A ruptured vulvar labial artery pseudoaneurysm causes a secondary postpartum hemorrhage: A case report.

Background:Postpartum hemorrhage is the most common cause of maternal morbidity in the United States. However, secondary postpartum hemorrhage is rare and includes pseudoaneurysms, which represent only 3.3% of all cases of secondary postpartum hemorrhage. Vulvar labial artery pseudoaneurysm had never been reported in the literature. Case:This is a case of ruptured vulvar labial pseudoaneurysm leading to secondary postpartum hemorrhage. Computerized tomography angiography showed it to be located in a distal branch of the vulvar labial artery. This location is unique, although there are reported cases of pseudoaneurysms in the uterine artery. The patient was successfully treated with arterial embolization. Conclusion:Recognition of a ruptured pseudoaneurysm as the cause of postpartum hemorrhage allows for its proper management by arterial embolization

Implementation of an Enhanced Recovery After Surgery (ERAS) Pathway for Benign Gynecologic Surgery

Introduction: Enhanced Recovery after Surgery (ERAS) protocols have gained traction in the surgical field as evidence-based interventions aimed at speeding functional recovery. These protocols are designed to minimize the physiological changes and stress associated with surgery, and have been demonstrated in other surgical settings such as Gynecologic Oncology and Colorectal Surgery to decrease medical costs and improve patient outcomes. Recently, ERAS protocols have been refined and adopted in the field of benign gynecology by various institutions following an important endorsement of ERAS protocols by the American College of Obstetricians and Gynecologists (ACOG). However, there is a sparsity of research looking at the feasibility of using ERAS protocols in benign Gynecologic surgery or the outcomes associated with implementation of such protocols. Interventions, including an ERAS bundle, have become increasingly important with the growing cost of medical care and shift in focus to quality improvement initiatives. The primary aim of this quality improvement initiative was to successfully standardize perioperative and postoperative care with an ERAS protocol for the benign Gynecology patient population. Materials/Methods: A systematic review of established ERAS protocols used across the United States, in various surgical sub-specialties, was performed. The degree of evidence supporting each aspect of an ERAS protocol, such as venous thromboembolism (VTE) prophylaxis, was reviewed to ensure only the highest level of literature was used for this protocol. A new ERAS protocol specific for benign Gynecologic surgical patients was then created. Specifically, the preoperative order set was designed to include preoperative fluid management, preoperative cessation of PO intake, nursing interventions, pain control, prevention of surgical site infection, type of admission (outpatient, observation, or inpatient), code status, and venous thromboembolism (VTE) prophylaxis. The postoperative order set was designed to include orders for vital sign frequency, threshold for notification of physician, isolation, activity, precautions (fall, seizure, etc.), diet, VTE prophylaxis, obstructive sleep apnea monitoring, nursing communication, respiratory care, urinary catheter care, postoperative labs, tobacco cessation, intravenous fluids, diabetic management, pain management, and gastrointestinal management. Results: We were able to successfully develop an ERAS protocol for the benign Gynecology patients at the University of New Mexico including preoperative and postoperative measures that are well established by other medical institutions. This protocol is intended to be uniformly used for all patients undergoing any type of benign Gynecologic procedure, regardless of the level of invasiveness of the procedure. Specifically, this includes patients operated on by the gynecological divisions of General Gynecology, Family Planning, and Female Pelvic Medicine and Reconstructive Surgery. The ERAS protocol is currently being reviewed by the department of Anesthesiology to facilitate a multidisciplinary approach. Once approved by Anesthesia, other stakeholders such as preoperative, intraoperative, and postoperative nursing staff shall also vet the protocols. Once approved by all stakeholders, the ERAS protocol will be added to the electronic medical record (EMR) for daily use. Improvements after the protocol is instituted, such as decreased oxygen requirement, early patient ambulation, quicker return to bowel function and overall decreased hospital stay, will be measured for objective longitudinal data and compared to historical controls. Conclusions: ERAS protocols have paved a promising path for patients undergoing varying types of surgical procedures. Well established protocols have been largely successful for both the Colorectal and Gynecologic Oncology patient population, but they are also gaining speed in benign Gynecology at hospitals such as the University of Virginia and University of Pittsburgh. We were able to create an evidence-based preoperative and postoperative order set based on review of optimal interventions in the literature, and were able to get buy-in from early stakeholders. We anticipate that with implementation of this standard ERAS protocol for Gynecologic procedures we will see a decrease in cost to the healthcare system and improvement in surgical outcomes for benign Gynecologic patients undergoing surgery

Clinical vignette: CONNed out of a diagnosis: a case of an ectopic ACTH-secreting tumor

Ectopic ACTH-secreting tumors represent a rare clinical entity which can cause a secondary Cushing\u27s syndrome. These hormone-secreting tumors can result in a syndrome that shares many clinical features of primary hyperaldosteronism (Conn\u27s syndrome), and typically require a high degree of clinical suspicion for diagnosis. A 72-year-old female with a past medical history significant for hypertension, non-insulin dependent diabetes mellitus, and tobacco use was referred to the University of New Mexico Hospital from her rural primary care provider for severe refractory hypokalemia. The patient was asymptomatic other than mild lower extremity edema that had been present for the past week and constipation over the last 2.5 weeks. The patient had been treated during this time with increasing doses of laxatives and oral potassium. Failing this treatment with an outpatient potassium level of 2.8 mmol/L and continued constipation, the patient was referred for inpatient evaluation. Upon presentation, the patient\u27s labs included a potassium of 2.8mmol/L and bicarbonate of 31mg/dL, as well as hyperglycemia, leukocytosis and evidence of a urinary tract infection. Blood pressures ranged from 160-186/79-83mmHg. Initial physical exam was notable only for lower extremity edema. Initial treatment was focused on aggressive potassium replacement and treatment of the patient\u27s infection. Due to the persistent hypertension and hypokalemia, renin and aldosterone levels were obtained which were 0.1ng/dL and 7.9ng/dL respectively, not suggestive of hyperaldosteronism. Follow up physical exam found a palpable abdominal mass prompting an abdominal CT scan, which showed colonic thickening and innumerable liver masses. Colonoscopy was grossly normal. Further history obtained suggested that the in-hospital hyperglycemia and hypertension were inconsistent with the patient\u27s recent outpatient history. 24-hour urine cortisol was obtained which was markedly elevated. An overnight dexamethasone suppression test was performed, with pre-suppression ACTH levels of 460pg/mL and post-suppression levels of 441pg/mL. A liver biopsy showed pathology consistent with small cell carcinoma which further raised suspicion for a paraneoplastic syndrome. The patient was diagnosed with Cushing\u27s syndrome caused by ectopic ACTH secretion and hyperaldosteronism-like hypokalemia with hypertension and alkalosis. A chest CT would later reveal the primary lung tumor. The patient unfortunately succumbed to her disease soon after diagnosis. We present a case of an ACTH-secreting pulmonary tumor with a secondary Cushing\u27s syndrome and hyperaldosteronism-like state. Being that the patient\u27s chief complaint was constipation, diagnosis was delayed until we achieved a full clinical picture. Our case represents the need for a high index of suspicion and global consideration of a patient\u27s signs and symptoms, as well as a presentation of a rare entity with a common chief complaint

Cardiophrenic lymph node metastasis in low-grade serous ovarian adenocarcinoma.

•Cardiophrenic lymph node metastasis in low-grade ovarian carcinoma is rare.•Two cases presented here identify clinical strategies needing further attention.•Low-grade disease is treated with surgery given high chemotherapeutic resistance.•Preoperative awareness of lymph node metastasis allows for optimal debulking.•Identifying radiologic evidence of distant metastasis improves patient outcomes

Cardiophrenic lymph node metastasis in low-grade serous ovarian adenocarcinoma.

•Cardiophrenic lymph node metastasis in low-grade ovarian carcinoma is rare.•Two cases presented here identify clinical strategies needing further attention.•Low-grade disease is treated with surgery given high chemotherapeutic resistance.•Preoperative awareness of lymph node metastasis allows for optimal debulking.•Identifying radiologic evidence of distant metastasis improves patient outcomes

A ruptured vulvar labial artery pseudoaneurysm causes a secondary postpartum hemorrhage: A case report.

BackgroundPostpartum hemorrhage is the most common cause of maternal morbidity in the United States. However, secondary postpartum hemorrhage is rare and includes pseudoaneurysms, which represent only 3.3% of all cases of secondary postpartum hemorrhage. Vulvar labial artery pseudoaneurysm had never been reported in the literature.CaseThis is a case of ruptured vulvar labial pseudoaneurysm leading to secondary postpartum hemorrhage. Computerized tomography angiography showed it to be located in a distal branch of the vulvar labial artery. This location is unique, although there are reported cases of pseudoaneurysms in the uterine artery. The patient was successfully treated with arterial embolization.ConclusionRecognition of a ruptured pseudoaneurysm as the cause of postpartum hemorrhage allows for its proper management by arterial embolization