Minimally Invasive Surgery in Pregnancy.

If it is medically necessary to perform nonobstetrical abdominal surgery in pregnancy, a minimally invasive approach should be considered. The benefits of laparoscopy are well known and current studies promote the safety of laparoscopy in pregnancy, when certain guidelines are followed. This article will review the safety of surgery in pregnancy, maternal physiology, fetal considerations, maternal obesity, laparoscopic cerclage, large adnexal mass, and complications. Guidelines for surgery will be reviewed as well.

Effect of validated skills simulation on operating room performance in obstetrics and gynecology residents: a randomized controlled trial.

OBJECTIVES: To estimate whether training on previously validated laparoscopic skill stations translates into improved technical performance in the operating room. METHODS: We performed a multicenter, randomized, controlled trial evaluating the performance of a laparoscopic bilateral midsegment salpingectomy. Residents were randomized to either traditional teaching (no simulation) or faculty-directed sessions in a simulation laboratory. A sample size of at least 44 lower-level residents (postgraduate year [PGY] 1 or 2) and 66 upper-level (PGY 3 or 4) were necessary to demonstrate a 50% improvement in performance assuming an α error of 0.05 and ß error of 0.20 for each group independently. The primary outcomes were the final total normalized simulation score and the operating room performance score. Paired t test and Wilcoxon rank-sum tests were used to evaluate the differences within and between cohorts. Our final model involved a multiple linear regression analysis for the main effects of a priori--specified variables. RESULTS: We enrolled 116 residents from eight centers across the United States. There was no statistically significant difference in baseline simulation or operative performances. Although both groups demonstrated improvement with time, the trained group improved significantly higher normalized simulation scores (378 ± 54 compared with 264 ± 86; P<.01) and higher levels of competence on the simulated tasks (96.2% compared with 61.1%; P<.01). The simulation group also had higher objective structured assessment of technical skills scores in the operating room (27.5 compared with 30.0; P=.03). CONCLUSION: We found that proficiency-based simulation offers additional benefit to traditional education for all levels of residents. The use of easily accessible, low-fidelity tasks should be incorporated into formal laparoscopic training.

Emotional intelligence and selection to administrative chief residency.

OBJECTIVE: The authors sought to determine whether emotional intelligence, as measured by the BarOn emotional quotient inventory (EQ-i), is associated with selection to administrative chief resident. METHOD: Authors invited senior-year residents at the University of Texas Health Science Center at Houston to participate in an observational cross-sectional study using the BarOn EQ-i. In October 2009 they sent an invitation e-mail to 66 senior residents, with a reminder e-mail 1 month later. The study was designed to detect a 15-point difference in EQ-i scores with 80% power. RESULTS: Of the 66 invited residents, 69.6% participated in the study. Average total EQ-I score was 104.9. Among senior-year residents, there were no statistically significant differences in EQ-i scores between administrative chief residents (at 109) and non-administrative chief residents (at 103.2). CONCLUSION: Administrative chief residents do not demonstrate higher Emotional Intelligence, as measured by the EQ-i, than other senior-year residents.

La utilidad de la resonancia magnética en el abdomen agudo durante el embarazo / The use of MRI in acute abdomen in pregnancy

La utilidad de la resonancia magnética para el diagnóstico en el abdomen agudo en el embarazo está demostrada. Permite evaluar el ángulo de inclinación cecal para intentar identificar el apéndice en una paciente embarazada con diagnóstico presuntivo de apendicitis. Se requiere una elevada sospecha diagnóstica para determinar que una embarazada con antecedentes de cirugía bariátrica padece un cuadro de obstrucción de intestino delgado. Los métodos de diagnóstico por imágenes no siempre resultan útiles en esta ocasión. Estos métodos carecen de la sensibilidad suficiente como para reemplazar el examen clínico oportuno de una embarazada con diagnóstico presuntivo de apendicitis. La demora del tratamiento incrementa la morbilidad. El tratamiento conservador de una ruptura apendicular se basa sobre la información retrospectiva. Sólo existen publicaciones de casos aislados sobre el empleo de esta estrategia en las embarazadas.

Laparoscopy in the morbidly obese pregnant patient using a modified foley lap-lift technique: case report.

Obesity in women of reproductive age is increasing. Gynecologic laparoscopy in the morbidly obese pregnant patient presents challenges, and is not often attempted. Herein is reported a successful case using a modified Foley lap-lift technique, which improved visualization and facilitated mechanical ventilation.

Laparoscopic management of fallopian tube torsion at 35 weeks of gestation: case report.

Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube torsion that was managed laparoscopically at 35 weeks of gestation.

Cervical and prolapsed submucosal leiomyomas complicating pregnancy.

UNLABELLED: Cervical and prolapsed submucosal leiomyomas are rarely seen in pregnancy. Depending on the size threshold used to diagnose a leiomyoma, the prevalence of uterine leiomyomas in pregnancy is approximately 3% to 10%. The prevalence of clinically evident cervical leiomyomas in pregnancy is less than 1%. Contrary to prior thought, the majority of uterine leiomyomas in pregnancy do not usually lead to complications. Indications for surgical intervention in pregnancy for cervical leiomyomas include bleeding, infection, degeneration, pain, and urinary stasis. Preoperative imaging with ultrasound and magnetic resonance imaging may help to delineate the location and nature (e.g., pedunculated) of the cervical leiomyoma when clinical examination is inconclusive. We reviewed the current literature in regard to cervical leiomyomas in pregnancy and summarize the major findings. After completing this CME activity, readers should be better able to evaluate the prevalence and natural history of uterine and cervical leiomyomas in pregnancy, assess indications for surgical intervention in pregnant patients, manage surgical complications, and select imaging modalities that may determine their origin. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the reader should be better able to evaluate the prevalence and natural history of uterine leiomyomas in pregnancy; assess indications for surgical intervention in pregnant patients; manage surgical complications; and select imaging modalities that may determine their origin.

Chronic nonpuerperal uterine inversion and necrosis: a case report.

INTRODUCTION: Inversion of the non-pregnant uterus is rare. CASE PRESENTATION: A 56-year-old African American woman presented to our emergency center with complaints of a mass protruding from her vagina. She subsequently underwent vaginal myomectomy, abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathologic examination revealed a necrotic fibroid and endometrium. At the time of laparotomy an inverted uterus was diagnosed when a 3 cm dimple containing bilateral round ligaments, infundibulopelvic ligaments and bladder was observed. CONCLUSION: Chronic nonpuerperal inversion of the uterus is rare. Infection should be suspected and appropriate broad spectrum antibiotics begun while planning surgery. An attempt at vaginal restoration and removal is difficult. Abdominal hysterectomy may be necessary taking care to locate the distal urinary collecting system.

Vaginal myomectomy in pregnancy: a report of two cases.

Prolapsed fibroids presenting in pregnancy are rare. Two cases of bleeding prolapsed fibroids, one cervical and the other submucosal, are presented to demonstrate the clinical features and outcomes following surgical treatment during pregnancy. While vaginal myomectomy of a prolapsed cervical fibroid in pregnancy appears safe, prolapse of a submucosal fibroid in pregnancy necessitating excision may be associated with rupture of the membranes.

Factors complicating surgical management of the vulvar abscess.

OBJECTIVE: To delineate risk factors and demographics in those patients with vulvar abscess that required surgical intervention, identify the most common bacterial isolate present at the time of surgery and comment on the progression to necrotizing fasciitis and the need for reoperation. STUDY DESIGN: Retrospective chart review. RESULTS: A total of 47 vulvar abscesses with cellulitis were managed surgically. The most common isolate was methicillin-resistant Staphylococcus aureus (MRSA), which comprised 43% of the total. The median length of stay was 4 days (1-66), and 17% had stays >7 days. Diabetes was significantly related to hospitalization >7 days (38% vs. 6%, p<0.01), reoperation (25% vs. 3%, p=0.02) and progression to necrotizing fasciitis (19% vs. 0%, p=0.01). CONCLUSION: When treating abscess of the vulva with cellulitis, antibiotic coverage of MRSA should be undertaken. Inpatient management with aggressive treatment for abscess of the vulva in those patients with concomitant diabetes is recommended.

Intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy: a practice survey.

OBJECTIVE: To assess practice patterns concerning intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy among members of the Association of Professors of Gynecology and Obstetrics (APGO). STUDY DESIGN: A 16-question survey regarding intraoperative fetal heart rate monitoring during nonobstetric surgery was delivered to the 1300 APGO members via email. Descriptive statistics were used to determine the reasons for fetal monitoring during nonobstetric surgery in pregnancy. RESULTS: Concerning intraoperative monitoring during nonobstetric surgery, 98% of respondents recorded the fetal heart rate pre-and post-surgery, and 43% of respondents reported they usually monitor intraoperatively. Of the 1151 physicians surveyed, 16% completed the survey. CONCLUSION: The majority of APGO members surveyed do not employ intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy.

Laparoscopy in pregnancy: a literature review.

The first laparoscopic surgery in pregnancy was a cholecystectomy in 1991. Since that time, a number of articles and case series have been published addressing laparoscopy in pregnancy. Current recommendations are on the basis of these findings, such as operating during any trimester in pregnancy can be safely performed, fetal heart monitoring should be made preoperatively and postoperatively, prophylactic tocolytics should not be used, and multiple entry techniques (Veress needle, Hasson trocar, or optical trocar) can be safely performed. This article will review anesthesia, fetal effects, obesity, complications, adnexal masses, and gastrointestinal issues.

Patterns of antibiotic resistance among group B streptococcus isolates: 2001-2004.

The objectives were to determine the prevalence of group B streptococcus (GBS) and to characterize antibiotic resistance patterns. All pregnant women presenting to the triage units at two urban hospitals during three intervals from 2001 to 2004 were included. Each interval lasted approximately four weeks. Swabs were inoculated into selective broth and cultured on tryptic soy agar with 5% sheep blood. GBS was identified using the StrepTex latex agglutination system. GBS positive cultures were tested for their resistance to ampicillin, erythromycin, clindamycin, and cefazolin. GBS was isolated from 154 (12.2%) of 1264 swabs collected during the study period. African-American women were more likely to be colonized with GBS than Caucasians and Hispanics. Resistance to routinely administered antibiotics was common, but there were no statistically significant increases in resistance to antibiotics over the study period. Ongoing surveillance of antibiotic resistance patterns is important in determining optimal prophylaxis and therapy.