Liposomal Bupivacaine Use During Orthognathic Surgery in Cleft Lip and Palate Patients.

INTRODUCTION: Effective pain management is crucial in cleft lip and palate (CLP) patients undergoing orthognathic surgery for earlier recovery and decreased opioid reliance. Liposomal bupivacaine (Exparel) is a local anesthetic that provides extended postoperative analgesia in adult patients; however, research on its use in adolescents is limited. This study explores the efficacy of liposomal bupivacaine for postoperative pain management in adolescent CLP patients undergoing orthognathic surgery. METHODS: The authors performed a retrospective chart review at their institution between July 2020 and December 2022 to identify patients who underwent LeFort I or mandibular osteotomy. Two cohorts were compared: patients who received liposomal bupivacaine and patients who received standard pain medications alone. Outcome measures included intraoperative pain medications, length of stay, breakthrough opioid use, time to first oral intake, volume of oral intake, and opioids prescribed at discharge. RESULTS: This study included 22 patients who underwent orthognathic surgery. The liposomal bupivacaine group (n=10) demonstrated earlier and greater oral intake during hospitalization compared with controls (n=12). The most significant difference was observed in total breakthrough opioid use, with an average of 8.60 morphine milligram equivalents for liposomal bupivacaine patients compared with 35.1 morphine milligram equivalents for controls (P=0.037). CONCLUSIONS: This study provides the first analysis of liposomal bupivacaine use in adolescent CLP patients undergoing orthognathic surgery, demonstrating a significant reduction in postoperative opioid consumption compared with controls. These results may guide future studies of liposomal bupivacaine within CLP patients, potentially as a component of enhanced recovery after surgery guidelines, as well as in cost-analysis studies.

Modified technique for endobronchial blocker placement in pediatric patients undergoing thoracic surgery.

BACKGROUND: One lung ventilation (OLV) in small children can be achieved using an Arndt endobronchial blocker (AEBB), but it presents challenges. OLV during thoracic procedures provides better surgical conditions and postoperative outcomes. AIM: To report a novel technique to improve placement and repositioning of an extraluminal AEBB for OLV. MATERIAL AND METHODS: We describe how an angled wire is successfully used for extraluminal AEBB placement in pediatric thoracic procedures. DISCUSSION: Since 2017, we have successfully used this technic in over 50 infants and toddlers and overcome challenges of the classic OLV in this age group. CONCLUSIONS: The described technique allows for fast, safe, and reliable OLV while maintaining the ability to reposition the AEBB.

Airway management for neonates requiring ex utero intrapartum treatment (EXIT).

In utero congenital malformations in the fetus can occasionally lead to an obstructed airway at birth accompanied by hypoxic injury or peripartum demise, without intervention. Ex utero intrapartum treatment (EXIT) may help reduce morbidity and mortality associated with challenging airways by providing extra time on uteroplacental circulation to secure the airway. Meticulous preparation and planning are crucial for this procedure. Many different types of congenital malformations can result in a difficult airway, but there is no correlation between specific malformations and a required type of airway intervention. Based on our experience and literature review, an airway process flow diagram has been created to help assist teams in decision-making for airway intervention in a neonate during the EXIT procedure. The management of the airway in this scenario involves additional unique considerations that accompany handling a partially delivered newborn in the uterine environment. Extensive preparation and team rehearsal are essential to the success of this procedure.

Anesthetic management of acute nasal epistaxis occurring during general anesthesia.

Spontaneous epistaxis under general anesthesia is a rare untoward event. Typically, mild epistaxis occurs from a nasal airway manipulation and usually resolves spontaneously or with external pressure to the affected nares for a short period of time. In case of epistaxis that is difficult to control with pressure or oxymetazoline, thorough evaluation should be considered. We present a case of a 12-year-old experiencing spontaneous nasal bleeding upon emergence difficult to control with noninvasive methods and required intervention by otolaryngology.

Higher Fresh Gas Flow Rates Decrease Tidal Volume During Pressure Control Ventilation.

BACKGROUND: We observed that increasing fresh gas flow (FGF) decreased exhaled tidal volume (VT) during pressure control ventilation (PCV). A literature search produced no such description whereby unintended VT changes occur with FGF changes during PCV. METHODS: To model an infant's lungs, 1 lung of a mechanical lung model (Dual Adult TTL 1600; Michigan Instruments, Inc, Grand Rapids, MI) was set at a compliance of 0.0068 L/cm H2O. An Rp50 resistor (27.2 cm H2O/L/s at 15 L/min) simulated normal bronchial resistance. The simulated lung was connected to a pediatric breathing circuit via a 3.5-mm cuffed endotracheal tube. A ventilator with PCV capability (Model 7900; Aestiva, GE Healthcare, Madison, WI) measured exhaled VT, and a flow monitor (NICO; Respironics, Murraysville, PA) measured peak inspiratory flow, positive end-expiratory pressure (PEEP), and peak inspiratory pressure. In PCV mode, exhaled VT displayed by the ventilator at FGF rates of 1, 6, 10, and 15 L/min was manually recorded across multiple ventilator settings. This protocol was repeated for the Avance CS2 anesthesia machine (GE Healthcare). RESULTS: For the Aestiva, higher FGF rates in PCV mode decreased exhaled VT. Exhaled VT for FGFs of 1, 6, 10, and 15 L/min were on average 48, 34.9, 16.5, and 10 mL, respectively, at ventilator settings of inspiratory pressure of 10 cm H2O, PEEP of 0 cm H2O, and respiratory rate of 20 breaths/min. This is a decrease by up to 27%, 65.6%, and 79.2% when FGFs of 6, 10, and 15 L/min are compared with a FGF of 1 L/min, respectively. In the GE Avance CS2 at the same ventilator settings, VT for FGF rates of 1, 6, 10, and 15 L/min were on average 46, 43, 40.4, and 39.7 mL, respectively. The FGF effect on VT was not as pronounced with the GE Avance CS2 as with the GE Aestiva. CONCLUSIONS: FGF has a significant effect on VT during PCV in the Aestiva bellows ventilator, suggesting caution when changing FGF during PCV in infants. Our hypothesis is that at higher FGF rates, an inadvertent PEEP is developed by the flow resistance of the ventilator relief valve that is not recognized by the ventilator. In turn, less change in pressure is needed to reach the set inspiratory pressure, resulting in lower VT delivery at higher FGF rates. This underappreciated FGF-VT interaction during PCV with a bellows ventilator may be clinically significant in pediatric patients; prospective data collection in patients is needed for further evaluation.

Hemolysis, Elevated Liver Enzymes and Low Platelet Count Syndrome Complicated by Disseminated Intravascular Coagulation and Posterior Reversible Encephalopathy Syndrome: A Case Report.

A 22-year-old pregnant woman was transferred from an external medical facility after experiencing an eclamptic seizure linked to hemolysis, elevated liver enzymes and low platelet count syndrome (HELLP) syndrome, and posterior reversible encephalopathy syndrome (PRES). Her situation was further complicated by intrauterine fetal demise and disseminated intravascular coagulation, necessitating a comprehensive multidisciplinary approach. This report details the diagnostic process and challenges in managing this complex patient with diverse medical requirements. Emphasis is placed on the observed hemostatic abnormalities, and we delineate the nuances in our approach compared to managing a similar condition in a nonpregnant patient. Heightened awareness among healthcare professionals is imperative for prompt diagnosis and effective intervention in such uncommon neurological complications during pregnancy.

Role of Platelet-Rich Plasma in Genitourinary Syndrome of Menopause.

The genitourinary syndrome of menopause (GSM) encompasses a range of symptoms linked to the genitourinary tract stemming from the reduction in estrogen levels following menopause. These symptoms may endure throughout a woman's lifetime. Platelet-rich plasma (PRP), known for its capacity to induce angiogenesis and the restoration effects of growth factors, has been widely employed in various disorders, including GSM. This article aims to comprehensively review the existing literature on the utilization of PRP for managing GSM. The search was executed in electronic databases, specifically PubMed, Scopus, and Google Scholar, up until April 2023. Eligible studies were meticulously chosen for inclusion in this systematic review. PRP emerges as a viable alternative for addressing vaginal atrophy, exhibiting favorable outcomes. Notably, it can be considered for patients with contraindications to hormonal therapy. However, the available body of evidence supporting the use of PRP for GSM remains limited. PRP presents itself as a promising agent, offering a patient-friendly, cost-effective alternative modality. To establish the efficacy of PRP in treating GSM definitively, future randomized trials are imperative.

The Role of Dydrogesterone in the Management of Luteal Phase Defect: A Comprehensive Review.

The luteal phase of the menstrual cycle is a pivotal period characterized by hormonal intricacies that lay the foundation for successful embryo implantation and early pregnancy development. Luteal phase defect (LPD), marked by abnormalities in luteal function, presents challenges that can impede reproductive outcomes. This comprehensive review article explores the role of dydrogesterone in LPD management, elucidating its mechanisms of action, evidence of efficacy, safety profile, and potential in combination therapies. Dydrogesterone, a synthetic progestogen, closely mirrors natural progesterone's actions, effectively supplementing the luteal phase and enhancing endometrial receptivity. Clinical studies demonstrate improved pregnancy rates, extended luteal phase support, and enhanced reproductive outcomes with dydrogesterone supplementation. Its favorable safety profile, minimal side effects, and reduced risk of unwanted hormonal effects contribute to its appeal. Furthermore, dydrogesterone's inclusion in international guidelines solidifies its importance in LPD management. Combination therapies, leveraging synergistic effects, offer a comprehensive approach. As gaps in knowledge persist, future research directions and personalized treatment strategies pave the way for a future where dydrogesterone stands as a beacon of hope in conquering the challenges of LPD and achieving successful reproductive outcomes.

Pregnancy in Women With Cerebral Palsy.

Cerebral palsy is a permanent, non-progressive, irreversible, non-curable condition with high co-morbidities and lifelong complications. Brain lesions may be present at birth or shortly after that. It may be congenital or acquired, prenatal, or abnormal brain development. The damage to the brain is non-progressive. It mainly affects movement, coordination, strength, and posture. Cerebral palsy is believed to increase women's chance of unfavorable pregnancy outcomes. According to studies, the main outcome of cerebral palsy in pregnant women is premature birth. Secondary outcomes like LSCS, labor induction, low 5-minute APGAR, small for gestational age (SGA), large for gestational age (LGA), and stillbirth point to the necessity for increased surveillance during prenatal treatment. A 27-year-old primigravida with a known case of dystonic Cerebral palsy since childhood presented with a history of nine months of amenorrhea, pain in the abdomen, and backache for one day. Per abdominal examination, the uterus was 34 weeks in size with Breech presentation, mild contractions were present, and a fetal heart rate of 146 beats per minute, which was regular. On per-vaginal examination cervical os was one finger loose, the show was present. The patient underwent a planned Lower segment caesarean section after neuro physician and anesthesiologist clearance and delivered a healthy female baby of 2.4 kg. Both mother and baby were stable.

Aesthetic Gynaecology: What Women Want?

The demand for aesthetic gynecology is growing among patients and medical professionals. It is becoming a field of increasing interest. In obstetrics and gynecology, there are currently few superspecialization or fellowship training programs that teach this subject; nevertheless, improvements have been made in aesthetic and plastic surgery training that foresee the need to add specialized training in this sector. In the US and the UK, numerous reputable certification and preceptorship programs are now where many surgeons start their careers. To give physicians interested in surgical and non-surgical therapies certification training, new programs were introduced globally in 2016-2017. We provide an overview of both surgical and non-surgical "aesthetic gynecology" treatments, as well as the opinions of the top gynecologic associations on this new field of study.

Impetigo Herpetiformis Complicating Pregnancy: A Case Report on a Rare Gestational Dermatosis With Constitutional Symptoms.

Impetigo herpetiformis (IH) is a rare dermatosis that can manifest during the last trimester of pregnancy. It has the potential to cause fatality to both the mother and the fetus. After birth, it often vanishes spontaneously and rapidly. Clinically and histologically, it resembles pustular psoriasis, leading some authors to call it "the pustular psoriasis of pregnancy." Steroids were previously the treatment of choice, but treatment remains challenging. A dermatologist with experience in skin conditions during pregnancy should assess any generalized pustular psoriasis instances. There is a danger of stillbirth when a systemic sickness develops, so both the mother and fetus should be properly watched. A well-known side effect of pregnancy-related generalized pustular psoriasis is maternal sepsis. We report our own experience with a case of a 26-year-old pregnant woman who presented with IH that resolved postpartum.

Cervical Intraepithelial Neoplasia Grade 3 in the Third Trimester of Pregnancy: A Case Report.

The incidence of malignancies during pregnancy has been on the rise in the recent years, primarily due to an increase in older age pregnancies. This poses a significant risk to both the mother and the developing fetus. We present the case of a 29-year-old woman who experienced intermittent vaginal bleeding during her pregnancy. In the last trimester, the patient presented with abnormal vaginal bleeding and abdominal pain. The gestational age was 37.6 weeks. Notably, to our knowledge, there have been no reported cases of grade 3 cervical intraepithelial neoplasia in the third trimester.

Genitourinary Syndrome of Menopause: A Narrative Review Focusing on Its Effects on the Sexual Health and Quality of Life of Women.

Genitourinary syndrome of menopause (GSM) is a progressive condition due to a hypoestrogenic state affecting perimenopausal and menopausal women. GSM was previously known as urogenital syndrome, vulvovaginal atrophy, or atrophic vaginitis. The term vulvovaginal atrophy did not encompass the symptoms of the urinary tract like incontinence, urgency, and discomfort, or allude that it is due to a hypoestrogenic state. Although a significant segment of the population is affected by GSM, it is very sparsely studied, detected, and treated. GSM affects the quality of life and sexual health of most menopausal women suffering from it. Only a few healthcare providers ask about the symptoms of GSM and a tiny percentage of women seek consultation for it. This may be because they are either embarrassed or believe it to be a part of the natural process of aging. As the life expectancy of women has increased in general, the prevalence of GSM has also risen, while it still remains underdiagnosed and untreated. Properly educating women so that they can seek consultation regarding symptoms of GSM, and training healthcare professionals about communicating with the patient, as well as correctly identifying, diagnosing, and managing the patient are all important to overcome this communication barrier. Once we cross the barrier of diagnosing patients with GSM, we still have to manage the patients with tailor-made prescriptions according to the severity of the symptoms and their preferences. While there are various treatment options, the most effective one is low-dose topical estrogen therapy. In this review, we intend to explore the existing knowledge about GSM and its effect on the quality of life and sexual health of women along with the treatment options for managing and reversing the effects of GSM.

Post-ovulatory Hemoperitoneum in a Patient on Anticoagulation Therapy for Mitral Valve Replacement.

When a patient is receiving anticoagulant therapy, the rupture of a corpus luteum cyst may go unrecognized in healthy women but becomes clinically relevant as it might exacerbate a hemoperitoneum episode. This report describes the case of a 26-year-old primipara who underwent surgical treatment for a heart defect and later experienced extensive hemoperitoneum. The patient reported to the casualty with symptoms of unstable hemodynamic status such as hypotension 90/60 mmHg and tachycardia 120 beats/minute. A multidisciplinary team decided upon surgical management after stabilizing the coagulation profile and correcting the shock with blood and blood products. The reason was discovered to be a ruptured cyst wall, which was fixed electrosurgically. The patient had a full recovery with no postoperative complications. The most noteworthy aspect of this case was the catastrophic hemoperitoneum caused by improper anticoagulant treatment monitoring. Management of such cases depends on the age of the patient, fertility, and calculating the long-term prognosis of the anticoagulation therapy for the patient.

Unicornuate Uterus and Rudimentary Horn: An Unusual Cause of Recurrent Fetal Malpresentation Identified During a Scheduled Cesarean Delivery.

This case report presents a unique clinical scenario involving a 32-year-old woman with a unicornuate uterus and a rudimentary horn, leading to recurrent fetal malpresentation. The patient, gravida 3, para 1, presented at 36 weeks of gestational age with contractions and vaginal bleeding. Clinical evaluation revealed a breech presentation and nonreassuring fetal heart tracings. An emergency cesarean section was performed, during which a unicornuate uterus with a rudimentary horn was identified and fused to the main uterine cavity on the left posterior aspect. The rudimentary horn bore a functional left tube and ovary. The surgical procedure was successful, resulting in the delivery of a healthy baby girl. This case underscores the importance of meticulous preoperative assessment, multidisciplinary collaboration, and informed consent in managing complex uterine anomalies to ensure optimal maternal and fetal outcomes.

Echinococcal Disease of the Fallopian Tube as a Rare Cause of Primary Subfertility.

Echinococcosis is a significant zoonotic infection caused by Echinococcus granulosus, which has a worldwide distribution. In India, the annual incidence varies from one to 200 in 100,000 people. The liver and lungs are often affected, making diagnosis difficult when infections occur in uncommon areas. We report a case of a hydatid cyst in the fallopian tube, which presented as subfertility and was confirmed by radiological imaging.

A Case of Chemical Pregnancy in a Female With Turner Syndrome.

Turner syndrome (TS) is a genetic anomaly that is characterized by the absence of an X chromosome, either completely or partially. Primary amenorrhea, short stature, webbed neck, cubitus valgus, and a little intellectual disability are some of the characteristics. Infertility is also one of the most common clinical symptoms of TS-affected females. With the advent of assisted reproductive technology (ART), chances of childbearing possibilities for TS females have risen. Infertility issues in females with TS are challenging, but they can be managed with proper counseling and ART by artificial implantation, oocyte donation, and others. This case report aims to present the case of a 27-year-old female who had not attained her menarche and wanted to conceive. She was diagnosed with TS on the basis of clinical and laboratory investigations. The patient was, thereafter, treated for infertility by oocyte donation and conceived successfully.

Maternal Hyperhomocysteinemia as a Predictor of Placenta-Mediated Pregnancy Complications: A Two-Year Novel Study.

Background Placenta-mediated pregnancy complications (PMPCs) are a significant contributor to adverse maternal and fetal outcomes. Though the exact cause of the array of pregnancy-related vascular disorders is still unknown, increased maternal serum homocysteine (Hct) levels have been linked to the pathophysiology. Hyperhomocysteinemia (HHct) has been strongly linked with the risk of developing PMPCs such as preeclampsia (PE), fetal growth restriction (FGR), intrauterine fetal death (IUFD), preterm births and placental abruption. Methodology The present observational study was carried out on 810 low-risk antenatal women in their early second trimester (13-20 weeks gestation age) in the department of obstetrics and gynecology of a tertiary care rural hospital to identify the significance of abnormally raised maternal serum Hct level in developing PMPCs. Results Of the 810 participants studied, 224 (27.65%) had raised Hct levels whereas the rest of the 586 (72.35%) participants had normal Hct levels. The mean Hct level of raised homocysteine group (18.59 ± 2.46 micromol/L) was substantially raised than the normal Hct group (8.64 ± 3.1 micromol/L). It was observed that women with elevated serum Hct levels developed PMPCs significantly more than women with normal serum Hct levels (p-value <0.05). Among HHct subjects, 65.18% developed PE, 34.38% had FGR, 28.13% had a preterm delivery, 4.02% had abruptio placentae and 3.57% had IUFD. Conclusions The focus of the current study is on an easy and quick intervention such as assessing the often-ignored levels of Hct during pregnancy that can help predict and prevent PMPCs. It also highlights the necessity for well-thought-out large-scale studies and trials to further examine the phenomena, as pregnancy may be the only time when rural women will have the opportunity to receive advice and to be tested for HHct.

Hysteroscopy as a Therapeutic Tool: A Vision to Spare the Uterus in Premenopausal Abnormal Uterine Bleeding (AUB)/Heavy Menstrual Bleeding (HMB), an Update.

Heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB) is a common cause of gynecological complaints in perimenopausal women. The treatment chosen by most of the women having HMB/AUB in the perimenopausal age group when medical therapy fails is hysterectomy, which unfortunately has significant issues related to safety and long-term quality of life apart from being a burden on the health care system and cost to patients. Minimal access surgical techniques like hysteroscopic targeted therapies are available which are conservative and spare the uterus and major surgery and its complications and sequelae. Hysteroscopic management of HMB is a minimally invasive and targeted approach in diagnosing and treating the pathological lesions causing the symptoms and not radical like hysterectomy which has more chances of occurrence of adverse events both intra and postoperatively. In terms of health-related quality of life, women suffering from HMB who underwent a hysteroscopic conservative approach had better scores when compared to those with hysterectomy. The present review aims to review the evidence generated to compare the two surgical modalities, hysteroscopic targeted therapy and hysterectomy, in terms of their effectiveness, safety, and effect on the quality of life of these perimenopausal women having HMB/AUB.

Massive Pyometra Due to Senile Endometritis in a Postmenopausal Woman: A Rare Entity.

An 83-year-old postmenopausal female P5L5 (all full-term normal deliveries) presented with complaints of foul-smelling purulent discharge per vagina for 15 days associated with pain in abdomen. A midline mass was palpable per abdomen in the suprapubic region corresponding to 16 weeks size gravid uterus, which was soft to firm in consistency. On examination per vaginum, the atrophied cervix was found flush with the vagina and purulent discharge was seen draining through the cervix. Blood reports showed raised total leucocyte count with granulocyte predominance. Abdominal ultrasonography revealed a uterine cavity filled with echogenic contents, with no abdominal cavity collection. The patient was started on IV antibiotics and planned for dilatation and curettage. On histopathology acute on chronic senile endometritis was found with no evidence of malignant cells. Tuberculosis gene testing was found to be negative. We conclude that the senile endometritis leading to cervical stenosis as seen during dilatation and curettage had led to the pyometra and no evidence of malignancy was found.