Roopina Sangha

Metastatic Colorectal Cancer Resembling Severe Preeclampsia in Pregnancy

Although colorectal cancer (CRC) is the third most common cancer in women, it is a rare malignancy in pregnancy. Symptoms of CRC such as fatigue, malaise, nausea, vomiting, rectal bleeding, anemia, altered bowel habits, and abdominal mass are often considered typical symptoms of pregnancy. Many cases of CRC are diagnosed in advanced stages due to missed warning signs of CRC, which may be misinterpreted as normal symptoms related to pregnancy. This report reviews 2 cases of CRC diagnosed within a 4-month interval at our institution. Both cases were initially thought to be atypical presentations of preeclampsia. Prenatal history, hospital course, and postpartum course were reviewed for both patients. CRC is often diagnosed at advanced stages in pregnancy. Common physiological symptoms of pregnancy should be scrutinized carefully and worked up appropriately, especially if symptoms remain persistent or increase in intensity or severity.

Identifying What Matters to Hysterectomy Patients: Postsurgery Perceptions, Beliefs, and Experiences

Purpose Hysterectomy is the most common non-obstetrical surgery for women in the United States. Few investigations comparing hysterectomy surgical approaches include patient-centered outcomes. Methods The study was performed at Henry Ford Health System in Detroit, Michigan between February 2015 and May 2015. The data were collected through structured focus groups with 24 post-hysterectomy women in order to identify PCOs to employ in a subsequent cohort study of hysterectomy surgical approaches. One pilot focus group and five additional focus groups were held. Qualitative data analysis, using data from coded transcripts of focus groups, was used to identify themes.Eligible women, aged between 18 and 65 years and had an EMR documented Current Procedural Terminology (CPT™) code or an International Statistical Classification of Diseases and Related Health Problems - Ninth Edition (ICD-9) code of hysterectomy between December 2012 and December 2014 (N=1,381, N=307 after exclusions) were selected and recruited. A question guide was developed to investigate womens experiences and feelings about the experience prior and subsequent to their hysterectomy. Analysis utilized the Framework Method. Results Focus groups with women who previously had a hysterectomy revealed their pre- and post-hysterectomy perceptions. Responses grouped into topics of pre- and post-surgical experiences, and information all women should know. Responses grouped into themes of 1) decision making, 2) the procedure - surgical experience, 3) recovery, 4) advice to past self, and 5) recommendations to other women. Conclusion These findings about perceptions, beliefs, and attitudes of women having undergone hysterectomy could support health care providers deliver patient-centered care. These results informed data collection for a prospective longitudinal cohort study that is now underway. The data suggest a need for increased education and empowerment in the decision making process, while expanding on information given for post-operative expectations and somatic changes that occur post-hysterectomy.

Placental Chorangiosis: Increased Risk for Cesarean Section

We describe a patient with Class C diabetes who presented for nonstress testing at 36 weeks and 4 days of gestation with nonreassuring fetal heart tones (NRFHT) and oligohydramnios. Upon delivery, thrombosis of the umbilical cord was grossly noted. Pathological analysis of the placenta revealed chorangiosis, vascular congestion, and 40% occlusion of the umbilical vein. Chorangiosis is a vascular change of the placenta that involves the terminal chorionic villi. It has been proposed to result from longstanding, low-grade hypoxia in the placental tissue and has been associated with such conditions such as diabetes, intrauterine growth restriction (IUGR), and hypertensive conditions in pregnancy. To characterize chorangiosis and its associated obstetric outcomes we identified 61 cases of “chorangiosis” on placental pathology at Henry Ford Hospital from 2010 to 2015. Five of these cases were omitted due to lack of complete records. Among the 56 cases, the cesarean section rate was 51%, indicated in most cases for nonreassuring fetal status. Thus, we suggest that chorangiosis, a marker of chronic hypoxia, is associated with increased rates of cesarean sections for nonreassuring fetal status because of long standing hypoxia coupled with the stress of labor.

Who Will Suffer From Postablation Pelvic Pain? A Retrospective Analysis of Risk Factors [7Q]

INTRODUCTION: Identifying risk factors for post ablation pain is a critically important task. Data on individual predictors of postablation pain are mixed and conflicting. Our objective was to identify various patient characteristics associated with development of new onset or worsening pelvic pain after endometrial ablation. METHODS: A retrospective cohort study of all patients who underwent endometrial ablation at Henry Ford Health System, during 2012–2014. Baseline characteristics at the time of ablation, relevant medical comorbidities, and ablation technique and treatment outcome were analyzed. RESULTS: A total of 368 women met the inclusion criteria for the study. Sixteen percent experienced new or worsening pelvic pain after ablation; 40% of them required a hysterectomy for intractable pain. Only two factors that emerged as potential contributor to postablation pain were history of tubal ligation (adjusted odds ratio [OR] 2.34, 95% confidence interval [CI] 1.21–4.63) and prior pelvic pain (adjusted OR 7.81, 95% CI 2.97–20.98). Age, BMI, prior cesarean sections, endometriosis, preablation dysmenorrhea, presence of uterine fibroid and presumptive diagnosis of adenomyosis were not associated with the development of postablation pain. Ablation technique did not affect the rate of post ablation pain. Patients with postablation pain underwent a hysterectomy within a shorter time than those without pain (P<.001). CONCLUSION: Patient selection for endometrial ablation is crucial. Physicians should counsel women with history of tubal ligation and chronic pelvic pain about the potential for post procedure pain and subsequent treatment failure.

Recurrence After Robotic Myomectomy: Is It Associated With Use of GnRH Agonists Preoperatively? [9Q]

INTRODUCTION: GnRH agonist administration is a routine practice before myomectomy. GnRH agonist administration preoperatively not only makes myomectomy easier by decreasing the size the fibroids but also safer by decreasing operative time and blood loss. The primary objective of this study was study the association between GnRH agonist administration before robotic myomectomy and symptomatic recurrence of fibroids. METHODS: A retrospective chart review was performed and a total of 118 patients who underwent robotic-assisted laparoscopic myomectomy between January 2005 and December 2009 were analyzed. Electronic medical records of all women who were at least 2 years out from surgery were reviewed. RESULTS: We identified 17 (14.4%) symptomatic recurrences as early as 5 months to as late as 30. Recurrence group had significantly higher preoperative GnRH use (35% vs 9%; P=.009). 7.6% of all patients underwent a second surgical procedure. When comparing subset of patients who underwent a second surgical procedure, GnRH agonist use was significantly higher in patients with reoperation (56%) than those without (9%; P=.002). Cavity entry during the initial surgery was also more frequent in the reoperation group (56% vs 20%; P=.030) whereas presence of multiple fibroids, size of the largest leiomyoma, and uterine volume were not statistically significant. CONCLUSION: The overall symptomatic recurrence of uterine fibroids after a Robotic assisted Laparoscopic myomectomy was 14.4% at 2 years. Preoperative use of GnRH agonists before the surgery is associated with increased recurrence. Cavity entry during the initial surgery and GnRH use preoperatively is associated with reoperation.

Malpositioned Intrauterine Device: Risk Factors, Management, and Outcomes [242]

INTRODUCTION: Malpositioned intrauterine devices (IUDs) are a common clinical problem seen by gynecologists. The objective of this study was to perform a retrospective chart review for documented radiographically confirmed malpositioned IUDs in patients in Detroit, Michigan. The charts were reviewed for presenting symptoms, risk factors, IUD position, imaging modality, and the effects on clinical outcome. METHODS: Investigators performed a retrospective chart review using International Classification of Diseases, 9th Revision codes from 2010 to 2014 at Henry Ford Health System, Michigan. Charts were reviewed for presenting symptoms (pain, inability to feel IUD strings, vaginal bleeding, dyspareunia), risk factors for malpositioned IUDs (including, but not limited to, age, parity, body mass index, indication for placement, type of IUD, level of training of the health care provider), and clinical outcomes (removal compared with nonremoval). Bivariate comparisons were done using Fishers exact tests. RESULTS: Possible risk factors investigated for malpositioned IUDs included higher parity (multigravida women 91%), level of training of the health care provider (physicians 76%), and indication for placement (contraception 86% compared with menorrhagia 14%). Chief complaints included pain (36%), IUD string nonvisualization (13%), vaginal bleeding (35%), and dyspareunia (3%). Position of the IUD was found to be cervical (30%), lower uterine segment (33%), myometrial penetration (73%), or all of these. Eleven percent were noted to be pregnant (8% intrauterine pregnancy and 3% ectopic pregnancies). Clinical outcomes included removal of IUD in 83 (laparoscopy 49%, laparotomy 4%, hysteroscopy 22%, and instrument removal 25%). CONCLUSION: Patients present with a variety of symptoms with malpositioned IUDs and have significant clinical heterogeneity regarding risk factors. Clinically, practitioners should be aware of the variety of presentations and influence of demographic varietals that may affect a womens risk for malpositioned IUDs.

Hysterectomy Trends Before and After the FDA Morcellator Warning: Have We Changed Our Practice and Perioperative Outcomes?

Patients: Three hundred-fifty consecutive patients undergoing laparoscopic supracervical hysterectomy or myomectomy submitted to EC-BMM from February 2012 to December 2014. Intervention: the uterus or myoma(s) were placed in a ‘‘Memo-Bag’’ specimen pouch (Rusch, Teleflex Medical IDA Business and Technology, Park, Athlone, Ireland) for 12 mm laparoscope trocar, that was exteriorized through the umbilical incision. The Clamps were used to hold the uterine tissue while it is circumferentially cored with scalpel. When needed, the umbilical incison was enlarged up to 20-30 mm to allow the morcellation of bigger specimens. Measurements and Main Results: Among 350 cases, 224 underwent supracervical hysterectomy and 126 myomectomy. The median for age and BMI was respectively 53.61 (28-75) and 24.7 (17.6-32.4). The median morcellation time (MT) was 5 min (2-39) The median weight of the specimen was 64 g (12-950). Postoperative complications related to EC-BMM occured in 2% of cases (3 awful scars; 3 umbilical hematoma, 1 bag disruption). There was no case of umbilical hernia. We detected a significant statistically correlation between specimen weight and morcellation time (P:0.0001). Logistic-regression analysis showed a relationship between MT and specimen weighting only up to 200 gr (P\0.001). Conclusion: EC-BMM represents fast and effective technique to extract uterine specimens without significant complications or additional costs related to instrumental morcellation.