William Goh

Management of the adnexal mass in pregnancy

Purpose of review With the increased use of ultrasonography in the first trimester, up to 1% of all pregnancies are diagnosed with an adnexal mass. Yet, the management of asymptomatic adnexal masses in pregnancy continues to be controversial as management guidelines are mainly based on case–control or observational studies. The purpose of this article was to review the recent literature and provide clinical guidance on patient management. Recent findings This review will highlight the increasing sensitivity of ultrasound imaging in diagnosing the rare malignant lesion, allowing for antenatal expectant management of benign asymptomatic adnexal masses until delivery or postpartum. The recent literature also highlights the well tolerated use of laparoscopy for the antenatal removal of suspicious or symptomatic masses and that expectant management of asymptomatic masses does not increase the risk of adverse pregnancy outcomes. Summary Most adnexal masses are benign and ultrasound characteristics can help guide the assessment of asymptomatic ovarian masses. When surgical management is chosen, laparoscopy can be safely performed in pregnancy. Ovarian torsion is a complication for persistent masses in pregnancy.

Placenta accreta: diagnosis, management and the molecular biology of the morbidly adherent placenta.

Abstract Placenta accreta is now the chief cause of postpartum hemorrhage resulting in maternal and neonatal morbidity. Prenatal diagnosis decreases blood loss at delivery and intra and post-partum complications. Ultrasound is critical for diagnosis and MRI is a complementary tool when the diagnosis is uncertain. Peripartum hysterectomy has been the standard of therapy but conservative management is increasingly being used. The etiology of accreta is due to a deficiency of maternal decidua resulting in placental invasion into the uterine myometrium. The molecular basis for the development of invasive placentation is yet to be elucidated but may involve abnormal paracrine/autocrine signaling between the deficient maternal decidua and the trophoblastic tissue. The interaction of hormones such as Relaxin which is abundant in maternal decidua and insulin-like 4, an insulin-like peptide found in placental trophoblastic tissue may play role in the formation of placenta accreta.

Relaxin, Its Receptor (RXFP1), and Insulin-Like Peptide 4 Expression Through Gestation and in Placenta Accreta

This study was designed to show whether placental relaxin (RLN), its receptor (RXFP1), or insulin-like peptide 4 (INSL4) might have altered expression in patients with placenta accreta. The baseline expression of their genes through gestation (n = 34) was quantitated in the placental basal plate (BP) and villous trophoblast (TR), and compared to their expression in placenta accreta (n = 6). The proteins were also immunolocalized and quantitated in the accreta tissues. The messenger RNAs (mRNAs) of matrix metalloproteinase 9, -2, and tissue inhibitors of matrix metalloproteinase (TIMP)-1 were also measured. Results demonstrated that the BP and TR expressed low levels of RLN/RXFP1 and INSL4 through gestation. In accreta, increased RLN gene and protein in BP were associated with antepartum bleeding whereas INSL4 expression decreased throughout the TR. There were no changes in mRNAs for MMPs, but TIMP-1 was increased only in the invasive TR.

Persistent ovarian masses and pregnancy outcomes

Abstract Objective: To determine if persistent ovarian masses in pregnancy are associated with increased adverse outcomes. Methods: This is a retrospective cohort of 126 pregnant women with a persistent ovarian mass measuring 5 cm or greater who delivered at two university hospitals between 2001 and 2009. Maternal outcomes included gestational age (GA) at diagnosis, delivery and surgery as well as miscarriage, preterm birth (PTB), ovarian torsion and hospital admission for pain. Neonatal outcomes included birth weight, respiratory distress syndrome (RDS), intra-ventricular hemorrhage (IVH), death and sepsis. Results: A total of 1225 ovarian masses were identified (4.9%) in 24 868 patients. A persistent ovarian mass was found in 0.7%. Average GA at diagnosis was 17.8 weeks. Miscarriage rate was 3.3%. Average GA at delivery was 37.9 weeks. Of the patients, 8.5% had ovarian torsion, 10.3% had admission for pain and 9.3% had PTBs. The mean cesarean delivery rate was 46.3%. The average neonatal weight was 3273 g. There was one neonatal death in this cohort. The rate of RDS was 2.8%, IVH 0.9% and neonatal sepsis 1.9%. The most common surgical pathologic diagnosis was dermoids (37.6%). No overt malignancies were seen. Conclusion: A persistent ovarian mass in pregnancy does not confer an increased risk of adverse pregnancy outcomes.

Chocolate and acne: How valid was the original study?

Recent reviews on “The role of diet in acne: facts and controversies”1 and “Nutrition and acne”2 were interesting but may not have adequately challenged the dogma that chocolate does not exacerbate acne vulgaris. Our Medline search, using the key words “acne and chocolate,” showed that only 3 studies examined the role of chocolate consumption and acne. One clinical trial had 8 patients,3 another did not specify sample size,4 and the third study by Fulton, Plewig, and Kligman (1969) supported the oft-repeated assertion that eating chocolate has no effect on acne.5 While some reviewers acknowledge that few studies exist, they describe Fultons study among them as “a methodologically stronger trial.”1 As a result, Fultons (1969) finding that chocolate consumption does not exacerbate acne has continued to remain virtually unchallenged for decades and continues to be cited even in this most recent review. For the first time in over forty years, we thoroughly examined this 1969 classic paper entitled, “Effect of Chocolate on Acne Vulgaris,” published in the Journal of the American Medical Association. It was a crossover study with 65 participants consuming chocolate or placebo bars for four weeks (3-week wash-out period). A 30% decrease or increase in weekly lesion count resulted in “mild to moderate” acne being assessed as improved or worsened, respectively. The authors concluded that chocolate had no effect on acne severity; however, an analysis of this frequently cited paper reveals the following flaws: