Episode Of Vaginal Bleeding Research Articles

Risk factors for intensive care unit admission after cesarean hysterectomy for placenta accreta spectrum.

Placenta accreta spectrum (PAS) is a complex disorder of uterine wall disruption with significant morbidity and mortality, particularly at time of delivery. Both physician and physical hospital resource allocation/utilization remains a challenge in PAS cases including intensive care unit (ICU) beds. The primary objective of the present study was to identify preoperative risk factors for ICU admission and create an ICU admission prediction model for patient counseling and resource utilization decision making in an evidence-based manner. This was a case-control study of 145 patients at our PAS referral center undergoing cesarean hysterectomy for PAS. Final confirmation by histopathology was required for inclusion. Patient disposition after surgery (ICU vs post-anesthesia care unit) was our primary outcome and pre-/intra-/postoperative variables were obtained via electronic medical records with an emphasis on the predictive capabilities of the preoperative variables. Uni- and multivariate analysis was performed to identify independent predictive factors for ICU admission. In this large cohort of 145 patients who underwent cesarean hysterectomy for PAS, with histopathologic confirmation, 63 (43%) were admitted to the ICU following delivery. These patients were more likely to be delivered at an earlier gestational age (34 vs 35 weeks, P < 0.001), have had >2 episodes of vaginal bleeding and emergent delivery compared to patients admitted to patients with routine recovery care (44% vs 18.3%, P = 0.009). Uni- and multivariate logistic regression showed an area under the curve of 0.73 (95% CI: [0.63, 0.81], P < 0.001) for prediction of ICU admission with these three variables. Patients with all three predictors had 100% ICU admission rate. Resource prediction, utilization and allocation remains a challenge in PAS management. By identifying patients with preoperative risk factors for ICU admission, not only can patients be counseled but this resource can be requested preoperatively for staffing and utilization purposes.

Association between Antenatal Vaginal Bleeding and Adverse Perinatal Outcomes in Placenta Accreta Spectrum.

Background and Objectives: Placenta accreta spectrum (PAS) disorders are placental conditions associated with significant maternal morbidity and mortality. While antenatal vaginal bleeding in the setting of PAS is common, the implications of this on overall outcomes remain unknown. Our primary objective was to identify the implications of antenatal vaginal bleeding in the setting of suspected PAS on both maternal and fetal outcomes. Materials and Methods: We performed a case-control study of patients referred to our PAS center of excellence delivered by cesarean hysterectomy from 2012 to 2022. Subsequently, antenatal vaginal bleeding episodes were quantified, and components of maternal morbidity were assessed. A maternal composite of surgical morbidity was utilized, comprised of blood loss ≥ 2 L, transfusion ≥ 4 units of blood, intensive care unit (ICU) admission, and post-operative length of stay ≥ 4 days. Results: During the time period, 135 cases of confirmed PAS were managed by cesarean hysterectomy. A total of 61/135 (45.2%) had at least one episode of bleeding antenatally, and 36 (59%) of these had two or more bleeding episodes. Increasing episodes of antenatal vaginal bleeding were associated with emergent delivery (p < 0.01), delivery at an earlier gestational age (35 vs. 34 vs. 33 weeks, p < 0.01), and increased composite maternal morbidity (76, 84, and 94%, p = 0.03). Conclusions: Antenatal vaginal bleeding in the setting of PAS is associated with increased emergent deliveries, earlier gestational ages, and maternal composite morbidity. This important antenatal event may aid in not only counseling patients but also in the coordination of multidisciplinary teams caring for these complex patients.

Sonographic Predictors of Antepartum Bleeding in Placenta Previa.

To evaluate the association between sonographic features of placenta previa and vaginal bleeding (VB). Retrospective cohort study of women with placenta previa identified on ultrasound between 160/7 and 276/7 weeks gestation. Placental distance past the cervical os (DPO), placental thickness, edge angle, and cervical length (CL) were measured. The primary outcome was any VB and the secondary outcome was VB requiring delivery. Median values of the sonographic features were compared for each of the outcomes using the Mann-Whitney U test. Receiver operating characteristic curves were used to compare the predictive value of sonographic variables markers and to determine optimal cut points for each measurement. Logistic regression was used to estimate the association between each measure and the outcomes while controlling for confounders. Of 149 women with placenta previa, 37% had VB and 15% had VB requiring delivery. Women with VB requiring delivery had significantly more episodes of VB than those who did not require delivery for VB (1.5, interquartile range [IQR] [1-3] vs 1.0 [1-5]; p = 0.001). In univariate analysis, women with VB had decreased CL (3.9 vs. 4.2 cm; p < 0.01) compared with those without. Women with VB requiring delivery had increased DPO (2.6 cm IQR [1.7-3.3] vs. 1.5 cm [1.1-2.4], p = 0.01) compared with those without. After adjusting for confounders, only CL < 4 cm remained independently associated with increased risk of VB (adjusted odds ratio: 2.27, 95% confidence interval [1.12-4.58], p = 0.01). None of the measures were predictive of either outcome (area under the curve < 0.65). Decreased CL may be associated with risk of VB in placenta previa. · Placenta previa is associated with VB.. · Sonographic markers of placenta previa are associated with VB.. · CL is associated with VB in placenta previa, whereas placental DPO is associated with higher rates of bleeding leading to delivery..

Prenatal and postnatal care in a frozen conflict zone: results from a household survey

Abstract Introduction Maternal and child health are crucial for the well-being of a society. Armed conflicts negatively affect health systems including maternal and child health services. We explored access and utilization of prenatal and postnatal care services in Nagorno-Karabakh: a frozen conflict zone. Methods We applied cluster sampling to draw a sample of 1023 households in Nagorno-Karabakh in 2022. Interviewer-administered surveys were conducted among women of reproductive age (18-49) from the selected households. The instrument captured key reproductive health, and maternal and child health indicators, for the youngest 0-5 y.o. child. Results Out of 1023 women, 299 (29.5%) had at least one 0-5 y.o. child: 54.5% males and 45.5% females. Almost all the respondents received prenatal care (97.7%), the majority of them (95%) starting in the first trimester with frequency of more than 4 visits (90.7%). The visits included blood pressure measurement (99.3%), urine test (99.7%), blood test (99.7%), checking baby's heartbeat (99.3%), ultrasound (98.3%), nutrition education (82.9%) and breastfeeding counseling (79.8%), and asking about vaginal bleeding episodes (58.2%). Less than half of the respondents reported folic acid (49.5%) and iron (46.5%) supplementation during the pregnancy. While in the healthcare facility, mostly doctors checked mothers’ and babies’ health, 78.6% and 90.3%, respectively. Once discharged, less than 50% of the mothers and more than 80% of the babies received follow-up health checks. Conclusions Despite operating in a frozen-conflict zone, the health system of Nagorno-Karabakh was able to provide prenatal care in line with global evidence-based recommendations. Our findings indicate some gaps in breastfeeding counseling, folic-acid supplementation, and utilization of postnatal services. Capacity-building and community-based educational programs have the potential to improve overall prenatal and postnatal care and build sustainable health systems. Key messages • This unique study showed that despite operating in a frozen-conflict zone, the health system of Nagorno-Karabakh was able to provide prenatal care in line with global evidence-based recommendations. • Capacity building, as well as patient-provider and community-based educational programs have the potential to improve overall prenatal and postnatal care in Nagorno-Karabakh.

Association between insulin resistance and abnormal menstrual cycle in Saudi females with polycystic ovary syndrome

BackgroundPolycystic ovary syndrome (PCOS) is an endocrine disorder experienced by women of reproductive age and is marked by insulin resistance (IR) and menstrual cycle abnormalities. In this study, we set out to assess how the level of menstrual abnormalities relates to the degree of IR in women with PCOS. MethodsThe participants in this study were 93 women diagnosed with PCOS and 100 controls with regular vaginal bleeding. Data was collected through blood samples, physical examinations, and medical histories. The primary outcome measures were body mass index (BMI), fasting glucose, fasting insulin, homeostatic model assessment for IR (HOMA-IR), and hormonal parameters. ResultsValues for BMI and HOMA-IR were higher in PCOS cases than in controls [(28.6 ± 1.9 vs. 23.7 ± 2.3) and (2.29 ± 2.87 vs. 1.48 ± 1.02), respectively]. Oligomenorrhea was documented in 79.4% of women with PCOS, with the others experienced vaginal bleeding intervals under 45 days. The greater the menstrual irregularity, the higher the levels of luteinizing hormone/follicle-stimulating hormone and testosterone. Among the PCOS group, those with vaginal bleeding intervals of above 90 days had a higher HOMA-IR values (2.46 ± 2.77), after adjustments for age and BMI, than the participants who went<45 days between periods (2.01 ± 2.14) and those whose interval was 45–90 days (2.09 ± 2.43). ConclusionsMost of the participants with PCOS had obvious oligomenorrhea of at least 6 weeks between episodes of vaginal bleeding and had significantly higher insulin resistance than did the controls. This suggests that insulin resistance in PCOS cases may be predicted by the presence of clinically overt menstrual dysfunction.

Vaginal bleeding in children: A retrospective audit at a tertiary paediatric gynaecology service.

The aim of this study was to describe the clinical features and investigations of vaginal bleeding in prepubertal children. We performed a retrospective case series of children under the age of 10 who presented with vaginal bleeding to our institution between 2018 and 2019. There were 32 cases identified during the timeframe, with a mean age of 5.5 years (standard deviation 3.2 years, range 5.5 days to 9.6 years). Vulvovaginitis was the most common diagnosis (n=12, 37.5%), followed by precocious puberty (n=5, 15.6%). Uncommon but serious causes were vaginal rhabdomyosarcoma (n=1), and sexual abuse (one patient presenting with gonorrhoea and one with a non-accidental injury). Vaginoscopy was performed in nine patients (28.1%) for various reasons, and a vaginal foreign body was identified in two patients (6.3%). All the patients who had a serious cause of bleeding (neoplasm or sexual assault) or who required specific treatment (precocious puberty, lichen sclerosus, urethral prolapse) presented with red flags on history and/or examination: recurrent episodes of vaginal bleeding, heavy bleeding, associated general symptoms (poor feeding and growth), presence of thelarche, abdominal mass, associated profuse vaginal discharge and abnormal genital examination (skin changes, urethral prolapse or protruding mass from the vagina). A thorough history-taking and clinical examination aiming at identifying red flags may help to discriminate between benign causes of vaginal bleeding, where no further investigations are indicated, and alternative diagnoses with a poor outcome and/or requiring specific treatment and additional investigations.

Malformación arteriovenosa uterina. Un reto diagnóstico y terapéutico

IntroductionUterine arteriovenous malformations (UAVM) usually present as vaginal bleeding in women of childbearing age. Obstetric or uterine surgical history and ultrasound are key when suspecting this pathology. There are multiple treatments available, including medical surgery or interventional radiology with different effectiveness. Material and methodsWe analysed the diagnosis and management of three patients with episodes of vaginal bleeding and obstetric history, or uterine surgeries with a MAVU diagnosis. ResultsIn the three cases analysed, medical treatment was provided as first line treatment. After the failure of medical treatment with oral gestagens, methylergometrine, or tranexamic acid, transarterial embolization was performed with occlusion of the nidus or fistula point. ConclusionsBased on our experience, due to the delay between diagnosis and the wide variety of MAVU treatments, supraselective embolization could be assessed as one of the treatments with the highest rate of efficacy in a patient profile that has usually not fulfilled their reproductive desire. Although the short-term results do not seem to affect fertility, it is important to prospectively follow-up these patients regarding achievement of a new pregnancy or recurrence of MAVU.

Safety of Booster Doses of Coronavirus Disease 2019 (COVID-19) Vaccine in Pregnancy in the Vaccine Adverse Event Reporting System.

To evaluate and summarize reports to the Vaccine Adverse Event Reporting System (VAERS), a national spontaneous reporting system, in pregnant people who received a booster dose of mRNA coronavirus disease 2019 (COVID-19) vaccine. We searched VAERS for U.S. reports of adverse events in pregnant people who received a booster dose of an mRNA COVID-19 vaccine from September 22, 2021, to March 24, 2022. Clinicians reviewed reports and available medical records. The Vaccine Adverse Event Reporting System received 323 reports of adverse events in pregnant people who received a booster dose of COVID-19 vaccine; 178 (55.1%) after BNT162b2 from Pfizer-BioNTech and 145 (44.9%) after mRNA-1273 from Moderna. Seventy-two (22.3%) reports were coded as serious. One neonatal death was reported, but no maternal deaths occurred. Pregnancy-specific outcomes included 56 (17.3%) spontaneous abortions (before 20 weeks of gestation), eight (2.5%) episodes of vaginal bleeding, five (1.5%) stillbirths (at or after 20 weeks of gestation), four (1.2%) episodes of preeclampsia, and two (0.6%) preterm deliveries. Reporting rates for stillbirth and preterm delivery were below background rates. Ten instances of adverse events in neonates were reported, which included two reports of birth defects. Non-pregnancy-specific adverse events (n=207; 64.1%) were mostly systemic (eg, headache, fatigue) and local reactions and occurred in proportions comparable with those seen in pregnant people who received the primary COVID-19 vaccination series and reported to VAERS during the same period. Review of reports after a booster dose of mRNA COVID-19 vaccine in pregnant people in VAERS found their safety profile was comparable with that of published reports after primary COVID-19 vaccination in pregnant people.

Importance of the gynecologic oncologist in management of cesarean hysterectomy for Placenta Accreta Spectrum (PAS)

ObjectivePlacenta Accreta Spectrum (PAS) is an invasive placental disorder characterized by significant maternal and fetal morbidity. Utilization of multidisciplinary teams has been shown to optimize patient outcomes. Our objective was to assess the impact of cesarean hysterectomy performed by gynecologic oncologists versus Ob/Gyn specialists in maternal morbidity. MethodsA retrospective cohort study was performed of singleton, non-anomalous pregnancies complicated by PAS University of Texas Health San Antonio Placenta Accreta program from 2010 to 2021. Our primary outcome was a maternal morbidity composite of any of the following: estimated blood loss >2 L, ICU admission, intraoperative acidosis and post-operative length of stay >4 days. In addition, demographic and pregnancy data were obtained. Univariate and multivariate analyses were performed to identify the individual impact of variables such as general anesthesia, episodes of vaginal bleeding, uterine artery embolization, emergent delivery and placenta percreta pathology. Results122 pregnancies complicated by PAS who underwent cesarean hysterectomy were identified from 2010 to 2021. Gynecologic oncologists were the primary surgeons for 62 (50.8%) of these cases. The involvement of gynecologic oncologists increased over the time period from 16% to 80%. Gynecologic oncologists were more like to be involved in cases with an antenatal diagnosis of placenta percreta (11.7 vs 37.1%, p = 0.001) and these cases were characterized by increased composite maternal morbidity (65 vs 83.9%, p = 0.02). These cases were also significantly longer (151 vs 271 min, p < 0.0001), involved greater usage of urinary stents (36.7 vs 66.1%, p = 0.002) and had longer post-operative lengths of stay (3 vs 4 days, p < 0.0001). PAS cesarean hysterectomies by gynecologic oncologists were less likely to be supracervical (25 vs 3.2%, p = 0.0005). Multivariate analysis controlling for placenta percreta, uterine artery embolization, vaginal bleeding and emergent delivery showed no difference in composite maternal morbidity (aOR = 0.95, 95%CI [0.35–2.52]) and lower rates of intraoperative acidosis (aOR = 0.36, 95%CI [0.14–0.93]) or post-operative length of stay >4 days (aOR = 0.37, 95%CI [0.15–0.91]). ConclusionsGynecologic oncologists play a critical role in the surgical management of PAS cesarean hysterectomies. When compared to Ob/Gyn specialists, gynecologic oncologists are more likely to act as primary surgeons in complex cases similar morbidity and greater post-operative outcomes.

The Degree of Menstrual Disturbance Is Associated With the Severity of Insulin Resistance in PCOS.

ObjectiveInsulin resistance (IR) is an important determinant of the phenotype and morbidity of the polycystic ovary syndrome (PCOS). In this study, we aimed to figure out the association between the degree of menstrual disturbance and the severity of IR in women with PCOS.DesignIt is a cross-sectional study conducted in an academic tertiary setting.PatientsThe patients comprised five hundred twenty-seven women diagnosed with PCOS by the 2003 Rotterdam criteria and 565 controls with regular vaginal bleeding.InterventionsThe interventions done for this study are medical history collection, physical examination, and blood sampling.Main outcome measuresThe main outcome measures are body mass index (BMI), fasting glucose, fasting insulin, homeostatic model assessment for IR (HOMA-IR), and hormonal parameters.ResultsWomen with PCOS had a higher level of BMI, HOMA-IR, and HOMA-β than controls, with a decreased level of sex hormone-binding globulin and QUICK I index. The luteinizing hormone (LH)/follicle-stimulating hormone (FSH), testosterone (T), antral follicle count (AFC), dehydroepiandrosterone sulfate, free androgen index, modified Ferriman–Gallwey score, and the incidence of delayed insulin peak increased with the degree of menstrual disturbance, although there was no significance for the latter four parameters. Women with vaginal bleeding intervals of 45–90 days had a relatively higher level of HOMA-IR and HOMA-β, although it was adjusted with age and BMI than the other two groups. Similar results were observed in AUCI (area under the curve of insulin) and I/G [the ratio of AUCI and AUCG (area under the curve of glucose)]. Anovulatory women with vaginal bleeding episodes of less than 45 days tended to have higher glucose and insulin levels, area under the curve of glucose (AUCG), area under the curve of insulin (AUCI), HOMA-IR, and HOMA-β but decreased QUICK I and Matsuda index than those who were ovulatory. Women with vaginal bleeding intervals of longer than 45 days who had hyperandrogenism (HA) showed a higher level of glucose, insulin, HOMA-IR, and HOMA-β but lower QUICK I and Matsuda Index.ConclusionsIn women with PCOS, the severity of IR, the LH/FSH ratio, and androgen level increased with a higher degree of disturbance in menstrual cyclicity (i.e., the vaginal bleeding intervals). Subgroup analysis indicated that the situation of HA may aggravate the disorder of glucose metabolism in women with PCOS. Overall, the interval between episodes of vaginal bleeding may be useful as a ready measure for predicting the severity of IR in PCOS.

Correlation of clinical outcomes with the application of the 2020 consensus panel on histological classification for Placenta Accreta Spectrum (PAS)

Objective Placenta Accreta Spectrum (PAS) is a range of disorders characterized by placenta adherence to uterine myometrium. The pathologic nomenclature of PAS has varied. In 2020, a consensus panel proposed a system which would parallel the antenatal grading. Our goal was to assess if greater PAS associated morbidity correlated with increasing histopathological grades in this novel system for confirmed cases of PAS. Methods A retrospective cohort analysis was performed of 125 singleton, non-anomalous pregnancies complicated by PAS at the University of Texas Health San Antonio Placenta Accreta program from 2005 to 2020. PAS cases confirmed after cesarean hysterectomy were classified by the new system and outcomes were analyzed including Kaplan-Meier analysis of gestational age at delivery by new pathology categorization. Results Antepartum admission, length of stay and episodes of vaginal bleeding correlated with increasing grades of PAS. In addition, increased PAS grades were associated with deliveries at earlier gestational age and surgical outcomes including operative time, blood loss, ICU admission and post-operative length of stay. Conclusions The grading system proposed by the 2020 consensus panel correlates with antepartum, intra-operative and postoperative outcomes in cases of PAS cesarean hysterectomy and should be implemented for uniformity of reporting.

Post-authorization surveillance of adverse events following COVID-19 vaccines in pregnant persons in the vaccine adverse event reporting system (VAERS), December 2020 – October 2021

BackgroundPregnant persons are at increased risk of severe illness from COVID-19 infection, including intensive care unit admission, mechanical ventilation, and death compared with non-pregnant persons of reproductive age. Limited data are available on the safety of COVID-19 vaccines administered during and around the time of pregnancy. ObjectiveTo evaluate and summarize reports to the Vaccine Adverse Event Reporting System (VAERS), a national spontaneous reporting system, in pregnant persons who received a COVID-19 vaccine to assess for potential vaccine safety problems. MethodsWe searched VAERS for US reports of adverse events (AEs) in pregnant persons who received a COVID-19 vaccine from 12/14/2020–10/31/2021. Clinicians reviewed reports and available medical records. Crude reporting rates for selected AEs were calculated, and disproportional reporting was assessed using data mining methods. ResultsVAERS received 3,462 reports of AEs in pregnant persons who received a COVID-19 vaccine; 1,831 (52.9%) after BNT162b2, 1,350 (38.9%) after mRNA-1273, and 275 (7.9%) after Ad26.COV2.S. Eight maternal deaths and 12 neonatal deaths were reported. Six-hundred twenty-one (17.9%) reports were serious. Pregnancy-specific outcomes included: 878 spontaneous abortions (<20 weeks), 101 episodes of vaginal bleeding, 76 preterm deliveries (<37 weeks), 62 stillbirths (≥20 weeks), and 33 outcomes with birth defects. Crude reporting rates for preterm deliveries and stillbirths, as well as maternal and neonatal mortality rates were below background rates from published sources. No disproportional reporting for any AE was observed. ConclusionsReview of reports to VAERS following COVID-19 vaccines in pregnant persons did not identify any concerning patterns of maternal or infant-fetal outcomes.

77. Rapid Progression of Puberty on Low Dose Estrogen in Girls with Turner Syndrome: A Case Series

<h3>Background</h3> Over 95% of girls with Turner syndrome (TS) who lack all or part of the X chromosome will experience premature ovarian insufficiency and will require estrogen replacement therapy to initiate and maintain puberty. However, the optimal protocol that mimics physiologic puberty while preserving growth potential is not yet known. Current recommendations to start with low dose estrogen increased incrementally over two to three years will typically result in thelarche within six months and menarche after an average of two years. Here we present three patients with TS who experienced rapid progression of puberty, with menarche occurring shortly after initiating the lowest dose of transdermal estrogen. Our institutional review board deemed this retrospective case series exempt from the need for IRB approval. <h3>Case</h3> Three 12-year-old females with mosaic TS (Table 1) presented for pubertal induction. On exam, the patients had tanner stage I breasts and pubic hair. Labs were consistent with ovarian insufficiency with elevated levels of follicle stimulating hormone (FSH) and undetectable levels of estradiol. They were each started on estradiol 14 ucg transdermal patch weekly for pubertal induction and experienced menarche within five months. Breast and pubic hair progressed to tanner stage II and III. Cases 1 and 2 subsequently had regular monthly menses with moderate flow. The dose of their transdermal estradiol patch was decreased by half to 7 ucg weekly. Case 3 developed heavy, irregular bleeding, which caused her to stop using the transdermal estrogen patch. Four months later, she reinstated estrogen use with half of her prior dose at 7 ucg weekly. At one year follow up, all three cases continued with the ultra low dose estradiol 7 ucg transdermal patch weekly without further episodes of vaginal bleeding. On imaging bone age was within normal limits. <h3>Comments</h3> These cases highlight the importance of starting estrogen replacement therapy at the lowest available dose in girls with Turner syndrome. Given the possible advancement of bone age with pubertal levels of estrogen, rapid progression to menarche could further impair the final growth potential in these patients who are already susceptible to short stature. Thus girls with TS should be monitored closely when initiating estrogen therapy and should be re-evaluated if they experience vaginal bleeding with low dose therapy.

71. Case Report: Vaginal Endometriosis After Treatment of an Imperforate Hymen

<h3>Background</h3> Obstructive anomalies at any level of the reproductive tract increase the risk of endometriosis. While endometriosis may improve after relieving the obstruction, persistent endometriosis has been reported. While not common, vaginal endometriosis may occur in adolescents. A case of vaginal endometriosis in an adolescent with history of imperforate hymen is presented. <h3>Case</h3> A 14-year-old, never sexually active, female presented to a tertiary pediatric and adolescent gynecology clinic with secondary amenorrhea. She reported one episode of vaginal bleeding 4 months prior to presentation and had noted a "bulge" at her introitus for 1 year prior to the bleeding episode. She sought gynecologic care for the secondary amenorrhea and was diagnosed with an imperforate hymen and hematocolpos (Figure 1). She underwent a hymenectomy – notable for 800mL of menstrual blood, a dilated single cervix, and normal appearing vaginal mucosa. Her post-operative course was uncomplicated. She had monthly menses without dysmenorrhea. Three months after the hymenectomy she complained of painless intermenstrual vaginal bleeding that occurred after bowel movements. She had a history of constipation. An external genital exam and bimanual exam were unremarkable. A speculum exam was significant for diffuse red friable lesions on the vaginal mucosa and cervix which appeared similar to endometriosis (Figure 2). Her hymenectomy site was well healed. Constipation treatment was initiated. She underwent an exam under anesthesia and biopsy of the vaginal lesions. Pathology confirmed endometriosis. Progestin only pills (POPs) were started for hormonal suppression. Resolution of the vaginal bleeding with bowel movements occurred, however she initially struggled with pill compliance and breakthrough bleeding with POPs. At her most recent visit, she was doing well with minimal breakthrough bleeding, no bleeding after bowel movements, and no dysmenorrhea. She continues to treat her constipation. <h3>Comments</h3> The risk of endometriosis with obstructive outflow tract anomalies is well known, however, painless vaginal bleeding is not the typical presentation of adolescent endometriosis. While providers must consider other etiologies of vaginal bleeding in the adolescent, endometriosis should be included in the differential – particularly in women with a history of an outflow tract obstruction. Medical management using hormonal suppression to reduce the risk of endometriosis proliferation is recommended for adolescents with endometriosis – thereby achieving the overall goals of therapy: minimizing pain symptoms and maximizing quality of life and future fertility.

A case of McCune Albright syndrome in the context of an ovarian mass and late development of café-au-lait macules

McCune-Albright syndrome (MAS) is a genetic disorder characterized by polyostotic fibrous dysplasia, precocious puberty, and café-au-lait spots. In this case, a patient presented with precocious puberty in the setting of an ovarian mass and late development of café-au-lait macules, confounding the final diagnosis of MAS. A 3-year-old girl presented with vaginal bleeding. She had a previous episode of vaginal bleeding, breast budding, and a right ovarian cyst at 5 months of age. Work-up at that time showed no abnormal findings, though past medical history was notable for two fractures. Physical exam was significant for increased height (89th percentile), increased weight (99th percentile), bilaterally elevated breast mounds with palpable breast tissue and darkened areolae (Tanner stage 3), and residual blood in the vaginal introitus. Notable labs included low FSH and high ultrasensitive estradiol. Pelvic MRI showed a right ovarian cyst, which, in the context of precocious puberty, raised the suspicion for a juvenile granulosa cell tumor. Follow-up pelvic MRI demonstrated features that instead suggested an ovarian response to hormonal stimulation. On a subsequent visit several months later, the patient had small café-au-lait macules on the chest and right buttock, which were not present on the initial evaluation. Further workup revealed advanced bone age on an x-ray at 6 years 10 months, and multifocal polyostotic fibrous dysplasia involving bilateral femurs and right tibia. Failure to include MAS in the differential had led to unnecessary oophorectomy. It is crucial to identify MAS as a cause of peripheral precocious puberty to guide proper management.

Diagnostic cyst-endoscopy in management of complex pelvic cyst as an unusual presentation of OHVIRA/HWW syndrome

We share our approach to management of a complex pelvic cyst. Antenatal diagnosis of absent right kidney and pelvic cyst, thought to be ovarian in nature. Postnatal imaging (US, MRU) suggestive of right-left crossed fused renal ectopia, normal ovaries and hemi hydrometrocolpos. At age 9, she was clinically and biochemically pre-pubertal, but reported episodes of vaginal bleeding. A multidisciplinary team (paediatric urology, endocrinology and gynaecology) decided to proceed with EUA and cystovaginoscopy. Cystoscopy revealed a normal urethra and only one ureteric orifice (left) in an otherwise normal bladder. EUA revealed a cystic structure bulging into the right wall of the vagina. Needle puncture aspirated clear fluid, with a pH of 8 on dipstick. Due to the possibility of this representing an ectopic ureter, a Seldinger technique was used, introducing a guidewire via the needle, over which a 7 Fr cystoscope was passed. Examination of the cystic cavity confirmed presence of a cervix at the cranial extremity, suggesting that this was an obstructed hemi-vagina. There was no evidence of an ectopic ureter. The puncture site into the hemivagina was widened to define the septum between the two vaginas, and this was divided using a Harmonic scalpel. At 2-month follow-up, the patient was asymptomatic. Post-operative US revealed significant decrease in the size of the previously visualised cystic structure. Cyst endoscopy helped to confirm the obstructed hemivagina (and rule out an ectopic ureter). We present our cautious approach to draining a pelvic cyst in the context of identifying a single ureter, despite radiological suggestion of two ureters.

Complete hydatidiform mole with a twin pregnancy at 26 weeks: a rare obstetric complication.

Complete hydatidiform mole with a twin pregnancy at 26 weeks: a rare obstetric complication.

Obstetrical and neonatal outcomes after a single episode of third-trimester vaginal bleeding†

Objective: The objective of this study is to determine whether a single episode of vaginal bleeding occurring between 24 and 34 weeks gestation is associated with preterm delivery and other adverse maternal and neonatal outcomes. Study design: We conducted a retrospective cohort study in the Maternal–Fetal unit of two campuses of a large tertiary, medical center with approximately 12,000 deliveries annually. The study group consisted of all women with a singleton pregnancy between 24 + 0/7 and 33 + 6/7 weeks of gestation, admitted to the high-risk antenatal ward due to a single episode of vaginal bleeding of unknown origin between May 2003 and December 2014. Maternal and neonatal parameters of the study group were compared to the maternal and neonatal parameters of the rest of the singleton deliveries occurring in our institution during the study period. The primary outcome was rate of preterm delivery while secondary outcomes were other adverse maternal and neonatal outcomes. Multivariate logistic regression was performed to identify risk factors for preterm delivery in the study group. Results: Two hundred thirty women met the inclusion criteria and 51,468 women were in the comparison group. Preterm delivery rates were 20% and 5.5% in the study and the comparison group, respectively OR = 3.55 [2.63–4.78] (p < .001). The aOR for preterm delivery among the study group for women with a previous preterm delivery was 4.62 [1.17–18.20] (p = .029) and for women with a short cervix was 9.35 [2.30–37.95] (p = .002). Conclusions: A single episode of third-trimester vaginal bleeding is an independent risk factor for spontaneous preterm delivery. The presence of a shortened cervix or a history of a prior spontaneous preterm delivery increases this risk significantly. Key message Third trimester vaginal bleeding is strongly associated with preterm delivery. Knowledge of this relationship has valuable clinical implications for practicing obstetricians.

RIGHT UNILATERAL PULMONARY APLASIA

SESSION TITLE: Lung Pathology 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary agenesis is an extremely rare congenital abnormality. There is incomplete development of lung due to embryological defects. This condition is diagnosed in neonates presenting with respiratory distress. CASE PRESENTATION: A 24 year old male, asymptomatic, consulted for pre-employment clearance. Mother had episode of vaginal bleeding on 5th month of gestation but patient was carried to full term with uneventful birth history. Patient was noted frail growing up, with recurrent pulmonary infection. There was noted shallowness of right nasolabial fold, unequal shoulder height. Right hypothenar was atrophied. Trachea was shifted to the right. There was lag on right chest wall and absence of breath sounds on right lung. Chest xray showed full opacification of the right hemithorax with tracheal deviation to the right. Chest CT scan showed absence of right lung and supplying vasculature. Mediastinum was noted occupying the right hemithorax. Diagnosis was right pulmonary aplasia. DISCUSSION: Pulmonary agenesis encompasses undeveloped pulmonary parenchyma, pulmonary vasculatures, and airways. There is failure of development of the primitive lung bud. Arrest in the development of respiratory system from the foregut corresponds to these embrogenic malformations. Respiratory anlage may develop unilaterally leading to lung agenesis. Unilateral aplasia and hypoplasia are better viable with life. Functionally, unilateral agenesis and aplasia are similar. Sole functional lung is larger than normal to compensate and this enlargement is true hypertrophy and not emphysema.Primary causes include deficiency in TTF-1, HNF310, and EGFR. Secondary causes include small fetal thoracic volume, prolonged oligohydramnios, and congenital heart diseases. A third diagnosed during adulthood are asymptomatic. Recurrent childhood respiratory infections are common symptoms leading to identification. Diagnosis is suspected in patients examined with tracheal deviation, in the presence of a clinically symmetric chest and massive atelectasis in chest xray. Chest CT scan has emerged as diagnostic modality of choice in diagnosis. There is no treatment needed for asymptomatic cases. Treatment is necessary in the presence of respiratory tract infections. Prognosis of pulmonary aplasia depends on severity of co-existing congenital malformations and involvement of normal lung in infection and large vessels kink due to mediastinal displacement. Normal life span is expected for those surpassing first five years without major infection.There is higher mortality with right lung agenesis than left due to greater compression of tracheobronchial tree by shifting of midthoracic structures into the right chest. CONCLUSIONS: Pulmonary aplasia is a rare congenital abnormality characterized by absence of lung parenchyma and supporting vasculature. Patients with no other concomitant congenital anomaly survive well into adulthood. Reference #1: Mardini M K, Nyhan W L. Agenesis of lung: Report of 4 patients with unusual anomalies. Chest 1983; 87:522-7. Reference #2: Conway K, Gibson RL, Perkins J, Cunningham ML. Pulmonary agenesis: Expansion of the VCFS phenotype. Am J Med Genet. 2002:11389–92. Reference #3: Richard S. Synopsis of Diseases of the Chest. 2nd ed. Phildelphia: W. B. Saunders Company; 1994. Pulmonary Abnormalities of Developmental Origin; p. 25686. DISCLOSURES: No relevant relationships by Portia Maria Tanyag, source=Web Response

Fertility preservation of PSTT by interventional therapy: a case report

Introduction: Placental site trophoblastic tumor (PSTT) is a rare form of gestational trophoblastic disease (GTD) and this disorder is usually seen in young women with a 20% mortality rate. Although hysterectomy is useful for treating PSTT, it is not the best choice for patients who wish to preserve their fertility. Due to the fact that PSTT is resistant to chemotherapy frequently, it is very important to find new therapeutic schedules used for PSTT. Case Report: The patient is a 24-year-old female, gravida 2, para 1, with intermittent vaginal bleeding episodes for ten days following her latest pregnancy of 50 days ago. Pelvic utrasonographic results showed a 4×5×5- cm mass in hypo-hyperechogenic areas of the uterine wall and the initial serum β-hCG level was 6,359 mIU/ml. Immunohistochemical analysis revealed that the Ki-67 proliferative index was about 10%; the tumor cells showed strong diffuse staining with Pan cytokeratin, human placental lactogen (hPL), placental alkaline phosphatase, and epidermal growth factor receptor (EGFR). Meanwhile, the tumor cells also showed focal positive with hCG. The histological and immunohistochemical findings led to the diagnosis of PSTT. At first, the patient took three courses of chemotherapy and three times of curettages, but the condition was not in remission. In order to preserve the patient's fertility, the patient underwent twice uterine artery drug pouring and embolism treatment. The drugs included adriamycin, cisplatin, and methotrexate. This therapy had gained a satisfactory effect. Conclusion: When the tumor is localized to uterus without diffuse infiltrative, for younger PSTT patients who wish to conserve fertility, the authors suggest that uterine artery drug pouring and embolism treatment could be considered.