Best Practice & Research Clinical Obstetrics & Gynaecology RSS feed: Current Issue. In practical paperback format, each 200 page topic-based issue of Best Practice & Research Clinical Obstetrics & Gynaecology will provide a comprehensive review of current clinical practice and thinking within the specialties of obstetrics and gynaecology. All chapters are commissioned and written by an international team of practising clinicians with the Guest Editors for each issue drawn from a pool of renowned experts and opinion leaders. Reference is made to: • the latest original research • Cochrane Reviews • audits and confidential enquiries • national and international conferences • national and international guidelines • personal communications All chapters take the form of practical, evidence-based reviews that seek to address key clinical issues of diagnosis, treatment and patient management. Each issue follows a problem-orientated approach that focuses on the key questions to be addressed, clearly defining what is known and not known. Management will be described in practical terms so that it can be applied to the individual patient. Boxed and bulleted Learning Objectives and Practice Points are features within each chapter and will highlight the core and essential knowledge that will help the physician to provide the best care to their patients. The series' objective is to provide a continuous update for the busy clinician and researcher. 2011 Topics Volume 25 Issues 1-6 1. Diabetes in pregnancy J. Modder 2. Gynaecological surgery via vaginal route S. Sheth and C. Zimmerman 3. Placental bed and maternal-fetal disorders I. Brosens 4. Hypertensive disease in pregnancy P. von Dadelszen and L. Magee 5. Colposcopy and cervical pathology M. Shafi and S. Nazeer 6. Sarcoma of the female genital tract H. Ngan 2012 Topics Volume 26 Issues 1-6 1. Haematological disorders in obstetrics and gynaecology J. Hassan 2. Screening for gynaecological cancers L. Denny 3. Microbicides in obstetrics and gynaecology J. Moodley 4. Fertility preservation in gynaecological cancer A. Ilancheran and J. Low 5. Advances in fetal genetic diagnosis and therapy A. Biswas and M. Choolani 6. Investigation and management of the infertile couple P.C. Ho and E. Ng http://www.bestpracticeobgyn.com/?rss=yesElsevier Inc.en © 2012 Published by Elsevier Inc. All rights reserved. Best Practice & Research Clinical Obstetrics & Gynaecology1521-6934263June 2012 © 2012 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.bestpracticeobgyn.com/article/PIIS1521693412000570/abstract?rss=yesAims and Scope/Editorial Board10.1016/S1521-6934(12)00057-0Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-06-01Best Practice & Research Clinical Obstetrics & Gynaecology2012-06-01263S1521-6934(12)X0003-8iiiiiihttp://www.bestpracticeobgyn.com/article/PIIS1521693412000284/abstract?rss=yesWomen in Western societies are progressively delaying child bearing until their mid- to late- thirties, thereby increasing the possibility of developing a gynaecological malignancy before completing their family. A review of 2100 women with cervical, endometrial or ovarian cancer treated at the Gynaecological Cancer Centre of the Royal Hospital for Women in Sydney between 1994 and 2003 revealed that about 31% of the women with cervical cancer, 18% with ovarian cancer, and 3% with endometrial cancer were under the age of 40 years, and therefore potential candidates for fertility-sparing surgery.ForewordNeville F. Hacker10.1016/j.bpobgyn.2012.01.003Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-24Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-24263S1521-6934(12)X0003-8291292http://www.bestpracticeobgyn.com/article/PIIS1521693412000168/abstract?rss=yesStandard treatment for invasive cervical cancer involves either radical surgery or radiotherapy. Childbearing is therefore impossible after either of these treatments. A fertility-sparing option, however, by radical trachelectomy has been shown to be effective, provided that strict criteria for selection are followed. Fertility rates are high, whereas recurrence is low, indicating that a more conservative approach to dealing with early small cervical tumours is feasible. Careful preoperative assessment by magnetic resonance imaging scans allows accurate measurement of the tumour with precise definition to plan surgery. This will ensure an adequate clear margin by wide excision of the tumour excising the cervix by radical vaginal trachelectomy with surrounding para-cervical and upper vaginal tissues. An isthmic cerclage is inserted to provide competence at the level of the internal orifice. A primary vagino-isthmic anastomosis is conducted to restore continuity of the lower genital tract. Subsequent pregnancies require careful monitoring in view of the high risk of spontaneous premature rupture of the membranes. Delivery by classical caesarean section is necessary at the onset of labour or electively before term. Over 1100 such procedures have been carried out vaginally or abdominally, resulting in 240 live births. Radical vaginal trachelectomy with a laparoscopic pelvic-node dissection offers the least morbid and invasive route for surgery, provided that adequate surgical skills have been obtained.Cervical cancerJohn H. Shepherd10.1016/j.bpobgyn.2011.12.004Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-20Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-20263S1521-6934(12)X0003-8293309http://www.bestpracticeobgyn.com/article/PIIS1521693412000247/abstract?rss=yesEndometrial carcinoma is the most common gynaecological malignancy in the Western world. The standard management of endometrial carcinoma is total hysterectomy and bilateral salpingo-oophorectomy with or without pelvic and para-aortic lymph-node dissection. Increasingly, endometrial cancer is being diagnosed in younger women in whom preserving fertility may be an important consideration when deciding optimal management. Conservative management of endometrial carcinoma may be a therapeutic option in carefully selected women with well-differentiated endometrial cancer in the absence of any myometrial invasion or adnexal disease seen on imaging. The biggest concern with conservative management of endometrial carcinoma is disease progression while on treatment or after initial response to medical treatment. Women opting for conservative management should be aware that hormonal therapy is not the standard form of management. Potential adverse outcomes should be taken into consideration.Endometrial cancerVivek Arora, Michael A. Quinn10.1016/j.bpobgyn.2011.12.007Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-24Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-24263S1521-6934(12)X0003-8311324http://www.bestpracticeobgyn.com/article/PIIS1521693412000235/abstract?rss=yesBorderline ovarian tumours account for 10–20% of all epithelial ovarian cancer. Historically, standard primary surgery has included borderline ovarian tumours, omentectomy, peritoneal washing and multiple biopsies. As one-third of borderline ovarian tumours are diagnosed in women under the age of 40 years, fertility-sparing treatment has been more frequently used in the past 10 years. Fertility drugs are well tolerated in women with infertility after fertility-sparing surgery. Careful selection of candidates is necessary. Laparoscopic techniques can be used, but should be reserved for oncologic surgeons. This conservative treatment increases the rate of recurrence, albeit with no effect on survival. The pregnancy rate is nearly 50%, and most are achieved spontaneously. These women should be closely followed up. The question is whether this is acceptable from a gynaecologic oncologic point of view. For this reason, we will discuss recently published studies and gynaecologic oncologic concerns about the mode of fertility-sparing surgery and its consequences.Borderline ovarian tumoursClaes Göran Tropé, Janne Kaern, Ben Davidson10.1016/j.bpobgyn.2011.12.006Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-24Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-24263S1521-6934(12)X0003-8325336http://www.bestpracticeobgyn.com/article/PIIS152169341200017X/abstract?rss=yesThe incidence of epithelial ovarian cancer in women aged 40 years and younger is 3–17%. The management of these women is challenging and requires balancing the need to treat epithelial ovarian cancer adequately and preserving reproductive potential. Fertility-sparing surgery, especially for early stage epithelial ovarian cancer, seems to be associated with equivalent clinical and cancer outcomes while preserving reproductive potential. A complete staging and cytoreductive procedure retaining the uterus, and at least one grossly normal ovary, is the minimum recommended procedure. Adjuvant chemotherapy with a platinum-taxane combination is recommended as clinically indicated, and is associated with better cancer and survival outcomes. Adjuvant treatment does not seem to increase the risk of congenital anomalies in subsequent pregnancies. Targeted therapy and ovarian cryopreservation are largely experimental and cannot be recommended as part of the clinical standard of care.Epithelial ovarian cancerJoseph S. Ng, Jeffrey J.H. Low, A. Ilancheran10.1016/j.bpobgyn.2011.12.005Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-20Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-20263S1521-6934(12)X0003-8337345http://www.bestpracticeobgyn.com/article/PIIS1521693412000272/abstract?rss=yesMalignant ovarian germ-cell tumours account for about 5% of all ovarian malignancies and typically present in the teenage years. They are almost always unilateral and are exquisitely chemosensitive. As such, the surgical approach in young women with such tumours confined to a single ovary should aim to preserve fertility. In early disease, a unilateral salpingo-oophorectomy with careful surgical staging is of great importance in selecting appropriate adjuvant therapy. In advanced disease, the role of aggressive cytoreducation is not well defined, and removal of both ovaries does not confer improvement in outcome. Bleomycin, etoposide and cisplatin combination chemotherapy is regarded as the gold standard for adjuvant therapy. Studies evaluating ovarian and reproductive capacity after conservative surgery and chemotherapy for malignant ovarian germ-cell tumours have consistently demonstrated excellent prognosis, with the return of normal menstrual function and fertility rates in these women with no increase in the risk of teratogenicity.Malignant ovarian germ-cell tumoursJeffrey J.H. Low, Arunachalam Ilancheran, Joseph S. Ng10.1016/j.bpobgyn.2012.01.002Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-24Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-24263S1521-6934(12)X0003-8347355http://www.bestpracticeobgyn.com/article/PIIS1521693412000156/abstract?rss=yesMost women with gestational trophoblastic disease are of reproductive age. Because the disease is readily treatable with favourable prognosis, fertility becomes an important issue. Hydatidiform mole is a relatively benign disease, and most women do not require chemotherapy after uterine evacuation. A single uterine evacuation has no significant effect on future fertility, and pregnancy outcomes in subsequent pregnancies are comparable to that of the general population, despite a slight increased risk of developing molar pregnancy again. If women develop persistent trophoblastic disease, single or combined chemotherapy will be needed. Although ovarian dysfunction after chemotherapy is a theoretical risk, a term live birth rate of higher than 70% has been reported without increased risk of fetal abnormalities. Successful pregnancies have also been reported after choriocarcinoma. Only a few case reports have been published on fertility-sparing treatment in placental-site trophoblastic tumour, and the successful rate is about 67%. Women are advised to refrain from pregnancy for at least 6 months after a molar pregnancy, and at least 12 months after a gestational trophoblastic neoplasia. Most of the contraceptive methods do not have an adverse effect on the return of fertility. Finally, at least one-half of these women suffer from some form of psychological or sexual problems. Careful counselling and involvement of a multi-disciplinary team are mandated.Gestational trophoblastic diseaseK.Y. Tse, Hextan Y.S. Ngan10.1016/j.bpobgyn.2011.11.009Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-24Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-24263S1521-6934(12)X0003-8357370http://www.bestpracticeobgyn.com/article/PIIS1521693412000296/abstract?rss=yesCancer in pregnancy, fortunately, is uncommon. This is even more so for gynaecological cancer. Fertility preservation in gynaecological cancer is already a difficult issue, as the common gynaecological cancers affect organs intimately associated with conception and delivery. The presence of a viable pregnancy with gynaecological cancer presents tremendous challenges to the clinician, especially if the woman wants to conserve both her pregnancy and fertility. In this chapter, we address issues involved in such circumstances and suggest management decisions.Gynaecological cancer in pregnancyArunachalam Ilancheran, Jeffrey Low, Joseph S. Ng10.1016/j.bpobgyn.2011.12.009Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-25Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-25263S1521-6934(12)X0003-8371377http://www.bestpracticeobgyn.com/article/PIIS1521693412000144/abstract?rss=yesThe overall increase in cancer prevalence and the significant increase in long-term survival have generated worldwide interest in preserving fertility in young women exposed to gonadotoxic chemo- and radiotherapy. Infertility represents one of the main long-term consequences of combination chemotherapy given for lymphoma, leukaemia and other malignancies in young women. The gonadotoxic effect of various chemotherapeutic agents is diverse, may involve a variety of pathophysiologic mechanisms, and is not unequivocally understood. Proliferating cells, such as in tissues with high turnover (i.e. bone marrow, gastrointestinal tract and growing ovarian follicles) are more vulnerable to the toxic effect of alkylating agents. These agents may also be cytotoxic to cells at rest, as they are not cell-cycle specific. Alkylating agents, the most gonadotoxic chemotherapeutic medications, cause dose-dependent, direct destruction of oocytes and follicular depletion, and may bring about cortical fibrosis and ovarian blood-vessel damage. The reported rate of premature ovarian failure after various diseases and chemotherapeutic protocols differ enormously, and depend mainly on the chemotherapeutic protocol used and age range of the woman. Several options have been proposed for preserving female fertility, despite gonadotoxic chemotherapy: ovarian transposition, cryopreservation of embryos, unfertilised metaphase-II oocytes and ovarian tissue, and administration of gonadotropin-releasing hormone agonistic analogs in an attempt to decrease the gonadotoxic effects of chemotherapy by simulating a prepubertal hormonal milieu. None of these methods is ideal and none guarantees future fertility in all survivors; therefore, a combination of methods is recommended for maximising women’s chances of future fertility.Chemotherapy and fertilityZeev Blumenfeld10.1016/j.bpobgyn.2011.11.008Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-20Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-20263S1521-6934(12)X0003-8379390http://www.bestpracticeobgyn.com/article/PIIS1521693412000260/abstract?rss=yesOptions for preserving fertility in women include well-established methods such as fertility-sparing surgery, shielding to reduce radiation damage to reproductive organs, and emergency in-vitro fertilisation after controlled ovarian stimulation, with the aim of freezing embryos. The practice of transfering frozen or thawed embryos has been in place for over 25 years, and today is a routine clinical treatment in fertility clinics. Oocytes may also be frozen unfertilised for later thawing and fertilisation by intracytoplasmic sperm injection in vitro. In recent years, oocyte cryopreservation methods have further developed, reaching promising standards. More than 1000 children are born worldwide after fertilisation of frozen and thawed oocytes. Nevertheless, this technique is still considered experimental. In this chapter, we focus on options for fertility preservation still in development that can be offered to women. These include freezing of oocytes and ovarian cortex and the transplantation of ovarian tissue.Recent advances in oocyte and ovarian tissue cryopreservation and transplantationKenny A. Rodriguez-Wallberg, Kutluk Oktay10.1016/j.bpobgyn.2012.01.001Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-01-24Best Practice & Research Clinical Obstetrics & Gynaecology2012-01-24263S1521-6934(12)X0003-8391405http://www.bestpracticeobgyn.com/article/PIIS1521693412000466/abstract?rss=yesAs a result of the trend toward late childbearing, fertility preservation has become a major issue in young women with gynaecological cancer. Fertility-sparing treatments have been successfully attempted in selected cases of cervical, endometrial and ovarian cancer, and gynaecologists should be familiar with fertility-preserving options in women with gynaecological malignancies. Options to preserve fertility include shielding to reduce radiation damage, fertility preservation when undergoing cytotoxic treatments, cryopreservation, assisted reproduction techniques, and fertility-sparing surgical procedures. Radical vaginal trachelectomy with laparoscopic lymphadenectomy is an oncologically safe, fertility-preserving procedure. It has been accepted worldwide as a surgical treatment of small early stage cervical cancers. Selected cases of early stage ovarian cancer can be treated by unilateral salpingo-ophorectomy and surgical staging. Hysteroscopic resection and progesterone treatment are used in young women who have endometrial cancer to maintain fertility and avoid surgical menopause. Appropriate patient selection, and careful oncologic, psychologic, reproductive and obstetric counselling, is mandatory.Fertility-preserving surgical procedures, techniquesAlejandra Martinez, Mathieu Poilblanc, Gwenael Ferron, Mariolene De Cuypere, Eva Jouve, Denis Querleu10.1016/j.bpobgyn.2012.01.009Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-02-13Best Practice & Research Clinical Obstetrics & Gynaecology2012-02-13263S1521-6934(12)X0003-8407424http://www.bestpracticeobgyn.com/article/PIIS1521693412000636/abstract?rss=yes In the management of a woman of reproductive age with a diagnosis of epithelial ovarian cancer, balancing concerns of improving cancer outcomes and preserving the patient's reproductive potential, prime ethical considerations underpinning the counselling and management would include:Fertility Preservation in Gynaecological Cancer – Multiple Choice Questions for Vol. 26, No. 310.1016/j.bpobgyn.2012.03.001Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-04-03Best Practice & Research Clinical Obstetrics & Gynaecology2012-04-03263S1521-6934(12)X0003-8FrontmatterA1A6http://www.bestpracticeobgyn.com/article/PIIS152169341200034X/abstract?rss=yes a) Fb) Fc) Fd) Fe) TScreening for Gynaecological Cancers – Answers to Multiple Choice Questions for Vol. 26, No. 210.1016/j.bpobgyn.2012.01.008Best Practice & Research Clinical Obstetrics & Gynaecology 26, 3 (2012)2012-02-13Best Practice & Research Clinical Obstetrics & Gynaecology2012-02-13263S1521-6934(12)X0003-8FrontmatterA7A12