Valerie I. Shavell

Adverse obstetric outcomes associated with sonographically identified large uterine fibroids.

STUDY OBJECTIVE To determine the impact of sonographically identified large uterine fibroids (>5 cm in diameter) on obstetric outcomes. DESIGN Retrospective cohort study. SETTING University teaching hospital. PATIENT(S) Women with singleton gestations (n = 95) noted to have uterine fibroids on obstetric ultrasonography from September 2009 through April 2010 and age-matched controls (n = 95). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Obstetric outcomes including short cervix, preterm premature rupture of membranes, and preterm delivery. RESULT(S) Compared to women with no fibroids or small fibroids (≤5 cm), women with large fibroids (>5 cm) delivered at a significantly earlier gestational age (38.6 vs. 38.4 vs. 36.5 weeks). Short cervix, preterm premature rupture of membranes, and preterm delivery were also significantly more frequent in the large fibroid group, and were associated with number of fibroids >5 cm in diameter. Blood loss at delivery was significantly higher in the large fibroid group (486.8 vs. 535.6 vs. 645.1 mL), as was need for postpartum blood transfusion (1.1 vs. 0.0 vs. 12.2%). CONCLUSION(S) Women with large uterine fibroids in pregnancy are at significantly increased risk for delivery at an earlier gestational age compared to women with small or no fibroids, as well as obstetric complications including excess blood loss and increased frequency of postpartum blood transfusion.

Post-Essure Hysterosalpingography Compliance in a Clinic Population

STUDY OBJECTIVE To determine the follow-up rate for post-Essure hysterosalpingography (HSG) in a non-study, general clinic population in an urban environment. DESIGN Retrospective chart review (Canadian Task Force classification II-2). SETTING University teaching hospital. PATIENTS Eighty-three University Health Center (UHC) patients who underwent attempted placement of the Essure permanent birth control device at the ambulatory surgery center at Hutzel Womens Hospital from January 2003 through June 2007. INTERVENTION Hysteroscopic placement of the Essure permanent birth control device. MEASUREMENTS AND MAIN RESULTS Placement of the Essure permanent birth control device was attempted in 83 patients, of which 79 were successfully completed (95.2%). Of the 79 patients, 10 underwent post-Essure HSG (12.7%). HSG was performed 3 to 6 months after placement of the Essure device. Bilateral tubal occlusion was documented in all 10 patients. CONCLUSION Despite preoperative and postoperative counseling, the follow-up rate for post-Essure HSG for this clinic population was only 12.7%. For those in whom HSG was performed, bilateral tubal occlusion was confirmed in all. Steps or approaches to promote compliance with postprocedural confirmation of tubal occlusion should be utilized to improve future follow-up rates.

Influenza immunization in pregnancy: overcoming patient and health care provider barriers

Seasonal influenza imparts disproportionate morbidity and death to pregnant women. Immunization against influenza is the most effective intervention to mitigate the burden of influenza disease during pregnancy; nevertheless, immunization rates remain suboptimal in this patient population. Therefore, there is a clear need for strategies to optimize influenza vaccination among pregnant women. We reviewed potential patient and health care provider barriers to influenza immunization and propose effective strategies for overcoming them.

Pathogenesis of benign metastasizing leiomyoma: A review

Uterine leiomyomas are benign tumors of smooth muscle origin with protean symptomatology, and are the most common gynecological tumor in women of reproductive age. Very rarely, benign uterine leiomyomas display bizarre growth patterns with associated extrauterine benign-appearing smooth muscle tumors, similar to the smooth muscle cells found in a uterine fibroid, and are given the name benign metastasizing leiomyoma (BML). We reviewed the published literature to outline the possible etiology of benign metastasizing leiomyoma (BML), and explored the similarities between BML and endometriosis. Several observations and animal experiments support the findings that BML may evolve from lymphatic and hematological spread, coelomic metaplasia and intraperitoneal seeding. The weight of available evidence support the conclusion that the mechanism used to explain the pathogenesis of endometriosis can also be used to explain BML. However, in making a diagnosis of BML, meticulous sampling of the pathology specimen should be undertaken to exclude leiomyosarcoma, which unlike BML, has an aggressive course. It is hoped that analyses of the etiology and features of this disorder will facilitate a better understanding of its pathogenesis and treatment. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to asses the clinical characteristics of Benign Metastasizing Leiomyoma. Compare the potential pathophysiology with endometriosis and differentiate benign metastasizing Leiomyoma from Leiomyosarcoma.

Trends in Sterilization since the Introduction of Essure Hysteroscopic Sterilization

STUDY OBJECTIVE To investigate trends in sterilization in women at the Detroit Medical Center, Michigan (DMC), since the introduction of Essure hysteroscopic sterilization. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING Outpatient surgery center and university teaching hospitals. PATIENTS Women who underwent interval sterilization procedures at the DMC (Hutzel Womens Hospital, Sinai-Grace Hospital, and the Berry Center) and postpartum sterilization procedures at Hutzel Womens Hospital between January 1, 2002, and December 31, 2007. INTERVENTIONS Permanent sterilization procedures including minilaparotomy tubal ligation, laparoscopic sterilization, Essure hysteroscopic sterilization, and postpartum tubal ligation performed at the time of cesarean section or after vaginal delivery. MEASUREMENTS AND MAIN RESULTS In all, 5509 permanent sterilization procedures were performed in the 6 years between January 1, 2002, and December 31, 2007, at the DMC facilities analyzed: 2484 interval sterilization procedures at Hutzel Womens Hospital, Sinai-Grace Hospital, and the Berry Center, and 3025 postpartum tubal ligations at Hutzel Womens Hospital. From 2002 through 2007, the decrease in laparoscopic sterilizations from 97.9% to 48.5% of all interval sterilization procedures corresponded significantly with the increase in Essure hysteroscopic sterilizations from 0.0% to 51.3% (p <.001). Postpartum tubal ligations performed after vaginal delivery also decreased significantly during the study period from 7.9% to 3.3% of all vaginal deliveries (p <.001) while the percentage of tubal ligations performed at the time of cesarean section remained constant (p =.051). CONCLUSION At the DMC facilities analyzed from January 1, 2002, through December 31, 2007, a significant decrease occurred in the percentage of laparoscopic sterilizations and postpartum tubal ligations performed after vaginal delivery. Of the interval sterilizations performed, the percentage of Essure hysteroscopic sterilizations increased significantly from 0.0% to 51.3% of all procedures. Since the approval of Essure hysteroscopic sterilization in November 2002, this minimally invasive method of hysteroscopic sterilization has increased in popularity at the DMC.

Conservative management of cervical ectopic pregnancy: utility of uterine artery embolization

OBJECTIVE To evaluate the use of uterine artery embolization (UAE) in conjunction with methotrexate in the conservative treatment of cervical ectopic pregnancy (CEP). DESIGN Case series. SETTING Tertiary-care university hospital. PATIENT(S) Cases of CEP treated at Hutzel Womens Hospital between January 1997 and December 2008. INTERVENTION(S) Multidose methotrexate treatment with or without UAE and intra-amniotic potassium chloride injection (KCl). MAIN OUTCOME MEASURE(S) Beta-human chorionic gonadotropin level, vaginal bleeding, length of hospital stay, and future fecundity. RESULT(S) A retrospective analysis of 15 patients with CEP treated conservatively using methotrexate with leucovorin rescue (MTx/Leu) alone (group 1, five cases), with UAE as an adjunctive therapy (group 2, six cases), or also having received intra-amniotic KCl before UAE (group 3, four cases) is reported. There was no significant difference in age, parity, or gestational age among treatment groups. The median β-hCG level on presentation was 9,606 mIU/mL for group 1, 26,516 mIU/mL for group 2, and 130,464 mIU/mL for group 3. The difference was found to be statistically significant. No patients developed complications from UAE. Of the 10 patients who underwent UAE, 2 subsequently had confirmed viable pregnancies. CONCLUSION(S) Uterine artery embolization with methotrexate is an option for minimally invasive intervention in the treatment of CEP.

Hysterectomy Subsequent to Endometrial Ablation

STUDY OBJECTIVE To estimate the incidence of and factors associated with hysterectomy subsequent to endometrial ablation. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Gynecology practice. PATIENTS Women who underwent endometrial ablation from January 2003 to June 2010, with a minimum follow-up of 9 months. INTERVENTIONS Endometrial ablation and hysterectomy. MEASUREMENTS AND MAIN RESULTS Of 1169 women, 157 (13.4%) underwent hysterectomy subsequent to endometrial ablation. Women who underwent subsequent hysterectomy were significantly younger at ablation (mean [SD; 95% CI] 39.0 [6.8; 38.0-40.1] years vs 41.4 [7.0; 41.0-41.9] years; p < .001) and were more likely to have previously delivered via cesarean section (26.3 vs 18.1%; p = .02). The rate of hysterectomy was significantly associated with the type of ablation performed: 33.0% for rollerball vs 16.5% for thermal balloon (p = .003), 11.0% for radiofrequency (p < .001), and 9.8% for cryoablation (p < .001). Time to hysterectomy also differed significantly based on the type of ablation performed (p = .006). Adenomyosis was present in 44.4% of hysterectomy specimens. CONCLUSION With a mean follow-up of 39 months, 13.4% of women underwent hysterectomy subsequent to ablation. Women who were younger at ablation had an increased likelihood of hysterectomy. Rate and time to hysterectomy were associated with the type of ablation performed.

Small bowel obstruction subsequent to Essure microinsert sterilization: a case report

OBJECTIVE To report a case of small bowel obstruction (SBO) subsequent to Essure microinsert sterilization. DESIGN Case report. SETTING University teaching hospital. PATIENT(S) A 38-year-old woman, gravida 1, para 1, with a history of pelvic pain, vaginal spotting, nausea, vomiting, and constipation 1 month after Essure hysteroscopic sterilization. INTERVENTION(S) Radiologic investigation, including a computed tomography scan of the abdomen and pelvis, followed by operative laparoscopy. MAIN OUTCOME MEASURE(S) Alleviation of the SBO. RESULT(S) Radiologic investigation suggested a distal SBO, with the left Essure microinsert noted in the left lower pelvis. These findings, including an inflamed appendix, were confirmed at operative laparoscopy. Lysis of adhesions, removal of the Essure microinsert, appendectomy, and left salpingectomy were performed. CONCLUSION(S) This case is reported to increase awareness that SBO is a potential complication of Essure microinsert placement.

Review: Cellular Metabolism: Contribution to Postoperative Adhesion Development

Postoperative adhesions are a significant source of morbidity, including contributions to pelvic pain, bowel obstruction, and infertility. While the mechanisms of postoperative adhesion development are complex and incompletely understood, hypoxia appears to trigger a cascade of intracellular responses involving hypoxia-inducible factors, lactate, reactive oxygen species, reactive nitrogen species, and insulin-like growth factors that results in manifestation of the adhesion phenotype. Thus, substantial evidence exists to implicate the direct role of cellular metabolism in wound repair and adhesion development.

Nickel hypersensitivity associated with an intratubal microinsert system

BACKGROUND: Although known nickel hypersensitivity is a contraindication to intratubal microinsert placement in the United States, this case demonstrates that nickel hypersensitivity to intratubal microinserts can occur. CASE: A young woman developed an allergic reaction after placement of intratubal microinserts. Nickel hypersensitivity was confirmed with skin patch testing. The microinserts were removed hysteroscopically, and the patient improved. CONCLUSION: If a patient experiences symptoms of an allergic reaction after hysteroscopic sterilization, referral to an allergy specialist is recommended. If nickel hypersensitivity is confirmed, the microinserts should be removed; this may be performed under hysteroscopic guidance.