Risk factor analysis of medical litigation outcomes in obstetrics and gynecology: A retrospective cohort study of 344 claims in Japan.

AIM: Medical errors are critical in obstetrics and gynecology (OB/GYN) and contribute to high litigation risks. However, few studies have examined system and diagnostic errors as potential preventable problems. This study aimed to enhance medical safety and reduce litigation by identifying and addressing key contributory factors. METHODS: We retrospectively searched the national Japanese malpractice claims database for OB/GYN cases between 1961 and 2017. We evaluated provider characteristics and background information of the patients (plaintiffs). The main outcome was litigation (acceptance or rejection) in the final judgment. Using multivariable logistic regression models, we assessed the associations between medical malpractice variables (system and diagnostic errors, facility size, situation, place, time, and clinical outcomes) and litigation outcomes (acceptance). RESULTS: Overall, 344 malpractice claims were analyzed. Among these, 277 (80.5 %) were obstetric, and 67 (19.5 %) were gynecological. Of the obstetric cases, 193 were perinatal, and 84 were maternal. Malpractice claims were accepted (OB-GYN losses) in 185 cases (53.8 %). In multivariable analyses, system errors (odds ratio 97.4, 95 % confidence interval 35.2-270.0), diagnostic errors (odds ratio 4.5, 95 % confidence interval 1.8-11.3), and clinic (odds ratio 2.7, 95 % confidence interval 1.2-4.8) had a significant statistical association with accepted claims. CONCLUSION: System errors, diagnostic errors, and clinics were significantly associated with acceptance claims. These findings underscore the necessity of addressing modifiable factors at the physician level and within the healthcare management system to enhance patient safety and reduce litigation risks, thereby ensuring a safer and more reliable healthcare environment for patients and medical professionals.

Obstetrics and Gynecology Residency Geographic Match Location Patterns: Comparison of Pre and Post Virtual Interviews.

OBJECTIVE: To evaluate the impact of virtual interviews on geographic trends for applicants and programs in the obstetrics and gynecology (OBGYN) resident match. DESIGN: Cross-sectional study of a random 50% sample of all OBGYN residency programs listed by the Accreditation Council for Graduate Medical Education (ACGME) for the 2023 to 2024 academic year. Data collected from each program included geographic location, number of residents per year, and total number of residents. Residents were categorized into 4 mutually exclusive geographic match categories: matched into the same institution, matched into same state (but different institution), matched into the same US Census region but a different state/institution, or matched into a different US Census region. RESULTS: A total of 148 of 295 (50.2%) residency programs were included (known total number of residents = 2,928 from four US census regions and Puerto Rico). Most programs were considered small (≤16 residents; n = 52, 35.1%). In general, 43.9% (1148 of 2617) residents matched in a different region from their medical school training. For the primary outcome, no differences in the geographic placement in the previrtual (2020) and virtual application cycles (2021-2023) were observed (p = 0.51). When analyzed by program size or program region, there was no difference in the geographic placement in the previrtual and virtual application cycles. CONCLUSIONS: This study suggests that the virtual interview process did not demonstrate an impact on geographical placement of OBGYN residents, regardless of the size of the residency program or the program's geographic region.

A Devastating Diagnosis: Anencephaly With Unexpected Fetal Heartbeat.

This case report describes a severe birth defect called anencephaly in a fetus at 18 weeks of pregnancy. Anencephaly occurs when the upper part of the baby's brain and skull do not form correctly. This condition is usually detected earlier in pregnancy, often in the first three months. However, this case was discovered at 18 weeks, highlighting the need for careful monitoring throughout pregnancy. The unique aspect of this case is that most pregnancies with anencephaly do not progress this far. This later diagnosis provides important information about the different ways the condition can develop. By studying cases like this, healthcare providers can improve prenatal care and potentially detect such defects earlier, even in the later stages of pregnancy. Overall, this report emphasizes the importance of continuous monitoring during pregnancy and offers insights that could lead to better diagnosis, care, and support for families facing similar situations.

Disciplinary Imbalances in Urology and Gynecology Research Publications within Functional Urology.

(1) Background: This study aimed to quantify and evaluate the publication rate and discrepancies of functional urology abstracts from international conferences, and to explore the interdisciplinary contributions of urology and gynecology to the field. (2) Methods: A retrospective bibliometric and content analysis was conducted on abstracts presented between 2015 and 2019 at the EAU and ICS congresses, focusing on functional-urological keywords. A discrepancy scoring system ranging from 0 (minor discrepancies) to 3 (significant discrepancies) assessed the consistency between conference abstracts and full-text publications, and an in-depth analysis determined the disciplinary origin of these publications. (3) Results: Between 2015 and 2019, 53% of EAU and 57% of ICS congress abstracts were published as full-text articles, with minor discrepancies in 38% of EAU and 49% of ICS publications, and significant discrepancies in 17% from both. Urology departments dominated publications, contributing 68% at EAU and 55% at ICS, whereas gynecology contributed only 1% at EAU and 12% at ICS. (4) Conclusions: This study illuminates the need for improved reporting standards and interdisciplinary collaboration in functional urology, as well as increased gynecology research in functional urology-related fields, suggesting that addressing these issues is crucial for advancing the field and enhancing patient care.

Egfl6 promotes ovarian cancer progression by enhancing the immunosuppressive functions of tumor-associated myeloid cells.

Tumor-associated macrophages (TAMs) and myeloid-derived suppressor cells (MDSCs) play a critical role in resistance to immunotherapy. In this study, we identified epidermal growth factor-like 6 (Egfl6) as a new regulator of myeloid cell functions. Our analyses indicated that Egfl6, via binding with ß3 integrins and activation of p38 and SYK signaling, acts as a chemotactic factor for myeloid cells migration and promotes their differentiation towards an immunosuppressive state. In syngeneic mouse models of ovarian cancer (OvCa), tumor expression of Egfl6 increased the intra-tumoral accumulation of polymorphonuclear (PMN) MDSCs and TAMs and their expression of immunosuppressive factors, including CXCL2, IL-10 and PD-L1. Consistent with this, in an immune 'hot' tumor model, Egfl6 expression eliminated response to a-PD-L1 therapy, while Egfl6 neutralizing antibody decreased the accumulation of tumor-infiltrating CD206+ TAMs and PMN-MDSCs and restored the efficacy of a-PD-L1 therapy. Supporting a role in human tumors, in human OvCa tissue samples, areas of high EGFL6 expression co-localized with myeloid cell infiltration. scRNAseq analyses revealed a correlation between EGFL6 and immune cell expression of immunosuppressive factors. Our data provide mechanistic insights into the onco-immunologic functions of EGFL6 in mediating tumor immune suppression and identified EGFL6 as a potential novel therapeutic target to enhance immunotherapy in OvCa patients.

A National Survey of Obstetrics and Gynecology Resident Perspectives on Their Preparedness to Provide Care for Underserved Patients with Gynecologic Malignancies.

Obstetrics and Gynecology (Ob/Gyn) residents will encounter, screen for, and diagnose gynecologic malignancies. This survey assessed residents' confidence in providing NCCN Guidelines-based care to Gynecologic Oncology patients of differing racial/ethnic backgrounds and insurance statuses while accounting for residents' backgrounds. An anonymous, novel Qualtrics survey was disseminated to current US Ob/Gyn residents, with multiple-choice questions about subject demographics and Likert scale questions about their readiness to care for diverse patients. Differences in responses between racial groups were analyzed using the Kruskal-Wallis Rank Sum test. Differences in responses between ethnic groups were evaluated using the Wilcoxon Rank Sum test. Regardless of their backgrounds, residents feel "somewhat prepared" to care for diverse patients. There was no statistical between ethnic groups regarding confidence in caring for racial minorities or insurance types. Similarly, there was no statistical difference between racial groups regarding caring for racial minorities, but a difference did exist for insurance types (p = 0.027). No significant racial/ethnic differences were found in opinions on trial enrollment or chemotherapy delays, though most residents agreed that racial/ethnic minorities face delays in chemotherapy. Finally, resident ethnicity and race both impacted resident perceptions of difficulties for Medicaid and minority patients in obtaining non-operative gynecologic care (p = 0.044; p = 0.017) and scheduling outpatient appointments (p = 0.016; p = 0.032). Ob/Gyn residents feel prepared to provide NCCN Guidelines-based care to socioeconomically diverse patients with gynecologic malignancies, though differences exist when accounting for residents' racial/ethnic backgrounds. These results reflect the importance of emphasizing on culturally competent care in residency, particularly for patients with cancer.

Torsion of distal right hydrosalpinx in a primiparous woman at term: A case report.

INTRODUCTION AND IMPORTANCE: Adnexal torsion is a significant cause of acute pelvic pain and a common gynaecological emergency. While ovarian cysts are well-recognized predisposing factors, hydrosalpinx is a less common precursor. This case report presents a unique instance of isolated fallopian tube torsion accompanied by hydrosalpinx. CASE PRESENTATION: A 27-year-old primiparous woman at 37 weeks gestation presented with severe right lumbar pain. The patient's vital signs were stable, and abdominal and vaginal examinations were conducted. Imaging confirmed a progressing pregnancy and a 7.5 cm hemorrhagic cystic formation on the right side. Suspecting adnexal torsion, she underwent an urgent cesarean section and surgical exploration, which revealed a twisted distal right hydrosalpinx-the treatment involved detorsion, right salpingectomy, and ovarian suspension. Postoperative recovery was uneventful with histopathological confirmation of hydrosalpinx. DISCUSSION: Isolated fallopian tube torsion is rare, particularly during pregnancy. This condition's etiopathogenesis involves rotation of the tube around its ligamentous supports, possibly exacerbated by factors such as hydrosalpinx, pregnancy, and anatomical variances. Despite the availability of imaging techniques, diagnosis remains challenging, often confirmed only during surgical intervention. The literature highlights the importance of considering this diagnosis in pregnant women with acute pelvic pain and identifying characteristic ultrasound features. CONCLUSIONS: Isolated tubal torsion in pregnancy is an exceptional clinical challenge. Early and accurate diagnosis is critical to prevent irreversible damage to the fallopian tube and preserve fertility. This case underscores the need for awareness among clinicians and provides insights into the effective management of such cases.

Reasons for consultation in gynecological and obstetrical emergencies among adolescents in Tunisia.

OBJECTIVES: The main objective is to study gynecological and obstetrical emergencies among adolescents admitted to the emergency room in our department. METHODS: At the Farhat Hached University Hospital in Sousse's Obstetrics and Gynecology Department, we carried out a retrospective study. Sociodemographic and clinical characteristics of adolescents who consulted over a period of 12 months were described. RESULTS: We recorded 78 emergencies during the study period, representing a frequency of 0.39 %. Gynecological and obstetrical emergencies in adolescents are dominated by abdominal-pelvic pain (36 %), followed by pregnancy diagnoses (16.7 %), and dysmenorrhea in 10 % of cases. Admission decisions were made in only 6.4 % of cases. CONCLUSIONS: Advances in adolescent gynecology highlight the importance of specialized care for this population, crucial for preventive healthcare. Evaluation and management rely on recognizing clinical challenges and understanding specific issues.

Superior hypogastric nerve plexus (SHNP) block for pain management after minimally invasive gynecology surgeries: A prospective randomized controlled trial.

OBJECTIVES: Our study aimed to evaluate the effect of superior hypogastric nerve plexus (SHNP) block in postoperative pain management in the first 24 h after minimally invasive gynecological (MIG) surgeries. METHODS: We conducted a double-blinded, randomized controlled trial in the Department of Obstetrics and Gynecology at a tertiary care centre from May 1, 2023 to September 30, 2023 in women undergoing major MIG surgeries. At the completion of the surgery, women were randomized to the intervention group who received SHNP block with ropivacaine 10 mL (0.75%) before port removal, whereas no intervention was taken in the control group. The extubation time was noted, and the pain score was assessed after 1, 2, 6, 12, and 24 h of extubation in the postoperative period using the visual analog scale (VAS). Statistical analysis was done, with a significance level of 0.05, to test the differences between the two groups. RESULTS: A total of 64 patients were randomly allocated to intervention and control groups. The median pain score was lower at 1 and 2 h post-extubation and comparable between the two groups at 6, 12, and 24 h. The surrogate markers that is need for additional analgesia and duration of stay did not differ significantly in the two groups, with P-values of 0.08 and 0.943, respectively. CONCLUSION: Although the SHNP group experienced considerably lower immediate postoperative pain levels in the initial hours following extubation, the impact of this benefit remains uncertain in the longer postoperative period. The effectiveness of this modality for pain control needs further study, particularly at later postoperative hours.

Evaluation of the effect of fluid management on intracranial pressure in patients undergoing laparoscopic gynaecological surgery based on the ratio of the optic nerve sheath diameter to the eyeball transverse diameter as measured by ultrasound: a randomised controlled trial.

BACKGROUND: During gynecological laparoscopic surgery, pneumoperitoneum and the Trendelenburg position (TP) can lead to increased intracranial pressure (ICP). However, it remains unclear whether perioperative fluid therapy impacts ICP. The purpose of this research was to evaluate the impact of restrictive fluid (RF) therapy versus conventional fluid (CF) therapy on ICP in gynecological laparoscopic surgery patients by measuring the ratio of the optic nerve sheath diameter (ONSD) to the eyeball transverse diameter (ETD) using ultrasound. METHODS: Sixty-four patients who were scheduled for laparoscopic gynecological surgery were randomly assigned to the CF group or the RF group. The main outcomes were differences in the ONSD/ETD ratios between the groups at predetermined time points. The secondary outcomes were intraoperative circulatory parameters (including mean arterial pressure, heart rate, and urine volume changes) and postoperative recovery indicators (including extubation time, length of post-anaesthesia care unit stay, postoperative complications, and length of hospital stay). RESULTS: There were no statistically significant differences in the ONSD/ETD ratio and the ONSD over time between the two groups (all p > 0.05). From T2 to T4, the ONSD/ETD ratio and the ONSD in both groups were higher than T1 (all p < 0.001). From T1 to T2, the ONSD/ETD ratio in both groups increased by 14.3%. However, the extubation time in the RF group was shorter than in the CF group [median difference (95% CI) -11(-21 to -2) min, p = 0.027]. There were no differences in the other secondary outcomes. CONCLUSION: In patients undergoing laparoscopic gynecological surgery, RF did not significantly lower the ONSD/ETD ratio but did shorten the tracheal extubation time, when compared to CF. TRIAL REGISTRATION: ChiCTR2300079284. Registered on December 29, 2023.

Enhanced Recovery After Surgery (ERAS) Practices in Minimally Invasive Gynaecologic Surgery: A National Survey.

OBJECTIVE: Enhanced recovery after surgery (ERAS) pathways are evidence-based practices that minimize perioperative physiologic stress, reducing postoperative complications and recovery time. This study assessed the Canadian application of, and adherence to, ERAS recommendations during minimally invasive gynaecologic surgery, and identified barriers to ERAS uptake. METHODS: A self-administered cross-sectional survey was distributed to obstetrics and gynaecology residents, fellows, and attendings through three national listservs from February 2021 to January 2022. The survey assessed 14 perioperative components per the AAGL (American Association of Gynecologic Laparoscopists) ERAS consensus guidelines. Two study groups were defined-participants with vs. without an established ERAS program-and comparison analyses as well as inferential statistical tests were performed. RESULTS: 158 responses were analyzed. 41.9% of respondents work in a centre with an ERAS program. Adherence to ERAS recommendations was high with engaging patients in the operative processes, changing equipment after a contaminated procedure, discontinuing urinary catheters, and initiating early postoperative mobilization. ERAS programing enhanced adherence to preoperative carbohydrate loading, intraoperative fluid management, normothermia, and bowel regimen adjuncts (P < 0.05). Despite ERAS programming, adherence to some recommendations-preoperative fasting, comorbidity optimisation-remained low. Most respondents felt that ERAS is safe (98%) and improves outcomes (82%). CONCLUSION: While the implementation of formal ERAS pathways differs between provinces and hospitals, practitioners across Canada engage in various ERAS components. ERAS program sites had higher adherence to some perioperative recommendations; however, some high-level evidence recommendations still have national adherence gaps. Targeted research around low-adherence components would help identify and address barriers to optimize surgical care.

Reducing maternal infection after assisted vaginal birth in a diverse and deprived population.

Postpartum maternal sepsis is a leading cause of maternal mortality and morbidity. A single dose of prophylactic antibiotics following assisted vaginal births has been shown to significantly reduce postpartum maternal infection in a landmark multicentre randomised controlled trial, which led to its national recommendation. This project aimed to improve the local implementation of prophylactic antibiotics following assisted vaginal births to reduce postnatal maternal infections.Using a prospectively collated birth register, data were collected retrospectively on prophylactic antibiotics administration and postnatal maternal infection rates after assisted vaginal births at the Sandwell and West Birmingham Hospitals National Health Service Trust in North-West Birmingham of the UK. The data were collected from routinely used electronic health records over three audit cycles (n=287) between 2020 and 2023.A mixed-method approach was used to improve the use of prophylactic antibiotics: (1) evidence-based journal clubs targeting doctors in training, (2) presentations of results after all three audit cycles at our and (3) expedited a formal change of local guidelines to support prophylactic antibiotics use.Prophylactic antibiotic administration increased from 13.2% (December 2021) to 90.7% (July 2023), associated with a reduction in maternal infection rates (18.2% when prophylaxis was given vs 22.2% when no prophylaxis was given). However, we observed a gradual increase in the overall postnatal maternal infection rates during the project period.Our repeat audit identified prophylactic antibiotics were regularly omitted after deliveries in labour ward rooms (59.3%), compared with 100% of those achieved in theatre. After further interventions, prophylactic antibiotics administration rates were comparable between these clinical areas (>90%) in 2023.Together, we have demonstrated a simple set of interventions that induced sustainable changes in practice. Further evaluation of other modifiable risk factors and infection rates following all deliveries is warranted in view of the gradual increase in the overall postnatal maternal infection rates.

Lower Limb Doppler Ultrasound Prior to Pneumatic Compression for the Prevention of Pulmonary Embolism in Gynecological Cancer Patients: A Retrospective Cohort Study.

INTRODUCTION: Venous thromboembolism, which includes deep-vein thrombosis and pulmonary embolism, is the third most common cardiovascular disease after myocardial infarction and stroke. This study aimed to determine the effect of Doppler ultrasound on the prophylaxis and prevention of postoperative venous thromboembolism in gynecological oncology. METHOD: This is a retrospective cohort study of procedures performed at King Abdulaziz Medical City in Jeddah, Saudi Arabia, between 2016 and 2021. The study included all patients diagnosed with gynecological cancers who underwent major cancer resection. A total of 295 eligible patients were enrolled and divided into two groups: the first group consisted of 104 patients who were screened for deep vein thrombosis using lower limb Doppler ultrasound prior to their gynecologic oncology surgery, while the second group included 190 patients who were not screened. RESULTS: The prevalence of pulmonary embolism and/or deep vein thrombosis was found to be eight out of 104 patients (7.7%) in the group screened for deep-vein thrombosis using lower limb Doppler ultrasound prior to their gynecologic oncology surgery. In the group that was not screened, one out of 190 patients (0.5%) developed deep vein thrombosis. The prevalence of postoperative pulmonary embolism and/or deep-vein thrombosis was reported in four out of 104 screened patients (3.8%) and in three out of 190 patients (1.6%) in the unscreened group. CONCLUSION: This study concluded that Doppler screening did not change the incidence of pulmonary embolism and/or deep-vein thrombosis postoperatively, but it may be helpful in detecting these conditions preoperatively. Therefore, Doppler screening for deep-vein thrombosis before surgical procedures in gynecological oncology could be considered after clinical assessment of the patient. To improve the study and address its limitations, a larger sample size would help to further investigate and identify relevant factors and determine their significance.

Adult obstetricians and gynecologists lack knowledge of anorectal malformations - a call for action: Gynecologists lack knowledge of anorectal malformations.

OBJECTIVE: Patients with anorectal malformations (ARMs) may have concurrent gynecologic abnormalities. As patients grow, they typically transition from pediatric subspeciality care and seek adult OB/GYN related services. We aimed to assess adult OB/GYN physicians' knowledge, competency, and comfort meeting the sexual and reproductive health care needs of patients with ARM. METHODS: We performed a cross-sectional observational survey-based study of graduates from a single academic OB/GYN residency program from 2013-2022. Physicians were surveyed on experience, comfort, and challenges caring for patients with ARMs and given a knowledge assessment. Descriptive and comparative statistics between those who did and did not complete a pediatric and adolescent gynecology (PAG) rotation were generated. RESULTS: There were 59 respondents (53.6%). Fewer than half (39.0%) report caring for a patient with ARM, an appendicovesicostomy (12.3%) or an appendicostomy (5.4%). Most felt uncomfortable (80.4%) or felt they lacked competence caring for these patients (81.8%). The majority (64.3%) felt ARMs should be discussed in residency. Only one physician (1.7%) answered all questions in the knowledge assessment correctly; 33.9% did not answer any question correctly. On subgroup analysis, more physicians completing a PAG rotation recalled learning about ARMs (83.3 vs 51.9%, p=0.03); however, there were no differences in experience, comfort, competence, or willingness to learn. CONCLUSION: OB/GYN providers report lack of knowledge and comfort in caring for patients with ARMs. Development of a standardized OB/GYN residency curriculum and education for practicing OB/GYN physicians is necessary to allow access to knowledgeable sexual and reproductive health for this patient population.

Prospective evaluation of uterine artery Doppler for prognosis in endometrial cancer: A tertiary single-center experience.

AIMS: Our research aims to shed light on the connection between histopathological differences that affect the prognosis of endometrial cancer and Doppler indices measured in the uterine arteries. METHODS: Seventy-four women with a confirmed diagnosis of endometrial cancer participated in this prospective study. The flow characteristics of the bilateral uterine arteries were evaluated and recorded using color Doppler sonography. After hysterectomy, a correlation analysis was performed between these factors and histological findings. RESULTS: Patients who complained of menometrorrhagia had significantly higher uterine artery peak systolic flow (p = 0.020) than those who had postmenopausal vaginal bleeding. Endometrioid adenocarcinoma was the most common type (71.4%). Doppler pulsatility index and resistance index in the uterine arteries didn't show statistically significant differences between histologic subtypes, tumor grade, myometrial invasion, lymphovascular invasion, lymph node involvement, malignant peritoneal cytology, genetic mutation, or extrauterine involvement. Those without cervical involvement had higher uterine artery Doppler peak systolic flow/end diastolic flow (p = 0.024). CONCLUSIONS: Endometrial cancer made uterine artery, myometrium and endometrium less resistant to blood flow. However, these blood flow indices have not been standardized enough to be utilized as diagnostic tests just yet. Standardization based on more advanced studies would make it possible to use ultrasonography for non-invasive diagnosis and would accelerate and facilitate clinical management.

Menopausal symptoms and utilization of menopausal hormone therapy among women aged 40-60 years in Addis Ababa, Ethiopia: a cross-sectional study.

BACKGROUND: The onset of menopause leads to diminished estrogen exposure, resulting in a high morbidity burden related to menopausal symptoms. Menopausal hormonal therapy is an effective therapy that offers more advantages than disadvantages for women aged less than 60 years or who have had menopause for less than 10 years. OBJECTIVE: This study aimed to assess the prevalence of menopausal symptoms, identify factors associated with menopausal symptoms, and assess the use of menopausal hormone therapy among women aged 40-60 who visited the gynecological clinics of three hospitals in Addis Ababa, Ethiopia. METHODS: A facility-based cross-sectional study was conducted from January 2022 to June 2022 at Gandhi Memorial Hospital, Tikur Anbessa Hospital, and Zewditu Memorial Hospital on 296 middle-aged women. Data were collected using an interviewer-administered structured questionnaire and analyzed for sociodemographic factors, utilization of menopausal hormone therapy, and prevalence of menopausal symptoms using the menopause rating scale. Data were analyzed using SPSS version 25. Bivariate and multivariate logistic regression analyses were performed to identify independent predictors of each subscale of menopausal symptoms. The strength of the association was measured using odds ratios with 95% confidence intervals, and statistical significance was set at a value of P < 0.05. RESULT: The prevalence of menopausal symptoms was 89.9%. According to the menopausal rating scale, the frequency of reported symptoms was hot flushes (54.7%), muscle and joint pain (32.1%) on the somatic subscale; physical and mental exhaustion (55.1%), irritability (48.6%) on psychological subscale; and sexual problems (41.3%), bladder problems (39.2%) on urogenital subscale. This study also showed that the age of women [aOR: 0.317, 95%CI (0.102, 0.990)], and monthly family income [aOR = 0.182, 95% CI (0.041, 0.912)] were significantly associated with somatic menopausal symptoms. There was no utilization of menopausal hormonal therapy to treat menopausal symptoms and to prevent complications. CONCLUSION: The prevalence of menopausal symptoms is high; however, the utilization of individualized administration of menopausal hormone therapy according to symptoms is negligible. It appears essential for these institutions to work on service availability and delivery of menopausal hormone therapy for those in need of wider benefits for their clients.

Regenerative medicine in Obstetrics & Gynecology: Current status under the Act on the Safety of Regenerative Medicine in Japan.

Introduction: While the provision of unapproved regenerative medicine has been problematic worldwide, few studies have examined the implementation status of regenerative medicine (RM) in the specific field. This study aimed to determine the current status of therapy and clinical research in the obstetrics and gynecology (OBGYN) in Japan under the Act on the Safety of Regenerative Medicine (RM Act). Methods: Detailed data were extracted from publicly available websites provided by the Ministry of Health, Labour, and Welfare. We extracted descriptive details, including risk classification of the RM Act, modality, target disease, locality, institution, and administration route. For therapy, the price for each modality was evaluated. Results: The total number of therapeutic provision plans in OBGYN (1.9% of RM in Japan) are classified as Class II (moderate) risk. Most were administered in clinics in urban areas for treating endometrial or ovarian infertility by locally administering platelet-rich plasma (PRP) or autologous mesenchymal stem cells (MSCs). The price using MSCs is approximately eight times more expensive that of those involving PRP (1832.1 ± 1139.8 vs 240.8 ± 106.5 thousand yen, p < 0.0001). Regarding research, four plans (2.2%) were submitted to target implantation failure and advanced gynecological cancer using autologous lymphocytes, dendritic cells, or MSCs. Conclusion: The RM Act permits knowledge of the current status of regenerative medicine even for unapproved uses in a specific clinical field. The study findings shall prompt a worldwide discussion regarding the required regulations for therapy and clinical research of RM.

Updates in emergency medicine: Ectopic pregnancy.

INTRODUCTION: Ectopic pregnancy is a serious condition that can have significant morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy. CONCLUSIONS: Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.