Management of cervical ectopic pregnancy with uterine artery embolization: a case report.

BACKGROUND: Cervical ectopic pregnancy is a rare occurrence but carries the risk of life-threatening maternal hemorrhage. CASE: A 35-year-old woman, gravida 4 para 2, presented to the Emergency Room with the complaint of pelvic cramping and vaginal spotting. Initial quantitative serum beta-hCG value was 79,506.7 mIU/mL. Obstetrical ultrasound demonstrated a single, live pregnancy of approximately 8 weeks' gestation located within the endocervical canal. Pelvic MRI confirmed a live cervical ectopic pregnancy. Following discussion of management options, the decision was made to employ uterine artery embolization (UAE). Subsequent to UAE and by hospital day 4, no embryonic cardiac activity was noted. Postdischarge day 12 gynecologic ultrasound demonstrated a small, complex endocervical fluid collection compatible with resolving cervical pregnancy. CONCLUSION: If clinical circumstances are amenable to trial of embolization, interventional radiology should be consulted for cervical ectopic pregnancy management. In cases in which there may be relative contraindications to methotrexate therapy alone and there is desire to avoid hysterectomy, clinicians should give consideration to a combination of strategies, including UAE, to manage cervical pregnancy. The case report highlights a review of the current literature and discusses options for conservative cervical ectopic pregnancy management.

Naturally occurring heterotopic pregnancy in a multiparous patient: a case report.

BACKGROUND: Heterotopic pregnancy, or simultaneous intrauterine and extrauterine pregnancy, occurs rarely. Consequently, clinicians might not always consider a diagnosis of heterotopic pregnancy. Transvaginal ultrasound or other imaging modalities cannot be completely relied upon to exclude heterotopic pregnancy from the differential diagnosis of pregnant patients with abdominal pain. CASE: A 32-year-old woman, G5 P3105, presented to the emergency room with acute onset of diffuse abdominal pain. Ultrasound demonstrated an approximately 8-week intrauterine pregnancy. The patient underwent exploratory laparotomy for suspected torsion of a right ovarian cyst. Repeat exploratory laparotomy was required due to symptomatic anemia. The patient underwent exploratory laparotomy and right salpingo-oophorectomy. Pathology results demonstrated a right tubal ectopic pregnancy. CONCLUSION: Surgical and medical options exist for heterotopic pregnancy management. Despite negative heterotopic pregnancy results for transvaginal ultrasound, the possibility of heterotopic pregnancy should remain within the differential diagnosis of any pregnant patient with either natural or assisted reproduction technology intrauterine pregnancy who presents with abdominal pain and/or clinical signs of ectopic pregnancy.

Using the Pregnancy Perception of Risk Questionnaire to assess health care literacy gaps in maternal perception of prenatal risk.

In order to make appropriate decisions, patients must be able to understand and use the context-specific health information with which they have been provided, and health providers must be able to convey information to patients who possess varying degrees of health literacy. Adherence to medical recommendations often depends on patient perception of their medical risks and the importance they attach to those risks. In obstetrics, maternity patients are generally identified as high risk or non-high risk (routine). Conferring the designation of "high risk" may confer additional benefits in educational efforts, literacy evaluation, and relief of educational barriers to care that are reflected in high-risk patients' higher assessments of their risks. In this study, medically identified risk factors were reviewed for patients in the high-risk and routine obstetrical clinics. Patients labeled as "routine" might still possess significant numbers and types of medically identified risk factors (MIFs) due to patients' socioeconomic status and health risks. If prenatal risk is a spectrum, adaptation of obstetrical health care materials and culturally appropriate counseling may mitigate gaps between patient understanding of their MIF number and type and patient risk perception in order to reach the goal of universally improved patient adherence to medical recommendations.

Diagnosis of macroamylasemia in a pregnant patient.

BACKGROUND: Macroamylasemia occurs with the formation of macroamylase complexes that cannot be cleared via renal excretion. In patients with persistent serum amylase elevation or hyperamylasemia with normal urine amylase and lipase levels, the diagnosis of macromylasemia is suggested. MAIN FINDINGS: The patient is a 31-year-old G2P1 who presented to the ob/gyn triage with the complaint of recurrent right-sided abdominal pain. Serum amylase values were elevated. The patient had been admitted previously at GA 16 weeks for recurrent acute cholecystitis and gallstone pancreatitis and had undergone laparoscopic cholecystectomy. CONCLUSION: In the absence of characteristic findings suggestive of acute cholecystitis or gallstone pancreatitis, clinicians should evaluate urinary and serum amylase isoenzymes to exclude hyperamylasemia due to elevated serum macroamylase levels. Additional interventions may not be required to assure optimal maternal or fetal outcome.

The use of missing birth record data as a marker for adverse reproductive outcomes: a geocoded analysis of birth record data.

Adverse reproductive outcomes (AROs) disproportionately affect black American infants and significantly contribute to the U.S. infant mortality rate. Without accurate understanding of AROs, there remains little hope of ameliorating infant mortality rates or eliminating infant health disparities. However, despite the importance of monitoring infant mortality rates and health disparities, birth record data quality is not assured. Racial disparities in the reporting of birth record data have been documented, and missing birth record data for AROs appears to be disproportionate. Due to the extent of missing birth record data, innovative strategies have been developed to evaluate relationships between maternal socioeconomic status (SES) and community-based ARO rates. Because addresses convey aggregate information about income level, education and occupation, ZIP codes, census tracts and census block-groups have been applied to geocoding efforts. The goals of this study are to: 1) analyze the extent of missing birth record data for New Jersey areas with high rates of an ARO (preterm birth), 2) evaluate associations between the extent of missing birth record data and other AROs, and 3) consider how geocoding strategies could be applied to provide a basis for understanding maternal SES risk factors and ARO resource allocation for at-risk communities.

Generations of loss: contemporary perspectives on black infant mortality.

The U.S. black infant mortality rate (IMR) remains a significant public health concern. Although improved during the last four decades, the U.S. IMR remains within the lowest tier of IMRs for all industrialized countries, and black American infants remain disproportionately represented in low birthweight (LBW) and infant death statistics. Numerous risk factors have been analyzed for their relative contributions to the U.S. IMR and black-white infant survival health disparities. Those factors include prenatal care quality and access, maternal socioeconomic status (SES), HIV/AIDS status, infections, intrapartum risk factors, existing comorbidities, social support, and nutritional status. However, the role of these and other factors have not fully explained the higher infant mortality risks for black infants. This review will discuss a variety of risk factors that contribute to infant mortality disparities between non-Hispanic black and white infants. Among those factors, the goal will be to review selected topics pertaining to maternal SES, LBW, preterm birth, perinatology advances, birth record data quality, maternal stress, prenatal care adequacy, and physical and substance abuse, and the relationships of those topics to black-white IMR health disparities.

Opportunistic approaches for delivering preventive care in illness visits.

OBJECTIVE: To describe how clinicians create opportunities to deliver preventive care in illness visits and assess the impact this has on preventive service delivery. METHOD: Detailed and descriptive fieldnotes were collected from 18 purposefully selected family practices, including direct observations of 53 primary care clinicians and 1620 patient encounters. Conversation analysis was used to examine the conversational techniques employed to deliver four preventive services (smoking counseling, immunization delivery, mammography, and cervical cancer screening) in illness visits. Qualitative data was coded and analyzed to assess impact on preventive service delivery rates. RESULTS: Two methods for opportunistic preventive service delivery were observed. In the first, clinicians used the close of the medical encounter to make arrangement for follow-up preventive care. In the second approach, clinicians use a stepwise conversational device to exit talk about the patient's presenting problem and enter into relevant health habit advice. Quantitative analyses show that opportunistic methods are rarely used to deliver preventive services in illness visits. The stepwise technique was the most frequently used method. Patients treated by clinicians who used opportunistic techniques to deliver preventive care in illness visits were more likely to be up-to-date on smoking counseling and cervical cancer screening than those patients who were treated by clinicians who did not use opportunistic approaches. CONCLUSIONS: Opportunistic preventive service delivery in illness visits can be an efficient and effective way to deliver preventive care. Although infrequently used, quantitative data suggest that the use of opportunistic approaches to deliver preventive services during illness visits can enhance preventive care rates. Interventions aimed at helping clinicians develop effective strategies for offering preventive care during illness visits may be an important complement to existing mechanical interventions that might, by themselves, be insufficient to improve preventive care.

Necrotizing soft tissue infections: a primary care review.

Patients with necrotizing soft tissue infections often present initially to family physicians. These infections must be detected and treated rapidly to prevent loss of limb or a fatal outcome. Unfortunately, necrotizing soft tissue infections have no pathognomonic signs. Patients may present with some evidence of cellulitis, vesicles, bullae, edema, crepitus, erythema, and fever. They also may complain of pain that seems out of proportion to the physical findings; as the infection progresses, their pain may decrease. Magnetic resonance imaging and laboratory findings such as acidosis, anemia, electrolyte abnormalities, coagulopathy, and an elevated white blood cell count may provide clues to the diagnosis. No single organism or combination of organisms is consistently responsible for necrotizing soft tissue infections. Most infections are polymicrobial, with both anaerobic and aerobic bacteria frequently present. Fungal infections also have been reported. Generally, bacterial and toxin-related effects converge to cause skin necrosis, shock, and multisystem organ failure. Aggressive debridement of infected tissues is critical to management. Antimicrobial therapy is important but remains secondary to the removal of diseased and necrotic tissues.