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BACKGROUND: Keratin pearls are intraepithelial accumulations of squamous cells and debris that can be an etiology of vulvovaginal irritation in pediatric patients and are often associated with clitoral adhesions. Historically, most cases have been managed with manual or operative lysis of adhesions. CASE: Two prepubertal girls presented to our clinic with chronic clitoral irritation and were found to have clitoral adhesions with keratin pearls. Both were managed with topical estrogen cream, which resulted in resolution of their symptoms. SUMMARY AND CONCLUSION: Keratin pearls can form when the overlying clitoral epithelium becomes blocked by clitoral adhesions. Hypoestrogenism is thought to be implicated in adhesion development; thus, topical estrogen cream is a reasonable option in initial management. Our results demonstrate a noninvasive alternative to the initial treatment of clitoral keratin pearls.

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OBJECTIVE: This study aimed to evaluate the effects of an antenatal behavioral lifestyle intervention on total gestational weight gain (GWG) and perinatal outcomes. METHODS: Pregnant women with overweight and obesity in South Carolina were recruited into a theory-based randomized controlled trial (n = 112 intervention, n = 105 standard care), which was designed to target weight self-monitoring, increased physical activity, and improved dietary practices. RESULTS: Participants were racially/ethnically diverse (44% African American). Intervention and standard care participants had similar total GWG at delivery (12.9 ± 6.9 vs. 12.4 ± 8.3 kg, respectively), but intervention participants had a smaller standard deviation (P = 0.04) in total GWG. The treatment effects were moderated by race/ethnicity and prepregnancy BMI. Among African American participants with overweight, intervention participants gained 4.5 kg less, whereas, among African American women with obesity, intervention participants gained 4.1 kg more than standard care participants. Total GWG among White participants was similar regardless of weight status and group assignment. Fewer intervention participants than standard care participants had adverse pregnancy outcomes (P ≤ 0.01). CONCLUSIONS: The behavioral lifestyle intervention favorably impacted GWG in African American participants with overweight but not African American participants with obesity. The intervention's overall favorable impact on perinatal outcomes suggests that the mechanisms beyond total GWG may drive these outcomes.

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Purpose: Pregnant women with elevated body mass index (BMI) are difficult to recruit into lifestyle studies. This article (1) summarized strategies to recruit pregnant women into a randomized trial, and (2) reported recruitment statistics and their correlates. Materials and Methods: African American and white women with BMI ≥25 and gestational age <16 weeks were recruited primarily through obstetric clinics into the Health in Pregnancy and Postpartum study. Women completed a brief screening form, and if initially eligible, a phone screening. We compared characteristics of those randomized versus not randomized. Results: Initially eligible pregnant women (N = 1578) were identified through direct recruitment by research staff, indirect recruitment by clinic staff at obstetric clinics, and self-referrals through advertisements. Of these women, 54.0% (850) were reached for further screening, and 43.5% (685) were fully eligible. Among eligible women, 58.8% (403) were scheduled for a baseline visit, and 33.3% (228) were randomized. The overall recruitment yield was 14.4%. Recruited participants were diverse (44% African Americans) and averaged 12.6 weeks gestation at baseline. Randomized (vs. nonrandomized) women were more likely to own a cell phone, have access to a computer with internet at home or work, and have downloaded a podcast. Conclusions: Although this study did not reach the recruitment goal, a relatively large and diverse sample of pregnant women were recruited early in pregnancy. Recruiting women with elevated BMI for a behavioral lifestyle intervention is challenging, particularly among women with characteristics, including less phone and internet access and limited experience in using podcasts. This study is registered at Clinicaltrials.gov: NCT02260518.

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BACKGROUND: Prepubertal genital bleeding can be caused by a variety of etiologies including trauma, infection, structural, hematologic disorders, precocious puberty, and malignancy. Urethral prolapse can be seen in prepubescent girls due to a relative estrogen deficiency. Urethral prolapse classically presents with urethral mass and vaginal bleeding, often associated with constipation. CASE REPORT: A healthy 6-year-old White girl presented to the Pediatric Emergency Department (ED) with vaginal bleeding for 1 day preceded by a few months of constipation. In the ED the patient's physical examination was remarkable for a tender, nonmobile mass at the vaginal introitus. Transabdominal pelvic and renal ultrasounds were unremarkable. The emergency physician's working diagnosis was a vaginal mass concerning for sarcoma botryoides. Pediatric and Adolescent Gynecology (PAG) was consulted. They performed an examination under anesthesia (EUA) with cystoscopy and vaginoscopy. The EUA confirmed a urethral prolapse approximately 2 cm in diameter. The patient was treated with conjugated estrogen vaginal cream. At her 1-month follow-up, the urethral prolapse had resolved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Performing a proper pelvic examination of a prepubescent girl presenting with vulvovaginal bleeding is crucial to form an accurate diagnosis in the ED setting. By placing the young girl in the frog-leg or knee-chest position and using both lateral and downward traction of the vulva, one can adequately visualize the external genitalia and outer 1/3 of the vagina. This can help streamline diagnosis and avoid unnecessary examinations and anxiety.

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BACKGROUND: Interventions to prevent excessive gestational weight gain and promote postpartum weight loss have yielded modest results, particularly in overweight and obese women. OBJECTIVES: To examine the impact of a theory-based lifestyle intervention on gestational weight gain, postpartum weight loss, and related maternal and child outcomes and to examine race differences in these outcomes. DESIGN: A randomized controlled trial (target N=400; 200 intervention, 200 standard care; 200 African American, 200 white). METHODS: Overweight and obese African American and white women ≤16weeks gestation are recruited from obstetrics and gynecology clinics in South Carolina. Intervention participants receive two in-depth counseling sessions (early pregnancy and postpartum), telephone counseling, behavioral podcasts, and social media support that target weight self-monitoring and increasing physical activity and healthy dietary behavior practices, guided by Social Cognitive Theory. Standard care participants receive monthly mailings and a matched number of podcasts on non-weight related topics. All intervention activities last from ≤18weeks gestation to 6months after delivery. Gestational weight gain is the primary outcome. Secondary outcomes are meeting gestational weight gain guidelines (inadequate, adequate, excessive), weekly rate of gestational weight gain, postpartum weight retention, physical activity and dietary behaviors, health-related quality of life, and offspring adiposity. Participants are assessed at baseline (≤16weeks gestation), 32weeks gestation, and 6 and 12months postpartum, and offspring are assessed at 6 and 12months. SUMMARY: HIPP is an innovative study that addresses significant gaps in the literature. Primary outcome results are expected in 2019.

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Interest in ultrasound education in medical schools has increased dramatically in recent years as reflected in a marked increase in publications on the topic and growing attendance at international meetings on ultrasound education. In 2006, the University of South Carolina School of Medicine introduced an integrated ultrasound curriculum (iUSC) across all years of medical school. That curriculum has evolved significantly over the 9 years. A review of the curriculum is presented, including curricular content, methods of delivery of the content, student assessment, and program assessment. Lessons learned in implementing and expanding an integrated ultrasound curriculum are also presented as are thoughts on future directions of undergraduate ultrasound education. Ultrasound has proven to be a valuable active learning tool that can serve as a platform for integrating the medical student curriculum across many disciplines and clinical settings. It is also well-suited for a competency-based model of medical education. Students learn ultrasound well and have embraced it as an important component of their education and future practice of medicine. An international consensus conference on ultrasound education is recommended to help define the essential elements of ultrasound education globally to ensure ultrasound is taught and ultimately practiced to its full potential. Ultrasound has the potential to fundamentally change how we teach and practice medicine to the benefit of learners and patients across the globe.

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Cervical cancer screening guidelines have evolved significantly over the past ten years in the adolescent population. The objective of this article is to review the cervical screening guidelines in the adolescent population as well as examine the evidence and studies that support delaying screening until 21 years old. Delaying HPV and Papanicolaou testing until 21 years old is safe and will not increase cervical cancer rates in the adolescent population.

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PURPOSE: To characterize factors related to the development of hyperprolactinemia and the ensuing reproductive/sexual adverse events in children and adolescents treated with antipsychotic and other psychotropic agents, and the additional risk posed for those with comorbid obesity, metabolic, or endocrine disorders. METHODS: A retrospective cohort design evaluating medical and pharmacy claims from South Carolina's Medicaid program was used to compare incidence rates for sexual/reproductive adverse events in 4140 children and adolescents who were newly prescribed one of six atypical or two conventional antipsychotic medications, and a random sample of 4500 children not treated with psychotropic medications, January 1998 to December 2005. Logistic and Cox Proportional Hazards regression and Kaplan-Meier survival analysis were performed. RESULTS: The treated cohort was not significantly more likely to evince hyperprolactinemia-related disorders than the control sample, but females and adolescents 13 and older were. Incident reproductive/sexual conditions were more likely for females (odds ratio [OR] = 9.52; confidence interval [CI] = 7.63-11.90), adolescents (OR = 3.91; CI = 3.25-4.70), those also taking selective serotonin reuptake inhibitors (SSRIs) (OR = 2.04; CI = 1.56-2.37) or valproic acid derivatives (OR = 1.29; CI = 1.03-1.64), and those with comorbid obesity/weight gain (OR = 1.92; CI = 1.56-2.37), metabolic (OR = 1.41; CI = 1.12-1.78), or endocrine disorders (OR = 2.76; CI = 1.98-3.84). CONCLUSION: In this treated cohort, female adolescents exposed to SSRIs or valproic acid derivatives and those with comorbid obesity, metabolic, or endocrine disorders while taking antipsychotics were at higher risk of developing hyperprolactinemia and ensuing sexual/reproductive adverse events.

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The consensus guidelines recognize adolescents as a special group and allow for more conservative follow- up of abnormal cytology and histology. The guidelines recognize the role of high rates of HPV infection and reinfection in teens, along with high rates of clearance of HPV and low rates of invasive cervical cancer. Risks of treatment are balanced with risk for disease progression. The cervical cancer vaccine is now recommended for teens. The approved vaccine protects against HPV related disease caused by four subtypes of HPV 6, 11, 16, and 18. The Food and Drug Administration has approved the vaccine as routine for 11- and 12-year-old girls. The vaccine is most effective prior to HPV exposure or before the sexual debut. In South Carolina only 4.8% of high school girls indicate having sexual intercourse before age 13. Vaccination provides an opportunity to review risky behaviors with adolescent patients and to encourage healthy, safe lifestyles. Vaccination is not protective for sexually transmitted infections and this can be emphasized at vaccination visits as well. The importance of cancer screening can also be reviewed with patients at vaccination visits.

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BACKGROUND: Skene's glands are believed to be homologues of the prostate gland derived from the urogenital sinus.(1) Complications of Skene's glands occur most often in the third and fourth decades and are rarely seen in premenarchal females. CASE: A 3-year-old presented to her pediatrician with a 9-day complaint of vulvar pain. Both pediatric and gynecologic office examination revealed an enlarged right labium majus and an erythematous area adjacent to the urethra. Examination under anesthesia revealed a Skene's gland abscess that was treated with incision and drainage. The patient experienced complete resolution of symptoms. CONCLUSION: A Skene's gland abscess is rare among premenarchal girls. An abscess presenting in a patient complaining of pain can be successfully managed with incision and drainage.

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OBJECTIVE: To report two cases of pregnancy after placement of Essure micro-inserts. DESIGN: Case report. SETTING: University-based Department of Obstetrics and Gynecology. PATIENT(S): Patient 1, a 38-year-old woman, presented with a positive pregnancy test 7 months after Essure hysteroscopic sterilization. Patient 2, a 35-year-old female, became pregnant approximately 1 year after undergoing the Essure procedure. INTERVENTION(S): Patient 1 received obstetric ultrasounds, a prophylactic cerclage, a cesarean section, and a tubal ligation. Patient 2 underwent a postprocedure hysterosalpingogram, an obstetric ultrasound, pregnancy termination, diagnostic pelvic ultrasound, and a hysterectomy. MAIN OUTCOME MEASURE(S): Documentation of normal progress of pregnancy after Essure placement. RESULT(S): Patient 1 carried an uncomplicated pregnancy to term with an Essure micro-insert in place. Patient 2 became pregnant despite an hysterosalpingogram showing tubal occlusion and was ultimately found to have a micro-insert perforating the uterine wall. CONCLUSION(S): The presence of Essure micro-inserts in the fallopian tubes do not appear to interfere with implantation and pregnancy. Uterine perforation by an Essure micro-insert in proximity to the tubal ostia may mimic proper micro-insert placement and bilateral tubal occlusion on both hysterosalpingogram and saline infusion sonography.

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STUDY OBJECTIVE: To document an unusual presentation of a pure Sertoli Cell tumor. DESIGN: Case report. RESULTS: We present a 10-year-old female who presented with abdominal pain and diarrhea with no symptoms of puberty. Surgical exploration revealed a metastatic pure Sertoli Cell tumor, which was treated with resection and chemotherapy. CONCLUSION: Sertoli cell tumors are rare occurrences and should be considered in the differential diagnosis for a prepubescent girl with an abdominal mass.

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BACKGROUND: In 2003, the reported gonorrhea rate among women was 118.8 per 100,000 women. Most gonococcal infections in pregnant women are asymptomatic or produce a mildly symptomatic genital infection. Disseminated infections can occur when gonococcal bacteremia produces extragenital symptoms, most commonly arthritis. CASE: A patient presented in the third trimester of pregnancy with fever, body aches, neck soreness, and skin lesions. There was no arthritis. Cultures performed during evaluation confirmed extragenital Neisseria gonorrhoeae. CONCLUSION: A high index of suspicion is necessary to diagnose disseminated gonococcal infection and prevent disease sequelae.

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Hair thread tourniquet syndrome has been recognized since the 1600s when a strangulating hair was reported around the glans penis. Since that time sporadic reports have appeared in the literature describing strangulation of appendages by human hair. Most often the constriction involves fingers, toes, or the penis. There are several reports of clitoral strangulation. Most cases present to their primary care provider or emergency department. A high index of suspicion is required for diagnosis in order to prevent prolonged devascularization. We describe a hair thread tourniquet syndrome of the labia minora in a 13-year-old. It was successfully treated with exam under anesthesia and resection of the devascularized tissue. We believe this is the oldest patient described as well as the only description of hair tourniquet syndrome of the labia minora. Prompt recognition of this unusual condition is essential for treatment of this potentially serious problem.

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Providing health care to adolescents begins with good communication. Teens appreciate providers who are genuine and not parental. Guidelines to facilitate adolescent communication are presented. A good dialogue with teens can initiate a lifetime of care.

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