Uncommon Surgical Emergencies in the Adult Gynecologic Patient: Two Cases of Missed Diagnosis of Outflow Tract Obstruction from Congenital Uterine Anomalies.

Gynecologic emergencies may result from congenital uterine anomalies (CUAs) with outflow tract obstruction. Not limited to the "classic" presentation of an adolescent amenorrheic pain patient, such anomalies should be part of the differential diagnosis for adult female patients presenting with severe pelvic pain. Obstructed rudimentary noncommunicating cavitary horns may result in severe chronic or acute pain and necessitate urgent surgical management. While two-dimensional (2D) ultrasound is often the initial diagnostic tool, three-dimensional (3D) ultrasound and MRI can accurately delineate CUAs for definitive diagnosis. When excision of a rudimentary horn is required, a laparoscopic approach is preferable. This case series focuses on two adult patients with severe pelvic pain due to unicornuate uteruses with obstructed noncommunicating cavitated rudimentary horns. Both cases involve a delayed diagnosis, the inability to make the diagnosis at standard surgical observation, and the resultant need for urgent surgical management.

Optimal timing of the second trimester fetal ultrasound in the obese gravida.

OBJECTIVES: Obesity is increasingly prevalent in the obstetric patient population, becoming one of the most commonly occurring risk factors in obstetric practice. Obesity has implications for maternal and fetal morbidity; in fact, some data suggest it is associated with higher rates of fetal anomaly. Coincident with this, maternal obesity poses an inherent challenge for ultrasound quality. The objective of this study is to investigate the relationship between ultrasound completion rates and advancing gestational age in obese gravidas, and to help identify an ideal gestational age to perform the second trimester ultrasound for fetal evaluation in the obese patient population. We hypothesized that in the obese patient, the odds of a completed scan would increase with each gestational age week, as fetal size increases. METHODS: This is a retrospective cohort study at a single tertiary care center. Inclusion criteria were pregnant women with BMI greater than 30 who had second trimester fetal ultrasound and delivery at our institution. Exclusion criteria were pregnancies without documented BMI, ultrasound not performed between 18 0/6 and 21 6/7 weeks, multiple gestations, or ultrasound performed for indication other than fetal anatomic assessment. Ultrasound reports were considered incomplete if they indicated suboptimal or non-visualization of any anatomic structures included in the comprehensive anatomic survey. Demographic data was compared using Student's t test and chi-square analysis where appropriate. Chi-square analysis was used to compare rates of completed surveys. p < .05 was considered significant. RESULTS: After application of eligibility criteria, our cohort included 1,954 subjects. When comparing subjects with a completed scan to those with an incomplete scan, there were more white subjects in the incomplete group (p = .012), but other analyzed demographics were similar between groups. When using 18 weeks as a referent group, with each additional completed week of gestation, subjects were more likely to have a completed scan, at 19 weeks (OR 1.29, CI 1.05-1.58); at 20 weeks (OR 1.46, CI 1.1-1.95); at 21 weeks (OR 2.12, CI 1.42-3.17) (p < .05 for each). This association persisted when adjusting for demographic factors. To identify the optimal timing for the second trimester ultrasound for fetal evaluation, we re-analyzed the data using each completed week of gestational age as the referent group. When using 19 weeks as the referent group, the odds of a complete scan were lower at 18 weeks, and higher at 21 weeks, but not different at 20 weeks. When using 20 weeks as the referent group, the odds of a complete scan were lower at 18 weeks, but not different at 19 or 21 weeks. Finally, when using 21 weeks as the referent group, the odds of a complete scan were lower at 18 and 19 weeks, but not different at 20 weeks. CONCLUSIONS: In this cohort of obese gravidas, the odds of having a completed anatomic survey continued to improve until 21 weeks gestational age. When comparing completed scans between each week, 18 weeks demonstrated consistently lower odds of a complete scan, however 20 weeks did not differ significantly from 19 weeks. Therefore, consideration should be made to perform the initial second trimester ultrasound for fetal evaluation in obese patients at 19 weeks gestational age to optimize completion rates while minimizing scans performed at advancing gestational ages.

Fallopian tube endometriosis in women undergoing operative video laparoscopy and its clinical implications.

OBJECTIVE: To determine the incidence of fallopian tube endometriosis in patients undergoing laparoscopic surgery with a preoperative diagnosis of endometriosis, pelvic pain, infertility, or cystic adnexal mass. DESIGN: Retrospective cross-sectional study. SETTING: Gynecologic oncology and minimally invasive surgery practice. PATIENT(S): All patients who underwent surgery for endometriosis from July 2015 to June 2018 were included. Exclusion criteria were age ≥55 years, diagnosis of cancer, laparotomy, previous bilateral salpingectomy, and preoperative diagnosis other than endometriosis, pelvic pain, infertility, or cystic adnexal mass. INTERVENTION(S): Subjects were divided by those who did and those who did not have a salpingectomy at the time of surgery. MAIN OUTCOME MEASURE(S): Diagnosis of tubal endometriosis was based on macroscopic evidence of endometrial implants on the fallopian tube(s) noted within the operative report and microscopic evidence of endometriosis noted within the pathology report. RESULT(S): A total of 444 surgeries were performed and 185 met the study criteria. Among those, 153 (82.7%) had histologically diagnosed endometriosis within the abdominopelvic cavity. The incidence of tubal endometriosis was 11%-12% macroscopically and 42.5% microscopically after salpingectomy. Patients with tubal endometriosis were more likely to have severe disease. CONCLUSION(S): Among patients with endometriosis, the incidence of microscopic tubal endometriosis was significantly greater than that of macroscopic disease.

Navigating the body of literature assessing BRCA1/2 mutations and markers of ovarian function: a systematic review and meta-analysis.

PURPOSE: Twelve percent of women in the USA will develop invasive breast cancer in their lifetime, and that risk increases to 80% if they carry a BRCA1 or BRCA2 mutation. BRCA1/2 mutations are thought to potentially affect ovarian reserve and/or fertility. METHODS: PubMed and PubMed Central were searched for publications on ovarian reserve-related outcomes (i.e., AMH and response to controlled ovarian hyperstimulation (COH) protocols) that were reported in relation to BRCA1 and/or BRCA2 mutations from 1950 through May 2019. A meta-analysis was conducted to create forest plots and summary effect measures using Review Manager 5.3. RESULTS: This article reviews the 16 qualifying publications. There were several fundamental methodological differences in the study designs and outcome details reported in AMH studies. Summary statistics found no difference in AMH levels between BRCA1/2+ women as compared with controls (Z overall test effects p ≥ 0.45). Regarding responses to COH, there were overall non-significantly fewer total and mature numbers of oocytes retrieved in BRCA1/2+ cases as compared with controls (meta-analysis Z overall test effects p ≥ 0.40). CONCLUSIONS: While the summary measures indicate no significant differences in AMH levels between BRCA1/2+ cases and controls, readers should be aware that there are significant methodological differences in the AMH reports. Additionally, the response to COH protocols does not seem to be significantly lower in BRCA1/2 mutation carriers in the existing literature. Continued research on both of these clinical parameters would be beneficial for patient counseling.

Does theFMR1 gene affect IVF success?

FMR1 CGG trinucleotide repeat expansions are associated with Fragile X syndrome (full mutations) and primary ovarian insufficiency (premutation range); the effect of FMR1 on the success of fertility treatment is unclear. The effect of FMR1 CGG repeat lengths on IVF outcomes after ovarian stimulation was reviewed. PubMed was searched for studies on IVF-related outcomes reported by FMR1 trinucleotide repeat length published between 2002 and December 2017. For women with CGG repeats in the normal (<45 CGG), intermediate range (45-54 CGG), or both, research supports a minimal effect on IVF outcomes, including pregnancy rates; although one study reported lower oocyte yields after IVF stimulation in women with lower CGG repeat lengths and normal ovarian reserve. Meta-analysis revealed no association within subcategories of normal repeat length (<45 CGG) and IVF pregnancy rates (summary OR 1.0, 95% CI 0.87 to 1.15). Premutation carriers (CGG 55-200) may have reduced success with IVF treatment (lower oocyte yield) than women with a normal CGG repeat length or a full mutation, although findings are inconsistent. Direct implications of the repeat length on inheritance and the risk of Fragile X syndrome have been observed. Patients may require clinical and psychological counselling, and further preimplantation genetic testing options should be considered. Thus, there are clinical and psychological counseling implications for patients and potential further patient decisions regarding preimplantation genetic testing options.