Uterine Sacculation With Entrapped Placenta After Delivery.

BACKGROUND: Uterine sacculation refers to a temporary pouch or sac within the uterus that may contain the placenta or fetal parts and that may be diagnosed antepartum or after delivery. There is very limited published information about this rare condition and its management. CASES: We report two cases of uterine sacculation with entrapped placenta diagnosed immediately postpartum, managed with two different approaches. In one case, the patient underwent immediate laparotomy and placental extraction. In the second case, the patient was managed conservatively but ultimately developed signs of infection and underwent laparotomy. CONCLUSION: Uterine sacculation with entrapped placenta is a rare condition that is a potential etiology of retained placenta. Obstetric clinicians should be aware of this diagnosis and the management strategies available.

An investigation into human papillomavirus (HPV) vaccination for patients undergoing surgery for high-grade cervical or vulvar dysplasia.

Introduction: Eligibility for the human papillomavirus (HPV) vaccine now includes adults 27 through 45 years. It has not been reported how providers are addressing HPV vaccination in patients with existing preinvasive disease. Our objectives were to determine the rates at which vaccination is offered to and received by patients undergoing surgery for high-grade cervical or vulvar dysplasia. Materials and Methods: This was a single-institution retrospective cohort study including patients ages 18 through 45 years undergoing surgery for high-grade cervical or vulvar dysplasia from 10/2018 to 2/2020. Our primary outcome was the rate at which HPV vaccination was discussed at the pre- and/or post-operative visits. The secondary outcome was the rate of vaccine uptake in these individuals. Characteristics of those offered HPV vaccination were compared to those not offered vaccination. Results: Of the 115 patients included, 36 (31.3%) had HPV vaccination addressed in the perioperative setting. Thirty-two of these patients had never been vaccinated, and 21 of these (65.6%) went on to receive partial or complete HPV vaccination. Those in whom HPV vaccination was addressed were more likely to be under 27 years (RR 3.2; 95% CI 2.1-4.8) and less likely to be smokers (RR 0.5; 95% CI 0.2-0.9) or have prior excisional procedures (RR 0.3; 95% CI 0.1-0.9). The absolute rate of discussing HPV vaccination with patients improved from 26.0% within six months of vaccine age eligibility expansion, to 35.4% after six months (P = 0.32). Conclusions: Providers did not consistently address HPV vaccination among patients being treated for high-grade cervical or vulvar dysplasia despite the potential benefits. However, a high proportion of these patients are amenable to vaccination. Quality improvement initiatives are warranted to increase the rate of HPV vaccine counseling in this context.

Less is more: Abdominal closure protocol does not reduce surgical site infection after hysterectomy.

OBJECTIVES: To determine rates of surgical site infection (SSI) with and without an abdominal closure protocol for gynecologic oncology patients undergoing abdominal hysterectomy. METHODS: Consecutive patients were identified using CPT codes who underwent total abdominal hysterectomy by gynecologic oncologists at a tertiary care center from January 1, 2015 to December 31, 2019, and stratified by use of the abdominal closure protocol. Demographic, perioperative, and pathologic variables were collected. Fisher's exact and Chi squared tests were used for categorical variables, logistic regression and student t-tests for continuous variables. Multiple logistic regression was used to analyze the relationships between these variables, use of the closure protocol, and development of SSI. RESULTS: 739 patients were included over the study period (n = 393 pre-implementation, n = 346 post-implementation of the abdominal closure protocol,). Baseline demographics including ASA score, BMI, diabetes, and smoking were similar between these groups (P = 0.14-0.94). The rate of SSI within 30 days was 5.9% (23/393) in the pre-protocol group and 8.1% (28/346) under the abdominal closure protocol (P = 0.25). On univariate analysis, factors associated with SSI were BMI >40, diabetes, bowel resection, ASA score 3 or 4, hypertension, and contaminated wound class (uOR 2.31-4.09). On multivariate analysis BMI >40, diabetes, and bowel resection remained independent risk factors (aOR 2.27-2.99), with the closure protocol not achieving significance (aOR 1.43, 95% CI 0.79-2.59). There were no potentially high-risk sub-groups in whom the closing protocol showed benefit. CONCLUSION: The abdominal closure protocol in isolation did not decrease SSI in those undergoing TAH by a gynecologic oncologist.

Wound complications following vulvar excision for nonmalignant lesions.

BACKGROUND: There is a paucity of literature regarding the outcomes following vulvar excision for nonmalignant lesions. This is a common procedure among gynecologists and gynecologic oncologists, and a body of evidence is warranted to guide clinical care and future research. OBJECTIVE: This study aimed to estimate the rate of wound complications following simple vulvar excision and to identify the risk factors for these outcomes. Our secondary objectives were to determine the rates of (1) positive margins and (2) occult carcinoma in the cases of vulvar dysplasia. STUDY DESIGN: We conducted a single-institution, retrospective cohort study of the patients who underwent simple vulvar excision procedures for suspected premalignant or benign lesions between June 2016 and February 2020. Our primary outcome was the rate of composite wound complications, including wound separation or breakdown, infection, or hematoma. Our secondary outcomes were the incidence of (1) margins positive for residual dysplasia and (2) occult minimally invasive carcinoma. The Fisher exact tests and chi-squared tests were used to compare the categorical variables and logistic regression models and independent student t tests were used for continuous variables, as appropriate. Multivariate stepwise selection and multiple logistic regression was performed to evaluate the risk factors for complications and generate the odds ratios. RESULTS: Of the 338 patients included in the study, 143 (42.3%) experienced wound complication. Most of these complications were wound separation or breakdown (n=134, 39.6%), followed by infection (n=22, 6.5%), and hematoma (n=4, 1.2%). On multivariate analysis, the presence of high-grade vulvar dysplasia (adjusted odds ratio, 1.83; 95% confidence interval, 1.06-3.15), longer specimen diameter (adjusted odds ratio, 1.03; 95% confidence interval, 1.01-1.05), and lesion location on the perineum (adjusted odds ratio, 2.25; 95% confidence interval, 1.38-3.66) were independent risk factors. With high-grade vulvar dysplasia, the rate of positive margins was 50.2% (114/227) and that of occult microinvasive carcinoma was 17.2% (39/227). Notably, the primary and secondary outcomes were similar among gynecologic oncologists and gynecologists. CONCLUSION: Wound complications following vulvar excision for nonmalignant lesions are common. Select groups may benefit from anticipatory counseling and future interventional studies to prevent complication. The incidence of positive surgical margins and occult minimally invasive carcinoma is also high, reflecting the challenging nature of treating vulvar disease.

Septic arthritis of the pubic symphysis in pregnancy.

Septic arthritis of the pubic symphysis is a rare but serious entity which can be difficult to distinguish from common pregnancy-related problems. The following highlights the risk factors and clinical features of this uncommon condition and describes its diagnosis and management. The patient is a 26-year-old gravida 2 para 1 (second pregnancy that lasted >20 weeks and one prior term delivery) who presented to the labour and delivery triage unit of a tertiary care centre at 23 weeks' gestation with pelvis and hip pain. The patient had elevated inflammatory markers and Staphylococcal bacteraemia. MRI demonstrated pubic symphyseal septic arthritis and osteomyelitis. The patient underwent two fluoroscopy-guided joint aspirations; synovial fluid contained abundant neutrophils and grew colonies of methicillin-susceptible Staphylococcus aureus She then completed 6 weeks of intravenous antibiotic therapy. Repeat MRI of the pelvis at 31 weeks' gestation was favourable. The patient underwent caesarean delivery at 39 weeks' gestation without complication. Pelvic pain is common in pregnancy. However, abnormal musculoskeletal exam findings, historical elements and elevated inflammatory markers may suggest septic arthritis or osteomyelitis of the pubic symphysis. Accurate microbial identification, aggressive source control and multidisciplinary treatment are essential to optimal maternal and pregnancy outcomes.

Practical considerations for pregnant women with diabetes and severe acute respiratory syndrome coronavirus 2 infection.

Epidemiologic data available so far suggest that individuals with diabetes, especially when not well controlled, are at a greater risk than the general population for severe acute respiratory syndrome coronavirus 2 morbidity such as acute respiratory distress syndrome, multiorgan failure, and mortality. Given the significant correlation between severity of coronavirus disease 2019 and diabetes mellitus and the lack of pregnancy-specific recommendations, we aim to provide some guidance and practical recommendations for the management of diabetes in pregnant women during the pandemic, especially for general obstetricians-gynecologists and nonobstetricians taking care of these patients.

Complete surgical resection of isolated recurrent high-grade epithelial ovarian cancer in highly selected patients without chemotherapy is associated with an excellent outcome.

The purpose of this study was to determine the outcome for patients with recurrent ovarian cancer treated with surgical resection alone. Consecutive patients were identified who had complete resection of a surgically isolated metastasis of recurrent high-grade ovarian cancer between 1/2006 and 1/2018 who did not receive adjuvant chemotherapy. Eight such patients were identified. The mean age was 54.4 yrs. (range, 46.1-62.9 yrs). Six of the 8 patients (75%) had a complete resection at initial surgery and all but one (88%) were initially treated with intraperitoneal chemotherapy. The median time from completion of primary chemotherapy to recurrence was 38.7 mo (14.4-96.4 mo). Sites of recurrence included lymph nodes (n = 2), spleen (n = 1), and peritoneal cavity (n = 5). Minimally invasive surgical techniques were used in 7 of the 8 patients. Mean progression-free survival after secondary surgery was 19.8 mo (95% CI, 15.8-N.R.) and mean overall survival was 64.8 mo (95% CI, 54.6-N.R.). With a median follow-up of 65.2 months (23.3-84.6 mo) from the secondary resection, 4 of 8 patients remain without evidence of recurrence. Only 1 of the 5 patients with peritoneal recurrence remains disease-free. All 4 patients in remission have a post-resection time longer than the time from initial treatment to the surgery for recurrence. This study finds that it may be reasonable to omit chemotherapy in highly selected patients after complete secondary surgical resection. Resection of isolated recurrences can be accomplished with minimally invasive surgery, and these patients have an excellent prognosis. Non-peritoneal recurrences may have a better prognosis after secondary surgery.