Tethered Cord Syndrome in the Pediatric-Adolescent Gynecologic Patient.

STUDY OBJECTIVE: To describe how pediatric and adolescent patients present to the gynecologist when they have tethered cord syndrome (TCS). DESIGN: We conducted a retrospective chart review on all patients suspected by the gynecologist of having TCS. SETTING: Single pediatric and adolescent gynecology clinic in a mid-sized city in the midwest. PARTICIPANTS: Thirty-two patients, first seen between 2005 and 2012, suspected of having TCS and for whom follow-up information was available. INTERVENTIONS AND MAIN OUTCOME MEASURES: Patient characteristics, including patient history, gynecologic clinical indicators, clinical outcomes, indications for surgery, and postoperative resolution of symptoms, were reviewed. RESULTS: The initial review of systems indicated stress urinary incontinence, back pain, and constipation as common markers in the 32 patients who were suspected of having TCS. All 32 patients underwent lumbar magnetic resonance imaging without contrast and evaluation by neurosurgery. Of the 32 patients with suspected TCS, 18 were later confirmed and 14 were shown to not have TCS. Of the 18 patients with sufficient information to justify a detethering procedure, 14 patients were followed and 93% (13 patients) had complete resolution of symptoms. Final diagnosis in the non-TCS group varied, including vulvovaginitis, enuresis, chronic constipation, and lichen sclerosis. Symptoms improved with the treatment of each primary condition. CONCLUSIONS: TCS symptoms overlap with gynecologic conditions; therefore, patients with TCS may present initially to the gynecologist. In pediatric/adolescent patients, TCS should be considered when stress urinary incontinence, back pain, and constipation are discovered in the review of systems. Because possible irreversible ischemic and neurologic changes are believed to be involved, early diagnosis and surgery are crucial for resolution. Providers should be aware of TCS in these pediatric and adolescent settings, because quick assessment may result in complete resolution of a chronic progressive disease.

Labial adhesions and outcomes of office management.

STUDY OBJECTIVE: To evaluate clinical outcomes of labial adhesions (LA) and to examine the association between LA, lichen sclerosus (LS), eczema (ECZ), or asthma. DESIGN: Retrospective study. SETTING: Single pediatric and adolescent gynecology clinic, Houston, Texas. PARTICIPANTS: 50 girls diagnosed with LA from 2006-2011. INTERVENTIONS AND MAIN OUTCOME MEASURES: Resolution, recurrence, single vs multiple treatments, need for surgery, and conditions such as LS, ECZ, and asthma were reviewed. RESULTS: Mean age was 19.6 months (range 0-84 months), and 48% were Caucasian. Most patients were symptomatic (62%) and all 50 patients chose estrogen treatment. The majority (74%) required multiple treatments, as opposed to a single treatment (26%). Patients with multiple treatments were more likely to be severely agglutinated (P = .05) and to need manual separation after failed topical treatment (P = .08). The prevalence of asthma, LS, and ECZ was 9.8%, 7.8%, and 3.9% respectively. There was no association between LS, ECZ, or asthma, and number of treatments. Both asthma (N = 3; 8%), and LS (N = 2; 5%) were present among the severe agglutinated group; however, this difference was not statistically significant (P values .59 and .99). No association with ECZ was seen in either group. CONCLUSION: Severe agglutination tends to be associated with need of multiple treatments and manual separation. A concurrent diagnosis of LS, ECZ, or asthma was not associated with number of treatments but there appears to be a trend towards severity of LA in patients with asthma and LS.

Can overt diabetes mellitus be predicted by an early A1C value in gestational diabetics?

OBJECTIVE: To test the hypothesis that a hemoglobin A1C value (A1C) in early pregnancy is predictive of overt diabetes mellitus (DM) postpartum in women with gestational diabetes (GDM). STUDY DESIGN: In this case-control analysis of women with an early pregnancy diagnosis of GDM, we estimated the association between an early pregnancy A1C and subsequent diagnosis of DM. Women with a normal postpartum diabetic screen (controls) were compared against those with confirmed postpartum DM (cases). Ability of A1C levels to predict DM was examined via logistic regression analysis and corresponding receiver operating characteristic values. RESULTS: During the 10-year study period 166 women met the inclusion criteria: 140 (84%) had normal postpartum testing (controls), and 26 (16%) were diagnosed with DM (cases). The mean A1C value was significantly higher among cases than controls (6.7 vs. 5.6, p < 0.0001, SD 1.3-5). Cases had A1Cs ranging from 5.5- 11.7%, while controls had A1Cs ranging from 4.3-7.8%. The best discriminatory cut point for postpartum DM was an A1C > 5.9% (sensitivity 81%, specificity 83%, positive predictive value 47%, negative predictive value CONCLUSION: Our findings suggest that an elevated early pregnancy A1C may be predictive of overt DM. Larger studies are needed to further validate this association.

Update on adolescent gynecology.

Adolescent gynecology is an important part of clinical care of adolescent females. This discussion provides a basic review of current issues in adolescent gynecology, including consideration of current pubertal concepts with attention also given to delayed and precocious puberty. Causes of breast masses are reviewed, including discussion of the ANDI classification. It is recommended that physicians provide sexuality education to their adolescent patients, in addition to the community, to reduce the high rates of unintended adolescent pregnancy and STIs in teens that continue in the United States. Finally, attention is provided to ovarian masses and their management. Adolescent medicine physicians may have to work with a variety of specialists in their care of adolescents and the many gynecologic conditions that may arise.

Use of microcatheter for intraabdominal survey.

BACKGROUND: Laparoscopy is the most common procedure for minimally invasive intraabdominal surveys. Patients with pulmonary hypertension (PHTN) may need an alternate approach because the systemic absorption of carbon dioxide may lead to hypercapnia, acidemia, and increases in systemic and pulmonary pressures. We report a case of intraabdominal survey using a microcatheter trocar (Check-Flo Introducer) in a patient with a large adnexal mass and PHTN. CASE: An adolescent girl with severe PHTN and multiple cardiac anomalies presented with oligomenorrhea. During the course of workup, an ultrasound revealed an 8-cm simple cyst in the right adnexa, which required removal. The decision was made to proceed with cystectomy. The patient was not a candidate for laparoscopy, and an alternative method was used. The Check-Flo Introducer, a microcatheter trocar; crystalloid fluid infusion; and a 3-mm laparoscopic camera were used to survey the abdominal cavity, revealing a 10-cm simple paratubal cyst that could be safely drained and removed via a minilaparotomy incision. CONCLUSION: The microcatheter trocar is a useful and novel alternative in patients who cannot tolerate increases in intraabdominal pressure.