Uncomplicated Vaginal Delivery Research Articles

Right sided congenital diaphragmatic hernia

Introduction: Congenital diaphragmatic hernia is a rare affection, has been classified as posterolateral, anterior or central. The posterolateral defect occurs on the left side (85%), although it may involve the right side (13%) or be bilateral (2%). Patients and methods: We report the evolution after surgical treatment of right diaphragmatic hernia in one case. Results: A male neonate, born via uncomplicated vaginal delivery at a gestational age of 10 days, weighed 3.8 kg at birth and initially presented with weak crying and a dusky skin tone. He required intubation and was placed on a ventilator. Subsequent imaging studies including chest radiography and CT scan revealed a right congenital diaphragmatic hernia, while ultrasound confirmed the presence of pulmonary hypertension. Following stabilization, the newborn underwent thoracotomy surgery, during which intraoperative exploration revealed the entire liver within the thoracic cavity along with intestinal loops. The liver was challenging to maneuver but was successfully relocated into the abdomen, and the intestinal loops were reduced. Repair of the diaphragmatic defect was accomplished using non-absorbable sutures. Following surgery, the neonate was transferred to the neonatal intensive care unit (NICU), where a postoperative chest radiograph on the fourth day showed expansion of the right lung. Over the subsequent two years, the patient's condition remained stable without the development of respiratory complications or worsening symptoms. Conclusion: Success in this difficult case is optimized by close cooperation between the neonatologist, anesthesiologist, and pediatric surgeon. Although the hospital stay was prolonged, the survival outcome is excellent in this high-risk case.

Contained Uterine Rupture Managed Conservatively after Vaginal Delivery

Background Uterine rupture in an otherwise unscarred uterus is a rare event, with most sources describing it on the order of 1/5700 to 1/20,000 deliveries [1]. Risk factors include high multiparity, use of uterotonics, advanced maternal age, macrosomia, malpresentation, placental invasion, and prolonged labor [2-3]. Historically, management of this complication involves exploratory laparotomy with surgical repair or hysterectomy. Few reports have been published that describe conservative management in the setting of uterine rupture. Objective(s) To describe the conservative management of contained uterine rupture. Study Design Case report Case Summary A 39-year-old gravida 5, para 4 with history of pre-eclampsia was admitted for induction of labor at 40 weeks 0 days. Her intrapartum labor was complicated by pre-eclampsia with severe features. She had a vaginal delivery after 20 hours of induction without immediate complications. Following delivery, the patient complained of severe right lower quadrant pain, which was treated with escalating pain regimen, but continued to worsen. A CT scan was obtained, which revealed a right retroperitoneal hematoma with findings suspicious for uterine rupture. The patient was taken to the operating room for exploratory laparotomy with findings of a right-sided broad ligament hematoma measuring 15 cm by 6 cm, extending into the retroperitoneal space. The surgery ended without additional procedures since the patient was hemodynamically stable, and the hematoma was non-expanding. Postoperatively, she was started on a multimodal pain regimen, and eventually discharged on postoperative day 3 after pain improved. Conclusion We describe a contained uterine rupture noted in the immediate postpartum period after an uncomplicated vaginal delivery. Our patient had several risk factors for uterine rupture such as advanced maternal aged, high multiparity, and macrosomia. Surgical exploration noted a large non-expanding hematoma overlying the site of suspected uterine rupture, which was stable. In an otherwise hemodynamically stable patient with contained uterine rupture, conservative management is a reasonable option.

Retinal Hemorrhages in a Newborn with Prenatal Cocaine Exposure

A term male newborn small for gestational age and with microcephaly was born from uncomplicated vaginal delivery. Pregnancy was not followed up until 32 weeks. Maternal serologies and vaginal/rectal swabs were negative. Routine ophthalmoscopy revealed hemovitreous in the right eye and massive retinal hemorrhages (RH) in the left eye; subsequent RetCam II examination with fluorescein angiography revealed bilateral RH, involving the fovea in the left eye. Retinal vascularization was normal in both eyes, without signs of ischemic injury or pathological angiogenesis. Complete blood count, coagulation, and thrombophilic studies were normal; a toxicology screen, performed on a hair sample from both mother and infant, was positive for cocaine. With its significant vasoconstrictive effects, cocaine may induce ischemic-hypoxic damage in the developing retinal vascular system of the fetus, leading to extensive RH. Although cocaine-related RH is indistinguishable from other birth-related RH, the formers persist for longer periods, warranting prolonged follow-up and long-term evaluation of visual function.

Maternal height, and ethnicity and birth weight: A retrospective cohort study of uncomplicated term vaginal deliveries in Malaysia.

Small for gestational age (SGA) and large for gestational age (LGA) are designations given to neonates based solely on birthweight, with no distinction made for maternal height. However, there is a possibility that maternal height is significantly correlated with neonatal birthweight, and if so, SGA and LGA cutoffs specific to maternal height may be a more precise and useful tool for clinicians. To explore this possibility, we analyzed the association between maternal height and ethnicity and neonate birthweight in women with low-risk, 37- to 40-week gestation, singleton pregnancies who gave birth vaginally between 2010 and 2017 (n = 354,488). For this retrospective cohort study, we used electronic obstetric records obtained from the National Obstetrics Registry in Malaysia. National Obstetric Registry (NOR) data were used to calculate the 10th and 90th birthweight percentiles for each maternal height group by gestational age and neonatal sex. Multiple linear regression models, adjusted for maternal age, weight, parity, gestational age, and neonatal sex, were used to examine the association between neonate birthweight and maternal ethnicity and height. The following main outcome measures were assessed: small for gestational age (<10th percentile), large for gestational age (>90th percentile), and birthweight. The median height was 155 cm (IQR, 152-159), with mothers of Chinese descent being the tallest (median (IQR): 158 cm (154-162)) and mothers of Orang Asli (Indigenous) descent the shortest (median (IQR): 151 cm (147-155)). The median birthweight was 3000 g (IQR, 2740-3250), with mothers of Malay and Chinese ethnicity and Others having, on average, the heaviest babies, followed by other Bumiputeras (indigenous) mothers, mothers of Indian ethnicity, and lastly, mothers of Orang Asli ethnicity. For infants, maternal age, height, weight, parity, male sex, and gestational age were positively associated with birthweight. Maternal height had a positive association with neonate birthweight (B = 7.08, 95% CI: 6.85-7.31). For ethnicity, compared with neonates of Malay ethnicity, neonates of Chinese, Indian, Orang Asli, and other Bumiputera ethnicities had lower birthweights. Birthweight increases with maternal height among Malaysians of all ethnicities. SGA and LGA cutoffs specific to maternal height may be useful to guide pregnancy management.

Uncomplicated vaginal delivery 5 years after acute traumatic aortic transection and transluminal endovascular aortic repair

We describe the case of a 40-year-old patient who sustained an aortic transection in 2016 following a road traffic accident and had two subsequent full-term pregnancies. This case adds to the literature on pregnancy after endovascular aortic repair.

Uterine rupture secondary to pyomyoma leading to intraabdominal abscesses following an uncomplicated vaginal delivery

Uterine rupture secondary to pyomyoma leading to intraabdominal abscesses following an uncomplicated vaginal delivery

Comparative analysis of thiol-disulfide homeostasis dynamics between elective cesarean section and uncomplicated vaginal delivery: insights into perinatal oxidative balance.

Thiols are organic compounds containing sulfhydryl groups that exert antioxidant effects via dynamic thiol-disulfide homeostasis. The shift towards disulfide indicates the presence of an oxidative environment. Different modes of delivery can affect thiol-disulfide homeostasis. Accordingly, we planned this research to evaluate the effects of the mode of delivery on thiol-disulfide homeostasis in both maternal serum and fetal cord blood samples. We conducted a prospective case-control study involving two groups: vaginal delivery (n=50) and elective cesarean section (CS) (n=45). The vaginal delivery group exclusively comprised uncomplicated term deliveries, while the CS group included pregnant individuals with scheduled cesarean deliveries due to the absence of spontaneous labor onset. Maternal serum and fetal cord blood samples were collected, and thiol-disulfide exchanges were analyzed using an automated method capable of measuring both aspects of the thiol-disulfide balance. The levels of native thiol (-SH) and total thiol in both maternal serum and fetal cord blood samples were significantly higher in the vaginal delivery group than those in the CS group. An important discovery of our study was that fetal cord disulfide (-SS) level, which may reflect oxidative stress, was higher in newborns born via vaginal delivery when examined alone. However, in both maternal and fetal cord blood, the combined ratios, SS/SH ratio (%), SS/Total thiol ratio (%), and SH/Total thiol ratio (%) were observed to be similar between the groups in both maternal and fetal cord blood. It was observed that as the mother's weight gained during pregnancy increased, SS/SH and SS/total thiol increased (positive correlation), while SH/total thiol decreased (negative correlation). Our results showed that the dynamic thiol-disulfide homeostasis was greatly influenced by the way of delivery and supported the idea that vaginally-delivered infants may have more oxidative stress.

Kord Kanı ve Yenidoğan Plazma Beyin Natriüretik Peptid Düzeyleri ile Doğum Şekli Arasındaki İlişki

Fetal-to-neonatal adaptation involves many complex mechanisms. Cardiovascular biomarkers may help to understand fetal and maternal physiology in pregnancy and during the perinatal transition period. In this present study, our aim was to assess the association between delivery type and brain natriuretic peptide (BNP) levels in healthy full-term neonates. Forty-eight neonates born by vaginal delivery (n=25) and cesarean section (n=23) were included in the study. Plasma BNP levels were measured at cord blood samples. In addition antropometric measurements and physical examination were evaluated at first day of life. BNP levels measure and clinical evaluation were repeated 3 days later after birth. The median cord and infant BNP levels were similar in vaginal and cesarean delivery. There was no difference between the median cord and infant BNP levels in vaginal deliveries [54.0 pg/ml (q1-q3: 40.0-111.5) and 66.0 pg/ml (q1-q3: 43.0-90.0) respectively, p=0.619]. However, the median infant BNP level was statistically significantly higher than the median cord BNP level [56.0 pg/ml (q1-q3: 39.0-84.0) and 75.0 pg/ml (q1-q3: 54.0-145.0), p=0.027] in cesarean deliveries. Uncomplicated vaginal deliveries were not associated with high BNP levels and thus fetal cardiac distress. Increased levels of BNP levels on the 3rd day in elective cesarean deliveries may be predictive of delayed postnatal pulmonary and cardiac adaptation.

THU439 Baby's Coming, Break A Leg! A Case Of Transient Osteoporosis Of The Hip

Abstract Disclosure: A. Khan: None. A. Syeda: None. H.B. Aftab: None. Introduction: Pregnancy-associated osteoporosis (PAO) is a rare condition presenting as fragility fractures usually in the latter part of pregnancy or immediate postpartum period. Vertebral fractures are more commonly reported but femoral fractures have also been described in the literature as a distinct entity: transient osteoporosis of the hip (TOH). We present a case of bilateral (B/L) femoral fractures in a woman during pregnancy and in the postpartum period. Case: A 31-year-old, gravida 1 female developed left leg pain at 26 weeks of gestation. The pain radiated from her left lower back to her left knee. It was severe in intensity resulting in her walking with crutches. Subsequent MRI of the left hip showed subchondral insufficiency fracture of the femoral head with prominent bone marrow edema extending from the head into the femoral neck. She was managed conservatively with non-weight bearing status and oral analgesics. She had an uncomplicated vaginal delivery at 39 weeks of gestation. During the first postpartum week she developed right hip pain. MRI of right hip revealed nondisplaced right femoral head subchondral insufficiency fracture with associated effusion and synovitis. She recovered within the next 3 months with resolution of her pain with conservative management. Other than limited calcium intake in childhood, there were no other identifiable risk factors for osteoporosis. Bone density scan revealed normal Z-scores at the lumbar spine and non-dominant wrist. The hips were not evaluated. Workup for secondary causes of osteoporosis was unremarkable including normal serum calcium, PTH, phosphorus, magnesium, SPEP, tissue transglutaminase antibodies, estradiol, LH, FSH, prolactin levels. However, 24-hour urine calcium level was low at 11 (35-250) mg/24hr. Elevated levels of bone specific alkaline phosphatase and urine N-telopeptide (NTX) were noted at 19.9 (5.3-19.5) mcg/L and 110 (4-64) nM BCE/mM creatinine, respectively. Patient was continued on vitamin D and calcium supplements. She breastfed for the initial 2 months but was advised to stop. At her most recent follow up visit 4 months postpartum patient was doing well. Discussion: TOH is a rare entity, and presentation as B/L femoral fractures is exceedingly rare. During pregnancy and lactation, the skeletal system undergoes bone loss to compensate for the calcium demand of the fetal skeletal system. In TOH, venous stasis from the gravid uterus resulting in bone marrow edema is the proposed mechanism in addition to pregnancy associated bone loss. In our patient, a low 24-hr urine calcium could suggest low calcium intake which could have contributed to the fracture as well. While recurrence of PAO has been described, no recurrence of TOH has been reported in subsequent pregnancies. Our case highlights the importance of keeping this rare entity on the differential in pregnant women presenting with back or hip pain. Presentation: Thursday, June 15, 2023

FRI204 A Rare Case Of Cushing Syndrome In Pregnancy: Diagnosis And Therapeutic Challenges

Abstract Disclosure: Z. Cardona: None. E.D. Szmuilowicz: None. Introduction: Cushing’s syndrome (CS) rarely occurs during pregnancy, and diagnosis of Cushing’s syndrome in pregnancy is challenging due to physiologic changes during gestation. CS is associated with severe maternal and fetal complications. Clinical Case: A 36-year-old woman presented at 21 weeks gestational age with a known adrenal nodule admitted for evaluation of HTN, bilateral lower extremity edema, transaminitis, hyperglycemia, and acute hypoxemic respiratory failure. Reported proximal muscle weakness, facial swelling, anxiety, depression, perspiration, and headaches associated with HTN. Physical exam notable for mild supraclavicular fat deposition, chest and neck plethora, hypertrichosis, and bruising. CT abdomen pelvis revealed a 2.3-cm left adrenal nodule measuring 30 Hounsfield units. Biochemical evaluation included a plasma renin activity of 0.719 ng/mL/h [ref range: 0.167-5.380 ng/mL/h], aldosterone &amp;lt;1.0 ng/dL [ref range: 0.167-5.380 ng/dL], potassium 2.6 mEq/dL, free plasma metanephrines (MN) &amp;lt; 25 pg/mL [ref range: &amp;lt; or = 57 pg/mL], free normetanephrines (NMN) &amp;lt; 25 pg/mL [ref range: &amp;lt; or = 148 pg/mL, total free MN and NMN &amp;lt; 25 [ref range: &amp;lt; or = 205 pg/mL]. 24-hour urine free cortisol (UFC) was markedly elevated at 1854.1 mcg/24h [ref range: 3.1-50.0 mcg/24h], repeat 2186.2 mcg/24h, ACTH: 1.5 pg/mL [ref range: 7.2-63.6 pg/mL], confirming a diagnosis of ACTH-independent CS. Her case was complicated due to the adrenal nodule location. Patients with left adrenal nodules are at risk of developing inferior vena cava (IVC) syndrome during left adrenalectomies, especially in the third trimester, due to compression exerted by the uterus while lying on the right side during the procedure. She underwent an uncomplicated laparoscopic left adrenalectomy. Was started on hydrocortisone (HC) following surgery. There was concern for transient neonatal adrenal insufficiency at delivery. Measuring adrenal insufficiency in utero is challenging; however, estriol could serve as a surrogate marker of fetal adrenal function. Her estriol was normal, possibly indicating intact fetal adrenal activity. She had an uncomplicated vaginal delivery with no signs of adrenal insufficiency in her baby. Interestingly, she had a severely low alkaline phosphatase (ALP) which completely normalized soon after adrenalectomy. Clinical Lesson: This case depicts the challenges in managing CS in pregnancy and its repercussions regarding maternal, fetal, and delivery outcomes. Additionally, it highlights the importance of implementing a multidisciplinary approach, including obstetricians, endocrinologists, endocrine surgeons, and pediatricians, to ensure the optimization of therapeutic strategies. Presentation: Friday, June 16, 2023

SAT134 CGM Use During Pregnancy Complicated By CF-Induced Diabetes

Abstract Disclosure: A.Y. Mazori: None. E.S. Markovic: None. C.J. Levy: Advisory Board Member; Self; Dexcom, Eli Lilly &amp; Company. Research Investigator; Self; Abbott Laboratories, Insulet Corporation, Tandem Diabetes Care, Dexcom. Introduction: Glycemic control remains challenging in pregnancies complicated by diabetes mellitus. Strict glycemic targets are required to optimize maternal and neonatal outcomes, but euglycemia is hindered by fluctuating insulin sensitivity and the need for frequent blood-glucose monitoring (BGM). Consensus guidelines recommend therapeutic continuous glucose monitoring (CGM) for pregnant and nonpregnant individuals with type 1 and type 2 diabetes, but current data support therapeutic CGM use in cystic fibrosis (CF)-related diabetes (CFRD) only outside of pregnancy. We report the case of a patient with CFRD who achieved recommended glycemic targets with a therapeutic CGM during a singleton pregnancy. Methods: A case report and literature review are presented. Results: A 32-year-old nulliparous woman with CF became pregnant via frozen-embryo transfer. Prior CF complications included CFRD, pancreatic insufficiency, and recurrent pancreatitis. A therapeutic Dexcom G6 CGM and intermittent BGM were used to monitor glycemic control before and during pregnancy; sensor use exceeded 96%. Pressure-induced sensor attenuations yielded sporadic hypoglycemic values discordant with simultaneous BGM. CGM analysis for the 90 days preceding conception revealed: time in range of 63-140 mg/dL (TIR) was 90.8%, time above range (TAR) 6.3%, and time below range (TBR) 2.9%. Throughout pregnancy, TIR was 92.9%, TAR 3.4%, and TBR 3.6%; no severe hypoglycemia occurred. Daytime (6AM to midnight) and nighttime hypoglycemia were 4.6% and 2.2%, respectively. In the first trimester, TIR was 90.8%, TAR 3.7%, and TBR 5.5%. During the second trimester, the patient achieved TIR 94.2%, TAR 2.6%, and TBR 3.2%. In the third trimester, TIR was 95.7%, TAR 0.9%, and TBR 3.4%. The pregestational CFRD regimen consisted of insulin glargine 12 units and lispro 3-8 units. The basal-insulin dose was 10 units at 13 weeks’ gestation, 9 units at 27 weeks’ gestation, and 8 units at 38 weeks’ gestation. The prandial-insulin doses varied between 1.5-5 units at 13 weeks’ gestation, 0-7 units at 27 weeks’ gestation, and 0-5 units at 38 weeks’ gestation. After an uncomplicated vaginal delivery at 38 weeks and six days’ gestation, maternal fasting hypoglycemia occurred after one dose of glargine 3 units. Euglycemia was obtained without basal, prandial, or correctional insulin. The neonate experienced mild hypoglycemia that resolved with oral glucose gel and feeding. The neonate was neither macrosomic nor large for gestational age (birth weight, 3.54 kg, 71st percentile) and did not require intensive-care unit management. Both the patient and neonate were discharged on postpartum day two. Conclusion: Therapeutic CGM use in a pregnancy complicated by CFRD was effective for maternal and neonatal outcomes. Further study is warranted to examine CGM use and efficacy in this population. Presentation: Saturday, June 17, 2023

FRI479 Resistance To Thyroid Hormone Due To Thyroid Hormone Receptor Alpha (THRA) Gene Mutation

Abstract Disclosure: J.O. Abdelkarim: None. S. Parveen: None. M.G. Jakoby: None. J. Fleischer: None. Introduction: Resistance to thyroid hormone (RTH) is a heritable disorder characterized by diminished response to triiodothyronine (T3). Most cases of RTH are due to mutations in the thyroid hormone receptor beta (THRB) gene (“RTH-beta”). Mutations in thyroid hormone receptor alpha (THRA) gene appear to be a rare cause of RTH (“RTH-alpha”), with the first case reported in 2012. We present a case of RTH-alpha in a patient confirmed to have a pathogenic THRA mutation. Clinical Case: A 38-year-old Caucasian male was referred to genetic clinic due to mild developmental delay, dyscalculia and mild autism spectrum disorder. He was born at term by uncomplicated spontaneous vaginal delivery. Parents first noticed developmental delays at age 5 y, though no evaluation occurred during childhood. As an adult, the patient completed seminary studies and was employed as a Catholic priest. An intellectual disability gene panel revealed a pathogenic variant of the THRA gene (c.1151G&amp;gt;A p.R384H). Both parents tested negative for the mutation. Examination was notable for obesity (183 cm, 186 kg, BMI 55.5), macrocephaly, hypertelorism, pectus excavatum and small hands with short digits. No thyroid anatomic thyroid abnormalities were appreciated on neck examination or ultrasonography. TSH was 1.860 mIU/L (0.358-3.740), free T4 0.71 ng/dL (0.76-1.46), and free T3 3.2 pg/mL (2.2-4.0). The patient had no symptoms of hypothyroidism, and supplemental thyroid hormone was deferred. Discussion: There are 29 reported THRA gene mutations and 32 cases of RTH-alpha reported in the peer reviewed literature. Common clinical features include mild-to-moderate intellectual impairment, low basal metabolic rate (BMR), mild skeletal dysplasia, normocytic anemia, bradycardia, consistent with high expression of THRA in brain, heart, gastrointestinal tract, skeletal muscle, and bone. TSH is normal to slightly increased, free T4 is low to low normal, and free T3 is normal to modestly elevated. This is the third reported case of the c.1151G&amp;gt;A missense mutation resulting in an arginine to histidine substitution at codon 384. Thyroid function tests conform to the pattern described for other cases of RTH-alpha. Like the other two patients with the R384H mutation, developmental delays occurred, though intellectual manifestations mitigated with time and the patient completed seminary studies without difficulty. Mitigation of phenotype with age has been reported in RTH-alpha mice with the R384C missense mutation. Short stature did not occur in this patient or the other R384H cases. Unlike other patients, this patient did not experience anemia or constipation. Macrocephaly is a common feature of the three R384H cases, but the patient’s other skeletal manifestations (e.g. pectus excavatum) were not reported. This case demonstrates the difficulty of recognizing THR-alpha and extends our understanding of the R384H phenotype. Presentation: Friday, June 16, 2023

Unstable pelvic fractures in women: implications on obstetric outcome

PurposeObstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery.MethodA retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16–45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared.ResultsForty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate.ConclusionPostoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies.

Impact of an accessory cavitated uterine mass on fertility: case presentation and review of the literature

We report a case of an accessory cavitated uterine mass (ACUM) in a patient with infertility and chronic pelvic pain. In addition, we summarize the literature to better characterize ACUM diagnosis and management. A comprehensive literature search using the PubMed database was performed through April 2023. Historical ACUM diagnostic criteria were applied as inclusion criteria. Descriptive statistics and statistical evaluation were reported. A 31-year-old nulligravid woman presented with chronic pelvic pain, dysmenorrhea, primary infertility, and history of endometriosis. Three-dimensional ultrasonography identified an ACUM and laparoscopic excision provided complete resolution of symptoms. Subsequently, she conceived without assistance twice with uncomplicated vaginal deliveries. A total of 154 articles were identified, 34 papers met inclusion criteria and were individually reviewed, consisting of 70 reported cases. The most common presenting complaints were dysmenorrhea (81.4%), chronic pelvic/abdominal pain (54.1%), and refractory pain (34.3%). Diagnostic imaging included magnetic resonance imaging (62.9%) and transvaginal ultrasound (55.7%). Management included resection via laparoscopy (75.7%) or laparotomy (18.6%), or hysterectomy (5.7%). Of cases with reported outcomes, 90.7% had complete relief of symptoms after surgery. ACUM often presents with dysmenorrhea, chronic pelvic pain, or abdominal pain and is identifiable on magnetic resonance imaging as a hyperenhancing mass. Three-dimensional transvaginal ultrasound can also accurately identify ACUM. A total of 90.7% of patients had complete relief of symptoms after intervention. It is important to identify ACUM early to relieve pain and reduce unnecessary interventions. Like our patient, other reports have demonstrated concomitant infertility and endometriosis. However, further investigation is needed to explore the association between infertility and ACUM.

Discontinuation of Routine Postpartum Complete Blood Count in Uncomplicated Vaginal Deliveries

Discontinuation of Routine Postpartum Complete Blood Count in Uncomplicated Vaginal Deliveries

Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects.

Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.

Asynchronous Learning Module for Pediatric Emergency Medicine Physicians on How to Manage Vaginal Birth and Neonatal Resuscitation in the Emergency Department.

Newborn deliveries and neonatal resuscitation events are rare but essential skills for pediatric emergency medicine (PEM) physicians. We sought to evaluate the effect of an online module on PEM physicians' knowledge and confidence in managing newborn deliveries and neonatal resuscitation. A team of experts in PEM, obstetrics, neonatology, and medical education developed a self-directed, 1-hour online module on managing newborn deliveries with neonatal resuscitation. The module was designed to address the learning needs of the targeted group. The module was piloted before dissemination to PEM faculty. A 10-question multiple choice test was given to assess knowledge of the material covered. A 10-point Likert scale questions survey was used to evaluate confidence. Measures were administered before initiation, after module completion, and 6 months after completion. Paired t tests were used to compare mean knowledge scores, and rank sum tests were used to compare median confidence levels. Most (n = 47, 89%) of the PEM faculty members completed the module. The majority (n = 43, 91%) thought the information was relevant to their practice. After completing the module, physicians' overall knowledge scores improved by 18% (mean [SD]: 74% [14.7] vs 92% [8.0], P < 0.01). Self-assessed confidence improved after the module in terms of managing uncomplicated vaginal deliveries (median 5 vs 7, P < 0.01), care of patients with complicated vaginal deliveries (2 vs 5, P < 0.01), and managing neonatal resuscitation (7 vs 8, P < 0.01). During the 6-month follow-up, there was sustained improvement in physicians' overall knowledge score (82% [16.9], P = 0.007) and self-assessed confidence in managing complicated vaginal deliveries (median 2 vs 4, P = 0.0012); however, other measures were not statistically significant. An online module is an appropriate method for training PEM providers about rarely used but essential skills such as managing vaginal deliveries and neonatal resuscitation.

Defined Protocol Including Quantitative Blood Loss Obviates the Need for Postpartum Day 1 Complete Blood Count in Uncomplicated Vaginal Deliveries [ID: 1371414

INTRODUCTION: A postpartum day 1 (PPD1) complete blood count (CBC) is a common postpartum practice. The purpose of PPD1 CBCs is to identify patients with anemia that may benefit from a blood transfusion (BT). However, after the introduction of quantitative blood loss (QBL), we questioned the benefit of PPD1 CBC collection. This study aimed to determine whether PPD1 CBCs provided clinical utility in objectively defined uncomplicated vaginal deliveries. METHODS: A retrospective chart review was performed on all vaginal deliveries from January 1, 2021 to January 31, 2022, at a single-site level IV maternity facility. Exclusion criteria were as follows: intraamniotic infections, QBL of 1,000 mL or more, starting hematocrit less than 35, or no documented QBL. Patients were divided into three groups based on QBL: less than 500 mL, 501–749 mL, and 750–999 mL. RESULTS: The total number of deliveries was 2,427. One thousand two hundred fifty-three met inclusion criteria: QBL less than 500 mL: 922; 501–749 mL: 240; and QBL 750–999 mL: 91. Among all included deliveries, one patient, in the QBL 750- to 999-mL group, received a BT due to symptomatic anemia but had hemoglobin and hematocrit greater than 7/21. The total cost of PPD1 CBCs for included deliveries was $87,710. CONCLUSION: None of the patients in this study who met the inclusion criteria received a BT based on the PPD1 CBC result. This indicates that a PPD1 CBC is of limited clinical utility when uncomplicated vaginal deliveries are defined using this purely objective protocol in the setting of QBL. Therefore, elimination of a PPD1 CBC is consistent with best practice and results in postpartum care cost reduction.

Abstract #1398468: Lymphocytic Hypophysitis Successfully Treated with Prednisone

Lymphocytic Hypophysitis is an inflammatory disorder of the pituitary gland that has classically been described in pregnant and postpartum women. It is the most common type of Primary Hypophysitis which refers to inflammation of the pituitary gland that is not secondary to other systemic diseases or drugs. This is a rare group of disorders with an estimated annual incidence of 2.4 in 10 million. We present the case of a young woman diagnosed with Lymphocytic Hypophysitis and successfully treated with prednisone. A 27-year-old previously healthy female presented with daily headaches and fatigue that began 4 months after an uncomplicated vaginal delivery. She was amenorrheic despite cessation of breast milk production. Physical exam was within normal limits. Laboratory evaluation revealed an AM cortisol of 1 mg/dl (4-22), Free T4 of 0.4 ng/dL (0.8-1.8), LH of 0.5 mIU/mL (1.9-12.5), and estrogen of 30 pg/ml (12.5-166, follicular), consistent with adrenal insufficiency, hypothyroidism, and hypogonadism. Prolactin was normal. She had no evidence of Diabetes Insipidus. MRI pituitary with and without contrast revealed an intensely and homogenously enhancing sellar mass measuring 2 x 2 x 1.3 cm with suprasellar extension and mass effect on the optic chiasm. She did not have any abnormalities in her visual fields or acuity. Lymphocytic Hypophysitis was felt to be the most likely diagnosis based on her clinical presentation and imaging features. Via shared decision-making, she was started on 40 mg of oral prednisone daily in addition to levothyroxine and oral combined contraceptive pills. On reevaluation 2 months later, her symptoms improved and a repeat MRI revealed a dramatic improvement in the appearance of the lesion following which prednisone was reduced to 30 mg with a plan for revaluation after 2 more months. Lymphocytic Hypophysitis should always be suspected in pregnant and postpartum women with neurological complaints of headaches or visual abnormalities and pituitary hormonal deficiency. The investigation involves obtaining an anterior pituitary hormonal profile including TSH with free T4, ACTH with cortisol, FSH, LH, estradiol, and prolactin. Serum sodium with plasma and urine osmolality can be used to evaluate diabetes insipidus in suspected cases. MRI pituitary with and without contrast frequently reveals a symmetric sellar lesion that enhances intensely and homogeneously with gadolinium. A pituitary adenoma, in contrast, enhances less than the normal pituitary tissue. A tool based on clinical and radiological features called the Gutenberg score can also aid in differentiating lymphocytic hypophysitis from an adenoma. Treatment involves management of hormonal deficiencies including Diabetes Insipidus and relief of symptoms of mass effect. Glucocorticoids can induce remission and possible recovery of hormonal function. Follow-up with serial imaging in a few months after initiation of glucocorticoids is essential. Diagnosis needs to be reconsidered if there is no improvement in the appearance of the lesion and a pituitary biopsy may be indicated.

Abstract #1402502: Hypercalcemia of Malignancy in Pregnancy, a Management Dilemma

Hypercalcemia of Malignancy (HCM) is a complication that is typically managed with bisphosphonates (BP). However, BP are not studied in pregnant patients with HCM and avoided due to potential adverse outcomes on mother and fetus thus limiting available options to manage hypercalcemia in pregnancy. We describe a case of HCM in a pregnant patient managed with Zoledronic acid. 36-year-old female, 32 weeks pregnant diagnosed during pregnancy with stage IV Breast cancer with liver and bone metastases, was admitted with hypercalcemia with no previous history. She did not have renal stones, polyuria, constipation, bone pain, fractures or taking calcium supplements. Lab data showed high calcium 12.9mg/dl, low PTH 5pg/ml, 25-OH vitamin D 15.5ng/ml, 1,25 OH vitamin D 70.28pg/ml, high PTHrP 6.1pmol/L. She received IV fluids and calcitonin with minimal benefit. After weighing risks and benefit and discussion with other teams, she was given IV Zoledronic acid. With chemotherapy and hypercalcemia, she developed severe emesis and decreased oral intake resulting in dehydration, low magnesium and phosphorus. She developed arrhythmia, frequent uterine contractions and fetal tachycardia and was treated for preterm labor with steroids, penicillin prophylaxis, aggressive hydration, and electrolyte replacement. Preterm delivery was safely avoided. After 4 days of BP dose, calcium normalized to 8.2 mg/dL and she was stable to be discharged home. She later received second cycle of chemotherapy and had uncomplicated vaginal delivery at 38 weeks with no neonatal complications. There are few studies on use of BP in pregnancy showing no increased risk of serious adverse effects. A systematic review of 51 cases with exposure to BP before or during pregnancy did not result in skeletal abnormalities or congenital malformations in the infants. In another case control study of 36 women with BP exposure, no major teratogenic effects were found but rates of neonatal complications were increased in women with systemic diseases, as were spontaneous abortions for women with bone disease. One case of 24 weeks pregnant female with metastatic breast cancer, pamidronate improved HCM and uterine contractions with no adverse effects on neonate. In our patient, treating hypercalcemia was necessary to avoid severe complications. We treated her with zoledronic acid as it is more effective then pamidronate at normalizing calcium and has similar safety profile. We optimized hydration status and monitored electrolytes to mitigate risk of side effects expected from BP use with good maternal and fetal results. More studies are required to determine safe use of BP in pregnant patients to guide management and avoid complications of HCM in mother and fetus.