Department of Obstetrics and Gynecology Medical Student Works

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A BRCA1+ Patient with Twin Pregnancy of a Complete Mole with Complete Fetus
(American Medical Women's Association, 2023-03-23) Yaqub, Amna; Taminack, Hope; Ungureanu, Ilinca; Ganapaneni, Sruthi; Tian, Wendy; Scifres, Christina; Robertson, Sharon
Title: A BRCA1+ Patient with Twin Pregnancy of a Complete Mole with Complete Fetus Authors: Yaqub, A., Tominack, H., Ungureanu, I., Ganapaneni, S., Tian, W. MD, Scifres, C. MD, & Robertson, S. MD Background: A complete molar pregnancy is a non-viable pregnancy that results from the implantation of a diploid fertilized egg containing no maternal DNA. Twin pregnancy of a complete mole with complete fetus (CMCF) is a very rare occurrence with an incidence of 1/22,000 to 1/100,000 pregnancies. Continuing a CMCF pregnancy can result in many risks to the health of the mother and fetus. Case: A 35-year-old G3P2 female presented to an obstetric scan at 20 weeks gestation, which was suspicious for both a viable fetus and a molar pregnancy. She had no significant medical history other than being BRCA1+, with two previous uncomplicated pregnancies. Her initial ultrasound at 10 weeks gestation was indeterminate on whether this was a partial mole vs CMCF. The patient was offered the option to terminate the pregnancy due to risk of complications but chose to proceed with the pregnancy. Because she was BRCA1+ with a strong family history of breast and ovarian cancer, she had a planned Cesarean-hysterectomy with bilateral oophorectomy at 34 weeks. Mother and infant were discharged on postoperative day 2, and the pathology report of the placenta confirmed the removal of a complete mole. Serial β-hcg levels were followed after delivery. Clinical Significance: Due to the high risk of complications, pregnancy termination is typically offered to patients in this situation. Patients who choose to continue the pregnancy should be thoroughly informed of potential complications. Risks associated with continuing a CMCF pregnancy include preeclampsia, vaginal bleeding, intrauterine death of the fetus, and the development of gestational trophoblastic disease. This patient was also complicated by being BRCA1+, which impacted surgical planning. Conclusion: CMCF pregnancy is a rare occurrence with many associated risks. In BRCA1+ patients who choose to continue a CMCF pregnancy, extensive counseling is necessary with consideration for risk-reducing surgical management at time of delivery.
A case of postpartum hypothermia
(2023-03-24) Salmon, Chase; Hartman, Jennifer; Cook, Myanna; Venkatesh Shantharam, Rajalakshmi
A 22 y/o G2P1 at 39+5 presented for a scheduled repeat cesarean section. Pt. had reassuring fetal heart rate tracings and no history of complications during her pregnancy. Her only past medical history included one prior full term cesarean section and morbid obesity. She had no known drug allergies and her only known allergy is to contrast dye. Pt. underwent a repeat low-transverse C-section with a spinal epidural containing Ropivacaine 0.5% 30mL. She had no immediate complications and had an estimated blood loss of 500 ml. Approximately 2 hours postpartum, anesthesia was called to the bedside for a pt. temp of 93.5 ℉, diaphoresis, SBP 140, HR 65, and O2 Sat 95%. Pt. was given 2L O2 via nasal cannula, warm blankets, a bair hugger, and 2mg ativan IV. One hour later, the patient’s temp had improved to 97.1 ℉ and the patient was taken off the bair hugger at 8 hours postpartum. Cesarean sections with spinal anesthesia come with the risk of adverse side effects, such as hypothermic reactions. In this patient, post-op multimodal warming therapies were successful within eight hours of deployment. Core temperature monitoring post-op could serve to catch downward trending body temperatures earlier. Proactive warming measures could be utilized preoperatively and intraoperatively, such as continued forced-air warming and administering warmed IV fluids, to lower the risk of post-cesarean spinal anesthesia-related hypothermia. Hypothermic reactions are a common adverse reaction seen in cesarean sections with spinal anesthesia. Furthermore, this reaction has been associated with additional complications such as wound infection, shock, and maternal mortality. Clinically, this case highlights the efficacy of forced-air and warm blanket warming in treating post-op hypothermia, but it also highlights a potential need for more consistent monitoring of temperature post-op and further research into post-op hypothermia in obese patients, as minimal research on this topic exists.
A Case of Uterine Sarcoma: The Impact of Insurance Policy on Timely Access to Hysterectomy
(2024-03-22) Bell, Kameron; Cook, Myanna; Karki, Sabin; Sakbun, Vannara
Background: Uterine sarcoma, a uterine cancer subtype, is a rare, aggressive malignancy with non-specific symptoms, complicating early diagnosis and management. Its common symptom, abnormal uterine bleeding, can be mistaken for benign uterine fibroids, leading to treatment delays and poor prognosis. Case: A 41-year-old premenopausal female with a smoking history presented with persistent heavy uterine bleeding for over 6 months. Physical examination and transvaginal ultrasound suggested a 13-week gestational size bulky uterus and a 6.3 x 7.32 cm intrauterine fibroid, respectively. Despite these findings, hysterectomy request was denied by insurance. After a year of continued bleeding, insurance approved the surgery. During the robotic-assisted laparoscopic hysterectomy, anterior and sidewall adhesions raised malignancy suspicion. The surgical team performed a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and right colectomy. Post-operative pathology confirmed uterine sarcoma. Clinical Significance: This case highlights the impact of insurance decisions on patient care, emphasizing timely interventions' necessity and the challenges in distinguishing benign fibroids from uterine malignancy in symptomatic patients. Current literature underscores the diagnostic dilemma surrounding uterine sarcoma, especially differentiating it from benign uterine fibroids. A significant literature gap exists regarding insurance policy impact on accessing timely surgical interventions like hysterectomy, affecting uterine sarcoma prognosis and management. Conclusion: Abnormal uterine bleeding can indicate benign uterine fibroids or uterine sarcoma. In this case, the lack of alternative diagnostics and poor imaging differentiation necessitated a hysterectomy for diagnosis. The delay in insurance approval for surgery underscored the significant impact of insurance decisions on patient care, potentially exacerbating the prognosis and delaying necessary intervention for uterine sarcoma.
A Glimpse into Menstrual Health Literacy in Appalachian Ohio
(American Medical Women's Association (AMWA) 108th Annual Meeting, 2023-03-24) Cook, Myanna; Yeend, Brianna; Karki, Sabin; Stephanian, Brooke; Richcreek, Stephanie
Evidence supports that health literacy is intricately linked to education level. Appalachian Ohio reports the second lowest percentage of postsecondary education in Appalachian states, which falls 10% below the national average. Coshocton, Ohio is located in North Central Appalachia and is classified as a high poverty rural area. Prior research has established that youth across the United States often lack adequate menstrual health education, which could lead to delayed recognition of serious health issues. Currently, the Ohio Department of Education does not require menstrual education as part of broader sexual health education in schools. Given the low rates of higher education, and thus health literacy, along with lack of state required menstrual education, low levels of menstrual health literacy might disproportionately affect this area. Within the same month at an outpatient clinic in Coshocton, Ohio, two adolescent females and their mothers, who also grew up in Appalachian Ohio, presented with menstrual concerns. Both parties expressed concerns about early menarche, cycle length, menstrual flow, and clots. In both cases, the patients were experiencing clinically normal menstruation. The patients and their mothers were counseled on normal range menses. Research surrounding menstrual health literacy in rural areas is lacking. The presented cases may point to a pattern of inadequate menstrual education in Coshocton, Ohio, as the patients and parents were unaware of normal menstrual patterns. In order to progress patient care, further research should aim to discern whether this area and greater Appalachia demonstrate lower levels of menstrual health literacy. Patients in Appalachia demonstrate lower education levels, which is correlated to lower health literacy. These cases highlight potentially inadequate menstrual education in Coshocton, Ohio. Further research and improved menstrual education should be pursued in the area.
An Abscessed Tooth that Wasn't: An Unusual Case of Mumps in an Elderly Patient
(2020-03) Lin, Jenny; Willhite, Sydney; Moore, Hannah; Smith, Maddie; Duncan, Francesca
Case: A 62-year-old African American female with history of self-resolving parotitis initially presented with progressive neck and bilateral facial swelling. She attributed this to an abscessed tooth. CT revealed parotitis with inflammatory changes and mass effect on the hypopharynx and larynx, although the patient denied breathing difficulty. Antibiotics were administered for two days, discontinuing due to lack of abscess. Six days later, the patient presented with worsening facial swelling, sore throat, and dysphagia. She remained afebrile but with a WBC count of 12.8. Antibiotics and steroids were given. MRI displayed retropharyngeal space involvement of 2.6 cm in thickness. ENT performed surgical debridement and culture collection. Upon return from the OR, respiratory distress and inability to manage secretions resulted in intubation via an upright awake fiberoptic approach given concern for impending airway compromise. Finally, a positive IgM antibody to mumps virus was detected from the debridement culture. Discussion: The differential for nonsuppurative parotitis includes viruses, autoimmune disorders, and granulomatous inflammation. Paramyxovirus, specifically mumps, is the most common viral cause, with EBV, HSV, CMV, and HIV as other concerns. Autoimmune causes are Sjogren syndrome and SLE. Mycobacterium species are the likely granulomatous culprit. Though mumps is the most common viral cause of parotitis, it typically occurs in children and young adults, not fitting of the patient described. However, mumps cases have increased recently. MMR vaccination began in 1967 and cases decreased more than 99%; yet, since 2006 there have been outbreaks. Vaccine-induced protection may wane over time. Mumps is highly contagious and complications include meningitis, encephalitis, pancreatitis, and deafness, occurring more commonly in elderly patients. Patients with nonsuppurative parotitis should thus be surveyed for vaccination history and examined for MMR titers.
Acknowledging Racial and Ethnic Health Disparities in Mass Incarceration
(Indiana State Medical Association, 2022-06-06) Brown, Lucy; Clark, Sydney; Nunge, Rebecca A; Fazle, Trilliah; Cooper, Siena; Robinson, Peyton; Darroca, Roberto
Whereas, the United States incarcerates more people per capita than any country in the world, where the U.S. comprises only 4% of the world’s population, yet is home to nearly 16% of all incarcerated people in the world; and Whereas, in Indiana, the total jail population increased by 526% between 1970 and 2015, while rates of pretrial detainees have increased by 72% in the state’s 48 rural counties, 43% in the state’s 21 small/medium counties, 40% in the state’s 22 suburban counties, and 268% in Marion County alone since 2000; and Whereas, in 2015 in Indiana, when including jail, prison, immigration detention, and juvenile facilities, the incarceration rate was 765 per 100,000 people, well above the rate of the United States as a whole, which was 665 per 100,000 people; and Whereas, Black residents make up 10% of Indiana’s population, but represent 24% of people in jail and 34% of people in prison; additionally, pretrial populations, disproportionately Black and Hispanic, more than doubled from 2002 to 2017; and Whereas, in 2019, Native people made up 2.1% of all federally incarcerated people, larger than their share of the total U.S. population, which was less than one percent; additionally, Native women are particularly overrepresented in the incarcerated population, making up 2.5% of women in prisons and jails and only 0.7% of the total U.S. female population; and Whereas, populations of color are more impacted by the use of money bail, where Black defendants often receive higher bail amounts, even when controlling for legal factors such as offense severity; and Whereas, Black and brown defendants are 10-25% more likely to be detained pretrial or to receive financial conditions of release; and Whereas, significant racial and ethnic disparities exist among policing, arrests, and incarceration rates, which further exacerbate disparate health outcomes for Black communities, including, but not limited to, Black individuals disproportionately being stopped by the police, experiencing use of force and repeated arrests, serving sentences of life and life without parole, being sent to solitary confinement, and receiving convictions that place them on death row; and Whereas, nearly one in three Black men will ever be imprisoned, and nearly half of Black women currently have a family member or extended family member who is in prison; and Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; however, ISMA has no policy acknowledging the inequitable burden of incarceration and policing on minoritized individuals and communities of color; and Whereas, the AMA (H-65.954) recognizes police brutality as a manifestation of structural racism which disproportionately impacts Black, Indigenous, and other people of color; therefore, be it RESOLVED, that ISMA recognize that unjust and disproportionate racial and ethnic disparities exist in policing, sentencing, and mass incarceration among Black, indigenous, and other people of color (BIPOC) and have devastating impacts on BIPOC communities; and be it further, RESOLVED, that ISMA refer to the Committee on Diversity, Equity and Inclusion for study on what policies would be germane for ISMA to act on regarding racial and ethnic disparities in mass incarceration.
Activation of the oncogene ERG by the Ras/ERK and PI3K/AKT pathways
(2019-08) Willhite, Sydney; Strittmatter, Brady; Hollenhorst, Peter
Background and Hypothesis: The TMPRSS2-ERG re-arrangement occurs in ~50% of prostate cancers and results in aberrant expression of the transcription factor ERG in the prostate. ERG is known to be activated by the Ras/ERK and PI3K/AKT pathways, however, the exact mechanism of this activation is not fully understood. The aim of this project is to identify how activation of these signaling pathways differentially effect transcription of ERG target genes. Experimental Design or Project Methods: In order to test how the Ras/ERK and PI3K/AKT pathways effect ERG target gene transcription, normal prostate epithelial cells (RWPE1) were transfected with constitutively active AKT in combination with phospho-mutants of ERG. These cell lines were then used to conduct Quantitative Reverse Transcription PCR and Western blotting of known downstream ERG target genes to identify how the activation status of these signaling pathways affected transcription and protein production. Results: Overall, our results demonstrate that ERG mediated transcription of the VIM gene, a marker of EMT, was activated by the Ras/ERK pathway and was repressed by the PI3K/AKT pathway. In addition, we found that ERG expression decreased FOXO1 protein expression in our cell lines regardless of Ras/ERK and PI3K/AKT status. Transcription and protein quantification was also measured for ERG target gene VEGFA, a critical regulator of angiogenesis. Conclusion and Potential Impact: This project helps identify the molecular mechanisms by which a common oncogene in prostate cancer is activated. Our results demonstrate how upstream signaling pathways differentially regulate oncogenic transcription and cell transformation. Overall, this project will provide insight to the molecular mechanisms of possible therapeutic targets in prostate cancer, the most common cancer amongst men.
Adequacy of glycemic control in early pregnancy with Type 2 diabetes and perinatal outcomes
(2023-02-09) Izewski, Joanna; Tang, Rachel; Crites, Kundai; Campbell, Meredith; Pelton, Sarah; Saiko-Blair, Morgan; Scifres, Christina
Objective In non-pregnant individuals with type 2 DM (T2DM), an HbA1c target < 7% is recommended. We sought to assess if an HbA1c < 7% in early pregnancy is associated with a lower risk for adverse pregnancy outcomes. Study Design We conducted a retrospective cohort study of individuals with T2DM and a singleton gestation who delivered at 2 health systems between 2018-2020. Demographics, markers of health care utilization, and perinatal outcomes were abstracted from the medical record. Race and ethnicity were self-reported. The primary exposure was levels of glycemic control at less than 20 weeks’ gestation using recommended HbA1c targets in non-pregnant individuals (HbA1c < 7% vs. HbA1c ≥7%). Patients without documentation of HbA1c prior to 20 weeks were excluded. Perinatal outcomes were abstracted from the medical record, and logistic regression was used to adjust for covariates. Results Of the individuals who had a documented HbA1c < 20 weeks of gestation, 128/281 (46%) had a HbA1c < 7%, and 153/281 (54%) had a HbA1c ≥7%. Patients with HbA1c < 7% were more likely to be of White race and have private insurance. They also had the first HbA1c measured earlier in pregnancy, a lower mean HbA1c across gestation, less overall weight gain, and were less likely to require insulin at the time of delivery. There were no significant differences in other demographics or markers of healthcare utilization (Table 1). Outcomes are shown in Table 2. After adjusting for covariates, those with a HbA1c ≥7% were more likely to have a preterm birth < 37 weeks (aOR 2.3, 95% CI 1.3-4.0), cesarean delivery (aOR 1.9, 95% CI 1.1-3.3), and a neonate requiring NICU admission (aOR 2.9, 95% CI 1.7-4.9). Conclusion Adverse perinatal outcomes are common among individuals with T2DM even when early pregnancy HbA1c values are within recommended targets for non-pregnant individuals. Those who present with a HbA1c ≥7% are at even higher risk for several outcomes. We observed important disparities in HbA1c values in early pregnancy that likely represent barriers in accessing medical care prior to pregnancy.
Adherence Barriers to Breast Cancer Treatment: Fragmentation of Care, Mood Disorders, and Substance Use Disorder
(2021-03) Wells, Lindsey; Brown, Lucy; Heitz, Adaline; Newton, Erin
Case: The patient is a premenopausal, recently divorced 40-year-old female with a history of alcohol use disorder, anxiety, and depression. She presented with a 3-month history of a palpable right sided breast mass and was found to have Stage IIB/IIIA ER+ PR+ invasive ductal carcinoma of her right breast. She successfully completed preoperative therapy followed by a right mastectomy. She subsequently had a relapse in her alcohol use disorder and since then has had inconsistent and incomplete radiation treatment. Her substance use led to the loss of her job, custody of her children, and social support. Conclusions: We identified four primary barriers to adherence to cancer treatment: fragmentation of care, major depressive disorder, generalized anxiety disorder, and substance use disorder. As a result of these mental health and systemic communication challenges, her treatment was discontinued and her care team lost her in follow-up. Clinical Significance: As many as 28% of breast cancer patients do not complete their recommended treatment, which increases risk for recurrent breast cancers. Discontinuation of and non-adherence to therapy for breast cancers are associated with increased mortality. Among breast cancer patients who have difficulty adhering to chemotherapy treatment, a common barrier is fragmentation of care. Studies have also indicated that anxiety and depression may play explanatory roles in non-adherence to breast cancer treatment. Prevalence of depression is as high as 24% among breast cancer patients. Furthermore, rates of co-occurrence of substance use disorders in cancer patients can reach up to 35%. Substance use disorders, including alcoholism, have been associated with increased rates of non-adherence and discontinuation of hormonal treatment in individuals with ER+ breast cancer diagnoses. Interventions addressing the occurrence of mental illness and fragmented cancer care are important steps in increasing adherence among these patients.
Adnexal Torsion Secondary to Primary Cystadenoma of the Fallopian tube
(American Medical Women's Associaiton, 2024-03-22) Ganapaneni , Sruthi; Ali, Yasmin; Phiri, Maggie; Sarda, Bhavi
Background: Ovarian torsion is twisting of the ovary, typically due to an ovarian mass. However, rare primary fallopian tube tumors can be in the differential. Symptoms can occur intermittently as the adnexal mass torses and de-torses. Prompt diagnosis is crucial for the preservation of ovarian functionality and fertility. Case Description: Pt. is an 18 yo. who presented to the ED four times over the course of 6 months with repeated episodes of severe LLQ abdominal pain. During each evaluation, CTAP showed bilateral cysts, however, concurrent ovarian dopplers were negative for ovarian torsion. Gynecologists were consulted and based upon clinical exam; outpatient follow up was recommended. A follow up outpatient MRI had new concerning changes for a compromised ovary in comparison to prior imaging, so the patient was immediately contacted for counseling and recommended surgical management. Intraoperative findings revealed a twisted enlarged necrotic mass primary within the fallopian tube with normal ovaries bilaterally. Left ovarian detorsion and salpingectomy were performed with bilateral ovarian preservation. Pathology was consistent with serous cystadenoma within the left fallopian tube. Clinical Significance: This case highlights difficulties in diagnosing gynecological pathology in a patient with intermittent symptoms and varying presentation on imaging. Torsion was not due to an ovarian mass, but rather a rarer primary cystadenoma of the fallopian tube. Surgical intervention was successful in detorsion, salpingectomy of the affected tube, and preserving the ovary in order to decrease cardiovascular and osteoporotic risks and increase fertility options. Conclusion: Ovarian torsion represents a surgical emergency that requires prompt diagnosis. This case was complicated by rarer torsion due to a fallopian tube mass and inconsistent imaging findings. MRI findings lead to necessary laparoscopy for ovary detorsion and preservation.

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