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

Abdominal myomectomies can be associated with a large amount of blood loss due to the vascular nature of fibroids. Laparoscopic management of fibroids is a difficult task in minimally invasive surgery given the extensive amount of suturing typically involved. The advantages of robotic surgery, including increased precision and fine motor coordination as well as excellent suturing capabilities, have led to its increased use in myomectomies. In comparision to conventional laparotomy, studies have shown reduced blood loss, complication rates, and length of stay with robotic myomectomies. This video demonstrates the improved precision in the enucleation of a myoma with attention to preserving fertility and the advantage of using monopolar and bipolar energy together to decrease blood loss. The ease of laparoscopic suturing shown in this robotic myomectomy due to increased fine motor coordination demonstrates a key advantage in robotic surgery in comparision to conventional laparoscopy

Minimally invasive surgery has been shown to decrease length of hospital stay, time to recovery, and postoperative pain scores. There has been a tremendous rise in the use of robotic surgery for high-precision surgeries, including gynecologic surgery for benign disease. It has been reported that one in nine women will eventually have a hysterectomy for benign indications, including symptomatic fibroids, adenomyosis, lower pelvic pain, and abnormal bleeding. Several studies have suggested advantages of robotic surgery over conventional laparotomy and laparoscopy regarding visualization, improved ergonomics, and fine motor coordination, although long-term patient outcomes have yet to be determined. This video explores the feasibility of robotic hysterectomy and the advantage of using monopolar and bipolar energy together with increased precision during dissection. In addition, we will show several conditions, including extensive pelvic adhesions and large uterine size, that can make a robotic hysterectomy more challenging

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