Christopher M. Zahn

Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.

Puerperal hematomas, although rare, can be potentially morbid or life-threatening events. Early surgical management, including clot evacuation, layered closure, drainage, antibiotics, and fluid replacement (including blood), usually result in satisfactory outcome. Prevention is clearly preferable and often achievable with careful initial repair of episiotomies and lacerations.

Discrepancy in the interpretation of cervical histology by gynecologic pathologists.

OBJECTIVE To determine if subspecialty review of cervical histology improves diagnostic consensus of cervical intra‐epithelial neoplasia (CIN). METHODS After routine histologic assessment within the hospital pathology department, 119 colposcopic cervical biopsies were interpreted by two subspecialty‐trained gynecologic pathologists (GYN I and GYN II) blinded to each others interpretations and to the interpretations of the hospital general pathologists (GEN). Biopsies were classified as normal (including cervicitis), low grade (LG, including CIN I and human papillomavirus changes), and high grade (HG, including CIN II/III). The interobserver agreement rates between GEN and GYN I, between GEN and GYN II, and between GYN I and GYN II were described using the κ statistic. The proportions of biopsies assigned to each biopsy class were compared using McNemar test. RESULTS Interobserver agreement rates between GEN and GYN I were moderate for normal (κ = 0.53) and LG (κ = 0.46) and excellent for HG (κ = 0.76). There were no significant differences in the classifications between GEN and GYN I. Interobserver agreement rates between GEN and GYN II were moderate for normal (κ = 0.50) and LG (κ = 0.44) and excellent for HG (κ = 0.84). Also, GYN II was significantly more likely to classify biopsies as normal (P < .001) and less likely to classify biopsies as LG (P < .001). The interobserver agreement rates between GYN I and GYN II were moderate for normal (κ = 0.61) and LG (κ = 0.41) and excellent for HG (κ = 0.84). Also, GYN II was significantly more likely to classify biopsies as normal (P < .001) and less likely to classify biopsies as LG (P = .01). CONCLUSION Interobserver agreement between two gynecologic pathologists was no better than that observed between general and gynecologic pathologists. Subspecialty review of cervical histology does not enhance diagnostic consensus of CIN.

Postpartum hemorrhage: abnormally adherent placenta, uterine inversion, and puerperal hematomas.

With astute management of labor and the employment of basic and sometimes advanced skills in the delivery room, obstetricians can still achieve a vaginal delivery for most pregnant women. Occasionally, the labor is long and oxytocin stimulation is required. The use of instruments to complete the delivery may be necessary. The experienced practitioner is well aware, however, that serious complications are often encountered after the delivery of the baby. The risk of obstetric hemorrhage is greatest during the third stage (placental separation and delivery) and fourth stage (the hour after delivery of the placenta) of labor. Proper management of postpartum hemorrhagic complications when they occur, and possibly even prevention of these complications, may avoid significant maternal morbidity and mortality. The subject of postpartum hemorrhage has been periodically reviewed. After a brief summary on postpartum hemorrhage in general, the primary focus of this chapter is to address 3 relatively uncommon third and fourth-stage complications: abnormally adherent placenta, uterine inversion, and puerperal vulvovaginal hematomas.

Establishing a Mean Postvoid Residual Volume in Asymptomatic Perimenopausal and Postmenopausal Women

OBJECTIVE: To estimate mean postvoid residual (PVR) volumes among perimenopausal and postmenopausal women without significant lower urinary tract or pelvic organ prolapse symptoms. METHODS: Patients presenting for well-women encounters were offered study participation. Women with a history of urinary incontinence greater than twice per week, urinary retention, symptomatic pelvic organ prolapse, or neurologic disorders were excluded. Pelvic relaxation, if present, was characterized according to the pelvic organ prolapse quantification system. Within 10 minutes of spontaneously voiding, PVR volume was assessed with bladder ultrasonography. RESULTS: A total of 96 patients were enrolled; mean age was 60±11 years. The majority (80%) were postmenopausal; 30% had a previous hysterectomy. Most women (92%) had some degree of prolapse; the median stage was one, most commonly involving the anterior compartment (70%). The median PVR volume was 19 mL (range 0–145 mL); the mean PVR volume was 24±29 mL. Only 15% of patients had a PVR volume greater than 50 mL, and 95% had a PVR volume 100 mL or less. Only age 65 years or older was associated with a higher mean PVR volume; hormone therapy, vaginal atrophy, parity, and stage of asymptomatic prolapse did not affect PVR volumes. CONCLUSION: Most asymptomatic perimenopausal and postmenopausal women had a PVR volume less than 50 mL, which was unaffected by multiple factors that were thought to potentially affect bladder function. Establishing “normal” volumes in this population may aid in developing recommendations regarding appropriate bladder function and retention criteria for women who are symptomatic or those who have had pelvic floor surgery. LEVEL OF EVIDENCE: II

Anatomic comparison of two transobturator tape procedures.

OBJECTIVE: Both outside-in and inside-out methods are available for transobturator tape placement. Our objective was to compare these methods regarding proximity of the tape to the obturator canal and ischiopubic ramus. METHODS: Using seven fresh frozen cadavers, transobturator tapes were placed using the inside-out (TVT-Obturator System, Gynecare, Ethicon Inc, Somerville, NJ) and outside-in (Monarc, American Medical Systems, Minnetonka, MN) methods bilaterally in each cadaver. We dissected to the level of the obturator membrane and measured the distance from the closest aspect of the obturator canal and ischiopubic ramus to each tape. RESULTS: Transobturator tapes placed by using the inside-out technique were significantly closer to the obturator canal than with the outside-in method (mean distances: 1.3±0.44 cm compared with 2.3±0.41 cm, respectively, P<.001); the greater proximity of the inside-out method was noted in all dissections. Tapes placed with the inside-out method were also farther from the ischiopubic ramus than those placed with the outside-in approach (mean distances: 0.39±0.44 cm compared with 0.04±0.13 cm, respectively, P=.008). When distances between the tapes relative to the obturator canal were further analyzed according to left or right side, the difference between methods was maintained. Additionally, the distances were consistently farther from the obturator canal on the left side than on the right side regardless of transobturator tape approach. CONCLUSION: The outside-in technique results in the mesh being placed farther from the obturator canal and closer to the ischiopubic ramus, theoretically reducing the risk of neurovascular injury. LEVEL OF EVIDENCE: II

Correlation of National Board of Medical Examiners scores with United States Medical Licensing Examination Step 1 And Step 2 scores.

Purpose Determine whether the National Board of Medical Examiners (NBME) Subject Examination performance from six clerkships correlated with United States Medical Licensing Examination (USMLE) Steps 1 and 2 Clinical Knowledge (CK) Examination scores. Also, examine correlations between medical students’ preclinical and clinical year mean cumulative grade point average (GPA), subject exam, and USMLE performance. Method The sample consisted of 507 students from the 2008–2010 graduating classes from the authors’ medical school. Pearson correlations followed by stepwise linear regressions were used to investigate variance in USMLE Steps 1 and 2 CK scores explained by subject exam scores and GPA. Results Data from 484 (95.5%) students were included. USMLE Steps 1 and 2 CK scores had moderate-to-large positive correlations with all subject exam scores and with both GPA variables. Correlations between composite subject exam scores and USMLE Steps 1 and 2 CK exams were 0.69 and 0.77, respectively. Regression analysis demonstrated that subject exams and GPA accounted for substantial variance in Steps 1 and 2 CK exam scores (62% and 61%); when entered into the regression model first, primary care clerkship subject examination scores accounted for most of this variance. Conclusions The moderate-to-large correlations between subject exam performance and USMLE scores provide reassurance that subject exam scores are associated with USMLE performance. Furthermore, the considerable variance in USMLE scores accounted for by primary care NBME scores may be due to primary care topics being reinforced through all clerkships and comprising a significant portion of the USMLE examinations, particularly Step 2 CK.

Laparoscopic hysterectomy using various energy sources in swine: a histopathologic assessment

OBJECTIVE Analyze energy-induced damage to the swine vagina during laparoscopic hysterectomy. STUDY DESIGN Laparoscopic colpotomy was performed in swine using ultrasonic, monopolar, and bipolar energy. Specimens (n = 22) from 13 swine were stained with hematoxylin and eosin and Massons trichrome for energy-related damage. The distal scalpel-cut margin was used as reference. Energy induced damage was assessed by gynecologic and veterinary pathologists blinded to energy source. RESULTS Injury was most apparent on Massons trichrome, demonstrating clear injury demarcation, allowing consistent, quantitative damage measurements. Mean injury was 0 ± 0 μM (scalpel, n = 22), 782 ± 359 μM (ultrasonic, n = 7), 2016 ± 1423 μM (monopolar, n = 8), and 3011 ± 1239 μM (bipolar, n = 7). Using scalpel as the reference, all were significant (P < .001). CONCLUSION All energy sources demonstrated tissue damage, with ultrasonic showing the least and bipolar the greatest. Further study of tissue damage relative to cuff closure at laparoscopic hysterectomy is warranted.

To ECC or Not to ECC : The Question Remains

The usefulness of endocervical curettage (ECC) in evaluating women who have abnormal cervical cytology and histopathology has been debated for years; data regarding performance of ECC in the diagnostic evaluations of squamous and glandular lesions are mixed. There are no well-done randomized trials or systematic reviews regarding the usefulness of ECC. The yield on ECC increases in the setting of unsatisfactory colposcopy; in this situation, there seems less controversy regarding performance of an ECC. Reproducibility of ECC-rendered diagnosis is a concern. Data are needed to further define the role of ECC in evaluating women who have cervical disease.

Gene Expression Analysis of Early Stage Endometrial Cancers Reveals Unique Transcripts Associated with Grade and Histology but Not Depth of Invasion

Endometrial cancer is the most common gynecologic malignancy in the United States but it remains poorly understood at the molecular level. This investigation was conducted to specifically assess whether gene expression changes underlie the clinical and pathologic factors traditionally used for determining treatment regimens in women with stage I endometrial cancer. These include the effect of tumor grade, depth of myometrial invasion and histotype. We utilized oligonucleotide microarrays to assess the transcript expression profile in epithelial glandular cells laser microdissected from 79 endometrioid and 12 serous stage I endometrial cancers with a heterogeneous distribution of grade and depth of myometrial invasion, along with 12 normal post-menopausal endometrial samples. Unsupervised multidimensional scaling analyses revealed that serous and endometrioid stage I cancers have similar transcript expression patterns when compared to normal controls where 900 transcripts were identified to be differentially expressed by at least fourfold (univariate t-test, p < 0.001) between the cancers and normal endometrium. This analysis also identified transcript expression differences between serous and endometrioid cancers and tumor grade, but no apparent differences were identified as a function of depth of myometrial invasion. Four genes were validated by quantitative PCR on an independent set of cancer and normal endometrium samples. These findings indicate that unique gene expression profiles are associated with histologic type and grade, but not myometrial invasion among early stage endometrial cancers. These data provide a comprehensive perspective on the molecular alterations associated with stage I endometrial cancer, particularly those subtypes that have the worst prognosis.

Reflex High-Risk Human Papillomavirus Testing for Women With Atypical Squamous Cells of Undetermined Significance in Cytologic Smears Effects Since Implementation in a Large Clinical Practice

Reflex high-risk human papillomavirus (HPV) testing often is used in the management of women with atypical squamous cells of undetermined significance identified in cervicovaginal screening. Following implementation of reflex testing, our laboratory processed 8,022 specimens during a 20-month period; sufficient material was available for testing in 7,334 specimens. High-risk HPV was detected in 34.10% of these specimens. Detection rates varied with age, with positive rates as high as 58.46% in women 20 years old or younger, decreasing to 14.58% in women older than 35 years. The detection rate, categorized in 5-year age increments, showed a significant decrease until after 35 years, when the rate remained fairly constant (P < .0001). The detection rate decreased over the time of the study. These results demonstrate that high-risk HPV detection might vary according to the age mix of the population tested and the interval after implementation of testing.