Guideline No. 437: Diagnosis and Management of Adenomyosis.

OBJECTIVE: To describe the current evidence-based diagnosis and management of adenomyosis. TARGET POPULATION: All patients with a uterus of reproductive age. OPTIONS: Diagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy). OUTCOMES: Outcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes). BENEFITS, HARMS, AND COSTS: This guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options. EVIDENCE: Databases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows. TWEETABLE ABSTRACT: Adenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available. SUMMARY STATEMENTS: RECOMMENDATIONS.

Directive clinique no 437 : Diagnostic et prise en charge de l'adénomyose.

OBJECTIF: Décrire les pratiques actuelles fondées sur des données probantes pour le diagnostic et la prise en charge de l'adénomyose. POPULATION CIBLE: Toutes les patientes en âge de procréer qui ont un utérus. OPTIONS: Les options diagnostiques sont l'échographie endovaginale et l'imagerie par résonance magnétique. Les options thérapeutiques doivent être adaptées aux symptômes (saignements menstruels abondants, douleur et/ou infertilité) et comprendre des options médicamenteuses (anti-inflammatoires non stéroïdiens, acide tranexamique, contraceptifs oraux combinés, système intra-utérin à libération de lévonorgestrel, diénogest, autres progestatifs, analogues de la gonadotrophine), des options interventionnelles (embolisation de l'artère utérine) et des options chirurgicales (ablation de l'endomètre, excision de l'adénomyose, hystérectomie). RéSULTATS: Les critères de jugement sont la réduction des saignements menstruels abondants, l'atténuation de la douleur pelvienne (dysménorrhée, dyspareunie, douleur pelvienne chronique) et l'amélioration du devenir reproductif (fertilité, avortement spontané, issues de grossesse défavorables). BéNéFICES, RISQUES ET COûTS: Par la présentation des méthodes de diagnostic et des options de prise en charge, cette directive sera bénéfique pour les patientes qui expriment des plaintes de nature gynécologique potentiellement causées par l'adénomyose, en particulier celles qui souhaitent préserver leur fertilité. La directive sera également utile aux praticiens qui pourront améliorer leurs connaissances sur les différentes options. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed et Embase. La recherche initiale a été réalisée en 2021 et mise à jour avec les articles pertinents en 2022. Les termes de recherche utilisés sont les suivants : adenomyosis, adenomyoses, endometritis (utilisés ou indexés sous adenomyosis avant 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis ET [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des articles dans toutes les langues ont été répertoriés et examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (Tableau A1 pour les définitions et Tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Obstétriciens-gynécologues, radiologistes, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques (fellows). RéSUMé POUR TWITTER: L'adénomyose est fréquemment observée chez les femmes en âge de procréer. Il existe des options de diagnostic et de prise en charge qui préservent la fertilité. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Internal iliac artery ligation-a contemporary simplified approach.

Bilateral ligation of the anterior division of the internal iliac arteries can be a lifesaving intervention for severe pelvic hemorrhage. The procedure results in decreased pelvic perfusion and promotes coagulation. The classical method of internal iliac artery ligation involved extensive retroperitoneal dissection with complete circumferential isolation of the vessel to allow the passage of a suture around the artery. This can be surgically challenging and fraught with risks of inadvertent injury to the surrounding iliac veins. We propose a contemporary technique that requires limited dissection of the anterior division of the internal iliac artery. A few millimeters of space is created on either side of the artery by spreading right-angle forceps parallel to the vessel. The artery is occluded by 2 large vascular clips. Because circumferential vessel dissection is not necessary with this technique, there is limited disruption of the delicate underlying internal iliac vein. In addition, this approach may decrease the risk of inadvertent injury to the adjacent external iliac vein. By showcasing the ease of our approach to internal iliac artery ligation, we hope to empower surgeons with an alternative approach to this lifesaving procedure.

Prophylactic internal iliac artery ligation versus balloon occlusion for placenta accreta spectrum disorders: A retrospective cohort study.

OBJECTIVE: To compare surgical outcomes between women undergoing prophylactic internal iliac artery ligation or preoperative placement of balloon-occlusive devices at cesarean hysterectomy for placenta accreta spectrum (PAS) disorders. METHODS: A retrospective cohort study was conducted at a tertiary-care referral center for PAS disorders in Ontario, Canada. Eligible electronic records were reviewed of women undergoing cesarean hysterectomy for PAS disorders between November 2012 and June 2018. Outcomes for the ligation and balloon groups were compared primarily on procedure-related complications and secondarily on total procedure time, bleeding and transfusion metrics, and intraoperative and postoperative complications. RESULTS: Of the 79 cases of cesarean hysterectomy, 47 underwent balloon placement and 32 underwent ligation. Baseline characteristics between the groups were similar except for more emergency procedures in the ligation group (37.5% vs 12.8%, P=0.014). The balloon-related complication rate was 5/47 (10.6%), with no reported complications in the ligation group (P=0.077). Procedural time was longer in the balloon group (353 ± 14 vs 227 ± 13 minutes, P<0.001). Estimated blood loss was similar (1874 ± 245 mL vs 1713 ± 181 mL, P=0.590). CONCLUSION: Women undergoing prophylactic placement of endovascular balloons at caesarean hysterectomy for PAS disorders had a 10.6% procedure-related complication rate and increased total procedure time, with no decrease in blood loss compared to those undergoing surgical ligation.

Effect of a Surgical Teaching Video on Resident Performance of a Laparoscopic Salpingo-oophorectomy: A Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the effect of a surgical teaching video on junior resident knowledge and performance of a laparoscopic salpingo-oophorectomy (LSO). DESIGN: Randomized controlled trial. SETTING: Urban tertiary care academic obstetrics and gynecology department. PATIENTS: First- and second-year gynecology residents. INTERVENTIONS: Access to an education video on LSO for 1 week before performing this surgery in the operating room. MEASUREMENTS AND MAIN RESULTS: Twenty-four junior residents were recruited and randomized to either the educational video group or traditional residency training group. All participants completed a demographic survey and knowledge questionnaire before performing an LSO, which was video-recorded. Video recordings of surgical performance were analyzed using the Objective Structured Assessment of Technical Skills (OSATS; 20 points) and an LSO-specific tool (30 points). Participants completed a self-assessment questionnaire before completing the procedure. The primary outcome measure was the difference in OSATS scores. The secondary outcomes were the knowledge questionnaire scores and self-assessed confidence scores. There were no significant differences between demographic variables of the 2 groups. The primary outcome revealed no significant differences in mean (standard deviation) OSATS scores (10.64 [2.05] vs 11.55 [1.85], p = .3) or LSO-specific tool scores (16.45 [2.68] vs 17.85 [2.63], p = .24). However, there was a significant difference in mean knowledge scores between the video and the traditional training (8.42 [0.79] vs 7.11 [1.36], p = .01) groups. In addition, residents in the video group had more confidence in their knowledge of pelvic anatomy (3.83 [0.39] vs 3.00 [1.00] out of 5.00, p = .04). CONCLUSION: For junior learners, the use of an LSO video improved knowledge and confidence in anatomy but did not translate to improved surgical performance in the operating room. Surgical videos are a useful adjunct and complement hands-on technical teaching.

Keep Your Landmarks Close and the Hypogastric Nerve Closer: An Approach to Nerve-sparing Endometriosis Surgery.

OBJECTIVE: Excisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction [1-4]. This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus. DESIGN: Using didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery. SETTING: Tertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy. INTERVENTIONS: Radical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE. CONCLUSION: The hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation.

Graduating Obstetrics and Gynaecology Residents' Readiness for Practice: A Cross-Sectional Survey Study.

OBJECTIVE: This study sought to evaluate the self-reported and program director-reported comfort of graduating Canadian obstetrics and gynaecology residents in independently performing various surgical skills. METHODS: A Web-based survey was distributed to four cohorts of graduating obstetrics and gynaecology residents across Canada (2014-2017). Residents were asked to indicate their comfort level with independently performing 34 core surgical procedures by using a five-point Likert-type scale. A similar survey was sent to program directors. Comfort scores for residents and program directors were compared using quantitative and qualitative methods as appropriate (Canadian Task Force Classification II-3). RESULTS: Resident and program director survey response rates were 168 of 320 (52.5%) and 20 of 48 (41.7%), respectively. Residents were "comfortable" or "very comfortable" performing 7 of 13 (54%) gynaecology and 4 of 6 (67%) obstetrics List A procedures independently. Program directors reported that residents were "comfortable" or "very comfortable" performing 10 of 13 (77%) gynaecology and 4 of 6 (67%) obstetrics List A procedures. Compared with program directors, residents reported lower comfort with certain minimally invasive and obstetrics List A procedures (P < 0.05). Differences in comfort when performing several List A procedures were related to training program size and plans to pursue fellowship. Qualitative analysis revealed several major and minor themes supporting the dichotomy between residents' lack of comfort and program directors' expectation of comfort. CONCLUSION: Graduating residents were not comfortable performing many core surgical procedures independently. Additionally, program directors believed that trainees were more comfortable than they reported, and comfort varied according to program size and future fellowship plans. The new competency-based curriculum is an opportunity to address this gap.

Ulipristal Acetate for Disseminated Peritoneal Leiomyomatosis.

BACKGROUND: Disseminated peritoneal leiomyomatosis is a rare condition manifesting as hormone-sensitive soft tissue nodules lining the peritoneal cavity. Given the extensiveness of this disease, surgical management is challenging, making hormonal suppression the primary treatment. CASE: A 23-year-old woman presenting with abdominal pain was found to have innumerable abdominopelvic nodules on imaging. Biopsy of these lesions was consistent with disseminated peritoneal leiomyomatosis. Treatment using leuprolide acetate led to satisfactory results but was discontinued owing to vasomotor symptoms. Treatment was changed to cyclic ulipristal acetate, a selective progesterone receptor modulator. Over the past 2 years, the patient has completed five 3-month courses of ulipristal acetate with excellent symptomatic and radiologic response. CONCLUSION: The use of ulipristal acetate may be an effective, novel therapeutic option for the management of disseminated peritoneal leiomyomatosis.

Surgical Management Algorithm for Caesarean Scar Pregnancy.

OBJECTIVES: To report our experience with the management of Caesarean scar pregnancy (CSP) in the first trimester and to develop a unique treatment algorithm allowing physicians to customize their management based on clinical patient characteristics. METHODS: A retrospective review of 12 patients diagnosed with CSP between December 2012 and June 2016 was conducted in a tertiary care hospital in Toronto. All patients were diagnosed with CSP by transvaginal ultrasound using radiologic criteria. Patients were initially treated with an ultrasound-guided embryocidal injection when fetal heart activity was present. Next, patients underwent medical management with systemic multidose methotrexate (MTX) or surgical management using a laparoscopic or transcervical approach depending on CSP characteristics. RESULTS: The mean age at diagnosis was 35.6 years. The median number of previous CSs was one. The mean serum human chorionic gonadotropin level was 59 938 IU/L. The mean GA at presentation was 8+1 weeks. Two-thirds of patients received medical management with systemic multidose methotrexate. Of these, 50% required additional surgical treatment for the resolution of their CSP. One-third of patients underwent primary surgical treatment, resulting in complete resolution of CSP with no complications. Given the improved outcomes of surgical management in our series, we suggest a treatment algorithm that tailors the surgical approach, either laparoscopic or transcervical, to the characteristics of the CSP. CONCLUSION: This constitutes the largest case series of CSP in Canada. Based on our results, CSP can be safely and effectively managed using the suggested surgical algorithm, which accounts for individual patient characteristics.

Internal Iliac Artery Rupture Caused by Endovascular Balloons in a Woman with Placenta Percreta.

BACKGROUND: Prior to Caesarean section (CS) for morbidly adherent placenta (MAP), endovascular balloons are often placed prophylactically to minimize hemorrhage. However, there have been few reports describing complications of this intervention. CASE: A 41-year-old woman with a diagnosis of placenta percreta had endovascular balloon catheters placed before CS. Intraoperatively the right internal iliac artery ruptured, requiring vascular repair, multiple transfusions of blood and plasma, and admission to the intensive care unit. CONCLUSION: Prophylactic placement of endovascular balloons to reduce maternal hemorrhage at CS for MAP may result in complications. Until more evidence becomes available supporting their use, safety guidelines must be instated in centres using them.

An Analysis of Cesarean Section and Emergency Hernia Ratios as Markers of Surgical Capacity in Low-Income Countries Affected by Humanitarian Emergencies from 2008 - 2014 at Médecins sans Frontières Operations Centre Brussels Projects.

BACKGROUND: Surgical capacity assessments in low-income countries have demonstrated critical deficiencies. Though vital for planning capacity improvements, these assessments are resource intensive and impractical during the planning phase of a humanitarian crisis. This study aimed to determine cesarean sections to total operations performed (CSR) and emergency herniorrhaphies to all herniorrhaphies performed (EHR) ratios from Médecins Sans Frontières Operations Centre Brussels (MSF-OCB) projects and examine if these established metrics are useful proxies for surgical capacity in low-income countries affected by crisis. METHODS: All procedures performed in MSF-OCB operating theatres from July 2008 through June 2014 were reviewed. Projects providing only specialty care, not fully operational or not offering elective surgeries were excluded. Annual CSRs and EHRs were calculated for each project. Their relationship was assessed with linear regression. RESULTS: After applying the exclusion criteria, there were 47,472 cases performed at 13 sites in 8 countries. There were 13,939 CS performed (29% of total cases). Of the 4,632 herniorrhaphies performed (10% of total cases), 30% were emergency procedures. CSRs ranged from 0.06 to 0.65 and EHRs ranged from 0.03 to 1.0. Linear regression of annual ratios at each project did not demonstrate statistical evidence for the CSR to predict EHR [F(2,30)=2.34, p=0.11, R2=0.11]. The regression equation was: EHR = 0.25 + 0.52(CSR) + 0.10(reason for MSF-OCB assistance). CONCLUSION: Surgical humanitarian assistance projects operate in areas with critical surgical capacity deficiencies that are further disrupted by crisis. Rapid, accurate assessments of surgical capacity are necessary to plan cost- and clinically-effective humanitarian responses to baseline and acute unmet surgical needs in LICs affected by crisis. Though CSR and EHR may meet these criteria in 'steady-state' healthcare systems, they may not be useful during humanitarian emergencies. Further study of the relationship between direct surgical capacity improvements and these ratios is necessary to document their role in humanitarian settings.

A cross-sectional study of indications for cesarean deliveries in Médecins Sans Frontières facilities across 17 countries.

OBJECTIVE: To review the major indications for cesareans performed by Médecins Sans Frontières (MSF) personnel from the Operational Center Brussels. METHODS: A retrospective study was undertaken of all singleton cesarean deliveries from 2008-2012 for which indications were recorded. Location of project, age of patient, type of anesthesia, and duration of operation were also recorded. RESULTS: A total of 14 151 singleton cesarean deliveries were identified from 17 countries. Among the 15 905 indications recorded, the most common was failure to progress or cephalopelvic disproportion (4822 [30.3%]), followed by previous uterine scar (2504 [15.7%]), non-reassuring fetal status (2306 [14.5%]), and fetal malpresentation (1746 [11.0%]). Other indications were placenta or vasa previa (794 [5.0%]), uterine rupture (676 [4.3%]), hypertensive disorders (659 [4.1%]), placental abruption (520 [3.3%]), pre-rupture (450 [2.8%]), and cord prolapse (365 [2.3%]). CONCLUSION: Indications for cesareans in MSF settings differ from those in higher-income countries. Further investigation is needed for adequate emergency obstetric care coverage.

The role of sonographic cervical length in labor induction at term.

The purpose of this study is to review the literature examining the role of ultrasound in the induction of labor. Databases including Ovid, PubMed, Web of Science, Google Scholar, and UpToDate were searched and current guidelines from the SOGC, the ACOG, the RCOG, and the RANZCOG were reviewed. Although studies have not demonstrated the superiority of cervical sonography to the Bishop score, the evidence indicates that sonography could be useful in planning induction of labor, significantly reducing the need for cervical ripening agents. A more comprehensive method integrating both sonography and digital exam may be more appropriate.