Direct Visualization of a Cesarean Scar Ectopic Pregnancy After Medical Management.

BACKGROUND Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy that can result in severe maternal morbidity and mortality. Medical, surgical, and minimally invasive therapies alone or in combination have been described in the literature, but the optimal treatment modality of cesarean scar ectopic pregnancies is unknown. Limited information exists on the course of cesarean scar ectopic pregnancy following treatment with cytotoxic agents. CASE REPORT We present a case of a woman with a history of multiple cesarean births that was provided with medical abortion for an unintended pregnancy. However, upon follow-up, the patient was found to have a cesarean scar ectopic pregnancy. Following the diagnosis, she was treated by multi-dose systemic methotrexate-leucovorin and with ultrasound-guided intra-gestational sac injection of potassium chloride. After resolution of beta human gonadotropin levels, ultrasound follow-up revealed persistence of residual tissue in the cesarean scar. The patient elected for resection of the residual tissue with operative hysteroscopy. We report a novel hysteroscopic finding after medical treatment of a cesarean scar ectopic pregnancy with intra-gestational sac injection of potassium chloride. CONCLUSIONS Direct visualization of the intra-abdominal cavity and intra-uterine cavity showed that combined medical management with systemic methotrexate and local potassium chloride injection is an effective treatment modality for live cesarean scar ectopic pregnancies, with minimal anatomical harm. Hysteroscopic resection offers a safe and effective approach for removal of persistence of residual tissue.

Risk of endometrial polyp and surgical intervention in postmenopausal women with proliferative endometrium.

OBJECTIVE: To study the long-term risks of postmenopausal women with proliferative endometrium developing benign uterine pathologies (endometrial polyps and uterine fibroids) and requiring future gynecological interventions, and to compare them with women with atrophic endometrium. DESIGN: Retrospective cohort study of all women aged 55 or over who underwent endometrial biopsy between 1/1997 and 12/2008. Outcome data were available through to 2/2018. Women with proliferative endometrium were compared with those with atrophic endometrium for the presence of endometrial polyps, uterine fibroids, future endometrial biopsy for recurrent vaginal bleeding, and future hysteroscopy or hysterectomy. Logistic regression models were used to evaluate the association of endometrial histology and other covariates with the risk of morbidities. MAIN FINDINGS: Postmenopausal women with proliferative endometrium are at higher risk of developing endometrial polyps, uterine fibroids and need for surgical intervention. Of 1808 women who underwent endometrial biopsy during the study period, 962 met inclusion criteria: 278 had proliferative and 684 had atrophic endometrium. Length of surveillance was similar in the two groups (11.9 vs. 11.5 years, p = 0.2). Compared with women with atrophic endometrium, women with proliferative endometrium had significantly higher rates of endometrial polyps (17.3 % vs 9.7 % p = 0.001). Multivariable logistic regression confirmed that women with proliferative endometrium had more fibroids on ultrasound (62.1 % vs 50.3 % 3 = 0.02), and had increased risks of developing endometrial polyps (aOR 1.9, 95 % CI 1.28-3.07, p = 0.002), repeat endometrial biopsy (34.9 % vs. 16.8%p < 0.001) and future hysterectomy or hysteroscopy (26.6 % vs 16.2 % p < 0.001). CONCLUSIONS: In addition to the long-term increased risk of cancer, postmenopausal women with proliferative endometrium are more likely to have future bleeding, surgical interventions and diagnosis of endometrial polyps. Medical management to reduce estrogenic activity and associated risks may be considered in these cases.

Long-term outcome of postmenopausal women with proliferative endometrium on endometrial sampling.

BACKGROUND: Proliferative endometrium has been reported in 15% of endometrial biopsies of women aged 50 years and older. Contrary to endometrial hyperplasia, proliferative endometrium has not been associated with the risk of endometrial cancer. OBJECTIVE: This study aimed to report on the long-term outcome of postmenopausal women who received a diagnosis of proliferative endometrium. STUDY DESIGN: This is a retrospective cohort study of 1808 women aged 55 years and older who underwent endometrial sampling between January 1997 and December 2008. Outcome data were available through February 2018. Women with a proliferative endometrium were compared with those with an atrophic endometrium for future development of endometrial hyperplasia or cancer. A subanalysis was performed for those who presented with postmenopausal bleeding. Uni- and multivariable logistic regression analyses were used to assess for confounders. RESULTS: In this study, 297 women (16.4%) received a diagnosis of proliferative endometrium. Furthermore, 962 women met the inclusion criteria. Among those women, 278 had a proliferative endometrium, and 684 had an atrophic endometrium. Women with a proliferative endometrium were younger (61.2 vs 64.5 years; P<.0001) and had a higher body mass index (33.9 vs 30.6 kg/m2; P<.0001). More African American women had a proliferative endometrium. Both groups had a similar length of surveillance (11.9 vs 11.5 years; P=.27). Women with a proliferative endometrium had a higher risk of developing endometrial hyperplasia or cancer (11.9% vs 2.9%; P<.0001), any endometrial cancer (5.8% vs 1.8%; P=.002), atypical endometrial hyperplasia (2.2% vs 0.4%; P=.02), and nonatypical endometrial hyperplasia (2.0% vs 0.7%; P=.001). The risk of developing endometrial cancer and endometrial hyperplasia remained similar after excluding cases on hormonal replacement therapy (12.2% vs 3%; P=.001). On logistic regression analysis, proliferative endometrium histology (odds ratio, 3.89; 95% confidence interval, 2.03-7.49; P<.0001), age >60 years (odds ratio, 1.98; 95% confidence interval, 1.03-3.82; P=.04), and body mass index >35 kg/m2 (odds ratio, 2.3; 95% confidence interval, 1.09-4.83; P<.0001) remained significant risk factors for progression to cancer. CONCLUSION: One of the 6 postmenopausal women who underwent endometrial sampling had a proliferative endometrium. Furthermore, 11.9% of women developed endometrial hyperplasia or cancer, a 4-fold greater incidence than women with an atrophic endometrium. The findings of this study suggest that long-term monitoring is warranted for women with postmenopausal bleeding and a proliferative endometrium histology. Further studies are needed to examine if a treatment is required to negate the risk of unopposed estrogen.

Methotrexate Administration to Patients With Presumed Ectopic Pregnancy Leads to Methotrexate Exposure of Intrauterine Pregnancies.

OBJECTIVE: To report clinical experience with methotrexate (MTX) treatment for suspected but not definite ectopic pregnancy (EP). METHODS: This was a retrospective cohort study. All patients treated with MTX for presumed EP between 2000 and 2016 were included. Demographic, clinical, sonographic, and outcome data were collected and analyzed. RESULTS: A total of 820 patients were treated with MTX, 692 (84.4%) of which were lacking definitive features of EP; 155 (22.4%) failed to follow up until complete resolution and were excluded. Retrospective sonographic categorization was applied to 537 patients; of those patients, 393 (73.2%) were categorized as probable EPs, 136 (25.3%) pregnancies of unknown location (PULs), and 8 (1.5%) probable intrauterine pregnancies (IUPs). Sixteen were eventually diagnosed with IUP: 6 from the probable EPs, 9 from the PULs, and 1 from the probable IUP group. Patients with final diagnosis of IUP had higher values of ß-human chorionic gonadotropin as well as lower prevalence of adnexal mass (38% versus 74%; P = .003), higher prevalence of intracavitary fluid (44% versus 9%; P = .0004) and thicker endometrium (17.1 ± 11.8 versus 9.7 ± 5.6; P = .04). None of the sonographic parameters were able to distinguish patients with IUP. One patient of the 16 with IUP was diagnosed with a viable pregnancy, and 7 additional patients had a possible viable pregnancy. None of them elected to continue the pregnancy. CONCLUSIONS: Most patients with suspected EP who are eligible for medical treatment lack definitive sonographic features of EP. Treatment with MTX in such cases should be delayed, as clinically reasonable, to improve the diagnosis and prevent inadvertent administration of MTX to patients with a viable IUP.

A novel cross-species inhibitor to study the function of CatSper Ca2+ channels in sperm.

BACKGROUND AND PURPOSE: Sperm from many species share the sperm-specific Ca2+ channel CatSper that controls the intracellular Ca2+ concentration and, thereby, the swimming behaviour. A growing body of evidence suggests that the mechanisms controlling the activity of CatSper and its role during fertilization differ among species. A lack of suitable pharmacological tools has hampered the elucidation of the function of CatSper. Known inhibitors of CatSper exhibit considerable side effects and also inhibit Slo3, the principal K+ channel of mammalian sperm. The compound RU1968 was reported to suppress Ca2+ signaling in human sperm by an unknown mechanism. Here, we examined the action of RU1968 on CatSper in sperm from humans, mice, and sea urchins. EXPERIMENTAL APPROACH: We resynthesized RU1968 and studied its action on sperm from humans, mice, and the sea urchin Arbacia punctulata by Ca2+ fluorimetry, single-cell Ca2+ imaging, electrophysiology, opto-chemistry, and motility analysis. KEY RESULTS: RU1968 inhibited CatSper in sperm from invertebrates and mammals. The compound lacked toxic side effects in human sperm, did not affect mouse Slo3, and inhibited human Slo3 with about 15-fold lower potency than CatSper. Moreover, in human sperm, RU1968 mimicked CatSper dysfunction and suppressed motility responses evoked by progesterone, an oviductal steroid known to activate CatSper. Finally, RU1968 abolished CatSper-mediated chemotactic navigation in sea urchin sperm. CONCLUSION AND IMPLICATIONS: We propose RU1968 as a novel tool to elucidate the function of CatSper channels in sperm across species.

Paraurethral Leiomyoma as an Incidental Finding in Patient with Fibroid Uterus.

Paraurethral leiomyomas are rare benign fibromuscular tumors developing from urethra. The presenting symptoms are usually related to mass effect. We present a case of an incidental diagnosis of a paraurethral leiomyoma in a patient with a fibroid uterus. Case was managed by hysterectomy concurrent with periurethral leiomyoma excision. Patient had uncomplicated clinical course. Due to close localization of paraurethral leiomyoma to urethra and bladder care must be taken to minimize the injury during resection.

Resident Knowledge, Surgical Skill, and Confidence in Transobturator Vaginal Tape Placement: The Value of a Cadaver Laboratory.

OBJECTIVES: The objective of this study is to examine the effect of additional cadaver laboratory use in training obstetrics and gynecology (OBGYN) residents on transobturator vaginal tape (TOT) insertion. METHODS: Thirty-four OBGYN residents were randomized into 2 groups (group 1, control; group 2, intervention; 17 in each group). Before and after the interventions, written knowledge and confidence levels were assessed. Both groups received didactic lectures using a bony pelvis and an instructional video on TOT insertion; group 2 participated in a half day cadaver laboratory. Surgical skills were assessed by placing 1 arm of the TOT trocar on a custom-designed pelvic model simulator while being graded by an Female Pelvic Medicine and Reconstructive Surgery (FPMRS) board-certified proctor. RESULTS: Demographics were comparable. Baseline knowledge and confidence level before interventions were similar. After interventions, knowledge scores improved for both groups (8.8% for group 1; 14.1% for group 2); TOT insertion scores were significantly higher in group 2 (6.76/15 ± 2.54 group 1; 10.24/15 ± 2.73 group 2, P < 0.01); confidence scores improved in both groups. The pelvic model simulator was rated as the most useful method to learn TOT placement by group 1. Group 2 rated TOT simulation (47%) and cadaver laboratory (41%). All trainees reported that the pelvic model was highly realistic. CONCLUSIONS: Cadaver laboratory exposure, along with other educational interventions (lectures and video), improves OBGYN residents' confidence, knowledge, and surgical skills regarding TOT placement. The custom-designed pelvic model allows for a realistic simulation of TOT placement: it can be used to assess resident surgical skills and also aid the training of OBGYN residents.

The CatSper channel controls chemosensation in sea urchin sperm.

Sperm guidance is controlled by chemical and physical cues. In many species, Ca(2+) bursts in the flagellum govern navigation to the egg. In Arbacia punctulata, a model system of sperm chemotaxis, a cGMP signaling pathway controls these Ca(2+) bursts. The underlying Ca(2+) channel and its mechanisms of activation are unknown. Here, we identify CatSper Ca(2+) channels in the flagellum of A. punctulata sperm. We show that CatSper mediates the chemoattractant-evoked Ca(2+) influx and controls chemotactic steering; a concomitant alkalization serves as a highly cooperative mechanism that enables CatSper to transduce periodic voltage changes into Ca(2+) bursts. Our results reveal intriguing phylogenetic commonalities but also variations between marine invertebrates and mammals regarding the function and control of CatSper. The variations probably reflect functional and mechanistic adaptations that evolved during the transition from external to internal fertilization.

Monozygotic Triplets and Dizygotic Twins following Transfer of Three Poor-Quality Cleavage Stage Embryos.

Background. Assisted reproductive technology has been linked to the increased incidence of monozygotic twinning. It is of clinical importance due to the increased risk of complications in multiple pregnancies in general and in monozygotic twins in particular. Case. A 29-year-old female, nulligravida underwent her first IVF cycle. Three poor-quality cleavage stage embryos were transferred resulting in monochorionic triamniotic triplets and dichorionic diamniotic twins. Selective embryo reduction was performed at 12 weeks leaving dichorionic twins. The patient underwent emergency cesarean section due to preterm labor and nonreassuring fetal heart tracing at 30 weeks of gestation. Conclusion. Our case emphasizes that even embryos with significant morphological abnormalities should be considered viable and the possibility of simultaneous spontaneous embryo splitting must be factored into determining number of embryos to transfer.

Predictors of H1N1 vaccination in pregnancy.

The purpose of this review was to determine factors that influence a pregnant woman's acceptance of the H1N1 vaccine with the use of the Health Belief Model (HBM). A self-administered questionnaire based on the HBM was used in a cross-sectional study of postpartum women during the 2009 H1N1 epidemic. Overall, 212 postpartum women were approached and agreed to participate; of these women, 25.5% had received an H1N1 vaccination. Perceived barriers to vaccination (P = .001) and perceived severity of infection (P = .018) were independent predictors of vaccination. The total predictive utility of the full model that incorporated HBM dimensions, age, race, care provider, and education level was moderate (area under the curve, -0.86). The addressing of perceived barriers (such as fear of side-effects), an explanation of the safety of the vaccine for the fetus, and the stressing of complications that are associated with H1N1 infection in pregnancy may increase the rate of vaccination.

Fistula between degenerated uterine leiomyoma and the bladder: case report.

Most common reason for the vesicouterine fistula is a cesarean section; no cases were reported of degenerated uterine leiomyoma communicating with the urinary bladder. We report a case of fistulous communication between the degenerated leiomyoma and the bladder. The patient's initial clinical presentation was consistent with recurrent UTI. She underwent multiple examinations including cystoscopy, cystouretrography, retrograde pyeolography, and MRI. The ultimate treatment was an exploratory laparotomy and en-block resection of the bladder wall, fistula tract, and degenerated leiomyoma. Fistula can develop between the bladder and degenerated leiomyoma and could be one of the reasons for the chronic pelvic pain and dysuria.

The immediately available physician standard.

The promulgation of the immediately available physician standard has contributed to the rapid decline in vaginal birth after cesareans (VBACs). While having an immediately available obstetrician during a VBAC trial will reduce risk, it is not clear that similar advantage wouldn't also accrue to women without uterine scars. However, many hospitals can't staff up to that standard. In this article we suggest 1) set a goal of providing an immediately available team for all women in labor, 2) tailor informed consent to women's unique risks- unique because of their own risk profile (e.g., previous scar, hypertension, etc) or unique because of characteristics of the birthing site (e.g. a team is or is not available), 3) in smaller hospitals, if an immediately available team cannot be routinely provided, consideration should be given to bringing in a team for the occasional patient requesting a trial, and to allowing labor for lower risk trials.

Subserosal misplacement of Essure device manifested by late-onset acute pelvic pain.

OBJECTIVE: To increase awareness of the potential to present with late-onset acute pelvic pain secondary to subserosal misplacement of an Essure device (Conceptus Inc., Mountain View, CA). DESIGN: Case report. SETTING: University-affiliated teaching hospital. PATIENT(S): A 30-year-old woman who was seen with severe left lower quadrant pain 4 months after elective sterilization with an Essure device placed under local anesthesia. Mild to moderate resistance was encountered in the placement of the device in the left fallopian tube. INTERVENTION(S): Hysterosalpingogram showing patency of the left fallopian tube and operative laparoscopy. MAIN OUTCOME MEASURE(S): Laparoscopic removal of the Essure device with left salpingectomy. RESULT(S): The patient was free of pain and was discharged home the same day of the laparoscopic procedure. CONCLUSION(S): This report reinforces the need to consider a misplaced Essure device in the differential diagnosis of late-onset acute pelvic pain in women who had difficult placement of the device.

Novel influenza H1N1 in pregnancy: a report of two cases.

BACKGROUND: Pregnant women are a high-risk group for morbidity and mortality from influenza. During the current pandemic of H1N1 influenza, few cases of H1N1 have been reported in pregnancy. CASES: We report two cases of H1N1 influenza which occurred in single institution in the course of one month. The first patient developed acute respiratory distress syndrome, required intubation, and eventually died. The second patient had influenza H1N1 that did not have any major sequela. CONCLUSION: H1N1 influenza in pregnancy can be associated with severe complications. Widespread vaccination, when available, prompt diagnosis, and adequate treatment with antiviral medications when infection occurs are required.