Faculty Bibliography

Background: Cervical pregnancy (CP) is a rare form of ectopic pregnancy. Profuse and uncontrolled bleeding remains a concern when treating CP. Although many therapeutic approaches have been proposed with various outcomes, however, the optimal treatment of CP remains elusive. Case: Two patients diagnosed with CP were successfully treated with a novel multimodal therapy.
Result(s): After uterine artery embolization, intracervical vasopressin infiltration, bilateral cervical stay suture placement, and suction dilation and curettage (D&C), both CPs had a complete resolution with negligible blood loss.
Conclusion(s): The use of multimodal therapy for the treatment of CP is safe and effective. This treatment approach significantly reduces blood loss during suction D&C and can be used as a planned elective outpatient procedure.

The increase in the cesarean delivery (CD) rate, from 5% in 1970 to 32% in 2015, has been associated with an increase in cesarean scar pregnancies (CSP) approximately 1 in 1,800-2,500 pregnancies complicated by previous cesarean deliveries (CD). There is currently no consensus on the optimal management of CSP or recurrent CSP. We describe the case of a 35-year-old G7P2042 with two prior CD and four prior CSP with positive fetal heart activity, all treated with intra-gestational injection of methotrexate, in conjunction with the practice of favoring termination of CSP. Transabdominal and transvaginal ultrasound was used to perform serial 2D and 3D renderings. A live CSP was diagnosed on initial scan at 6 4/7 weeks as a gestational sac was noted to be at the cesarean scar niche with a mostly posterior placenta previa wrapping anteriorly to the level of the bladder. By 9 4/7 weeks the placenta had multiple lacunae and hypervascularity therefore a morbidly adherent placenta (MAP) was diagnosed. A placenta percreta was diagnosed by 17 5/7 weeks. An MRI was performed at 32 2/7 weeks with an impression of placenta previa with increta. Outpatient betamethasone course was given 48 hours prior to scheduled cesarean hysterectomy at 34 0/7 weeks. The pathology confirmed a MAP, placenta percreta. The details of this case highlight that although CSP is a rare pregnancy complication of CD, its frequency is mirroring the increasing CD rates. Cases of recurrent CSP are even more infrequent, and a fifth repeat has not been previously described and adds more to the mounting data that CSP is a precursor to MAP. Additionally, this case displays how the counseling of CSP has shifted over time; indicating that patients with CSP can be offered continuation of pregnancy with understanding the maternal risks, including uterine rupture and cesarean hysterectomy for MAP.

Background: The optimal management of intrauterine fluid accumulation in postmenopausal women with cervical stenosis is currently debatable. Diagnostic challenge still remains, because of the low accuracy of sonographic histologic prediction. Case: In the case described, an asymptomatic postmenopausal woman was found to have an echogenic endometrial fluid collection on pelvic ultrasound, suspicious for uterine malignancy. Results: After a failed attempt at endometrial sampling secondary to cervical stenosis, the patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The fluid-filled endometrial cavity was found to have extensive benign squamous differentiation. Conclusions: Extensive endometrial squamous metaplasia should be considered as a rare differential diagnosis when postmenopausal women are found to have echogenic intrauterine fluid collections on ultrasound. Mary Ann Liebert, Inc

Background: Complete separation of the vaginal vault from the uterus is a rare complication of cesarean delivery, requiring assistance with a vaginal hand. Case: A 24-year-old nulliparous woman at 40 weeks plus 3 days of gestation experienced arrest of the second stage of labor, and a vaginal hand was required during cesarean delivery to disimpact a deeply engaged fetal head. Results: Following delivery, complete detachment of the vaginal vault from the cervix was noted without disruption of the uterine vessels. Normal anatomy was surgically restored without complications. The neonate was treated for respiratory distress, and examined for sepsis and hyperbilirubinemia, requiring phototherapy. He was discharged 6 days and was healthy at a 2-week follow-up. Conclusions: Complete separation of the uterus and vaginal vault is a previously unknown complication resulting from elevation of an impacted fetal head vaginally. Simple reattachment of the uterus to the vaginal cuff represents a reasonable alternative to peripartum hysterectomy. 2013, Mary Ann Liebert, Inc

Study Objective: To evaluate the clinical value of office endometrial Pipelle biopsy (Embx) for detection of premalignant and malignant lesions in the presence of an endometrial polyp. Design: A retrospective study. Setting: A tertiary care academic hospital. Patients: 335 patients with a preoperative Embx and subsequent hysteroscopy (HSC), dilation and curettage (D&C), with or without polypectomy. Intervention: The accuracy of Embx was compared between the study group (with visible polyps on hysteroscopy) and control group (without visible polyps on hysteroscopy). Measurements and Main Results: Using final pathology (D&C +/- polypectomy specimen) as the gold standard, the accuracy of Embx was compared between the study (n = 217) and control groups (n = 118). After excluding all patients with an insufficient sample, results suggest improved sensitivity of Embx in detecting premalignant and malignant lesions in the absence of an endometrial polyp (control group 57% vs study group 36%, p = 0.314). Specificity, positive predictive value, and negative predictive value were comparable for both groups (96% vs 98%, 67% vs 69%, 94% vs 91%, respectively, p value not significant). Notably, discordance between Embx and final pathology was 13% for both groups and, of these cases, 71% in the control group and 84% in the study group had upgraded lesions on final pathology. Insufficient sampling by either Embx or D&C occurred significantly more frequently in postmenopausal women. Finally, Embx detected only 40% of premalignant and malignant lesions confined to polyps. Conclusion: The presence of an endometrial polyp may decrease the detection of premalignant and malignant endometrial lesions with Pipelle biopsy; further studies with a larger sample size are necessary to demonstrate statistical significance. Given the rates of discordance and upgraded lesions, endometrial Pipelle biopsy should not be used solely for counseling patients who desire conservative management

Abnormal uterine bleeding is one of the most common presenting complaints encountered in a gynecologist's office or primary care setting. The availability of diagnostic tools, such as ultrasound, endometrial sampling, and diagnostic hysteroscopy has made it possible to promptly diagnose and treat an increasing number of menstrual disorders in an office setting. The incorporation of newer medical therapies: antifibrinolytic drugs, shorter hormone-free interval oral contraceptive pills, and levonorgestrel inserts along with office minimally invasive treatments operative hysteroscopy and endometrial ablations have proven to be powerful therapeutic arsenals to provide short-term relief of abnormal uterine bleeding, and potentially, avoiding or delaying the hysterectomy.

Objective. To evaluate the efficacy of tranexamic acid in the treatment of idiopathic and non-functional heavy menstrual bleeding. Design. Systematic review. Population. Women with a diagnosis of idiopathic and non-functional heavy menstrual bleeding treated with tranexamic acid. Methods. Electronic searches were conducted in literature databases up to February 2011 by two independent reviewers. We included all trials involving the efficacy of tranexamic acid for the treatment of heavy uterine bleeding. Pregnant, postmenopausal and cancer patients were excluded. Main outcome measures. Effect of tranexamic acid treatment on objective reduction of menstrual bleeding and improvement in patient quality of life. Results. A total of 10 studies met our inclusion criteria. Available evidence indicates that tranexamic acid therapy in women with idiopathic menorrhagia resulted in 34-54% reduction in menstrual blood loss. Following tranexamic acid treatment, patient's quality-of-life parameters improved by 46-83%, compared with 15-45% for norethisterone treatment. When compared with placebo, tranexamic acid use significantly decreased the blood loss by 70% in women with menorrhagia secondary to an intrauterine device (p<0.001). Limited evidence indicated potential benefit in fibroid patients with menorrhagia. No thromboembolic event was reported in all studies analyzed. Conclusions. Available evidence indicates that tranexamic acid treatment is effective and safe, and could potentially improve quality of life of patients presenting with idiopathic and non-functional heavy menstrual bleeding. Data on the therapeutic efficacy of tranexamic acid in patients with symptomatic fibroids are limited, and further studies are therefore needed.