Prenatal detection of chromosome abnormalities has been offered for more than 40 years, first by amniocentesis in the early 1970s and additionally by chorionic villus sampling (CVS) in the early 1980s. Given the well-recognized association between increasing maternal age and trisomy,1-3 the primary utilization of prenatal testing has been by older mothers. This has drastically reduced the incidence of aneuploid children born to older mothers.4 Although younger women have relatively low risks of conceiving a child with aneuploidy, the majority of pregnant women are in their late teens, 20s, and early 30s. As such, most viable aneuploid babies are born to these younger mothers.5 Invasive prenatal diagnosis (CVS and amniocentesis) is not a feasible option for all low-risk mothers, as these procedures carry a small but finite risk and would ultimately cause more miscarriages than they would detect aneuploidy. For this reason, a number of noninvasive tests have been developed-including first-trimester risk assessment at 11 to 14 weeks, maternal serum analyte (quad) screening at 15 to 20 weeks, and sonographic fetal structural survey at 18 to 22 weeks-all of which are designed to give a woman an adjusted (more accurate) estimate of having an aneuploid fetus using as baseline her a priori age-related risk. Ultrasound and maternal serum analysis are considered screening procedures and both require follow up by CVS or amniocentesis in screen-positive cases for a definitive diagnosis of a chromosome abnormality in the fetus. The ability to isolate fetal cells and fetal DNA from maternal blood during pregnancy has opened up exciting opportunities for improved noninvasive prenatal testing (NIPT). Direct analysis of fetal cells from maternal circulation has been challenging given the scarcity of fetal cells in maternal blood (1:10,000-1:1,000,000) and the focus has shifted to the analysis of cell-free fetal DNA, which is found at a concentration almost 25 times higher than that available from nucleated blood cells extracted from a similar volume of whole maternal blood. There have now been numerous reports on the use of cell-free DNA (cfDNA) for NIPT for chromosomal aneuploidies-especially trisomy (an extra copy of a chromosome) or monosomy (a missing chromosome)-and a number of commercial products are already being marketed for this indication. This article reviews the various techniques being used to analyze cell-free DNA in the maternal circulation for the prenatal detection of chromosome abnormalities and the evidence in support of each. A number of areas of ongoing controversy are addressed, including the timing of maternal blood sampling, the need for genetic counseling, and the use of confirmatory invasive testing. Future applications for this technology are also reviewed.

Interest in global maternal health has steadily increased over the past decade. Medical schools are offering courses on this subject, residencies are incorporating international elective rotations into their practices, and retiring practitioners are opting to spend a year or two in low-resource settings. Although interest is growing, sometimes wellmeaning health practitioners are not entirely prepared for their new experience. Prior to departure, a multistep process is necessary to prepare physicians for living and practicing overseas.

Abnormal uterine bleeding (AUB) affects 30% of women at some time during their reproductive years and is one of the most common reasons a woman sees a gynecologist. Many women are turning to endometrial ablation to manage their AUB. This article reviews the data relating to the available endometrial ablation techniques performed with hysteroscopic sterilization, and focuses on data from patients who had Essure® (Conceptus, San Carlos, CA) coils placed prior to performance of endometrial ablation. Reviewed specifically are data regarding safety and efficacy of these two procedures when combined. Data submitted to the US Food and Drug Administration for the three devices currently approved are reviewed, as well as all published case series. Articles included were selected based on a PubMed search for endometrial ablation (also using the brand names of the different techniques currently available), hysteroscopic sterilization, and Essure.

Streptococcus agalactiae, also known as Group B Streptococcus (GBS), is an opportunistic pathogen that colonizes the gastrointestinal and genitourinary tracts of up to 50% of healthy adults and newborns; it is responsible for significant morbidity and mortality. Early detection can be used to establish the use of antibiotic prophylaxis to significantly reduce neonatal sepsis. This article reviews methods of detection and prevention of GBS infection in the neonate.

Vascular lesions of the uterus are rare; most reported in the literature are arteriovenous malformations (AVMs). Uterine AVMs can be congenital or acquired. In recent years, there has been an increasing number of reports of acquired vascular lesions of the uterus following pregnancy, abortion, cesarean delivery, and curettage. It can be seen from these reports that there is confusion concerning the terminology of uterine vascular lesions. There is also a lack of diagnostic criteria and management guidelines, which has led to an increased number of unnecessary invasive procedures (eg, angiography, uterine artery embolization, hysterectomy for abnormal vaginal bleeding). This article familiarizes readers with various vascular lesions of the uterus and their management.

The migration of gynecologic procedures to office-based settings provides numerous advantages for patients and providers alike, including reduced patient expenses, improved scheduling convenience, favorable provider reimbursement, and enhanced continuity of care and patient satisfaction. With rising health care costs-a major concern in health care-procedures will continue to shift to practice environments that optimize care, quality, value, and efficiency. It is imperative that gynecologic offices ensure that performance and quality variations are minimized across different sites of care; physicians should strive to provide care to patients that optimizes safety and is at least equivalent to that delivered at traditional sites. The gynecologic community should nonetheless heed the Institute of Medicine's recommendations and embrace continuous quality improvement. By exercising leadership, office-based gynecologists can forge a culture of competency, teamwork, communication, and performance measurement.

This review discusses in detail robotic tubal reanastomosis as one of the classic reproductive surgery procedures. Other applications of robotics in adnexal surgery are also reviewed, including adult and pediatric adnexectomy, resection of endometriosis, benign ovarian mass resection, early ovarian cancer resection and staging, ovarian transposition, and treatment of ovarian remnant syndrome and ovarian vein syndrome.

Sex trafficking involves some form of forced or coerced sexual exploitation that is not limited to prostitution, and has become a significant and growing problem in both the United States and the larger global community. The costs to society include the degradation of human and women's rights, poor public health, disrupted communities, and diminished social development. Victims of sex trafficking acquire adverse physical and psychological health conditions and social disadvantages. Thus, sex trafficking is a critical health issue with broader social implications that requires both medical and legal attention. Healthcare professionals can work to improve the screening, identification, and assistance of victims of sex trafficking in a clinical setting and help these women and girls access legal and social services.

Fetomaternal alloimmune thrombocytopenia (FMAIT) is a relatively uncommon disease, but is the leading cause of severe thrombocytopenia in the newborn. It can cause severe complications and long-term disabilities. The main objective of screening is to reduce both the morbidity and mortality associated with FMAIT, primarily by preventing intracranial hemorrhage. However, controversy surrounds both pre- and antenatal management. This article discusses pathogenesis, screening, diagnosis, and both pre- and neonatal management of FMAIT.

In addition to causing developmental disability in future offspring, fragile X carrier status has important reproductive and mental health implications for the individual being tested. Accordingly, prenatal carrier screening and diagnosis using DNA-based molecular methods has become crucial in early detection, intervention, and family planning. Although the list of known genetic disorders is growing daily, controversy remains over who should be tested for fragile X. FMR1 gene mutations can result in inherited intellectual disability, infertility, and neurodegeneration syndromes that are encountered by clinicians in a variety of settings. Patients and clinicians are still largely unfamiliar with this disorder, its complicated inheritance, and its heterogeneous phenotype. Debate continues over who should be offered prenatal carrier screening. As more disease screening is offered, pretest counseling will become only more complex and clinicians will further struggle to balance the needs of the individual and allocation of public health resources.

Pulmonary embolism in pregnancy is a major cause of maternal mortality and morbidity. We describe the case of a 27-year-old pregnant woman who underwent successful thrombolysis. Our patient presented to the emergency department after a fainting episode and complaining of shortness of breath. A computed tomography pulmonary angiogram revealed a pulmonary embolism, which was found to be causing significant right ventricular strain. After examination by our gynecologic and medical teams, she underwent successful thrombolysis, made a successful recovery, and carried an uneventful pregnancy.

Validated prognostic and predictive factors currently play an important role in treatment planning for patients with early-stage breast cancer. The role of personalized medicine has led to the search for markers that can be applied to individual patients to optimize treatment regimens. In addition to traditional clinicopathologic measures, scores and gene tests have been developed to independently predict risk of patients in the neoadjuvant and adjuvant settings. The discovery of these markers provides the opportunity to identify patients at such low risk of recurrence that toxic therapy side effects are not justified. Selection and management of patients with early-stage, hormone receptor-positive breast cancer who are appropriately treated with endocrine therapy alone after receiving locoregional therapy but do not necessarily require adjuvant chemotherapy is currently problematic. This article reviews the current state-of-theart biomarker assessment methods and discusses the potential role for the prediction of chemotherapy benefit focusing on endocrine sensitive disease.

Intimate partner violence (IPV) is defined as an actual or threatened abuse by an intimate partner that may be physical, sexual, psychological, or emotional in nature. Each year approximately 1.5 million women in the United States report some form of sexual or physical assault by an intimate partner; it is estimated that approximately 324,000 women are pregnant when violence occurs. Pregnancy may present a unique opportunity to identify and screen for patients experiencing IPV. This article provides health care practitioners and clinicians with the most current valid assessment and screening tools for evaluating pregnant women for IPV.