Persistent Vaginal Bleeding Research Articles

A Case of Placental Implantation with Exaggerated Placental Site

Objective: This study aims to investigate the clinical symptoms, diagnosis, differential diagnosis, and prognosis of exaggerated placental site (EPS), in order to reduce misdiagnosis and missed diagnosis of EPS, avoid the occurrence of serious complications such as massive hemorrhage, and provide some references for clinical doctors. Methods: Retrospective analysis of the medical history and treatment of a patient with placental implantation with exaggerated placental site. A 23-year-old female presented with persistent vaginal bleeding after medical abortion. She was diagnosed with retained products of conception and underwent hysteroscopic surgery. The preliminary postoperative pathological results indicate the possibility of EPS and placental site trophoblastic tumor (PSTT). Further immunohistochemical testing was performed, and the results suggested EPS. Results: The patient recovered well after surgery and did not require further treatment. Her serum human chorionic gonadotropin levels and transvaginal ultrasound findings were normal. Conclusion: EPS is a benign disease, and symptoms will disappear after lesion clearance, requiring no special treatment or follow-up, with a good prognosis. Due to the low incidence rate, atypical clinical symptoms, and insufficient recognition by clinical doctors, EPS are prone to misdiagnosis and missed diagnosis, leading to serious consequences such as massive hemorrhage and hysterectomy. EPS should be considered as a possible diagnosis in any woman who has irregular bleeding following medical abortion.

Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men.

While it is common for menstrual cycles to cease within the initial 6months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition. In this case-control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6months. A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019). Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.

Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation

To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair. A stepwise video demonstration with narration. A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended. A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply CONCLUSIONS: Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries.

Prophylactic Chemotherapy for the Prevention of Gestational Trophoblastic Neoplasia- A descriptive study

Background: Gestational trophoblastic neoplasia develops from the trophoblastic cells which later form the placenta. It ranges from the relatively benign partial and complete hydatidiform mole while choriocarcinoma and the rare placental site trophoblastic tumor are its malignant variants. The risk of developing gestational trophoblastic neoplasia (GTN) is 15-17% after complete mole and 3.5-4% after partial mole1,2. This risk is more in patients with high-risk molar pregnancy1,2. Aim: To evaluate the role of prophylactic chemotherapy in prevention of gestational trophoblastic neoplasia in patients who fall in high-risk molar category. Place and duration of study: Ghurki Trust Teaching Hospital and Surgimed Hospital, 2016-2020 (4 years duration) Study design: Descriptive case series Methodology: Twenty three patients who presented with high-risk molar pregnancy in the study period were included in this study after takinginformed consent.These patients were divided into two groups. Group A included those patients who underwent suction evacuation followed by prophylactic chemotherapy; they were 13 in number, while group B had 10 patients and they underwent suction and evacuation only. Single dose of methotrexate 1mg/kg body weight was given to the patients in group A. Patients were asked about the history of excessive vaginal bleeding and serial beta hcg levels were carried out on follow up. Results: The patients average age was 32 years with the range between 25-42 years.14 patients (61%) were more than 40 years old while 9 patients (39%) were less than 40 years old. Three patients had beta hcg levels above 100,000 IU/ml. Patients were followed up withserial beta hcg levels till they became negative.No patient (0%) in group A developed gestational trophoblastic neoplasia while two patients (15.3%) in group B developed persistent vaginal bleeding and 1 patient (7%) developed choriocarcinoma involving the brain. Conclusion: Prophylactic chemotherapy reduces the risk of development of gestational trophoblastic neoplasia as concluded by thisstudy. However, only 16% of patients in high-risk molar category develop gestational trophoblastic neoplasia2 which means this will expose 84% patients to unnecessary chemotherapy. This will increase the cost of treatment also. Keywords: Molar pregnancy, Prophylactic chemotherapy, Gestational trophoblastic neoplasia

A clinical analysis of intestinal mucosal necrosis and exfoliation induced by superior mesenteric vein thrombosis: A case report.

Superior mesenteric vein (SMV) thrombosis is a rare intestinal ischemic disease. The clinical manifestations of patients differ, and most experience gastrointestinal symptoms. A 45-year-old female patient presented with persistent abdominal pain and abnormal vaginal bleeding for 7 days. A physical examination revealed significant abdominal tenderness with positive rebound tenderness. A laboratory examination revealed a white blood cell count of 27 × 109/l, hemoglobin level of 52 g/L, and D-dimer of 4.54 mg/l. Enhanced computed tomography revealed a thickening and swelling of the jejunum and ileum in the left upper quadrant and portal vein. Filling defects in the main lumen and branch lumen suggested the possibility of portal vein and superior mesenteric vein thrombosis. Symptoms improved after treatment with low-molecular-weight heparin and warfarin. One month later, the patient developed occasional dull pain in the left lower quadrant, with long strips of discharge. An electronic colonoscopy revealed avascular necrosis and tissue exfoliation of the intestinal mucosa. After the continuation of warfarin therapy, the abdominal pain resolved. Five months later, the patient experienced recurrent abdominal pain and vomiting. A physical examination revealed a blood pressure of 75/49 mm Hg. An incomplete ileus with the portal and superior mesenteric vein thrombosis was diagnosed, partial jejunectomy and gastrointestinal bypass anastomosis were performed, and warfarin was continued postoperatively. The intestinal mucosal shedding observed, in this case, was caused by SMV thrombosis, which enriched the clinical manifestations of the disease and provided a new basis for the clinical diagnosis of SMV thrombosis.

Novel Presentation of Placenta Accreta Spectrum

Placenta accrete spectrum (PAS) previously known as morbid adherent placenta, is a complex obstetric complication that has risen exponentially in the last couple of decades. It carries serious fetomaternal risk in terms of morbidity and mortality, also increasing perinatal mortality owing to prematurity. PAS include three variants depending upon the degree of placental penetration, i.e. accrete, increta and percreta. We highlighted the unique diagnostic criteria of the placenta accrete spectrum,which includes the history of incomplete removal of the placenta, with repeated evacuation, persistent vaginal bleeding and ultrasound evidence of retained products of conception.

Relationship between the Volume Ratio of Subchorionic Hematoma to Gestation SAC in First-trimester and Pregnancy Outcome of Patients with Threatened Abortion.

To find the relationship between the volume ratio of subchorionic hematoma (SCH) to gestation sac measured by three-dimensional ultrasound and pregnancy outcome of patients with threatened abortion. Descriptive study. The Second Affiliated Hospital of Soochow University, Suzhou, China, from January 2016 to December 2020. Medical data of patients, who were diagnosed with threatened abortion (persistent or intermittent vaginal bleeding) were collected. All included patients underwent ultrasonography for SCH at gestation age of 6-8 weeks. According to the patients' evaluation, they were classified into a case group combined with threatened abortion and SCH (n=145), and a control group with threatened abortion (n=76). The clinical data and three-dimensional ultrasound parameters of the two groups were compared to find the relationship between the volume ratio of SCH to gestation sac and pregnancy outcome. In the case group, the hospital stay was longer, the abdominal pain, its duration ≥7 days, and adverse pregnancy outcomes were higher than in the control group (p<0.05). Patients with moderate and severe area ratio and volume ratio of SCH to gestation sac were significantly related to higher abortion and stillbirth rates than patients with mild ratio (p<0.05). The area under the curve, sensitivity and specificity of the volume ratio of SCH to gestation sac in predicting abortion and stillbirth were higher than that of the area ratio of SCH to gestation sac. The volume ratio of SCH to gestation sac by three-dimensional ultrasound in first-trimester plays an important role to predict pregnancy outcome. Ultrasonography, Hematoma, Pregnancy outcome, Threatened abortion, ROC curve.

Multiple Plasmodium falciparum drug resistance polymorphisms identified in a pregnant woman with severe malaria and a concomitant spontaneous abortion in Cross River, Nigeria, West Africa

BackgroundThe development of resistance by Plasmodium falciparum to anti-malarial drugs impedes any benefits of the drug. In addition, absence or delayed availability of current anti-malarial drugs in remote areas has the potential to results to parasite escape and continuous transmission.Case presentationThe case of a 29-year old pregnant woman from Biase Local Government Area in Cross River State Nigeria presenting with febrile illness and high body temperature of 38.7 °C was reported. She looked pale and vomited twice on arrival at the health facility. Her blood smear on the first day of hospitalization was positive for P. falciparum by RDT, microscopy (21,960 parasite/µl) and real-time PCR, with a PCV of 18%. She was treated with 600 mg intravenous quinine in 500 ml of 5% Dextrose/0.9% Saline 8-hourly for 24 h. On the second day of hospitalization, she complained of weakness, persistent high-grade fever and vaginal bleeding. A bulging amnion from an extended cervix was observed. Following venous blood collection for laboratory investigations, 600 µg of misoprostol was inserted into the posterior fornix of her vagina as part of her obstetric care. Parenteral quinine was discontinued, and she was given full therapeutic regimen of artemether-lumefantrine 80/480 mg tablets to be taken for 3 days beginning from the second day. Her blood samples on the second and third day of hospitalization remained positive for P. falciparum by all three diagnostic methods. Single nucleotide polymorphism (SNP) assay on all three P. falciparum isolates revealed the presence of variants associated with multiple drug resistant markers.DiscussionInfecting P. falciparum isolates may have been resistant to initial quinine treatment resulting from parasite cross-resistance with other quinoline associated resistant markers such as 86Y and 184 F.ConclusionsTherefore, the likely transmission of similarly resistant parasites in the study area calls for reinforcement of interventions and adherence to current World Health Organization guidelines in administering only approved drugs to individuals in order to mitigate parasite escape and eventual transmission to other susceptible individuals.

The significance of clinical symptoms of subchorionic hematomas, “bleeding first”, to stratify the high-risk subgroup of very early preterm delivery

ObjectiveTo investigate the factors that stratify high-risk cases among subchorionic hematomas (SCHs) patients with persistent vaginal bleeding in early pregnancy. Materials and methodsA total of 56 patients who required hospitalization for SCH with vaginal bleeding in early pregnancy were classified into two groups: 1) no hematoma by ultrasonography when vaginal bleeding occurred, and then hematoma was observed by ultrasonography “bleeding to hematoma (BH group, n = 15)” and 2) no vaginal bleeding when hematoma was observed by routine ultrasonography, and then vaginal bleeding occurred later “hematoma to bleeding (HB group, n = 41)”. Retrospective cohort study was performed and maternal and neonatal outcomes were evaluated. ResultsThe duration of SCHs and/or vaginal bleeding was significantly longer in the BH group than in the HB group (mean: 60.8 days [BH group] vs. 33.3 days [HB group], p = 0.015). BH group patients delivered earlier than HB group patients significantly (mean: 27.3 weeks [BH group] vs. 35.6 weeks [HB group], p = 0.0028). The frequency of chronic abruption and oligohydramnios sequence (CAOS) was significantly higher in the BH group than in the HB group (3/15; 20.0% [BH group] vs. 0/41; 0.0% [HB group], p = 0.016). The frequency of sever fetal distress (Apgar score <4 points) was significantly higher in the BH group than in the HB group (4/15; 26.7% [BH group] vs. 0/41; 0.0% [HB group], p = 0.0037). The levels of factor XIII were relatively lower in the BH group than in the HB group (mean: 54.8% (n = 4) [BH group] vs. 76.1% (n = 7) [HB group], p = 0.077). ConclusionThe order of the symptoms, bleeding first, is an important feature that reflects the subsequent prolonged duration of SCHs/vaginal bleeding, resulting in very early preterm delivery. Continuous hemorrhage consumes coagulation factor XIII, which further worsen the hemostasis.

Invasive Mole of the Uterus: A Case Report

Invasive mole is a rare subgroup of gestational trophoblastic disease characterized by the invasion of molar tissue into the myometrium or uterine vasculature. In this paper, we report the third case of invasive mole described in the Malagasy literature. A 33-year-old woman was referred to the Soavinandriana Hospital, her complaint was persistent vaginal bleeding during 2 months, occurring at 3 months of pregnancy with biological anemia without hemodynamic repercussions. The human chorionic gonadotropin (HCG) level was 385,931 mIU/ml. A haemostasis hysterectomy was performed. Histological examination showed an enlarged uterus and endometrial cavity containing edematous chorionic villi with trophoblastic proliferation invading the myometrium. The diagnosis was an invasive mole, stage I, FIGO score 6. Chemotherapy was prescribed but was not honored. After 45 days of follow-up, the serum βHCG level decreased to 1803 mIU/ml, without clinical symptoms. The patient then lost sight. Persistent vaginal bleeding after pregnancy may be the only clinical symptom of an invasive mole and should raise suspicion. Histological examination establishes the diagnosis. As this is an unusual cause of vaginal bleeding, our case should remind physicians that when faced with this symptom, the possibility of an invasive mole should be considered in order to make an early diagnosis for less aggressive treatment.

Arteriovenous Malformation of the Uterus: A Review and Update.

Arteriovenous malformation of the uterus (AVMU) is a very rare and uncommon condition, because it has been documented that less than 100 cases of AVMU have been reported in the literature. AVMU is potentially a life-threatening condition with regard to the fact that some cases of AVMU could manifest with profuse bleeding from the uterus via the vagina. AVMU could either be congenital AVMU which is less common or acquired AVMU with pregnancy noted to have a role to play in the pathogenesis of AVMUs. The true incidence of AVMU is stated to be difficult to ascertain in view of the fact that some cases of bleeding that have been caused by AVMU do tend to conservative, medical management and many of these AVMUs could remain undiagnosed. The most common manifestations of AVMUs tend to be abnormal uterine bleeding that could be episodic, intermittent, continuous, mild or torrential which could lead to severe anaemia or shock. Some AVMUs could be found incidentally based upon radiology imaging for a different condition. Other symptoms of AVMUs do include: Metrorrhagia; Menorrhagia; Bleeding following a miscarriage; Bleeding following dilatation and curettage; Bleeding subsequently after hysterectomy; Bleeding associated with trophoblastic disease; Bleeding following caesarean section; Post-partum haemorrhage; Intermittent vaginal bleeding; Continuous vaginal bleeding; Post-menopausal bleeding; Acute abdominal pain with hemoperitoneum; Pallor; Dizziness; Weakness; Drowsiness; Being unwell following delivery of a baby; Bleeding following therapeutic abortion; Tachycardia; Supra-pubic pain at times; hypotension. Diagnosis of AVMU tends to be made based upon radiology imaging with utilization of ultrasound scan / Doppler scan of the uterus and pelvis, Contrast Computed Tomography scan, and Contrast Magnetic Resonance Imaging Scan, as well as by selective angiography which tends to be ensued by treatment with embolization of the feeding vessels to the AVMU. The treatment of AVMUs these days has ranged between conservative and medical management that includes hormones for small AVMUs, Hysterectomy, which tends to be a definitive treatment that removes the AVMU but does leave the individual not being able to maintain her future fertility, as well as selective angiography and super-selective embolization of the uterine arterial branches feeding the AVMU, which does tend to maintain the future fertility of the patients and which has the advantage of being undertaken under local anaesthesia. Questions that should be on the minds of clinicians include should doppler ultrasound scan of the uterus be undertaken with regard to all women who develop persistent vaginal bleeding pursuant to or during management of miscarriage, considering that there are very few interventional radiologists in many hospitals. This means that selective angiography plus super-selective embolization cannot be undertaken in district hospitals should all women who have suspected AVMU that have severe bleeding that may require surgical operation be referred to a tertiary hospital so that they could possibly benefit from the undertaking of selective angiography and embolization of their AVMUs instead of hysterectomy to enable them to maintain their future fertility? It is also important for clinicians to be made aware of the existence of AVMUs so that they could appreciate the risk factors as well as the clinical manifestations who should be suspected of possibly having AVMUs. Clinicians also need to learn about various conservative and expectant methods of treating AVMUs including hormonal treatment. Clinicians also need to appreciate the future implications for future fertility of women who have AVMUs. Possible treatment options that have not been utilized for the treatment of AVMUs include: (a) Radiology image-guided cryotherapy of AVMU, (b) Radiology image-guided radiofrequency ablation of AVMU, and (c) Radiology Image-guided Irreversible electroporation of AVMU. There is a global need for the training of more interventional radiologists all over the world including in the developing countries as well as some of the developed countries to that they can undertake embolization of AVMUs as well as they can provide various interventional radiology treatment options for various other conditions.

A COMPARATIVE STUDY OF 0.5 % BUPIVACAINE WITH FENTANYL VERSUS 0.75% ROPIVACAINE WITH FENTANYL IN EPIDURALANESTHESIA FOR ABDOMINAL HYSTERECTOMY

INTRODUCTION Abdominal hysterectomy (AH) is a quite common gynaecological surgical procedure and electively done under central neuraxial blockade. AH is performed for malignant as well as benign indications such as uterine leiomyoma, persistent vaginal bleeding, or pelvic organ prolapse. AIMS AND OBJECTIVES Compare the onset of motor and sensory block. Find out the duration of the sensory and motor blockade. Observe intraoperative hemodynamic changes and assess post-operative analgesia requirements in 24 hour. Duration of analgesia assessed by requirement of rst rescue analgesic. Observe any untoward incident during intraoperative and post-operative period and managed accordingly MATERIALS AND METHODS Study Area: Department of Anesthesiology &amp; critical care, DARBHANGAMEDICALCOLLEGE AND HOSPITAL. Study Population: Adult patients (30- 65 years) undergoing elective abdominal hysterectomy with regional anaesthesia were included for this study. Study Period:January 2019 to March 2020 Sample Design: Subjects were divided into two groups (n=35) equal in numbers and they sampled as per computerized randomization chart. These patients were divided into two groups, group B (with epidural 0.5% bupivacaine and 100g fentanyl) and group R (with epidural 0.75% ropivavaine and 100g fentanyl). Study Design: Prospective, open, randomized, controlled study. RESULTS: In Our study showed that 3.38kg/m2 and 24.86 3.60 kg/m2in group B and R respectively. The duration of surgery was 100.86 9.35minutes and 98.86 8.32 minutes and the duration of stay, was4.86 0.81days and 4.60 0.914 days in group B and group R respectively. Now with comparison of both groups, time to onset of sensory block (uptoT6) has signicant variation. But the other parameters namely, time to onset of motor block, two segment regression or duration of sensory block, rescue analgesia timing and complete motor recovery time were comparable and not signicant statistically in both groups. SUMMARY &amp; CONCLUSIONS To conclude that in the present study using 0.5% bupivacaine with fentanyl and 0.75% ropivacaine with fentanyl epidurally, ropivacaine produced an earlier onset but similar duration of sensory block. The onset, quality and duration of motor block werecomparable in both the groups. It is important that new local anaesthetics with lower cardiotoxic property are adopted to ensure that regional techniques using large amounts of local anaesthetics remain safe with minimal complications. The recovery prole of ropivacaine may be useful where prompt mobilization is require

Gynecological clinical case

Herein is reported the case of a child observed in the Emergency Department due to urinary retention, suprapubic pain, and dysuria. Urine culture was performed upon cystitis suspicion, which was positive for Escherichia Coli, and the patient was treated with amoxicillin and clavulanic acid. Three days later, the child was reevaluated for persistent urinary retention, fever, and vaginal bleeding. At gynecological examination, she had an imperforate hymen. Imaging evaluation was performed, revealing an abdominal mass, suggestive of piohematocolpos. The patient was submitted to surgical drainage, with complete condition resolution.

Postpartum hemorrhage and prolonged hyperfibrinolysis as complications of uterine cavernous hemangioma: a case report and literature review

Background: Uterinecavernous hemangioma can cause persistent vaginal bleeding or massive hemorrhage and can lead to severe pregnancy complications. Case: A 23-year old woman with cutaneous hemangiomas presented for caesarean delivery of her second child nine days after successful delivery, she was admitted with severe postpartum hemorrhage and disseminated intravascular coagulation (DIC). A hysterectomy was performed as a result. The diagnosis of cavernous uterine hemangioma was made only on histopathological examination. In addition, an atypically extended period of refractory fibrinolytic hyperactivity developed after hysterectomy. Such extensive hyperfibrinolysis has not previously been reported in conjunction with hysterectomy. Conclusion: This case underscores the importance of cavernous uterine hemangioma as one of the causes of refractory uterine bleeding at the time of operation delivery. The definitive diagnosis can be made only on histological examination. Changes in the coagulation mechanism should be monitored closely during postpartum, and clinicians should be aware of the possibility of fibrinolytic hyperactivity.

Vaginal bleeding and spotting in transgender men after initiation of testosterone therapy: A prospective cohort study (ENIGI)

Previous studies have cross-sectionally described amenorrhea in cohorts of transgender men on intramuscular or subcutaneous testosterone injections. It remains uncertain which testosterone preparations most effectively suppress vaginal bleeding and when amenorrhea occurs after testosterone initiation.To investigate the clinical effects of various testosterone preparations on vaginal bleeding and spotting in transgender men.This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Data on the persistence and intensity of vaginal bleeding and spotting, serum sex steroid levels and body composition were prospectively and cross-sectionally assessed in 267 transgender men during a three-year follow-up period, starting at the initiation of various testosterone preparations.After three months of testosterone, 17.9% of transgender men reported persistent vaginal bleeding and 26.8% reported spotting. The percentages reporting vaginal bleeding and spotting decreased over the first year of testosterone (bleeding 4.7% and spotting 6.9% at 12 months, respectively), with no participants reporting vaginal bleeding or spotting after 18 months of testosterone. Factors associated with vaginal bleeding or spotting included lower serum testosterone levels and being on testosterone gel as compared to injections (e.g., esters or undecanoate preparations). If vaginal bleeding persisted, starting progestogens at three months resulted in a decrease in the intensity of vaginal bleeding and spotting.Transgender men and hormone-prescribing providers can be reassured that vaginal bleeding and spotting usually stop within three months after testosterone initiation. If not, serum testosterone levels should be measured and testosterone dose adjusted to achieve serum testosterone levels in the physiologic male range. Adding a progestin can be considered after three to six months if bleeding persists. Providers should be aware that cessation of bleeding can be more difficult to achieve in transgender men with lower serum testosterone levels or those on testosterone gel.

Complications Following Total Laparoscopic Hysterectomies: A Cohort Study Analyzing One Vs. Two-Layer Laparoscopic Vaginal Cuff Closure

Study Objective To determine whether two-layer laparoscopic vaginal cuff closure during laparoscopic hysterectomies is associated with lower postoperative complications compared to standard one-layer closure. Design Retrospective cohort study. Setting Academic tertiary care center. Patients or Participants 2,973 patients. Interventions During a 6-year period, 1760 (59.2%) and 1213 (40.8%) patients underwent single (1-LVC) vs. two-layer (2-LVC) laparoscopic vaginal cuff closure, respectively. Factors influencing laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, immunosuppressant medications, and sexual activity were recorded. We compared total postoperative complications including visceral injury, blood transfusion, hematoma, thromboembolism, infection, and cuff complications. The latter were further examined for cuff dehiscence, mucosal separation, hematoma, cellulitis/abscess, granulation tissue and persistent vaginal bleeding. Statistical analyses included Chi-square and Wilcoxon rank sum testing. Measurements and Main Results 2-LVC closure was associated with decreased total postoperative complications (2-LVC: 3.38% vs. 1-LVC: 5.57%; p=0.006) without impacting intraoperative complications (1.40% vs. 1.25%; p=0.721) or emergency room/hospital readmissions (11.05% vs. 12.67%; p=0.181). 2.44% of 1-LVC patients experienced postoperative cuff complications compared to only 0.74% women in the 2-LVC group (p=0.002). No subjects in the 2-LVC cohort experienced a vaginal cuff dehiscence or mucosal separation compare to 0.63% and 0.23% of patients in the 1-LVC group, respectively. Granulation tissue (1-LVC: 0.40% vs. 2-LVC: 0.16%), persistent vaginal bleeding (0.57% vs. 0.16%), and cuff cellulitis (0.51% vs. 0.33%) were also more common in the 1-LVC cohort. Univariate analysis of total postoperative cuff complications revealed that a 2-LVC closure was protective of postoperative complications (OR=0.37, 95% CI: 0.188-0.712). Conclusion Although postoperative problems linked to laparoscopic hysterectomies are already exceptionally low, the added use of a 2-LVC closure further lowers postoperative total and vaginal cuff complications.

A Strategic Approach to a Total Laparoscopic Hysterectomy for an Advanced Cesarean Section Scar Ectopic Pregnancy with Cystotomy Repair.

Study Objective Present an interesting case of an advanced cesarean scar ectopic pregnancy that failed medical management and underwent treatment with a total laparoscopic hysterectomy. Design Video Case Report. Setting Tertiary Referral Hospital at a community-based OB/GYN residency program. Patients or Participants 37-year-old G3P3013 at 9 weeks gestation with a cesarean scar ectopic pregnancy. Interventions This video will present an interesting case of a 37yo G5P3013 that presented with a 9-week cesarean scar ectopic pregnancy. Initial treatment was with injection of KCL into the fetal heart and methotrexate into the gestational sac at 10 weeks gestation. The patient presented 5 weeks after initial treatment with persistent pain and vaginal bleeding. The patient was the thoroughly counseled on her treatment options. She had no desire for future pregnancy and the plan was made for total laparoscopic hysterectomy with bilateral salpingectomy. This video presentation shows how as strategic anatomic approach using isolation of the blood supply and utilizing avascular spaces can allow this case to be completed in a minimally invasive fashion. This case will also present the steps to repairing an incidental cystotomy that was encountered in the dissection Measurements and Main Results N/A Conclusion Advanced cesarean scar ectopic pregnancy can be treated in a minimally invasive fashion with total laparoscopic hysterectomy when future fertility is not desired.

A Cervical Smear Scare due to Monsel’s Solution: A Case Report

Monsel’s solution has been in use since the end of the 19th century for its valuable property of creating hemostasis in minor disruptions of the epithelium. Its styptic effect was first described by Leon Monsel, a pharmacist in the French army, in a letter dated on October 13, 1852. Containing ferric subsulphate, it is used as a topical hemostatic agent in minor procedures such as biopsies in gynecology, proctology, dermatology, otorhinolaryngology and odontology. A 28-year-old nulliparous woman, with a known history of adenomyosis, had presented for sudden heavy intermenstrual vaginal bleeding. Examination revealed a bleeding Nabothian cyst. Monsel’s solution application helped stop the bleeding. She returned 3 days later with persistent heavy vaginal bleeding. Examination showed active oozing from the Nabothian cyst. A cervical smear and a human papillomavirus (HPV) swab were taken, and vaginal packing was inserted. The cervical smear result was reported as atypical cells, suspicious for malignancy. Colposcopy performed showed a grade 2 acetowhite lesion, suspicious for cervical intraepithelial neoplasia (CIN) III/microinvasive disease. However, punch biopsies of the cervix revealed only CIN I/koilocytosis. The patient was counselled and subsequently underwent a laser cone biopsy, which showed CIN I with clear margins. The discrepant results between the cervical smear and the cone biopsy prompted a review of the cervical smear and cervical histology; and a relook at the chronology of events. The cytological features observed in the initial cervical smear could be explained by the interference from the Monsel’s solution, which was applied just 3 days before the cervical smear. In cases where Monsel’s solution has been used for hemostasis, it is best to delay taking a cervical smear or a biopsy for at least 3 weeks as the histologic effect of Monsel’s solution may persist for up to that duration of time in tissues. J Med Cases. 2020;11(10):324-326 doi: https://doi.org/10.14740/jmc3556

Optimal timing of the loop electrosurgical excision procedure according to different phases of the menstrual cycle

ObjectiveTo determine whether treatment of cervical precancerous lesions in the follicular phase or luteal phase of the menstrual cycle affects perioperative and postoperative blood loss during the LEEP. MethodsIn this randomized trial, 73 patients were assigned to either the follicular phase group (n = 37) or the luteal phase group (n = 36). Ultimately, the conditions of 36 patients in the follicular phase group and 34 patients in the luteal phase group were analyzed. The primary outcome measure was median early postoperative blood loss. Secondary outcomes were median intraoperative bleeding, the rate of late postoperative bleeding, and persistent vaginal bleeding. ResultsBaseline demographic data were similar in the two groups. Median intraoperative blood loss was significantly lower in the follicular phase group than in the luteal phase group (32.7 [20.1–78.3] vs. 44.6 [30.4–104.2] mL, respectively; P < 0.001). Median early postoperative blood loss was also lower in the follicular phase group than in the luteal phase group (209.2 [67.7–468.6] vs. 289.0 [120.3–552.8] mL, respectively; P = 0.01). Moreover, the rate of late postoperative bleeding was higher in the luteal phase group than in the follicular phase group (20.6% vs. 2.8%, respectively; P = 0.02). ConclusionPerforming LEEP during the follicular phase of the menstrual cycle significantly reduces median intraoperative blood loss, early postoperative blood loss, and the rate of late postoperative blood loss.

SUN-007 Elevated Levothyroxine Requirements Post-Partum as Initial Presentation of Placenta Accreta

Introduction: It is well known that estrogen plays an important role in thyroid regulation. We report an unusual case of post-partum placenta accreta causing pathologic estrogen secretion leading to increased levothyroxine (LT4) requirements and inability to lactate. Case: A 36-year-old woman with history of Hashimoto’s hypothyroidism presented post-partum day 11 after a normal vaginal delivery with inability to produce breast milk and mildly elevated TSH levels. Prior to her pregnancy, she required an equivalent dose of 142 mcg of LT4 supplementation daily, which increased appropriately to 171 mcg during pregnancy. After delivery, LT4 was decreased to 150mcg in anticipation of normalization of levothyroxine requirements to pre-pregnancy level. However, she had difficulty lactating and was found to have elevated prolactin, estradiol, and TSH levels. The following day, she presented to her obstetrician for persistent vaginal bleeding and was found to have placenta accreta requiring dilation and curettage (D&C). Her LT4 requirements eventually dropped to 125 mcg with decreasing beta-HCG and estrogen levels after successful D&C treatment. She was also then able to produce sufficient breast milk for lactation. Discussion: This case highlights the effect of estrogen on LT4 requirements during physiologic pregnancy and postpartum with placenta accreta. It is expected that hypothyroid patients have approximately 25-50% increased thyroid replacement requirements during pregnancy, which normalizes soon after delivery.1 Estrogen increases thyroxine-binding globulin and lowers circulating free thyroxine2,, which causes higher thyroid replacement requirements. Estrogen is also known to inhibit lactation. Our patient demonstrates that this holds true even in a pathologically high estrogen state from placenta accreta. Our case uniquely demonstrates a temporal association between estrogen levels and LT4 requirements in the post-partum hypothyroid patient. Patients with inappropriately high TSH levels after delivery should prompt investigation into pathologic causes of elevated estrogen-states, as levothyroxine requirements are expected to normalize immediately post-partum.