Episode Of Vaginal Bleeding Research Articles

Precocious puberty in McCune-Albright syndrome: a case report

McCune-Albright syndrome (MAS) is a rare disease characterized by a triad of fibrous dysplasia, cafe-au-lait spots and peripheral precocious puberty. We reported a 5-year- 8-month old girl with MAS who has been followed-up for 2 years and 8 months. She was referred to pediatric endocrinology clinic in our hospital for vaginal bleeding at age of 2 years 11 months. She had peripheral precocious puberty, i.e. increased estrogen level associated with very low gonadotropins, and cafe-au-lait spots on her face and was diagnosed as MAS. The patient was treated with estrogen receptor blocker (tamoxifen). She had no menses during the 2 years and 8 months of tamoxifen treatment. Her growth rate and bone maturation were also in normal ranges. However, at the end of tamoxifen treatment she had an episode of vaginal bleeding so that we had to change to other treatment modalities.

Precocious puberty in McCune-Albright syndrome: a case report

McCune-Albright syndrome (MAS) is a rare disease characterized by a triad of fibrous dysplasia, cafe-au-lait spots and peripheral precocious puberty. We reported a 5-year- 8-month old girl with MAS who has been followed-up for 2 years and 8 months. She was referred to pediatric endocrinology clinic in our hospital for vaginal bleeding at age of 2 years 11 months. She had peripheral precocious puberty, i.e. increased estrogen level associated with very low gonadotropins, and cafe-au-lait spots on her face and was diagnosed as MAS. The patient was treated with estrogen receptor blocker (tamoxifen). She had no menses during the 2 years and 8 months of tamoxifen treatment. Her growth rate and bone maturation were also in normal ranges. However, at the end of tamoxifen treatment she had an episode of vaginal bleeding so that we had to change to other treatment modalities.

Early sonographic detection of a succenturiate placenta after IVF in a 42-year-old woman with multiple comorbidities

We present a case of a 42-year-old woman with a pregnancy resulting from in vitro fertilisation and a medical history including two spontaneous abortions, hypercoagulable state and other comorbidities. At...

Therapeutic uterine artery embolization in a life-threatening postpartum hemorrhage: a case report

Postpartum hemorrhage (PPH) is one of the most common complications of delivery and is a major cause of maternal morbidity and mortality. The aim of this report is to introduce a case of therapeutic uterine artery embolization (UAE) in a life-threatening postpartum hemorrhage. A 26-year old G3P3 woman with severe postpartum hemorrhage after 50 days of delivery referred to the emergency unit of an academic hospital of Mashhad University of Medical Sciences, Iran with third episode of vaginal bleeding. Gynecological examination and sonography were completely normal. Hypovolemic shock that was managed by fluid and blood replacement-therapy with uterotonic medical agents including oxytocin infusion (40 unit/lit), injection of 0.2 mg methyl-ergonovin and 1000 µg rectal misoprostol. Uterine artery embolization was planned due to unremitting severe hemorrhage. Embolization resulted in successful control of hemorrhage and the patient was discharged. At 6 months follow-up, no adverse events pertinent to embolization were noted. Therefore, UAE is suggested as a useful method for controlling intractable bleeding due to postpartum hemorrhage.

Decidualized Endometriosis

Decidualized endometriosis is a benign condition associated with ectopic endometrial tissue that has undergone a decidual reaction during pregnancy. A case is presented of a 31-year-old female who presented to an imaging center for a follow-up sonogram after experiencing one episode of vaginal bleeding during pregnancy. A solid, highly vascular mass, with irregular borders, was seen that was not present in the sonogram two weeks prior. The mass was later revealed to be decidualized endometriosis. This is a rare condition that lacks extensive reporting in the literature. The case demonstrates a particularly odd location for this disease, in between the uterus and bladder. With multiple sonograms, it was difficult to ascertain the host of the mass. Due to the extent of vascularity within this structure, malignancy had to be considered, which led to a referral for additional testing.

Uterine fluid lactate dehydrogenase isoenzyme activity profile

Objective The objective of the present study was to evaluate the diagnostic accuracy of the lactate dehydrogenase (LD) isoenzyme activity profile in uterine fluid, and transvaginal ultrasound (TVS) in the detection of endometrial cancer in women with postmenopausal bleeding. Patients and methods A total of 200 postmenopausal women with one or more episodes of vaginal bleeding were included in the study after signing informed consent. The study was approved by the ethics committee of the Faculty of Medicine, Alexandria University, Egypt. Patients with recent endometrial sampling, current hormone replacement therapy, uterine fluid collection at TVS, or clinical signs of endometritis were excluded from the study. The TVS and uterine fluid sampling for the LD isoenzyme analysis were carried out as office examinations. Endometrial thickness was classified as greater than 5 mm or less than 5 mm on TVS. The LD isoenzyme activity profile was described as normal or abnormal. The LD isoenzyme profile was subsequently related to histopathological diagnosis. Patients with endometrial thickness greater than 5 mm on TVS were evaluated with diagnostic curettage, and those with endometrial thickness less than 5 mm were evaluated with office endometrial biopsy. Results Endometrial carcinoma was found in 18 out of 200 patients (9%). In total, 162 (81%) were found to have endometrium greater than 5-mm thickness on TVS. The LD isoenzyme activity profile was abnormal for 38 (19%) patients. Histopathological diagnosis revealed 18 cases with endometrial cancer and 20 cases with no malignancy. The LD isoenzyme activity profile has 100% sensitivity, 90.1% specificity, 45.4% positive predictive value, 100% negative predictive value, and 88.6% accuracy. TVS for 200 postmenopausal women showed that 162 cases had endometrial thickness greater than 5 mm (81%); 18 of them were diagnosed with endometrial carcinoma (9%) and the remaining 144 cases were diagnosed with benign endometrial pathology (72%); 38 cases had endometrial thickness less than 5 mm (19%) and all of them showed no malignancy (P=0.201). The LD profile showed 38 abnormal results (19%); 18 cases of them diagnosed as endometrial carcinoma (9%) and the remaining 20 cases had benign endometrial pathology (10%). The LD profile showed 162 normal results, all of which had no malignancy (P=0.000*). Conclusion LD isoenzyme profile of uterine fluid could be added as a diagnostic tool for endometrial carcinoma of postmenopausal women. It is a reliable and easy, and is highly tolerable for the patients. At the same time, it can be applied as an office technique. LD isoenzyme profile of uterine fluid could be used as a second step after TVS at a cutoff point of 5 mm, which has proved to be highly reliable. The use of these two methods can reduce the need for curettage and hysteroscopy.

Polycystic Ovary Syndrome: An Apparently Simple yet Challenging Diagnosis.

Polycystic Ovary Syndrome: An Apparently Simple yet Challenging Diagnosis.

Management of Menstrual Bleeding During Treatment for Nongynecologic Malignancy [88

INTRODUCTION: More than 800,000 new cases of cancer are diagnosed in women each year. Standard treatments can cause severe thrombocytopenia that may result in heavy menstrual bleeding. The objective of this study was to assess current practices for menstrual suppression and identify the frequency of acute vaginal bleeding that requires gynecologic consultation, medical or surgical intervention, or blood transfusion. METHODS: This was a retrospective case–control study of female patients aged 10–54 years with nongynecologic malignancies treated at Northwestern Memorial Hospital between 2008 and 2013. Women with a documented episode of vaginal bleeding were matched by age, cancer type, and year of diagnosis with women who did not have a bleeding episode. χ2 tests estimated differences between groups. RESULTS: Seventy-three women with an episode of vaginal bleeding were identified and matched with 73 women in a control group. Mean age was 49.4 years. The most common diagnoses were breast (80.8%) and thyroid cancer (12.3%). Of women with bleeding, 68 required gynecologic consultation (93.2%) and 36 required intervention (49.3%). The most common interventions were dilatation and curettage (26%), intrauterine device (IUD) (9.6%), hysterectomy (6.8%), oral contraceptive pills (5.5%), and oral progestins (2.7%). One patient received a transfusion. Few patients received menstrual suppressive therapy, but this was more common among women who bled (13.7% compared with 2.7%; P=.02). Six women used oral contraceptive pills, five an IUD, and two a gonadotropin-releasing hormone agonist for suppression. CONCLUSION: Among women with nongynecologic malignancies, treatment-associated thrombocytopenia can result in significant vaginal bleeding, requiring medical or surgical intervention. Optimal preventative strategies should be explored to avoid these complications.

Novel Management of Immune Thrombocytopenia in Gaucher Disease Patients

Type I Gaucher disease (GD) the is characterized by hepatosplenomegaly, pancytopenia and skeletal complications due to the accumulation of glucocerebroside in macrophages. Thrombocytopenia is usually related to hypersplenism and infiltration of bone marrow by lipid-laden macrophages namely Gaucher cells. Enzyme replacement therapy (ERT) restores the hemoglobin and platelet count in GD patients. In GD ERT treated patients, manifesting persistent low platelet counts, immune thrombocytopenia (ITP) should be considered.Treatment of GD with concomitant ITP is a challenge. Splenectomy may worsen bone manifestations in GD patients and is controversial. Steroids should be used with caution because of possible induction of osteopenia and joints avascular necrosis. Thrombopoietin receptor analogues (TPO-RA) are therapeutic option in GD patients with ITP. Beneficial use of TPO-RA is reported in 2 cases.Patient 1: 39 YO male with new onset of purpura and low platelet count failed treatment with 1 mg/kg of Prednisone. Bone marrow biopsy (BM) showed Gaucher cells infiltration, numerous atypical megakaryocytes, normal erythropoiesis and myelopoiesis with no fibrosis. Low level of ß-glucocerebrosidase activity with compound heterozygosity for 84GG /R495H mutations, established the diagnosis of Type I GD. Low C4 and detection of IgG platelet antibodies added to the diagnosis of concomitant immune thrombocytopenia. ERT with taliglucerase alfa (ElelysoTM) 60 Units/kg/month was given with Prednisone for six weeks. Occurrence of retinal bleeding and purpura, with decrease of platelet count necessitated addition of high-dose IVIG with no response regarding platelet counts. Splenectomy was not considered due to known bony complication risk in splenectomised GD patients. Rituximab was given to prevent wet purpura recurrence with short response regarding platelet count. Romiplostim was initiated raising platelet count from 29,000/µL to 60,000/µL after 3 wks. and to 90,000/µL after 8 wks. enabling corticosteroids withdrawal. Same dose Romiplostim is maintained for the last 30 months with platelet counts of 90,000 - 110,000/µL with no bleeding events. Repeated BMB showed no increase in collagen fibrosis.Patient 2: 63 YO female patient diagnosed with Gaucher at age 33 with a history of purpura, ecchymosis, and occasional vaginal bleeding episodes. At age 53 the platelet count dropped to < 20,000/µL with presence of Anti Platelets Ab (IgG). BMB revealed megakaryocytic hyperplasia with atypical forms, focal infiltration by Gaucher cells and no fibrosis. Combined therapy by ERT (Imiglucerase® followed by Velaglucerase Alfa®), Prednisone (1mg/kg/d for 2 months) and one course of IVIG yielded no increase in platelet count. The patient refused Rituximab®. Romiplostim was initiated increasing platelet count to100,000/µL maintained throughout a year of follow up. Repeated BMB showed slight increase of fibrosis and marked hyperplasia of atypical megakaryocytes.Discussion: Thrombocytopenia is often present in GD and may be severe in approximately 15% of the patients. Persistent cytopenias may be caused by other underlying pathologies such as autoimmune disorders and are important to be recognized and addressed. Before ERT era GD patients with hypersplenism and severe cytopenia were splenectomised. Risks of splenectomy include serious bacterial infection and vascular complications limiting its use in chronic refractory ITP. Splenectomy is avoided in Gaucher patients, due to risk of exacerbating skeletal complications (bone infarcts, avascular necrosis). Stable bone marrow results regarding fibrosis in our patients are consistent with data from a recent 2-year follow-up of 100 ITP patients receiving Romiplostim treatment with no evidence of BM fibrosis.Conclusion: In patients with type I Gaucher disease and concomitant ITP, adjunctive treatment with Romiplostim was successful in maintaining haemostatic platelet counts with no adverse effects. Traditional treatment regimens of corticosteroids and splenectomy should be used with caution or avoided in GD patients due to possible aggravation of Gaucher skeletal disease and the risk of osteopenia and avascular necrosis resulting in increased morbidity in this cohort of patients. Use of TPO-RA should be considered in GD patients with ITP. DisclosuresOff Label Use: Romiplostim in gaucher patients.

Endometrial pathology in postmenopausal women with no bleeding

Objective The aim of this study was to determine the rate of unexpected uterine pathology in postmenopausal women admitted to a gynecology clinic with symptoms other than vaginal bleeding and who were scheduled to undergo hysterectomy.Materials and methods We reviewed retrospectively the medical records of 283 postmenopausal patients who had gynecological surgery between September 2007 and January 2014. We reviewed their presenting symptoms on admission, the indications for surgery, and their transvaginal ultrasonographic findings. Postoperative histopathological results based on uterine specimens were also recorded. The results were analyzed statistically.Results Of 283 patients who had surgery, 209 had no vaginal bleeding at the time of admission. From this group, 75.6% were found to have unsuspected pathology, including endometrial hyperplasia, endometrial polyps, uterine fibroids, adenomyosis, and one case of endometrial carcinoma (0.5%). The remaining 74 patients had experienced postmenopausal bleeding and in 87.8% there were pathological findings including 13 cases (17.6%) of endometrial cancer (p = 0.0001).Conclusion Vaginal bleeding in postmenopausal women is indicative of a wide array of gynecological pathologies, including endometrial carcinoma. However, uterine fibroids, pelvic masses, or even endometrial cancer may develop without co-morbid vaginal bleeding. Therefore we advocate that postmenopausal women should undergo yearly screening and consultation, without waiting for an episode of vaginal bleeding.

Benign vaginal bleeding in 24 prepubertal patients: clinical, biochemical and imaging features.

Premature menarche is an uncommon, benign condition characterized by isolated or recurrent menstrual bleeding in the absence of secondary sexual characteristics. We performed an observational retrospective study to further characterize the clinical, biochemical and imaging features of benign prepubertal vaginal bleeding (BPVB). Out of 1037 girls evaluated for precocious puberty over a 5-year period, 24 girls with BPVB were identified based on ≥1 episodes of vaginal bleeding, Tanner I or non-progressive Tanner II breast development, and lack of physical findings suggesting genital infection, trauma or foreign body. Age at presentation ranged from 3 years 2 months to 9 years 11 months. Ten patients (42%) had one episode of vaginal bleeding, six (25%) had two episodes and eight patients (33%) had three or more. First bleeding episode lasted 3 days (range; 1-30 days). Six girls had intermittent spotting for up to 1 year. No breast development was noted in 19 (79%) patients. Minimal breast was present in five girls; early pubic hair was present in 2. LH and FSH were prepubertal; estradiol was >20 pg/mL in two girls. Pelvic ultrasound, performed in 11 patients, showed pre-pubertal uterus and ovaries without adnexal masses. Isolated prepubertal vaginal bleeding is typically benign and self-limited, in the absence of sexual precocity signs or other vaginal pathology. Laboratory and imaging studies are generally unrevealing.

Vascular Hamartoma in the Uterus of a Female Sprague-Dawley Rat with an Episode of Vaginal Bleeding

An annular, reddened lesion with mild serosal hemorrhage and no tumorous mass formation was detected in the right uterine horn of a 37-week-old female Sprague-Dawley rat that had postpubertal vaginal bleeding. Histological examination revealed prominent proliferation of the endometrium, which occupied the uterine lumen. There were numerous aberrant vascular spaces filled with erythrocytes, proliferation of stromal cells, and inflammatory infiltrates including hemosiderin-laden macrophages in the endometrium. These vasculatures extended into the myometrium, and in a transverse section of the lesion, they were mostly distributed throughout the circumference of the uterus. They were irregular in shape and interconnected, forming a large vascular sinus and anastomosing reticular channels. In the area with serosal hemorrhage, the muscular layer covering the large irregular vascular space had undergone degeneration and necrosis. The lining cells of the vasculatures were often plump, and they protruded into the lumen and were arranged in a tombstone or hobnail manner. Immunostaining revealed that these cells were positive for von Willebrand factor and CD34. The aberrant vasculatures were not accompanied by pericytes or muscular layer, although a discontinuous muscular wall was present around some of them. From these results, the uterine lesion was diagnosed as a vascular hamartoma.

Delayed postpartum hemorrhage: the implications of making a diagnostic mistake

A 25-year-old woman, P1001 with unremarkable clinical history was admitted to her local referral hospital for severe vaginal bleeding (SVB), significant anemia (Hb 7 g/dl) and abdominal pain occurred 6 weeks after caesarean section. Ultrasound revealed a minimal flap in the Douglas and a 25-mm vascularized area on the uterine wall at the site of caesarean scar, which was confirmed by CT scan, hence a vascular malformation (AVM) was suspected. Angiography showed the presence of AVM at left corner of the uterus. Left ipogastric arteriography showed the early opacification of the dilated para-uterine venous plexus, associated with multiple microflow of active spreading of contrast from a branch of the uterine artery. Hemoglobin blood value rose to 10.1 g/dl after the first arterial embolization and red blood cell transfusion, but after the second hemorrhage it dropped to 8.0 g/dl. Then, a second selective embolization of the left uterine artery was performed with complete vessel occlusion. Nevertheless, the SVB persisted and a further embolization was performed on anterior branch of the left internal iliac artery. After few days SVB reappeared and the patient was admitted to our hospital (101 days after caesarean section). Ultrasonography and color Doppler evaluation showed a 15 9 8 9 5 mm left parametrial vascularized formation and intraperitoneal free fluid. Hysteroscopy was not performed because of the SVB. Because the angiography had been already detected location, size and relation of AVM to the uterine vasculature, an operative laparoscopy with multiple ligations of the uterine plexus was performed. This approach was preferred to laparotomic surgery because of its minimal invasion and complications, few hospitalization and recovery days. An ultrasound control showed a reduction of the left parametrial formation and the patient was asymptomatic. Elapsed 4 days, the patient presented the same symptoms and she was prepared for emergency hysteroscopy; a dehiscence of previous hysterotomy at the left uterine corner extended to isthmus–cervical tract was detected. Dehiscence was sutured after a laparotomy on previous scar. Common causes of delayed postpartum hemorrhage are retention of gestational products and endometritis. In this case, both were excluded. The management of vaginal bleeding provides hysteroscopy, which has not been possible to perform at first, because of the severe bleeding. Operative laparoscopy was carried out, but the lesion was not visible outside the uterus. A new episode of vaginal bleeding required an emergency diagnostic hysteroscopy, which showed the underlying cause of bleeding: a uterine scar dehiscence. This is a rare but potentially dangerous cause of delayed postpartum hemorrhage, which should be considered because of the increasing number of cesarean deliveries. Uterine scar dehiscence is estimated to occur between 0.3 and 1.9 % of cases and only a minority of these shows vaginal bleeding or abdominal pain [1]. Many patients may be asymptomatic, consequently incidence rate may be underestimated. The risk of scar deficiency is increased in retroflexed uterus and after multiple cesarean sections [2]. The etiopathogenesis is unclear. Generally, the uterine incision is performed transversely in the lower uterine segment, whose reduced thickness and vascularization decrease the risk of dehiscence [3]. Dehiscence could depend on the suture material used, the suturing technique itself, or both [4]. High uterine incisions, ischemic technique and the slowest resorbable suture should be considered. In our case, the D. Surico (&) C. Codeca A. Vigone N. Surico University of Eastern Piedmont, Novara, Italy e-mail: daniela.surico@med.unipmn.it

P31.11: Complete hydatidiform mole and normal live birth: placental mosaicism or twin with CHM?

Introduction: survival of a normal fetus to term in the presence of hydatidiform mole remains an extremely uncommon occurrence. Prenatal diagnosis is possible by ultrasonography showing molar invasion of the normal placenta without clear margin. Antenatal detection of mole co existing with a viable fetus should warrant genetic analysis and search for gross malformation of the fetus. Case report: we report a rare case exhibiting molar pregnancy and a coexisting normal fetus. A 29 year, primigravida had an episode of vaginal bleeding at 18 weeks which suggested avascular lower placenta with multiple cystic area measuring 12 × 5 × 9 cm with normal fetus. She had two weekly growth scan and Doppler as diagnosis was not clear. It was thought to be multiple placental lakes. Growth and Doppler remains normal and had term SVD. Placenta was sent for histopathology which suggested normal placenta with an area of complete hydatidiform mole. It was difficult to differentiate from mosaic CHM, twin with normal co-twin and CHM. Discussion: coexistent live fetus and molar placenta has never been reported. Complications including pre-eclampsia, hyperthyroidism, vaginal bleeding, persistent gestational trophoblastic disease, preterm labour, miscarriage and anaemia increases. Several factors may influence the outcome in partial mole such as karyotype of the fetus, size of the molar placenta, the speed of molar degeneration and fetal anaemia.

Atrial myxoma in early pregnancy

Atrial myxoma is the most common primary cardiac tumour with a prevalence of 0.075% with a mean age for sporadic cases of 56 years.We report the case of a 30...

Primary Amenorrhea in an Adolescent Secondary to a Virilizing Luteinized Thecoma of the Ovary

16 months later she presented to pediatric endocrinology with 4 more episodes of vaginal bleeding at 1-3 month intervals. No leucorrhea, pubic hair or breast developmentwas noted. Onphysical examherheight velocity was 11.6 cm/year, she had diffuse hypotonia, and a normal palpable thyroid. Sparse fine dark hair was noted in the axilla. Breasts and pubic hair were Tanner I, hymenwas intact, and the vaginal mucosa appeared estrogenized. Laboratory studies showed LH 45.31 IU/L, FSH 89.69 IU/L, estradiol<20 pg/ mL, and normal thyroid function tests. Ultrasound showed a peripubertal uterine configuration measuring 4.6 x 1.5 x 2.6 cm with the fundus larger than the cervix. The right ovarianvolumewas0.5 cc, and the left ovary could not be seen. No adnexal masses were seen. The evidence of chronic estrogen exposure on uterine configuration and elevated gonadotropins to the menopausal range raised concern for precocious puberty followed by impending ovarian failure. A bone agewas performed which was 6 years 10 months suggesting estrogen exposure. 3 months later, she had Tanner II breasts and fine dark hair apparent over the monspubis. Repeat labs showedLH13.50 IU/L, FSH5.20 IU/L, estradiol 275.4 pg/mL, DHEAS 14.4 mcg/dL (normal 5.0-40.0), Prolactin 20.52 ng/mL, and anti-m€ ullerian hormone (AMH)<assay. She had another episode of vaginal bleeding. Given evidence of central precocious puberty, a luteinizinghormone-releasing hormone agonist (histrelin acetate implant) was placed. 2 months after the implant no further vaginal bleeding or progression of breast development was noted and laboratories confirmed gonadotropin suppression (LH 0.92 IU/L, FSH 2.9 IU/L, Estradiol<20pg/mL). Comments: This case illustrates the rare association of precocious puberty with ovarian failure and describes elevated gonadotropins early in life. In addition, it demonstrates the utility of AMH in diagnosing diminished ovarian reserve because of the inter and intra cycle variability of FSH.

Partial benefit of anastrozole in the long-term treatment of precocious puberty in McCune-Albright syndrome

We report a long-term follow-up on the use of anastrozole in the treatment of peripheral precocious puberty (PP) in McCune-Albright syndrome (MAS). A girl, age 3 years and 9 months, was diagnosed with MAS due to PP, café-au-lait spots, and polyostotic fibrous dysplasia. Serum estradiol was elevated, and gonadotropins were suppressed. Pelvic ultrasound showed an enlarged uterus and a follicle cyst (13 mm) in the left ovary. Bone scintigraphy showed osteogenic lesions on the skull, humerus, tibia, and acetabulum. Bone age was 3 years and 5 months at the chronological age of 3 years. After 36 months of treatment with anastrozole (1 mg/day), there was suppression of breast growth, normalization of growth velocity and serum estradiol, and disappearance of ovarian cysts. However, there was increase in uterine volume, advancement of bone age, and two episodes of vaginal bleeding (18th and 24th months). This report shows the partial benefit of anastrozole in the treatment of peripheral PP of girls with MAS.

Two placentas in singleton pregnancy with fused umbilical cord: A case report

Two placentas in singleton pregnancy with fused umbilical cord which has its own placental insertion site forming 3-vessel cord at fetal end is an extremely rare case. This present case describes two placentas with fused umbilical cord with an episode of vanishing twin syndrome and there seems to be a strong relationship between these two events. A 37-year-old woman, gravid 0, para 0, visited emergency room with an episode of vaginal bleeding without pelvic cramps at 8 weeks and 5 days of gestation and repeated ultrasonic exams revealed reabsorption of vanishing twin and two separate placentas on anterior and posterior body of uterus. At 40 weeks and 4 days, the patient delivered a viable female infant weighing 3,900 g via Cesarean section and postpartum examination of the placentas and membranes confirmed two placentas with fused umbilical cord. Two placentas were almost equal in size and there were 2 cord insertions, 1 into each placenta. The cord at each of the placental disc had marginal insertion site and main placental disc cord had 2 arteries with one vein (3 vessel-cord) whereas side placental disc cord had one artery with one vein (2 vessel-cord). Several hypothesis for this two placentas with fused umbilical cord in singleton pregnancy, were proposed including placenta abnormalities after in vitro fertilization-embryo transfer procedure, succenturiate lobes and fetus in fetus, however, further evaluation is need.

156: Antenatal vaginal bleeding and perinatal outcomes among women with suspected placenta accreta

156 Antenatal vaginal bleeding and perinatal outcomes among women with suspected placenta accreta Marilee Simons, Tracy Manuck, Alexandra Eller, Bob Silver University of Utah Health Sciences Center and Intermountain Healthcare, Obstetrics and Gynecology, Salt Lake City, UT OBJECTIVE: Placenta accreta (PA) is associated with high rates of major maternal and neonatal morbidity and mortality. Delivery timing among women with suspected PA attempts to balance the risks of prematurity and maternal morbidity. We hypothesized that among pregnancies with suspected PA, those with antenatal vaginal bleeding (VB) would have increased morbidity. STUDY DESIGN: Retrospective cohort of women with a clinically suspected PA who delivered 1/2000-4/2011 in our tertiary hospital system. Women were identified by ICD-9 codes and delivery logs. Women with 1 episode of VB were compared to those without VB. Major maternal morbidity was defined as at least one of the following: coagulopathy, transfusion of 4 units pRBCs, reoperation, thromboembolism, ureter or bowel injury, ICU stay 24 hrs, or maternal death. Major neonatal morbidity was defined as at least one of the following: NEC, RDS, IVH, or neonatal death. Data were analyzed by Chi-square, Fishers exact, students t-test, and Kaplan-Meier. A pvalue 0.05 was considered significant. RESULTS: 60 women were included; all had 1 prior cesarean delivery. 38 (63%) had antenatal VB. Women with VB had a median of 2 VB episodes; 14 (23%) had more than 3 episodes of VB. Demographic characteristics and hospital courses were similar among women with and without VB, although those with VB were more likely to be transported, admitted antenatally, and receive betamethasone (Table). All women had a clinically confirmed PA at delivery and were delivered by cesarean hysterectomy. 40 (67%) had a pathologically confirmed PA. Women with VB were delivered earlier compared to those without VB (Figure). VB was highly correlated with delivery gestational age (r -0.31, p 0.012). CONCLUSION: Women with suspected PA who experience antenatal VB are more likely to be admitted to the hospital, receive betamethasone, and require blood transfusion at the time of delivery compared to women who do not experience VB. Despite delivering 2 weeks earlier than women without antenatal VB, initial maternal and neonatal outcomes are similar. 157 Rates of preterm delivery in women receiving nurse administered 17P in a home vs office setting Victor Hugo Gonzalez-Quintero, Felipe Jose Tudela, Yvette Cordova, Letty Romary, Debbie Rhea, Cheryl Desch, Niki Istwan Associates in Advanced Maternal Fetal Medicine, Maternal Fetal Medicine, Miami, FL, University of Miami School of Medicine, Obstetrics and Gynecology, Miami, FL, Alere Health, Department of Clinical Research, Atlanta, GA OBJECTIVE: To compare clinical characteristics and rates of preterm delivery (PTD) in women receiving 17P via a weekly home nurse visit vs. through their physician’s office. STUDY DESIGN: Study sample identified from a database of clinical information received from pregnant women enrolled for risk assessment-case management or outpatient perinatal nursing services. Included were records with a documented delivery date from women with singleton gestations prescribed 17P by their physician. PTD history and rates of recurrent spontaneous PTD (SPTD) were compared between those women enrolled in the 17P home administration program which included a weekly home nurse visit with compounded17P injection and maternal assessment vs. women receiving 17P injections through their physician’s office. A logistic regression model was used to assess the effect of significant univariate differences between the groups onto dependent outcome of SPTD. RESULTS: Of the 16,225 records identified, 15,533 (95.7%) were enrolled in the 17P home administration program and 692 (4.3%) received 17P at their physician’s office. Women enrolled for home administration services were more likely to have a history of PTD (90.0% vs. 62.0%, p 0.001), received a greater number of 17P injections (14.9 / 4.8 vs. 12.6 / 5.5, p 0.001), and had lower rates of SPTD (28.0% vs. 39.0%, p 0.001) than those women receiving 17P through their physician’s office. In only women with PTD history, Poster Session I Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology www.AJOG.org

Oral contraception: from birth control to pregnancy prevention with noncontraceptive benefits

Considerable changes have occurred in oral contraceptives since their introduction in the 1960s. Initial reductions in sex steroid dosing were followed by alterations in dosing regimens that allowed for the minimization, reduction or elimination of scheduled vaginal bleeding episodes. More recently, oral contraceptives have incorporated novel progestins or estrogens other than ethinylestradiol, many of which are now associated with noncontraceptive benefits. The 21/7 regimen, developed to maximize the likelihood of a monthly withdrawal bleed, is likely to no longer be the pre-eminent dosing regimen used in new pill formulations, which can be expected to feature lower doses of new progestins and novel estrogens combined in dosing regimens that will reduce withdrawal bleeding, provide new noncontraceptive benefits and possibly be associated with an improved safety profile.