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Item Indiana Pregnancy Options Resources(2024-03-01) Cook, MyannaItem 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, VannaraBackground: 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.Item Steroids Precipitating Acute Thyrotoxic Paralysis(2022-03-25) Garcia, Jennifer; Pelton, Sarah; Vander Missen, Marissa; Vultorius, Daniela; Patel, Neha; Saeed, ZebCase Description: A 34-year-old Black male was admitted with a new diagnosis of Graves’ disease and impending thyroid storm with a Burch-Wartofsky Score of 25. Initial labs showed undetectable TSH, total T3 of >800, free T4 of 7.21, and TrAb of 21.53. He was started on methimazole, propranolol, and hydrocortisone 100mg q8h. On day 2 of hospitalization, he presented with acute bilateral lower extremity paralysis shortly after eating lunch. His blood glucose was 231, and a stat BMP showed a potassium of 2.0. He was found to have thyrotoxic periodic paralysis (TPP). Steroids were stopped immediately, and he was given additional propranolol and potassium repletion. He received a total of 60mEq KCl and did not have recurrence after steroids were stopped. Conclusion: Steroids are very commonly used in treatment of thyroid storm but can potentially exacerbate endocrine emergencies, such as thyrotoxic periodic paralysis. Additionally, demographic factors may have also decreased the likelihood of considering the potential for TPP as the patient’s race did not correspond to the most common demographics, Asian populations. Thus, it is important to be aware of the potential effects of steroids. Clinical Significance: TPP is a rare complication of thyrotoxicosis. Excess thyroid hormones in the blood increase activity of the Na+/K+-ATPase pump, leading to intracellular shifts of potassium and consequential hypokalemia. Glucocorticoids have been shown to increase the relative amounts of Na+/K+-ATPase pumps and exacerbate hypokalemia. Steroids are one of four common treatments for thyroid storm, so their effects on transcellular ion balance must be monitored. Insulin was also found to increase Na+/K+-ATPase pump activity, explaining why episodes of TPP often correlate with carbohydrate-rich meals. Treatment of TPP, which can be done with repletion of KCl and beta blockers, must monitor for and avoid inducing a hyperkalemic state.Item A case of postpartum hypothermia(2023-03-24) Salmon, Chase; Hartman, Jennifer; Cook, Myanna; Venkatesh Shantharam, RajalakshmiA 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.Item 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, ChristinaObjective 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.Item Maternal weight gain among individuals with Type 2 diabetes and associated perinatal outcomes(2023-02-10) Izewski, Joanna; Crites, Kundai; Tang, Rachel; Saiko-Blair, Morgan; Campbell, Meredith; Pelton, Sarah; Scifres, ChristinaObjective The prevalence of type 2 Diabetes Mellitus (T2DM) in pregnancy is increasing, and adverse perinatal outcomes are common. We sought to assess whether higher or lower weight gain is associated with adverse perinatal outcomes in T2DM. Study Design This was a retrospective cohort study of patients with T2DM and a singleton gestation who delivered at 2 health systems between 2018-2020. Demographics, markers of health care utilization, and various perinatal outcomes were abstracted from the medical record. Race and ethnicity were self-reported. Our primary exposure was weight gain < 5 kilograms(kg) across gestation compared to those who gained ≥5kg. We excluded patients for whom weight gain could not be calculated. We assessed multiple perinatal outcomes, and we used multinomial logistic regression to adjust for covariates. Results We included 341 individuals with T2DM. There were 216/341 (63%) in the ≥5kg group, and 125/341 (37%) in the < 5kg group. The < 5kg group was more likely to be of Black race. The ≥5kg group initiated prenatal care earlier in gestation, were more likely to have ≥12 total prenatal visits, and be on insulin at the time of delivery. There were no significant differences in other demographics or markers of healthcare utilization (Table 1). Perinatal outcomes are shown in Table 2. Those with < 5kg of weight gain were less likely to develop a hypertensive disorder of pregnancy (aOR 0.3, 95% CI 0.2-0.5), or undergo a cesarean delivery (aOR 0.6, 95% CI 0.4-0.9). Stillbirth was more common among those who gained < 5kg (7 vs. 2%, p=0.02). There was a statistical difference in neonatal birthweight category (AGA vs. SGA vs. LGA) (p=0.04) between the 2 groups that did not persist after adjusting for covariates. Conclusion Weight gain is associated with adverse perinatal outcomes among individuals with T2DM. While weight gain < 5kg is associated with a reduced risk for certain outcomes, the increased risk for stillbirth deserves further study.Item Resolution 23-008: Mestrual Health and Hygiene Education(2023-10-01) Cook, Myanna; Cornwell, Ailish; Orozco, Ana; Hatfield, AngelaItem Treatment of Metastatic Her2Neu+ Breast Cancer with Oligoprogressive Disease(2024-03-22) Pelton, Sarah; Ayub, Jinan; Kenyon, Taylor; Ramchandani, Muskaan; Newton, ErinBackground Information: In treating metastatic Her2Neu+ breast cancer, trastuzumab-based chemotherapy regimens typically result in fairly durable tumor control. Historically, when there was any disease progression, the systemic therapy was changed, but it has recently been recognized that “oligoprogressive disease” (when only a limited number of metastatic sites progress) might be approached differently. This heterogeneous response to treatment is due to variation in tumor cell phenotypes, which confer drug resistance. Oligoprogressive disease is often treated with local therapy, such as stereotactic body radiotherapy (SBRT), or resection, and determination of optimal treatment regimens remains a challenge. Case Description: We report a case of a 37-year-old, premenopausal female with locally advanced, Her2Neu+ right breast cancer with de novo metastases to the liver and bone. First line systemic therapy was well-tolerated and resulted in disease control. Unfortunately, she had symptomatic progression in her primary breast tumor, which was treated with mastectomy while continuing the same systemic therapy. Later, she developed a painful, right infraclavicular metastasis; surgical resection was ultimately declined due to local edema and the tumor’s proximity to significant neurovasculature. She elected to receive palliative radiation therapy for pain control via SBRT, and her systemic therapy remained unchanged. Currently, she shows no signs of progression and continues to have excellent tolerance of her systemic therapy. Clinical Significance: Oligoprogression is a clinically significant concept for numerous cancers, but the best methods of control have not been elucidated. This case contributes to the limited knowledge base as an example of treating Her2Neu+ breast cancer-associated oligoprogressive disease with local therapy. Conclusion: The treatment approach in this case helps to define best practices for treatment of Her2Neu+ breast cancer-associated oligoprogressive disease.Item The Effects of Maternal Stress on TLR Expression in Neonatal Mus musculus Alveolar Epithelial Cells(2018-10-18) Cook, Myanna; Smith, AriannaPrior research has confirmed an association between maternal stress and offspring asthma. Recent studies suggest a role for epithelial expressed toll-like receptors (TLRs) in allergic asthma development. In this study, we were interested in isolating alveolar epithelial cells (AECs) from neonatal mice and analyzing how maternal stress potentially changes the expression of TLRs in the AECs. C57bl/6J strain mice were mated and pregnant dams started treatment at midgestation (E12.5) with free access to Vehicle or CORT-treated drinking water until the litter was born. The litter was sacrificed on postnatal day 7 (7 PND). The lungs were harvested and both AECs (EpCAM+) and immune cells (CD45+) were isolated based on staining with epithelial cell adhesion molecule (EpCAM) , CD45, and CD31 fluorescent antibodies. Here we present our optimized protocol for isolating EpCAM+ and CD45+ cells in 7 PND neonates through fluorescence activated cell sorting (FACS). Further experiments to investigate TLR expression in 7 PND AECs will be conducted. Also, we plan to further explore alveolar immune cell populations in the neonates.Item Assessing Disparities in Care Utilization and Outcomes Among Pregnant Women with T2D Based on Race and Ethnicity(2022-07-29) Pelton, Sarah; Izewski, Joanna; Scifres, ChristinaBackground/Objective: Disparities faced by individuals with type 2 diabetes (T2D) or gestational diabetes mellitus have been identified. However, because less is known about disparities faced by pregnant women with T2D and since the prevalence of T2D is increasing, we sought to investigate this issue. Methods: We performed a retrospective cohort study that included 369 women with singleton gestation and T2D that delivered from 2018-2020. Using maternal self-reported race and ethnicity abstracted from the electronic medical record, we categorized the women as Non-Hispanic White, Non-Hispanic Black, or Hispanic. Demographics, health care utilization, and maternal and neonatal outcomes were also abstracted. One way ANOVA and chi-squared tests were utilized to compare outcomes among the groups, and logistic regression was used to control for co-variates. Results: Non-Hispanic White and Non-Hispanic Black women had a higher BMI at their first prenatal visit and were more likely to be nulliparous. They were also more likely to have a prior caesarean delivery and chronic hypertension. Non-Hispanic Black women were more likely to have ≥12 prenatal visits compared to Non-Hispanic White and Hispanic women (70 vs. 43 vs. 45%, p<0.001), and non-Hispanic Black women had the lowest early pregnancy HbA1c (7.0±1.6 vs. 7.9±2.1 vs. 7.5±1.7%, p<0.001). Additionally, caesarean delivery rates were lowest for Hispanic women compared to Non-Hispanic White and Non-Hispanic Black women (45 vs. 63 vs. 71%, p<0.001); this difference persisted after controlling for co-variates (aOR 0.53, 95% CI 0.30-0.92). Conversely, there were no differences in birth weight category, preterm birth <37 weeks, hypertensive disorders of pregnancy, or NICU admission. Conclusion and Potential Impact: Pregnancies complicated by T2D have an increased risk of poor maternal and neonatal outcomes. For some outcomes, there is a significant difference among Non-Hispanic White, Non-Hispanic Black, and Hispanic women. Future studies are therefore needed to investigate causative factors and potential interventions. Presentation recording available online: https://purl.dlib.indiana.edu/iudl/media/h04d673g6h