Emergency physician gender is associated with early pregnancy loss management: a multisite retrospective cohort study.

BACKGROUND: Patients experiencing early pregnancy loss often first present to the emergency department (ED) where they can be managed non-operatively through expectant or medical management, or surgically by the obstetrical team. Studies have reported that physician gender can influence clinical decision making, but there is limited research on this phenomenon in the ED. The objective of this study was to determine whether emergency physician gender is associated with early pregnancy loss management. METHODS: Data were retrospectively collected from patients who presented to Calgary EDs with a non-viable pregnancy from 2014 to 2019. Pregnancies >12 weeks gestational age were excluded. The emergency physicians included saw at least 15 cases of pregnancy loss over the study period. The primary outcome was obstetrical consult rates by male versus female emergency physicians. Secondary outcomes included rates of initial surgical evacuation via dilation and curettage (D&C) procedures, ED returns, returns to care for D&Cs and total D&C rates. Data were analysed using χ2, Fisher's exact and Mann-Whitney U tests, as appropriate. Multivariable logistic regression models accounted for physician age, years of practice, training programme and type of pregnancy loss. RESULTS: 98 emergency physicians and 2630 patients from 4 ED sites were included. 76.5% of the physicians were male accounting for 80.4% of pregnancy loss patients. Patients seen by female physicians were more likely to receive an obstetrical consultation (adjusted OR (aOR) 1.50, 95% CI 1.22 to 1.83) and initial surgical management (aOR 1.35, 95% CI 1.08 to 1.69). ED return rates and total D&C rates were not associated with physician gender. CONCLUSION: Patients seen by female emergency physicians had higher rates of obstetrical consultation and initial operative management compared with those seen by male emergency physicians, but outcomes were similar. Additional research is required to determine why these gender differences exist and how these discrepancies may impact the care of early pregnancy loss patients.

Who Should be Following the Trans-Female Patient Pre and Post Vaginoplasty? An Argument for the Pediatric Gynaecologist.

Increasing numbers of transgender patients are opting for gender-affirming care. Since pediatric and adolescent gynaecology (PAG) providers perform the majority of vaginoplasty procedures for developmental anomalies of the female reproductive tract (such as vaginal agenesis), this commentary supports the position that PAG providers should be involved in the pre- and postoperative care of trans women.

Management of incomplete and missed spontaneous abortions: a cohort study of trends in Calgary emergency departments.

OBJECTIVES: Incomplete and missed spontaneous abortion cases often first present to the emergency department (ED), where they can be managed operatively via dilation and curettage (D&C) or non-operatively through medical or expectant management. The primary objective of this study was to determine how rates of operative management have changed over time across Calgary EDs. The secondary objective was to assess correlates of effectiveness and potential drivers in management including gynecological consults, ED return visits requiring admission, and subsequent D&Cs. METHODS: Sunrise Clinical Manager (electronic medical system) was accessed to collect data for patients who presented to a Calgary ED with an incomplete or missed spontaneous abortion from 2014 to 2019. Patients requiring resuscitation and those with complications were excluded. Return to care for D&C and ED revisits requiring admission were used as a proxy for failed non-operative management. Trends in management are reported using 95% confidence intervals. RESULTS: Of the 3845 patients included, 1110 (28.9%) received a D&C on initial ED visit. The remaining 2735 (71.1%) were initially managed non-operatively. Rates of D&Cs decreased 11.6% from 2014 to 2019, 95% CI (6.5%, 16.8%). There was minimal change in the rates of gynecological consults, ED returns requiring admission, and returns to care resulting in D&Cs over time. CONCLUSIONS: The management of incomplete and missed spontaneous abortions has shifted toward non-operative management over 6 years in Calgary. As this is not associated with increased ED returns requiring admission or subsequent D&Cs, the shift appears to be appropriate. As gynecological consults were consistent over time, further knowledge translation around non-operative spontaneous abortion management may be useful for ED physicians.

RéSUMé: OBJECTIFS: Les cas d'avortement spontané incomplets et manqués sont souvent les premiers à se présenter au service d'urgence (SU), où ils peuvent être gérés opérationnellement par dilatation et curetage (D&C) ou non opératoire par une prise en charge médicale ou d'attente. Le principal objectif de cette étude était de déterminer comment les taux de prise en charge opératoire ont changé au fil du temps dans les SU de Calgary. L'objectif secondaire était d'évaluer les corrélats de l'efficacité et les facteurs potentiels de la prise en charge, notamment les consultations gynécologiques, les visites de retour aux urgences nécessitant une admission et les D&C ultérieures. MéTHODES: Sunrise Clinical Manager (système médical électronique) a été consulté pour recueillir les données des patients qui se sont présentés à un service d'urgence de Calgary avec un avortement spontané incomplet ou manqué entre 2014 et 2019. Les patients nécessitant une réanimation et ceux présentant des complications ont été exclus. Le retour aux soins pour une D&C et les nouvelles visites aux urgences nécessitant une admission ont été utilisés comme indicateur de l'échec de la prise en charge non opératoire. Les tendances en matière de gestion sont signalées en utilisant des intervalles de confiance à 95%. RéSULTATS: Sur les 3 845 patients inclus, 1 110 (28,9%) ont reçu un D&C lors de la première visite à l'urgence. Les 2 735 autres (71,1%) ont été initialement pris en charge de manière non chirurgicale. Les taux de D&C ont diminué de 11,6% entre 2014 et 2019, IC à 95% (6,5%, 16,8%). Il y a eu un changement minime dans les taux de consultations gynécologiques, de retours aux urgences nécessitant une admission et de retours aux soins entraînant des D&C au fil du temps. CONCLUSIONS: La prise en charge des avortements spontanés incomplets et manqués a évolué vers une prise en charge non opératoire en 6 ans à Calgary. Comme cela n'est pas associé à une augmentation des retours à l'urgence nécessitant une admission ou des D&C ultérieurs, le changement semble être approprié. Les consultations gynécologiques étant constantes au fil du temps, une application plus poussée des connaissances sur la prise en charge des avortements spontanés non opératoires pourrait être utile aux médecins des urgences.

Difficulties in Transition of Care from Pediatric to Adult Gynecology Providers: Should We Maintain Care into Adulthood?

There is evidence that transfer of care for older adolescent patients to adult care is associated with a deterioration in health, especially in those with chronic conditions. Because several specific conditions in pediatric and adolescent gynecology continue into adulthood, it is important that patients have a seamless healthcare transition. In this commentary, it is argued that instead of arranging transfer, long-term retention of patients by the same physician or physician team may be the more caring, patient-centered approach.

Literature Review of Periclitoral Cysts in the Prepubertal Population.

STUDY OBJECTIVE: Clitoral cysts in the pediatric population are rare conditions that require careful evaluation. In this review of the literature we discuss the evaluation of clitoral abnormalities in the pediatric population, the development of clitoral cysts, and how to differentiate benign from malignant tumors. In addition, a summary of relevant cases of clitoral tumors in the literature are discussed. DESIGN: Literature review. DATA SOURCE: A MedLine and advanced PubMed search was conducted of all English language articles published using the search terms "clitoris" and "cyst" until February 2015. Reference tracing was completed for all articles for completeness. MAIN OUTCOME: Literature review of clitoral cysts in the prepubertal population. RESULTS: In total, we found 15 cases of benign, spontaneously forming clitoral cysts reported. Eleven of those cases document symptom onset before puberty. Reports of other benign clitoral lesions in the pediatric population include 1 angiokeratoma, 1 hemangiopericytoma, 1 granular cell tumor, 6 hemangiomas, and approximately 30 neurofibromas. Clitoral malignancies in the pediatric population are even more rare with only 3 cases of clitoral schwannomas, 2 rhabdomyosarcomas, 1 lymphoma, and 1 endodermal sinus tumor documented in the literature. CONCLUSION: Clitoral cysts must be considered as a possible cause of clitoral enlargement in the prepubertal population. Clitoral tumors are distinguished clinically from hormonal abnormalities and intersex disorders by their hormonal profile, and the presence of an underlying mass. Ultrasound and magnetic resonance imaging might be useful imaging modalities to further characterize the clitoral enlargement. When confirmed as the most likely diagnosis, surgical resection is the mainstay of treatment for clitoral cysts.

Isolated luteinizing hormone (LH) elevation in a woman with secondary amenorrhea: a clue to the diagnosis of an inhibin B-producing thecoma and insights into the influence of inhibin B on LH.

OBJECTIVE: To review the diagnostic possibilities that exists when the workup of amenorrhea reveals an isolated LH elevation; and to examine the effect of inhibin B on LH levels in vivo. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 20-year-old woman presented with secondary amenorrhea. Her FSH measurement was low, and the LH level was elevated. The recognition that this was an unusual pattern led to the diagnosis of a rare but very treatable inhibin B-producing thecoma, despite the fact that results on the initial pelvic ultrasound examination performed 10 months after presentation of amenorrhea were relatively unremarkable. INTERVENTION(S): Surgical removal of an ovarian thecoma. MAIN OUTCOME MEASURE(S): Gonadotropins, E2, inhibin B, menstrual bleeding, and fertility. RESULT(S): Removal of the ovarian thecoma resulted in a normalization of FSH, LH, and inhibin B levels and a return of spontaneous menses 28 days later. Pregnancy occurred with the third postoperative menstrual cycle, followed by the delivery of a healthy full-term girl. CONCLUSION(S): Inhibin B-producing sex cord granolosa-stromal cell tumors should be considered in women who present with amenorrhea with isolated LH elevations, even in the setting of a previously normal pelvic ultrasound report. Diagnostic considerations that arise in the workup of amenorrhea when there is an isolated elevation in LH that is accompanied by normal or low FSH levels are reviewed. This rare clinical presentation provides the opportunity to observe the impact of inhibin B on gonadotropins in vivo.