Animal models of postpartum hemorrhage.

Postpartum hemorrhage (PPH)-heavy bleeding following childbirth-is a leading cause of morbidity and mortality worldwide. PPH can affect individuals regardless of risks factors and its incidence has been increasing in high-income countries including the United States. The high incidence and severity of this childbirth complication has propelled research into advanced treatments and alternative solutions for patients facing PPH; however, the development of novel treatments is limited by the absence of a common, well-established and well-validated animal model of PPH. A variety of animals have been used for in vivo studies of novel therapeutic materials; however, each of these animals differs considerably from the anatomy and physiology of a postpartum woman, and the methods used for achieving a postpartum hemorrhagic condition vary widely. Here we critically evaluate the various animal models of PPH presented in the literature and propose additional and alternative methods for modeling PPH in in vivo studies. We highlight how current animal models successfully or unsuccessfully mimic the anatomy and physiology of a postpartum woman and how this may impact treatment development. We aim to equip researchers with the necessary background information to select appropriate animal models for their research related to PPH solutions, while supporting the goals of refinement, reduction and replacement (3Rs) in preclinical animal studies.

Forensic Nurses' Understanding of Emergency Contraception Mechanisms: Implications for Access to Emergency Contraception.

BACKGROUND: An estimated 25,000 pregnancies result from sexual assault in the United States annually. Numerous professional healthcare organizations endorse offering emergency contraception (EC) as an integrated aspect of post-sexual-assault care. Lack of knowledge surrounding EC's mechanism of action, including misinterpreting ECs as abortifacients, might restrict patient access to this important healthcare option. PURPOSE: We evaluated sexual assault nurse examiners' understanding of the mechanism of action of oral ECs levonorgestrel (LNG) and ulipristal acetate (UPA). METHODS: A cross-sectional survey of practicing sexual assault nurse examiners was conducted through the International Association of Forensic Nurses. RESULTS: Among 173 respondents, 96.53% reported they prescribed/dispensed EC at the time of medical forensic examinations. LNG was prescribed more frequently than UPA (57.80% vs. 38.2%, respectively). When asked if they agreed or disagreed if LNG and UPA can disrupt an established pregnancy, 83.2% selected disagree/strongly disagree for LNG versus 78.6% for UPA, which were not significantly different. When asked whether the Supreme Court ruling overturning Roe v. Wade would change their EC prescribing, 79.77% reported it will have no change, 6.94% said it would increase, and 12.72% reported they were unsure. Several commented they were concerned whether state laws would prohibit EC and at least one program stopped prescribing EC because of their state laws. IMPLICATIONS: Addressing misinformation regarding EC's mechanism of action and increasing access to oral EC options after sexual assault have the potential to reduce the incidence of rape-related pregnancy.

A Novel Curricular Design Exposing Clinical Medical Students to the Hidden Curriculum.

BACKGROUNDS: The Curriculum Committee of a medical school introduced a longitudinal course for clinical medical students addressing the hidden curriculum as a way to enhance the overall learning environment in undergraduate medical education. METHODS: This novel design included podcasts, virtual online sessions, and self-reflection videos. OUTCOMES: Students and faculty viewed it as successful.

Clostridium perfringens of unclear origin causing pelvic inflammatory disease and toxic shock syndrome in a previously healthy young woman.

A 22-year-old woman presented to the emergency room with right lower abdominal pain. A CT scan suggested potential appendicitis and perforation. She had no relevant medical or surgical history, and she last had vaginal sex 4 years prior to admission. During surgery, turbid fluid, secondary inflammatory changes, and dilated, fluid-filled fallopian tubes pointed to a diagnosis of pelvic inflammatory disease (PID), so she was started on azithromycin, metronidazole and piperacillin/tazobactam. The following day, she continued to have abdominal pain and developed tachycardia, hypotension, a marked leukemoid response, haemoconcentration, third space fluid accumulation and acidosis. Culture results led to her being further diagnosed with Clostridium perfringens PID with peritonitis and toxic shock syndrome. A gynaecological infection of C. perfringens leading to toxic shock syndrome is both extremely rare and highly fatal. Her antibiotics were changed to meropenem and clindamycin, and she slowly made a full recovery.

Prevalence of female sexual dysfunction among women attending college presenting for gynecological care at a university student health center.

Objective: To estimate the prevalence of female sexual dysfunction (FSD) among women attending college (18-29 years of age) presenting for routine gynecological care at a university-based student health center. Participants: Location: University affiliated women's health care clinic. Methods: Study design: Descriptive, cross sectional study. Primary endpoint: Estimated prevalence of FSD in the 18-29-year- old population. A subanalysis between those with and without recent sexual activity was performed. Logistic Regression was performed to identify potential predictors of FSD among those affected. Results: Of 310 women, FSFI was estimated as ranging from 35.5% (not sexually active) to 42.3% (sexually active). Those of younger age (18-21), with prior mental health diagnosis, and self-reported problems with arousal were at increased risk for FSD. Conclusion: Screening for FSD in the 18-29-year-old population is justified and recommended.

Etonogestrel contraceptive implant-associated secondary anorgasmia.

The etonogestrel contraceptive implant is a 4-cm radio-opaque subdermal rod, inserted in the nondominant arm, providing up to 3 years of continuous contraception. We describe a 21-year-old nulligravid, nondepressed female who experienced new-onset secondary anorgasmia 1 month after etonogestrel insertion. Off-label, oral use of bupropion and sildenafil did not restore orgasmic ability. Finally, 1 week after implant removal (4½ months after insertion), spontaneous return of orgasmic ability occurred. Anorgasmia after etonogestrel implant use is a rare adverse event; nonetheless, clinicians should be alert to its possibility. IMPLICATION STATEMENT: This report documents secondary anorgasmia in a nondepressed female temporally associated with etonogestrel implant insertion. Clinicians should be aware that this rare event can occur but is quickly reversible with implant removal.

Metastatic neuroblastoma diagnosed on prenatal sonographic examination performed for decreased fetal movement.

We report a case of fetal neuroblastoma presenting with massive liver metastasis diagnosed during the biophysical profile sonographic examination performed for decreased fetal movement. The patient presented at 37 weeks' gestation with limited fetal movement over 24 hours. Biophysical profile showed marked polyhydramnios and an enlarged abdomen filled with a homogeneous mass lesion suspicious for liver metastasis. Primary urgent cesarean section was performed revealing a cachectic neonate with a rigid and grossly distended abdomen. Neonatal evaluation confirmed the etiology of the abdominal mass to be liver metastasis from neuroblastoma. The child died on the 46th day. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:502-506, 2017.

Vaginoscopy compared to traditional hysteroscopy for hysteroscopic sterilization. A randomized trial.

OBJECTIVE: To compare vaginoscopic hysteroscopic sterilization with traditional hysteroscopic approach for differences in pain, bilateral microinsert placement rates, and procedure time. STUDY DESIGN: We performed a prospective, randomized, single-blinded study of hysteroscopic sterilization using the Essure System. The study setting was an inner city ObGyn clinic. Ninety patients were randomized to either vaginoscopy or traditional approach. The traditional approach was speculum insertion, paracervical analgesia, and tenaculum. All procedures were done with a 5 mm, 30 degree rigid hysteroscope. Main outcome measures were pain scores (10-point visual analog scale), bilateral placement rates, and procedure times. RESULTS: Vaginoscopy was successful in 42/45 patients (93%). There was no statistically significant difference in pain-scores for microinsert placement between the groups (p = 0.71). First attempt, bilateral microinsert placement rate was 95% (40/42) with vaginoscopy and 95% (43/45) with traditional (p = 0.89). Time for treatment completion was 16 minutes (mean) (range, 13-21) in the traditional group versus vaginoscopy time of 9 minutes (mean) (range, 7-11) (p = 0.03). CONCLUSION: Hysteroscopic sterilization via vaginoscopy is feasible with bilateral microinsert rates comparable to those of traditional hysteroscopy. Vaginoscopy is associated with less overall discomfort and is faster to perform.

Economic Impact of the Use of an Absorbable Adhesion Barrier in Preventing Adhesions Following Open Gynecologic Surgeries.

We used an economic model to assess the impact of using the GYNECARE INTERCEED absorbable adhesion barrier for reducing the incidence of postoperative adhesions in open surgical gynecologic procedures. Caesarean section surgery, hysterectomy, myomectomy, ovarian surgery, tubal surgery, and endometriosis surgery were modeled with and without the use of GYNECARE INTERCEED absorbable adhesion barrier. Incremental GYNECARE INTERCEED absorbable adhesion barrier material costs, medical costs arising from complications, and adhesion-related readmissions were considered. GYNECARE INTERCEED absorbable adhesion barrier use was assumed in 75% of all procedures. The economic impact was reported during a 3-year period from a United States hospital perspective. Assuming 100 gynecologic surgeries of each type and an average of one GYNECARE INTERCEED absorbable adhesion barrier sheet per surgery, a net savings of $540,823 with GYNECARE INTERCEED absorbable adhesion barrier during 3 years is estimated. In addition, GYNECARE INTERCEED absorbable adhesion barrier use resulted in 62 fewer cases of patients developing adhesions. Although the use of GYNECARE INTERCEED absorbable adhesion barrier added $137,250 in material costs, this was completely offset by the reduction in length of stay ($178,766 savings), fewer adhesion-related readmissions ($458,220 savings), and operating room cost ($41,078 savings). Adoption of the GYNECARE INTERCEED absorbable adhesion barrier for appropriate gynecologic surgeries would likely result in significant savings for hospitals, driven primarily by clinical patient benefits in terms of decreased length of stay and adhesion-related readmissions.

Preprocedure patient preferences and attitudes toward permanent contraceptive options.

OBJECTIVE: To determine patient preference for laparoscopic tubal occlusion or hysteroscopic tubal occlusion, two common sterilization interventions, and the acceptability of a postprocedure confirmation test for a hysteroscopic approach. PARTICIPANTS AND METHODS: A total of 100 patients were offered two procedures. A description of each procedure was developed and read to each patient by a research nurse on site. Patients were then asked to respond to a questionnaire concerning options. Final informed consent, procedure review, and procedural date determination were provided by a physician upon completion of the questionnaire. Patients were not allowed to change their questionnaire responses after completion. No interviewer or physician input was allowed during the questionnaire. The study was completed in English or Spanish, as per patient request, by a bilingual/fluent speaker. Physicians completing informed consent were unaware of the questionnaire responses. Patients were not financially incentivized. RESULTS: Of 100 participants, 93 (93%) preferred hysteroscopic sterilization to laparoscopy. The reasons were as follows: fear of general anesthesia (24/93 [26%]), fear of incision (25/93 [27%]), cost (32/93 [34%]), and time (12/93 [13%]) to return to routine activity. All 93 viewed "office-based location" as the main advantage over laparoscopy; 88/93 (94.6%) considered a confirmation test to be a benefit of the procedure. After informed consent was obtained, one additional patient switched from a laparoscopic decision to hysteroscopy (total = 94/100); 89/94 (95%) hysteroscopic decisions underwent hysteroscopic sterilization; 4/6 (67%) laparoscopic decisions proceeded to that surgery. The remainder (N = 7) cancelled due to lack of financial resources. CONCLUSION: A nonincisional, office-based approach to sterilization has high patient acceptability. Patients viewed a confirmatory test for tubal occlusion as a benefit after sterilization.

Peritoneal adhesion prevention at cesarean section: an analysis of the effectiveness of an absorbable adhesion barrier.

OBJECTIVE: To evaluate the effectiveness of an absorbable adhesion barrier utilized at cesarean delivery. STUDY DESIGN: We performed a retrospective, two-arm cohort, chart review of primary and subsequent first repeat cesarean sections from January 1, 2006-December 31, 2009. Exclusion criteria were incomplete operative report, history of prior abdominal-pelvic surgery, pelvic inflammatory disease, chorioamnionitis, emergency cesarean delivery or use of corticosteroids within 2 weeks. Adhesion incidence/severity as well as skin incision to newborn delivery times were analyzed. Effects of peritoneal closure and suture types were examined. RESULTS: Of 262 primary cesareans performed, 43% (N= 112) had repeat cesarean section. With barrier, 74% had no adhesions at repeat surgery, versus 22% in the no barrier group (p = 0.011). Eleven percent had grade 2 adhesions with barrier, while 64% had grade 2-3 in the no barrier group (p = 0.012). The barrier group had no grade 3 adhesions. Those with parietal peritoneal closure had less incidence (p = 0.02) and mean adhesion severity (p = 0.03); no significant difference was found per suture type. No statistical difference in time from skin incision to newborn delivery was noted between primary and barrier group (p = 0.006); those without barrier had a statistically longer delivery interval (p = 0.35). CONCLUSION: Use of an absorbable adhesion baóóórrier reduces the incidence and severity of adhesions at cesarean.

One patient, two uteri, two endometrial ablations: case report of thermal balloon ablation in uterine didelphys.

OBJECTIVE: To describe the clinical application and outcomes after endometrial ablation with ThermachoiceIII (Ethicon, Somerville, NJ) in a patient with uterine didelphys with heavy menstrual bleeding. DESIGN: Case report. SETTING: Inner-city community obstetrics and gynecology clinic. PATIENT(S): A 44-year-old Hispanic woman, gravida 3, para 0, with three spontaneous abortions. INTERVENTION(S): The patient underwent diagnostic hysteroscopy, gynecologic dilation and curettage, and endometrial ablation with ThermachoiceIII. MAIN OUTCOME MEASURE(S): Menstrual pattern at 3 months postoperatively, as either amenorrhea (complete lack of menstrual flow), hypomenorrhea (scant or minimal flow lasting <5 days, requiring only light pads), or failure (flow similar to pretreatment state or requiring any other therapy), as well as dysmenorrhea reduction from baseline. Hemoglobin value at 3 months was compared with baseline. RESULT(S): At 3 months, hypomenorrhea was maintained. Bleeding days were 10 per month at baseline and 2 per month after therapy. Visual analogue scale score for dysmenorrhea was 8 at baseline and 2 (mean) at study end. Hemoglobin was 8.9 g/dL at baseline (preoperatively) and 11.1 g/dL at 3 months postoperatively. CONCLUSION(S): Successful conservative therapy of menorrhagia seems possible with thermal balloon ablation in a uterine didelphic patient.

[Heart transplant in Monterrey, Nuevo León]. / Trasplante cardiaco en Monterrey, Nuevo León.

Heart failure constantly increases its incidence and prevalence in our society, it was imperative to start a heart transplant program to improve the survival rates of patients with end stages of the disease. Legal issues made impossible to transplant patients out of Mexico City until recent years. Even with an acute hemodynamic and clinic improvement after the transplant, these patients frequently develop complications such as graft rejection or opportunistic infections due to the immunosuppressive schemes increasing the morbidity and mortality of the procedure. In the present article we report the experience acquired with 65 heart transplant patients from 4 transplant programs in Monterrey, Nuevo Leon, one of them from the socialized system and the other three from private hospitals. Our program not only has successfully transplanted patients with advanced age but, for the first time in Latin America we have transplanted patients assisted with the ambulatory Thoratec TLC II system. Even that we have faced obstacles like a newly started donation culture in our population and limited resources, our patient's survival rate push us to continue working with these very ill population.

Ketorolac-mepivacaine lower uterine block for in-office endometrial ablation: a randomized, controlled trial.

OBJECTIVE: To investigate the effectiveness of a nonsteroidal antiinflammatory drug (NSAID) administered in combination with a local anesthetic as a deep paracervical block for in-office endometrial ablations. STUDY DESIGN: Double-blind, placebo-controlled, randomized trial. Patients received either sublingual ketorolac (30 mg/1 mL) or a mepivacaine-only paracervical injection (standard group) or received sublingual saline (1 mL) and a ketorolac (30 mg/1 mL)-mepivacaine paracervical block (NSAID group)for Gynecare Thermachoice III ablation (Ethicon, Inc., Somerville, New Jersey). All received sublingual ketorolac/placebo and 1 mg alprazolam sublingually 20 minutes preprocedure. Primary outcome was intraoperative pain control measured by 100 mm visual analogue scale. Secondary outcomes were postablation pain control (visual analogue scale [VAS]), postoperative use of narcotic analgesics and patient satisfaction in the first 24 hours (not satisfied, satisfied or very satisfied). RESULTS: Twenty patients were randomized into each group. No statistically significant difference was noted in overall intraoperative VAS score (p = 0.81), but there was a significant reduction in postoperative VAS (p = 0.01). There was less need for postoperative analgesic use in the first 24 hours (p = 0.02) in the NSAID group. More patients were "very satisfied" in the NSAID group. CONCLUSION: Injectable ketorolac-mepivacaine anesthetic solution functions well as a deep paracervical block for in-office gynecologic procedures, with better postoperative pain control than mepivacaine-alone protocols.

Emergent thermal balloon ablation for acute uterine hemorrhage: a report of 2 cases.

BACKGROUND: The management of acute, recalcitrant uterine hemorrhage has traditionally included gynecologic dilation and curettage, uterine balloon tamponade or emergent hysterectomy. These options were considered after failed medical therapy (intravenous estrogen, oral contraceptives or intramuscular progestins). The advent of global endometrial ablation devices now allow for an in-office treatment modality for these patients. CASES: Two cases of thermal balloon ablation to treat recalcitrant uterine bleeding are reported from an inner city obstetrics and gynecology practice. No further vaginal bleeding was noted up to eight weeks posttherapy, with an increase in hemoglobin in each patient. Each patient avoided emergent hysterectomy and/or blood transfusion. CONCLUSION: Office-based Thermachoice III ablation provides an alternative to traditional management of the acutely bleeding patient without the need for hospital admission.

In-office thermachoice III ablation: a comparison of two anesthetic techniques.

BACKGROUND: Patient comfort and safety are prerequisites for office procedures. STUDY OBJECTIVE: comparison of the fentanyl transdermal patch with injection of local anesthesia for intraoperative/postoperative pain from in-office Thermachoice III ablations. METHODS: Single-center prospective randomized (1:1) cohort study. Primary Endpoint: intraoperative and postoperative VAS pain scores (0 as no pain, 10 as extreme pain). Secondary Endpoints: patient satisfaction between cohorts and adverse events. RESULTS: 41 patients were randomized [21 patch protocol (FP), 20 injection protocol (IP)]. For patch users, the median VAS scores were 2.60 (range 1-4) intraoperatively and 3.30 (range 2-5) postoperatively (p = 0.09, CI = -0.8 to 0.4), with the most common adverse events being nausea (62%) and vomiting (38%). Compared to injection, there was no significant difference in intraoperative VAS score (FP median VAS = 2.60, IP median VAS = 2.59; p = 0.15, CI = -0.05 to 0.48), but a significant difference postoperatively (FP median VAS = 3.30, IP median VAS = 6.0; p = 0.01, CI = -2.6 to -1.4). Less NSAIDs were used postoperatively with the FP. At 24 h, more FP patients were 'very satisfied' or 'satisfied' than IP patients. CONCLUSION: Patch intraoperative VAS pain scores are comparable to uterine block scores; postoperative VAS pain scores were statistically lower with the FP. FP resulted in more favorable 'satisfaction' rates compared to IP.

In-office endometrial ablation and clinical correlation of reduced menstrual blood loss and effects on dysmenorrhea and premenstrual symptomatology.

OBJECTIVE: To evaluate in-office Thermachoice III endometrial ablation on subsequent dysmenorrhea and premenstrual mood symptoms in relation to decreased menstrual blood loss. STUDY DESIGN: The study conducted was in a prospective cohort single group. Ablations were performed on 148 patients under parametrial block using dilute mepivacaine and oral anxiolysis for a diagnosis of menorrhagia. The primary endpoint was eumenorrhea or less, with secondary endpoints of dysmenorrhea reduction and premenstrual symptom alleviation. Patients were evaluated at 3 and 6 months postprocedure. Of 148 patients, 134 (90.5%) complied with follow-up. RESULTS: At 3 months, 52% were amenorrheic; 48% reporting hypomenorrhea. Results persisted at 6 months, with 50% and 48%, respectfully. Of 134 patients, 3 were considered nonresponders at 6 months. Mean hemoglobin values increased for all groups at each time endpoint. Of 115 patients, 79 reported baseline dysmenorrhea, with improvement in visual analog scale findings at both 3 and 6 months (p<0.005). Premenstrual mood symptoms of agitation, irritability and depression also improved at both 3 and 6 months. CONCLUSION: In-office Thermachoice III endometrial ablation results in decreased dysmenorrhea and improved mood in relation to decreased menstrual blood loss.

In-office endometrial ablation using a third-generation uterine balloon therapy system: 12-month prospective follow-up on menstrual patterns and dysmenorrhea impact.

OBJECTIVE: To evaluate the efficiency of in-office Thermachoice III (Ethicon, Somerville, New Jersey) endometrial ablations in resolving menstrual abnormalities as well as dysmenorrhea at 12 months after the procedure. STUDY DESIGN: This was a prospective, single arm, cohort study of women from an inner city, community based, physician group medical/ surgical clinic. Diagnostic hysteroscopy, dilation and curettage, and Thermachoice III endometrial ablation were performed under local analgesia. RESULTS: At baseline, N = 148. At 12 months, 23 patients were lost to follow-up, leaving 125 for the evaluable cohort. The largest resulting patient category was amenorrhea, with 66.4% (83 of 125 evaluable), followed by hypomenorrhea at 31% (39 of 125 evaluable). Three patients (2.4%) were considered clinical failures. These 3 patients initially were designated as having hypomenorrhea at 3 months. Dysmenorrhea reduction was statistically significant (p < 0.05) at 6 months and 12 months as compared to baseline. CONCLUSION: At 1 year after the procedure, the efficiency of in-office Thermachoice III was observed, with high amenorrhea rates as well as persistently decreased dysmenorrhea.

Utility of in-office endometrial ablation: a prospective cohort study of endometrial ablation under local anesthesia.

OBJECTIVE: To determine tolerability of in-office endometrial ablation under local anesthesia and the rate of adverse events in the first 2 postoperative weeks. STUDY DESIGN: The study was a prospective cohort single group study. RESULTS: Ablation was performed on 148 patients under deep parametrial block using dilute mepivacaine and oral anxiolysis. No patient requested the procedure be stopped due to pain, but 1 requested intraoperative reinjection of anesthetic. No patient required admission due to pain. No serious adverse events were noted intraoperatively or in the first 2 weeks following the procedure. The most common adverse event at follow-up was bacterial vaginosis in 16 of 143 (11%) of the evaluable cohort. Five patients were seen after the first 2 weeks, without complications, but were therefore excluded from the study. Patient satisfaction was assessed at 2-week follow-up visit in the 143 evaluable cohort. A total of 130 of 143 patients (90%) reported being "Very Satisfied", 13 (9.1%) reported being "Satisfied" and none were "Unsatisfied". CONCLUSION: Endometrial ablation can be performed successfully in the physician's office under local anesthesia and oral anxiolysis with low patient pain scores, high tolerability and high patient satisfaction. Serious adverse events were not encountered when performed by properly trained practitioners.