Atypical Hemolytic-Uremic Syndrome Following Obstetric Hemorrhage in the Setting of Fetal Demise and Placenta Accreta: A Case Report.

Multiple disease processes can contribute to coagulopathy in the setting of intrauterine fetal demise. A 34-year-old woman with multiple prior uterine surgeries presented for dilation and evacuation of a fetal demise at 17 weeks. Her case was complicated by significant hemorrhage and coagulopathy requiring massive transfusion and hysterectomy. She developed atypical hemolytic-uremic syndrome postoperatively. Pathology identified a focal placenta accreta. While not known to present together, fetal demise, placenta accreta, and atypical hemolytic-uremic syndrome can occur in the same patient with an overlapping presentation. Early hematology consultation is recommended in the setting of ongoing hemolysis and renal dysfunction.

Disseminated Intravascular Coagulation and Hemorrhage After Dilation and Evacuation Abortion for Fetal Death.

OBJECTIVE: To examine the association between fetal death and risk of hemorrhage and disseminated intravascular coagulation (DIC) among women undergoing dilation and evacuation (D&E) procedures. METHODS: We conducted a retrospective cohort study of all D&Es at one academic abortion clinic in San Francisco between 2009 and 2013. We abstracted data on fetal death status, demographic characteristics, and complications including hemorrhage and DIC. We examined the risk of hemorrhage and DIC among women with fetal death compared with those without. We conducted unadjusted and adjusted analyses for the outcomes of hemorrhage, DIC, and any complication. RESULTS: Among 92 cases of D&E for fetal death and 4,428 cases of D&E for other reasons, hemorrhage occurred in 10% and 7%, respectively (P=.28), and DIC occurred in 2.0% and 0.2% of the fetal death and nonfetal death cohorts (P<.001). In adjusted analysis, fetal death was associated with 2.9 times higher odds of hemorrhage (95% CI 1.4-6.0). In an unadjusted analysis, fetal death was associated with 12.3 times higher odds of DIC (95% CI 2.6-58.6) and 3.0 times higher odds of any complication (95% CI 1.6-5.9). CONCLUSION: Women undergoing D&E for fetal death are far more likely to experience DIC and hemorrhage than are women without fetal death, yet the absolute risk is low (2%). Although D&E providers should be prepared for DIC and hemorrhage, we do not recommend any specific preoperative preparation because the vast majority of D&E abortions for fetal death are uncomplicated.

Blastic variant of plasma cell myeloma mimicking squamous cell carcinoma of the uterine cervix in a super-morbidly obese female.

•Plasmablastic plasma cell myelomas of the cervix can mimic the more common cervical squamous cell carcinoma.•It can be difficult to differentiate plasmablastic lymphoma of the cervix from cervical plasmablastic plasma cell myeloma.•The clinician must rely on clinical, laboratory, and radiologic findings to diagnose genital plasma cell myeloma.•Prompt diagnosis of this rare clinical condition can potentially allow timely treatment with systemic chemotherapy.

Safety of Deep Sedation Without Intubation for Second-Trimester Dilation and Evacuation.

OBJECTIVE: To estimate the incidence of pulmonary aspiration and other anesthesia-related adverse events in women undergoing dilation and evacuation (D&E) under intravenous deep sedation without tracheal intubation in an outpatient setting. METHODS: We reviewed all D&Es done under anesthesiologist-administered intravenous deep sedation without tracheal intubation between February 2009 and April 2013. The study's primary outcome was pulmonary aspiration; secondary outcomes included other anesthesia-related complications. We calculated the incidence of anesthesia-related adverse events as well as a 95% CI around the point estimate. RESULTS: During the 51-month study period, 4,481 second-trimester abortions were completed. Of these, 2,523 (56%) were done under deep sedation without tracheal intubation, 652 (26%) between 14 and 19 6/7 weeks of gestation, and 1,871 (74%) between 20 and 24 weeks of gestation. Seven cases of anesthesia-related complications were identified: two cases of pulmonary aspiration (0.08%, 95% CI 0.01-0.29%), four cases of upper airway obstruction (0.016%, 95% CI 0.04-0.41%), and one case of lingual nerve injury (0.04%, 95% CI 0.001-0.22%). CONCLUSION: Deep sedation without tracheal intubation for women undergoing D&E has a low incidence of anesthesia-related complications.

Training Physicians in Advocacy: Why It Matters.

At a time in our country's history when state and federal legislative regulations on medical practice and access to services are at an all-time high, effective physician advocacy in women's health is crucial to the evolution of our profession and the provision of quality and equitable patient care. Inclusion of specific advocacy training programs in residency and beyond should be considered a priority. Ensuring a unified set of goals for advocacy training is important to training the next generation of competent and skilled physician advocates for leadership in academia and professional organizations. Sharing of initiatives and efforts to integrate advocacy into the training continuum across our community may inspire broader acceptance and implementation of such programs.

Obesity as a Risk Factor for Complications After Second-Trimester Abortion by Dilation and Evacuation.

OBJECTIVE: To evaluate the association between obesity (body mass index [BMI] 30 or higher) and dilation and evacuation (D&E) complications. METHODS: We conducted a retrospective cohort study of women who underwent D&E abortion from February 2009 to April 2013 at a hospital-based abortion practice in California. We evaluated the association between obesity and risk of complication after D&E using logistic regression. We defined complications a priori as cervical laceration, hemorrhage, uterine atony, anesthesia complications, uterine perforation, disseminated intravascular coagulation, and retained products of conception. We defined major complications as those requiring hospitalization, transfusion, or further surgical intervention. RESULTS: Complications occurred in 442 of 4,520 D&Es (9.8%), with equal proportions in obese and nonobese women (9.8%). Major complications occurred in 78 (1.7%) patients. After adjustment for age, ethnicity, prior vaginal delivery, prior cesarean delivery, and gestational duration, there was no association between BMI and D&E complications. Any individual complication was associated with each additional week of gestation (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.3-1.4), prior vaginal delivery (OR 1.5, 95% CI 1.2-1.9) and prior cesarean delivery (OR 1.8, 95% CI 1.4-2.3). Major complications were associated with each additional week of gestation (OR 1.3, 95% CI 1.1-1.4) and cesarean delivery (OR 1.8, 95% CI 1.1-3.1). CONCLUSION: We found no association between obesity and D&E complications. Our findings are consistent with previous studies demonstrating that later gestational duration is associated with an increased risk of complications. Obesity may not warrant referral to a high-risk abortion center, particularly because referral-associated delay might increase the risk of complications. LEVEL OF EVIDENCE: II.

Unintended consequences: abortion training in the years after Roe v Wade.

The US Supreme Court's 1973 Roe v Wade decision had clear implications for American women's reproductive rights and physician ability to carry out patient choices. Its effect on physician abortion training was less apparent. In an effort to increase patient access to abortions after Roe, provision shifted from hospitals to nonhospital clinics. However, these procedures and patients were taken out of the medical education realm, and physicians became vulnerable to intimidation. The consequent provider shortage created an unexpected barrier to abortion access. Medical Students for Choice was founded in 1993 to increase abortion-training opportunities for medical students and residents. Its mission ensures that motivated medical students will learn and a growing number of physicians will commit to comprehensive abortion provision.

Female genital cutting and other intra-vaginal practices: implications for TwoDay Method use.

This report examines the implications of female genital cutting and other intra-vaginal practices for offering the TwoDay Method® of family planning.This fertility awareness-based method relies on the identification of cervicovaginal secretions to identify the fertile window. Female genital cutting and traditional vaginal practices, such as the use of desiccants, may affect the presence or absence of secretions and therefore the woman's perception of her fertility. These issues and their implications for service delivery of the method are discussed.

Obtaining an isolate of Ancylostoma braziliense from dogs without the need for necropsy.

Isolation of a specific Ancylostoma species typically requires death of the source animal, or holding an animal long enough to collect feces after treatment, for worm recovery and identification. The reason for collecting worms is that the eggs are not easy to distinguish morphologically. In keeping with the 3 Rs of laboratory animal research (reduction, refinement, replacement), the objective of this study was to obtain an isolate of Ancylostoma braziliense from 1-time field-collected samples of canine feces without the need for killing the host. During a collection trip to Florida, fecal samples (n  =  148) were collected and identified as containing eggs of Ancylostoma species (n  =  64) using centrifugal sugar flotation. Eggs from hookworm-positive slides were washed into tubes, DNA was extracted, and 2 samples were identified as A. braziliense using restriction fragment length polymorphism (RFLP) with Hinf1. Larval cultures were initiated from these samples, and larvae from the cultures were returned to New York and used to inoculate a purpose-bred kitten with the goal of inhibiting the growth of any contaminating Ancylostoma caninum that might be present in the culture. The infection was patent at 15 days, and eggs were identified as A. braziliense by RFLP and DNA sequencing. Using forceps during endoscopy, 2 adult worms (1 male, 1 female) were recovered from the cat and identified morphologically as A. braziliense . Larvae were cultured from the feces of this cat and used to infect a laboratory-reared beagle dog. Additionally, worms recovered from the feces of the cat post-treatment were confirmed to be A. braziliense , except for 1 female A. caninum containing infertile eggs. The dog (patent 14 days post-infection) was also infected with A. braziliense as determined by RFLP and DNA sequencing of eggs and cultured larvae. Both the cat and dog were treated, verified to be no longer shedding eggs, and then placed into adoptive homes.

Prevalence of Ancylostoma braziliense in dogs from Alachua and Marion Counties, Florida, United States.

A convenience collection of fecal samples from 148 dogs in northern Florida was examined for the presence of Ancylostoma braziliense eggs by using centrifugal sugar flotation and polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP). Of the 148 samples, 64 (43.2%) contained hookworm eggs. DNA from 42 samples was successfully amplified using PCR; using RFLP, 2 samples were identified as containing DNA of A. braziliense (4.8% of the 42 successfully amplified samples).