obstentrics_Williams

Obstentrics_Williams. Lee HJ, Lee IK, Kim JW, et a1: Clinical characteristics of gastric cancer associated with pregnancy. Dig Sutg 26(1):31,t2009 Leiserowitz GS, Xing G, Cress R, et al: Adnexal masses in pregnancy: how often are they malignant? Gynecol Oncol 101 :315, 2006 Lin H, Hwang JL, Huang L W, et al: Pyomyoma after a cesarean section. Acta Obstet Gynecol Scand 81:571, 2002 Liu J, Zanotti K: Management of the adnexal mass. Obstet Gynecol 117: 1413, 2011 Liu P, Xu L, Sun Y, et al: The prevalence and risk of human papillomavirus infection in pregnant women. Epidemiol Infect 142(8):1567,t2014 Lodish MB: Clinical review: kinase inhibitors: adverse efects related to the endocrine system. J Clin Endocrinol Metab 98(4):1333, 2013 Loibl S, Schmidt A, Gentillini 0, et al: Breast cancer diagnosed during pregnancy: adapting recent advances in breast cancer care for pregnant patients. JAMA Oncoltl(8):1145, 2015


Obstentrics_Williams

Obstentrics_Williams. Loibl S, Schmidt A, Gentillini 0, et al: Breast cancer diagnosed during pregnancy: adapting recent advances in breast cancer care for pregnant patients. JAMA Oncoltl(8):1145, 2015 Long ME, Dwarica OS, Kastner TM, et al: Comparison of dysplastic and benign endocervical polyps. J Low Genit Tract Dis 17(2):142,t2013 Longo DL: Malignancies of lymphoid cells. In: Kasper DL, Fauci AS, Hauser SL, et aI (eds): Harrison's Principles of Intenal Medicine, 19th ed. New York, McGraw-Hill Education, 20t15 Loren AW, Mangu PB, Beck LN, et al: Fertiliry preservation for patients with cancer: American Sociery of Clinical Oncology clinical practice guideline update. J Clin OncoIt31(19):2500, 2013 Lutz MH, Underwood PB Jr, Rozier JC, et al: Genital malignancy in pregnancy. Am J Obstet GynecoIt129:536, 1977


Obstentrics_Williams

Obstentrics_Williams. Lutz MH, Underwood PB Jr, Rozier JC, et al: Genital malignancy in pregnancy. Am J Obstet GynecoIt129:536, 1977 Luyckx M, Squiflet JL, Jadoul P, et al: First series of 18 pregnancies after ulipristal acetate treatment for uterine ibroids. Fertil Steril 102(5): 1404, 20t14 lalinowski AK, Sen J, Sermer M: Hyperreactio luteinalis: maternal and fetal efects. J Obstet Gynaecol Can 37(8):715, 2015 Maor GS, Czuzoj-Shulman N, Spence AR, et al: Maternal and neonatal outcomes of pregnancy associated breast cancer. Abstract No. 802, Am J Obstet GynecoIt216:S461,t2017 Mara M, Maskova J, Fucikova Z, et al: Midterm clinical and irst reproductive results of a randomized controlled trial comparing uterine ibroid embolization and myomectomy. Cardiovasc Intervent Radiol 31 (1): 73, 2008 Marinoni E, Di Netta T, Caramanico L, et al: Metastatic pancreatic cancer in late pregnancy: a case report and review of the literature. J Matern Fetal Neonatal Med 19(4):247,t2006


Obstentrics_Williams

Obstentrics_Williams. Marinoni E, Di Netta T, Caramanico L, et al: Metastatic pancreatic cancer in late pregnancy: a case report and review of the literature. J Matern Fetal Neonatal Med 19(4):247,t2006 Masarie K, Katz V, Baldersron K: Pregnancy lureomas: clinical presentations and management strategies. Obstet Gynecol Surv 65(9):575,t2010 Massad LS, Einstein MH, Huh K, et a1: 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. Obstet Gynecol 121(4):829,t2013 Matsuo K, Eno ML, 1m DO, et a1: Pregnancy and genital sarcoma: a systematic review of the literature. Am J Perinatol 26(7):507, 2009 McGovern PG, Noah R, Koenigsberg R, et al: Adnexal torsion and pulmonary embolism: case report and review of the literature. Obstet Gynecol Surv 54(9) :60 1, 1999 McNally L, Osmundson S, Barth R, et al: Urachal duct carcinoma complicating pregnancy. Obstet Gynecol 122:469,t20t13


Obstentrics_Williams

Obstentrics_Williams. McNally L, Osmundson S, Barth R, et al: Urachal duct carcinoma complicating pregnancy. Obstet Gynecol 122:469,t20t13 Melin J, Heinavaara S, Malila N, et al: Adverse obstetric outcomes among early-onset cancer survivors in Finland. Obstet Gynecol 126:803, 2015 Minter A, Malik R, Ledbetter L, et al: Colon cancer in pregnancy. Cancer Control 12(3):196,t2005 Mogos MF, Rahman S, Salihu HM, et al: Association between reproductive cancer and fetal outcomes: a systematic review. Int J Gynecol Cancer 23(7):1171,t2013 Morice P, Uzan C, Gouy S, et al: Gynaecological cancers in pregnancy. Lancet 379:558,t2012 Naqvi M, Kaimal A: Adnexal masses in pregnancy. Clin Obstet Gynecol 58(1):93,t2015 National Toxicology Program: NTP monograph: developmental efects and pregnancy outcomes associated with cancer use during pregnancy. NTP Monogr 2:1,t2013 Navrozoglou 1, Vrekoussis T, Kontostolis E et al: Breast cancer during pregnancy: a mini-review. Eur J Surg OncoIt34:837, 2008


Obstentrics_Williams

Obstentrics_Williams. Navrozoglou 1, Vrekoussis T, Kontostolis E et al: Breast cancer during pregnancy: a mini-review. Eur J Surg OncoIt34:837, 2008 Neiger R, Sonek JD, Croom CS, et al: Pregnancy-related changes in the size of uterine leiomyomas. J Reprod Med 1, 2006 Nisker JA, Shubat M: Stage IB cervical carcinoma and pregnancy: report of 49 cases. Am J Obstet Gynecol 145:203, 1983 Niwa K, Tagami K, Lian Z, et al: Outcome of fertiliry-preserving treatment in young women with endometrial carcinomas. BJOG 112:317,t2005 O'Gara P, Shepard J, Yared K, et al: Case 39-2009L: a 28-year-old pregnant woman with acute cardiac failure. N Engl J Med 361:2462, 2009 Otake M, Schull WJ, Lee S: Threshold for radiation-related severe mental retardation in prenatally exposed A-bomb survivors: atre-analysis. Int ] Radiat BioI 70:755-63, 1996 Palani R, Milojkovic 0, Apperley JF: Managing pregnancy in chronic myeloid leukaemia. Ann Hematolt94 SuppIt2:S167, 2015


Obstentrics_Williams

Obstentrics_Williams. Palani R, Milojkovic 0, Apperley JF: Managing pregnancy in chronic myeloid leukaemia. Ann Hematolt94 SuppIt2:S167, 2015 Palmer J, Vatish M, Tidy J: Epithelial ovarian cancer in pregnancy: a review of the literature. BJOG 116:480, 2009 Papoutsis 0, Sindos M, Papantoniou N, et al: Management options and prognosis of pancreatic adenocarcinoma at 16 weeks' gestation: a case report. :167,t2012 Parazzini F, Franchi M, Tavani A, et al: Frequency of pregnancy related cancer: a population based linkage study in Lombardy, Italy. Int J Gynecol Cancer 27(3):613,t2017 Park JY, Kim DY, Suh OS, et al: Reproductive outcomes after laparoscopic radical trachelectomy for early-stage cervical cancer. ] Gynecol Oncol 25:9, 2014 Peccatori FA, Azim HAtJr, Orecchia R, et al: Cancer, pregnancy and fertiliry: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 24 SuppIt6:viI60, 2013


Obstentrics_Williams

Obstentrics_Williams. Peccatori FA, Azim HAtJr, Orecchia R, et al: Cancer, pregnancy and fertiliry: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 24 SuppIt6:viI60, 2013 Perera 0, Kandavar R, Palacios E: Pancreatic adenocarcinoma presenting as acute pancreatitis during pregnancy: clinical and radiologic manifestations. J La State Med Soc 163: 114, 2011 Pettersson BF, Andersson S, Hellman K, et al: Invasive carcinoma of the uterine cervix associated with pregnancy: 90 years of experience. Cancer 116:2343,t2010 Pinnix CC, Osborne EM, Chihara 0, et al: Maternal and fetal outcomes after therapy for Hodgkin or non-Hodgkin lymphoma diagnosed during pregnancy. JAMA Oncol 2(8):1065, 2016 Pistilli B, Belletini G, Giovannetti E, et al: Chemotherapy, targeted agents, anti emetics and growth-factors in human milk: how should we counsel cancer patients about breastfeeding? Cancer Treat Rev 39(3):207,t2013


Obstentrics_Williams

Obstentrics_Williams. PrittS EA: Fibroids and infertiliry: a systematic review of the evidence. Obstet Gynecol Surv 56:483, 200t1 Qidwai II, Caughey AB, Jacoby AF: Obstetric outcomes in women with sonographically identiied uterine leiomyomata. Obstet Gynecol 107:376, 2006 Reulen RC, Zeegers MP, Wallace WH, et al: Pregnancy outcomes among adult survivors of childhood cancer in the British Childhood Cancer Survivor Study. Cancer Epidemiol Biomarkers Prev 18(8):2239,t2009 Reynoso EE, Shepherd FA, Messner HA, et 1: Acute leukemia during pregnancy: the Toronto Leukemia Study Group experience with long-term follow-up of children exposed in utero to chemotherapeutic agents. J Clin Oncol 5:1098,t1987 Richtig G, Byrom L, Kupsa R, et al: Pregnancy as driver for melanoma. Br J Dermatol 177(3):854,t2017 Rizack T, Mega A, Legare R, et al: Management of hematological malignancies during pregnancy. Am J Hematol 84(12):830, 2009


Obstentrics_Williams

Obstentrics_Williams. Rizack T, Mega A, Legare R, et al: Management of hematological malignancies during pregnancy. Am J Hematol 84(12):830, 2009 Rodriguez AO, Chew H, Cress R, et al: Evidence of poorer survival in pregnancy-associated breast cancer. Obstet Gynecol 112(1): 1, 2008 Rogers JE, Dasari A, Eng C: he treatment of colorectal cancer during pregnancy: cytotoxic chemotherapy and targeted therapy challenges. Oncologist 21(5):563,t2016 Rosenkranz KM, Lucci A: Surgical treatment of pregnancy associated breast cancer. Breast Dis 23:87, 2006 Routledge OJ, Tower C, Davies E, et al: Successful management of acute myeloid leukaemia in a twin pregnancy-a case report. Br J Haematol October 21, 2016 [Epub ahead of print] Russell P, Robboy SJ: Ovarian cysts, tumor-like, iatrogenic and miscellaneous conditions. In Robboy SJ, Mutter GL, Prat J, et al (eds): Robboy's Pathology of the Female Reproductive Tract, 2nd ed. London, Churchill Livingstone, 2009


Obstentrics_Williams

Obstentrics_Williams. Sahin M, Kocaman G, Ozkan M, et al: Resection of esophageal carcinoma during pregnancy. Ann horac Surg 99(1):333,t2015 Salani R, Billingsley CC, Crafton SM: Cancer and pregnancy: an overview for obstetricians and gynecologists. Am J Obstet Gynecol 211 (1): 7, 2014 Salvador E, Bienstock J, Blakemore KJ, et al: Leiomyomata uteri, genetic amniocentesis, and the risk of second-trimester spontaneous abortion. Am J Obstet Gynecol 186:913,t2002 Sanz MA, Montesinos P, Casale MF, et al: Maternal and fetal outcomes in pregnant women with acute promyelocytic leukemia. Ann Hematol 94(8):1357,t2015 Sarno MA, Mancari R, Azim HA, et al: Are monoclonal antibodies a safe treatment for cancer during pregnancy? Immunotherapy 5(7):733, 2013 Schammel DP, Mittal KR, Kaplan K, et al: Endometrial adenocarcinoma associated with intrauterine pregnancy: a report of ive cases and a review of the literature. Int J Gynecol Pathol 17:327, 1998


Obstentrics_Williams

Obstentrics_Williams. Schammel DP, Mittal KR, Kaplan K, et al: Endometrial adenocarcinoma associated with intrauterine pregnancy: a report of ive cases and a review of the literature. Int J Gynecol Pathol 17:327, 1998 Schmeler v1, Mayo-Smith W, Peipert JF, et al: Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol 105: 1098, 2005 Schwartz JL, Mozurkewich EL, Johnson TM: Current management of patients with melanoma who are pregnant, want to get pregnant, or do not want to get pregnant. Cancer 97(9):2130,t2003 Shepherd JH, Spencer C, Herod J, et al: Radical vaginal trachelectomy as a fertiliry-sparing procedure in women with early-stage cervical cancercumulative pregnancy rate in a series of 123 women. BJOG 113:719, 2006 Sherard GB III, Hodson CA, Williams HJ, et al: Adnexal masses and pregnancy: a 12-year experience. Am J Obstet Gynecol 189:358,2003


Obstentrics_Williams

Obstentrics_Williams. Sherard GB III, Hodson CA, Williams HJ, et al: Adnexal masses and pregnancy: a 12-year experience. Am J Obstet Gynecol 189:358,2003 Sienas L, Wong T, Collins R, et al: Contemporary uses of erythropoietin in pregnancy: a literature review. Obstet Gynecol Surv 68(8):594, 2013 Signorelli M, Caspani G, Bonazzi C, et al: Fertility-sparing treatment in young women with endometrial cancer or atypical complex hyperplasia: a prospective single-institution experience of21 cases. BJOG 116(1):114,t2009 Signorello LB, Cohen SS, Bosetti C, et al: Female survivors of childhood cancer: preterm birth and low birth weight among their children. J Nat! Cancer Inst 98:1453,t2006 Signorello LB, Mulvihill J], Green DM, et al: Congenital anomalies in the children of cancer survivors: a report from the childhood cancer survivor study. J Clin OncoIt30(3):239, 2012


Obstentrics_Williams

Obstentrics_Williams. Signorello LB, Mulvihill J], Green DM, et al: Congenital anomalies in the children of cancer survivors: a report from the childhood cancer survivor study. J Clin OncoIt30(3):239, 2012 Signorello LB, Mulvihill J], Green DM, et al: Stillbirth and neonatal death in relation to radiation exposure before conception: a retrospective cohort study. Lancet 6:624, 2010 Sisodia RM, Del Carmen MG, Boruta DM: Role of minimally invasive surgery in the management of adnexal masses. Clin Obstet Gynecol 58(1):66, 2015 Sisson Jc, Freitas J, McDougall IR, et al: Radiation safety in the treatment of patients with thyroid diseases by radioiodine 1311: practice recommendations of the American hyroid Association. Thyroid 21(4):335,t2011 Smith LH, Danielsen B, Allen ME, et al: Cancer associated with obstetric delivery: results of linkage with the California cancer registry. m J Obstet GynecoIt189:1128,t2003


Obstentrics_Williams

Obstentrics_Williams. Smith LH, Danielsen B, Allen ME, et al: Cancer associated with obstetric delivery: results of linkage with the California cancer registry. m J Obstet GynecoIt189:1128,t2003 Soares SR, Gomez R, Simon C, et al: Targeting the vascular endothelial growth factor system to prevent ovarian hyperstimulation syndrome. Hum Reprod Update 14(4):321,t2008 Spitzer M, Kaushal N, Benjamin F: Maternal CA-125 levels in pregnancy and the puerperium. J Reprod Med 43:387, 1998 Stensheim H, Klungs0yr K, Skjaerven R, et al: Birth outcomes among ofspring of adult cancer survivors: a population-based study. Int J Cancer 133(11):2696,t2013 Stokes LS, Wallace MJ, Godwin RB, et al: Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomas. J Vasc Interv RadioIt21(8):1153,t2010 Stout MJ, Frey A, Tuuli MG, et al: Loop electro surgical excision procedure and risk of vaginal infections during pregnancy: an observation study. B JOG 122(4):545,t2015


Obstentrics_Williams

Obstentrics_Williams. Stout MJ, Frey A, Tuuli MG, et al: Loop electro surgical excision procedure and risk of vaginal infections during pregnancy: an observation study. B JOG 122(4):545,t2015 Stout MJ, Odibo AO, GraseckAS, et al: Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstet Gynecol 116(5):1056,t2010 Stovall M, Blackwell CR, Cundif J, et al: Fetal does from radiotherapy with photon beams: report of AAPM Radiation Therapy Committee Task Group No. 36. Med Phys 22(1):63, 1995 Suzuki H, Matsubara S, Uchida S, et al: Ovary hyperstimulation syndrome accompanying molar pregnancy: case report and review of the literature. Arch Gynecol Obstet 290(4):803,t2014 Suzuki S: Comparison between spontaneous ovarian hyperstimulation syndrome and hyperreactio luteinalis. Arch Gynecol Obstet 269(3):227, 2004


Obstentrics_Williams

Obstentrics_Williams. Suzuki S: Comparison between spontaneous ovarian hyperstimulation syndrome and hyperreactio luteinalis. Arch Gynecol Obstet 269(3):227, 2004 Szecsi PB, Anderson MR, Bj0rngaard B, et al: Cancer antigen 125 after delivery in women with a normal pregnancy: a prospective cohort study. Acta Obstet Gynecol Scand 93(12):1295,t2014 Takushi M, Moromizato H, Sakumoto K, et al: Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment. Gynecol OncoI87:185, 2002 Tannus JF, Hertzberg BS, Haystead CM, et al: Unilateral luteoma of pregnancy mimicking a malignant ovarian mass on magnetic resonance and ultrasound. J Magn Reson Imaging 13, 2009 Teh T, Stern C, Chander S, et al: he impact of uterine radiation on subsequent fertility and pregnancy outcomes. Biomed Res Int 2014:482968,2014 Titus-ErnstofL, Troisi R, Hatch EE, et al: Mortality in women given diethylstilbestrol during pregnancy. Br J Cancer 95:107, 2006


Obstentrics_Williams

Obstentrics_Williams. Ungar L, Smith JR, PaIfavli L, et al: Abdominal radical trachelectomy during pregnancy to preserve pregnancy and fertility. Obstet Gynecol 108:811, 2006 Valachis A, Tsali L, Pesce LL, et al: Safety of pregnancy after primary breast carcinoma in young women: a meta-analysis to overcome bias of healthy mother efect studies. Obstet Gynecol Surv 65:786,t2010 Van Calsteren K, Hanssens I, Moerman P, et al: Successful conservative treatment of endocervical adenocarcinoma stage Ib1 diagnosed early in pregnancy. Acta Obstet Gynecol Scand 87(2):250, 2008 van der Vange N, Weverling GJ, Ketting BW, et al: The prognosis of cervical cancer associated with pregnancy: a matched cohort study. Obstet Gynecol 85:1022,t1995 van Vliet W, van Loon AJ, ten Hoor A, et al: Cervical carcinoma during pregnancy: outcome of planned delay in treatment. Eur J Obstet Gynecol Reprod 9:153,t1998


Obstentrics_Williams

Obstentrics_Williams. Velentgas P, Daling JR, Malone E, et al: Pregnancy after breast carcinoma: outcomes and influence on mortality. Cancer 85:2424, 1999 Vercruysse DC, Deprez S, Sunaert S, et al: Efects of prenatal exposure to cancer treatment on neurocognitive development, a review. Neurotoxicology 54:11, 2016 Viswanathan S, Ramaswamy B: Pregnancy-associated breast cancer. Clin Obstet Gynecol 54(4):546, 2011 Wang yc, Su HY, Liu JY, et al: Maternal and female fetal virilization caused by pregnancy luteomas. Fertil Steril 84:509.e15, 2005 Webb E, Sakhel K, Chauhan SP, et al: Adnexal mass during pregnancy: a review. Am J Perinatol 32(11): 10 10, 2015 Weibull CE, Eloranta S, Smedby E,et al: Pregnancy and the risk of relapse in patients diagnosed with Hodgkin lymphoma. J Clin OncoIt34(4):337, 2016 Weinmann S, Naleway A, Swamy G, et al: Pregnancy outcomes after treatment for cervical cancer precursor lesions: an observational study. PLoS One 12(1):e0165276,t2017


Obstentrics_Williams

Obstentrics_Williams. Weinmann S, Naleway A, Swamy G, et al: Pregnancy outcomes after treatment for cervical cancer precursor lesions: an observational study. PLoS One 12(1):e0165276,t2017 Weitzman VN, DiLuigi AJ, Maier DB, et al: Prevention of recurrent adnexal torsion. Fertil Steril 90(5):2018.e1, 2008 Werner CL, Lo JY, Hefernan, et al: Loop electrosurgical excision procedure and risk of preterm birth. Obstet Gynecol 115:605,t2010 Whitecar MP, Turner S, Higby MK: Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management. Am J Obstet Gynecol 181: 19, 1999 Williams SF, Schilsky L: Neoplastic disorders. In Barron WI, Lindheimer MD (eds): Medical Disorders During Pregnancy, 3rd ed. St. Louis, Mosby, 2001 Winther JF, Boice JD Jr, Svendsen L, et al: Spontaneous abortion in a Danish population-based cohort of childhood cancer survivors. J Clin Oncol 26(26):4340, 2008


Obstentrics_Williams

Obstentrics_Williams. Winther JF, Boice JD Jr, Svendsen L, et al: Spontaneous abortion in a Danish population-based cohort of childhood cancer survivors. J Clin Oncol 26(26):4340, 2008 Winther JF, Olsen JH, Wu H, et al: Genetic disease in the children of Danish survivors of childhood and adolescent cancer. J Clin OncoIt30(1):27, 2012 Wohlfahrt J, Olsen JH, Melby M: Breast cancer risk after childbirth in young women with family history. Cancer Causes Control 13:169, 2002 WOO JC, Yu T, Hurd TC: Breast cancer in pregnancy. Arch Surg 138:91,t2003


Obstentrics_Williams

Obstentrics_Williams. Yahata T, Numata M, Kashima K, et al: Conservative treatment of stage IA1 adenocarcinoma of the cervix during pregnancy. Gynecol Oncol 109(1):49, 2008 Yazbeck CF, Sullivan SD. hyroid disorders during pregnancy. Med Clin No America 96:235,t2012 Yeaton-Massey A, Brooield F, Aziz N, et al: Maternal bladder cancer diagnosed at routine first-trimester obstetric ultrasound examination. Obstet Gynecol 122:464,t2013 Yost NP, Santoso JT, McIntire DD, et al: Postpartum regression rates of antepartum cervical intraepithelial neoplasia II and III lesions. Obstet Gynecol 93:359, 1999 Yu 5S, Bischof A: hyroid cancer in pregnancy. Semin Reprod Med 34(6):351,t2016 Zagouri F, Sergentanis TN, Chrysikos D, et al: Platinum derivatives during pregnancy in cervical cancer: a systematic review and meta-analysis. Obstet GynecoIt121:337,t2013a Zagouri F, Sergentanis TN, Chrysikos D, et al: Trastuzumab administration during pregnancy: a systematic review and meta-analysis. Breast Cancer Res Treat


Obstentrics_Williams

Obstentrics_Williams. meta-analysis. Obstet GynecoIt121:337,t2013a Zagouri F, Sergentanis TN, Chrysikos D, et al: Trastuzumab administration during pregnancy: a systematic review and meta-analysis. Breast Cancer Res Treat (2):349,t2013b Zanetta G, Mariani E, Lissoni A, et al: A prospective study of the role of ultrasound in the management of adnexal masses in pregnancy. BJOG 110:578, 2003 Zemlickis D, Lishner M, Degendorfer P, et al: Maternal and fetal outcome after breast cancer in pregnancy. Am J Obstet Gynecol 166:781, 1992 Zweizig S, Perron J, Gtubb 0, et al: Conservative management of adnexal torsion. Am J Obstet Gynecolt168(6 Pt 1):1791,t1993


Obstentrics_Williams

Obstentrics_Williams. MATERNAL AND FETAL.IMMUNOLOGY .......i.... 1209 VIRAL INFECTIONS ...i.....i............i...... 1210 BACTERIAL INFECTIONS .............i.......... 1220 PROTOZOAL INFECTIONS .i.i....i.............. 1225 BIOTERRORISM . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 1228 According to many authorities, inluena exerts a very pernicious influence upon pregnancy. t would appear that the fects of inluena must vary with the severiy of the epidemic, and more particuary with the frequeny of pneumonic com plications. As a rule, any septic condition oers a worse prognosis in prenany. Several instances have been reported of transmission of the oending bacteria to the oetus. -J. Whitridge Williams (1903)


Obstentrics_Williams

Obstentrics_Williams. -J. Whitridge Williams (1903) Infections have historically been a major cause of maternal and fetal morbidity and mortality worldwide, and they remain so in the 21st century. he unique maternal-fetal vascular connection in some cases serves to protect the fetus from infectious agents, whereas in other instances it provides a conduit for their transmission to the fetus. Maternal serological status, gestational age at the time infection is acquired, the mode of acquisition, and the immunological status of both the mother and her fetus all inluence disease outcome.


Obstentrics_Williams

Obstentrics_Williams. Even after intensive study, many of the maternal immunological adaptations to pregnancy are not well elucidated. It is known that pregnancy is associated with an increase in the CD4+ T cells that secrete h2-type cytokines-for example interleukins (Fragiadakis, 2016). Th1-type cytokine production-for example, interferon gamma and interleukin 2-appears to be somewhat suppressed, leading to a h2 bias in pregnancy. This bias afects the ability to rapidly eliminate certain intracellular pathogens during pregnancy, although the clinical implications of this suppression are unknown (Kourtis, 2014; Svensson-Arvelund, 2014). Importantly, the h2 humoral immune response remains intact. It also appears that human leukocyte antigen (HA)-C expressed by extravillous trophoblasts elicits responses from decidual natural killer (dNK) and decidual CD8+ T cells (Crespo, 2017).


Obstentrics_Williams

Obstentrics_Williams. In describing infections, horizontal transmission is the spread of an infectious agent from one individual to another. Vertical transmission refers to passage from the mother to her fetus of an infectious agent through the placenta, during labor or delivery, or by breastfeeding. Thus, preterm rupture of membranes, prolonged labor, and obstetrical manipulations may enhance the risk of neonatal infection (Centers for Disease Control and Prevention, 2010). Table 64-1 details speciic infections by mode and timing of acquisition. A inal term, the seconday attack rate, is the probability that infection develops in a susceptible individual following known contact with an infectious person.


Obstentrics_Williams

Obstentrics_Williams. The active immunological capacity of the fetus and neonate is compromised compared with that of older children and adults. That said, fetal cell-mediated and humoral immunity begin to develop by 9 to 15 weeks' gestation (Warner, 2010). The primary fetal response to infection is immunoglobulin M (Ig.1). Passive immunity is provided by IgG transferred across the placenta. By 16 weeks, this transfer begins to rise rapidly, and by 26 weeks, fetal concentrations are equivalent to those of the mother. After birth, breastfeeding is protective against some infections, although this protection begins to decline at TABLE 4-1 . Specific Causes of Some Fetal and Neonatal Infections Viruses: varicella-zoster, coxsackie, human parvovirus B19, rubella, CMV, HIV, Zika Bacteria: Listeria, syphilis, Borrelia Protozoa: toxoplasmosis, malaria group B streptococcus, coliforms Viruses: HIV


Obstentrics_Williams

Obstentrics_Williams. Bacteria: Listeria, syphilis, Borrelia Protozoa: toxoplasmosis, malaria group B streptococcus, coliforms Viruses: HIV Bacteria: gonorrhea, chlamydia, group B streptococcus, tuberculosis, mycoplasmas Viruses: HSV, HPV, HIV, hepatitis B, hepatitis C, Zika External contamination Bacteria: staphylococcus, coliforms Viruses: HSV, varicella zoster Human transmission: staphylococcus, HSV Respirators and catheters: staphylococcus, coliforms CMV = cytomegalovirus; HIV = human immunodeficiency virus; HPV = human papillomavirus; HSV = herpes simplex virus. 2 months of age. Current World Health Organization (2013) recommendations are to exclusively breastfeed for the first 6 months of life with partial breastfeeding until 2 years of age.


Obstentrics_Williams

Obstentrics_Williams. 2 months of age. Current World Health Organization (2013) recommendations are to exclusively breastfeed for the first 6 months of life with partial breastfeeding until 2 years of age. Neonatal infection, especially in its early stages, may be dificult to diagnose because these newborns often fail to express classic clinical signs. If the fetus was infected in utero, there may be depression and acidosis at birth for no apparent reason. The neonate may suck poorly, vomit, or show abdominal distention. Respiratory insuiciency can develop, which may present similarly to idiopathic respiratory distress syndrome. he neonate may be lethargic or jittery. he response to sepsis may be hypothermia rather than hyperthermia, and the total leukocyte and neutrophil counts may be depressed.


Obstentrics_Williams

Obstentrics_Williams. Several viruses cause severe maternal infections, and some can also cause devastating fetal infections. Of these, cytomegalovirus (CMV) is a ubiquitous DNA herpes virus that eventually infects most humans. CMV is also the most common perinatal infection in the developed world. Speciically, some evidence of fetal infection is found in 0.2 to 2.2 percent of all neonates (American College of Obstetricians and Gynecologists, 2017). The virus is secreted into all body luids, and person-to-person contact with viral-laden saliva, semen, urine, blood, and nasopharyngeal and cervical secretions can transmit infection. The fetus may become infected by transplacental viremia, or the neonate is infected at delivery or during breastfeeding. vloreover, acquisition continues to accrue. Day-care centers, for example, are a frequent source. Revello and coworkers (2008) reported that amniocentesis in women whose blood is positive for CMV DNA does not result in iatrogenic fetal transmission.


Obstentrics_Williams

Obstentrics_Williams. Up to 85 percent of women from lower socioeconomic backgrounds are seropositive by the time of pregnancy, whereas only half of women in higher income groups are immune. Following primary CMV infection, and in a manner similar to other herpesvirus infections, the virus becomes latent with periodic reactivation characterized by viral shedding. This occurs despite high serum levels of anti-CMV IgG antibody. These antibodies do not prevent maternal recurrence, reactivation, or reinfection, nor do they totally mitigate fetal or neonatal infection.


Obstentrics_Williams

Obstentrics_Williams. Women who are seronegative before pregnancy, but who develop primary CMV infection during pregnancy, are at greatest risk to have an infected fetus. It is estimated that 25 percent of congenital CMV infections in the United States are from primary maternal infection (Wang, 2011). Most CMV infections are clinically silent, but they can be detected by seroconversion, and this may be as high as 1 to 7 percent annually (Hyde, 2010). Conversely, diagnosis of CMV nonprimary infection is a challenge (Picone, 2017).


Obstentrics_Williams

Obstentrics_Williams. Pregnancy does not increase the risk or severity of maternal CMV infection. Most infections are asymptomatic, but 10 to 15 percent of infected adults have a mononucleosis-like syndrome characterized by fever, pharyngitis, lymphadenopathy, and polyarthritis. Immunocompromised women may develop myocarditis, pneumonitis, hepatitis, retinitis, gastroenteritis, or meningoencephalitis. Nigro and associates (2003) reported that most women in a cohort with primary infection had elevated serum aminotransferases or lymphocytosis. Reactivation disease usually is asymptomatic, although viral shedding is common.


Obstentrics_Williams

Obstentrics_Williams. Transmission rates for primary infection are 30 to 36 percent in the first trimester, 34 to 40 percent in the second, and 40 to 72 percent in the third trimester (American College of Obstetricians and Gynecologists, 2017; Picone, 2017). In contrast, recurrent maternal infection infects the fetus in only 0.15 to 1 percent of cases. Naturally acquired immunity during pregnancy results in a 70-percent risk reduction of congenital CMV infection in future pregnancies (Fowler, 2003; LeruezVille, 2017). However, as noted earlier, maternal immunity does not prevent recurrences, and maternal antibodies do not prevent fetal infection (Ross, 2011) .


Obstentrics_Williams

Obstentrics_Williams. Newborns with apparent sequelae of in-utero-acquired CMV infection are described as having symptomatic CMV inection. Congenital infection is a syndrome that may include growth restriction, microcephaly, intracranial calcifications, chorioretinitis, mental and motor retardation, sensorineural deficits, hepatosplenomegaly, jaundice, hemolytic anemia, and thrombocytopenic purpura (Cheeran, 2009). An example of periventricular calcifications is shown in Figure 64-1. Of the estimated 40,000 infected neonates born each year, only 5 to 10 percent demonstrate this syndrome (Fowler, 1992). hus, most FIGURE 64-1 Coronal view of cranial sonogram from a neonate with congenital cytomegalovirus infection showing multiple periventricular calcifications.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 64-1 Coronal view of cranial sonogram from a neonate with congenital cytomegalovirus infection showing multiple periventricular calcifications. infected infants are asymptomatic at birth, but some develop late-onset sequelae. Complications may include hearing loss, neurological deicits, chorioretinitis, psychomotor retardation, and learning disabilities. Infections in dichorionic twins most 1ikely are nonconcordant (Egana-U grinovic, 2016).


Obstentrics_Williams

Obstentrics_Williams. Routine prenatal CMV serological screening is currently not recommended by the Society for Maternal-Fetal Medicine (2016). An algorithm for management is shown in Figure 64-2. Pregnant women should be tested for CMV if they present with a mononucleosis-like illness or if congenital infection is suspected based on abnormal sonographic indings. Primary infection is diagnosed using CMV-speciic IgG testing of paired acute and convalescent sera. CMV IgM does not accurately relect timing of seroconversion because IgM antibody levels may be elevated for more than a year (Stagno, 1985). Moreover, CMV IgM may be found with reactivation disease or reinfection with a new strain. Thus, specific CMV IgG avidity testing is valuable Abnormal Maternal CMV Screening CMV IgG: positive CMV IgM: positive CMV-specific IgG and IgM by EIA, IgG avidity by EIA, and CMV-specific IgM by immunoblot CMV IgG: negative CMV IgM: negative CMV IgG: positive IgG avidity index: high


Obstentrics_Williams

Obstentrics_Williams. CMV-specific IgG and IgM by EIA, IgG avidity by EIA, and CMV-specific IgM by immunoblot CMV IgG: negative CMV IgM: negative CMV IgG: positive IgG avidity index: high CMV IgM: negative in conirming primary CMV infection. High anti-CMV IgG avidity indicates primary maternal infection >6 months before testing (Kanengisser-Pines, 2009). Finally, viral culture may be useful, although a minimum of 21 days is required before findings are considered negative.


Obstentrics_Williams

Obstentrics_Williams. Several fetal abnormalities associated with CMV infection may be seen with sonography, computed tomography, or magnetic resonance imaging. In some cases, they are found at the time of routine prenatal sonographic screening, but in others they are part of a specific evaluation in women with CMV infection. Findings include microcephaly, ventriculomegaly, and cerebral calciications; ascites, hepatomegaly, splenomegaly, and hyperechoic bowel; hydrops; and oligohydramnios (Society for Maternal-Fetal Medicine, 2016). Abnormal sonographic findings seen in combination with positive findings in fetal blood or amnionic fluid are predictive of an approximate 75-percent risk of symptomatic congenital infection (Enders, 2001).


Obstentrics_Williams

Obstentrics_Williams. CMV nucleic acid amplification testing (NAA T) of amnionic luid is considered the gold standard for the diagnosis of fetal infection. Sensitivities range from 70 to 99 percent and depend on amniocentesis timing. Sensitivity is highest when amniocentesis is performed at least 6 weeks after maternal infection and after 21 weeks' gestation (Azam, 2001; Guerra, 2000). A negative result from amnionic luid polymerase chain reaction (PCR) testing does not exclude fetal infection and may need to be repeated if suspicion for fetal infection is high.


Obstentrics_Williams

Obstentrics_Williams. The management of the immunocompetent pregnant woman with primary or recurrent CMV is limited to symptomatic treatment. If recent primary CMV infection is conirmed, amnionic fluid analysis should be ofered. Counseling regarding fetal outcome depends on the gestational age during which primary infection is documented. Despite the high infection rate with primary infection in the first half of pregnancy, most fetuses develop normally. However, pregnancy termination may be an option for some.


Obstentrics_Williams

Obstentrics_Williams. Currently, no proven treatments are available for CMV infection (Society for Maternal-Fetal Medicine, 2016). Leruez-Ville and associates (2016) recently reported that oral treatment with valacyclovir, 8 g daily, apparently mitigated adverse outcomes in eight of 11 afected fetuses treated beginning at median of 25.9 weeks' gestation. Kimberlin and colleagues (2015) previously showed that intravenous valganciclovir administered for 6 weeks to neonates with symptomatic central nevous system (CNS) disease prevented hearing deterioration at 6 months and possibly later. Passive immunization with CMV-specific hyperimmune globulin may lower the risk of congenital CMV infection when given to pregnant women with primary disease (Nigro, 2005, 2012; Visentin, 2012). he Maternal-Fetal Medicine Units Network currently is conducting a randomized trial designed to address this.


Obstentrics_Williams

Obstentrics_Williams. here is no CMV vaccine, although several clinical trials are underway (Arvin, 2004; Schleiss, 2016). Prevention of congenital infection relies on avoiding maternal primary infection, especially in early pregnancy. Basic measures such as good hygiene and hand washing have been promoted, particularly for women with toddlers in day-care settings (Fowler, 2000). CMV may be sexually transmitted among infected partners, but no data address the eicacy of preventive strategies.


Obstentrics_Williams

Obstentrics_Williams. CMV may be sexually transmitted among infected partners, but no data address the eicacy of preventive strategies. Varicella-zoster virus (VZV) is a double-stranded DNA herpesvirus acquired predominately during childhood, and 90 percent of adults have serological evidence of immunity (Whitley, 2015). The incidence of adult varicella declined by 82 percent after the introduction of varicella vaccination, and this has resulted in a drop in maternal and fetal varicella rates (American College of Obstetricians and Gynecologists, 2017). In the United States between 2003 and 2010, the incidence of maternal varicella among 7.7 million pregnancy admissions was 1.21 per 10,000 (Zhang, 2015).


Obstentrics_Williams

Obstentrics_Williams. Primary infection-varicela or chickenpox-is transmitted by direct contact with an infected individual, although respiratory transmission has been reported. The incubation period is 10 to 21 days, and a nonimmune woman has a 60-to 95-percent risk of becoming infected after exposure (Whitley, 2015). Primary varicella presents with a 1-to 2-day flulike prodrome, which is followed by pruritic vesicular lesions that crust after 3 to 7 days. Infection tends to be more severe in adults (Marin, 2007). Afected patients are then contagious from 1 day before the onset of the rash until the lesions become crusted.


Obstentrics_Williams

Obstentrics_Williams. Mortality is predominately due to VZV pneumonia, which is thought to be more severe during adulthood and particularly in pregnancy. Although the incidence was once thought to be higher, only 2 to 5 percent of infected pregnant women develop pneumonitis (Marin, 2007; Zhang, 2015). Risk factors for VZV pneumonia include smoking and having more than 100 cutaneous lesions. Maternal mortality rates with pneumonia have decreased to 1 to 2 percent (Chandra, 1998). Symptoms of VZV pneumonia usually appear 3 to 5 days into the course of illness. Fever, tachypnea, dry cough, dyspnea, and pleuritic pain are characteristic. Nodular iniltrates are similar to other viral pneumonias (Chap. 51, p. 994). Although resolution of pneumonitis parallels that of skin lesions, fever and compromised pulmonary function may persist for weeks.


Obstentrics_Williams

Obstentrics_Williams. If primary varicella is reactivated years later, it causes herpes zoster or shingles (Whirley, 2015). This presents as a unilateral dermatomal vesicular eruption associated with severe pain. Zoster does not appear to be more frequent or severe in pregnant women. Congenital varicella syndrome rarely develops in cases of maternal herpes zoster (hn, 2016; Enders, 1994). Zoster is contagious if blisters are broken, although less so than with primary varicella.


Obstentrics_Williams

Obstentrics_Williams. In women with varicella during the irst half of pregnancy, the fetus may develop congenital varicella syndrome. Some features include chorioretinitis, microphthalmia, cerebral cortical atrophy, growth restriction, hydronephrosis, limb hypoplasia, and cicatricial skin lesions as shown in Figure 64-3 (Ahn, 2016; Auriti, 2009). Enders and coworkers (1994) evaluated 13 3 pregnant women with varicella. When maternal infection developed before 13 weeks, only two of 472 pregnancies-O.4 and scarring in a fetus infected during the first trimester by vari cella. (Reproduced with permission from Paryani SG, Arvin AM:


Obstentrics_Williams

Obstentrics_Williams. Intrauterine infection with varicella zoster virus after maternal varicella, N Engl J Med. 1986 Jun 12;314(24):1542-1546.) percent-had neonates with congenital varicella syndrome. he highest risk was between 13 and 20 weeks, during which time seven of 351 exposed fetuses-2 percent-had evidence of congenital varicella. Mter 20 weeks' gestation, the researchers found no clinical evidence of congenital infection. Ahn and colleagues (2016) recently described similar findings. hat said, sporadic reports have described CNS abnormalities and skin lesions in fetuses who developed congenital varicella in weeks 21 to 28 of gestation (Lamont, 2011 a; Marin, 2007).


Obstentrics_Williams

Obstentrics_Williams. If the fetus or neonate is exposed to active infection just before or during delivery, and therefore before maternal antibody has been formed, the newborn faces a serious threat. Attack rates range from 25 to 50 percent, and mortality rates approach 30 percent. In some instances, neonates develop disseminated visceral and CNS disease, which is commonly fatal. For this reason, varicella-zoster immune globulin (VZIG) should be administered to neonates born to mothers who have clinical evidence of varicella 5 days before and up to 2 days ater delivery.


Obstentrics_Williams

Obstentrics_Williams. Maternal varicella is usually diagnosed clinically. Infection may be confirmed by NAA T of vesicular fluid, which is very sensitive. The virus may also be isolated by scraping the vesicle base during primary infection and performing a Tzanck smear, tissue culture, or direct luorescent antibody testing. Congenital varicella may be diagnosed using NAA T analysis of amnionic luid, although a positive result does not correlate well with the development of congenital infection (Mendelson, 2006). A detailed anatomical sonographic evaluation performed at least 5 weeks after maternal infection may disclose abnormalities, but the sensitivity is low (Mandelbrot, 2012).


Obstentrics_Williams

Obstentrics_Williams. Maternal Viral Exposure. Several aspects of maternal VZV exposure and infection in pregnancy afect management. Exposed gravidas with a negative history for chickenpox should undergo VZV serological testing. At least 70 percent of these women will be seropositive, and thus immune. Exposed pregnant women who are susceptible (seronegative) should be given varicella-zoster immune globulin (VariZIG). Although best given within 96 hours of exposure, its use is approved for up to 10 days to prevent or attenuate varicella infection (Centers for Disease Control and Prevention, 2012, 2013d). Passive immunization appears to be highly efective Qespersen, 2016). In women with known history of varicella, VariZI G is not indicated. Maternal Infection. Any patient dianosed with primay varicella inection or herpes zoster should be isolated rom pregnant women.


Obstentrics_Williams

Obstentrics_Williams. Maternal Infection. Any patient dianosed with primay varicella inection or herpes zoster should be isolated rom pregnant women. Because VZV pneumonia often presents with few symptoms, a chest radiograph is recommended by many. Most women require only supportive care, but those who require intravenous (IV) luids and especially those with pneumonia are hospitalized. IV acyclovir therapy is given to women requiring hospital ization-500 mg/mror 10 to 15 mg/kg every 8 hours. Vaccination. An attenuated live-virus vaccine is recommended for nonpregnant adolescents and adults with no history of vari cella. Two doses of Varivax are given 4 to 8 weeks apart, and the seroconversion rate is 98 percent (Marin, 2007). Importantly, vaccine-induced immunity diminishes over time, and the (Chaves, 2007).


Obstentrics_Williams

Obstentrics_Williams. The vaccine is not recommended or pregnant women or or vaccine dose. That said, a registry of more than 1000 vaccine exposed pregnancies reports no cases of congenital varicella syn drome or other associated congenital malformations (Marin, 2014; Wilson, 2008). he attenuated vaccine virus is not secreted in breast milk. hus, postpartum vaccination should not be delayed because of breastfeeding (American College of Obstetricians and Gynecologists, 2016c). hese respiratory infections are caused by members of the family Orthomyxoviridae. Inluenza A and B form one genus of these RNA viruses, and both cause epidemic human disease (Cohen, 2015b). Inluenza A viruses are subclassiied further by hemagglutinin (H) and neuraminidase (N) surface antigens. Inluenza outbreaks occur annually, and the most recent epidemic was in 2016 to 2017 caused by an inluenza A/H3N2 strain (Shang, 2016).


Obstentrics_Williams

Obstentrics_Williams. Fever, dry cough, and systemic symptoms characterize this infection, which usually is not life-threatening in otherwise healthy adults. However, pregnant women appear to be more susceptible to serious complications, particularly pulmonary involvement (Cohen, 2015b; Mertz, 2017; Rasmussen, 2012). Severe infection has a maternal mortality rate of 1 percent (Duryea, 2015). And from 2009 to 2010, widespread inluenza A infection afected pregnant women and caused 12 percent of pregnancy-related deaths (Callaghan, 2015). No firm evidence links inluenza A virus and congenital malformations (Irving, 2000; Zerbo, 2017). Conversely, TABLE 64-2. Outpatient Influenza A and B Virus Testing Methods aNasopharyngeal or throat swab. RT-PCR = reverse transcription-polymerase chain reaction. Data from Centers for Disease Control and Prevention, 201r7e.


Obstentrics_Williams

Obstentrics_Williams. RT-PCR = reverse transcription-polymerase chain reaction. Data from Centers for Disease Control and Prevention, 201r7e. Lynberg and colleagues (1994) reported higher rates of neuraltube defects in neonates born to women with inluenza early in pregnancy. his was possibly associated with hyperthermia. Viremia is infrequent, and transplacental passage is rare (Rasmussen, 2012). Stillbirth, preterm delivery, and irst-trimester abortion have all been reported, but usually correlate with the severity of maternal infection (Centers for Disease Control and Prevention, 2011; Fell, 2017; vleijer, 2015).


Obstentrics_Williams

Obstentrics_Williams. Inluenza may be detected in nasopharyngeal swabs using viral antigen rapid detection assays (Table 64-2). Reverse transcriptase-polymerase chain reaction (RT-PCR) is the more sensitive and specific test, although not widely available (Cohen, 2015b). In contrast, rapid influenza diagnostic tests (RIDTs) are least indicative, with sensitivities of 40 to 70 percent. Decisions to administer antiviral medications or inluenza treatment or chemoprophylaxis should be based on clinical symptoms and epidemiological actors. Specifically, the start of therapy should not be delayed pending testing results (Centers for Disease Control and Prevention, 2017 e).


Obstentrics_Williams

Obstentrics_Williams. Two classes of antiviral medications are currently available. Neuraminidase inhibitors are highly efective for the treatment of early inluenza A and B. hese include oseltamivir (Tamilu), which is taken orally for treatment and for chemoprophylaxis; zanamivir (Relenza), which is inhaled for treatment; andperamivir (Rapivab), which is administered intravenously. he adamantanes include amantadine and rimantadine, which were used for years for treatment and chemoprophylaxis of inluenza A. In 2005, inluenza A resistance to adamantine was reported to exceed 90 percent in the United States. hus, its use is not currently recommended. It is possible that these drugs may again be efective for subsequently mutated strains. Patterns of resistance are available at cdc.gov/flu.