Objectives:Primary hyperaldosteronism can present during pregnancy. Due to its rarity and to the physiological changes occurring during pregnancy, diagnosis might be delayed with potential complications imposed on the mother and newborn. Case presentation:We report a 46-years-old middle eastern patient with chronic hypertension, who conceived with assisted reproductive technologies and was diagnosed with PA. She was referred back to cardiology for re-evaluation of her resistant hypertension. Serum electrolytes showed low potassium, high aldosterone, and high renin to aldosterone ratio. Magnetic resonance imaging of the adrenal glands revealed a unilateral nodule in the left adrenal gland. The patient was maintained on three antihypertensives; unfortunately, her pregnancy was complicated by intrauterine growth restriction and preterm delivery for preeclampsia with severe features. Conclusions:Primary hyperaldosteronism is a rare complication of pregnancy that is challenging to diagnose. However, timely and accurate diagnosis are essential to initiate appropriate treatment to ensure optimal fetal and maternal outcomes.

Heterotopic pregnancy is a rare complication; however, its incidence is increasing. Double heterotopic pregnancy is an even rarer and potentially life-threatening condition. It refers to a situation in which a pregnant woman has at least one intrauterine pregnancy along with two ectopic pregnancies. We report a case of double heterotopic pregnancy, comprising one intrauterine pregnancy and two ectopic pregnancies, one in each fallopian tube, in a 27-year-old woman. The diagnosis was confirmed during laparoscopic management of a presumed single heterotopic pregnancy, with intraoperative suspicion of a contralateral ectopic pregnancy. Conception occurred via intrauterine insemination following ovulation induction. The pregnancy subsequently resulted in a full-term vaginal delivery of a healthy male infant. Atypical forms of heterotopic pregnancy involving more than one ectopic gestation are extremely rare. Heterotopic pregnancy is life-threatening and poses significant challenges in both diagnosis and management, particularly in cases of double heterotopic pregnancy. An early and accurate diagnosis, along with timely management, whether medical or surgical, is key to a good prognosis and is considered life-saving for both the mother and the intrauterine pregnancy.

The evidence indicates that pregnancy is associated with increased severity of some infectious diseases. Given the high maternal morbidity associated with influenza in pregnancy and the high neonatal morbidity and mortality associated with pertussis, the traditionally two recommended vaccines during pregnancy were those against influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) vaccines. The recent COVID-19 pandemic introduced a third vaccine that after much debate is now recommended for all pregnant women. Other vaccines can be offered based for high-risk pregnant women, and only when the benefits of receiving them outweigh the risks. The soon expected vaccines against group B streptococcus infection and respiratory syncytial virus infection will be a breakthrough in reducing perinatal mortality. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed.

Purpose The aim of this study is to analyze obstetrical and reproductive health parameters in Lebanon from 2015 until 2018 in the setting of the Syrian refugee influx in order to evaluate potential risks and provide a management plan to improve outcomes. Description Data from the Lebanese Ministry of Public Health (LMPH) on all obstetrical deliveries that occurred in Lebanon between 2015 and 2018 was screened and analyzed. Number and mode of delivery as well as maternal and neonatal outcomes were included. Joinpoint regression analysis was used for trends of selected parameters. Independent two-sample t-tests were used for comparisons. Assessment Women of non-Lebanese nationality residing in Lebanon had a significantly greater number of total deliveries (p-value < 0.001), vaginal deliveries (p-value = 0.002), cesarean sections (p-value = 0.02). When looking at delivery trends from 2015 to 2018, Lebanese women had a significant decrease in total number of deliveries (p-value < 0.001) and vaginal deliveries (p-value < 0.001). Conclusion Total number of deliveries and cesarean sections is on the rise in Lebanon. Cesarean section practice should be audited by the LMPH and the Lebanese Order of Physicians (LOP). Local and international agencies should prioritize the implementation and management of family planning facilities in refugee hosting countries.

Borderline ovarian tumours (BOTs) commonly affect young nulliparous women, thus making fertility-preserving approaches more desirable. Women who opt for conservative management should be counselled about disease recurrence. In this retrospective study, the medical records of 57 women with BOT treated at the American University of Beirut Medical Centre between January 1986 and May 2018 were reviewed. Clinical, pathologic, and demographic data were collected and analysed to identify variables associated with poor clinical outcomes including advanced disease and risk of recurrence. Younger and nulliparous women were more likely to undergo fertility-sparing surgery. The open approach was adopted for women with larger adnexal masses and was associated with more blood loss with a mean difference of 172 mL (95% CI [110-235], p-value < .001) but no significant difference in operative time and length of hospital stay compared to the laparoscopic approach. CA-125 correlated with an advanced International Federation of Gynaecology and Obstetrics (FIGO) stage (p = .004). The recurrence rate was found to be 7% with a median recurrence time of 41.5 months.IMPACT STATEMENT What is already known on this subject? BOTs are common in young nulliparous women who often desire fertility-sparing procedures. Prognostic factors associated with disease severity and recurrence remain controversial. What do the results of this study add? This study presents an opportunity to understand the disease behaviour and compare local practices and outcomes to what was reported in the literature. CA-125 appears to be a useful marker in predicting the stage of BOT. What are the implications of these findings for clinical practice and/or further research? Future research should focus on exploring whether BOTs with micropapillary features represent an aggressive histologic subtype more prone to recurrence.

Objective To evaluate factors that affect a gynecologist's decision to remove an asymptomatic uterus at the time of removal of a presumed benign adnexal mass. Methods Retrospective chart review of hysterectomies conducted when removing presumed benign adnexal masses at a tertiary-care academic center. Primary outcome was the final pathology of the adnexal mass to determine whether the hysterectomy was medically indicated. Secondary outcomes included the rate of postoperative complications. Results We included 185 out of 1415 charts. Most hysterectomies were performed by gynecologic oncologists (68.8%); 113 (61%) had a frozen section and of those, 76 (67.3%) were benign. Final adnexal pathology was benign in 135 (73%) cases. Using a bivariate analysis, menopausal status (P = 0.019), parity (P = 0.047), sonographic appearance of the mass (P = 0.049), and the physician's preoperative suspicion for malignancy (P < 0.001) were significantly associated with the final adnexal pathology. At the multivariate level, only the physician's suspicion for malignancy was significantly associated with the final adnexal pathology (P < 0.0001) with an odds ratio of 7.28 (95% confidence interval 3.11-17.02). Conclusion Despite gynecologists' capacity to predict the malignant nature of an adnexal mass, 135 of 185 (73%) hysterectomies were performed without a clear medical indication, at the time of removal of benign adnexal masses.

"Chronic abdominal heterotopic pregnancy: a unique case report." Journal of Obstetrics and Gynaecology, 42(6), pp. 2527–2528

Timing of retroperitoneal tumor resection in pregnancy should be guided by patient symptoms, gestational age, and radiologic features to minimize potential maternal and fetal morbidity.

Journal of Gynecologic SurgeryVol. 38, No. 1 Trainee's PerspectiveSymptomatic Round Ligament Leiomyoma in a Patient with Müllerian AgenesisHassan Hamze, Ali Mourad, Muhieddine Seoud, and Dina ChamsyHassan HamzeDepartment of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon.Search for more papers by this author, Ali MouradDepartment of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon.Search for more papers by this author, Muhieddine SeoudDepartment of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon.Search for more papers by this author, and Dina ChamsyAddress correspondence to: Dina Chamsy, MD, Department of Obstetrics and Gynecology, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon E-mail Address: dc09@aub.edu.lbDepartment of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon.Search for more papers by this authorPublished Online:1 Feb 2022https://doi.org/10.1089/gyn.2021.0061AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 38Issue 1Feb 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Hassan Hamze, Ali Mourad, Muhieddine Seoud, and Dina Chamsy.Symptomatic Round Ligament Leiomyoma in a Patient with Müllerian Agenesis.Journal of Gynecologic Surgery.Feb 2022.75-81.http://doi.org/10.1089/gyn.2021.0061Published in Volume: 38 Issue 1: February 1, 2022Online Ahead of Print:June 29, 2021KeywordslaparoscopyleiomyomaMRKH syndromePDF download

Objectives: Urinary tract infection (UTI) is the most common bacterial infection to complicate pregnancy. Medical authorities recommend screening for asymptomatic bacteriuria (ASB) in pregnancy; albeit there is no consensus on ideal timing and frequency for testing. Due to the persistent physiologic changes of pregnancy postpartum, a recent trend to perform urinalysis upon presentation for delivery has been adopted at our institution and various satellite hospitals to putatively minimize cases of postpartum pyelonephritis. The aim of this study is to examine whether routine testing with urinalysis and screening for ASB following suspicious urinalysis with treatment can decrease the incidence of postpartum pyelonephritis, and to determine whether certain urinalysis parameters are more predictive of a positive urine culture. Study design: A retrospective chart review study of all term deliveries was conducted over two years at the American University of Beirut Medical Center, a university teaching hospital. A total of 2359 deliveries of women with no increased susceptibility to UTIs were reviewed. None had urinary symptoms upon presentation. Urinary parameters including time of urinalysis and urine culture collection with respect to time of delivery, corresponding results and mode of urine collection were correlated to intrapartum course, incidence of ASB and of postpartum pyelonephritis. Results: The incidence of ASB among women presenting for delivery was 4.83 %, with Escherichia coli as the most commonly detected pathogen. The presence of nitrite on urinalysis was significantly associated with a positive urine culture (p-value<0.001). Women with history of antenatal ASB or UTI were more likely to have ASB intrapartum with an odds ratio of 3.14 (95 % CI 1.71-5.75, p-value <0.001). Intrapartum urinalysis with subsequent diagnosis and treatment of ASB did not significantly affect the incidence of postpartum pyelonephritis (p-value 0.280). Similarly, intrapartum urinalysis in the setting of positive history of antenatal ASB or UTI did not increase the incidence of postpartum pyelonephritis compared to women with no such history (p-value 0.659). Conclusions: Urinalysis screening intrapartum does not decrease the incidence of postpartum pyelonephritis. Universal urinalysis screening intrapartum is not warranted and should be reserved for women reporting urinary symptoms and/or women at high risk of UTI. (C) 2021 Published by Elsevier B.V.

Background Laparoscopic surgery has become a standard of care for many gynecological surgeries due to its lower morbidity, pain and cost compared to open techniques. Unfortunately, the use of carbon dioxide (CO 2 ) to insufflate the abdomen is the main contributor to post-operative shoulder pain. Methods We aim to assess the effect of postoperative Trendelenburg position on shoulder pain after gynecological laparoscopic procedures. We hypothesize that maintaining the patient in Trendelenburg for 24 h postoperatively will significantly decrease postoperative shoulder pain and analgesic consumption. After obtaining written informed consent, 108 patients were prospectively randomized into two groups. In the control group, patients underwent standard gynecologic laparoscopic procedures; then after passive deflation of the pneumoperitoneum at the end of the surgery, the patients were placed in supine head up position in the post anesthesia care unit (PACU) and received our institution’s common postoperative care. Patients in the intervention group were subjected to the same maneuver but were positioned in a Trendelenburg position (20 °) once fully awake and cooperative in the PACU and retained this position for the first 24 h. Numerical rating scale (NRS) was used to assess shoulder pain and nausea upon patient arrival to the PACU, at 4, 6, 12 (primary outcome) and 24 h postoperatively. Time to first rescue pain medication, total rescue pain medications and overall satisfaction with pain control were recorded. 101 patients were included in the final data analysis. Results Both groups were comparable in terms of baseline characteristics. NRS pain scores were significantly lower in the intervention group at 12 h compared to the control group (0 [0–1] versus 5 [1–4], p < 0.001), furthermore improvement in postoperative shoulder pain between time of arrival to PACU (time zero) and 12 h postoperatively was significantly higher in patients allocated to the experimental group compared to the control group. Pain scores were significantly lower in patients allocated to the experimental group versus the control group (0 [0–1] versus 5 [1–4], p < 0.001). Conclusion In conclusion, Trendelenburg position is an easy non-pharmacologic intervention that is beneficial in reducing postoperative shoulder pain following gynecologic laparoscopic surgery. Trial registration Retrospectively registered at Clinicaltrials.gov, registration number NCT04129385 , date of registration: June 28, 2019

Coronavirus disease COVID-19 upended the whole world with everyone needing to practice social distancing, and quarantine These measures affected education in general, and medical education in particular Educators were faced with the dilemma of protecting the students versus fulfilling the mission of preparing qualified future healthcare providers In Lebanon, the seven medical schools had to act quickly to set up distance education in response to the requested closure of universities and social distancing measures, in a way that preserves student education despite the challenging times This paper will focus on the changes introduced to the curricula of the undergraduate medical education programs in Lebanon, involving both the teaching and learning facets and the assessment component at the preclinical and clinical phases

A 30-year-old pregnant female presented with a 2-week history of pityriasis rosea-like eruption. The rash started 2days after the patient had started taking ondansetron 8mg for alleviation of moderate-to-severe nausea and vomiting of pregnancy. Physical examination revealed erythematous papulosquamous lesions characterized by annular scaly margins and a dusky centre over the arms, chest, abdomen, lower back and legs. The rash did not involve the palms, sole or mucous membranes, and no lesions were observed on the lymph nodes. Ondansetron was discontinued. The rash ceased to spread and started to disappear within 2weeks with full resolution noted after 1month. Analysis of the case using the Naranjo adverse drug reaction probability scale indicated that ondansetron was the probable cause of the pityriasis rosea-like eruption. This is the first case report of pityriasis rosea related to ondansetron therapy.

Objective: To describe patient demographics, determine accuracy of clinical diagnosis, and evaluate reliability of laparoscopic uterine characteristics in the diagnosis of adenomyosis. Materials and Methods: Enrollment included 117 patients undergoing laparoscopic hysterectomy for benign indications. Intraoperatively, the attending surgeon predicted uterine weight; evaluated the presence of fibroids; and commented on the uterus' shape, color, and consistency while probing it with a blunt instrument. A prediction was also made about whether final pathology would reveal adenomyosis. Standardized video recordings were obtained at the start of the case. Each video was viewed retrospectively twice by three expert surgeons in a blinded fashion. Uterine characteristics were reported again with a prediction of whether or not there would be a pathologic diagnosis of adenomyosis. These data were used to calculate inter-and intrarater reliability of diagnosis. Results: Women with adenomyosis were more likely to complain of midline pain as opposed to lateral or diffuse pain (p = 0.048) with no difference in the timing of the pain (p = 0.404), compared to patients without adenomyosis. Uterine tenderness on examination was not an accurate predictor of adenomyosis (p = 0.566). Preoperative diagnosis of adenomyosis by clinicians was poor, with an accuracy rate of 51.7%. None of the intraoperative uterine characteristics were significant for predicting adenomyosis on final pathology, nor was any combination of the features (p = 0.546). Retrospective video reviews failed to reveal any uterine characteristics that generated consistent inter- or intrarater reliability (Krippendorff's α < 0.7) in making the diagnosis of adenomyosis. Conclusions: Clinical and video diagnosis of adenomyosis have low accuracy with no uterine characteristics consistently or reliably predicting adenomyosis on final pathology. (J GYNECOL SURG 34:183).

Study Objective To describe the laparoscopic repair of bladder and bowel injuries using barbed suture and review postoperative outcomes. Design Retrospective medical chart review (Canadian Task Force classification II-3). Setting Large academic medical institution. Patients Thirty-three women who underwent laparoscopic repair of the bladder and/or bowel wall using barbed suture between January 2009 and July 2013. Intervention Not applicable. Measurement and Main Results The patients underwent a total of 9 cystotomies (27.3%), 7 enterotomies (21.2%), 4 bladder seromuscular injuries (12.1%), 12 bowel seromuscular injuries (36.4%), and 1 bladder and bowel seromuscular injury (3.0%). Of the 33 injuries, 17 (51.5%) were intentional in the setting of bladder or bowel endometriosis nodule excision, whereas the other 16 (48.5%) were accidental and occurred at the time of lysis of adhesions. Thirteen of 14 bladder injuries (92.9%) were at the dome, and 1 injury (7.1%) was at the trigone. Fifteen of 20 bowel injuries (75%) were rectal, 3 (15%) were on the colon, and 2 (10%) were on the small intestine. Cystotomies ranged in length from 1 to 5 cm, and enterotomies ranged from 1.5 to 6 cm. All bladder and bowel seromuscular injuries were repaired using a single layer of barbed suture. Twelve full-thickness bladder or bowel wall defects (75%) were repaired using 2 layers of barbed suture, and 4 defects (25%) were repaired using a layer of barbed suture and a layer of a running or interrupted smooth delayed absorbable suture. Duration of follow-up ranged from 1 month to 15 months. There were no major complications. Only 1 patient who had undergone a large enterotomy repair developed constipation secondary to a mild rectal stricture diagnosed 3 months postoperatively. Symptoms of constipation since resolved spontaneously in that patient. Conclusion Barbed suture provides adequate tension-free bladder and bowel repair. No major complications have been encountered; therefore, the use of barbed suture for the repair of bladder or bowel defects seems feasible and safe.

Study Objective: To demonstrate surgical maneuvers to facilitate laparoscopic excision of sacrocolpopexy mesh and prevent potential complications.Design: Step-by-step illustration of various surgical techniques using a video compiled from 3 laparoscopic sacrocolpopexy mesh excision procedures performed at Magee Womens Hospital for various indications (Canadian Task Force classification xx-xx).Setting: Mesh complications such as infection and erosion are frequently managed conservatively but often necessitate mesh excision for symptom relief. Laparoscopic excision of sacrocolpopexy mesh procedures is typically challenging, even in the hands of experienced surgeons. Synthetic mesh, being a foreign body, activates an inflammatory process that leads to surrounding tissue fibrosis and scar tissue formation that can distort the pelvic anatomy, thereby putting vital organs at risk of injury. Such organs include the bladder, rectum, and vagina caudally; the left common iliac vein and middle sacral vessels cephalad; and the ureters at the level of the vaginal cuff angles.Intervention: Laparoscopic excision of sacrocolpopexy mesh.Conclusion: When planning laparoscopic sacrocolpopexy mesh excision, complications can be prevented with use of proper surgical technique. It is important to identify vital structures because they may be displaced due to tissue fibrosis. When developing various surgical planes, surgeons should first operate in areas that are free of adhesions. This will enhance exposure when dissecting the mesh in proximity of scarred tissue and vital organs. Use of vaginal and rectal probes helps to delineate the vesicovaginal and rectovaginal spaces to prevent bladder and bowel injury. (C) AAGL. All rights reserved.

Study Objective To describe a series of intraperitoneal perforated intrauterine contraception devices (IUDs) and to discuss associated findings, methods for diagnosis, and management of this complication. Design Retrospective review of surgical database between 1998 and 2012 (Canadian Task Force classification II-2). Setting University medical center. Patients Thirty-seven women with a perforated IUD in the intraperitoneal cavity. Measurements and Main Results Nineteen copper IUDs (51%), 17 levonorgestrel-releasing IUDs (LNG-IUDs) (46%), and 1 Lippes loop (3%) were identified. Twenty women (54%) had abdominal pain, 16 (43%) had no symptoms, and 1 (3%) was found to have strings protruding from her anus. Twenty-six women (70%) underwent laparoscopy to remove the IUD, and 6 (16%) underwent hysteroscopy along with laparoscopy. Conversion to laparotomy was required in 4 patients (11%). Two IUDs (5%) caused full-thickness rectouterine fistulas that required laparotomy for repair. Dense adhesions were found in 21 women (57%); and of those, 15 (71%) were associated with a copper IUD. Copper IUDs were significantly more likely than LNG-IUDs to be associated with dense adhesions (p = .02). Conclusions Perforated IUDs can be asymptomatic or cause short-term and long-term symptoms. Long-term complications include abscess and fistula formation. Copper IUDs cause a greater inflammatory process than do LNG-IUDs. Even if asymptomatic, we advocate prompt removal of all IUDs that perforate into the peritoneal cavity once they are identified. Laparoscopic surgical removal of an intraperitoneal IUD is a safe and preferred method.

STUDY OBJECTIVE:To describe a series of intraperitoneal perforated intrauterine contraception devices (IUDs) and to discuss associated findings, methods for diagnosis, and management of this complication. DESIGN:Retrospective review of surgical database between 1998 and 2012 (Canadian Task Force classification II-2). SETTING:University medical center. PATIENTS:Thirty-seven women with a perforated IUD in the intraperitoneal cavity. MEASUREMENTS AND MAIN RESULTS:Nineteen copper IUDs (51%), 17 levonorgestrel-releasing IUDs (LNG-IUDs) (46%), and 1 Lippes loop (3%) were identified. Twenty women (54%) had abdominal pain, 16 (43%) had no symptoms, and 1 (3%) was found to have strings protruding from her anus. Twenty-six women (70%) underwent laparoscopy to remove the IUD, and 6 (16%) underwent hysteroscopy along with laparoscopy. Conversion to laparotomy was required in 4 patients (11%). Two IUDs (5%) caused full-thickness rectouterine fistulas that required laparotomy for repair. Dense adhesions were found in 21 women (57%); and of those, 15 (71%) were associated with a copper IUD. Copper IUDs were significantly more likely than LNG-IUDs to be associated with dense adhesions (p = .02). CONCLUSIONS:Perforated IUDs can be asymptomatic or cause short-term and long-term symptoms. Long-term complications include abscess and fistula formation. Copper IUDs cause a greater inflammatory process than do LNG-IUDs. Even if asymptomatic, we advocate prompt removal of all IUDs that perforate into the peritoneal cavity once they are identified. Laparoscopic surgical removal of an intraperitoneal IUD is a safe and preferred method.

Introduction: Rectus sheath hematomas can result from shearing of rectus muscle fibers or injury to the inferior epigastric vessels, which is the most common vascular injury to occur at the time of laparoscopic surgery. Case Description:We describe a case of a rectus sheath hematoma that was diagnosed 5 days after operative laparoscopy.We review the clinical presentation, diagnostic criteria, and therapeutic options of managing rectus sheath hematomas, and we describe the innovative use of laparoscopy for hematoma drainage after failed conservative management.Discussion: Rectus sheath hematomas that fail conservative management can be effectively drained laparoscopically.This minimally invasive approach provides rapid symptom relief and patient recovery.