Acute Ulnar Neuropathy After Uncomplicated Contraceptive Implant Insertion: A Case Report.

To avoid the nerves and blood vessels of the upper extremity, the subdermal contraceptive implant Nexplanon (N.V. Organon, Oss, The Netherlands) is inserted into the subdermis at a location 8-10 cm proximal to the medial epicondyle of the humerus and 3-5 cm posterior to the groove between the biceps and triceps muscles. Ulnar nerve injury is a known but extremely rare complication associated with implant insertion. Risk factors for ulnar nerve insult include inadvertent deep insertion, device migration, and an underweight patient. This is a case report of an obese 40-year-old female who presented four days after uncomplicated contraceptive implant insertion with symptoms consistent with an acute ulnar neuropathy, despite the implant being located in the proper superficial location. Symptoms resolved soon after implant removal. This unique presentation may be explained by the aberrant anatomy of the ulnar nerve. It is important for clinicians to be able to recognize and treat this rare complication of contraceptive implant insertion, even in a patient who possesses no risk factors for ulnar nerve injury.

Occult symptomatic bilateral pure Leydig cell tumors in a postmenopausal woman: a case report.

BACKGROUND: Pure Leydig cell tumors (LCTs) represent 0.1% of ovarian masses. Postmenopausal patients typically present with virilization. Although LCTs can be challenging to locate on conventional imaging, positron emission tomography (PET) has been demonstrated to be effective. CASE: A 64-year-old postmenopausal woman presented with alopecia, facial hirsutism, and clitoromegaly. Laboratory findings included elevated testosterone and androstenedione. Ultrasound, computed tomography, and magnetic resonance imaging showed no adnexal masses. PET did not demonstrate ovarian fludeoxyglucose-avidity. Histopathology after bilateral salpingo-oophorectomy revealed bilateral Leydig cell tumors. Her testosterone normalized 2 weeks postoperatively. CONCLUSION: We describe the occult, symptomatic, bilateral ovarian Leydig cell tumors, an occurrence that has not been described in the literature. Virilizing tumors must be considered in patients with evidence of hyperandrogenism, even without pelvic masses on imaging.

Diabetes, Fetal Demise, and Shoulder Dystocia: The Importance of Glucose Screening to Prevent Catastrophic Obstetric Outcomes.

Diabetes is associated with increased risk of stillbirth and shoulder dystocia. Compared with uncomplicated pregnancies, diabetic patients have a 4-6x risk of stillbirth and 2-3x risk of shoulder dystocia. A 34 yo G2P0010 presented with a 40+3 wga IUFD with nonstandard antenatal glucose screening. Admission labs included a hemoglobin A1c of 6.6. She had a vaginal delivery complicated by a 30-minute shoulder dystocia that was not relieved by McRoberts, suprapubic pressure, Rubin II, Wood's Screw, or posterior arm delivery. Nitroglycerine was administered, after which Wood's Screw was successful resulting in delivery of an infant weighing 4190 grams (85th percentile for gestational age). A 31 yo G1 presented with a 37+1 wga IUFD. Her 28 wga three-hour GTT was notable for an elevated value at one hour (216 mg/dL). Admission labs included a hemoglobin A1c of 6.6. She had a vaginal delivery complicated by a 30-minute shoulder dystocia that was relieved via posterior axillary sling after failure of McRoberts, suprapubic pressure, Rubin II, Wood's Screw, and Gaskin's, resulting in the delivery of an infant weighing 3590 g (92nd percentile for gestational age). We present two cases of severe shoulder dystocia in patients who both presented with term IUFD and diabetic-range hemoglobin A1c. There is minimal literature on diabetic patients with pregnancies affected by both stillbirth and shoulder dystocia. These cases underscore the importance of glucose screening and control to prevent catastrophic obstetric outcomes.

Preeclamptic serous retinal detachment without hypertension: A case report.

Preeclampsia is a disease of pregnancy classically defined by the development of new-onset hypertension and proteinuria. Serous retinal detachment is a rare complication of severe preeclampsia that is associated with a high incidence of morbidity and mortality. We present the case of a 24-year-old primigravida who was diagnosed with preeclamptic serous retinal detachment at 30 weeks of gestation that occurred in the absence of hypertension. The patient was delivered by cesarean section for fetal malpresentation and she had complete recovery of her vision by three months postpartum. Providers should exercise vigilance for preeclampsia in women presenting with new-onset visual symptoms, even in the absence of hypertension.

Obstetric Hemorrhage Outcomes by Intrapartum Risk Stratification at a Single Tertiary Care Center.

Introduction Postpartum hemorrhage is a leading cause of maternal mortality worldwide. Performance of a postpartum hemorrhage risk assessment prior to delivery has been recommended to identify patients at higher risk for hemorrhage to support advanced planning for optimal response. The objective of this quality improvement initiative is to evaluate the transfusion and hemorrhage rates for patients at low, moderate, and high risk for postpartum hemorrhage by utilizing standardized risk assessment. Methods and materials A historic cohort study was performed among women delivering from March 2017 to June 2018 at a single United States military tertiary medical center. A postpartum hemorrhage risk assessment was performed utilizing the California Maternal Quality Care Collaborative toolkit for all patients admitted to Labor and Delivery and when the postpartum hemorrhage risk increased during the intrapartum period. An electronic log was reviewed to determine blood loss volume, change in hematocrit, and transfusion rates in patients at low, moderate, and high risk for postpartum hemorrhage for all deliveries, stratified by delivery type. Results There were 3,377 deliveries during the study period with 145 excluded due to lack of assigned risk category. The high-risk group (12.3% of deliveries) was 4.3 times more likely to receive a blood transfusion, 2.9 times more likely to have a blood loss over 1000 mL, and 2.1 times more likely to have a transfusion or hematocrit drop of 10 points when compared with the low-risk group (69.4% of deliveries). Of those transfused, the majority were classified as low risk as this was the most common assignment. Conclusion Risk stratification can differentiate low from high-risk patients for postpartum hemorrhage and associated transfusion or change in hematocrit. However, the majority of patients who receive a transfusion will be classified as low or moderate risk. Thus, all patients should be monitored closely and treated aggressively to prevent morbidity.