Jeffrey F. Peipert

Adnexal masses in pregnancy: Surgery compared with observation

OBJECTIVE: To estimate whether the delay of surgery impacts the risk of adverse maternal and fetal outcomes in patients diagnosed with an adnexal mass during pregnancy. METHODS: A review was performed of pregnant patients diagnosed with an adnexal mass 5 cm or greater in diameter. Data collected included age, gravity/parity, gestational age at diagnosis, and presenting symptoms. Ultrasound examinations were evaluated for mass size and complexity. Pregnancy outcome, complications, and surgical pathology were reviewed. RESULTS: Between 1990 and 2003, 127,177 deliveries were performed at our institution. An adnexal mass 5 cm in diameter or greater was diagnosed in 63 (0.05%) patients. Pathologic diagnosis was available for 59 (94%) patients. The remaining 4 patients were lost to follow-up and excluded from the analysis. Antepartum surgery was performed in 17 patients (29%): 13 because of ultrasound findings that suggested malignancy and 4 secondary to ovarian torsion. The remaining patients were observed, with surgery performed in the postpartum period or at time of cesarean delivery. The majority of masses were dermoid cysts (42%). Four patients were diagnosed with ovarian cancer (6.8% of masses, 0.0032% of deliveries), and one patient (1.7%) had a tumor of low malignant potential. Antepartum surgery due to ultrasound findings that caused concern was performed on all 5 women diagnosed with a malignancy or borderline tumor, compared with 12 (22%) of the patients with benign tumors (P < .01). CONCLUSION: In select cases, close observation is a reasonable alternative to antepartum surgery in patients with an adnexal mass during pregnancy. LEVEL OF EVIDENCE: II-3

Prevalence of Lower Genital Tract Infections Among Human Immunodeficiency Virus (HIV)—Seropositive and High-Risk HIV-Seronegative Women

This study was undertaken to assess whether the prevalence of lower genital tract infections among human immunodeficiency virus (HIV)-seropositive women was higher than among high-risk HIV-seronegative women at their baseline visit for the HIV Epidemiology Research Study. Results were available for 851 HIV-seropositive and 434 HIV-seronegative women. Human papilloma virus (HPV) infection was more prevalent among HIV-seropositive women (64% vs. 28%). Bacterial vaginosis was common (35% vs. 33%), followed by trichomoniasis (12% vs. 10%), syphilis (8% vs. 6%), Chlamydia trachomatis infection (4% vs. 5%), candidal vaginitis (3% vs. 2%), and Neisseria gonorrhoeae infection (0.8% vs. 0.3%). Alcohol use (odds ratio [OR], 1.8; 95% confidence interval [CI], 1. 3-2.4) and smoking (OR, 1.8; 95% CI, 1.3-2.5) were associated with bacterial vaginosis. Bacterial vaginosis (OR, 2.3; 95% CI, 1.5-3.4), trichomoniasis (OR, 2.3; 95% CI, 1.1-4.7), and syphilis (OR, 3.1; 95% CI, 1.3-7.4) were found to be more prevalent among black women. Our study showed no statistically significant difference in the prevalence of lower genital tract infections except for HPV between HIV-infected and demographically and behaviorally similar HIV-uninfected high-risk women.

A Prevalence Survey of Abuse and Screening for Abuse in Urgent Care Patients

Objective: To determine the prevalence of physical and sexual abuse in pregnant and nonpregnant women in an urgent care obstetrics and gynecology triage unit and the frequency with which these patients recall being screened by their health care provider. Methods: We carried out a structured survey of 255 pregnant and 142 nonpregnant women presenting to an urban New England urgent care obstetrics and gynecology unit between February 1995 and September 1995. Patients in advanced stages of labor or unable to participate due to a language barrier were excluded. The survey consisted of 22 questions, seven of which were modified from the abuse assessment screen. Results: Among 397 participants with complete data, we found that 184 (46%) reported a history of physical or sexual abuse in the past, and 38 (10%) reported recent abuse. Young age and insurance status (Medicaid or uninsured) were associated significantly with recent abuse after we controlled for race, education, and pregnancy status. Only 18% of women recalled being asked about abuse by a health care provider. Young women were more likely to report being asked about abuse. Among women reporting recent abuse, white women were significantly more likely to report being asked about abuse than nonwhite women (P = .02). The majority of women reporting a history of abuse did not recall being screened for violence by a health care provider. Conclusion: Women of all ages, income, and ethnic backgrounds reported a history of domestic violence or sexual assault. Providers should incorporate routine screening into the assessment of all women.

Laboratory evaluation of acute upper genital tract infection

Objective To evaluate the diagnostic test charactersitic of common tests used to diagnose upper genital tract infection. Methods Subjects included women who either met the Centers for Disease Control and Preventions minimal criteria for acute pelvic inflammatory disease or who had other signs of upper genital tract infection (ie, atypical pelvic pain, abnormal uterine bleeding, or cervicitis). The subjects were evaluated with a baseline interview, comprehensive laboratory testing, and either an endometrial biopsy of laparoscopy for definitive diagnosis or upper genital tract infection. Patients were considered positive for upper genital tract infection if they had any of the following findings: 1) histologic evidence of acute endometritis or salpingitis, 2) laparoscopic visualization of purulent exudate in the pelvis without another source, or 3) positive testing for Neisseria gonorrhoeae or Chlamydia trachomatis from the endometrium, fallopian tubes, or pelvis. Results One hundred twenty women with adequate endometrial samples were evaluated between August 1993 and September 1995. The median age of the study population was 24 years; 38% were white, 52% were smokers, 81% were insured by medicaid or were uninsured, and 67% were single. Sensitivities for elevated white blood cell count (WBC), erythrocyte sedimentation rate, C-reactive protein, and increased vaginal white blood cells are 57, 70, 71 and 78%, respectively. If any one test is abnormal, the sensitivity is 100% and specificity is 18%. If all four tests are abnormal, sensitivity, is 29% and specificity is 95%. Conclusion Testing for incresaed vaginal white blood cells was found to be the most sensitive laboratory indicator for upper genital tract infection, whereas serum WBC was the most specific. NO one diagnostic laboratory test is pathognomonic for upper genital tract infection. Combinations of positive tests can improve diagnostic specificity and positive predictive value, but with a diminution of sensitivity and negative predictive value. Combinations of negative tests can reliably exclude upper genital tract infection.

Perceptions of contraceptive effectiveness and health effects of oral contraception

The hypothesis that misperceptions about the effectiveness of contraceptive methods and the risks and benefits of oral contraceptive (OC) use are widespread in the US, even among the most educated population groups, was investigated in 147 women presenting to the Brown University (Providence, Rhode Island) health service and 189 students solicited by female volunteers on the campus. 90% of respondents correctly estimated the effectiveness of OCs in preventing pregnancy, but 32-34% inflated the pregnancy rates associated with subdermal implants and Depo-Provera. 60% overestimated the failure rate of the IUD. On the other hand, a majority underestimated the failure rates of barrier methods and spermicides. 41% believed OCs increase the risk of breast cancer and 33% thought the pill increases cervical cancer risk. 66% knew that OCs reduce dysmenorrhea and 50% were aware the pill decreases menstrual bleeding. However, the majority were unaware OCs reduce the risk of benign breast disease (95%), ectopic pregnancy (91%), pelvic inflammatory disease (90%), and anemia (89%). 81% were unaware of the protective effects of OCs against uterine cancer and 77% did not know they have a protective effect against ovarian cancer. In general, OC users were more aware of the health benefits of OCs than condom users. Finally, respondents were asked to rate their satisfaction with their current birth control method on a scale of 1-12. Mean satisfaction scores were significantly higher among OC users (10.3) than condom users (7.1). These findings indicate that, even among highly educated US women, misperceptions persist about the reliability of birth control, the risks of pregnancy, and the health effects of OCs.

Predictors of chronic pelvic pain in an urban population of women with symptoms and signs of pelvic inflammatory disease.

Objective: The objective of this study was to assess the risk profile for chronic pelvic pain (CPP) after pelvic inflammatory disease (PID). Study: Multivariate logistic regression was used to assess risk factors for CPP in a longitudinal study of 780 predominately black, urban women with clinically suspected PID: complaints of acute pain (<30 days); a clinical finding of pelvic tenderness; and leukorrhea, mucopurulent cervicitis, or untreated gonococcal or chlamydial cervicitis. CPP was defined as pain reported at ≥2 consecutive interviews conducted every 3 to 4 months for 2 to 5 years. Results: Nonblack race (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.31–3.58), being married (OR, 2.06; 95% CI, 1.02–4.18), a low SF-36 mental health composite score (OR, 2.71; 95% CI, 1.69–4.34), ≥2 prior PID episodes (OR, 2.84; 95% CI, 1.07–7.54), and smoking (OR, 1.65; 95% CI, 1.01–2.71) independently predicted CPP. Histologic endometritis or evidence of endometrial Neisseria gonorrhoeae or Chlamydia trachomatis infection was negatively associated with CPP (OR, 0.69; 95% CI, 0.44–1.10). Conclusions: A range of demographic, clinical, historical, and behavioral factors predict CPP after PID.

Association of lower genital tract inflammation with objective evidence of endometritis.

The purpose of this report is to evaluate the association between lower genital tract inflammation and objectively diagnosed endometritis. We analyzed the first 157 patients enrolled in the PEACH study, a multicenter randomized clinical trial designed to compare the effectiveness of outpatient and inpatient therapy for PID. Women less than 38 years of age, who presented with a history of pelvic discomfort for 30 days or less and who were found to have pelvic organ tenderness (uterine or adnexal tenderness) on bimanual examination, were initially invited to participate. After recruitment of the first 58 patients (group 1) we added the presence of leukorrhea, mucopurulent cervicitis, or untreated positive test for N. gonorrhoeae or C. trachomatis to the inclusion criteria (group 2, N = 99). We compared rates of endometritis in the two groups and calculated the sensitivity, specificity, and predicted values of the presence of white blood cells in the vaginal wet preparation. The rate of upper genital tract infection in group 1 was 46.5% (27/58) compared to 49.5% (49/99) in group 2. Microbiologic evidence of either N. gonorrhoeae or C. trachomatis increased from 22.4% in group 1 to 38.3% in group 2. The presence of vaginal white blood cells or mucopus has a high sensitivity (88.9%), but a low specificity (19.4%) for the diagnosis of upper genital-tract infection. Assessment of the lower genital tract for evidence of infection or inflammation is a valuable component of the diagnostic evaluation of pelvic inflammatory disease. The presence of either mucopus or vaginal white blood cells is a highly sensitive test for endometritis in patients with pelvic pain and tenderness.

Systematic reviews of medical evidence : The use of meta-analysis in obstetrics and gynecology

Objective To review the technique of meta-analysis and its uses and limitations in obstetrics and gynecology. Data Sources We reviewed four major journals in obstetrics and gynecology (American Journal of Obstetrics and Gynecology, Fertility and Sterility, Journal of Reproductive Medicine, and Obstetrics & Gynecology). Methods of Study Selection Journals were reviewed to determine frequency of meta-analysis as a method of systematic review in obstetrics and gynecology. We also summarized objectives and scientific guidelines for performing a meta-analysis. Tabulation, Integration, and Results Meta-analysis is used with increased frequency in obstetrics and gynecology as a way of systematically reviewing medical evidence. This technique is an attempt to improve on traditional methods of narrative review by an expert and as a framework for evidence-based medicine and developing practice guidelines. By combining data from replicate studies, a metaanalysis can increase statistical power, more precisely estimate the typical effect size of treatment or risk factor, and attempt to resolve controversies in the medical literature. Meta-analysis is a retrospective look at data already collected and is therefore subject to the biases of all retrospective studies. Conclusions The technique of meta-analysis requires all the scientific rigor of a randomized clinical trial with careful attention to study design, including a formal protocol for literature search strategies, quality assessment of candidate studies, specific inclusion and exclusion criteria, issues of sampling and publication bias, statistical tests of homogeneity, and sensitivity analysis.

Tubal Torsion Appearing as Acute Pelvic Inflammatory Disease

Torsion of the fallopian tube is an uncommon event with variable features, and may occur in the absence of adnexal disease. A woman had signs, symptoms, and ultrasound findings consistent with acute pelvic inflammatory disease. Laparoscopy established the definitive diagnosis of tubal torsion.

Identification and recruitment of low-income pregnant smokers: Who are we missing?

Extensive research has demonstrated the health consequences of smoking during pregnancy for both the mother and child. The majority of women, however, continue to smoke throughout the pregnancy and, of those who do quit, the majority return to smoking during the pregnancy or shortly after delivering the child. To best address this important public health problem, three critical goals must be accomplished: (1) development of effective interventions to help women quit smoking during pregnancy; (2) development of effective interventions to help women stay smoke-free during and after pregnancy; and (3) identification of effective methods of reaching women who smoke during pregnancy. Recruitment is the first window of opportunity to maximize our public health impact with pregnant women. Effective recruitment of women across all stages of change is needed, including both preaction stages and action stages. The current article examines the smoking habits of a large sample of low-income pregnant women. It compares those who enrolled in an intervention trial with those who did not enroll on a number of sociodemographic and individual characteristics, smoking patterns, and stage of change. The participants included 2280 pregnant women. Significant differences were found between enrollment groups on a number of variables, including stage of change [chi(2)(4)=54.74, P<.001], gestational age [t(955)=11.93, P<.001], and multiple smoking pattern variables (P<.001). In addition, a trend was found for ethnicity [chi(2)(5)=11.15, P<.05]. The findings of this study may help guide the development of enhanced recruitment strategies to expand our reach and thus our impact in this special population of smokers.