Nancy Monson is a freelance writer and certified health coach whose work has appeared in numerous major clinical and consumer print and online publications.  

Nancy Monson

Comorbidities such as endometriosis can confound the picture in patients with adenomyosis, a condition that may lead to poor IVF outcomes. This quiz goes over the major takeaways from our November 2018 article, 

1. Most cases of adenomyosis affect women aged: 

Please click here for answer, discussion, and next question.


	Approximately 20% of cases involve women younger than 40 and 80% are aged 40 to 50. 

2. Today, the diagnosis of adenomyosis can be suspected using: 

 histopathologic examination on hysterectomy


	Histopathologic examination on hysterectomy specimen was the traditional route of diagnosis, but has been supplanted by imaging today that can make the diagnosis with 80% to 90% accuracy without the need for excisional surgery. 

3. The consensus for diagnosis of adenomyosis is when the junctional zone (subendometrial myometrium) thickness is:
	


	Greater than 12 mm is the diagnostic threshold, but the disorder can be suspected when thickness is between 8 and 12 mm.

4. Adenomyosis is comorbid with pelvic endometriosis in over half of cases.
	A.


	There is a significant association between pelvic endometriosis and adenomyosis, with estimates indicating that it occurs in 54% to 90% of cases.

5. In women undergoing in vitro fertilization, adenomyosis has a detrimental effect on clinical outcomes, reducing:


	In addition to rates of implantation, clinical pregnancies per cycle, and live births, adenomyosis also affects clinical pregnancies per embryo transfer, and ongoing pregnancy rates after IVF.

6. Proposed mechanisms of infertility in patients with adenomyosis focus on which of the following pathways?


	Adenomyosis does not appear to affect folliculogenesis or oocyte quality/function, but it does appear to affect endometrial receptivity and implantation in addition to uterotubal transport. 

7. For patients with severe adenomyosis who want to retain fertility, a large prospective study showed that __________ was most effective. 

Gonadotrophin-releasing hormone agonist (GnRH-a) treatment 

 GnRH-a treatment plus conservative surgery

Answer D. GnRH-a treatment plus conservative surgery


	Combined GnRH-a treatment and conservative surgery, such as laparoscopic cytoreductive surgery, has been shown to lower symptom relapse rates and yield a trend toward improved reproductive outcomes.

Articles

This quiz goes over the major takeaways from the November 2018 article by Anthony N. Imudia, MD, and Rachel G. Sprague, MD

Quiz - Adenomyosis and its impact on fertility

Prenatal tetanus, diphtheria, acellular pertussis (Tdap) vaccination is not associated with an increased risk of autism spectrum disorder (ASD) in offspring, according to a study published in 

In response to rising incidence of pertussis (whooping cough), the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommended in October 2012 that all pregnant women, whether previously vaccinated or not, receive the Tdap vaccine between 27 and 36 weeks of gestation to prevent pertussis in their offspring. Pertussis is a highly contagious infection caused by 

that can lead to hospitalization and death in young infants. When given during pregnancy to mothers, the vaccine is 91.4% effective in offering some immunity to infants until they reach two months of age and are due to receive their first diphtheria-tetanus-acellular pertussis vaccine.

Previously, it had been found that Tdap vaccine does not increase the risk for a variety of maternal and pediatric outcomes, including small-for-gestational-age size, preterm delivery, or low birth weight. As there has been great speculation and concern among consumers about the potential of vaccines to cause ASD and limited data on vaccines given during pregnancy and autism risk, Kaiser Permanente Southern California Department of Research & Evaluation undertook the first-ever study examining any association between the two. 

The prenatal period is “strongly implicated” in the etiology of ASD, said the authors, who conducted a retrospective cohort study of mothers who delivered babies between January 1, 2011 and December 31, 2014 at Southern California hospitals within the Kaiser Permanente system. The population was restricted to pregnant women who conceived naturally and gave birth to live singleton infants at 22 to 45 weeks of gestation. The study included 81,993 children. In the 2012 birth cohort, 26% (5,407 of 20,553) of the children had mothers who had been vaccinated, whereas 79% (16,882 of 21,433) had vaccinated mothers in 2014. Most mothers were vaccinated at 28 to 29 weeks of pregnancy. The cohort was followed for 1.2 to 6.5 years. 

Compared to unvaccinated women, vaccinated women were more likely to be:

of Asian American or Pacific Islander descent

They were also more likely to have received the influenza vaccine prenatally and to have given birth at term, defined as >37 weeks of gestation. 

The incidence of ASD in the vaccinated group was 3.78 per 1,000 person-years versus 4.05 per 1,000 person-years in the unvaccinated group (unadjusted HR=0.98, 95% CI:0.88-1.09; adjusted HR=0.85, 95% CI=0.77-0.95). Most of the children with autism were diagnosed at 2 to 4 years of age. A decline in autism rates was noted from 1.8% to 1.2% in the vaccinated group and from 2.0% to 1.5% in the unvaccinated group across the birth years studied. The general autism rate in the United States was 1.7% of children. 

The results were consistent across all birth years included in the study and among first-born children. 

The authors suggested that more studies be conducted looking at additional birth years and with longer follow-up, but confirmed that prenatal Tdap vaccination is safe and desirable to protect vulnerable newborns from potentially deadly pertussis infection.

As consumers have expressed speculation and concern about the potential of vaccines to cause ASD, a recent study examined any association between the Tdap vaccine and autism.

Tdap vaccination in pregnant women and autism risk

This month's quiz goes over the key strategies to improve diagnoses and outcomes that were discussed in the article, "

Managing obstetric emergencies: Anaphylactoid syndrome of pregnancy (aka AFE)

This month's quiz goes over the key strategies to improve diagnoses and outcomes that were discussed in the article, "Managing obstetric emergencies: Anaphylactoid syndrome of pregnancy (aka AFE)" by Steven L. Clark, MD (July 2018).

Quiz - Managing obstetric emergencies: ASP

Mother-to-child transmission of HIV in the United States can be eliminated with the help of obstetricians. This quiz goes over the key strategies to improve outcomes that were discussed in the article, "

The obstetrician’s role in management of HIV in pregnancy

" by Laura E. Riley, MD, and Carey Eppes, MD, MPh.

Mother-to-child transmission of HIV in the United States can be eliminated with the help of obstetricians. Test your knowledge and ability to care for HIV patients.

Quiz: The obstetrician’s role in management of HIV in pregnancy

An association between endometriosis and endometrial cancer has been indirectly suggested by epidemiological, biological, and molecular studies, and a new international research study published in 

Endometriosis affects 6% to 10% of reproductive-age women and 35% to 50% of infertile women. Both endometriosis and endometrial cancer are associated with higher levels of estrogen exposure, with a lessened risk related to use of oral contraceptives (OCs) and progesterone-containing hormonal therapies. They share similar symptoms (e.g., pelvic pain) and comorbid conditions (e.g., an increased risk for uterine fibroids and ovarian cancer). Both endometriosis and endometrial cancer also have a genetic component: Twin studies show endometriosis heritability of approximately 50% (51%, 95% CI = 33%-66%) and endometrial cancer heritability of 27% (95% CI = 11%-43%). 

Previously, 19 independent single-nucleotide polymorphisms (SNPs) were found to be associated with endometriosis and nine with endometrial cancer in genomewide association studies (GWAS). However, these SNPs and their genetic locations were not overlapping between the diseases. 

Epidemiological studies, which are hampered by methodological complications such as under- and misdiagnosis of endometriosis, lack of control for confounders, and exclusion criteria, have produced suggestive but conflicting results for a link between the two diseases. 

The current team of researchers from Australia, the United Kingdom, Germany, the United States, Sweden, Belgium, Norway, and Cyprus used data from three GWAS datasets for endometriosis and endometrial cancer containing 462,430 common SNPs to perform a genetic correlation analysis. They also combined the datasets into a cross-disease GWAS metanalysis to assess for SNPs contributing to both diseases.

The authors found a significant weak-to-moderate genetic overlap between endometriosis and endometrial cancer in the genetic correlation analysis, with more SNPs than could expected by chance associated in the same direction of effect. In the cross-disease metanalysis, after adjustment, they found 13 SNPs (see Table) that appeared to be involved in replication. SNP rs2475335, which is located on chromosome 9p23, was most significantly associated with both diseases (

). This SNP is housed within the protein tyrosine phosphatase receptor type D (PTPRD) gene. PTPRD deletions and mutations have been found in endometrial tumors. In addition, PTPRD exerts an effect on the STAT3 pathway, which has been identified as relevant to both endometriosis and endometrial cancer. 

The researchers summarized their findings by stating “Our genetic correlation analysis supports recent large epidemiological studies indicating an increased risk of endometrial cancer in women previously diagnosed with endometriosis, while the cross-disease meta-analysis has revealed plausible loci that could increase the risk of both diseases and which should be pursued further in functional studies.” This work, they added, could be a pathway to new diagnostic and treatment options for patients with endometriosis and endometrial cancer.

Thirteen SNPs identified in cross-disease meta-analysis

A new international research study describes a genetic basis for overlap between endometriosis and endometrial cancer.

Are there genetic similarities between endometriosis and endometrial cancer?

Endometriosis is typically a pelvic disease. However, approximately, 12% of women with endometriosis have extrapelvic disease, including involvement of the diaphragm. A recent observational 

 attempted to identify patients with this condition through retrospective chart review utilizing extended criteria. 

Diaphragmatic endometriosis, which appears to be caused by retrograde menstruation, typically does not produce symptoms. When it does, they may or may not occur in concert with menstruation, and may include pain in the chest pain, upper quadrant, and catamenial shoulder pain. Diaphragmatic endometriosis may also occur with thoracic endometriosis syndrome (TES), which includes catamenial pneumothorax or hemothorax, catamenial hemoptysis or intrathoracic endometriotic nodules. A new extended definition of TES, called thoracic/diaphragmatic endometriosis or TED, includes endometriosis-associated diaphragmatic hernia, catamenial chest pain, and endometriosis-related pleural effusion. 

Using the extended TED criteria, ob/gyns and thoracic surgeons from Clinica Santa Maria in Santiago, Chile reviewed their experience with diagnosis and treatment of TES and diaphragmatic endometriosis. 

The study included all patients with a diagnosis of diaphragmatic or thoracic endometriosis managed at the clinic between January 2010 and October 2017. Diagnosis was determined intraoperatively by surgeons and confirmed by pathology if possible. A total of five cases were identified. 

 was a 36-year-old woman with one child and a history of pelvic endometriosis who was continuing to experience pain despite use of oral contraceptives (OCs). She underwent laparoscopy by gynecologic and thoracic surgeons working as a team, with partial cystectomy, uterosacral ligament resection, and full-thickness partial diaphragmatic resection after identification of deep pelvic endometriosis and right posterior hemidiaphragm endometriosis (which required mobilization of the liver for visualization). 

was a 42-year-old nullipara who had not been able to get pregnant. She had no history or symptoms of endometriosis, but had been treated previously for catamenial pneumothorax. Video-assisted thoracoscopic surgery (VATS) was performed and revealed diaphragmatic endometriosis, which was resected with repair of the diaphragm. Endometriosis was confirmed by analysis of tissue by the pathology department. After VATS, the patient became pregnant via in vitro fertilization.

 was a 26-year-old nullipara with pelvic endometriosis. Continuous OCs were failing to suppress her recurrent pelvic pain, dysmenorrhea, and dyspareunia. She also reported chronic right shoulder pain and dyspnea that worsened during menstruation. VATS revealed diaphragmatic endometriosis. Fulguration and resection were performed; the pathology report revealed fibrosis but not endometriosis. The patient spontaneously conceived 4 months after surgery and delivered a healthy child.

 was a 35-year-old nulliparous woman with chronic pelvic pain, severe dysmenorrhea and dyspareunia, and infertility. Laparoscopy identified endometriosis deep in the pelvis, which was resected, and in the hemidiaphragm, which was not resected. She became pregnant after surgery via intrauterine insemination. 

 was a 40-year-old nullipara with a history of endometriosis and infertility. When she presented with epigastric and left flank pain, dyspnea, and nausea, she was diagnosed with a left diaphragmatic hernia and underwent VATS. The hernia was resected and the diaphragm was repaired. Pathology revealed endometriosis. 

All patients had a continuing reduction in symptoms after surgery. 

The researchers suggested that thoracic/diaphragmatic endometriosis has been underdiagnosed due to “a failure to properly examine the patient and evaluate the diaphragm during surgery.” They recommended maintaining a high level of suspicion for diaphragmatic endometriosis in all cases of pelvic endometriosis, and that all patients with cyclic thoracic symptoms in addition to pelvic symptoms be evaluated for diaphragmatic endometriosis as well as pelvic endometriosis. They also suggested having a thoracic surgeon on hand during surgery in cases where TED is suspected.

A recent study attempted to identify endometriosis patients who have extrapelvic disease through retrospective chart review utilizing extended criteria.