mRNA COVID-19 vaccination during pregnancy was not linked to increased adverse neonatal outcomes.

SOURCE CITATION: Norman M, Magnus MC, Söderling J, et al. Neonatal outcomes after COVID-19 vaccination in pregnancy. JAMA. 2024;331:396-407. 38319332.

Fear, misinformation, and pharmaceutical messianism in the promotion of compounded bioidentical hormone therapy.

Compounded bioidentical hormone therapy (cBHT) for menopausal symptoms maintains popularity in western countries despite the availability of hormone products in different formulations and dosages produced by pharmaceutical companies with federal oversight. Akin to many populist therapeutic trends in the history of medicine, cBHT advocates tend to capitalize on consumer fears about existing FDA-approved hormone treatments. Unsubstantiated, exaggerated, or outright false claims are commonplace in promoting cBHT. Given these elements, the basic elements of pharmaceutical messianism continue to drive the cBHT movement.

Atypical haemolytic uraemic syndrome in a postpartum patient.

A postpartum patient presented 1 week following uncomplicated pregnancy and elective repeat caesarean section with acute hypertension, severe anaemia and acute kidney injury. Her workup demonstrated microangiopathic anaemia, thrombocytopenia and liver enzyme elevations. Differential diagnoses included postpartum haemolysis-elevated liver enzyme-low platelet (HELLP) syndrome, haemolytic uraemic syndrome (HUS), and thrombotic thrombocytopenic purpura (TTP). She was treated initially with systemic corticosteroids, haemodialysis and plasmapheresis for presumed TTP while awaiting the results of ADAMSTS13 assay performed at an outside laboratory. When reported back as normal, the diagnosis of atypical HUS was established. Eculizumab was administered with rapid improvement of her condition.

Vulvovaginal erosive lichen planus refractory to topical therapies: What's next? A case report.

A 60-year-old woman was referred for progressive and severe vulvovaginal pain characterized by erosions and Wickham's stria for the past 7 months. Her condition had not responded to oral fluconazole, topical estrogen cream, and topical clobetasol cream. Vulvar and vaginal biopsies were obtained under general anesthesia to verify the diagnosis of erosive lichen planus given the failed response to ultrapotent topical steroids. Tacrolimus cream was added but not tolerated. Oral and cutaneous lesions of lichen planus also developed. In the absence of evidence-based guidelines, three different systemic treatments were administered sequentially (hydroxychloroquine, mycophenolate, and finally cyclosporin) before a satisfactory, well-tolerated, and sustained clinical response was obtained. Topical betamethasone ointment in a taper was continued to assist in sustaining a vulvovaginal response after cyclosporin was discontinued.

Reproducibility of the Edinburgh Postnatal Depression Scale during the Postpartum Period.

OBJECTIVE: This study was aimed to evaluate the efficacy of the Edinburgh Postnatal Depression Scale (EPDS) in the immediate postpartum period, which we defined as between 3 and 24 hours postpartum for the purpose of this research. This is such that if it can predict scores obtained at the postpartum visit, it will be an opportunity to access psychiatric services for the patient that may otherwise be more difficult to access in the outpatient setting. STUDY DESIGN: Longitudinal observational study, which included an analysis of 848 consecutive participants screened with the EPDS in the hospital and at the 6-week postpartum visit. RESULTS: Receiver-operating characteristic (ROC) curve suggested >3 at delivery as a more optimal score to predict depression at the postpartum visit with sensitivity 76.5% and specificity 65.9%. The commonly accepted EPDS cut-off value of >9 was far less sensitive at 28.8% but reasonably specific at 93.2% for predicting elevated scores (>9) 6 weeks postpartum. In subgroup analysis, only a prior mental health disorder was found to be predictive of elevated scores at the postpartum visit (relative risk: 1.97, 95% confidence interval: 1.17-3.32, p = 0.01). CONCLUSION: The EPDS, originally designed to screen for postpartum depression (PPD) in the outpatient setting, does not predict the development of PPD, as determined by the EPDS (validated at the 6-week postpartum time interval) when administered during hospitalization shortly after delivery. KEY POINTS: · EPDS is a validated screening tool for PPD that is validated in the outpatient setting, but various guidelines are presently unclear on the exact timing for PPD screening.. · EPDS scores from 3 to 24 hours postpartum does not reliably predict elevated scores 6 weeks later.. · EPDS scores >3 from 3 to 24 hours postpartum may identify need to "rule out" PPD 6 weeks later..

Concordance for Gender Dysphoria in Genetic Female Monozygotic (Identical) Triplets.

The biopsychosocial etiology of gender dysphoria is poorly understood, but current thought suggests a complex interaction of genetic, hormonal, environmental, and differences in brain development and physiology. Twin studies have implicated a genetic role in the formation of gender identity. Congruence for gender dysphoria is more common among monozygotic twins compared to dizygotic twins. We present a case of monozygotic (identical) triplets who have each transitioned from female to male under the care of a university transgender health service. Each triplet experienced gender dysphoria from childhood and has undergone transitional endocrine care and various aspects of gender-affirming surgery. Although a pure genetic or biological component cannot be attributed as a cause of their gender dysphoria with absolute certainty since the triplets were raised together, this unusual case of gender dysphoria among a set of monozygotic triplets adds support for a heritable role in gender identity formation.

In women with stress UI, device-guided pelvic floor muscle training safely improved symptoms more than self-guided training.

SOURCE CITATION: Weinstein MM, Dunivan G, Guaderrama NM, et al. Digital therapeutic device for urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2022;139:606-15. 35271539.

Perivulvar Pseudoverrucous Papules and Nodules in a 4-Year-Old Girl with Urinary and Fecal Incontinence: Case Report.

BACKGROUND: Diaper (irritative) dermatitis is commonly encountered in pediatric practice. In severe cases, unusual lesions could mimic other vulvar dermatoses or sexually transmitted infections. CASE: A 4-year-old female refugee with urinary and fecal incontinence was referred for medicolegal evaluation (concern for childhood sexual abuse) due to presence of diffuse vulvar, perineal, and perianal lesions. Evaluation and histology were consistent with pseudoverrucous papules and nodules. Resolution occurred following frequent diaper changes and application of a protective ointment. DISCUSSION: Pseudoverrucous papules and nodules are a rare complication of irritative diaper dermatitis with variable appearance. Urinary or fecal incontinence are primary risk factors that should raise suspicion among clinicians when atypical genital or buttocks lesions appear. Biopsy is not always necessary but could be warranted when the diagnosis is uncertain or if childhood sexual abuse is suspected.

In overweight or obesity without diabetes, weekly semaglutide vs. daily liraglutide increased weight loss at 68 wk.

SOURCE CITATION: Rubino DM, Greenway FL, Khalid U, et al. Effect of weekly subcutaneous semaglutide vs daily liraglutide on body weight in adults with overweight or obesity without diabetes: the STEP 8 randomized clinical trial. JAMA. 2022;327:138-50. 35015037.

Septic abortion complicated by infective endocarditis, mitral valve vegetation, and septic and reactive arthritis: A case report.

BACKGROUND: Septic abortion with multisystem involvement is associated with significant morbidity and mortality. Access to care and legalization of abortion have greatly diminished the incidence of serious sequelae worldwide. Two complications, infective endocarditis and septic arthritis, are rarely encountered in contemporary practice. CASE: A 30-year-old woman developed infective endocarditis, septic arthritis, and reactive arthritis concurrently one week after undergoing dilation and curettage for an incomplete abortion with perioperative administration of doxycycline. She required systemic antibiotics, drainage and debridement of her right ankle, and a robotic-assisted mitral valve replacement due to septic vegetation. CONCLUSION: Septic abortion with life-threatening systemic complications is rarely encountered in modern practice. Prompt surgical uterine evacuation and broad-spectrum antibiotics are indicated to prevent systemic complications. Multispecialty consultation is usually required when endocarditis, arthritis, and other systemic complications are encountered.

Clitoral Priapism in a Transgender Male.

INTRODUCTION: Clitoral priapism due to venous outflow obstruction is a rare event and medical emergency. Androgen-induced clitoromegaly in transgender men has not been previously identified as a risk factor. AIMS: Advance current knowledge on identification and treatment of clitoral priapism in the transgender male. METHODS: A 32 year-old presurgical transgender male underwent gender-affirming laparoscopic total hysterectomy and bilateral salpingo-oöphorectomy without incident. Seven days postop, he developed progressive and painful clitoral engorgement that was persistent. Examination and imaging were consistent with clitoral priapism. RESULTS: Clitoral priapism was treated with adrenergic drugs (imipramine and pseudoephedrine) with rapid resolution of symptoms. CONCLUSION: Clitoral priapism is a rare phenomenon usually associated with use of a psychotropic medication. Whether clitoromegaly secondary to androgen administration in transgender men is a risk factor for this rare medical emergency is unknown. Prompt recognition and treatment is paramount. Kusko RE, Singhal E, Kauffman RP. Clitoral Priapism in a Transgender Male. Sex Med 2021;9:100431.

1-step screening approach detected more GDM than 2-step approach but did not improve clinical outcomes.

SOURCE CITATION: Hillier TA, Pedula KL, Ogasawara KK, et al. A pragmatic, randomized clinical trial of gestational diabetes screening. N Engl J Med. 2021;384:895-904. 33704936.

Perils of prolonged ovarian suppression and hypoestrogenism in the treatment of breast cancer: Is the risk of treatment worse than the risk of recurrence?

Premenopausal breast cancer is usually estrogen receptor positive, and hence, prolonged ovarian suppression by medical or surgical means to prevent recurrence has become standard of management to improve disease-free survival. Ten-year adjuvant tamoxifen therapy is associated with 3.5% fewer recurrences compared to five years. The SOFT trial demonstrated small but statistically significant incremental improvements in long-term disease-free survival by the addition of gonadotropin-releasing hormone analog treatment (triptorelin) to an aromatase inhibitor (exemestane). Profound hypoestrogenism in the premenopausal age group may not be well tolerated due to a host of bothersome side effects (primarily vasomotor symptoms, musculoskeletal complaints, genitourinary syndrome of menopause, and mood disorders). Prolonged hypoestrogenism in younger women is associated with premature development of cardiovascular disease, bone loss, cognitive decline, and all-cause mortality. This paper explores multi-system consequences of prolonged hypoestrogenism in premenopausal women derived from studies of women with and without breast cancer. Pretreatment counseling in estrogen receptor positive breast cancer should emphasize the benefit of prolonged estrogen suppression on breast cancer recurrence and established risks of lifelong hypoestrogenism on quality of life and all-cause mortality. Future genomic research may help identify the best candidates for extended ovarian suppression to avoid treating many women when only a minority benefit.

Complete resolution of arrhythmia-induced hydrops fetalis in utero.

A 21-year-old G3P2011 Caucasian woman at 27 weeks' gestation presented with fetal tachyarrhythmia between 240 and 270 beats per minute. Fetal supraventricular tachycardia, abdominal ascites, pleural effusion and pericardial effusion indicated hydrops fetalis. Management with digoxin and flecainide converted the fetus to sinus rhythm and resolved the ascites and pleural effusion within 4 days of treatment. Flecainide was discontinued at 31 weeks' gestation due to elevated liver enzymes. Intrahepatic cholestasis was treated with ursodiol. Caesarean section was performed at 37 weeks' gestation. Neonatal echocardiogram revealed a bicuspid aortic valve with mild regurgitation and a patent foramen ovale, and the infant showed no subsequent evidence of tachyarrhythmia or hydrops after delivery. Treatment of hydrops fetalis in the antenatal period is complex, and early diagnosis and treatment can quickly resolve supraventricular tachycardia-induced hydrops fetalis.

Spontaneous pneumomediastinum: an unusual complication of hyperemesis gravidarum.

A 21-year-old first trimester primagravida woman with hyperemesis gravidarum was noted to have incidental subcutaneous emphysema during thyroid ultrasound. Follow-up radiograph demonstrated supraclavicular subcutaneous emphysema, left apical pneumothorax and pneumomediastinum. The patient was transferred to the intensive care unit and evaluated for esophageal rupture. Because no defects were seen on swallow studies/endoscopy and the patient was stable, she was treated conservatively with antibiotics and monitored. The patient's condition improved, and she was discharged on hospital day 6. Subcutaneous emphysema secondary to hyperemesis gravidarum is a rare but potentially life-threatening condition in which the source of the mediastinal leak needs to be immediately determined. After the more serious sources of mediastinal air have been excluded, conservative management is suitable.

Multiorgan system structural malformations associated with Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS) type 2: avoiding pitfalls in diagnosis, counseling and treatment.

An 18-year-old virginal woman was referred to the reproductive endocrinology clinic with primary amenorrhoea and secondary sexual development in the absence of pelvic pain. Additionally, she had significant congenital sensorineural hearing loss, autism, bipolar disorder and class III obesity. On physical examination, secondary sexual development was confirmed (Tanner 5 breasts and Tanner 4 pubic hair). She refused further pelvic examination following prior attempts by the referring physicians. Serum leutinizing hormone (LH), follicle sitmulating hormone (FSH). prolactin, estradiol and total testosterone values were within normal limits. Karyotype was 46,XX. MRI demonstrated complete uterine agenesis, short vagina, sacral dysgenesis with complete absence of the coccyx and a horseshoe kidney. Diagnosis of Mayer-Rokitansky-Küster-Hauser Syndrome type 2 was established based on clinical, laboratory and MRI findings. The patient and family were counselled regarding the disease process, techniques for vaginal elongation, sexual activity and future reproductive options.

Haematometrocolpos and acute pelvic pain associated with cyclic uterine bleeding: OHVIRA syndrome.

Obstructed hemivagina and ipsilateral renal agenesis syndrome is a complex urogenital malformation usually presenting with obstructed menses and pelvic pain during female adolescence. The diagnosis can be established preoperatively with relative certainty by MRI or ultrasonography, and outcomes are usually satisfactory following surgical resection of the septal portion of the obstructed hemivagina. Such cases are best managed in referral centres with expertise in anatomical disorders of the female genital tract.

Polycystic ovarian syndrome (PCOS): Long-term metabolic consequences.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women during their reproductive ages, associated with a plethora of cardiometabolic consequences, with obesity, insulin resistance and hyperandrogenemia playing a major role in the degree of such manifestations. These consequences include increased risk of glucose intolerance and diabetes mellitus (both type 2 and gestational), atherogenic dyslipidemia, systemic inflammation, non-alcoholic fatty liver disease, hypertension and coagulation disorders. Whether this cluster of metabolic abnormalities is also translated in increased cardiovascular disease (CVD) morbidity and mortality in later life, remains to be established. Data so far based on markers of subclinical atherosclerosis as well as retrospective and prospective cohort studies indicate a possible increased CVD risk, mainly for coronary heart disease. Future studies are needed to further elucidate this issue.

Müllerian anomaly in a woman with Hirschsprung's disease.

Müllerian anomalies are usually isolated or found in association with abnormalities of the renal tract. Rarely, they are encountered with coexisting Ggastrointestinal anomalies. Similarly, Hirschsprung's disease may coexist with additional somatic abnormalities, yet only a single case report has reported a müllerian anomaly coexisting with Hirschsprung's. A 35-year-old woman with long-standing dysmenorrhoea and infertility and history of Hirschsprung's disease and some components of VATER syndrome (vertebral anomalies, anal atresia, tracheoesophageal fistula, renal anomalies) underwent operative laparoscopic exploration for pelvic pain and was found to have an incidental finding of a unilateral segmentally hypoplastic uterine horn (variation of an ASRM (American Society for Reproductive Medicine) type 2C müllerian anomaly). The genetics of müllerian anomalies and Hirschsprung's disease have been extensively studied with certain loci and candidate genes theorised as being causative. An established familial relationship and heritability exists with both syndromes; however, no genetic foci have been found to connect müllerian abnormalities and Hirschsprung's disease.