Todd J. Stanhope

Obstetric Nephrology: Lupus and Lupus Nephritis in Pregnancy

SLE is a multi-organ autoimmune disease that affects women of childbearing age. Renal involvement in the form of either active lupus nephritis (LN) at the time of conception, or a LN new onset or flare during pregnancy increases the risks of preterm delivery, pre-eclampsia, maternal mortality, fetal/neonatal demise, and intrauterine growth restriction. Consequently, current recommendations advise that the affected woman achieve a stable remission of her renal disease for at least 6 months before conception. Hormonal and immune system changes in pregnancy may affect disease activity and progression, and published evidence suggests that there is an increased risk for a LN flare during pregnancy. The major goal of immunosuppressive therapy in pregnancy is control of disease activity with medications that are relatively safe for a growing fetus. Therefore, the use of mycophenolate mofetil, due to increasing evidence supporting its teratogenicity, is contraindicated during pregnancy. Worsening proteinuria, which commonly occurs in proteinuric renal diseases toward the end of pregnancy, should be differentiated from a LN flare and/or pre-eclampsia, a pregnancy-specific condition clinically characterized by hypertension and proteinuria. These considerations present challenges that underscore the importance of a multidisciplinary team approach when caring for these patients, including a nephrologist, rheumatologist, and obstetrician who have experience with these pregnancy-related complications. This review discusses the pathogenesis, maternal and fetal risks, and management pertinent to SLE patients with new onset or a history of LN predating pregnancy.

Female genital mutilation reversal: a general approach.

Introduction and hypothesisFemale genital mutilation (FGM) is a violation of human rights; yet, more than 100 million females are estimated to have undergone the procedure worldwide. There is an increased need for physician education in treating FGM. Female pelvic surgeons have a unique opportunity to treat this population of patients. Here, we depict the classification of FGM and a general approach to FGM reversal. We specifically address the procedure of type III FGM reversal, or defibulation.MethodsIn this video, we first highlight the importance of the problem of FGM. Next, we present the classification of FGM using an original, simple, schematic diagram highlighting they key anatomic structures involved in the four types of FGM. We then present a simple case of reversal of type III FGM, a procedure also known as defibulation. After depicting the surgical procedure, we discuss clinical results and summarize key principles of the defibulation procedure.ResultsOur patient was a 25-year-old woman who had undergone type III FGM as a child in Somalia. She desired restoration of vaginal function. We performed a reversal, and her postoperative course was uncomplicated. By 6 weeks postoperatively, she was able to engage in sexual intercourse without dyspareunia.ConclusionFGM is a problem at the doorsteps of female pelvic medicine and reconstructive surgery. Our video demonstrates a basic surgical approach that can be applied to simple cases of type III FGM presenting to the female pelvic surgeon.

Obstetrics and Gynecology Skills Orientation Improves Student Perception of Third-Year Clerkship

INTRODUCTION: The aim of this intervention was to assess the value of an orientation for medical students. METHODS: This study was a prospective cohort of third-year medical students assigned to an obstetrics and gynecology clerkship at a single academic center. Students were given surveys at the first day of their rotation and during the fifth week. An orientation to obstetrics–gynecology-specific skills was developed and provided to the intervention group. Number of obstetrics–gynecology-specific skills performed clinically was recorded by the students and satisfaction scores were recorded on a Likert scale (1–5). Data were compared with Students t and Kruskal-Wallis tests. RESULTS: Sixty-four medical students participated from October 2011 to August 2013. Baseline comparison revealed no difference in number of obstetrics–gynecology-specific procedures previously performed in a clinical setting. At the conclusion of the clerkship, there was no significant difference in the number of most procedures performed during the rotation with the exception of cervical examinations (Table 1). Surveys at the completion of the rotation revealed students in the intervention group were more likely to report a positive perception of obstetrics–gynecology, to be satisfied with their rotation and to be satisfied with their obstetrics–gynecology-specific skills training. Table 1 Student Experience During Obstetrics and Gynecology Clerkship CONCLUSION: An orientation to obstetrics–gynecology-specific skills improves perception of obstetrics–gynecology and specialty-specific skills training.

Expression of Protease HtrA1 Is Increased at the Site of Ectopic Pregnancy

INTRODUCTION: HtrA1 is a serine protease with the capacity to degrade a variety of extracellular matrix proteins. Prior study has demonstrated that processes of abnormal placental invasion such as preeclampsia are associated with changes in local tissue regulation. We examined expression of HtrA1 in fallopian tubes containing ectopic pregnancy. METHODS: Fallopian tubes containing histologically confirmed ectopic pregnancy obtained by salpingectomy were collected from a tissue registry. Nuclear and cytoplasmic expression of HtrA1 at the interface between tubal endothelium and trophoblastic was assessed by immunohistochemistry and compared with a normal adjacent fallopian tube. Staining intensity was evaluated by a pathologist and matched data were compared with Students t test. RESULTS: Immunohistochemistry staining intensity was reported on a numeric scale from 0 (weakly or 0–25% tissue staining) to 3 (intense or 75–100% tissue staining). Both nuclear and cytoplasmic expression was increased at the site of tubal invasion by trophoblastic tissue (P<.001 and P=.005, respectively). Increased staining intensity was appreciated in a segmental pattern, and this distribution of staining was consistently noted in each of the samples (Table 1). Table 1 Immununohistochemistry Staining Intensity of HtrA1 in Ectopic Pregnancy and in Adjacent Normal Fallopian Tube CONCLUSION: Expression of HtrA1 is increased at the interface between fallopian tubal and trophoblastic tissue in ectopic pregnancy. Further study may be conducted to evaluate the potential of HtrA1 as a biomarker for ectopic pregnancy.

Successful external cephalic version after preterm premature rupture of membranes utilizing amnioinfusion complicated by fetal femoral fracture

Abstract We report a case of successful external cephalic version after preterm premature rupture of membranes. Transcervical amnioinfusion was used to facilitate the procedure due to minimal amniotic fluid, and the patient subsequently delivered vaginally. A femoral fracture was later identified in the neonate.

Efficiency of Postpartum Warfarin Anticoagulation

INTRODUCTION: The objective of this study was to determine the effectiveness of warfarin in achieving therapeutic anticoagulation during the initial 6 weeks after delivery. METHODS: Retrospective review of patients who were treated with warfarin anticoagulation for a minimum of 6 weeks postpartum. Electronic medical records were abstracted for cumulative weekly warfarin dose and international normalized ratio (INR) values during treatment. Analysis was performed for mean time to achieve a therapeutic INR value, initial and subsequent weekly dosage, mean weekly absolute change in dose, and duration of time with therapeutic INR value. RESULTS: A total of 20 patients meeting inclusion criteria was identified. A mean of 4.95 (range 1–10) INR values was obtained per patient. Inclusive of patients with supratherapeutic values (greater than 3), mean time to achieve an INR value in the target range was 1.75 weeks (range 0–5 weeks); however, only during 33% of weeks was a value in the therapeutic range maintained. Six patients (30%) did not record a therapeutic INR value at any point. Further subgroup analysis revealed mean weeks with target value recorded were similar between patients managed by either a dedicated anticoagulation clinic (10/30 weeks, 33%) or individual health care provider (13/30 [43%]) (P=.60) and between cesarean delivery (eight of 18 [44%]) and transvaginal delivery (19/50 [38%]) groups (P=.78). CONCLUSION: Treatment with warfarin during the initial 6 weeks postpartum resulted in therapeutic INR values less than 50% of the time in fewer than 50% of patients regardless of managing health care provider or route of delivery, suggesting current clinical practice patterns are inefficient and could potentially be improved through protocol standardization.