Perioperative Considerations for Hysterectomy in Second-Trimester Molar Pregnancy.

BACKGROUND: Second-trimester complete molar pregnancies are rare. Due to a later presentation, means to reduce surgical and long-term morbidity from hemorrhage, hyperthyroidism, and gestational trophoblastic neoplasia risk should be considered. CASE: A 48-year-old woman presented at 17 6/7 weeks of gestation with vaginal bleeding, with a human chorionic gonadotropin (hCG) level of 483,906 milli-international units/mL, biochemical hyperthyroidism, and ultrasonographic suspicion for complete molar pregnancy. The patient received preoperative uterine artery embolization and antithyroid medication before undergoing total abdominal hysterectomy. Her thyroid function and hCG level normalized by 1 week and 69 days postoperatively, respectively. CONCLUSION: Uterine artery embolization and hysterectomy may reduce surgical blood loss and lower the risk of malignancy for patients at high risk for gestational trophoblastic neoplasia. Preoperative treatment of hyperthyroidism with gestational trophoblastic disease can reduce morbidity from thyrotoxicosis.

Comparing preoperative dating and postoperative dating for second-trimester surgical abortions.

OBJECTIVES: To assess relationships between preoperative and postoperative dating of second-trimester surgical abortion. STUDY DESIGN: We used a deidentified institutional database to extract demographic, dating and pathology data for surgical abortions performed at 14 to 23-6/7 weeks' gestational age (GA) from 9/2015 to 5/2017. We excluded women with multiple gestations, fetal anomalies and missing fetal biometric measurements. We assigned preoperative GA by ultrasonography for unknown last menstrual period (LMP) or when discrepancy between sonographic and LMP dating exceeded 7 days (<15-6/7 weeks), 10 days (16 to 21-6/7 weeks) or 14 days (22 to 23-6/7 weeks). We determined postoperative GA using fetal foot length pathology standards published by Streeter in 1920 and Drey et al. in 2005. We performed regression analysis to estimate the relationship between pre- and postoperative estimates of GA and to assess demographic effects on these estimates, and χ2 tests to assess whether fetal foot lengths were concordant with, larger than or smaller than the expected range for the preoperative GA. RESULTS: The 469 patients analyzed had a median preoperative GA of 19-4/7 weeks (range 14-0/7 to 23-6/7 weeks). Preoperative dating highly correlated with postoperative dating using both pathology standards (r2=0.95, p<.001), without any clinically relevant effect by body mass index (Streeter and Drey, p=.79), parity (Streeter p=.89; Drey p=.71), race (Streeter p=.06; Drey p=.07) or GA. Fetal foot lengths were larger than expected in 134 (28.6%) women using Streeter and 17 (3.6%) women using Drey standards (p<.001). CONCLUSIONS: Preoperative dating and postoperative dating for second-trimester surgical abortion highly correlate. Use of Streeter standards results in more women with a postoperative GA greater than expected compared to Drey standards. IMPLICATIONS: Increasing legal gestational age restrictions have placed additional burden on clinicians providing safe abortions, but guidelines on gestational age determination are lacking. Contemporary pathology standards consistent with modern practice and universally accepted by abortion providers and gynecologic pathologists are critical to our goal of safe and legal abortion provision.

Family Practitioner-Directed Hepatitis C Therapy With Direct-Acting Antivirals Achieves High-Sustained Virologic Response in Prison Population.

The burden of hepatitis C virus (HCV) infection is disproportionately high in U.S. federal and state prisons. This offers a unique opportunity for targeted HCV screening and treatment. New, highly effective, oral direct-acting antiviral (DAA) agents have the potential to eliminate many of the hurdles previously imposed by older interferon-based therapies. However, a relative deficit of providers motivated or empowered to treat HCV, along with a lack of treatment data on use of DAAs in prisons, greatly restricts the ability to treat the prison population. Here, we present a retrospective chart review of HCV treatment with DAAs by a family practitioner in a California state prison. Our data demonstrate that focused treatment by a primary care practitioner can achieve high HCV cure rates even in historically difficult to treat populations. Treatment of prison populations per local and national guidelines by family practitioners should be pursued to facilitate the eradication of hepatitis C in the United States.

The relationship between shame and perceived biological origins of mental illness among South Asian and white American young adults.

Mental illness (MI) affects one in four people in their lifetime and a failure to seek help for MI can have grave consequences. To decrease stigma and increase help seeking, prior campaigns have promoted the biological origins of MI. Even though some research supports the efficacy of this approach, other research does not. We propose cultural differences as a partial explanation for these inconsistent results. The current study assessed ethnic differences in the relationship between perceived causes of MI, shame associated with MI and perceived family support for help seeking. White and South Asian American (SAA) undergraduate students completed an online survey (n = 177). Results indicated that SAAs were significantly more likely than whites to perceive character deficits as the cause of MI. Further, among those who had sought help for MI, ethnic differences emerged in perceptions of MI based on perceived cause. SAAs who believed that MI had biological origins perceived more shame and less family support for seeking help compared to SAAs who believed MI was due to character deficits. The converse was true for whites - those who believed that MI had biological origins perceived less shame and more family support for help seeking compared to whites who believed MI was due to character deficits. The results of the current study illuminate the role that culture plays in perceptions of MI. Further, these results have implications for interventions targeting South Asian populations and for mental health outreach in general.