Management of twin reversed arterial perfusion (TRAP) sequence with microwave ablation: A case report and review of the literature.

Twin reversed arterial perfusion (TRAP) sequence carries a high mortality risk to the "pump twin." Management involves disrupting blood flow to the acardiac mass. In this case, the pregnant patient presented at 20 weeks 6 days with Stage IIb TRAP Sequence and underwent percutaneous ultrasound-guided microwave ablation (MWA) of the acardiac mass at 21 weeks 0 days. The probe traversed the thorax of the acardiac mass and ablated the confluence of the umbilical vessels. A healthy child was delivered at 33 weeks 5 days gestation. This report demonstrates the utility of MWA in TRAP sequence and describes a novel approach.

Management of the adnexal mass in pregnancy.

PURPOSE OF REVIEW: With the increased use of ultrasonography in the first trimester, up to 1% of all pregnancies are diagnosed with an adnexal mass. Yet, the management of asymptomatic adnexal masses in pregnancy continues to be controversial as management guidelines are mainly based on case-control or observational studies. The purpose of this article was to review the recent literature and provide clinical guidance on patient management. RECENT FINDINGS: This review will highlight the increasing sensitivity of ultrasound imaging in diagnosing the rare malignant lesion, allowing for antenatal expectant management of benign asymptomatic adnexal masses until delivery or postpartum. The recent literature also highlights the well tolerated use of laparoscopy for the antenatal removal of suspicious or symptomatic masses and that expectant management of asymptomatic masses does not increase the risk of adverse pregnancy outcomes. SUMMARY: Most adnexal masses are benign and ultrasound characteristics can help guide the assessment of asymptomatic ovarian masses. When surgical management is chosen, laparoscopy can be safely performed in pregnancy. Ovarian torsion is a complication for persistent masses in pregnancy.

Vaginal repair of neobladder-vaginal fistula: a case report and review of the literature.

Neobladder substitution after radical cystectomy for invasive cancer has become commonplace as it preserves normal volitional voiding through the native urethra and avoids urinary diversion. Neobladder-vaginal fistula (NVF) is a rare postoperative complication of this procedure that results in decreased quality of life. We describe a case of vaginal repair of a NVF and present a review of the literature.

Hemoglobin A1c in pregestational diabetic gravidas and the risk of congenital heart disease in the fetus.

This study aimed to determine whether poor glycemic control in early pregnancy is associated with an increased risk of congenital heart disease (CHD) for infants of women with preexisting diabetes. A retrospective review examined two tertiary care centers of diabetic pregnancies that recorded early hemoglobin A1c (HbA1c) values (<20 weeks). The incidence of prenatally diagnosed CHD was calculated and stratified by HbA1c level. Poor glycemic control was defined as an HbA1c level of 8.5 % or higher. Fetal echocardiography was used to identify fetuses that resulted in infants with suspected CHD. Neonatal echocardiograms and pathology reports were reviewed for confirmation of the diagnosis. Of 535 patients, 30 (5.6 %) delivered an infant with confirmed CHD. Among the patients with poor glycemic control, 8.3 % (n = 17) delivered an infant with CHD, whereas 3.9 % (n = 13) of those with an HbA1c level lower than 8.5 % delivered an infant with CHD (p = 0.03). Poor glycemic control in early pregnancy is associated with an increased risk of CHD in offspring. The incidence of CHD in patients with adequate glycemic control still is sufficiently high to justify routine fetal echocardiography for all gravidas with preexisting diabetes regardless of HbA1c level.

Pelvic nerve injury following gynecologic surgery: a prospective cohort study.

OBJECTIVE: The purpose of this study was to determine the incidence and time course of postoperative neuropathy resulting from gynecologic surgery. STUDY DESIGN: A single cohort of 616 female patients undergoing elective gynecologic surgery for benign or malignant conditions at a tertiary care academic medical center underwent a postoperative neurologic evaluation to identify postoperative neuropathy of the lower extremities. RESULTS: Fourteen peripheral nerve injuries were observed in 11 patients, making the overall incidence of postoperative neuropathy 1.8% (95% confidence interval, 1.0-3.2). Injury to the lateral femoral cutaneous (5), femoral (5), common fibular (1), ilioinguinal/iliohypogastric (1), saphenous (1), and genitofemoral (1) nerves were detected. Complete resolution of neuropathic symptoms occurred in all but 1 patient (91%). Median time to resolution of symptoms was 31.5 days (range, 1 day to 6 months). CONCLUSION: The incidence of lower extremity neuropathy attributable to gynecologic operations is low, and these neuropathies resolve in the great majority of cases.

Operative Vaginal Delivery Is a Safe Option in Women Undergoing a Trial of Labor after Cesarean.

Objective To compare outcomes of operative intervention in the second stage of labor during trial of labor after cesarean (TOLAC). Study Design A secondary analysis of the Maternal-Fetal Medicine Units Network cesarean section registry was conducted. Analysis was by first attempted mode of delivery. Results A total of 1,837 met inclusion criteria. Subjects in the operative vaginal groups (OVDs) were more likely to have a prior vaginal delivery (vacuum 34.2%; forceps 34.3%) than the repeat cesarean delivery (RCD) group (22.6%; p < 0.0001). Most OVD attempts were successful (forceps 90.4%; vacuum 92.6%). Neonatal morbidity was not different (12.1% forceps vs. 14.6% vacuum; 14.8% RCD). Maternal morbidity was highest among forceps deliveries (32.3 vs. 24.3% vacuum; 22.0% RCD, p = 0.0001). RCD was associated with surgical injury (2.7 vs. 0.7% forceps; 0% vacuum; p < 0.0001), endometritis (8.4 vs. 3.2% forceps, 1.2% vacuum; p < 0.0001), and wound complications (1.9 vs. 0.4% forceps; 0.3% vacuum; p = 0.006). OVD was associated with anal sphincter laceration (22.7% forceps, 15.5% vacuum; 0% RCD; p = 0.01). Conclusion The success rate of OVD is high in TOLAC with similar outcomes to RCD. Maternal composite outcomes were highest with forceps-assisted vaginal deliveries. However, considering overall morbidity, OVD in the second stage of labor in TOLAC is a reasonable, safe option in selected cases.

Pudendal neuropathy involving the perforating cutaneous nerve after cystocele repair with graft.

BACKGROUND: Pudendal neuropathy is a documented complication of sacrospinous ligament fixation, but it is infrequently reported with other types of gynecologic surgery. CASE: A woman developed neuropathic symptoms of the right vulva, perianal area, and gluteal fold after vaginal surgery with graft for anterior pelvic organ prolapse. Pudendal nerve entrapment with involvement of the perforating cutaneous nerve was suspected. Suture removal 1 year after the operation resulted in improved pain symptoms and sexual function. CONCLUSION: Pudendal nerve entrapment is one potential complication of anterior vaginal repair with biologic graft. Removal of sutures, even long after surgery, can result in clinically significant improvement in pain symptoms and sexual function in patients with pudendal nerve entrapment.

Incidence and risk factors for surgical intervention after uterine artery embolization.

OBJECTIVE: To determine the incidence and risk factors for surgical intervention after uterine artery embolization for symptomatic uterine fibroids. STUDY DESIGN: Electronic medical records of all patients who underwent uterine artery embolization for symptomatic uterine leiomyomata were reviewed. Logistic regression was used to identify independent risk factors for any surgical intervention and for hysterectomy alone after uterine artery embolization. RESULTS: Uterine artery embolization was performed in 454 patients during the study period, with a median follow-up time (range) of 14 (0-128) months. Overall, 99 patients (22%) underwent any surgical intervention after uterine artery embolization in the operating room. Risk factors for any surgical intervention included younger age (P < .003), bleeding as an indication for uterine artery embolization (P < .01), presence of significant collateral ovarian vessel contribution to the uterus (P < .01), or use of 355-500 mum particles (P < .008). CONCLUSION: Patients undergoing uterine artery embolization have a 22% risk for requiring additional surgical intervention, but overall uterine artery embolization is an effective minimally invasive option.

Phylogenomic analysis of vertebrate thrombospondins reveals fish-specific paralogues, ancestral gene relationships and a tetrapod innovation.

BACKGROUND: Thrombospondins (TSPs) are evolutionarily-conserved, extracellular, calcium-binding glycoproteins with important roles in cell-extracellular matrix interactions, angiogenesis, synaptogenesis and connective tissue organisation. Five TSPs, designated TSP-1 through TSP-5, are encoded in the human genome. All but one have known roles in acquired or inherited human diseases. To further understand the roles of TSPs in human physiology and pathology, it would be advantageous to extend the repertoire of relevant vertebrate models. In general the zebrafish is proving an excellent model organism for vertebrate biology, therefore we set out to evaluate the status of TSPs in zebrafish and two species of pufferfish. RESULTS: We identified by bioinformatics that three fish species encode larger numbers of TSPs than vertebrates, yet all these sequences group as homologues of TSP-1 to -4. By phylogenomic analysis of neighboring genes, we uncovered that, in fish, a TSP-4-like sequence is encoded from the gene corresponding to the tetrapod TSP-5 gene. Thus, all TSP genes show conservation of synteny between fish and tetrapods. In the human genome, the TSP-1, TSP-3, TSP-4 and TSP-5 genes lie within paralogous regions that provide insight into the ancestral genomic context of vertebrate TSPs. CONCLUSION: A new model for TSP evolution in vertebrates is presented. The TSP-5 protein sequence has evolved rapidly from a TSP-4-like sequence as an innovation in the tetrapod lineage. TSP biology in fish is complicated by the presence of additional lineage- and species-specific TSP paralogues. These novel results give deeper insight into the evolution of TSPs in vertebrates and open new directions for understanding the physiological and pathological roles of TSP-4 and TSP-5 in humans.

Serotonin Deficiency Rescues Lactation on Day 1 in Mice Fed a High Fat Diet.

Obesity is an inflammatory state associated with delayed lactogenesis stage II and altered mammary gland morphology. Serotonin mediates inflammation and mammary gland involution. The objective of this study was to determine if a genetic deficiency of tryptophan hydroxylase 1, the rate-limiting enzyme in peripheral serotonin synthesis, would result in an improved ability to lactate in dams fed a high fat diet. Twenty-six female mice were fed a high (HFD) or low fat (LFD) diet throughout pregnancy and lactation. Fourteen mice were genetically deficient for Tph1 (Tph1-/-), and twelve were wild type. Milk yield, pup mortality, and dam weights were recorded and milk samples were collected. On day 10 of lactation, dams were sacrificed and mammary glands were harvested for RT-PCR and histological evaluation. HFD dams weighed more than LFD dams at the onset of lactation. WT HFD dams were unable to lactate on day 1 of lactation and exhibited increased pup mortality relative to all other treatments, including Tph1-/- HFD dams. mRNA expression of immune markers C-X-C motif chemokine 5 and tumor necrosis factor alpha were elevated in WT HFD mammary glands. Mammary gland histology showed a reduced number of alveoli in WT compared to Tph1-/- dams, regardless of diet, and the alveoli of HFD dams were smaller than those of LFD dams. Finally, fatty acid profile in milk was dynamic in both early and peak lactation, with reduced de novo synthesis of fatty acids on day 10 of lactation in the HFD groups. Administration of a HFD to C57BL/6 dams produced an obese phenotype in the mammary gland, which was alleviated by a genetic deficiency of Tph1. Serotonin may modulate the effects of obesity on the mammary gland, potentially contributing to the delayed onset of lactogenesis seen in obese women.

The genetics of ray pattern variation in Caenorhabditis briggsae.

BACKGROUND: How does intraspecific variation relate to macroevolutionary change in morphology? This question can be addressed in species in which derived characters are present but not fixed. In rhabditid nematodes, the arrangement of the nine bilateral pairs of peripheral sense organs (rays) in tails of males is often the most highly divergent character between species. The development of ray pattern involves inputs from hometic gene expression patterns, TGFbeta signalling, Wnt signalling, and other genetic pathways. In Caenorhabditis briggsae, strain-specific variation in ray pattern has provided an entree into the evolution of ray pattern. Some strains were fixed for a derived pattern. Other strains were more plastic and exhibited derived and ancestral patterns at equal frequencies. RESULTS: Recombinant inbred lines (RILs) constructed from crosses between the variant C. briggsae AF16 and HK104 strains exhibited a wide range of phenotypes including some that were more extreme than either parental strain. Transgressive segregation was significantly associated with allelic variation in the C. briggsae homolog of abdominal B, Cb-egl-5. At least two genes that affected different elements of ray pattern, ray position and ray fusion, were linked to a second gene, mip-1. Consistent with this, the segregation of ray position and ray fusion phenotypes were only partially correlated in the RILs. CONCLUSIONS: The evolution of ray pattern has involved allelic variation at multiple loci. Some of these loci impact the specification of ray identities and simultaneously affect multiple ray pattern elements. Others impact individual characters and are not constrained by covariance with other ray pattern elements. Among the genetic pathways that may be involved in ray pattern evolution is specification of anteroposterior positional information by homeotic genes.

Other adverse pregnancy outcomes and future chronic disease.

Cardiovascular disease is the leading cause of morbidity and mortality in females worldwide. Pregnancy is associated with significant physiologic changes that may function as a natural stress test to detect women at future risk. It is established that women who have had a pregnancy complicated by gestational diabetes or a hypertensive disorder of pregnancy are at increased risk of cardiovascular disease later in life, and there is growing evidence that women who deliver infants preterm or growth-restricted infants have an elevated risk as well. Consideration should be given to including these outcomes as indicators of cardiovascular risk. Pregnancy represents a teachable moment when it would be ideal to identify women at risk. Improved integration of women's primary health care and an enhanced knowledge base on the part of clinicians will be necessary to fully incorporate these findings into the clinical care of women.

A case of ruptured splenic artery aneurysm in pregnancy.

Background. Rupture of a splenic artery aneurysm is rare complication of pregnancy that is associated with a significant maternal and fetal mortality. Case. A multiparous female presented in the third trimester with hypotension, tachycardia, and altered mental status. A ruptured splenic artery aneurysm was discovered at the time of laparotomy and cesarean delivery. The patient made a full recovery following resection of the aneurysm. The neonate survived but suffered severe neurologic impairment. Conclusion. The diagnosis of ruptured splenic artery aneurysm should be considered in a pregnant woman presenting with signs of intra-abdominal hemorrhage. Early intervention by a multidisciplinary surgical team is key to preserving the life of the mother and fetus.

Rectal mesh erosion after robotic sacrocolpopexy.

We report an unusual case of rectal mesh erosion presenting 16 months after robotic sacrocolpopexy. The patient initially underwent a robotic sacrocolpopexy, lysis of adhesions, midurethral sling, and posterior colporrhaphy for symptomatic grade 2 pelvic organ prolapse and urodynamic stress incontinence. Her postoperative recovery was uneventful. Sixteen months later, an anterior 2 × 2-cm rectal mesh erosion was noted on the colonoscopy performed when she presented with hematochezia.

Persistent ovarian masses and pregnancy outcomes.

OBJECTIVE: To determine if persistent ovarian masses in pregnancy are associated with increased adverse outcomes. METHODS: This is a retrospective cohort of 126 pregnant women with a persistent ovarian mass measuring 5 cm or greater who delivered at two university hospitals between 2001 and 2009. Maternal outcomes included gestational age (GA) at diagnosis, delivery and surgery as well as miscarriage, preterm birth (PTB), ovarian torsion and hospital admission for pain. Neonatal outcomes included birth weight, respiratory distress syndrome (RDS), intra-ventricular hemorrhage (IVH), death and sepsis. RESULTS: A total of 1225 ovarian masses were identified (4.9%) in 24,868 patients. A persistent ovarian mass was found in 0.7%. Average GA at diagnosis was 17.8 weeks. Miscarriage rate was 3.3%. Average GA at delivery was 37.9 weeks. Of the patients, 8.5% had ovarian torsion, 10.3% had admission for pain and 9.3% had PTBs. The mean cesarean delivery rate was 46.3%. The average neonatal weight was 3273 g. There was one neonatal death in this cohort. The rate of RDS was 2.8%, IVH 0.9% and neonatal sepsis 1.9%. The most common surgical pathologic diagnosis was dermoids (37.6%). No overt malignancies were seen. CONCLUSION: A persistent ovarian mass in pregnancy does not confer an increased risk of adverse pregnancy outcomes.

Acute chorioamnionitis at term caused by the oral pathogen Fusobacterium nucleatum.

Fusobacterium nucleatum is an oral pathogen associated with preterm birth. Presented is a case of acute chorioamnionitis that progressed to maternal sepsis in a term patient with intact membranes. In addition to its role in periodontal disease and preterm birth, our case demonstrates that intrauterine infection with Fusobacterium nucleatum can result in severe disease at term.

Persistent bilateral ureteral obstruction secondary to endometriosis despite treatment with an aromatase inhibitor.

OBJECTIVE: To present a case demonstrating lack of efficacy of an aromatase inhibitor in treating ureteral endometriosis. DESIGN: Case report. SETTING: A tertiary-care hospital. PATIENT(S): A 47-year-old woman with severe ureteral endometriosis. INTERVENTION(S): Anastrozole 1 mg daily for 15 months. MAIN OUTCOME MEASURE(S): Renal function. RESULT(S): Despite medical management with anastrozole, our patient continued to have worsening renal function and subsequently required surgical intervention. CONCLUSION(S): Anastrozole was ineffective at preventing deterioration of renal function in this patient.