Severe COVID-19 in Third Trimester Pregnancy: Multidisciplinary Approach.

The rapidly expanding cases of the coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have exposed vulnerable populations, including pregnant women to an unprecedented public health crisis. Recent data show that pregnancy in COVID-19 patients is associated with increased hospitalization, admission of the intensive care unit, and intubation. However, very few resources exist to guide the multidisciplinary team in managing critically ill pregnant women with COVID-19. We report our experience with managing a morbidly obese pregnant woman at 36 weeks' gestation with history of asthma and malignancy who presented with persistent respiratory symptoms at an outside hospital after being tested positive for SARS-CoV-2 polymerase chain reaction (PCR). Early in the course of the hospitalization, patient received remdesivir, convalescent plasma, bronchodilator, systemic steroids, and IV heparin for COVID-19 and concomitant asthma exacerbation and pulmonary embolism. Due to increasing oxygen requirements, she was eventually intubated and transferred to our institution for higher level of care. Respiratory acidosis, severe hypoxemia, and vent asynchrony were managed with vent setting adjustment and paralytics. After 12 hours from spontaneous rupture of her membranes and with stabilization of maternal status, patient underwent a term cesarean delivery for nonreassuring fetal heart tracing. The neonate was discharged on the 2nd day of life, while the patient was extubated on the 6th postpartum day and was discharged to acute inpatient rehabilitation facility on the 19th hospital day. This report highlights the disease progression of COVID-19 in a pregnant woman, the clinical challenges in the critical care aspect of patient management, and the proposed multidisciplinary strategies utilizing an algorithmic approach to optimize maternal and neonatal outcomes.

Resident experiences with and post-training plans for cystoscopy at the time of hysterectomy.

AIMS: To determine OB/GYN residents' experience with and opinions toward cystoscopy at the time of hysterectomy. STUDY DESIGN: An internet survey of OB/GYN residents assessed utilization of cystoscopy at the time of hysterectomy, familiarity with literature regarding universal versus selective cystoscopy, and plans post residency. RESULTS: Cystoscopy was performed universally in the minority of cases of vaginal hysterectomy (12%), laparoscopically assisted vaginal hysterectomy (14%), supracervical hysterectomy (0%), total abdominal hysterectomy (2%), laparoscopic supracervical hysterectomy (9%), total laparoscopic hysterectomy (27%), and hysterectomy with adnexa removal (5%). Residents planned universal cystoscopy post-training more frequently for all hysterectomy types. CONCLUSION: Cystoscopy at the time of hysterectomy was performed universally in the minority for all hysterectomy categories. For all hysterectomy types, residents planned post-graduation to utilize universal cystoscopy at the time of hysterectomy more often than occurred in training.

Postpartum endometritis caused by herpes and cytomegaloviruses.

BACKGROUND: Postpartum endometritis is usually a polymicrobial infection caused by organisms that are part of the normal vaginal flora. A pathologically confirmed case of postpartum endometritis secondary to herpes and cytomegalovirus in a human immunodeficiency virus (HIV)-positive patient is reported. CASE: A 29-year-old, HIV-positive woman presented 6 days postpartum with abdominal pain and foul-smelling vaginal discharge. Pelvic ultrasonography revealed retained products of conception. Dilation and evacuation was performed, and antibiotics were started. Despite adequate antibiotics and laparoscopic drainage of a pelvic collection, fevers and pain continued. A total abdominal hysterectomy, salpingectomy, and appendectomy were performed. Pathology reported herpes and cytomegalovirus infection of the uterus. CONCLUSION: Herpes simplex virus (HSV) and cytomegalovirus need to be considered as a potential cause of postpartum endometritis. When antibiotic therapy fails, an antiviral regimen should be considered.

Compliance with methotrexate therapy for presumed ectopic pregnancy in an inner-city population.

Fewer than 1 in 5 patients comply with the established follow-up protocol to treat presumed ectopic pregnancy medically in an urban clinic population. Institutions should consider tracking their patient compliance with follow-up to determine the efficacy of their treatment decisions.

Embolization of uterine arteriovenous malformation for treatment of menorrhagia.

BACKGROUND: Uterine arteriovenous malformations are rare but potentially life-threatening conditions that should be suspected in unexplained severe vaginal bleeding. CASE: A 28-year-old gravida 7, para 3 presented to the emergency department with heavy vaginal bleeding and passage of blood clots. In the emergency room, her hemoglobin dropped from 11.2 to 7.4 gm%. Transvaginal ultrasonographic scan showed a large vascular mass in the uterus measuring 2.6 cm in diameter with low resistance of flow within, concerning for arteriovenous malformation or an arteriovenous fistula. Digital subtraction arteriography confirmed the lesion. She underwent angiography and bilateral uterine artery embolization. CONCLUSION: The diagnosis of uterine arteriovenous malformation requires a high index of suspicion in the scenario of unexplained severe vaginal bleeding. Digital subtraction angiography is the gold standard for definitive diagnosis and allows immediate treatment by embolization.

Acceptance of human papillomavirus vaccine by gynecologists in an urban setting.

OBJECTIVE: To determine the percentage of patients vaccinated per individual provider and to document attitudes and reasons for the acceptance of the human papillomavirus vaccine. METHODS: Computerized records were reviewed for individual practitioners in an urban department of obstetrics and gynecology to determine vaccination rates. Questionnaires filled out by practitioners were used to assess individual attitudes and reasons for the unequal distribution of vaccination. RESULTS: Overall vaccination rate was 28% (range 6%-55.8%) for the initial 3-month period when the vaccine became available. Barriers to acceptance included patient concerns, provider concerns over safety, and provider concerns over cost. Experience in practice and self-described attitudes toward early acceptance of new medication were not predictive. CONCLUSIONS: Early acceptance of human papillomavirus vaccination was provider dependent and was not related to provider experience or attitude. Concerns over cost and safety may be barriers to increasing vaccination rates by gynecologists.

Erythropoietic therapy: cost efficiency and reimbursement.

PURPOSE: The practice of blood conservation is aimed at improving patient outcomes by avoiding allogeneic transfusions via a coordinated multidisciplinary, multipronged approach. The numerous blood conservation techniques and transfusion alternatives now available are described. SUMMARY: Ongoing concerns exist regarding the availability of the nation's and the world's blood supply. In addition, the number of measures required to ensure blood safety has led to increases in the price of blood and blood products over the past 10-15 years. Moreover, blood transfusion carries inherent risks even under the most favorable circumstances. Investigations have established that injudicious transfusion is associated with development of ventilator-associated pneumonia, nosocomial infection, and organ dysfunction. Because most single blood-conservation techniques reduce blood usage by a mere 1-2 units, a series of integrated conservation approaches are required. These include preoperative autologous donation, use of erythropoietic agents, blood conservation techniques such as acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss. Erythropoietic agents such as epoetin alfa have been used successfully to increase hemoglobin and decrease transfusion requirements, and are appropriate when used in advance of elective surgical procedures. Acquisition costs of erythropoietic stimulating agents versus costs of blood justify economic evaluation by hospitals to make the most cost-effective choice under current economic constraints. CONCLUSION: Initiating a blood management program requires planning and support from those who are concerned about blood usage reduction and outcomes improvement. Launching a vigorous and ongoing educational program to raise awareness about the risks and hazards associated with blood transfusion is an important step in helping to reshape the medical staffs' attitudes about transfusion and the most cost-effective way to achieve clinical goals.

Oxidized regenerated cellulose presenting as a postoperative cyst: a case report.

BACKGROUND: Barriers placed intraabdominally may aid in hemostasis and help prevent adhesion formation. CASE: A 17-year-old woman presented with acute pelvic pain and a complex pelvic mass. A laparotomy was performed. To ensure hemostasis, Surgicel (Johnson & Johnson Medical, Arlington, Texas) was placed, and Seprafilm (Genzyme Corp., Cambridge, Massachusetts) was used for adhesion prevention. Within the first postoperative day the patient's status deteriorated, with increasing pain and significant pyrexia. Computed tomography was highly suspicious for a bowel injury. Repeat laparotomy found no injury. The Surgicel was removed and the abdomen irrigated. The remaining postoperative course was uneventful. CONCLUSION: Seprafilm has been associated with acute reactions, and Surgicel has mimicked many radiologic abnormalities. It is imperative to inform the radiologist of the intraoperative use of these agents to allow use of a proper imaging modality in the postoperative period and to avoid unnecessary repeat surgeries.

Trends in the rate of shoulder dystocia over two decades.

OBJECTIVE: To describe the trend in the rate of shoulder dystocia over twenty-four years and identify the risk factors related to the occurrence of dystocia. METHODS: Data was obtained from Maryland State regarding all vaginal deliveries that occurred during six different time periods at five-year intervals since 1979. Trends in the rate of shoulder dystocia, episiotomy, forceps and vacuum delivery were examined. RESULTS: There were a total of 277 974 vaginal deliveries. The overall rate of shoulder dystocia was 1.29% (n = 3590). Induction of labor (adjusted OR 1.2, 1.1-1.3), presence of diabetes (gestational (OR 1.9, 1.7-2.3) or pre-gestational (OR 3.8, 2.7-5.4)), fetal macrosomia (OR 5.1, 4.1-6.3) use of episiotomy (OR 1.6, 1.5-1.8), forceps (OR 1.3, 1.0-1.8) or vacuum (OR 2.3, 2.0-3.9) at delivery were associated with a higher rate of shoulder dystocia. TREND: There was an increase in the rate of shoulder dystocia from 0.2% in 1979 to 2.11% in 2003. In addition there was a drop in the overall episiotomy rate from 73.67% to 23.94% and increase in the use of vacuum from 0.1% to 8.36%. CONCLUSION: The rate of shoulder dystocia has increased by 10 fold during the study period. The use of episiotomy either at spontaneous delivery or instrumental delivery does not appear to decrease the occurrence of shoulder dystocia.