Megan S. Bradley

Sleep Duration and Blood Glucose Control in Women With Gestational Diabetes Mellitus.

OBJECTIVE: To describe the relationship between objectively assessed sleep and blood glucose in a prospective cohort of women recently diagnosed with gestational diabetes mellitus (GDM). METHODS: Women with GDM were enrolled immediately after attending a GDM education class. All patients were recruited during their first week of attempted dietary management of GDM. They were instructed on the use of a glucometer and on the principles of a GDM diet. Women wore an actigraph and completed a sleep log for 7 consecutive days. Glucose records were compared against the objective sleep data. Linear mixed model analysis was used to estimate the association of sleep duration on morning fasting and 1-hour postprandial blood glucose concentrations. RESULTS: Thirty-seven participants provided data for 213 sleep intervals that corresponded to at least one glucose reading. Sleep duration was negatively associated with fasting and 1-hour postprandial blood glucose concentrations In analyses adjusted for age, gestational age, and body mass index, a 1-hour increase in sleep time was associated with statistically significant reductions in fasting glucose (−2.09 mg/dL, 95% confidence interval [CI] −3.98 to −0.20) as well as postprandial glucose concentrations (lunch −4.62 mg/dL, 95% CI −8.75 to −0.50; dinner −6.07 mg/dL, 95% CI −9.40 to −2.73). CONCLUSION: Short sleep durations are associated with worsened glucose control in women with gestational diabetes. Educating women on healthy sleep and screening for and treating sleep disorders during pregnancy may have a role in optimizing blood glucose control in gestational diabetes. LEVEL OF EVIDENCE: II

Effect of rotation on perineal lacerations in forceps-assisted vaginal deliveries.

OBJECTIVE: To determine the difference in the rates of severe perineal lacerations between forceps-assisted vaginal deliveries in the occiput-posterior position compared with forceps-assisted vaginal deliveries in which the fetal head was rotated to occiput-anterior before delivery. METHODS: We studied a retrospective cohort of 148 women who had a forceps-assisted vaginal delivery from 2008 to 2011 at the University of Pittsburgh. Mild perineal lacerations were defined as first or second degree, and severe lacerations were defined as third or fourth degree. &khgr;2 and t tests were used for bivariate and logistic regression was used for multivariable analyses. P<.05 was considered statistically significant. RESULTS: Of 148 forceps-assisted deliveries, 81 delivered occiput-anterior after either manual or forceps rotation, 10 delivered in the occiput-posterior or occiput-transverse position after an unsuccessful rotation, and 57 delivered occiput-posterior without attempted rotation. No significant differences were found among demographic, obstetric, and neonatal characteristics of the groups. Overall, 86 (67.7%) women had mild lacerations and 41 (32.3%) had severe lacerations. A significantly greater rate of severe perineal lacerations was found in the occiput-posterior nonrotated compared with the rotated group (43.4% compared with 24.3%; P=.02). In multivariable analyses, adjusted for age, race, insurance, body mass index, gestational age, parity, episiotomy, and birth weight, forceps-assisted vaginal delivery in the occiput-posterior position without rotation remained significantly more likely to be associated with severe lacerations (odds ratio 3.67, 95% confidence interval 1.42–9.47). CONCLUSION: Forceps-assisted vaginal delivery after rotation of an occiput-posterior position to an occiput-anterior position is associated with less severe maternal perineal trauma than forceps-assisted delivery in the occiput-posterior position. LEVEL OF EVIDENCE: II

Role of salpingectomy at the time of urogynecologic surgery.

Purpose of review This article reviews the current literature about prophylactic bilateral salpingectomy and provides guidelines for clinicians in regard to the inclusion of salpingectomy at the time of urogynecologic surgery. Recent findings After the Nurses’ Health Study showed that all-cause mortality was increased in women undergoing oophorectomy at the time of hysterectomy for benign indications, there was a shift in focus toward ovarian conservation at the time of gynecologic surgery. As there has been continued interest in the fallopian tube as the origin of ovarian cancer, a move toward prophylactic salpingectomy has occurred. This strategy has become widely accepted in high-risk women, but is not universal in either premenopausal or postmenopausal women who are primarily served by the urogynecologic community. Summary Current literature supports that, if easily accessible, the fallopian tubes should be removed at the time of urogynecologic surgery. In premenopausal women, salpingectomy does not likely affect ovarian reserve, but this possibility should be discussed with patients. If inaccessible (i.e., at the time of a midurethral sling), there should not be additional surgery performed to access the fallopian tubes. In addition, the pathologic evaluation of the fallopian tubes should include complete examination of the fimbriae and a representative section of the nonfimbriated portion.

Vaginal extrusion of a ventriculo-peritoneal shunt catheter in an adult.

Ventriculo-peritoneal shunts (VPS) are commonly used in the treatment of various neurosurgical conditions, including hydrocephalus and pseudotumor cerebri. We report only the second case of vaginal extrusion of a VPS catheter in an adult, and the first case with a modern VPS silastic peritoneal catheter. A 45-year-old female with a history of VPS for pseudotumor cerebri, Behcets syndrome, and hysterectomy presented to our institution with the chief complaint of tubing protruding from her vagina after urination. On gynecologic examination, the patient was found to have approximately 15 cm of VPS catheter protruding from her vaginal apex. A computed tomography scan of the abdomen and shunt X-ray series demonstrated no breaks in the tubing, but also confirmed the finding of the VPS catheter extruding through the vaginal cuff into the vagina. The patient had the VPS removed and an external ventricular drain was placed for temporary cerebrospinal fluid diversion. Ventricular catheter cultures were positive for diphtheroids. After an appropriate course of antibiotics, a contralateral ventriculo-pleural shunt was placed one week later. Although vary rare, vaginal extrusion can occur in adults, even with modern VPS catheters.

A genome-scale DNA methylation study in women with interstitial cystitis/bladder pain syndrome

To assess the feasibility of using voided urine samples to perform a DNA methylation study in females with interstitial cystitis/bladder pain syndrome (IC/BPS) as compared to age‐ and race‐matched controls. A unique methylation profile could lead to a non‐invasive, reproducible, and objective biomarker that would aid clinicians in the diagnosis of IC/BPS.

Robotic-Assisted Sacrocolpopexy: Early Postoperative Outcomes after Surgical Reduction of Enlarged Genital Hiatus

BACKGROUND Currently, the decision to perform a concurrent posterior repair/perineoplasty at the time of robotic‐assisted sacrocolpopexy is not standardized. OBJECTIVE We sought to compare anatomic failure after robotic‐assisted sacrocolpopexy among 3 groups of patients categorized by their preoperative and postoperative genital hiatus size. STUDY DESIGN We performed a retrospective cohort study of women who underwent robotic‐assisted sacrocolpopexy, from January 2013 through September 2016. We defined a wide genital hiatus as ≥4 cm and a normal genital hiatus as <4 cm. We compared 3 groups: (1) wide preoperative and postoperative genital hiatus (persistently wide); (2) wide preoperative and normal postoperative genital hiatus (improved); and (3) normal preoperative and postoperative genital hiatus (stably normal). Our primary outcome was composite anatomic failure defined as either recurrent prolapse in any compartment past the hymen or retreatment for prolapse with either surgery or pessary. Our data were analyzed using 1‐way analysis of variance and χ2 test. Logistic regression was performed to evaluate for independent risk factors for anatomic failure among the 3 groups. P < .05 was considered significant. RESULTS Our study population consisted of 452 women with a mean age of 59.3 ± 10.0 years and a mean body mass index of 27.8 ± 5.3 kg/m2. Of the women with reported race, 394/447 (88.1%) were white. The genital hiatus groups were distributed as follows: 57 (12.6%) were persistently wide, 296 (65.5%) were improved, and 99 (21.9%) were stably normal. The stably normal group had less advanced preoperative prolapse (stage ≥3) than the other groups (P < .01). A similar percentage of patients among groups had a concomitant posterior repair/perineoplasty (P = .09) with a total of 84 (18.6%) women undergoing this procedure. There was a statistically significant difference in overall composite anatomic failure among the groups (P = .03). There was an increase in failure in the persistently wide group (14.0%) compared to the improved group (5.7%, P = .04) and compared to the stably normal group (4.0%, P = .03). In a logistic regression model, controlling for number of vaginal deliveries and posterior repair/perineoplasty, there was a 5.3‐fold increased odds of composite anatomic failure in the persistently wide group (adjusted odds ratio, 5.3; 95% confidence interval, 1.4–19.1; P = .01) compared to the stably normal group. In a subanalysis of failure by compartment, there was an increase in failure of the posterior compartment in the persistently wide group compared to the improved group (8.8% vs 2.0%, P < .01), but not the stably normal group (3.0%, P = .12). There was not a statistically significant difference in failure of the combined apical and anterior compartments among groups (P = .29). CONCLUSION Surgical reduction of an enlarged preoperative genital hiatus decreases early composite anatomic failure, after robotic sacrocolpopexy, specifically related to the posterior compartment. Studies investigating the correlation of intraoperative measurement of genital hiatus to postoperative genital hiatus are needed to help clinicians determine who may benefit from a concomitant posterior repair/perineoplasty at the time of robotic‐assisted sacrocolpopexy.

Correlation of Virtual Reality Simulation and Dry Lab Robotic Technical Skills

STUDY OBJECTIVE To examine whether a set of virtual reality (VR) surgical simulation drills have correlative validity when compared with the validated Robotic Objective Structured Assessment of Technical Skills (R-OSATS) dry lab drills. DESIGN A prospective methods comparison study (Canadian Task Force classification II-2). SETTING A teaching hospital. PARTICIPANTS Thirty current residents, fellows, and faculty from the Departments of Obstetrics and Gynecology, Urology, and General Surgery. INTERVENTIONS Participants completed 5 VR drills on the da Vinci Skills Simulator and 5 dry lab drills. Participants were randomized to the order of completion. MEASUREMENTS AND MAIN RESULTS VR drills were scored automatically by the simulator. Dry lab drills were recorded, reviewed by 3 blinded experts, and scored using the R-OSATS assessment tool. Spearman correlation coefficients were calculated comparing simulator scores and R-OSATS scores for the same surgeon. The correlation for overall summary scores between VR and dry lab drills was strong (r = 0.83; p < .01). Each of the 5 VR drills was also found to have a statistically significant correlation to its corresponding dry lab drill, with correlation coefficients ranging from r = 0.49 to 0.73 (p < .01 for all). The performance on VR drills also confirmed construct validity. Faculty and fellows had consistently higher overall scores than residents (median VR scores: 458 for faculty, 425 for fellows, 339 for residents; p < .01). CONCLUSION We selected a core set of VR drills that reliably correlate with validated dry lab R-OSATS drills. Because dry lab drills require significant time and effort on the part of the trainees and the evaluators, this set of VR drills could serve as an ancillary method of determining trainee competence.

Vaginal repair of a vesicocervical fistula after labored-cesarean delivery without concomitant hysterectomy

A 30-year-old woman presented with a chief complaint of urinary leakage per vagina for 5 months following a labored-cesarean delivery complicated by a cystotomy and need for a ureteral reimplantation. Pelvic examination showed her to have a very short anterior cervical lip, which was flush with the vaginal wall. Office cystourethroscopy revealed a 3mm fistula on the cystotomy repair scar, which tracked to the cervix. There was obvious irrigation flow from a distal location in the cervical os, which was notably still open from her recent labor. She underwent a preoperative CT urogram that was negative for a uretero-vaginal fistula. Surgery was performed under general anesthesia with the patient in the dorsal lithotomy position and using a table-fixed perineal Bookwalter® retractor with malleable vaginal blades. The fistulous tract was cannulated with a Glidewire® to aid visualization (Fig. 1). The vesicocervical plane was sharply dissected until the cannulated vesicocervical fistula was identified (Fig. 2). The bladder was completely mobilized away from the anterior surface of the cervix (Fig. 3). Closure of the bladder was performed with three layers of imbricating interrupted 4.0 absorbable suture. The closure was water tight and remote from both ureteral orifices on cystoscopy. A Foley was replaced and the vaginal epithelium was re-approximated. The Foley catheter was removed 3 weeks after surgery. There was no evidence for fistula recurrence at the 6-week follow-up visit.