Accepted Manuscript

Clinical Recommendation: Adnexal Torsion

Oluyemisi Adeyemi-Fowode, MD, Kate A. McCracken, MD, Nicole J. Todd, MD

PII: S1083-3188(18)30187-6
DOI: 10.1016/j.jpag.2018.03.010
Reference: PEDADO 2225

To appear in: Journal of Pediatric and Adolescent Gynecology

Received Date: 8 March 2018

Revised Date: 28 March 2018
Accepted Date: 30 March 2018

Please cite this article as: Adeyemi-Fowode O, McCracken KA, Todd NJ, Clinical Recommendation:
Adnexal Torsion, Journal of Pediatric and Adolescent Gynecology (2018), doi: 10.1016/
j.jpag.2018.03.010.

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 ACCEPTED MANUSCRIPT

Clinical Recommendation: Adnexal Torsion

Oluyemisi Adeyemi-Fowode MD1,*, Kate A McCracken MD2, Nicole J Todd MD3

1 Department of Obstetrics and Gyneology, Division of Pediatric and Adolescent Gynecology, Baylor College of

Medicine, Houston, Texas.

2 Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, Ohio State

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University, Columbus, Ohio .
3 Division of General Gynaecology and Obstetrics, University of British Columbia, Vancouver, British Columbia,

Canada.

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The authors indicate no conflict of interest.
This Clinical Recommendation was prepared by Oluyemisi Adeyemi-Fowode, MD
Kate McCracken , MD, and Nicole J Todd, MD, with expert review from Lisa Allen, MD

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and Sari Kives MD.

*Corresponding author:

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Oluyemisi Adeyemi-Fowode, MD
Assistant Professor
Baylor College of Medicine
Department of Obstetrics and Gynecology
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Division of Pediatric and Adolescent Gynecology

6651 Main St, Suite F1020
Houston, TX 77030
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832-826-7464 (academic office)

832-825-9349 (fax)
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adeyemi@bcm.edu (email)

Word Count
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Abstract: 100
Main text: 5520
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Background:

Adnexal torsion (AT) is an uncommon gynecologic disorder caused by the partial or

complete rotation of the ovary and/or the fallopian tube on its vascular support.
AT mainly occurs in adolescents and women of childbearing age, thus when
suspected, urgent surgical intervention is indicated to preserve ovarian function. A
delay in treatment can lead to impaired or lost fertility.

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Epidemiology

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Adnexal torsion (AT) is the fifth most common gynecologic emergency and accounts
for 2.7% of all cases of children with acute abdominal pain.1-6 Pediatric ovarian
torsion accounts for approximately 15% of all cases of ovarian torsion.7-10 While the

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actual incidence of adnexal torsion is unknown, studies have reported between 0.3-
3.5 cases per year.3,5,11-13 The largest analysis of pediatric ovarian torsion related
hospitalizations in the United States (Kids Inpatient Database) provides an
estimated incidence of ovarian torsion of 4.9 per 100,000 females aged 1 to 20

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years14 Overall incidence of adnexal torsion described in the pediatric ED was 0.5 to
2 per 10,000 patients.13-15 A systemic literature review of AT in the pediatric
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population reported a mean age of 11.6 years, with premenarchal girls accounting
for 43.4% of the cases and postmenarchal girls for 56.6%.15
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AT is usually unilateral and may involve a normal or a pathologic ovary, tube or

both. Adnexal pathology has been reported to be present in 51-84% of AT cases.3,12
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The most frequently encountered lesions are mature cystic teratoma and follicular
cysts.12,16-19 Torsion of a normal ovary is more prevalent in the prepubescent
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population.11,20-22 Overall, AT is reported more commonly on the right side than on

the left.10,11,17,21,23 This preference has been attributed to the relative mobility of the
cecum allowing for more ovarian movement, in comparison with the fixed nature of
the sigmoid colon.23
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Although most frequently unilateral, bilateral synchronous torsion and

asynchronous AT has also been reported.6,11,24-28 Recurrence rate of torsion
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associated with adnexal pathology is approximately 2-12%.11,29 Recurrent AT

appears to be more common among girls without the presence of ovarian masses at
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the first episode. A 10 year multicenter retrospective study estimates the risk of
recurrence to be 7 times greater in these patients.11,30 Malignant lesions are
uncommonly associated with AT in pediatric patients.3,12

Pathophysiology

The adnexa includes the ovaries and fallopian tube, which receive dual blood supply
from the ovarian and uterine arteries. Torsion of the adnexa occurs when the
vasculature supplying the ovary and tube undergoes excessive rotation about its
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axis, producing a mechanical impairment to flow. Severity of vascular impairment is

variable depending on the degree of rotation which causes varying degrees of
partial to complete obstruction of flow.3,31 Venous flow is the first to be
compromised due to the compressibility of the lower pressure vessels; venous
congestion ensues with subsequent edema of the ovarian tissue. Early in the process
arterial flow may be present however stretching of the ovarian capsule eventually
compromises arterial blood flow. Ischemia of the adnexa follows with resulting

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hemorrhage and finally necrosis.3,7,31 The duration of vascular interruption
necessary to produce irreversible damage is unknown, however normal ovarian
function has been reported even after 72 hours.3,32-34 Expeditious intervention

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provides the best chance of adnexal and reproductive salvage. If left untreated the
ovary becomes ischemic and then necrotic and autoamputation of the ovary may
occur.35

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Abnormal rotation of the ovary is usually due to an underlying ovarian pathology
such as ovarian cysts or mass.36,37 The increased incidence during adolescence is
likely secondary to hormonal influence and gonadal growth resulting in an

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increased frequency of physiologic and pathologic masses.7,13,17 A 10 year
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retrospective review of AT at a single academic center showed a 6 fold increased
incidence in girls older than 10 years.13 Most frequently encountered ovarian
lesions causing torsion in children are typically benign including cystic teratoma,
hemorrhagic/follicular cysts, paratubal cysts, cystadenoma and
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hydrosalpinx.7,12,35,38,39 Mechanism of torsion in women and girls with benign

ovarian masses is likely related to the increased size and weight of the involved
ovary.5,7 Oltmaan demonstrated a strong association of torsion with pelvic masses
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larger than 5cm.17 Malignant lesions associated with torsion are extremely
rare.7,17,22,30,35,39-41
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The etiology of AT in the absence of cysts or masses is more obscure and could be
due to increased mobility of the adnexal structures due to an elongated ovarian
ligament or a hyperelastic-like mesosalpinx or meso-ovarium.3,11,24,35 Greater than
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average ligamentous laxity may predispose some girls to torsion as had been
hypothesized in cases of asynchronous multiple torsion events.7 It is also speculated
that the relatively small uterine size in premenarchal girls may create a long utero
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ovarian pedicle and an appropriate space for torsion of the ovary.37 Other reported
possible mechanisms increasing the risk of torsion are abrupt changes in the intra-
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abdominal pressure with vomiting and coughing, adnexal venous congestion due to
constipation and sigmoid distention.11,26

Adnexal torsion involving both the ovary and tube is far more common than pure
isolated torsion of the ovary or fallopian tube alone.7,42 Isolated tubal torsion is rare
and involves twisting of the mesosalpinx with conservation of blood supply to the
ipsilateral ovary. It is almost always associated with tubal pathology such as
hydrosalpinx or tubal mass.5,42 The incidence of tubal torsion in pediatric and
adolescent patients is difficult to determine with a case series from a large pediatric
referral hospital reporting 15 cases in 10 years.43
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Clinical Presentation

The preoperative diagnosis of AT is challenging due to its nonspecific clinical

presentation. In addition, the clinical presentation is variable and depends on
whether the torsion is complete, incomplete or intermittent with periods of

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spontaneous detorsion.44 A systematic literature review reported the most common
presenting symptom as abdominal pain present in 97.5% of all reviewed studies.15
Adnexal torsion typically presents with sudden onset of severe unilateral pain in the

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lower abdomen or pelvic area.1,3,29,36,37,45,46 Pain may be described as acute sharp
constant pain, colicicky intermittent pain or gradually increasing pain.15,44 In some
cases, waxing and waning pain may indicate intermittent torsion – a condition in

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which the adnexa twists, then spontaneously untwists.8,47

In confirmed cases of adnexal torsion, abdominal pain is commonly associated with

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nausea and/or vomiting;12,15,36,48 These symptoms are typically acute and described
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as severe; while the majority of patients affected by AT present within 72 hours,
some studies show that pediatric patients may present later .21,29,33,34 A wide range
of gastrointestinal, genitourinary and ovarian pathology must be considered as
possible etiologies in part because of the intraabdominal location of the female
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reproductive tract.17,49,50 Despite the infrequent occurrence, it is crucial that

clinicians include adnexal torsion in their differential diagnoses for all females
presenting with lower abdominal pain to avoid a delay in diagnosis.35,44,51 The list of
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differential diagnosis of AT is long, including many other emergency causes for

abdominal pain such as ectopic pregnancy, PID, appendicitis, diverticulitis ruptured
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ovarian cyst and renal colic.42,52 Due to the non specific nature of the symptoms and
signs, cases of AT can be initially missed.
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On physical examination, abdominal tenderness is the main finding, peritoneal signs

such as rebound and guarding may also be present. In some cases, a palpable lower
abdominal mass may be present. If a bimanual exam is performed, the involved
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adnexa will be tender to palpation, and may feel enlarged; however a bimanual
exam is rarely indicated in the pediatric population. If the torsion is persistent and
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remains untreated, necrosis, low grade fever and leukocytosis may develop. The
diagnosis of isolated tubal torsion is often not made before surgical intervention
given that there is no specific clinical feature that distinguishes it from torsion
involving the whole adnexa.23 The typical symptom is pelvic pain which may be
associated with nausea and vomiting. High level of suspicion must be held as it can
have a more insidious presentation.23,43,52 Appelbaum et al1 performed a
retrospective study looking at key clinical predictors in the early diagnosis of AT in
children and noted that the presence of intermittent pain, non radiating pain and
increased adnexal size (on imaging) when combined have a strong association with
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AT. The authors do caution that a high clinical suspicion still needs to be maintained
even in the absence of these signs.

Diagnosis

The diagnosis of AT torsion is clinical, based on patient presentation and imaging.

Imaging alone should not be relied upon for diagnosis.

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a. Bloodwork – Laboratory investigations may help in generating a differential
diagnosis, but no specific test is recommended for AT. Serum pregnancy

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hormone should be completed in sexually active women. Urinalysis may
show blood and/or leukocytes, however positive urine cultures are not
common.15,32 Mild elevations in white blood cell count (10.3-17.6 x 109/L)

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are seen in 20-62% of women with AT.5,21,32,51 Markers of inflammation
(CRP, ESR, interleukins) are not specific to AT. IL-6 has been found to be
elevated in few studies, however further research is needed.51 D-dimer may

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also be a promising marker, as initial animal studies have demonstrated
elevation after 2 hours of AT.51 Surgery for suspected torsion should not be
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delayed for results of inflammatory markers.

b. Imaging
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Ultrasound – Ultrasound is the gold standard imaging choice for AT due

to its ability to directly and rapidly evaluate both ovarian anatomy and
blood flow in a non invasive manner.31 Transvaginal ultrasound may
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improve the Positive Predictive Value (PPV) but use is limited in the non-
sexually active patient.51 A metaanalysis of B-Mode Ultrasound, Doppler
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ultrasound and CT found ultrasound to be a better imaging modality over

CT. B-mode Ultrasound was the most sensitive and specific in detecting
AT at 92% and 96% respectively.36 Doppler ultrasound was moderately
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specific but lacked sensitivity at 87% and 55% respectively , the

sensitivity is variable and operator dependent thus a combination of
grayscale B-mode US and Doppler US is most useful.
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Doppler Ultrasound - On ultrasound, absent Doppler arterial flow and

ovarian enlargement are reported to be the hallmarks of torsion, but
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these findings are not always present.9,53 Preservation of Doppler

arterial flow can be seen, as venous and lymphatic outflow is first
affected,42 this explains 45-61% normal doppler findings in surgically
confirmed AT cases. Therefore the presence of flow does not exclude
torsion.9,42 Measurement of Doppler can also be affected by presence
of ovarian engorgement and/or underlying mass. Care should be
taken that Doppler is measured at the infundibular pelvic ligament,
not ovarian cortex. A “whirlpool sign” whereby the twisted vascular
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pedicle is seen, is highly specific, but technically difficult to visualize

on transabdominal ultrasound

• Ultrasound Features - Findings suggestive of AT include: increased

ovarian size, peripheral distribution of follicles, abnormal location of
adnexa compared to uterus, free fluid.1,8,15,42,51 Increased adnexal

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volume ratio (volume of affected ovary/volume of unaffected ovary)
of greater than 20 has high PPV.51 A completely normal appearing
ovary on ultrasound is unlikely to have twisted, Linam et al reported

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an adnexal volume less than 20 ml offers strong evidence against AT
in menarchal females with a negative predictive value of a 100% in
their study. 53 A Pre-existing adnexal mass, especially when size

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exceeds 5 cm in the largest diameter, should increase suspicion for
AT.17,42 In some cases, adnexal masses may be poorly characterized
due to ovarian edema causing a heterogenous appearance to the

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ovary.42 In premanarchal patients, AT is more likely to occur in the
absence of ovarian pathology thus imaging may not reveal a
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discernable cyst.21,29 For isolated tubal torsion ultrasound findings
include: dilated tubular structure, normal ipsilateral ovary, cystic
mass separate from the ovary.43
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• X-Ray – X ray may be ordered to help narrow the differential

diagnoses. Findings raising suspicion for AT include: soft tissue radio-
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opaque masses, foci of calcification, ossifications with masses,

although these are not specific to AT.15
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• CT – The patient with acute abdominal pain may undergo CT to aid in

identifying non-gynecologic causes of acute pelvic pain, such as
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gastrointestinal and urinary tract causes.31 Sensitivity for CT is low at

42.2%.15,36 Normal appearing adnexal structures on CT can sometimes
rule out AT. Nevertheless, incomplete views of the adnexa necessitate
further imaging. In addition, the most common finding for AT on CT is
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asymmetric ovarian enlargement.42 AT should be suspected with the

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presence of peripheral follicle distribution, whirlpool sign, fallopian

tube thickening, eccentric/concentric wall thickening, inflammatory
fat stranding, free fluid, and uterine deviation toward torsion.42,51,54
Torsion demonstrated on CT, does not require further scans, and
surgical intervention should be emergently offered. Considering the
low diagnostic sensitivity and associated ionizing radiation to tissues
in the pelvis, CT has no role in the initial workup of girls with acute
AT.36
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• MR – MR does not offer improved sensitivity compared to ultrasound.

MR however may be helpful when torsion is suspected during
pregnancy due to its ability to better characterize the adnexal mass.42
Suspicion for torsion should be raised when the presence of
asymmetric ovarian enlargement, stromal edema, peripheral follicle
distribution, and twisted pedicle is noted.42 Decreased enhancement

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of a torsed ovary may be seen with intravenous contrast.42

Management

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Urgent surgical intervention is indicated when AT is suspected as ovarian viability
decreases with increased time from onset of pain to time of surgery. The duration of

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vascular interruption necessary to produce irreversible damage is unknown3,5 and
normal ovarian function has been reported for up to 72 hours after torsion.3,32,34,41 A
sharp decrease is seen after 72 hours however ovarian function has been reported

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up to 5 days after symptom onset.33,34 Regardless, expeditious intervention provide
the best chance of adnexal and reproductive salvage.3 A 10 year retrospective study
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revealed that girls with suspected AT waited twice as long for imaging and surgical
intervention when compared to boys presenting with testicular torsion.13 More
urgent surgical intervention for suspected AT without reliance on definitive
diagnosis by imaging should be considered in girls with lower abdominal pain.
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Historically, oophorectomy was the preferred intervention to prevent consequences

from ovarian necrosis. Kokoska et al reviewed records of children aged 16 years or
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less at a hospital center from 1983 to 1999, all 51 participants underwent

oophorectomy.16 Reasons cited for oophorectomy included concern for continued
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pain, fear of the risk of malignancy associated with torsed ovaries, concern for
increased thromboembolic events related to detorsion, sepsis secondary to necrosis
and the belief that a grossly black hemorrhagic adnexa is irreversibly
damaged.2,16,55,56 The overall risk of malignancy in adolescents is low, and
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malignancies are more often associated with adhesions, thus making torsion less
likely.51 The risk of increased thrombolic events with detorsion of the adnexa is
theoretical and no cases have been reported in the pediatric literature.14,57 Ovarian
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conservation is not associated with increased complication rate.33,55,57

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The treatment paradigm has changed to favor adnexal detorsion with ovarian
conservation in an effort to preserve ovarian function.2,3,6,12-14,17,18,20-22,24,25,38,52,58-60
Implementing this standard of care requires improved dissemination. A study
looking at a nationwide database to review the national trend in surgical treatment
of AT in children analyzed 2041 pediatric patients and noted that release of torsion
alone without oophorectomy had increased from 9% to 25% from 1998 to 2011.56
However in contrast, Gutrie et al found that oophorectomy in the setting of torsion
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from 2000 to 2006 had not improved with over half of patients receiving
oophorectomy.14 A high rate of oophorectomy at 61.6% was also demonstrated in a
large Italian retrospective study.11 Furthermore, a recent literature review
demonstrated 32.1% salvage rate over 14 studies.15 Other studies are more
promising demonstrating a higher rate of adnexal conservation at 85-95%.29,33,38
Overall it should be noted that oophorectomy is still a widely used procedure
procedure for AT despite the excellent results of conservative therapy reported in

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the literature in recent years. Also, over the years there has been a shift in the mode
of surgery. For example, laparotomy16,25,60 is now being replaced by laparoscopy as
proficiency in laparoscopy has increased.18,52,60,61 Lo et al looked at laparoscopy

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versus laparotomy for surgical intervention and noted that laparoscopy is
recommended most favorably given its shorter hospital stay, fewer postoperative
complications and ovarian preservation.52,60 However, Pediatric Health Information

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System (PHIS) data from 2007 to 2011 revealed laparoscopic approach only in
24.6% of surgical cases.55

The aim of surgery is ovarian tissue conservation, and detorsion alone should be

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considered, even when the ovary appears necrotic (blue-black). There is no valid
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clinical method to predict viability of the ovary and surgeons cannot reliably
identify viable tissue by examination only.51,62 Pathology studies have demonstrated
viable ovarian tissue, despite surgeon impression of necrosis.58 The ovary has dual
blood supply from the utero-ovarian vessels and the infundibular pelvic vessels
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which provide greater protection from complete ischemia. The darkened

appearance to the ovary may be secondary to venous congestion rather than
ischemia.5,51,60 Furthermore, the appearance of the ovary does not correlate with
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ovarian function.57 Studies have consistently demonstrated ovarian function status

post detorsion as high as 92%.2,24,41,51,60
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In the post-menarchal patient, over half of torsions will occur in the setting of
adnexal mass. In many cases, the twisted adnexa can be detorsed and a cystectomy
performed at the same time. Occasionally, the twisted adnexa can be severely
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edematous and friable, in which case, attempts at cystectomy can result in further
ovarian tissue damage, bleeding, and need for emergent oophorectomy.
Furthermore, the enlarged ovary due to edema may be wrongly interpreted as a
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mass, when no adnexal pathology is present. Some authors have advocated that
patients with cysts at the time of AT should undergo detorsion only and repeat
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imaging to re-evaluate the cyst 6 to 12 weeks post surgery.13,51,57 Simple cysts often
resolve within 6-8 weeks, and interval surgery may not be required. Management of
cysts > 5cm status post detorsion should be in accordance with published clinical
practice guidelines.63 In patients with persistent cysts, an interval laparoscopic
ovarian cystectomy can be offered given their increased risk of torsion. In order to
prevent the need to return to the operating room, we recommend that adnexal
detorsion with concurrent cystectomy (ovarian or paratubal) be attempted but
approached with caution in cases of severely edematous ovaries. Biopsy of the
contralateral ovary is not recommended.24
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While the recurrence rate of AT is approximately 2-12% of torsion and even higher
in cases of spontaneously torsed normal adnexa,11,29,51 the benefit of oophoropexy of
the ovary is controversial.11,24 Some have cited fear that ovarian fixing could alter
ovarian function and the deformed relation between the ovarian follicles and
oviduct could decrease fertility.59 In premenarchal girls specifically, one
consideration cited is that fixing the developing ovary may physically hinder its
normal descent to the ovarian fossa at the time of puberty.64 Oophoropexy can be

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offered in the setting of repeat torsion, absent contralateral ovary, elongated
ovarian ligament, and torsion of normal adnexa.11,24,30,34,41,51 It appears reasonable
to pex bilaterally in only cases of asynchronuous or synchronous bilateral torsion of

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normal adnexa.11,28,34 Oophoropexy can be accomplished laparoscopically with
permanent suture to the pelvic side wall, round ligament, uterosacral ligament, back
of the uterus, and by shortening the ovarian ligament.11,51,65 Pexing does not

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eliminate the risk of retorsion with a reported rate of about 9% in the pediatric
population after adnexal fixation.21,66 In patients who have experienced torsion with
a functional ovarian cyst, oral contraceptives may be recommended to avoid
recurrence of a functional cyst which may predispose to repeat torsion.5

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Though the trend towards ovarian conservation via minimally invasive surgery has
increased, there is still much work to be done. There continues to be a need to
educate general, pediatric and gynecologic surgeons regarding current treatment
recommendations for AT.56 Surgical treatment at nonteaching hospitals has higher
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oophorectomy rates.16 Dissemination of information on the standard of care leads to

improvement Continuous quality improvement strategies including educational
programs, collaborative care pathways, formal outcome reviews and policy
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implementation have been noted to increase ovarian conservation

significantly,33,67,68 and in some cases as high as 95%.59 Minimally invasive detorsion
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with ovarian conservation should be offered by a qualified surgeon in a timely

manner. Some studies show that compared to pediatric gynecologists, pediatric
surgeons are more likely to perform oophorectomy.2,55 It can be postulated that this
is due to gynecologists being more aware of the long-term risks to fertility with
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removal of ovaries or fallopian tubes however some studies reveal no difference

between the specialties34 thus it is more likely that experience and awareness of
the individual surgeon is most important.55
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Conclusion
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Adnexal torsion is an uncommon occurrence, but should be kept high on the

differential diagnosis for girls presenting with acute abdominal pain. Patients often
present with acute abdominal pain associated with nausea and emesis. In
premenarchal patients, AT often occurs in the setting of normal ovaries. In the
reproductive age population, AT is most commonly associated with an adnexal
mass. Common masses include simple cysts, hemorrhagic cyst, and mature cystic
teratoma. Ultrasound for the investigation of abdominal pain should include
evaluation of the pelvic organs. While absent Doppler flow is consistent with
torsion, it is important to remember that flow is frequently present in the setting of
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AT; thus the documentation of flow on an ultrasound report does not rule out the
possibility of AT. Therefore, one should take into account the ultrasound findings,
but the diagnosis is clinical. Ultrasound findings should not delay surgical
exploration when high clinical suspicion exists and urgent laparoscopic adnexal
detorsion with ovarian conservation should be offered. Concurrent attempt at
cystectomy with detorsion is possible, but should be approached with caution in
cases of severely edematous ovaries or when it is uncertain if a mass is present.

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Patients should undergo repeat pelvic imaging 6-12 weeks post-surgery to reassess
for adnexal masses, ovarian viability and the need for interval cystectomy in the
event this was delayed initially. While there are no clear criteria for oophoropexy,

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consideration should be given to offering this approach in the setting of repeat AT,
torsion of a normal ovary, and when a solitary ovary is present.

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Recommendations

Level A

•
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No long-term studies or randomized controlled trials in this population exist
to permit Level A recommendations.
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Level B

Level II-2
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• Ultrasound is the gold standard imaging choice for suspected adnexal

torsion, due to its ability to directly and rapidly evaluate both ovarian
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anatomy and perfusion in a non-invasive manner.

Level II-2B
• Adnexal torsion should be on the differential diagnosis for girls presenting
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with lower abdominal pain.

• The diagnosis of adnexal torsion is clinical, based on patient presentation and

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imaging. Imaging alone should not be relied upon for diagnosis. Urgent
surgical intervention is indicated when adnexal torsion is suspected.
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• Adnexal conservation should be the goal of treatment, there is no evidence of

a risk of thrombotic event or complication due to treatment with detorsion of
the adnexa, theoretical risks should not influence surgical management.

• Minimally invasive surgery is the desired surgical approach to adnexal

torsion.
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Level C

• The benefit of oophoropexy of the gonads is controversial; Oophoropexy can

be offered in the setting of repeat torsion, absent contralateral ovary, long
utero-ovarian ligament, and torsion without underlying etiology.

• Continuous quality improvement strategies including educational programs,

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collaborative care pathways, formal outcome reviews and policy
implementation should be offered whenever possible to improve the
standard of care.

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The authors have no conflict of interest.

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NASPAG Clinical Recommendation

The committee name for the top of the article is: Education Committee

The Education Committee members for the box on the first page are:

Kate McCracken, MD (Co-chair)

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Nichole Tyson, MD (Co-chair)
Mary Romano, MD, MPH (Co-chair rotating off)
Yemi Adeyemi-Fowode, MD

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Kenisha Campbell, MD
Serena Chan, MD
Lauren Damle, MD
Fareeda Haamid, DO

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Megan Harrison, MD, FRCPC
Kim Hoover, MD
Katrina Nicandri, MD

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Staci Pollack, MD
Amy Williamson, MD
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The blurb for how the paper was created is: This topic was chosen by the NASPAG Education committee
as an important one to NASPAG membership, and appropriate content experts were invited as authors.
The document has already been reviewed and approved by the NASPAG education committee and the
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NASPAG Board.
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