Nigel Pereira

Postablation risk factors for pain and subsequent hysterectomy.

OBJECTIVE: To assess patient characteristics associated with pain and hysterectomy after endometrial ablation. METHODS: A retrospective cohort study was performed using data from two large academic medical centers. Three hundred patients who underwent endometrial ablation between January 2006 and May 2013 were identified for study. Data collected included baseline characteristics at the time of ablation, relevant medical history, and ablation technique. Univariate tests of association and logistic regression were used to evaluate risk factors for postablation pain or hysterectomy. RESULTS: Of the 300 women who had endometrial ablation performed during the study period, 270 had follow-up data for analysis. Twenty-three percent developed new or worsening pain after ablation and 19% underwent a hysterectomy. A history of dysmenorrhea gave a 74% higher risk of developing pain (adjusted odds ratio [OR] 1.74, 95% confidence interval [CI] 1.06–2.87) and tubal sterilization conferred more than double the risk (adjusted OR 2.06, 95% CI 1.14–3.70). Women of white race were 45% less likely to develop pain (adjusted OR 0.55, 95% CI 0.34–0.89). For hysterectomy, a history of cesarean delivery more than doubled the risk (adjusted OR 2.33, 95% CI 1.05–5.16), whereas uterine abnormalities on imaging, including leiomyoma, adenomyosis, thickened endometrial strip, and polyps, quadrupled the risk (adjusted OR 3.96, 95% CI 1.25–12.56). A procedure performed in the operating room decreased the risk of hysterectomy by 76% (adjusted OR 0.24, 95% CI 0.07–0.77). Hysterectomies for the indication of pain occurred more than 3 years sooner than for other indications (P<.001). CONCLUSION: Patient characteristics should be considered when counseling patients about the possible outcomes of endometrial ablation. A significant portion of ablations are complicated by postablation pain. LEVEL OF EVIDENCE: II

Electric Morcellation-related Reoperations After Laparoscopic Myomectomy and Nonmyomectomy Procedures

STUDY OBJECTIVE To identify, collate, and summarize the most common causes and pathologies of electric morcellation-related reoperations after laparoscopic myomectomy and nonmyomectomy procedures. DESIGN A systematic review of published medical literature from January 1990 to February 2014 reporting morcellation-related reoperations after laparoscopic myomectomy and nonmyomectomy procedures involving the use of intracorporeal electric tissue morcellators. Publications were included in this review if patients underwent a second surgical procedure because of the onset of new clinical symptoms after a primary surgical procedure that involved intracorporeal morcellation or if histopathology of the morcellated surgical specimen revealed malignancy (Canadian Task Force classification II-3). SETTING All case reports and case series were reported from community and academic hospitals in the United States and the rest of the world. PATIENTS We identified 66 patients from 32 publications. INTERVENTIONS Reoperation after laparoscopic myomectomy and nonmyomectomy procedures involving intracorporeal electric tissue morcellation. MEASUREMENTS AND MAIN RESULTS For patients who presented with new clinical symptoms requiring reoperation, we recorded the follow-up period, nature and duration of the new symptoms, details of the second surgical procedure, intraoperative findings during the second surgical procedure, and the final histopathologic diagnosis. When histopathology of the morcellated specimen revealed malignancy, we recorded the specific type of malignancy, the corresponding surgical treatment that the patient underwent, and the follow-up period. Percentages and 95% confidence intervals were calculated for all categoric variables. Twenty-four (36.4%) patients underwent laparoscopic myomectomies, of which 19 (79.2%) and 5 (20.8%) patients required a second surgical procedure because of new clinical symptoms and the diagnosis of malignancy in the morcellated surgical specimen, respectively. Forty-two (63.6%) patients underwent laparoscopic hysterectomies; of these, 25 (59.5%) patients required a second surgical procedure because of the onset of new clinical symptoms, whereas the remaining 17 (40.5%) patients underwent a second surgical procedure because of the diagnosis of malignancy in the morcellated surgical specimen. The most common benign pathology was parasitic leiomyomata (22 patients, 33.3%). The most common malignant pathology was leiomyosarcoma (16 patients, 24.2%). CONCLUSION Dispersion of tissue fragments into the peritoneal cavity at the time of morcellation continues to be a concern. It was previously thought that morcellated tissue fragments are resorbed by the peritoneal cavity; however, there is some evidence highlighting the long-term sequelae related to the growth and propagation of these dispersed tissue fragments in the form of parasitic leiomyomata, iatrogenic endometriosis, and cancer progression. Yet, the majority of laparoscopic myomectomy and nonmyomectomy procedures involving the use of intracorporeal electric tissue morcellators are uncomplicated, and institutions having no women with endometriosis or cancer are very unlikely to report surgical outcomes of uneventful electric morcellation. Thus, prospective studies are still required to validate the role of electric intracorporeal tissue morcellation in the pathogenesis of parasitic leiomyomata, iatrogenic endometriosis, and cancer progression.

Vaginal toxic shock reaction triggering desquamative inflammatory vaginitis.

Objective The study aimed to report 2 cases of desquamative inflammatory vaginitis associated with toxic shock syndrome toxin 1 (TSST-1)–producing Staphylococcus aureus strains. Materials and Methods Case report of 2 patients, 1 with an acute and 1 with a chronic presentation, diagnosed with desquamative inflammatory vaginitis on the basis of clinical findings and wet mount microscopy. Pretreatment and posttreatment vaginal bacterial and yeast cultures were obtained. Results Pretreatment vaginal bacterial cultures from both patients grew TSST-1–producing S. aureus. Subsequent vaginal bacterial culture results after oral antibiotic therapy were negative. Conclusions Desquamative inflammatory vaginitis may be triggered through TSST-1–mediated vaginal toxic shock reaction.

Comparison of human papillomavirus infection and cervical cytology in women using copper-containing and levonorgestrel-containing intrauterine devices.

OBJECTIVE: To investigate whether there is a difference in cervical cytology and high-risk human papillomavirus (HPV) infection clearance between levonorgestrel- and copper-containing intrauterine device (IUD) users. METHODS: The electronic medical record system was searched by the appropriate procedural code for IUD insertion for all patients undergoing IUD placement during the study period (January 31, 2005 to January 31, 2012). Patients who received treatment for cervical dysplasia, had their IUDs removed, or conceived during the study period were excluded. High-risk HPV and cervical cytology results immediately preceding and after IUD placement were obtained. RESULTS: One hundred fifty patients had a copper-containing and 152 patients a levonorgestrel-containing IUD placed. The groups were comparable in terms of age, body mass index, duration of follow-up, and percentage of smokers. Sixty-six patients were high-risk HPV-positive before IUD insertion (30 in copper compared with 36 in the levonorgestrel IUD group, P=.4), and the groups had similar follow-up times (364.1±26.3 compared with 357.2±29.7 days, respectively, between the IUD placement and a repeat Pap test with high-risk HPV cotesting, P=.2). Of those, 21 (70%; 95% confidence interval [CI] 53.6–86.4%) cleared the infection after copper-containing IUD placement compared with 15 (42%; 95% CI 25.6–57.8%) in the levonorgestrel group (P=.04). There were only two (1.7%) new high-risk HPV infections in the copper compared with eight (6.9%) in the levonorgestrel group (P=.056). CONCLUSION: Our data suggest that levonorgestrel-containing IUD could be associated with decreased high-risk HPV infection clearance and possibly increased acquisition compared with the copper-containing IUD. LEVEL OF EVIDENCE: II

Returning Inactive Obstetrics and Gynecology Physicians to Clinical Practice: The Drexel Experience

Introduction: Physicians returning to clinical practice after inactivity may face many challenges. Few programs provide reeducation, and data are limited about these experiences. We describe the physician refresher/reentry program at Drexel University College of Medicine, Philadelphia, and the lessons learned in our efforts to facilitate obstetrician‐gynecologists’ clinical reentry. Methods: In 2006, Drexel relaunched the Medical College of Pennsylvanias physician reentry course. This structured yet individualized program provides reeducation and assessment for physicians who have left clinical medicine for any reason and are hoping to return. We report the results achieved for 9 obstetrician‐gynecologists who successfully completed Drexels course between November 2006 and November 2012. Results: The 6 men and 3 women had left their practices for different reasons. Seven were reentry candidates, and 2 were remediating; none had left practice for medical negligence. Of the reentering physicians, 5 achieved their goal within 1 month. Of the remediating physicians, 1 achieved his/her goal. Discussion: Through continual self‐assessment and participant feedback, we have learned to expand our staff and faculty career advisory roles and seek specialty‐specific assessment. Despite our small sample size, Drexels experience may provide guidance to the growing field of obstetrician/gynecologist reentry in the United States.

Outcomes of effective transmission of electronic prenatal records from the office to the hospital

OBJECTIVE: To investigate the outcomes associated with improved transmission of prenatal test results between the outpatient and inpatient obstetric setting after implementation of an electronic prenatal record system. METHODS: Admission paper charts of patients admitted to our labor and delivery unit were reviewed before and after implementation of an electronic prenatal record system. The availability of maternal hepatitis B and human immunodeficiency virus (HIV) serology on admission, the occurrence of repeat hepatitis B surface antigen and rapid HIV blood testing, and the occurrence of hepatitis B immunoglobulin administration to the newborns of mothers without available hepatitis B serology was recorded. Fishers exact tests were performed to determine differences in availability of prenatal test results, the occurrence of repeat blood testing, and the occurrence of immunoglobulin administration before and after implementation. RESULTS: A total of 460 admission charts were reviewed, 229 preimplementation and 231 postimplementation. Of the preimplementation charts, 78.2% contained maternal hepatitis B and HIV serology results, whereas all postimplementation charts contained such results (P<.001). Although repeat hepatitis B surface antigen testing was performed in 3.1% of patients preimplementation, no patients required repeat testing postimplementation (P=.007). Similarly, rapid HIV blood testing was performed in 3.5% of patients preimplementation, but no patients required repeat testing postimplementation (P=.003). Increased availability of testing results prevented unnecessary administration of hepatitis B immunoglobulin postimplementation. CONCLUSION: Implementation of an electronic perinatal record system was associated with improved transmission of prenatal test results between the outpatient and inpatient obstetric setting and a decreased rate of unnecessary maternal testing and newborn interventions. LEVEL OF EVIDENCE: III

Placenta membranacea with placenta accreta: radiologic diagnosis and clinical implications.

Placenta membranacea, also called placenta diffusa, is a rare developmental abnormality of the human placenta in which fetal membranes are covered diffusely by chorionic villi of varying thickness. Although its etiology remains elusive, several reports have linked this entity to abnormal placental adherence, as well as life-threatening antepartum hemorrhage and fetal death. We searched MEDLINE using PubMed for all English-language articles published until 2013 with search terms ‘placenta membranacea’, ‘placenta diffusa’, ‘placenta accreta’, ‘hemorrhage’, and ‘cesarean hysterectomy.’ Our search returned 18 publications pertaining to this subject. In all publications, the diagnosis of placenta membrancea was achieved by post-delivery pathologic examination of the placenta. On the basis of this search, our report represents the first case of the antenatal diagnosis of placenta membranacea using magnetic resonance imaging (MRI). A 21-year-old African-American woman presented for routine ultrasonography (US) at a gestational age of 22weeks and 3days. The patient underwent a full-term cesarean delivery 1 year ago for fetal intolerance to labor. Although US imaging revealed fetal biometry consistent with gestational age, the placenta was visualized diffusely throughout the uterus, appearing thinner than usual (Figure 1). Placenta membranacea was suspected, and the patient was scheduled for monthly US evaluation of placental and fetal growth. On subsequent US imaging, the placenta appeared thinner that is, <2 standard deviations below the mean thickness, and was visualized throughout the anterior and posterior walls of the uterus, with portions suspicious for abnormal adherence. Given the suspicion of abnormal placental adherence, MRI of the abdomen and pelvis was performed at gestational age of 32weeks and 3 days. Using gradient-echo T1-weighted, T2-weighted, and T2 fat-saturated sequences, the placenta was now seen covering greater than 75% of the inner myometrial surface. Loss of normal myometrial-placental interface in multiple areas was also noted. This was particularly evident along the posterior wall of the uterus (Figure 2), particularly at the level of the aortic bifurcation. The descending colon appeared to immediately abut the uterine wall, suspicious for infiltration of placental tissue through the left lateral uterus into the wall of the colon. Multiple placental venous lakes within the posterior left placenta measuring up to 3.7 × 5.5 × 3.8 cm were also visualized. Interestingly, the anterior lower uterine segment, which was the site of the previous uterine incision, was the only portion of the uterus free of placenta. These findings confirmed the presence of placenta membranacea with several areas suspicious for placenta percreta particularly along the posterior uterine wall. In anticipation of complicated surgery and the possibility of life-threatening intraoperative hemorrhage, we formulated a meticulous plan of having ready availability of blood products, specialized intraoperative surgical, anesthesia and nursing staff, as well as immediate postoperative intensive care monitoring. Given the findings of placenta membranacea with several areas suspicious for placenta percreta, we planned to proceed with a cesarean hysterectomy under general anesthesia between 34 and 35weeks of gestational age. At a gestational age of 34weeks and 2 days, the patient was taken to the operating room, where US-guided placental mapping was performed prior to abdominal entry. A 10 cm midline vertical skin incision was created, and a live male infant weighing 2495 g and APGAR scores of 4/8 was delivered through a low-transverse hysterotomy. Despite no intraoperative evidence of placenta percreta along the posterior or anterior uterine wall, we still suspected at least a placenta accreta and deemed the large placental mass not amenable to delivery through the hysterotomy. We, therefore, proceeded with the cesarean hysterectomy. The placenta was left in situ, and an uneventful subtotal hysterectomy was

Acute Hemorrhage Related to a Residual Cervical Pregnancy: Management with Curettage, Tamponade, and Cerclage

Cervical ectopic pregnancy is uncommon, with no universally accepted protocol for conservative management of acute hemorrhage due to residual cervical ectopic pregnancy. Herein is presented the case of a 33-year-old woman with profuse vaginal bleeding 3 months after receiving treatment including intraamniotic potassium chloride injection, systemic methotrexate, and uterine artery embolization because of a cervical ectopic pregnancy. A residual cervical pregnancy was suspected. Hemorrhage was controlled using curettage, tamponade with a Bakri balloon, and cerclage. The balloon and cerclage were removed on postoperative day 2, with no recurrence of symptoms. Our experience suggests that a combination of curettage, balloon tamponade, and cerclage may be considered in the management of cervical ectopic pregnancies with acute hemorrhage, in particular in patients desiring future childbearing.

Placental malperfusion as a possible mechanism of preterm birth in patients with Müllerian anomalies.

Abstract Objective: Müllerian anomalies are associated with increased risk of miscarriage, intrauterine growth restriction (IUGR) and preterm birth. While a commonly implicated cause is restricted expansion of endometrial cavity, alternatively it could be due to abnormal placentation. We sought to examine clinical and histopathologic factors associated with preterm delivery in women with Müllerian anomalies. Study design: One hundred and eleven singleton pregnancies in 85 women were analyzed retrospectively. There were 42 pregnancies with bicornaute, 24 with unicornuate, 24 with septate, 19 with didelphys and one each with arcuate and T-shaped uterus. Primary outcomes included gestational age at delivery, placental histopathology, placenta previa and accreta. Results: Twenty-eight (25.2%) of pregnancies were delivered prior to term. Of those, only 14 (50%) were due to preterm labor or preterm premature rupture of membranes (PPROM). Histological evidence of placental malperfusion was present in 22% of all pregnancies and those delivered at an earlier median gestational age [34 (IQR 31–37) vs. 37 weeks (IQR 34–39); P=0.001]. Malperfusion was more common in preterm than in full term births (46% vs. 14%; P=0.04). Conversely, inflammation was not more common in preterm compared to term deliveries (17.9% vs. 16.9%; P=0.89). Five pregnancies had placenta previa, three of which were complicated by accreta. Conclusion: Placental malperfusion, rather than inflammation, was more commonly associated with preterm births in women with uterine anomalies.

Perinatal Risks Associated with Early Vanishing Twin Syndrome following Transfer of Cleavage- or Blastocyst-Stage Embryos

Objective. To investigate whether the perinatal risks associated with early vanishing twin (VT) syndrome differ between cleavage- or blastocyst-stage embryo transfers (ET) in fresh in vitro fertilization (IVF) cycles. Methods. Retrospective, single-center, cohort study of IVF cycles with fresh cleavage- or blastocyst-stage ETs resulting in a live singleton birth. The incidence of preterm birth (PTB), low birth weight (LBW), and very low birth weight (VLBW) was compared between cleavage- and blastocyst-stage ET cycles complicated by early VT. Results. 7241 patients had live singleton births. Early VT was observed in 709/6134 (11.6%) and 70/1107 (6.32%) patients undergoing cleavage-stage and blastocyst-stage ETs, respectively. Patients in the blastocyst-stage group were younger compared to the cleavage-stage group. The cleavage-stage group had a similar birth weight compared to the blastocyst-stage group. There was no difference in the incidence of PTB (9.87% versus 8.57%), LBW (11.1% versus 11.4%), or VLBW (1.13 versus 1.43%) when comparing the cleavage-stage early VT and blastocyst-stage early VT groups, even after adjustment with logistic regression. Conclusions. Our study highlights that the adverse perinatal risks of PTB, LBW, and VLBW associated with early VT syndrome are similar in patients undergoing cleavage-stage or blastocyst-stage ETs during fresh IVF cycles.