Bala Bhagavath

Previous Cesarean Section and Abortion as Risk Factors for Developing Placenta Previa

Objective: To determine the risk of subsequent occurrence of placenta previa in women with a history of previous cesarean sections and/or spontaneous and induced abortions.

Surgical aspects of removal of Essure microinsert

Essure is designed as a hysteroscopically placed permanent birth control. Removal of the Essure microinsert can be a technically challenging procedure. Requests for removal are uncommon but do occur. Although hysteroscopic and laparoscopic removal has been reported, there is limited information available describing appropriate surgical technique. There have been six patients requesting Essure removal at our institution (one approximately 2 years after placement). Based on this experience, we have developed specific counseling points and surgical principles for laparoscopic removal: avoid injection of a hemostatic solution into the fallopian tube; avoid excessive traction on the coils; avoid cauterization of the outer coil; follow the Essure coil into the interstitial end of the fallopian tube to ensure complete removal of the insert; perform a salpingectomy rather than a salpingostomy. By taking into account these principles, key preoperative counseling points can be discussed, and laparoscopic Essure removal years after placement can be accomplished in a safe and deliberate fashion.

Ectopic pregnancy in a cesarean-section scar: the patient >6 weeks into an ectopic pregnancy, underwent local treatment.

Cesarean scar ectopic pregnancies may be difficult to diagnose and may result in uterine rupture or hysterectomy. Based on location and vascularity, especially in the presence of fetal cardiac activity, local treatment with transvaginal ultrasound-guided injection of methotrexate is an excellent option which also optimizes the chance for fertility preservation.

Familial 46,XY sex reversal without campomelic dysplasia caused by a deletion upstream of the SOX9 gene.

BACKGROUND 46,XY sex reversal is a rare disorder and familial cases are even more rare. The purpose of the present study was to determine the molecular basis for a family with three affected siblings who had 46,XY sex reversal. METHODS DNA was extracted from three females with 46,XY sex reversal, two normal sisters, and both unaffected parents. All protein coding exons of the SRY and NR5A1 genes were subjected to PCR-based DNA sequencing. In addition, array comparative genomic hybridization was performed on DNA from all seven family members. A deletion was confirmed using quantitative polymerase chain reaction. Expression of SOX9 gene was quantified using reverse transcriptase polymerase chain reaction. RESULTS A 349kb heterozygous deletion located 353kb upstream of the SOX9 gene on the long arm of chromosome 17 was discovered in the father and three affected siblings, but not in the mother. The expression of SOX9 was significantly decreased in the affected siblings. Two of three affected sisters had gonadoblastomas. CONCLUSION This is the first report of 46,XY sex reversal in three siblings who have a paternally inherited deletion upstream of SOX9 associated with reduced SOX9 mRNA expression.

Metformin and Other Insulin Sensitizers in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a complex disorder affecting a substantial group of women from adolescent to menopausal age groups. A substantial subgroup of these women exhibits increased insulin resistance. Insulin resistance is difficult to establish in clinical practice and many surrogate tests are available, although their value in the clinical setting is uncertain. The QUICKI method is an inexpensive and easy test to administer and is probably the best test to be used in PCOS patients, preferably in a clinical trial context. There is considerable evidence that insulin-sensitizing agents are not contributory to infertility management in the majority of women with PCOS. Currently, there is no evidence that cardiovascular morbidity is decreased by long-term use of insulin sensitizers in PCOS women.

Role of routine monitoring of liver and renal function during treatment of ectopic pregnancies with single-dose methotrexate protocol

OBJECTIVE To assess whether or not baseline serum transaminases and creatinine measurements, before administration of methotrexate, identified significant liver or kidney disease, which have the potential to alter the management plan for the treatment of ectopic pregnancies. DESIGN This is a retrospective study of patients treated for ectopic pregnancy. SETTING Womens emergency room and reproductive endocrinology office at a teaching hospital over a 3-year period. PATIENT(S) Women presenting for treatment of ectopic pregnancy. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Assessment of baseline serum transaminases and creatinine measurements before administration of methotrexate to identify significant liver or kidney disease. RESULT(S) A total of 383 patients were managed for ectopic pregnancy from January 2006 to December 2008. Of these, 320 patients received methotrexate as part of their treatment. No patient was denied treatment with methotrexate secondary to concerns regarding liver or renal function. No complication related to methotrexate administration was documented. A subgroup of 81 patients had pre- and postadministration labs, and no significant difference was noted upon comparing the values. CONCLUSION(S) Routine measurement of serum aspartate aminotransferase and creatinine levels may not be necessary before instituting a single-dose methotrexate treatment regimen for the management of ectopic pregnancy.

Metroplasty to treat chronic pelvic pain resulting from outflow tract müllerian anomalies

Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities.

Uterine Malformations: An Update of Diagnosis, Management, and Outcomes

Importance The prevalence of uterine malformations has been reported in up to 7% of the general population and 18% of those with recurrent pregnancy loss. The diagnosis, classification, management, and outcome of the management have been subject to debate for decades. Objective The aim of this article is to summarize the current knowledge regarding the genetics of müllerian anomalies, the varied classification schemes, the appropriate diagnostic modalities, the surgical methods, and the obstetric outcomes related to these surgical methods. Evidence Acquisition An extensive literature review using the key words uterine anomaly, classification, mullerian, agenesis, unicornuate, didelphys, bicornuate, septate, arcuate, DES, and diethyl stilbestrol was conducted using PubMed. Only English-language publications were reviewed. Relevant references within these publications were also obtained and reviewed in preparing this article. Conclusions Current evidence favors continued use of the American Society of Reproductive Medicine classification. Three-dimensional sonography, especially when combined with saline infusion, can be very helpful in accurately classifying müllerian anomalies. Relevance Müllerian anomalies are relatively common. Accurate knowledge of the advantages and limitations of various diagnostic modalities, the limitations of the classification systems, the surgical options available where appropriate, and the obstetric outcomes after these surgeries will help in the optimal management of these patients.

Hysteroscopic morcellator to overcome cervical stenosis

OBJECTIVE To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. DESIGN Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. SETTING Academic-based practice. PATIENT(S) A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. INTERVENTION(S) A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. MAIN OUTCOME MEASURE(S) Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. RESULT(S) The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. CONCLUSION(S) Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications.

A Review of Laparoscopic Salpingo-Oophorectomy: Technique and Perioperative Considerations

Hysterectomy is the most frequently performed major gynecologic surgery in women in the United States. This procedure is often accompanied by unilateral or bilateral removal of the fallopian tubes and ovaries. Although the overall incidence of bilateral salpingo-oophorectomy has been shown to be in a decreasing trend in recent years, it is possibly 1 of the most common scenarios that the gynecologic surgeon will encounter. As the field of minimally invasive surgery continues to expand, it is expected that most of these surgeries will be performed using a laparoscopic approach. In fact, data support that adnexal surgery is more likely to take place during a laparoscopic hysterectomy when compared with abdominal or vaginal routes. This article reviews the basic surgical principles and relevant anatomic relations that every pelvic surgeon should know and aims to serve as a guide for effectively and proficiently performing a salpingo-oophorectomy at the time of hysterectomy.