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Background: Aggressive angiomyxoma (AA) is a rare, locally aggressive mesenchymal neoplasm that commonly involves the vulvoperineal region of females in reproductive age [1]. AA commonly presents as a painless, gelatinous soft mass of varying size [1]. It carries a high risk of local recurrence and can rarely metastasize [1]. Aggressive angiomyxoma is often misdiagnosed because it is such a rare tumor, therefore it should always be included in the differential diagnosis of vulvar masses. The rate of misdiagnosis varies from about 70-100% [2]. It must also be distinguished from a variety of other more common benign and malignant myxoid tumors. Along with this, it should also be differentiated from Bartholin cysts, Gartner duct cyst and from a vulval lipoma [3]. The differential diagnosis should include neurofibromas, desmoids tumors, leiomyomas, sarcomas and levator hernia [4,5]. The treatment of choice for aggressive angiomyxoma is surgical excision with wide margins to help prevent local recurrences [6]. A perineal surgical approach is often most successful. The tumor can recur at any time, therefore close monitoring of the patient is necessary following surgery. Case: We present a case of aggressive angiomyxoma of the vulva in a 20-year-oldcelibate female. The patient underwent wide local excision of the tumor with clear margins. Conclusion: Aggressive angiomyxoma (AA) is a mesenchymal tumor that most commonly occurs in women between the ages of 31-35 years old [3]. The tumor usually occurs in either the perineal or pelvic region and typically presents as a slow growing, painless mass [7]. AA is considered to be an aggressive tumor because it has a high risk of infiltration and local recurrence. However, it rarely metastasizes so it has an overall good prognosis [8]. This case highlights the need to consider angiomyxoma in the differential diagnosis for tumors of unknown cause in the vulvar region [7]. Even though it is a rare diagnosis, it must be identified in order to properly treat it and prevent invasion of local structures. Histopathology is the key to correctly diagnosing this mass. Magnetic resonance imaging (MRI) can help provide additional information about the size and extent of the tumor as well. Surgical excision of the tumor with wide margins to prevent local recurrence is the treatment of choice [6]. Alternative treatments such as GnRH agonists can aid in treatment as well by decreasing the size of the tumor prior to surgery. Since the local recurrence rate is about 30-72%, close monitoring after surgery is extremely important.

Underserved women face many barriers in their attempt to access postpartum tubal ligation as a means of contraception. The Federal policy regarding Medicaid sterilization funding hinders these women from exercising the same degree of reproductive healthcare autonomy as their more socio-economically advantaged counterparts. The two main barriers are 1) The Medicaid form must be signed 30-180 days prior to the procedure and brought to the hospital on the procedure day and 2) The reading level and design of the consent form is not appropriate for the patient population. In addition to the consent form that needs to be signed and verified before the procedure, other barriers include the age of the woman, in which some hospitals restrict sterilization procedures to woman who are more than 30 years of age, even though Medicaid funds sterilization for woman over 21 years of age. Additional restrictions arise when obstetric care is provided by Catholic affiliated hospitals where sterilization is not permitted, and any health care institution reporting a shortage of operating room facilities or resources. We suggest there is urgent need to revise Federal sterilization regulations in support of clinical and legal practice that adheres to ethical standards of medical practice.

Background: The literature is replete with reports describing the effect of diabetes on pregnancy outcomes, particularly the risk of stillbirth. The goal of this review is to explore the relationship between maternal diabetes and fetal demise. Aim: To review the risk of stillbirths in pregnancies complicated by Type 1, Type 2, and gestational Diabetes Mellitus. Discussion: Type 1 diabetes mellitus (T1D), Type 2 diabetes mellitus (T2D), and gestational Diabetes Mellitus (GDM) identified during pregnancy have been independently associated with an increased risk of stillbirth compared to pregnancies not affected by these conditions. Published guidelines for prevention and management of GDM are lacking, but the existing evidence indicates that achieving glycemic targets during pre-conception is associated with decreased rates of stillbirth. Conclusion: Diabetes is an independent risk factor for stillbirth that is amenable to achieving glycemic targets. Evidence-based recommendations for antenatal screening glycemic management are warranted to achieve reduction in stillbirth rates for gravidas with pre-gestational and gestational DM.

Background: Hemoglobin SC disease (HbSC) is second only to sickle cell anemia (SCA) as the most common hemoglobinopathy. Pregnant women with SCA are known to be at high risk of obstetrical complications and perinatal mortality as well as sickle related complications. The aim of this study is to review the morbidity and mortality associated with pregnancies complicated by haemoglobinopathies. Case(s): We describe two cases of HbSC disease complicating pregnancy with episodes painful crises and anemia. Both patients were managed with hydration, blood transfusions and analgesia. One of the pregnancies was complicated by other co-morbidities cholestasis of pregnancy, preeclampsia and postpartum hemorrhage. Conclusion: Painful crises, preterm delivery and preeclampsia are frequently complicate pregnancy affected by SCD. Although HbSC genotype typically presents a more benign clinical evolution than HbSS, both may present with complications of similar severity. Parturients with SCD regardless of their genotype should be managed by a multidisciplinary approach and carefully monitored to limit maternal and fetal complications.

Background: Highly active antiretroviral therapy has emerged as an essential treatment component to prevent vertical transmission of Human Immunodeficiency Virus (HIV). Yet there often remain missed opportunities to prevent vertical HIV transmission. We present a case that illustrates obstetric management and outcome for involving 2 generations of congenital HIV transmission. Presentation of the Case: Patient is a 19-year-old primigravida with congenital HIV presented to Lincoln Medical and Mental Health Center’s for her initial prenatal care at 36 weeks of gestation. Upon documentation of a high viral load, the patient was given intravenous Azidothymidine and scheduled for Caesarean delivery. AZT and lamivudine were recommended and prescribed for the neonate who tested positive HIV test for which AZT and lamivudine were recommended and prescribed, but the mother discontinued AZT after discharge from the hospital. At 1 month of age the infant succumbed to sudden infant death syndrome (SIDS). During the 2nd pregnancy the patient received adequate prenatal care as well as antiretroviral therapy, Truvada, Abacavir, Mepron, and Kaletra throughout the antenatal course. After preoperative intravenous AZT, via a repeat cesarean the patient delivered a neonate whose HIV test was negative. The patient’s 2nd child had an uncomplicated neonatal course and was negative for HIV on 3 subsequent tests and remained HIV negative until this date. Antiretroviral were removed and the child has remained HIV negative. The mother died from pneumonia and respiratory failure secondary to HIV 2 years after the 2nd delivery. Conclusion: This case serves as a reminder of the importance of adhering to current clinical standards for the care of pregnancies affected by HIV infection.

Background: During the first trimester of pregnancy, ectopic pregnancy is the leading cause of maternal mortality. Diagnosis and management of ectopic pregnancies require that health care providers maintain vigilance. Providing a variety of surgical and medical treatments at night can be challenging to the on call team in a teaching hospital. We present four cases of ectopic pregnancies managed over a 15 hour period by the night on call gynecology team. Cases: Case 1, 26-year-old women diagnosed with a ruptured ectopic pregnancy that required emergent laparotomy and blood transfusion. In Case 2, 27-year-old women underwent dilation, curettage and minimal invasive surgery of operative laparoscopy for ruptured ectopic pregnancy. In Case 3, a 24-year-old woman with unruptured ectopic pregnancy was treated with methotrexate. In Case 4, 35 yearold women underwent minimal invasive operative laparoscopy for unruptured ectopic pregnancy. Conclusion: Despite technological advances in early diagnosis of ectopic pregnancy with the use of transvaginal sonogram and serial β-HCG titers, patients still present to the emergency department with ruptured ectopic pregnancy necessitating acute surgical interventions. This is especially prevalent in inner city hospital catchment area where patients often wait until development of severe symptoms before presenting for medical care. Therefore, diagnosis of ectopic pregnancies warrens a high index of suspicion and treatment plans that are individualized, particularly to area of services with attention to patient

Summary: The combination of a high serum AFP and ovarian mass typically guide the physician towards a differential diagnosis that includes gonadal germ cell tumors and certain types of teratomas. Here we present a previously undocumented phenomenon of a serous cystadenoma where, upon thorough pathological examination and staining, benign ovarian epithelial cells were found to be the source of a serum AFP level of greater than 900 ng/ml (reference range of normal 0-10).

Pregnancy results in metabolic, hemodynamic, vascular, and immunologic changes. These physiological changes affect multiple organ systems including the visual system. The ophthalmic changes that occur during pregnancy are divided into physiological or pathological. Although ocular changes are common in pregnancy, many are mild, temporary, and require little to no treatment. However, it is important to recognize that serious ophthalmic pathology can occur which requires immediate medical intervention. This article is a review of the pathological and physiological changes which occur within the parturient as well as the safety of medication used to treat various conditions. Objective:The aim of this study was to review physiologic and pathologic ocular changes that are associated with pregnancy in pregnant women. After reading this article, readers should be able to: i. Distinguish physiological pregnancy-related ocular changes from pathological ii. Assess the relevance of ocular disease to the choice of childbirth method iii. Ophthalmic medication safe for pregnancy Conclusion:Pregnancy provides a great opportunity for physicians to establish care in a younger population who otherwise would not seek medical attention. As a result, physicians are able to treat and screen for several common pathologies during pregnancy. Certain ocular changes, whether physiological or pathological, may be increased during pregnancy. Thus, it is important to be educated on pathophysiological changes that are common in pregnancy in order to better counsel women who are pregnant or planning to become pregnant. Although many ocular changes are mild, temporary, and require little to no treatment, allocular symptoms in pregnancy requires ophthalmologic examination and management. However, long term data on ophthalmic drugs during pregnancy and lactation is insufficient. Thus, doctors should always be cautious and consult expert opinion before using any topical or systemic treatment on the patient.