Wilma I. Larsen

Long-term impact of the women’s health initiative on HRT

ObjectiveTo evaluate the long-term trends in the HRT following the results of the WHI, which were made public in July 2002.Study designAn observational cohort study was performed from prescription data of estrogen containing products ordered from Tripler Army Medical Center between July 1999 and July 2005. We used automated pharmacy data to identify all estrogen products dispensed to active duty soldiers, dependent wives, and retirees during the study period. Differences in prescription rate were compared between groups using a Student’s t-test.ResultsA total of 71,592 prescriptions were written for HRT. Prescriptions decreased from 1,272/month at the start of the study to 493/month at the conclusion of the study. Prior to July 2002 OBGYNs were the first to decrease their prescribing rate of estrogen, and this decrease was greater than other specialties analyzed. The frequency of HRT prescriptions decreased after July 2002 while the percentage of patients who filled HRT prescriptions increased from 68 to 72%.ConclusionsWe have found a significant decrease in prescriptions after release of the WHI initiative results. With this decrease in prescribing rate of HRT we found that a greater percentage of women actually filled their prescriptions perhaps indicating greater certainty in their choice.

Recognition and management of nerve entrapment pain after uterosacral ligament suspension.

OBJECTIVE: To estimate the incidence, risk factors, and characteristics of neuropathic pain related to nerve entrapment after uterosacral ligament suspension. METHOD: A review of patients who underwent uterosacral ligament suspension from January 2007 to August 2011 was performed. Patients with neuropathic pain attributable to nerve entrapment from uterosacral ligament suspensory suture placement were identified. Factors including surgeons dominant hand, side of pain, onset of pain, day of suture removal, number of sutures placed and removed, patient age, and body mass index (BMI) were collected. Follow-up of patients with neuropathic pain was performed at postoperative visits and by telephone contact. RESULT: Eight (1.6%) of 515 patients had neuropathic pain requiring suture removal from the affected side. The postoperative pain was recognized after discontinuation of intravenous narcotics on postoperative day 1. Patients reported their pain improved after removal of all sutures on the affected side. Patients with neuropathic pain did not differ from those without in regard to age, BMI, and preoperative prolapse stage, or in the number of sutures placed. None of the eight had recurrent pelvic organ prolapse (POP), with a median follow-up of 5 months. CONCLUSION: Eight patients (1.6%) had postoperative neuropathic pain that resolved after all sutures were removed on the affected side. The removal of sutures was not associated with recurrent POP in the short-term. LEVEL OF EVIDENCE: II

Inappropriate use of antibiotics in patients undergoing gynecologic surgery.

We retrospectively examined prophylactic antibiotic use and documentation of wound classification in patients having gynecologic surgery at a tertiary hospital. Of the 326 cases reviewed, 175 (54%) received prophylactic antibiotics when not indicated according to guidelines of the American College of Obstetricians and Gynecologists. Antibiotic administration varied significantly (P < 0.02) among the different types of surgery, being given in 82% of laparoscopic cases, 35% of nonobstetrical dilation and curettage and operative hysteroscopy procedures, and 51% of open abdominal procedures. There were no recorded episodes of anaphylaxis or pseudomembranous colitis. In conclusion, antibiotic use is high among gynecologic surgeons at a tertiary hospital, but this use was unnecessary.

Perineal Body Length and Perineal Lacerations During Delivery in Primigravid Patients

This study assessed the relation between perineal body length and the risk of perineal laceration extending into the anal sphincter during vaginal delivery in primigravid patients at an institution with a low utilization of episiotomy. This was a prospective study of primigravid patients in active labor. Primigravid women with singleton pregnancies who were in the first stage of labor at 37 weeks gestation or greater were recruited, and the admitting physician measured the length of the perineal body. The degree of perineal laceration and other delivery characteristics were recorded. Data were analyzed using univariate analyses, receiver-operator curve analyses, and multiple logistic regression for factors associated with increased severity of vaginal lacerations. The perineal body length, duration of second stage of labor, type of delivery, and patient age were associated (P < 0.1) with third- and fourth-degree (severe) perineal lacerations in primigravid women using receiver-operator curve analysis. Using logistic regression, only the duration of second stage of labor and length of the perineal body were significant (P < 0.04) predictors of third- and fourth-degree lacerations, with odds ratios of 32 (1.3 to 807 as 95% CI) and 24 (1.3 to 456), respectively. Both a perineal body length of ≤3.5 cm and a duration of second stage of labor >99 minutes were associated with an increased risk of third- and fourth-degree lacerations in primigravid patients.

Treatment of metastatic gestational choriocarcinoma with oral methotrexate in a combat environment.

BACKGROUND: Gestational trophoblastic neoplasia (GTN) is a rare neoplastic complication of pregnancy. This disease can be successfully treated with parenteral intravenous or intramuscular chemotherapy. We present a case of metastatic gestational choriocarcinoma following a term pregnancy that was treated successfully with oral methotrexate therapy. CASE: A 25-year-old, G4 P4, native Afghani with a history of irregular menses since the birth of her son 6 months ago received a physical examination that was within normal limits. Pelvic examination revealed minimal blood in the vault and slight bleeding from a closed cervical os. The uterus was slightly enlarged, 5 weeks in size, and without any adnexal masses. Laboratory evaluation was significant for a positive urine and serum β-HCG. Pelvic ultrasound examination revealed a 5-cm uterus with a 2-cm endometrial stripe. Chest radiograph revealed multiple bilateral ill-defined pulmonary nodules confirmed by computerized tomography. The patient underwent dilation and curettage productive of a moderate amount of tissue. The patient continued to have positive serum β-HCGs and was given the presumptive diagnosis of FIGO stage III gestational choriocarcinoma. Because of the lack of intravenous chemotherapeutic agents, the patient was begun on methotrexate 0.40 mg/kg orally on days 1–5, with 9 days off. The patient completed one course of chemotherapy, followed by an interval total abdominal hysterectomy with bilateral salpingo-oophorectomy. The patient had a complete response to therapy and was treated with oral methotrexate for 2 courses after a negative serum β-HCG. The patient tolerated the chemotherapy without any complication. CONCLUSION: Methotrexate is routinely used in a parenteral intramuscular fashion for the treatment of gestational choriocarcinoma. Physicians should be aware that, in very limited situations, oral methotrexate in combination with hysterectomy still could offer a patient successful treatment for stage III GTN.

Lack of preoperative predictors of the immediate return of postoperative bladder emptying after uterosacral ligament suspension.

Objectives To determine whether preoperative postvoid residual volume (PVR), pelvic organ prolapse quantification (POPQ) stage, patient characteristics, or concurrent operations are predictors of immediate postoperative bladder emptying after uterosacral ligament suspension (USLS). Methods A review of patients undergoing USLS in 2008 and 2009 was performed. The factors analyzed included patient age, body mass index, parity, preoperative PVR, POPQ stage, concurrent anterior repair, posterior repair, hysterectomy and/or sling procedures, and postoperative voiding trial status. Results During the study interval, 151 patients underwent USLS with various combinations of concurrent procedures. The mean preoperative PVR was 90 mL. Seventy-five patients (50%) passed the postoperative voiding trial on postoperative day 1. Patients who passed the postoperative voiding trial and those who failed had similar average preoperative PVR (P = 0.94), similar age (P = 0.14), body mass index (P = 0.45), parity (P = 0.82), and preoperative POPQ stage (P = 0.80). There was no difference (P ≥ 0.14) among concurrent surgical procedures in the proportion of patients who passed the postoperative voiding trial based on univariate analyses. Conclusions In our cohort of patients, preoperative PVR, POPQ stage, and other patient characteristics were not predictors of immediate postoperative bladder emptying after USLS. Postoperative voiding function is one of the most unpredictable aspects of pelvic reconstructive surgery.

Anatomic Relation Between Single-Incision Slings and the Obturator Vessels

The risk of arterial vascular injury within the retropubic space is a potentially life-threatening complication associated with mid-urethral sling placement for the treatment of female stress urinary incontinence. To determine the relationship between the major blood vessels and a single incision sling, these slings were placed in 12 fresh female cadavers. Following the insertion of each sling, the retropubic space was dissected and sling placement was observed relative to the obturator neurovascular bundle bilaterally. The distance between the most distal aspect of each sling arm, or the point of anchoring, was measured from the most medial aspect of the obturator vessels bilaterally. The mean distance between each sling arm and the medial portion of the obturator vessels was an average of 3.4 cm (range 2.0–6.0 cm) in 24 observations. Placement of the single incision sling may have a lower risk of injuring major vessels within the retropubic space compared to full-length mid-urethral slings.

Variation in Use of Prophylactic Antibiotics in Gynecologic Procedures Before and After an Educational Intervention

Objectives Guidelines for use of prophylactic antibiotics in gynecologic procedures are outlined by the American Congress of Obstetricians and Gynecologists. There remains, however, a high rate of unindicated administration of antibiotics for surgeries. A retrospective study performed at our institution in 2012–2013 demonstrated that unindicated prophylactic antibiotics were administered over half the time. This study aimed to examine variations in the use of prophylactic antibiotics in patients undergoing gynecologic surgery at Scott and White Memorial Hospital and determine whether an educational intervention to gynecology physicians was associated with a significant decrease in unindicated prophylactic antibiotics. Methods A retrospective chart review was performed for all women undergoing gynecologic surgery at Scott and White Memorial Hospital in Temple, Texas for 1 year. An educational intervention regarding prophylactic antibiotic usage was held for obstetricians and gynecologists in the middle of that year. Subjects were included if they had procedures with a Current Procedural Terminology code corresponding to a procedure that does not require prophylactic antibiotics. Subjects were excluded if they had concurrent procedures for which antibiotics are recommended. Results A total of 500 subjects met inclusion and exclusion criteria, with 243 before the educational intervention and 257 after the intervention. In our study, a significant decrease (P < 0.0001) in unindicated prophylactic antibiotic use was demonstrated: from 45.7% (111/243) preintervention to 24.9% (64/257) postintervention. Before the educational intervention, both the gynecology oncology and reproductive endocrinology and infertility divisions had the highest rates of unindicated antibiotic use—91.7% (44/48) and 91.7% (33/36), respectively. The generalist and urogynecology divisions had the lowest rates for specialists before the intervention: 20.6% (30/146) and 30.8% (4/13), respectively. After the intervention, all of the divisions demonstrated an improvement in their rates of unindicated prophylactic antibiotic use. The urogynecology division demonstrated an improvement that can be considered clinically significant while not meeting statistical significance. The adverse event rates were not different between subjects who received preoperative prophylactic antibiotics (2.9%) and subjects who did not (2.8%). Conclusions A simple educational intervention was associated with a significant decrease in unindicated prophylactic antibiotics in gynecologic procedures.

Incidence of Bladder Injury During Retropubic Midurethral Sling Placement After Prior Burch Colpopexy.

Objectives To elucidate if prior Burch changes the risk of bladder injury or rates of voiding dysfunction and continence in the immediate postoperative period when undergoing retropubic midurethral sling (MUS) placement. Methods In this retrospective case control, charts were selected by Current Procedural Terminology codes for MUS placement. Women undergoing retropubic MUS placement with history of Burch urethropexy were considered. For every case, 2 age-matched and parity-matched controls without prior Burch were selected. Results In total, 538 charts were reviewed from 2010 to 2014. Twenty cases were found. There was a difference (P = 0.023) in trocar penetration of the bladder. Twenty-five percent (5/20) of women with prior Burch had a 9-fold (odds ratio [OR], 9.0; 95% confidence interval [CI], 1.0–82) higher chance of bladder penetration compared with women without prior retropubic surgery as calculated with Mantel-Haenszel paired test. Women with prior Burch had more success passing their voiding trials (OR, 7.5; 95% CI, 1.1–49.2). At 6 weeks, there was no difference in voiding dysfunction. Cure of stress incontinence at 6 weeks occurred more in controls than cases (P = 0.044) with match pairs manifesting an OR of 0.20 and 95% CI of 0.04–1.1. Discussion This study shows a significant increase risk of trocar penetration of the bladder during retropubic MUS placement in women with a history of Burch urethropexy. Despite this, MUS placement was successful in all women. Women with prior surgery were much more likely to pass their voiding trials. There was no difference in voiding dysfunction at 6 weeks between the 2 groups. Conclusions This indicates that though bladder penetration with a trocar is more common in the setting of previous retropubic surgery, it does not impact a womans short-term intraoperative or postoperative course.

Iatrogenic Bladder Diverticulum 11 Years After Sacrospinous Ligament Fixation for Apical Prolapse.

Introduction In this case, we describe a bladder diverticulum due to apical vaginal suspension to the sacrospinous ligament presenting 11 years after surgery. This case report explores her signs and symptoms, diagnostic work-up, surgical intervention, and postoperative course. Case Description A 71-year-old G2P2 presented with symptoms of urinary urgency. Work-up including cystoscopy and retrograde fistulogram revealed a bladder diverticulum extending to the level of the sacrospinous ligament. Her surgical history was significant for a sacrospinous ligament fixation 11 years before her symptoms. The iatrogenic bladder diverticulum was removed via robotic-assisted laparoscopic excision. Her postoperative course was benign beyond a urinary tract infection. Her urgency symptoms resolved after treatment. Conclusions Iatrogenic injuries can present distant from initial surgery. Permanent foreign material, including suture, may increase the risk of complications. A high level of suspicion is necessary to diagnose complications given the subtle presentation.