Coccidioidomycosis in pregnancy: Case report and literature review of associated placental lesions.

BACKGROUND: Coccidioidomycosis is an endemic fungal infection found most commonly in the Southwestern United States, Northwestern Mexico, and parts of Central and South America. Although infection is relatively uncommon during pregnancy, it is imperative to have an index of suspicion in order to diagnose and begin timely treatment to prevent dissemination and dire consequences. CASE REPORT: A 33-year-old Hispanic female was evaluated after she was involved in an automobile accident. Radiographic evaluation showed a 3.2 × 3.2 cm cavitary thick-walled lesion. A biopsy was negative for malignancy. Evaluation was positive for coccidioidomycosis by complement fixation reaction. Four months later, the patient presented 7 weeks into a pregnancy with massive hemoptysis. Bronchoscopy revealed bleeding from the right upper lobe and emergency embolization was performed. The patient had a spontaneous abortion 9 days after admission. The right upper and middle lobes of the lung were resected due to continuous bleeding. A subsequent pregnancy was un-eventful. Coccidioidomycosis titers remained negative throughout the second pregnancy. DISCUSSION: This case demonstrates the potential for severe pulmonary coccidioidomycosis and vascular strain of pregnancy-associated vascular expansion in the first trimester of pregnancy and the possibility of a favorable pregnancy outcome in subsequent pregnancies after appropriate treatment. The route of feto-maternal transmission and placental lesions in coccidioidomycosis are discussed.

Women's Health Care Teams and the Future of Obstetrics and Gynecology.

Health care delivery is in a stage of transformation and a meaningful change in provision of care must also be accompanied by changes in the educational process of health care professionals. This article lays out a roadmap to better prepare obstetrician-gynecologists (ob-gyns) to succeed in interdisciplinary women's health care teams. Just as our current educational programs emphasize the development of competent surgical skills, our future programs must encourage and support the development of communication, teamwork, and leadership skills for ob-gyns. Formal integration of these fundamentals at all levels of the health care training continuum will create an educational system designed to equip all practitioners with a basic level of knowledge and provide opportunities to acquire additional knowledge and skills as needs and interest dictate. Integral to the implementation will be the evaluation of the effects of the contributions of interprofessional education on patient, practice, and health system outcomes. Successful demonstration of value will lead to the sustainability of the educational programs through recognition by physicians, health care teams, academia, health care systems, and payers.

Obstetric vulvar lacerations and postpartum dyspareunia.

OBJECTIVE: To report the type and prevalence of obstetric lacerations in a primigravid patient population after term spontaneous vaginal delivery without episiotomy. We examined the characteristics of lacerations in patients with postpartum dyspareunia or vulvodynia. STUDY DESIGN: This was a retrospective cohort of primiparous patients who spontaneously delivered in the residents' service at a large urban hospital under the supervision of Ob/Gyn faculty. Data was extracted from medical records using discharge diagnosis codes. Postpartum medical records and diagnostic codes of all patients with lacerations and postpartum dyspareunia were reviewed. The study was IRB approved. RESULTS: A cohort of 1617 primiparous patients with spontaneous vaginal delivery met the inclusion criteria. No tears were recorded in 836 patients (51.7%), first-degree tears in 413 cases (25.5%), second-degree tears in 271 cases (16.8%), third-degree tears in 58 cases (3.6%), fourth-degree in 21 cases (1.3%), and 18 cases (1.1%) were not further classified. Only 51 patients (3.2%) with first- and second-degree lacerations had postpartum complications, and merely 6 (0.4%) had vulvar pain and 6 (0.4%) had dyspareunia. However, 4 of those patients (33.3%) required vulvoplasty for complete dyspareunia remission. CONCLUSION: Almost half of patients with spontaneous vaginal delivery without episiotomy experienced some type of vaginal laceration. A first degree was documented in >25% of cases; however, <10% of those subsequently had complaints of vulvar pain or dyspareunia.

Management of endometrial precancers.

In the United States, endometrial cancer is the most commonly diagnosed cancer of the female reproductive system. Strategies to sensitively and accurately diagnose premalignant endometrial lesions are sorely needed. We reviewed studies pertaining to the diagnostic challenges of endometrial precancers, their predictive value, and evidence to support management strategies. Currently, two diagnostic schemas are in use: the four-class 1994 World Health Organization hyperplasia system, based on morphologic features of architectural complexity and nuclear atypia and, more recently, the two-class endometrial intraepithelial neoplasia system, which is quantitative. Diagnosis should use criteria and terminology that distinguish between clinicopathologic entities that can be managed differently. In some instances, such as for women with hereditary nonpolyposis colon cancer, biomarkers may aid in diagnosis, but the clinical utility of biomarkers has yet to be determined. Total hysterectomy is curative for atypical endometrial hyperplasia or endometrial intraepithelial neoplasia, and provides a definitive standard for assessment of a concurrent carcinoma, when clinically appropriate. If hysterectomy is performed for atypical endometrial hyperplasia or endometrial intraepithelial neoplasia, then intraoperative assessment of the uterine specimen for occult carcinoma is desirable, but optional. Nonsurgical management may be appropriate for patients who wish to preserve fertility or those for whom surgery is not a viable option. Treatment with progestin therapy may provide a safe alternative to hysterectomy; however, clinical trials of hormonal therapies for atypical endometrial hyperplasia or endometrial intraepithelial neoplasia have not yet established a standard regimen. Future studies will need to determine the optimal nonsurgical management of atypical endometrial hyperplasia or endometrial intraepithelial neoplasia, standardizing agent, dose, schedule, clinical outcomes, and appropriate follow-up.