Rates of Maori women receiving surgical treatment for urinary incontinence and pelvic organ prolapse in Southern District Health Board.

AIMS: Pelvic organ prolapse (POP) and urinary incontinence (UI) are common gynaecological conditions that are amenable to surgical management. The prevalence of these conditions has not been well studied in the New Zealand population, but limited evidence suggests that Maori women are likely to have a higher prevalence of POP and UI than non-Maori women. The aim of this study was to formally document the rate of access to these surgical procedures for Maori and non-Maori women in the area served by Southern District Health Board (SDHB). METHODS: A retrospective descriptive study of women who underwent surgical management for POP and/or UI at SDHB facilities between 2015 and 2019 was performed. RESULTS: Unadjusted results suggested that there was a difference in the accessibility of operations for Maori and non-Maori. However, standardisation for the difference in the age structures of the two populations showed that Maori and non-Maori women access gynaecological surgery for POP and UI at very similar rates. CONCLUSIONS: We have documented that the standardised rates for Maori and non-Maori women accessing POP and UI surgery are similar in SDHB. Owing to the likely greater prevalence of these conditions in Maori women, the near equality of standardised rates of surgical intervention is likely to represent an inequity of access for Maori women.

Oral Riboflavin to Assess Ureteral Patency During Cystoscopy: A Randomized Clinical Trial.

OBJECTIVE: To evaluate whether oral riboflavin is more effective than placebo as a marker of ureteric patency at cystoscopy. METHODS: Patients scheduled for gynecologic surgery where cystoscopy was a planned component of the procedure were randomized to receive riboflavin 400 mg or placebo orally the night before surgery. During cystoscopy, the operating surgeon visualized ureteric jets and video recorded the cystoscopy portion of the procedure. The primary outcome was to determine whether orally administered riboflavin produced stronger yellow color of urine seen on cystoscopy than placebo on a 3-point scale. Secondary outcomes were to assess whether riboflavin administration improved ease of identifying ureteric jets (5-point scale) and whether a greater proportion of patients had both ureteric jets visualized with riboflavin compared with placebo. A sample size of 33 per group was planned. RESULTS: From June 28, 2017, to February 19, 2018, 72 women were screened and 66 were randomized, with 33 patients in each study group. The groups were similar in age, weight, body mass index, and ethnicity. The patients in the riboflavin group had significant increase of yellow-colored urine as rated by the operating surgeon, with a median of 2 compared with 1 on a 3-point scale (P<.001). The ureteral jets were more easily visualized in the riboflavin group as rated by the operating surgeon, with a median of 5 compared with 4 on a 5-point scale (P<.013). Bilateral ureteral patency was confirmed in 30 of 33 women (91%) in the riboflavin group and in 28 of 33 women (85%) in the placebo group (P=.71). CONCLUSIONS: The administration of riboflavin before gynecologic surgery improves the ease of visualizing the ureteric jets by inducing yellow coloration of the urine. CLINICAL TRIALS REGISTRATION: Australian New Zealand Clinical Trials Registry, 12616001367437.

Patient-targeted Googling and social media: a cross-sectional study of senior medical students.

BACKGROUND: Social media and Internet technologies present several emerging and ill-explored issues for a modern healthcare workforce. One issue is patient-targeted Googling (PTG), which involves a healthcare professional using a social networking site (SNS) or publicly available search engine to find patient information online. The study's aim was to address a deficit in data and knowledge regarding PTG, and to investigate medical student use of SNSs due to a close association with PTG. METHOD: The authors surveyed final year medical students at the Otago Medical School, University of Otago in January 2016. A subset completed focus groups that were analysed using thematic analysis to identify key themes relating to students' attitudes towards PTG, and reasons why they might engage in PTG. RESULTS: Fifty-four students completed the survey (response rate = 65.1%), which showed that PTG was uncommon (n = 9, 16.7%). Attitudes were varied and context dependent. Most participants saw problems with PTG and favoured more explicit guidance on the issue (n = 29, 53.7%). SNS usage was high (n = 51, 94.4%); participants were concerned by the content of their SNS profiles and who they were connecting with online. Participants showing high SNS use were 1.83 times more likely to have conducted PTG than lower use groups. CONCLUSIONS: The diverse attitudes uncovered in this study indicated that teaching or guidelines could be useful to healthcare professionals considering PTG. Though ethically problematic, PTG may be important to patient care and safety. The decision to conduct PTG should be made with consideration of ethical principles and the intended use of the information.

Using Three-Dimensional Printing to Fabricate a Tubing Connector for Dilation and Evacuation.

BACKGROUND: This is a proof-of-concept study to show that simple instrumentation problems encountered in surgery can be solved by fabricating devices using a three-dimensional printer. The device used in the study is a simple tubing connector fashioned to connect two segments of suction tubing used in a surgical procedure where no commercially available product for this use is available through our usual suppliers in New Zealand. MATERIALS AND METHODS: A cylindrical tubing connector was designed using three-dimensional printing design software. The tubing connector was fabricated using the Makerbot Replicator 2X three-dimensional printer. The connector was used in 15 second-trimester dilation and evacuation procedures. Data forms were completed by the primary operating surgeon. Descriptive statistics were used with the expectation that the device would function as intended in all cases. EXPERIENCE: The three-dimensional printed tubing connector functioned as intended in all 15 instances. CONCLUSION: Commercially available three-dimensional printing technology can be used to overcome simple instrumentation problems encountered during gynecologic surgical procedures.

Uterine Scar Dehiscence Associated with Misoprostol Cervical Priming for Surgical Abortion: A Case Report.

BACKGROUND: Cervical priming prior to pregnancy termination is a common treatment. Both osmotic agents such as laminaria and Dilapan or pharmacologic agents such as misoprostol and mifepristone have been used for this purpose. CASE: A 30-year-old patient with a previous cesarean delivery was undergoing surgical termination of pregnancy at 13 weeks' gestation for a lethal fetal malformation. During preoperative cervical priming with misoprostol the uterine scar dehisced. Interval laparoscopic repair was performed. CONCLUSION: Uterine scar dehiscence can occur with misoprostol preoperative cervical priming for second trimester surgical termination of pregnancy.

Shoulder dystocia: management and documentation.

Shoulder dystocia is an obstetric emergency that occurs when the fetal shoulders become impacted at the pelvic inlet. Management is based on performing maneuvers to alleviate this impaction. A number of protocols and training mnemonics have been developed to assist in managing shoulder dystocia when it occurs. This article reviews the evidence regarding the performance, timing, and sequence of these maneuvers; reviews the mechanism of fetal injury in relation to shoulder dystocia; and discusses issues concerning documentation of the care provided during this obstetric emergency.

Log-linear human chorionic gonadotropin elimination in cases of retained placenta percreta.

PURPOSE: To describe the human chorionic gonadotropin (hCG) elimination rate in patients with intentionally retained placenta percreta. METHODS: Medical records for cases of placenta percreta with intentional retention of the placenta were reviewed. The natural log of the hCG levels were plotted versus time and then the elimination rate equations were derived. RESULTS: The hCG elimination rate equations were log-linear in three cases individually (R (2) = 0.96-0.99) and in aggregate R (2) = 0.92). The mean half-life of hCG elimination was 146.3 h (6.1 days). CONCLUSION: The elimination of hCG in patients with intentionally retained placenta percreta is consistent with a two-compartment elimination model. The hCG elimination in retained placenta percreta is predictable in a log-linear manner that is similar to other reports of retained abnormally adherent placentae treated with or without methotrexate.

Glove perforations with blunt versus sharp surgical needles in caesarean delivery: a randomized trial.

AIMS: To compare the rate of glove perforations and surgeon satisfaction when utilizing blunt surgical needles compared to conventional sharp surgical needles. METHODS: Patients undergoing Caesarean delivery were randomly assigned to the use of blunt or sharp surgical suture needles. Surgical team members reported any known needlesticks or perforations of gloves and the primary surgeon completed a survey to gauge their satisfaction with the needles. Glove perforation was assessed by suspending gloves and filling with water. The chi-square test was used to assess categorical variables and the Mann-Whitney U-test was used to assess ordinal data. RESULTS: A total 240 patients were enrolled into the study. There was no statistically significant difference in the rate of glove perforation per case between groups assigned to sharp (24%) or blunt surgical needles (26%). (RR 1.05, 95% CI 0.68-1.63). There were significant differences in the surgeon satisfaction surveys, with surgeons in the sharp needle group being more satisfied with the tissue penetration of the needle (p < .001), needle integrity (p = .01), force to penetrate tissue (p < .001) and control of bleeding at the needle insertion site (p = .001). Surveys from surgeons in the blunt needle group showed a statistically significant improvement in the perceived safety profile of the blunt needles (p < .001) CONCLUSIONS: There was no significant difference in the rate of glove perforation between blunt and sharp surgical needles during Caesarean delivery. Overall surgeons were more satisfied with the sharp surgical needles.

Laparoscopic removal of a large ovarian mass utilizing planned trocar puncture.

BACKGROUND: Large cystic ovarian masses pose technical challenges to the laparoscopic surgeon. Removing large, potentially malignant specimens must be done with care to avoid the leakage of cyst fluid into the abdominal cavity. CASE: We present the case of a large ovarian cystic mass treated laparoscopically with intentional trocar puncture of the mass to drain and remove the mass. DISCUSSION: Large cystic ovarian masses can be removed laparoscopically with intentional trocar puncture of the mass to facilitate removal without leakage of cyst fluid.

Chronic postpartum uterine inversion treated by abdominal replacement and cerclage.

BACKGROUND: Chronic uterine inversion is a potentially dangerous condition that often requires abdominal surgical reduction of the uterine inversion. Uterine inversion can recur after successful uterine replacement. CASE: A young primagravida presented with chronic recurrent uterine inversion 5 weeks after spontaneous vaginal delivery. The uterus was replaced abdominally and an abdominal cervical cerclage was placed to prevent recurrent inversion. CONCLUSION: Abdominal cervical cerclage can be utilized after treatment of chronic recurrent uterine inversion to prevent future recurrence of uterine inversion.

Unruptured 32-week rudimentary horn pregnancy presenting as right upper quadrant pain.

BACKGROUND: An unruptured third trimester rudimentary horn pregnancy is rare, life threatening, and can go undetected until the onset of symptoms. Given the high risk of uterine rupture, conservative management after viability is controversial. CASE: A 21 year-old with a 32-week rudimentary horn pregnancy, diagnosed via exploratory laparotomy five days earlier, presented with acute right upper quadrant pain. The patient underwent cesarean delivery. The rudimentary horn was noted to be intact, but so thin it was transparent. CONCLUSION: Advanced ectopic pregnancy or rudimentary horn pregnancy should be considered in cases of unusual or undiagnosed abdominal pain in pregnancy. When surgical exploration is performed, an incision allowing optimal visualization and exposure is recommended.

Use of a Yankauer suction tip combined with the Colpo-Pneumo Occluder balloon to suction the surgical field at the vaginal cuff during robotic hysterectomy.

A 39-year-old patient with complex endometrial hyperplasia without atypia underwent robotic total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The procedure was technically challenging because of the patient's obesity (body mass index 50 kg/m(2)). Concomitant suction of pooled blood and retraction of bowel and omentum were necessary to close the vaginal cuff. An endoscopic retractor was used through the assistant's port, and a Yankauer suction tip was placed through an inflated Colpo-Pneumo Occluder balloon in the vagina to provide directed suction to the vagina cuff. This technique enabled efficient closure of the vaginal cuff.

Dilation of the vaginal cuff using the Bakri Postpartum Balloon to extract the large uterus at the time of robotic hysterectomy for endometrial carcinoma.

Removal of large uterine specimens during robotic or total laparoscopic hysterectomy poses surgical challenges, particularly in cases performed for gynecologic malignancy. A 23-year-old patient with endometrioid adenocarcinoma of the endometrium underwent robotic total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The large uterine specimen was removed by dilating the colpotomy incision using the Bakri Postpartum Balloon™. Dilation of the colpotomy incision with the uterine tamponade balloon can allow for the intact removal of a large uterine specimen in cases of robotic or total laparoscopic hysterectomy performed for gynecologic malignancy when specimen morcellation is contraindicated.

Assessment of a simulation training exercise to teach intrauterine tamponade for the treatment of postpartum hemorrhage.

INTRODUCTION: Postpartum hemorrhage is a common complication of vaginal birth. Few midwives have experience in the performance of procedures to manage hemorrhage that fails to respond to initial management with medications and bimanual compression. METHODS: A simulation model was constructed by using a half-pelvis birth simulator and a hollowed out cantaloupe. Practicing midwives and students participated in a simulation exercise by using uterine packing and placement of a uterine tamponade balloon. Pre-exercise and post-exercise self-assessments were performed. Data were analyzed by using the Wilcoxon matched pairs signed rank test. RESULTS: A total of 25 learners participated in the training session. All 25 participants showed improvement in their self-assessed competency level for the placement of the Bakri Postpartum Balloon (P < .001), and 24 of 25 showed improvement in self-assessed competency levels for uterine packing (P < .001). DISCUSSION: An inexpensive simulation model can be used to effectively train midwives to treat postpartum hemorrhage by using methods of exerting direct pressure to the uterine cavity.

Successful pregnancy following conservative surgical therapy of an invasive molar gestation.

BACKGROUND: An invasive mole is a form of persistent trophoblastic disease. The traditional surgical treatment is hysterectomy. CASE: A young nullipara presented with a positive pregnancy test 6 months following a suction curettage for an incomplete abortion. Radiologic imaging was suspicious for intramural ectopic gestation. She was treated with methotrexate but became thrombocytopenic with failure to resolve the abnormal gestation. Surgical excision of the mass was performed. Pathologic evaluation revealed the diagnosis of invasive molar pregnancy. The beta-hCG levels remained negative for greater than a year. The patient subsequently conceived and underwent a cesarean delivery of a viable infant at 36 weeks gestation. CONCLUSION: Conservative surgical excision can successfully treat invasive molar gestation. This should be considered for patients who desire future fertility and have contraindications to medical therapy.

Vulvar abscess: a retrospective review.

Vulvar abscesses can progress to cause significant illness requiring disfiguring surgical debridement, broad spectrum antibiotics, and require hospitalization. A retrospective review of de-identified charts of 13 patients admitted for inpatient care for vulvar abscesses from 2004-2009 at West Virginia University Hospitals was conducted. Risk factors for vulvar abscess in these patients included obesity and diabetes. Body mass index (BMI) is directly proportionate to the size of the abscess and increased risk of intensive care unit admission. Most patients did not seek medical care prior to hospital admission. Polymicrobial infections were common, and methicillin resistant Staphylococcus aureus was seen in two cases. The presence of multiple risk factors increased the length of hospitalization. Clinicians should be aware of these risk factors and initiate aggressive therapy for patients with elevated BMI or multiple risk factors.

Prevalence of drug use in pregnant West Virginia patients.

INTRODUCTION: Substance abuse in pregnancy is of serious concern to society as well as health care providers caring for pregnant women and their infants. Various studies have suggested a prevalence of 10 -20%. This study used anonymous sampling of umbilical cord tissue to estimate the prevalence of substance abuse in West Virginia. METHODS: For the period of August 2009, as many umbilical cord samples as possible were collected at 8 regionally diverse hospitals in West Virginia. The cord tissue samples were then assayed for amphetamines, cocaine, opiates, marijuana, benzodiazapines, methadone, buprenorphine and alcohol. RESULTS: 146 of 759 collected (19.2%) were positive for drugs or alcohol. The regional diversity in drug and alcohol consumption was striking, as was the absence of cocaine, methamphetamine and buprenorphine. Voluntary reporting on birth certificates and other maternal questionnaires underestimated the prevalence by 2-3 fold. CONCLUSION: One in five infants born in West Virginia has a significant drug exposure that is not captured by conventional reporting instruments. It is hard to estimate the societal and financial cost since so many infants are exposed.

Diagnosis and management of a monochorionic/monoamniotic twin gestation discordant for fetal anomalies.

Monoamniotic twinning is rare and associated with fetal mortality as high as 13-32% (1). In pregnancies discordant for fetal anomalies, mortality is as high as 43% (2.3). Currently, the optimal management and timing of delivery is not clearly defined. A 28-year-old presented with a monochorionic/monoamniotic twin gestation with unexplained ascites, ventriculomegaly, and pericardial effusion of Twin B. She was admitted at 24 weeks for intensive fetal surveillance and sulindac therapy. Planned Cesarean delivery was performed at 32 weeks gestation. A favorable neonatal outcome was achieved. Aggressive inpatient surveillance and intentional preterm delivery may result in favorable outcomes in monochorionic/monoamniotic twin gestations.

Laparoscopic removal of a rudimentary uterine horn in a previously hysterectomized patient.

BACKGROUND: The unicornuate uterine anomaly is often difficult to diagnose and usually low on the list of differential diagnoses for pelvic pain and dysmenorrhea. The authors present a case of a rudimentary uterine horn as a cause for continued pelvic pain and dysmenorrhea in a previously hysterectomized woman. CASE REPORT: A 43-year-old woman, gravida 1, para 1, presented for evaluation of right lower quadrant pain of several years' duration. Her past surgical history was significant for multiple prior laparoscopies and a vaginal hysterectomy. Radiographic studies revealed a mass in the right lower quadrant. Laparoscopy revealed a solid mass in the right pelvis that was diagnosed as a rudimentary uterine horn. CONCLUSION: Uterine anomalies, although uncommon, should be thought of as part of the differential diagnosis for pelvic pain and dysmenorrhea. A thorough inspection of the pelvis should be performed at the time of any operative procedure for abdominal pain.