Management of Bilateral Ectopic Pregnancies after Ovulation Induction Using Unilateral Salpingectomy and Methotrexate for the Remaining Ectopic with Subsequent Intrauterine Pregnancy

Bilateral ectopic pregnancy is a rare phenomenon which is found with increased frequency when using assisted reproductive technology (ART). This diagnosis is most often made incidentally and intraoperatively, as ultrasound and serial β-hCG trends have shown poor efficacy for accurate diagnosis. Management of bilateral ectopic pregnancies is most commonly reported using bilateral surgical removal of the ectopic pregnancy (salpingostomy and/or salpingectomy). We present a case of an ART patient with incidentally found bilateral tubal ectopic pregnancies, where multiple management strategies including medical and surgical techniques were used concurrently which resulted in a subsequent spontaneous intrauterine pregnancy. While the standard of care is difficult to establish, we recommend individualizing management decisions based on the patient\u27s reproductive goals and overall risk profile

Healthcare Provider and Patient Knowledge, Attitudes and Practices (KAP) Regarding Zika Virus

Introduction: Zika virus emergence in the western hemisphere has prompted the critical need for tailored risk counseling. Our team created a KAP survey in order to assess provider and patient awareness of Zika virus symptoms, transmission, treatment, and current and future concerns in order to inform local risk counseling efforts. Methods: The cross-sectional survey was issued in Medical Faculty Associates (MFA) clinics and via online link to healthcare providers and community members. The REDCap Data Collection tool was used to capture responses with subsequent SAS data analysis. Results: A total of 172 responses were collected. Most respondents (97%) were aware of a link between Zika virus and microcephaly. 89% think that a vaccine is important. 52% will restrict travel to Zika endemic regions. 51% will take mosquito protective measures in the US versus 91% in Zika endemic areas. 35% of pregnant women would abstain from sex if their partners traveled to a Zika endemic area whereas 25% would if they themselves were the traveler. 37% plan to delay pregnancy and 58% are concerned about eventually having a child with microcephaly. Of the healthcare providers sampled, about one-fifth could not identify Zika infection symptoms, 16% were unaware of symptom treatment options and 5.4% did not know that Zika virus could be passed transplacentally. 34% believed DEET to be unsafe in pregnancy and 52% were unsure about permethrin safety in pregnancy. Of the 172 survey respondents, most (97%) were aware of a link between Zika virus and microcephaly. 89% think that a vaccine is important. 52% would restrict travel to Zika endemic regions. 51% would practice mosquito safety in the US versus 91% in Zika endemic countries. 35% of pregnant women would abstain from intercourse if their partners traveled to Zika endemic areas whereas 25% would if they themselves were the traveler. 37% plan to delay pregnancy and 58% worry about future children with microcephaly. Of the healthcare providers, 20% could not identify Zika infection symptoms, 16% were unaware of symptom treatment options, 5% were unaware that Zika virus passes transplacentally, and 34% believed DEET to be unsafe in pregnancy. Conclusion: The survey results provide novel insight into the KAP of patients and healthcare providers regarding Zika virus. This data will be used to optimize information distribution to our community, address large knowledge gaps in both patients and providers, and prepare medical providers to offer needed counseling

Management of Bilateral Ectopic Pregnancies after Ovulation Induction Using Unilateral Salpingectomy and Methotrexate for the Remaining Ectopic with Subsequent Intrauterine Pregnancy

Bilateral ectopic pregnancy is a rare phenomenon which is found with increased frequency when using assisted reproductive technology (ART). This diagnosis is most often made incidentally and intraoperatively, as ultrasound and serial β-hCG trends have shown poor efficacy for accurate diagnosis. Management of bilateral ectopic pregnancies is most commonly reported using bilateral surgical removal of the ectopic pregnancy (salpingostomy and/or salpingectomy). We present a case of an ART patient with incidentally found bilateral tubal ectopic pregnancies, where multiple management strategies including medical and surgical techniques were used concurrently which resulted in a subsequent spontaneous intrauterine pregnancy. While the standard of care is difficult to establish, we recommend individualizing management decisions based on the patient’s reproductive goals and overall risk profile

Tranexamic Acid for Prevention and Treatment of Postpartum Hemorrhage: An Update on Management and Clinical Outcomes

© 2018 Wolters Kluwer Health, Inc. All rights reserved. Importance: Postpartum hemorrhage (PPH) remains amajor cause ofmaternalmortality worldwide, occurring in both vaginal and cesarean deliveries.We have witnessed improvements in both prevention and treatment of PPH. Tranexamic acid (TXA) has been investigated as a potential adjunct therapy to uterotonics within this setting. Objective: The aim of this article is to summarize existing recommendations on the use of TXA in obstetrics and review current data on clinical outcomes after TXA use. Evidence Acquisition: We reviewed guidelines from a number of professional societies and performed an extensive literature search reviewing relevant and current data in this area. Results and Conclusions: In the prevention of PPH, TXA use before both vaginal and cesarean deliveries reduces the amount of postpartum blood loss and should be considered in patients at higher risk for hemorrhage. In the treatment of PPH, TXA should be initiated early for maximal survival benefit from hemorrhage, and it provides no additional benefit if administered more than 3 hours from delivery. Overall, current evidence assessing the risks of TXA use in an obstetric population is reassuring. Target Audience: Obstetricians and gynecologists, family physicians. Learning Objectives: After completing this activity, the learner should be better able to: define themechanism of action of TXA; evaluate the utility of TXA in prophylaxis and treatment of PPH; define common doses of TXA used in the peripartum period; and assess associated risk and possible adverse outcome when using TXA

Tranexamic Acid for Prevention and Treatment of Postpartum Hemorrhage: An Update on Management and Clinical Outcomes.

© 2018 Wolters Kluwer Health, Inc. All rights reserved. Importance: Postpartum hemorrhage (PPH) remains amajor cause ofmaternalmortality worldwide, occurring in both vaginal and cesarean deliveries.We have witnessed improvements in both prevention and treatment of PPH. Tranexamic acid (TXA) has been investigated as a potential adjunct therapy to uterotonics within this setting. Objective: The aim of this article is to summarize existing recommendations on the use of TXA in obstetrics and review current data on clinical outcomes after TXA use. Evidence Acquisition: We reviewed guidelines from a number of professional societies and performed an extensive literature search reviewing relevant and current data in this area. Results and Conclusions: In the prevention of PPH, TXA use before both vaginal and cesarean deliveries reduces the amount of postpartum blood loss and should be considered in patients at higher risk for hemorrhage. In the treatment of PPH, TXA should be initiated early for maximal survival benefit from hemorrhage, and it provides no additional benefit if administered more than 3 hours from delivery. Overall, current evidence assessing the risks of TXA use in an obstetric population is reassuring. Target Audience: Obstetricians and gynecologists, family physicians. Learning Objectives: After completing this activity, the learner should be better able to: define themechanism of action of TXA; evaluate the utility of TXA in prophylaxis and treatment of PPH; define common doses of TXA used in the peripartum period; and assess associated risk and possible adverse outcome when using TXA

Evolution of Knowledge, Awareness, and Practices regarding Zika Virus from 2016 to 2017.

Objective. Our team created a knowledge, attitudes, and practice (KAP) survey in order to assess changes over time in healthcare provider and community member awareness of Zika virus symptoms, transmission, treatment, and current and future concerns. Study Design. The cross-sectional survey was issued at an academic medical center in Washington, DC, and via an online link to healthcare providers and community members between June and August 2016. Survey distribution was then repeated the following year, from March to April 2017. Outcomes were compared by survey year and healthcare provider versus community member status using SAS Program Version 9.4. Results. Significant differences in knowledge, attitudes, and practices existed between 2016 and 2017 survey time points. By 2017, more respondents had knowledge of various Zika virus infection characteristics; however healthcare provider knowledge also waned in certain areas. Attitudes towards Zika virus infection displayed an overall decreased concern by 2017. Practice trends by 2017 demonstrated fewer travel restrictions to Zika-endemic areas and increased mosquito protective measures within the US. Conclusions. Our results provide novel insight into the transformation of knowledge, attitudes, and practice of community members and healthcare providers regarding Zika virus since its declaration as a public health emergency of international concern in 2016

Evolution of Knowledge, Awareness, and Practices regarding Zika Virus from 2016 to 2017

Objective. Our team created a knowledge, attitudes, and practice (KAP) survey in order to assess changes over time in healthcare provider and community member awareness of Zika virus symptoms, transmission, treatment, and current and future concerns. Study Design. The cross-sectional survey was issued at an academic medical center in Washington, DC, and via an online link to healthcare providers and community members between June and August 2016. Survey distribution was then repeated the following year, from March to April 2017. Outcomes were compared by survey year and healthcare provider versus community member status using SAS Program Version 9.4. Results. Significant differences in knowledge, attitudes, and practices existed between 2016 and 2017 survey time points. By 2017, more respondents had knowledge of various Zika virus infection characteristics; however healthcare provider knowledge also waned in certain areas. Attitudes towards Zika virus infection displayed an overall decreased concern by 2017. Practice trends by 2017 demonstrated fewer travel restrictions to Zika-endemic areas and increased mosquito protective measures within the US. Conclusions. Our results provide novel insight into the transformation of knowledge, attitudes, and practice of community members and healthcare providers regarding Zika virus since its declaration as a public health emergency of international concern in 2016

Hysterectomy for the Transgendered Male: a Review of Perioperative Considerations and Surgical Techniques with Description of a Novel 2-Port Laparoscopic Approach.

© 2017 American Association of Gynecologic Laparoscopists Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed

A Multinational Study of Acute and Long-term Outcomes of Type 1 Galactosemia Patients Who Carry the S135L (c.404C>T) Variant of GALT

Patients with galactosemia who carry the S135L (c.404C>T) variant of GALT, documented to encode low-level residual GALT activity, have been under-represented in most prior studies of outcomes in Type 1 galactosemia. What is known about the acute and long-term outcomes of these patients, therefore, is based on very limited data. Here, we present a study comparing acute and long-term outcomes of 12 patients homozygous for S135L, 25 patients compound heterozygous for S135L, and 105 patients homozygous for two GALT-null (G) alleles. This is the largest cohort of S135L patients characterized to date. Acute disease following milk exposure in the newborn period was common among patients in all 3 comparison groups in our study, as were long-term complications in the domains of speech, cognition, and motor outcomes. In contrast, while at least 80% of both GALT-null and S135L compound heterozygous girls and women showed evidence of an adverse ovarian outcome, prevalence was only 25% among S135L homozygotes. Further, all young women in this study with even one copy of S135L achieved spontaneous menarche; this is true for only about 33% of women with classic galactosemia. Overall, we observed that while most long-term outcomes trended milder among groups of patients with even one copy of S135L, many individual patients, either homozygous or compound heterozygous for S135L, nonetheless experienced long-term outcomes that were not mild. This was true despite detection by newborn screening and both early and life-long dietary restriction of galactose. This information should empower more evidence-based counseling for galactosemia patients with S135L. This article is protected by copyright. All rights reserved

A multinational study of acute and long-term outcomes of Type 1 galactosemia patients who carry the S135L (c.404C > T) variant of GALT

Patients with galactosemia who carry the S135L (c.404C > T) variant of galactose-1-P uridylyltransferase (GALT), documented to encode low-level residual GALT activity, have been under-represented in most prior studies of outcomes in Type 1 galactosemia. What is known about the acute and long-term outcomes of these patients, therefore, is based on very limited data. Here, we present a study comparing acute and long-term outcomes of 12 patients homozygous for S135L, 25 patients compound heterozygous for S135L, and 105 patients homozygous for two GALT-null (G) alleles. This is the largest cohort of S135L patients characterized to date. Acute disease following milk exposure in the newborn period was common among patients in all 3 comparison groups in our study, as were long-term complications in the domains of speech, cognition, and motor outcomes. In contrast, while at least 80% of both GALT-null and S135L compound heterozygous girls and women showed evidence of an adverse ovarian outcome, prevalence was only 25% among S135L homozygotes. Further, all young women in this study with even one copy of S135L achieved spontaneous menarche; this is true for only about 33% of women with classic galactosemia. Overall, we observed that while most long-term outcomes trended milder among groups of patients with even one copy of S135L, many individual patients, either homozygous or compound heterozygous for S135L, nonetheless experienced long-term outcomes that were not mild. This was true despite detection by newborn screening and both early and life-long dietary restriction of galactose. This information should empower more evidence-based counseling for galactosemia patients with S135L