Common obstetrics and gynecologic topics in critical care: A narrative review.

The fields of Obstetrics and Gynecology and Critical Care often share medically and surgically complex patients. Peripartum anatomic and physiologic changes can predispose or exacerbate certain conditions and rapid action is often needed. This review discusses some of the most common conditions responsible for the admission of obstetrical and gynecological patients to the critical care unit. We will consider both obstetrical and gynecologic concepts including postpartum hemorrhage, antepartum hemorrhage, abnormal uterine bleeding, preeclampsia and eclampsia, venous thromboembolism, amniotic fluid embolism, sepsis and septic shock, obstetrical trauma, acute abdomen, malignancies, peripartum cardiomyopathy, and substance abuse. This article aims to be a primer for the Critical Care provider.

The frequency and persistence of lymphedema diagnosis and self-reported symptoms over 5 years in patients with endometrial carcinoma.

A potentially debilitating sequela of diagnosis or treatment for endometrial cancer islower limb lymphedema (LLL), which can have significant impacts on quality of life. Theobjective of this study was to determine the frequency of LLL symptoms in uterinecancer survivors over a 5-year study period. An IRB-approved prospective study of quality of life of endometrial cancer patients whounderwent surgical intervention was undertaken. The Gynecologic CancerLymphedema Questionnaire (GCLQ) was used to survey patients in 2011 and again in2016 to evaluate for symptoms of LLL.205 patients initially answered the survey, and 75 patients completed the follow upsurvey as well, with no differences in demographics between the cohorts. 90.7% ofpatients underwent lymph node dissection. Patients commonly reported symptoms ofnumbness (66.83%), aching (54.2%), and poor physical function (47.8%). On initialsurvey, 14.7% (n = 11) of patients met criteria for LLL by GCLQ criteria, with 8 patientsreporting improvement in symptoms and 3 reporting persistent diagnosis at follow up. At follow up survey, 12.0% (n = 9) patients meeting criteria five years later, with 6patients newly meeting criteria. The most persistent symptoms were poor physicalfunction (70.6%), numbness (72.5%), general swelling (55.6%), aching (64.1%), andlimb-related swelling (60%).While the rate of LLL was similar to previous reports, there were a number of newdiagnoses of LLL at interval follow up distant from surgery, up to 7 years later.Symptoms of LLL also persisted for many years after diagnosis.

Family Planning in Liver Transplant: Patient and Provider Knowledge and Practices.

Fertility is often impaired in adolescents and women with cirrhosis, but it is rapidly restored after liver transplantation (LT). Early and unplanned pregnancies confer increased risks to maternal, fetal, and graft health, underscoring the need for reproductive counseling. However, data on reproductive practices or counseling in the LT setting are limited. An anonymous online Qualtrics (Provo, UT) survey was sent to transplant patients and providers to gauge knowledge and practices surrounding contraception and pregnancy. Eligible participants included transplant patients aged 14-45 years and their transplant providers. Patient response was 50.0% (74/148), 14 of whom were pre-LT patients and 60 of whom were post-LT patients. Counseling occurred in 37% of patients prior to transplant and 82% after transplant. Most patients (86%) considered family planning a high priority in their transplant care. Contraception- and pregnancy-specific counseling was provided by LT providers in 60% and 44% of patients, respectively. The most desired mode of counseling by patients was in-person discussion with an LT provider (89%). Despite most post-LT patients receiving counseling, only 41% used contraception during the first year after LT, of whom 32% relied on high failure methods. Of the 31/43 (72.1%) provider responses, 96% voiced interest in additional reproductive education. Most providers (90%) correctly advised that patients delay pregnancy during the first year after LT, although misconceptions about safety of estrogen and intrauterine devices were selected by 53% and 42%, respectively. Some favored resources by providers were educational pamphlets in clinic (88%) and automated note templates to prompt family planning inquiry (72%). Transplant patients and providers have key deficiencies in their knowledge of contraception and corresponding practices. Most post-LT patients receive counseling, yet contraception practices are inadequate for preventing unplanned pregnancy. Discussion with transplant providers was the most favored counseling modality by patients, underscoring our critical role in optimizing post-LT reproductive care.

Severe anemia from heavy menstrual bleeding requires heightened attention.

OBJECTIVE: The objective of the study was to analyze the behaviors of women that resulted in menstrually related severe anemia (hemoglobin <5 g/dL) from a single public hospital serving indigent women. STUDY DESIGN: This was a retrospective cohort study of all women identified as having been treated at Harbor-UCLA Medical Center for excessive menstruation (International Classification of Diseases, ninth revision, codes 285.9, 6256.2) and hemoglobin values less than 5 g/dL in the 6 years from 2008 to 2013. RESULTS: Approvals were obtained from the Human Subjects and Research Committees. This search identified 271 women with those 2 diagnoses; 122 were excluded because their severe anemia had nonmenstrual causes. The remaining 149 women had 168 episodes with hemoglobin levels below 5 g/dL attributed to chronic excessive menstrual bleeding. Mean age was 41 years (range, 19-55 years). Mean body mass index was 28.9 kg/m(2) (range, 18-57 kg/m(2)); 58.2% were actively bleeding at presentation, and 90.4% reported chronic excessive blood loss. Two thirds recognized heavy bleeding that had persisted for more than 6 months without seeking help. However, 7.8% described their bleeding as normal, and 40.5% had received at least 1 previous transfusion. Mean nadir hemoglobin was 4.15 g/dL (range, 1.6-4.9 g/dL). Mean corpuscular volume was 62.2 fL (range, 47.7-99.8 fL) and mean corpuscular hemoglobin concentration was 29.2 g/dL (range, 25.7-33.6 g/dL). Nearly a quarter had reactive thrombocytosis, which might have created a hypercoagulable state. Bleeding was ultimately attributed to leiomyoma in 47.9%; cancer was detected in 4.8%. A total of 33.9% were discharged without being offered any therapy to prevent subsequent bleeding; 3.0% declined any medical therapy; 35.1% were lost to follow-up prior to receiving effective therapy; and 26.8% had multiple subsequent transfusions before seeking/receiving definitive treatments. CONCLUSION: Even when faced with potentially life-threatening anemia because of chronic, excessive menstrual blood loss, some women are not impressed with the serious nature of their problem. Women will benefit from recognizing the health consequences of chronic excessive blood loss. Chronic excessive blood loss should be treated as both an urgent and potentially recurrent problem; physicians should address this clinical concern proactively.

Asymptomatic cervical polyps: can we just let them be?

AIM: Routine polypectomy is still practiced in many settings. The objective of this study was to establish the frequency of dysplasia or malignancy found in cervical polyps from a multiyear sample after abnormal specimens performed for indication were excluded. MATERIALS & METHODS: This is a retrospective study of the pathology results from 2006-2013, inclusive. RESULTS: The study included 898 polyps from 854 nonpregnant women, after the 17 abnormal specimens from women who presented with complaints of abnormal bleeding or for evaluation of abnormal cytological tests were excluded; none of the 898 specimens showed any significant abnormalities. The results did not vary by patient age or polyp size. CONCLUSION: Routine removal of cervical polyps in asymptomatic women with current, normal cervical cytology testing is unwarranted because it adds little to their management and it has the potential to cause harm.

Mechanisms and kinetics of alkaline hydrolysis of the energetic nitroaromatic compounds 2,4,6-trinitrotoluene (TNT) and 2,4-dinitroanisole (DNAN).

The environmental impacts of energetic compounds can be minimized through the design and selection of new energetic materials with favorable fate properties. Building predictive models to inform this process, however, is difficult because of uncertainties and complexities in some major fate-determining transformation reactions such as the alkaline hydrolysis of energetic nitroaromatic compounds (NACs). Prior work on the mechanisms of the reaction between NACs and OH(-) has yielded inconsistent results. In this study, the alkaline hydrolysis of 2,4,6-trinitrotoluene (TNT) and 2,4-dinitroanisole (DNAN) was investigated with coordinated experimental kinetic measurements and molecular modeling calculations. For TNT, the results suggest reversible formation of an initial product, which is likely either a Meisenheimer complex or a TNT anion formed by abstraction of a methyl proton by OH(-). For DNAN, the results suggest that a Meisenheimer complex is an intermediate in the formation of 2,4-dinitrophenolate. Despite these advances, the remaining uncertainties in the mechanisms of these reactions-and potential variability between the hydrolysis mechanisms for different NACs-mean that it is not yet possible to generalize the results into predictive models (e.g., quantitative structure-activity relationships, QSARs) for hydrolysis of other NACs.