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Despite a paucity of data that intrahepatic cholestasis of pregnancy (ICP) is a risk for unexplained term fetal demise, active management to achieve delivery between 36 0/7 and 37 0/7 weeks remains standard clinical practice. This practice continues despite conflicting evidence associating ICP with increased stillbirth risk, disregarding the simultaneous presence of voluminous data attesting to the perinatal and pediatric hazards associated with late preterm and early-term deliveries. This clinical risk correlation between possible antenatal death versus the potential long-term consequences for iatrogenic late preterm or early term infant born from an ICP affected pregnancy warrants inclusion of shared decision making to elicit the patient’s values and preferences during the ICP management option informed consent process.

Background: Preadmission testing has been recommended nationwide across specialties in hospitals as a screening tool for detecting asymptomatic COVID-19 positive patients prior to procedures. Healthcare workers (HCW) have been using these results to decide whether or not the patient can have the procedure done as well as to determine whether HCW should use PPE. However, the majorities of these recommendations are from expert opinion and not evidenced based investigations. In the absence of actual data on the benefits of universal screening in asymptomatic patients, clinicians should really consider the possible pros and cons of this. We set out to review previously published research on COVID-19 testing to determine if universal screening can be justified with science. Conclusion: At this time, there is no evidence-based data for a universal screening program of asymptomatic patients in the absence of contact tracing. Universal PPE use, hand hygiene and the practice of personal prevention measures should be the major component in decreasing the spread of COVID-19 in the hospital setting. Keywords: 2019-nCoV, acute respiratory distress syndrome, autoimmune, COVID-19, healthcare worker, novel coronavirus 2019, pandemic, personal protective equipment, polymerase chain reaction, preadmission testing, SARS coronavirus, severe acute respiratory syndrome coronavirus 2, severe acute respiratory syndrome

Summary SARS‐CoV‐2 has caused a pandemic which is putting strain on the health‐care system and global economy. There is much pressure to develop both preventative and curative therapies for SARS‐CoV‐2 as there is no evidence to support therapies to improve outcomes in patients with SARS‐CoV‐2. Medications that inhibit certain steps of virus life cycle that are currently used to treat other illnesses such as Malaria, Ebola, HIV and Hepatitis C are being studied for use against SARS‐CoV‐2. To date, data is limited for medications that facilitate clinical improvement of COVID‐19 infections.

Background. Throughout the world, intrauterine contraceptive devices (IUDs) are a frequently used, reversible, popular contraceptive method. They are usually placed without major complications. Uterine perforation is a rarely observed complication. Migration of the IUD to the pelvic/abdominal cavity or adjacent structures can occur after perforation. We present 3 cases of uterine perforation, possibly due to scarred myometrium associated with a cesarean delivery. We describe 3 perforations with IUDs lodged in the bladder serosa, the posterior cul-de-sac, and tissue adjacent to the cardinal ligament and external iliac artery. Cases. Case 1. 26-year-old, Gravid 4, Para 2113, nonpregnant female with a history of a cesarean delivery underwent placement of an IUD one year after an elective pregnancy termination, presenting with abdominal pain requesting removal of the IUD. On speculum, although the IUD strings were visualized, the IUD could not be removed. Sonogram imaging identified an empty endometrial cavity with the IUD in posterior cul-de-sac. The IUD was removed via laparoscopy. Case 2. 34-year-old Gravida 5, Para 4004, at 27 weeks and 3 days gestation, female with history of two previous cesarean deliveries underwent a third cesarean after spontaneous rupture of membranes with comorbid chorioamnionitis. Reproductive history was significant for placement of an IUD that had not been removed or imaged during obstetrical sonograms. The clinical evaluation revealed that the IUD had been spontaneously expelled. On the fifth operative day, the patient is febrile with CT demonstrating the IUD penetrating the anterior surface of bladder. On cystoscopy the bladder mucosa was intact. The IUD was removed via laparotomy with repair of the bladder, serosa, and muscular layer. Case 3. 26-year-old, Gravid 4, P3013, nonpregnant female with three previous Cesarean deliveries had an IUD in place. However, with the IUD in situ, the patient conceived and had a spontaneous abortion. After the spontaneous abortion, she presented to clinic to have the IUD removed due to pain that was present since placement. Although the IUD strings were visualized, attempts to remove it were unsuccessful. Imaging identified the IUD outside the uterine cavity. Palpation with a blunt probe laparoscopically revealed a hard object within the adhesion band, close to the cardinal ligament. As per radiology evaluation, IUD was embedded 1cm from the external iliac artery on the right side outside the uterus in the adnexal region. A multidisciplinary procedure with gynecologic-oncologist was scheduled for removal due to the high risk of perioperative bleeding. Conclusion. Patients in whom uterine perforation and IUD migration are suspected should have appropriate evaluation that includes transvaginal or transabdominal ultrasound or radiographs to confirm the position of the IUD, regardless of whether they are asymptomatic or present with symptoms. It is particularly important in the presence of a scarred uterus that imaging is used to identify the location of a missing IUD. The uterine scar of a cesarean may facilitate migration of the IUD. Cross sectional imaging, such as CT or MRI scan, may be needed to rule out adjacent organ involvement before surgical removal.

Background. Heterotopic pregnancy occurs when two pregnancies occur simultaneously in the uterus and an ectopic location. Treatment includes removal of the ectopic pregnancy with preservation of the intrauterine pregnancy. Treatment is done laparoscopically with either a Laparoendoscopic Single-Site Surgery (LESS) or a multiport laparoscopic surgery. Case. We present a case of a first trimester heterotopic pregnancy in a 42-year-old gravida 5, para 0-1-3-1 female with previous history of left salpingectomy, who underwent laparoscopic right salpingectomy and lysis of adhesions (LOA) via Single-Incision Laparoscopic Surgery (SILS). Conclusion. Although LESS for benign OB/GYN cases is feasible, safe, and equally effective compared to the conventional laparoscopic techniques, studies have suggested no clinically relevant advantages in the frequency of perioperative complications between LESS and conventional methods. No data on the cost effectiveness of LESS versus conventional methods are available. LESS utilizes only one surgical incision which may lead to decreased pain and better cosmetic outcome when compared to multiport procedure. One significant undesirable aspect of LESS is the crowding of the surgical area as only one incision is made. Therefore, all instruments go through one port, which can lead to obstruction of the surgeon’s vision and in some cases higher rate of procedure failure resulting in conversion to multiport procedure.

Background nbsp Natural nbsp Orifice nbsp Transluminal nbsp Endoscopic nbsp Surgery nbsp NOTES nbsp involves accessing the abdominal cavity through a natural orifice It provides easier access for the surgeon has a reduced recovery times and decreases postoperative pain Objective To present an initial experience with robotic natural orifice transluminal surgery R NOTES in gynecology using the da Vinci surgical system Case nbsp We present a case of a year old Asian female Gravida Para with irregular heavy menstrual cycle abnormal uterine bleeding due to uterine leiomyoma AUB L who under went Da Vinci Natural Orifice Transluminal Endoscopic Surgery NOTES total Laparoscopic hysterectomy TLH bilateral salpingectomy BS Lysis of nbsp adhesions nbsp LOA nbsp and nbsp cystoscopy nbsp The nbsp patient nbsp had nbsp uncomplicated nbsp recovery nbsp and postoperative care and was discharged on postoperative day zero Conclusion nbsp Robotic NOTES Total laparoscopic hysterectomy with bilateral salpingectomy is feasible and safe in gynecology patient This approach has the potential for a less morbid and scarless outcome

Background. Endometriosis usually occurs in the pelvis and often involves the ovaries, the uterosacral and broad ligaments, and the pelvic peritoneum. In rare instances, it can occur in the vasculature of the pelvis. Patients with endometriosis present with abnormal pain, menstrual cycle disruption and infertility. Management of endometriosis is usually surgical with excision of the tissue via laparoscopic means. Case. A 42-year-old Gravida 5, Para 2-0-3-2 patient with a 22 year history of endometriosis, who had had multiple laparoscopic endometriosis resections, total abdominal hysterectomy, and an exploratory laparotomy with bilateral salpingo-oophorectomy, presented with left pelvic pain when standing, dyspareunia, and a 3.7 cm cyst on ultrasound. The patient underwent laparoscopic vessel endometriosis resection and excision of endometriotic nodules from external iliac vessels. Final pathology report showed evidence of old endometriosis in all locations. On interval follow-up, the patient reported sustained relief from pain. Conclusion. Complete resection of endometriosis from large vessels can be successfully achieved laparoscopically by a well-experienced surgeon with delicate, proper techniques.

In the United States, 29.1 million people are affected by diabetes, of which 95% have type 2 diabetes. There has been a fivefold increase in type 2 diabetes in the latter half of the 20th century, an increase strongly linked to the obesity epidemic in the United States. In addition, insulin resistance affects 86 million Americans, or more than one-third of the adult population, as manifested by impaired fasting glucose tolerance with random glucose values ranging from ⩾100 to

Introduction.Heterotopic pregnancy is a rare complication usually seen in populations at risk for ectopic pregnancy or those undergoing fertility treatments. It is a potentially dangerous condition occurring in only 1 in 30,000 spontaneous pregnancies. With the advent of Assisted Reproduction Techniques (ART) and ovulation induction, the overall incidence of heterotopic pregnancy has risen to approximately 1 in 3,900 pregnancies. Other risk factors include a history of pelvic inflammatory disease (PID), tubal damage, pelvic surgery, uterine Mullerian abnormalities, and prior tubal surgery. Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. Most commonly, heterotopic pregnancy is diagnosed at the time of rupture when surgical management is required.Case.This paper represents two cases of heterotopic pregnancies as well as a literature review.Conclusion.Heterotopic pregnancy should be suspected in patients with an adnexal mass, even in the absence of risk factors. Clinicians must be alert to the fact that confirming an intrauterine pregnancy clinically or by ultrasound does not exclude the coexistence of an ectopic pregnancy. A high index of suspicion in women is needed for early and timely diagnosis, and management with laparotomy or laparoscopy can result in a favorable and successful obstetrical outcome.

Background The incidence of adnexal masses in pregnancy is estimated to be Surgical intervention is required particularly in the setting of potential malignancy ovarian torsion or direct mass affect on the pregnancy Single incision laparoscopic surgery SILS averts the potential morbidity of multiple trocar insertions as it is associated with less bleeding pain and better cosmetics and tissue retrieval We describe the use of SILS technique in a week pregnancy complicated by a cm left adnexal cystic mass that was managed with a single incision laparoscopic left salpingectomy with cystectomy Case The patient was a year old pregnant Gravida Para with gestational diabetes and morbid obesity Body Mass Index of Her only pregnancy ended as a spontaneous abortion She initially presented to our clinic at weeks for further evaluation of a large x x cm maternal abdominal cystic mass which had been detected on prenatal ultrasound She was managed by Single Incision diagnostic laparoscopy and Single incision laparoscopic left salpingectomy and left paratubal cystectomy at weeks Pathologic examination of the paratubal cyst revealed the mass to be a benign mullerian serous cystadenofibroma Her recovery was uncomplicated with discharge on the first postoperative day Conclusion In summary removal of this patient s adnexal mass in pregnancy was warranted to avert potential complications The patient s paratubal cyst was drained without leakage and then removed intact through the umbilical incision Single incision laparoscopic cystectomy for large ovarian and paratubal cysts in pregnancy is not only feasible but has also been shown to result in better outcomes There were no complications in this patient intraoperatively postoperatively or in a subsequent pregnancy

We read with great interest Liu et al's1 case report in the September 2018 issue describing a secundigravid patient with a history of a prior pregnancy affected by intrahepatic cholestasis who presented in the current pregnancy with elevated bile acid levels and severe pruritus not ameliorated b

Background Herlyn Werner Wunderlich HWW syndrome also known as obstructed hemivagina ipsilateral renal agenesis OHVIRA is characterized by the presence of a didelphys uterus obstructed hemivagina and ipsilateral renal agenesis OHVIRA most commonly presents with symptoms of menarche pelvic pain dysmenorrhea and an abdominal mass Surgical intervention is often required to correct malformations and reduce the incidence of pelvic endometriosis infection and adhesions and infertility for these patients We present three cases MDA with various presentations and clinical courses Objective Review of mullerian and other uterine abnormalities relationship to reproductive performance and pregnancy Outcome Presentation of Cases Case year old Hispanic female G P presented with Primary dysmenorrhea mullerian anomaly and solitary kidney Ultrasound and Magnetic Resonance Imaging MRI showed uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis OHVIRA Syndrome AKA Herlyn Werner Wunderlich Syndrome Case A years old Hispanic female Gravida Para with history of two previous cesarean deliveries presented with retained intrauterine device IUD The IUD strings could not be visualized on the exam but ultrasound and MRI revealed IUD in the right endocervical canal in the lower portion of the uterus Diagnostic hysteroscopy confirmed the diagnosis of didelphys uterus with a horizontal vaginal septum The retained IUD was clearly visible on the lower cervix under the vaginal septum and was easily removed with ring forceps Case year old Hispanic Female G P at weeks gestational age presented for her first prenatal visit Bedside ultrasound showed a second mass next to the uterus official ultrasound revealed duplicated uterine horns and cervices Differential diagnosis includes uterine didelphys and bicornuate bicollis uterus Single live intrauterine pregnancy within the right uterine horn noted Patient declined pelvic MRI for further evaluation of didelphys uterus despite counseling that MRI was safe imaging tool during pregnancy Discussion Mullerian duct anomalies MDA encompass a large range of defects resulting from an abnormal fusion or failure of fusion of paramesonephric ducts during embryogenesis Patient and were all diagnosed with didelphys uteri However for each patient the clinical symptomatology diagnostic imaging and management was different MDAs are present in a small percentage of the population However incidence increases among women with a history of recurrent pregnancy loss and many are incidental findings such as occurred in patients two and three If ultrasound suggests MDA it can be confirmed by magnetic resonance imaging MRI which is the gold standard for diagnosis A new classification system for HWW was created in at the Peking Union Medical College Hospital by Zhu et al Symptomatic treatment of these malformations can be hormonal or surgical The patient in case was placed on hormonal therapy to improve dysmenorrhea and pelvic pain However surgical intervention was ultimately needed to correct her anomaly thereby lowering the risk of infection adhesions endometriosis miscarriages and preterm labor Conclusion Mullerian duct anomalies encompass a range of uterine abnormalities that occur because of interrupted development and fusion of the paramesonephric ducts during embryogenesis Diagnosis may occur as a consequence of clinical symptoms fertility complications or as an incidental finding Mullerian duct abnormalities of a specific uterine anomaly and renal findings characterize OHVIRA HWW Ultrasound and MRI play an important role in prompt diagnosis of MDAs and HWW often being discovered during prenatal care Prompt diagnosis and treatment is needed to ensure relief of symptoms prevention of infection and preservation of fertility

Introduction. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is a relatively uncommon but traumatic condition occurring in the later stage of pregnancy as a complication of severe preeclampsia or eclampsia. Prompt brain computed tomography (CT) or magnetic resonance imaging (MRI) and a multidisciplinary management approach are required to improve perinatal outcome. Case. A 37-year-old, Gravida 6, Para 1-0-4-1, Hispanic female with a history of chronic hypertension presented at 26 weeks and 6 days of gestational age. She was noted to have hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome accompanied by fetal growth restriction (FGR), during ultrasound evaluation, warranting premature delivery. The infant was delivered in stable condition suffering no permanent neurological deficit. Conclusion. HELLP syndrome is an uncommon and traumatic obstetric event which can lead to neurological deficits if not managed in a responsive and rapid manner. The central aggravating factor seems to be hypertension induced preeclamptic or eclamptic episode and complications thereof. The syndrome itself is manifested by hemolytic anemia, increased liver enzymes, and decreasing platelet counts with a majority of neurological defects resulting from hemorrhagic stroke or subarachnoid hemorrhage (SAH). To minimize adverse perinatal outcomes, obstetric management of this medical complication must include rapid clinical assessment, diagnostic examination, and neurosurgery consultation.