Here are the top 10 most read posts of 2018

With only a few hours left for the calendar year 2018 to come to an end, take a look at the top 10 most read posts of the year as we gear up to look forward to another year of medical advances and health research. 

ACOG guidance on prevention of surgical-site infection in gynecologic surgery

Surgical site infections (SSIs) after gynecological surgery is a significant cause of postoperative morbidity leading to repeated hospital visits.  These infections also incur heavy social and economic burden on patients and the healthcare system.

The recent ACOG practice bulletin is published in the June issue of Journal of Obstetrics and Gynecology and replaces Practice Bulletin Number 104, May 2009, and Committee Opinion Number 571, September 2013.

https://obgynupdated.blogspot.com/2018/06/acog-guidance-on-prevention-of-surgical.html

New approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure where ‘scarless’ abdominal surgeries are performed through an endoscope inserted through a natural orifice (mouth, anus, vagina, and urethra) and is considered as a less invasive approach to laparoscopic surgeries. 

NOTES is considered a logical next step in the evolution of minimally invasive surgery, and the first NOTES procedure in humans is often considered to be a transgastric appendectomy performed in India in 2006 which was presented but not reported in manuscript form.

https://obgynupdated.blogspot.com/2018/01/new-approach-to-ovarian-cystectomy.html

Blob and Bagel sign on Ultrasound can be labeled as definitive for Ectopic Pregnancy

Women with the Blob and Bagel ultrasound sign should be reclassified from having ‘probable’ ectopic pregnancy (EP) to ‘definitive’ EP and should be treated as such reports the result of a large retrospective cohort study published March 11, 2018, in Journal of Ultrasound in Obstetrics and Gynecology.

Ectopic Pregnancy is still the leading cause of first-trimester maternal deaths and constitutes 4% of all pregnancy-related deaths. The incidence of ectopic is highest in women undergoing In-Vitro Fertilization (IVF) and ranges from 4% to 11% of all pregnancies.

https://obgynupdated.blogspot.com/2018/03/blob-and-bagel-sign-on-ultrasound-can.html

Novel cross-over sign in cesarean scar pregnancy helps predicts the risk of invasive placentation

First trimester ultrasound scan evaluating the relationship between the gestational sac and the endometrial line in women with cesarean scar pregnancy(CSP) helps predicts the development of abnormally invasive placenta (AIP) and consecutive intra and post-operative surgical morbidities reports the results of a retrospective case series published in the Journal of International Society of Ultrasound in Obstetrics and Gynecology.

Recent advances in prenatal imaging and increase rate of cesarean sections have led to increased diagnosis of CSP. Although, most of the patients with CSP present with severe hemorrhage or rupture uterus, that requires emergency surgical management, few advances further, evolving into AIP. 

https://obgynupdated.blogspot.com/2018/02/novel-cross-over-sign-in-cesarean-scar.html

Negative sliding sign by ultrasound in repeat cesarean section predicts the presence of severe intrabdominal adhesions

A negative sliding sign by ultrasonography (USG) in patients with previous cesarean section helps alert the surgeon to expect massive intraabdominal adhesions, difficult repeat cesarean section and need of blood transfusion during surgery reports the results of a prospective observational study published ahead of print in the February issue of Journal Obstetrics and Gynecology.

Postoperative adhesion formation is quite prevalent after an abdominal or pelvic surgery and any method which can predict the existence of such adhesion could optimize the outcome of current surgery.

https://obgynupdated.blogspot.com/2018/02/negative-sliding-sign-by-ultrasound-in.html

GE Healthcare introduces its new automated breast ultrasound for dense breast

There could not have been a more appropriate time for the launch of GE Healthcare new Invenia Automated Breast Ultrasound (ABUS) 2.0 than October, which is celebrated as breast cancer awareness month. The Invenia ABUS is the only FDA approved 3D ultrasound system for supplemental screening for breast cancer along with mammography.

In conjunction with mammography, it increases the chances of cancer detection in the dense breast by 55%. All breasts are not the same, the density of breast is determined by a proportion of fat and breast tissue—when the percentage of breast tissue exceeds that of fat, breasts are labeled as being dense.

https://obgynupdated.blogspot.com/2018/10/ge-healthcare-introduces-its-new.html

A practical guide to count ovarian antral follicles by ultrasound

A consensus opinion highlighting the main techniques of ovarian antral follicle count (AFC), and providing recommendations for future research is published in the special issue on Reproductive Medicine of the journal Ultrasound in Obstetrics and Gynecology.

The consensus makes several recommendations for varied methods used in counting the antral follicles, but no single method is superior over others and the choice should make the best use of resources available in a setting.

https://obgynupdated.blogspot.com/2018/02/a-practical-guide-to-count-ovarian.html

ACOG update: Letrozole is the first line therapy for ovulation induction in PCOS

The American College of Obstetricians and Gynecologists (ACOG) now recommends Letrozole (aromatase inhibitor) as the first-line treatment for ovulation induction in women with Polycystic Ovarian Syndrome (PCOS) due to data demonstrating increased ovulation rates, clinical pregnancy rates and live-birth rate vs clomiphene citrate. The guidelines are published as Practice Bulletin No. 194 in the June issue of Journal Obstetrics and Gynecology.

This replaces the Practice Bulletin Number 108, published October 2009, which recommends letrozole as first-line therapy for ovulation induction only in women with PCOS and a BMI greater than 30.

https://obgynupdated.blogspot.com/2018/05/acog-update-letrozole-is-first-line-for.html

Sonographically measured fetal head circumference ≥35 cm at term increases the odds of cesarean delivery

Sonographically measured fetal head circumference ≥35 cm, within a week of delivery increases the odds of unplanned cesarean section by 75% report the results of multicenter observational study accepted for publication in American Journal of Obstetrics and Gynecology.

Currently, In the US, one in every third baby is born by cesarean section and the high rate is a cause of concern for the healthcare industry.

https://obgynupdated.blogspot.com/2018/01/sonographically-measured-fetal-head.html

FDA approves a bedside test for assessing the risk of spontaneous preterm birth

QIAGEN won FDA approval for marketing its Novel PartoSure® point of care test for estimating the risk of spontaneous preterm birth in patients who present with symptoms of preterm labor. PartoSure represents a breakthrough in research and development of diagnostic tests for preterm birth.

Predicting preterm birth is a diagnostic challenge and nearly 85% of patients admitted to the hospital for threatened preterm labor (PTL) do not deliver within the next 7 days, resulting in unnecessary interventions.

https://obgynupdated.blogspot.com/2018/04/fda-approves-bedside-test-for-assessing.html

A novel route for tubal surgery: Transvaginal natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure where ‘scarless’ abdominal surgeries are performed through an endoscope inserted through a natural orifice (mouth, anus, vagina, and urethra) and is considered as a less invasive approach to laparoscopic surgeries.

NOTES is considered a logical next step in the evolution of minimal invasive surgery, and the first NOTES procedure in humans is often considered to be a transgastric appendectomy performed in India in 2006 which was presented but not reported in manuscript form.

vNOTES is a natural orifice surgery performed through the vaginal route. A look into history reveals that gynecologists have been performing colpotomies for years, adding their valuable experience towards NOTES surgeries and subsequent closure.

A recently published paper in July issue of Fertility and Sterility have demonstrated a new technique of performing tubal reanastomosis via the vaginal route. The step-by-step procedure is explained in the accompanying video, using the surgical case of a 42-year-old female G2P2 with a history of tubal ligation 11 years before, who requested a tubal reanastomosis.   

A three-dimensional sonohystogram at 8 weeks postop showed bilateral patency of both the fallopian tubes.

The current method of performing tubal reanastomosis involves a minimal invasive surgery with end-to-end anastomosis with a 60% to 90% success rate of post-operative intrauterine pregnancy.

A recent systematic review comparing laparotomy vs laparoscopy vs robotic mode of surgery showed that laparotomy had the worst outlook.

NOTES have the advantage of a fast recovery, no abdominal incision, and an extremely cosmetic outcome. With prophylactic antibiotic, the current rate of pelvic infection with NOTES is a 0%–3.1%.

In the hands of a skilled minimally invasive surgeon, vNOTES offers an alternate route for tubal surgery.

Here is a video showing the stepwise surgical procedure 

Abstract

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New approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

New approach to myomectomy: Transvaginal natural orifice transluminal endoscopic surgery

New approach to myomectomy: Transvaginal natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure where ‘scarless’ abdominal surgeries are performed through an endoscope inserted through a natural orifice (mouth, anus, vagina, and urethra) and is considered as a less invasive approach to laparoscopic surgeries.

NOTES is considered a logical next step in the evolution of minimal invasive surgery, and the first NOTES procedure in humans is often considered to be a transgastric appendectomy performed in India in 2006 which was presented but not reported in manuscript form.

vNOTES is a natural orifice surgery performed through vaginal route. A look into history reveals that gynecologists have been performing colpotomies since years, adding their valuable experience towards NOTES surgeries and subsequent closure.

A recently published paper in January issue of Fertility and Sterility have demonstrated a new technique of performing myomectomy by this route and reports the technique and results of a small study involving 8 patients. Eight patients were treated transvaginally for intramural, subserosal, and pedunculated myomas.

The study was conducted at Gynecology department of a non-university teaching hospital in Belgium.

In case of the anterior myoma, anterior colpotomy was used to gain access to the peritoneal cavity, if the myoma was located posteriorly, a 2.5-cm posterior colpotomy was made under general anesthesia. The pouch of Douglas was opened and a vNOTES port was inserted transvaginally.

A pneumoperitoneum was created and the myoma was identified. With the use of conventional endoscopic instruments and a standard endoscope, all inserted through the vNOTES port, the uterine serosa was incised over the myoma and the myoma was resected. After achieving hemostasis, the uterine scar was sutured in two layers with the use of a standard absorbable suture or an autolocking suture.

 An adhesion-preventing barrier was applied over the uterine scar. The myoma was removed through the colpotomy in an endobag. The vNOTES port was removed and the colpotomy was sutured with the use of an absorbable suture.

The patients’ data collected included demographics, number of previous abdominal surgeries, myoma size, myoma weight, operating time, length of hospital stay, visual analog scale pain score, and serum hemoglobin drop.

All fibroids were successfully removed without any intraoperative or postoperative complications via vNOTES without converting to open or standard laparoscopic access. Patients were discharged within 24 hours, 2 of them went home in 12 hours.

In a developed setting, the surgical time can be reduced with the use of an autolocking suture and a commercially available vNOTES port, while in low resource setting it can be replaced by standard absorbable suture and a self-constructed gloveport, as clearly seen in the following video.

The authors concluded that vNOTES provides a new less invasive approach for the resection of myoma types 3–7 that are conventionally resected via laparotomy, laparoscopy, or transabdominal robotic surgery.

This was the first successful IDEAL (idea, development, exploration, assessment, long-term study) stage 1 study which confirmed the feasibility of vNOTES myomectomy. This novel approach not only provides a better cosmetic result than conventional laparoscopy but also improves patient comfort.

Larger studies are warranted in future. 

A new approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

Full Text 

Here is the video of stepwise explanation of the technique.

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First US baby born after uterine transplant delivered in Texas

The first birth as a result of uterine transplant in the United States took place on Friday in Texas at the Baylor University Medical Center in Dallas. The women had undergone a live donor transplant and have received her uterus from Taylor Siler, 36, a registered nurse in the Dallas area.

The boy delivered by elective cesarean section is just named “baby number 9, as he is the 9th person in the world to be born out of transplanted uterus.

https://obgynupdated.blogspot.in/2017/12/first-us-baby-born-after-uterine.html

New approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure where ‘scarless’ abdominal surgeries are performed through an endoscope inserted through a natural orifice (mouth, anus, vagina, and urethra) and is considered as less invasive approach to laparoscopic surgeries. 

https://obgynupdated.blogspot.in/2018/01/new-approach-to-ovarian-cystectomy.html

ACOG updates its guidelines on Nausea and Vomiting in Pregnancy

The American College of Obstetricians and Gynecologists have updated its practice guidelines about managing Nausea and Vomiting in Pregnancy, published in the January issue of Obstetrics & Gynecology.

The guidelines replace the earlier document published in September 2015.

https://obgynupdated.blogspot.in/2017/12/acog-updates-its-guidelines-on-nausea.html

Stair-step ovulation induction protocols are not just limited to Clomiphene

Stair-step ovulation induction protocol with Letrozole is also as effective as stair-step method using Clomiphene Citrate, and has a slight edge over CC in obese patients reports the result of study published in March issue of Fertility and Sterility.

Stair-step ovulation induction protocols have shown to achieve ovulation induction in shorter time as compared to traditional protocols in women with PCOS. But, so far studies and clinical trials have mainly focused on Clomiphene Citrate(CC).

https://obgynupdated.blogspot.in/2017/12/stair-step-ovulation-induction.html

A simple, novel solution to identify and protect ureter during surgery

AllotropeMedical, a Houston based medical startup has devised StimSite, a novel, hand-held, single use device that precisely identifies ureter during surgery; thus, eliminating the need for ureteral stenting.

It is specifically useful in all gynecological, colorectal and oncosurgeries. Gynecological surgery accounts for 50% of all iatrogenic ureteric injuries.

https://obgynupdated.blogspot.in/2017/12/a-simple-novel-solution-to-identify-and.html

New approach to ovarian cystectomy: Transvaginal natural orifice transluminal endoscopic surgery

self constructed vNOTES glove port in low resource settings

Natural orifice transluminal endoscopic surgery (NOTES) is a challenging minimally invasive procedure where ‘scarless’ abdominal surgeries are performed through an endoscope inserted through a natural orifice (mouth, anus, vagina, and urethra) and is considered as less invasive approach to laparoscopic surgeries. 

NOTES is considered a logical next step in evolution of minimal invasive surgery, and the first NOTES procedure in humans is often considered to be a transgastric appendectomy performed in India in 2006 which was presented but not reported in manuscript form.

vNOTES is a natural orifice surgery performed through vaginal route. A look into history reveals that gynecologists have been performing colpotomies since years, adding their valuable experience towards NOTES surgeries and subsequent closure.

A recently published paper in forthcoming issue of Fertility and Sterility have demonstrated a new technique of performing ovarian cystectomy by this route and reports the technique and results of small study involving 14 patients.

The study was conducted at Gynecology department of non-university teaching hospital in Belgium.

All patients were placed in lithotomy position and under general anesthesia, a one-inch posterior colpotomy incision opened the pouch of Douglas.

vNOTES port was inserted through the incision, pneumoperitoneum was created by CO2, and the ovarian cyst was identified. Conventional endoscopic instruments and standard endoscope was used to dissect the cyst from the ovarian cortex by blunt and sharp dissection. Hemostasis achieved by bipolar forceps and cyst removed by bagging it in endobag through the colpotomy incision, which was closed by absorbable sutures.

All 14 patients underwent a successful fertility sparing cystectomy via the vNOTES procedure, without any complications or need for converting into open surgery.

The mean age of patients was 38 years, BMI= 24.7, cyst diameter = 45mm and mean parity = 2. The average surgical time was 37 minutes with only one patient having a history of previous pelvic surgery.

Nine patients were sent home within 12 hours and the rest within 30 hours of surgery.

The authors concluded, “Transvaginal natural orifice transluminal endoscopic surgery provides a new, less invasive approach for performing an ovarian cystectomy. This first IDEAL (idea, development, exploration, assessment, long-term study) stage 1 study confirms the feasibility of vNOTES ovarian cystectomy although it remains a novel approach that requires further investigation. It can provide improved patient comfort and better cosmetic results.”

Earlier studies involving small sample sizes have also reported successful performance of hysterectomies and uterine adnexal surgeries by transvaginal NOTES.

Abstract

Here is the video demonstrating the actual procedure.