Medical Malpractice Lawsuits.

The tenets of a lawsuit are a deviation from the applicable standard of care that caused an injury. Elements must be addressed, including duty of care, deviation or breach of the duty to care, evidence the breach caused injury, and the identification of associated damages. Steps include consultation by a plaintiff with the attorney, pertinent records and imaging studies, and a review of the material by an expert. A complaint is filed and served upon each party. The defendant(s) must respond typically within 20 days. The parties then engage in discovery. The case may be referred to mediation, trial settlement, or dismissal.

Insemination "Fraud": Potentially Criminal Actions in Reproductive Medicine.

Case law and statutory provisions ensure marital rules of paternity apply when artificial insemination is associated with the pregnancy. Virtually all jurisdictions in the United States provide for gamete donors to remain anonymous. Much of this has been challenged with access to donor information via 23 and me. A breach of trust and a number of lawsuits involving physician provider(s) have resulted. We provide case law examples related to artificial insemination and the identification of the sperm donor. Proposed future legislation to protect patients and offspring from harm in relation to the process of donor sperm inseminations is provided.

Are Apologies a Way to Reduce Malpractice Risks?

Apologies are a means of responding to a medical error. Explanation of information related to the episode often fills a need for the patient and family to feel adequately informed. There are pros and cons related to the apology. The American College of Physicians, the American Medical Association, and the Joint Commission of the Accreditation of Health Care Organization Hospital strongly encourage practitioners to disclose when an error or complication occurs. Apologies can be admissible in the courtroom and much of this is state dependent. An apology will be an integral part of the clinician's armamentarium.

Chromosomal instability in women with primary ovarian insufficiency.

STUDY QUESTION: What is the prevalence of somatic chromosomal instability among women with idiopathic primary ovarian insufficiency (POI)? SUMMARY ANSWER: A subset of women with idiopathic POI may have functional impairment in DNA repair leading to chromosomal instability in their soma. WHAT IS KNOWN ALREADY: The formation and repair of DNA double-strand breaks during meiotic recombination are fundamental processes of gametogenesis. Oocytes with compromised DNA integrity are susceptible to apoptosis which could trigger premature ovarian aging and accelerated wastage of the human follicle reserve. Genomewide association studies, as well as whole exome sequencing, have implicated multiple genes involved in DNA damage repair. However, the prevalence of defective DNA damage repair in the soma of women with POI is unknown. STUDY DESIGN, SIZE, DURATION: In total, 46 women with POI and 15 family members were evaluated for excessive mitomycin-C (MMC)-induced chromosome breakage. Healthy fertile females (n = 20) and two lymphoblastoid cell lines served as negative and as positive controls, respectively. PARTICIPANTS/MATERIALS, SETTING, METHODS: We performed a pilot functional study utilizing MMC to assess chromosomal instability in the peripheral blood of participants. A high-resolution array comparative genomic hybridization (aCGH) was performed on 16 POI patients to identify copy number variations (CNVs) for a set of 341 targeted genes implicated in DNA repair. MAIN RESULTS AND THE ROLE OF CHANCE: Array CGH revealed three POI patients (3/16, 18.8%) with pathogenic CNVs. Excessive chromosomal breakage suggestive of a constitutional deficiency in DNA repair was detected in one POI patient with the 16p12.3 duplication. In two patients with negative chromosome breakage analysis, aCGH detected a Xq28 deletion comprising the Centrin EF-hand Protein 2 (CETN2) and HAUS Augmin Like Complex Subunit 7 (HAUS7) genes essential for meiotic DNA repair, and a duplication in the 3p22.2 region comprising a part of the ATPase domain of the MutL Homolog 1 (MLH1) gene. LIMITATIONS REASONS FOR CAUTION: Peripheral lymphocytes, used as a surrogate tissue to quantify induced chromosome damage, may not be representative of all the affected tissues. Another limitation pertains to the MMC assay which detects homologous repair pathway defects and does not test deficiencies in other DNA repair pathways. WIDER IMPLICATIONS OF THE FINDINGS: Our results provide evidence for functional impairment of DNA repair in idiopathic POI, which may predispose the patients to other DNA repair-related conditions such as accelerated aging and/or cancer susceptibility. STUDY FUNDING/COMPETING INTEREST(S): Funding was provided by the National Institute of Child Health and Human Development. There were no competing interests to declare.

High quality RNA in semen and sperm: isolation, analysis and potential application in clinical testing.

PURPOSE: Male infertility is a complex health condition. To our knowledge there are no molecular biomarkers of male infertility. Sperm RNA is a potential biomarker for detecting sperm abnormalities and viability at infertility clinics. However, RNA use is hindered by its inconsistent quantity, quality, multiple cell types in semen and condensed sperm structure. MATERIALS AND METHODS: We tested the usefulness of high quality RNA isolated from mature sperm and whole semen by our protocol, which reduces RNA degradation by maintaining semen and protocol components at 37 C and decreasing processing time. We isolated RNA from 83 whole semen samples, 18 samples of motile sperm prepared by the swim-up protocol and 18 of sperm prepared by the standard Percoll gradient method. RESULTS: Electrophoretic and spectral analysis of RNA revealed high quality 18S and 28S rRNAs in 71 of 83 whole semen samples (86%) and 15 of 18 mature sperm swim-up samples (83%). However, high quality RNA was isolated from only 7 of 18 Percoll gradient sperm samples (39%). Interestingly quantitative reverse transcriptase-polymerase chain reaction analysis of 4 somatic and 10 germ cell markers showed that whole semen and swim-up samples had similar RNA profiles. RNA sequencing revealed that most encoded proteins were involved in mature sperm function, regulation of DNA replication, transcription, translation, cell cycle and embryo development. CONCLUSIONS: We believe that semen and sperm specific RNAs are highly informative biomarkers for germ cell stages and somatic cell contribution. Therefore, these RNAs could be valuable diagnostic indicators of sperm survival, fertilization and early embryogenesis, and could serve as a predictor of the in vitro fertilization prognosis.

Adolescent gynecology: special considerations for special patients.

Developments in the field of adolescent gynecology highlight the specific expertise and care required by this population. Given the ability to shape their future health choices, adolescents are a critical target for preventative health care. The approach to the evaluation and management of this unique population rests not only on the practitioner's adept ability to recognize the unique clinical challenges that may occur, but also rests on his/her understanding of these problems. Here, we review recent guidelines and practice patterns in the evaluation and management of issues in adolescent gynecology.

Adolescent gynecology.

Given new developments in the field of adolescent reproductive health, this review focuses on highlighting new guidelines and practice patterns in evaluation and management of adolescent gynecologic problems. First, understanding the proper techniques for the initial examination is key to establishing a long-term relationship with this age group. Reservations about the first gynecologic examination are common, and the practitioner's goal is foremost to make the patient as comfortable as possible. Preventive health in this patient population is key, and practitioners should become comfortable with providing education about topics as diverse as sexuality, eating disorders, and dating violence. Furthermore, the frequency with which teenagers report sexual activity and the high unintended pregnancy rate in this age group makes counseling regarding effective contraception essential. Additionally, practitioners are encouraged to take the opportunity to discuss the availability of the human papillomavirus (HPV) vaccine with adolescents. In 2007, adolescents were designated as a special population, given the frequency with which they acquire and clear mild HPV-related cervical dysplasia. More conservative treatment in this population is generally favored. During their transition through puberty, disorders of menstruation become the most common complaint requiring the attention of the gynecologist. Most commonly, anovulation serves as the cause behind such abnormal bleeding. Polycystic ovarian syndrome can develop in early puberty and carry its consequences into adulthood. Infertility, diabetes, and hirsutism mark the most important components of the syndrome and require age-appropriate management. Finally, the consequences of endometriosis on the future fertility of adolescents have brought early intervention to light. Recognition and prompt treatment are advocated to prevent the future implications of this disease.

Pediatric and adolescent gynecologic laparoscopy.

Minimally invasive techniques to treat children and adolescents requiring surgery have increasingly become standard of care. Similarly, gynecologists frequently use laparoscopy to treat pelvic pathology. We present the necessary equipment and surgical techniques required to perform gynecologic procedures on the pediatric and adolescent population. We will give particular focus to the treatment of adnexal masses, chronic pelvic pain, endometriosis, and ovarian torsion. We will also discuss the role of the incidental appendectomy in children and adolescents.

Female fertility preservation in the pediatric and adolescent cancer patient population.

The 5-year survival rate for childhood cancer is over 80%, thereby increasing the number of young women facing infertility in the future because of the gonadotoxic effects of chemotherapy and radiation. The gonadotoxic effects of childhood cancer treatment vary by the radiation regimen and the chemotherapeutic drugs utilized. Although the American Society of Clinical Oncology guidelines recommend fertility preservation for all patients, there are several barriers and ethical considerations to fertility preservation in the pediatric and adolescent female population. Additionally, the fertility preservation methods for pre- and postpubertal females differ, with only experimental methods available for prepubertal females. We will review the risk of chemotherapy and radiation on female fertility, the approach to fertility preservation in the pediatric and adolescent female population, methods of fertility preservation for both pre- and postpubertal females, barriers to fertility preservation, cost, and psychological and ethical considerations.

Polycystic ovary syndrome in adolescents.

Polycystic ovary syndrome (PCOS) typically manifests with a combination of menstrual dysfunction and evidence of hyperandrogenism in the adolescent population. No single cause has been identified; however, evidence suggests a complex interplay between genetic and environmental factors. Polycystic ovary syndrome presents a particular diagnostic challenge in adolescents as normal pubertal changes can present with a similar phenotype. Management of PCOS in the adolescent population should focus on a multi-modal approach with lifestyle modification and pharmacologic treatment to address bothersome symptoms. This chapter outlines the pathogenesis of PCOS, including the effects of obesity, insulin resistance, genetic, and environmental factors. The evolution of the diagnostic criteria of PCOS as well as specific challenges of diagnosis in the adolescent population are reviewed. Finally, evidence for lifestyle modification and pharmacologic treatments are discussed.

Endometriosis in the Adolescent Patient.

The recognition and management of endometriosis in the adolescent patient is challenging. A strong clinical suspicion for endometriosis should be maintained in the adolescent who suffers from acyclic pelvic pain as well as absenteeism from school and lack of participation in daily activities. Risk factors include the presence of an obstructive Mullerian anomaly, a family history of endometriosis, and conditions that prolong exposure to endogenous and exogenous estrogens. Empiric medical therapy with nonsteroidal anti-inflammatory drugs and combined oral contraceptive pills may be considered in most adolescents with endometriosis. Failure of empiric therapy may warrant diagnostic laparoscopy, which affords a concomitant opportunity for treatment via excision of endometriosis. Endometriotic implants in the adolescent tend to be more atypical, appearing red/flame-like, clear/polypoid, or vesicular. Endometriosis tends to recur more often in adolescents when compared with adults, and the role of postoperative medical therapy for the suppression of disease progression is not entirely clear. Current knowledge on the impact of adolescent endometriosis on future fertility is limited but overall reassuring.

Association of Concussion With Abnormal Menstrual Patterns in Adolescent and Young Women.

Importance: Brain injury may interrupt menstrual patterns by altering hypothalamic-pituitary-ovarian axis function. Investigators have yet to evaluate the association of concussion with menstrual patterns in young women. Objective: To compare abnormal menstrual patterns in adolescent and young women after a sport-related concussion with those after sport-related orthopedic injuries to areas other than the head (nonhead). Design, Setting, and Participants: This prospective cohort study of adolescent and young women with a sport-related concussion (n = 68) or a nonhead sport-related orthopedic injury (n = 61) followed up participants for 120 days after injury. Patients aged 12 to 21 years who presented within 30 days after a sport-related injury to a concussion or sports medicine clinic at a single academic center were eligible. Menstrual patterns were assessed using a weekly text message link to an online survey inquiring about bleeding episodes each week. The first patient was enrolled on October 14, 2014, and follow-up was completed on January 24, 2016. Inclusion criteria required participants to be at least 2 years postmenarche, to report regular menses in the previous year, and to report no use of hormonal contraception. Exposures: Sport-related concussion or nonhead sport-related orthopedic injury. Main Outcomes and Measures: Abnormal menstrual patterns were defined by an intermenstrual interval of less than 21 days (short) or more than 35 days (long) or a bleeding duration of less than 3 days or more than 7 days. Results: A total of 1784 survey responses were completed of the 1888 text messages received by patients, yielding 487 menstrual patterns in 128 patients (mean [SD] age, 16.2 [2.0] years). Of the 68 patients who had a concussion, 16 (23.5%) experienced 2 or more abnormal menstrual patterns during the study period compared with 3 of 60 patients (5%) who had an orthopedic injury. Despite similar gynecologic age, body mass index, and type of sports participation between groups, the risk of 2 or more abnormal menstrual bleeding patterns after injury was significantly higher among patients with concussion than among those with an orthopedic injury (odds ratio, 5.85; 95% CI, 1.61-21.22). Conclusions and Relevance: Adolescent and young women may have increased risk of multiple abnormal menstrual patterns after concussion. Because abnormal menstrual patterns can have important health implications, monitoring menstrual patterns after concussion may be warranted in this population. Additional research is needed to elucidate the relationship between long-term consequences of concussion and the function of the hypothalamic-pituitary-ovarian axis.

The expression level of C19MC miRNAs in early pregnancy and in response to viral infection.

INTRODUCTION: We have previously shown that miRNAs produced from the Chromosome 19 MiRNA Cluster (C19MC), which are expressed almost exclusively in primate trophoblasts and are released into the maternal circulation, reduce viral replication in non-placental cells and can modulate migratory behavior of extravillous trophoblast. We sought to define the expression pattern of C19MC miRNA in early pregnancy and in response to viral infection in vitro and in vivo. METHODS: We prospectively followed women undergoing in vitro fertilization (IVF) and determined their blood level of C19MC miRNA using RT-qPCR. To examine the effect of viral exposure on C19MC miRNAs expression, we used three systems: (1) a transgenic mouse overexpressing the C19MC cluster and exposed to Togaviridae during pregnancy, (2) cultured primary human trophoblasts exposed to Vesicular Stomatitis Virus in vitro, and (3) amniotic fluid from women exposed to cytomegalovirus during pregnancy. RESULTS: In 27 IVF pregnancies, C19MC miRNAs were detected as early as 2 weeks after implantation, and their levels increased thereafter. There was no change in C19MC miRNA expression levels in the mouse placenta in response to viral exposure. Similarly, Vesicular Stomatitis Virus infection of primary human trophoblast did not selectively increase C19MC miRNA expression. C19MC miRNA expression in the amniotic fluid was not affected by vertical transmission of cytomegalovirus. DISCUSSION: The expression of C19MC miRNAs in maternal circulation very early in pregnancy suggests a role in the establishment of the maternal-fetal interface. The levels of C19MC miRNA are not influenced by diverse types of viral infection.

Focused assessment of surgical performance: difficulty with faculty compliance.

OBJECTIVE: This study evaluated faculty compliance in the use of the global surgical rating scale of the Objective Structured Assessment of Technical Skills to rate resident surgical performance after every endoscopic procedure. STUDY DESIGN: For this prospective cohort study, 4 faculty members in the Minimally Invasive Gynecology Surgery Program were asked to rate resident surgical performance using the Objective Structured Assessment of Technical Skills instrument after every case. Faculty compliance was analyzed with respect to the influence of the resident or surgical case characteristics. Faculty and residents completed surveys about the value of the case-by-case ratings. RESULTS: Faculty members used the Objective Structured Assessment of Technical Skills instrument 36% of the time (range, 26%-60%). Faculty member compliance did not vary according to resident or surgical case characteristics. Faculty members did not think the forms had much impact on whether they gave feedback. Residents thought the opportunity to read their ratings was helpful. CONCLUSION: Faculty member compliance with case-by-case surgical performance evaluation of the residents was low.

Adolescent pelvic pain.

Chronic pelvic pain is a frequent complaint in adolescent females. It is a complex disorder with multiple causes. The assessment must attempt to differentiate between gynaecological and non-gynaecological sources of pain. An understanding of the physical, cognitive and environmental factors associated with the pain are essential. Laparoscopy has been used in the assessment of CPP but a significant number of patients will have no obvious aetiology at the time of laparoscopy. For the young patient with CPP, a multidisciplinary approach may be essential to facilitate diagnosis and management. Although the symptoms may not always be curable, management that allows the young female to obtain normal or near normal function may be possible. This chapter focuses on the various causes of pelvic pain in the adolescent female with a focus on the assessment, diagnosis and treatment of the different causes.

Laparoscopy in the pediatric and adolescent population.

The use of laparoscopy by gynecologists in treating pediatric and adolescent patients is a relatively new phenomenon. This article discusses the specialized instrumentation necessary for operating on these patients and preoperative considerations and generalized techniques unique to this population. Although laparoscopy has a myriad of uses, the main focus is on the diagnosis and treatment of pelvic pain, adnexal masses, and pelvic inflammatory disease. Incidental appendectomy in these patients is also discussed.

Vaginal foreign body: a delayed diagnosis.

BACKGROUND: To describe a case of prolonged vaginal bleeding in a prepubertal girl. Review of medical record and literature search. CASE: A 7-year-old female was referred to our pediatric and adolescent gynecologic clinic for evaluation of vaginal bleeding and ovarian cyst on ultrasonography. Her parents denied any history of trauma or sexual abuse. Initial evaluation revealed pre-pubertal luteinizing hormone and follicle stimulating hormone levels, and follow-up ultrasonography revealed normal pre-pubertal pelvic anatomy. However, a skeletal survey, which was obtained to assess for the presence of skeletal fibrous dysplasia, revealed a metal spring in the vagina. The patient ultimately underwent an exam under anesthesia and vaginoscopy with removal of 3 foreign bodies, with subsequent termination of symptoms. SUMMARY AND CONCLUSIONS: In cases of pre-pubertal vaginal bleeding, the possibility of vaginal foreign body should not be excluded despite normal sonographic imaging. If clinical suspicion for a vaginal foreign body persists, additional imaging modalities or exam under anesthesia should be considered.