Attitudes & practices surrounding pregnancy post heart transplant among pediatric providers.

BACKGROUND: Many pediatric heart transplant (HT) recipients reach adulthood and may be interested in family planning; there is little data regarding safety of pregnancy post HT and clinicians' opinions differ. Pediatric HT clinicians are instrumental in early counseling. Thus, a better understanding of pediatric HT clinicians' practices regarding family planning and how well aligned these practices are with adult transplant centers is essential. METHODS: We conducted a confidential, web-based survey of pediatric HT clinicians in fall 2021. We summarized and compared answers using Fisher's exact test. RESULTS: The survey was sent to 53 United States-based HT directors and to the International Society for Heart and Lung Transplantation and Pediatric Heart Transplant Society list serves. There were 69 respondents. The majority (77%) of respondents felt pregnancy was feasible in selected or all female HT recipients. Ten respondents reported that their institution had an established policy regarding pregnancy post HT. A majority (77%) of HT clinicians would either use a shared care model or recommend transition to their adult institution if pregnancy occurred, though 74% of respondents were either unaware of their corresponding adult institution's policy (62%) or had a counterpart adult program with a policy against pregnancy post HT (12%). CONCLUSIONS: While many clinicians feel pregnancy is feasible in pediatric HT recipients, there remains significant practice variation. Few pediatric programs have a policy regarding pregnancy post HT. Future efforts to provide consistent messaging between adult and pediatric HT programs regarding the feasibility and care of post HT pregnancy are warranted.

Topical Hemostatic Agent May Be Mistaken for Ovarian Teratoma.

BACKGROUND: Ovarian teratomas are common, as is use of topical hemostatic agents in ovarian surgery. CASE: Following laparoscopic right ovarian cystectomy, a flowable hemostatic agent was placed in the ovarian bed. Postoperative ultrasound demonstrated an enlarged heterogeneous right ovary with solid and cystic components interpreted as residual or recurrent teratoma. Visual inspection during repeat laparoscopy revealed an irregularly shaped, enlarged right ovary with a smooth cortex. A cavity inside the ovary contained brown, shaggy material. Pathological evaluation demonstrated normal ovary and fibrin. SUMMARY AND CONCLUSION: We report the first case of a hemostatic agent routinely used in ovarian cystectomy postoperatively, mimicking a teratoma. Consideration of this finding is important when planning surgery in adolescent patients to optimize fertility preservation and minimize ovarian follicle damage.

Clinicians Practicing Obstetrics and Gynecology Are Uniquely Situated to Recognize DICER1 Syndrome.

Pediatric gynecologic malignancies are rare, present with diverse pathologic findings, and can be associated with genetic syndromes such as Peutz-Jeghers, Lynch, and Li-Fraumeni. DICER1 mutation is an emerging entity that has been demonstrated to cause a hereditary tumor predisposition syndrome. Previously, gynecologic manifestations of DICER1 syndrome have been described in single or small case reports with an array of pathologic findings. Here, we discuss pediatric and adolescent patients with gynecologic DICER1-associated tumors, outline the significance of DICER1, and suggest points of care where the syndrome may be diagnosed in the context of routine obstetric and gynecology practice. Patients presenting with a personal or family history suspicious for DICER1 syndrome should undergo both germline and somatic testing, as the presence of DICER1 mutations will have an impact on both treatment and surveillance strategies.

Percutaneous Drainage of a Rapidly Enlarging Simple Ovarian Cyst in the Third Trimester.

BACKGROUND: Persistent adnexal masses increase the risk of pregnancy complications including cyst rupture, ovarian torsion, and labor obstruction. Treatment options include observation, surgical excision, and early first or second trimester drainage. Our case represents the most advanced gestational age for intervention with percutaneous drainage. CASE: A 32-year old G3P1102 at 29.2 weeks gestation presented with left lower quadrant pressure, right abdominal fullness, and left uterine displacement. She had a right, simple-appearing ovarian cyst, which had increased in size from previous ultrasounds to 12.8 × 13.4 × 15.7 cm. Ultrasound-guided percutaneous drainage with pigtail catheter placement removed 1.2 L serous green fluid. Fluid culture was negative and cytology showed no evidence of malignancy. The pigtail catheter was removed at 31.2 weeks because of pain at the surgical site and significant cyst regression. The cyst resolved and she delivered via uncomplicated vaginal delivery at term. CONCLUSION: A few case reports describe first and second trimester percutaneous or transvaginal drainage of symptomatic ovarian cysts as a less invasive approach than surgical excision. However, our case suggests drainage of a simple-appearing cyst as an alternative treatment option in the third trimester when the risk of preterm labor and fetal complications with surgical intervention is at its highest.