Department of Obstetrics and Gynecology Medical Student Works
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Item Robot Assisted Hysterectomy and Risk Assessment of Vaginal Cuff Dehiscence(2022-03) Avery, Chace; Kinney, Kelsey; Lawson, Katie; Chase, Salmon; Yeagley, ThomasItem Cholestasis in the First Trimester Associated with Rare ABCG5/8 Variants: A Case Study(2022-07-28) Ganapaneni, Sruthi; Arul Dhas, Blessed Winston; Vuppalanchi, Raj; Quinney, SaraCholestasis in the First Trimester Associated with Rare ABCG5/8 Variants: A Case Study Sruthi Ganapaneni 1, Blessed Winston Arul Dhas 2, Raj Vuppalanchi 2, Sara Quinney 2,3 1 Indiana University School of Medicine; 2 Indiana University School of Medicine, Department of Medicine; 3 Indiana University School of Medicine, Department of Obstetrics and Gynecology Purpose/Background: Obstetric cholestasis, or intrahepatic cholestasis of pregnancy (ICP), is a liver disease that usually presents in the third trimester of pregnancy. It is characterized by pruritis that is associated with elevated liver enzymes and bile acids. This condition can have potentially serious effects on the fetus due to the buildup of serum bile acids resulting from the obstruction of bile flow. Methods/Case Overview: A 28-year-old patient, who was pregnant for the third time, developed pruritis in the first trimester and presented with blood work that showed elevated total bile acids and liver enzymes. A medical history revealed similar symptoms amongst her female relatives during their pregnancies as well as the patient’s own previous pregnancies, suggesting a genetic component in the etiology of the disease. Genetic testing supported this hypothesis and showed variants of unknown significance that indicated a duplication in the ABCG5 and ABCDG8 genes. Results/Discussion: This finding was rather unusual as these genes have not yet been clinically associated with ICP. The ABCG5 and ABCG8 genes code for canicular bile transporters in the liver that transport cholesterol into the bile. Overexpression of these transporters due to the duplication in her genes may result in increased transport of cholesterol into bile, disrupting the regular composition of bile. The resulting increased bile viscosity may cause bile stasis or blockage, and this proposed mechanism can possibly explain the pathophysiology behind this unusual case of cholestasis. Conclusion and Potential Impact: ICP can have potential serious effects on the developing fetus, and its etiology is still being understood. The novel ABCG5/8 gene duplication is a novel variant that may lead to earlier onset of ICP than commonly known variants.Item 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, BhaviBackground: 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.Item 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, SharonTitle: 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.Item Cystic Fibrosis in Adults: Why you should keep it on the differential.(2024-03-24) Crowley, Evelyn M.; Mederos, Alexa V.; Rusiniak, Katie; Williams, Elijah; Robles, Maria Parker SpectorBackground: Cystic Fibrosis (CF) occurs from mutations in the Cystic Fibrosis transmembrane conductance regulator (CFTR) gene. This causes abnormal transport of electrolytes in exocrine tissues, leading to thick secretions that affect multiple organs.1 Newborn screens (NBS) allow for a diagnosis in infancy, but CF can present in adulthood. Adult-onset CF is often due to uncommon mutations that result in atypical presentations.2 Unlike the male predominance seen in children, most adult-onset cases are in females. To diagnose CF, there must be a positive NBS or one symptomatic organ system, with evidence of CFTR dysfunction from a sweat chloride test (ST), nasal potential difference, or gene mutation.1 ST can be inconclusive in adults, requiring multiple STs and genetic testing.3 Case Description: A 47-year-old Spanish-speaking immigrant female was diagnosed with CF at age 40. Prior history includes rheumatoid arthritis, insulin-dependent diabetes, and asthma. Her pancreatic insufficiency, multiple CT findings of chronic bronchiectasis, and hospitalization from Levaquin-resistant pseudomonas pneumonia suggested CF. Subsequent ST results on two occasions confirmed CF. Genetic testing revealed heterogeneity for a single nucleotide variant (SNV) of the CFTR gene, p.Arg352Gln. She has no known family history of CF, but this SNV is reported to have germline origin.4 Clinical Significance: The patient’s delayed diagnosis, immigration status, and lack of insurance served as barriers for proper care. Life expectancy is significantly decreased in uninsured patients with known CF,5 and likely further decreased when a diagnosis is delayed by additional barriers. CF is not screened worldwide, thus should still be evaluated in symptomatic immigrants.6 With most CF diagnosed in children, providers are less likely to consider it in adult patients, leading to several individual diagnoses prior to a CF diagnosis. Conclusion: Providers must be aware of bias and patient barriers when forming a differential for patients with signs of adult-onset CF.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.