Large-volume hemoperitoneum and hemodynamic instability in uterine fibroid rupture: A case report.

A perimenopausal woman with a known history of fibroid uterus presented to the emergency department with the chief complaint of three weeks of intermittent abdominal pain with acute worsening for two days. The pain was described as 10/10 "tearing" peri-umbilical pain with radiation to the rectum associated with nausea. Vital signs, laboratory results, and physical examination were largely unremarkable at presentation, aside from diffuse tenderness with rebound. Computed tomography revealed a markedly enlarged uterus and large-volume hemoperitoneum and sentinel clot sign, suggesting fibroid as the source of bleeding. Upon re-examination, the patient was found to be hypotensive and tachycardic with worsening hemoglobin, worsening abdominal distension, and a positive focused assessment with sonography in trauma (FAST) exam. Although the source of bleeding was non-specific, a decision was made by the gynecology and general surgery teams to perform an emergency exploratory laparotomy. A midline vertical incision was made and four liters of blood were evacuated from the peritoneal cavity. The gynecology and general surgery teams thoroughly inspected the abdomen. A myomectomy was performed and good hemostasis was confirmed. The patient was transferred to the surgical intensive care unit, where she had an uncomplicated post-operative course. She was discharged home on postoperative day 4. Uterine fibroid rupture should be on the differential for hemoperitoneum in a patient with known fibroids and should be addressed with a timely multi-specialty approach.

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis. We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

Diversity and inclusion: the role of unconscious bias on patient care, health outcomes and the workforce in obstetrics and gynaecology.

PURPOSE OF REVIEW: Although the business world has long recognized the benefits of diversity and inclusion and the effects of unconscious bias, the discourse is just now gaining traction in the medical field. In addition, many businesses have developed key initiatives to address unconscious bias in the workplace. RECENT FINDINGS: In the medical field, diversity leads to improved health outcomes, increased access to healthcare by the underserved and more innovation. However, unconscious bias may inadvertently propagate health disparities, affect trainee evaluations, hinder faculty satisfaction and exclude populations from meaningful research. SUMMARY: In this review, we discuss diversity, inclusion and unconscious bias in obstetrics and gynaecology, as it relates to patient care, health outcomes, medical faculty and trainees. We also discuss potential interventions that mitigate these issues.

Informed consent in gynecologic surgery.

PURPOSE OF REVIEW: Informed consent is frequently used interchangeably with obtaining a signature on a form. This oversimplification shifts the value from the process of informed consent to the documentation. This review focuses on the recommended components of the consent process, barriers encountered, factors influencing patient satisfaction, attempts to improve the consent practice, and considerations in special populations. RECENT FINDINGS: The process of informed consent is key to promoting shared decision-making and patient autonomy. Several barriers exist to providing optimal consent including time constraints as well as educational, cultural, and language barriers. Innovative approaches such as audiovisual aids show promise in overcoming barriers and improving the consent process. SUMMARY: Patients seek expertise and knowledge to aid in making decisions that align with their care goals. Providers have an obligation to provide individualized and accessible counseling. Ongoing research is needed to optimize this process.

Adverse events related to Trendelenburg position during laparoscopic surgery: recommendations and review of the literature.

PURPOSE OF REVIEW: Laparoscopy is routinely performed for the treatment and management of gynaecologic disorders. During gynaecologic laparoscopy, the patient is placed in the Trendelenburg position to optimize visualization and access to the pelvis. The Trendelenburg position may result in complications in many organ systems. RECENT FINDINGS: Trendelenburg positioning may cause rare, potentially life-threatening complications of the respiratory and cardiovascular systems. Case reports of visual field loss and cognitive aberrations following Trendelenburg positioning have been published. Few intervention studies have been performed evaluating attenuation of changes in intraocular pressure and haemodynamics. SUMMARY: This review summarizes possible complications related to the Trendelenburg position and current evidence regarding interventions to minimize the risk of complications.

Bilateral Salpingectomy Using Percutaneous Minilaparoscopy.

STUDY OBJECTIVE: To show a new technique for bilateral salpingectomy using percutaneous minilaparoscopy. DESIGN: Step-by-step video demonstration and narration of the surgical procedure. SETTING: Minilaparoscopy was first described in the late 1980s and early 1990s. Since then, minilaparoscopic instruments have been successfully applied to several general surgery and gynecologic procedures, including hysterectomy. Potential benefits of minilaparoscopy compared with conventional laparoscopy include decreased tissue trauma, pain, and improved cosmesis. INTERVENTIONS: Percutaneous minilaparoscopic approach for bilateral salpingectomy. CONCLUSION: Percutaneous minilaparoscopy, in addition to conventional laparoscopy, is a feasible approach for bilateral salpingectomy.

p16 Immunohistochemistry in Colposcope-Directed and Random Cervical Biopsies of CIN2 and CIN3.

OBJECTIVE: The aim of this study was to determine if there is a different p16 expression pattern between colposcope-directed and random (colposcope-undetectable) biopsies of cervical intraepithelial neoplasia (CIN2) and CIN3. METHODS: Cervical biopsies that were positive for CIN2 or CIN3 were selected from a database of samples acquired during a large population-based clinical trial in Guangdong Province in China (Shenzhen Cervical Cancer Screening Study II). Blocks were recut, reread, and then immunostained for p16. Biopsies were categorized as either colposcope-directed or random biopsies. Diffuse staining was considered p16 positive, whereas focal or no staining was considered p16 negative. Differences were determined by the Fisher exact test. RESULTS: Among the patients with CIN3, there were 232 individual biopsies of CIN3. Sixty were randomly collected, and 172 were colposcopy directed. p16 positivity for the colposcope-directed and random biopsies was 97.7% and 91.7%, respectively (p = 0.052). Like the CIN3 biopsies, colposcope-directed and random CIN2 samples expressed p16 similarly (86.8% [46/53] and 82.6% [19/23], p = .73, respectively). CONCLUSIONS: Based on our data, even small colposcope-undetectable biopsies of CIN3 are significant. Random biopsies of CIN2 or CIN3 demonstrate similar p16 positivity as visible lesions and therefore might be expected to have a similar natural history.