Establishing a peripartum perineal trauma clinic: a narrative review.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) is not rare, and its consequences are multiple and potentially severe, especially for young women. Some dedicated perineal clinics have been established to improve the management of OASI. Despite their obvious importance, these specific clinics are underrepresented and underdeveloped. The objectives of this review are to explore various options for developing a peripartum perineal clinic and to compare the different practices regarding the mode of delivery for subsequent pregnancies after an OASI. METHODS: This narrative review covers information from patients' questionnaires specific to anal incontinence, anal physiology assessment, pelvic floor and anal sphincter imaging, and the arguments for choosing the mode of delivery after an OASI. RESULTS: This review highlights the extensive range of practices regarding the delivery mode after an OASI throughout national professional organizations and experienced perineal clinics. CONCLUSION: This review summarizes the different choices in developing a perineal clinic to facilitate their development in promoting health care and education specific for peripartum women concerning the perineal consequences of delivery for obstetrician-gynaecologists, family doctors, and residents.

[Obstetrical anal sphincter injury†: How to manage the subsequent delivery†?] / Lésion obstétricale du sphincter anal†: comment aborder le prochain accouchement†?

Obstetric anal sphincter injury (OASI) is a complication of vaginal delivery. Its potential consequences are numerous and include anal and/or fecal incontinence, sexual problems and perineal pain, which can be aggravated by future pregnancies and childbirth. One common issue after OASI is the assessment of anorectal function to discuss the delivery modalities during the next pregnancy. This dedicated assessment includes a clinical and paraclinical evaluation, with an ultrasound and/or a manometry. This personalized assessment for each patient with a history of sphincter injury allows for a detailed discussion to decide on the route of delivery in an informed manner.

La lésion obstétricale du sphincter anal (LOSA) survient lors d'un accouchement vaginal. Ses conséquences potentielles sont l'incontinence anale et/ou fécale, les troubles sexuels et les douleurs périnéales, qui peuvent être aggravés par de futures grossesses et accouchements. Un des enjeux après LOSA est l'évaluation de la fonction anorectale dans le but de discuter les modalités d'accouchement lors de(s) prochaine(s) grossesse(s). Elle comprend une évaluation clinique et paraclinique spécialisée, incluant l'échographie et/ou la manométrie. Cette évaluation personnalisée pour chaque patiente avec antécédent de lésion sphinctérienne permet une discussion circonstanciée pour décider de la voie d'accouchement de manière éclairée.

Barriers to Cervical Cancer Screening in Geneva (DEPIST Study).

OBJECTIVES: Cervical screening is only efficient if a large part of eligible women participate. Our aim was to identify sociodemographic barriers to cervical screening and consider self-reported reasons to postpone screening. METHODS: Between September 2011 and June 2015, a questionnaire addressing reasons for nonparticipation in cervical screening was completed by 556 women who had not undergone a Pap test in the preceding 3 years. Pearson χ test was used to analyze differences between subgroups. Logistic regression was used to explore the association between sociodemographic characteristics and reasons for nonparticipation. RESULTS: The main reasons for nonparticipation in cervical cancer screening were practical barriers, such as lack of time and the cost of screening. These barriers were more likely to be reported by working women, women who were not sexually active, and those without health insurance. Younger women, non-European women living in Switzerland, and childless women were more likely to have never participated in a screening program before (adjusted odds ratio [aOR], 3.15; 95% CI, 1.41-6.98; aOR, 2.76; 95% CI, 1.48-5.16; aOR, 1.74; 95% CI, 1.03-2.99, respectively). CONCLUSIONS: Practical considerations seem to play a more important role in screening participation than emotional reasons and other beliefs. Particular attention should be paid to immigrant communities, where women seem more likely to skip cervical screening.

Management of presumed benign giant ovarian cysts: a minimally invasive technique using the Alexis Laparoscopic System.

STUDY OBJECTIVE: To evaluate a minimally invasive surgical technique for the treatment of presumed benign giant cysts using the Alexis Laparoscopic System (Applied Medical, Rancho Santa Margarita, CA), which includes a wound protector/retractor and a laparoscopic "cap." DESIGN: Step-by-step explanation of the procedure using videos. SETTING: The incidence of presumed benign giant ovarian cysts is rare. The standard surgical treatment traditionally requires gaining access by a midline laparotomy to facilitate retrieval of the resected specimen and minimize the risk of cyst spillage. Various minimally invasive techniques (ultrasound-guided or laparoscopic-guided intracystic aspiration methods) have been described in the last few decades to reduce morbidity associated with open surgery. Nonetheless, these techniques are poorly standardized and have not seen widespread use. They have been shown to be fairly technically complex to perform, and are sometimes unreliable in cases of unexpected malignancy. INTERVENTIONS: We propose a standardization of the minimally invasive surgical treatment of presumed benign giant ovarian cysts using the Alexis Laparoscopic System. We were driven by the advantages provided by the Alexis wound protector/retractor used in other surgical disciplines. This device allows for better surgical exposure and oncologic safety. The preoperative criteria for selection are very strict, to minimize the risk of unexpected malignancy. CONCLUSION: The use of the Alexis Laparoscopic System for the surgical management of presumed benign giant ovarian cysts offers excellent exposure and control, representing a safe alternative over other minimally invasive surgical procedures. This reproducible technique allows for reduced risk of intestinal or vascular injury by avoiding blind punctures; reduced risk of parietal tumoral seeding with use of the wound protector; reduced risk of intra-abdominal cyst spillage due to appropriate surgical exposure with the wound retractor, which allows tight closure of the puncture site; the possibility of converting the open surgery access into a standard laparoscopy using a laparoscopic "cap" that maintains pneumoperitoneum without tricks.

Educators and practitioners' perspectives in the development of a learning by concordance tool for medical clerkship in the context of the COVID pandemic.

BACKGROUND: The COVID-19 pandemic has forced medical schools to create educational material to palliate the anticipated and observed decrease in clinical experiences during clerkships. An online learning by concordance (LbC) tool was developed to overcome the limitation of students' experiences with clinical cases. However, knowledge about the instructional design of an LbC tool is scarce, especially the perspectives of collaborators involved in its design: 1- educators who wrote the vignettes' questions and 2- practitioners who constitute the reference panel by answering the LbC questions. The aim of this study was to describe the key elements that supported the pedagogical design of an LbC tool from the perspectives of educators and practitioners. METHODS: A descriptive qualitative research design has been used. Online questionnaires were used, and descriptive analysis was conducted. RESULTS: Six educators and 19 practitioners participated in the study. Important to the educators in designing the LbC tool were prevalent or high-stake situations, theoretical knowledge, professional situations experienced and perceived difficulties among students, and that the previous workshop promoted peer discussion and helped solidify the writing process. Important for practitioners was standards of practice and consensus among experts. However, they were uncertain of the educational value of their feedback, considering the ambiguity of the situations included in the LbC tool. CONCLUSIONS: The LbC tool is a relatively new training tool in medical education. Further research is needed to refine our understanding of the design of such a tool and ensure its content validity to meet the pedagogical objectives of the clerkship.

CONTEXTE: Face à la pandémie de la COVID-19, les facultés de médecine ont été contraintes à créer du matériel pédagogique pouvant pallier la diminution prévue et avérée de l'exposition clinique pendant les stages d'externat. Un outil numérique de formation par concordance (FpC) a été développé pour combler le manque d'exposition à des cas cliniques. Cependant, les connaissances sur la conception pédagogique des outils de FpC sont limitées, en particulier en ce qui concerne les perspectives des collaborateurs participant à leur réalisation : 1 ­ les éducateurs qui rédigent les questions des vignettes et 2 ­ les praticiens composant le groupe d'experts qui fournissent les réponses de référence aux questions de FpC. L'objectif de cette étude était de décrire les éléments clés qui ont étayé la conception pédagogique d'un outil FpC du point de vue des éducateurs et des praticiens. MÉTHODES: Il s'agit d'une recherche qualitative de type descriptif, pour laquelle on s'est servi de questionnaires en ligne et d'une méthode d'analyse descriptive. RÉSULTATS: Six éducateurs et 19 praticiens ont participé à l'étude. Dans la conception de l'outil FpC, les éducateurs ont attribué une importance particulière aux situations courantes ou à enjeu élevé, aux connaissances théoriques, aux situations professionnelles vécues par les étudiants et aux difficultés qu'ils ont perçues chez eux. Ils ont également tenu à faire en sorte que l'atelier qui précédait la conception favorise le débat entre pairs et contribue à solidifier le processus de rédaction. Les praticiens ont privilégié les normes de pratique et l'existence d'un consensus entre experts. Cependant, ils doutaient de la valeur pédagogique de leurs commentaires, compte tenu de l'ambiguïté des situations décrites dans l'outil FpC. CONCLUSIONS: Les outils FpC sont relativement nouveaux en éducation médicale. Des recherches plus poussées sont nécessaires pour affiner notre compréhension de la conception d'un tel outil et pour nous assurer de sa validité de contenu, pour bien répondre aux objectifs pédagogiques de l'externat.

Gestational trophoblastic disease in Switzerland: retrospective study of the impact of a regional reference centre.

AIMS OF THE STUDY: The European Society of Medical Oncology (ESMO) recommends that countries should have reference centres to provide adequate diagnosis and treatment of gestational trophoblastic disease. A trophoblastic disease centre in the French-speaking part of Switzerland was inaugurated in 2009. The objectives of this study were to report the activity of the centre during the last 10 years and analyse gestational trophoblastic disease outcomes. METHODS: This was a retrospective study with data collected from all cases of gestational trophoblastic disease referred to the centre from 2009 to 2018. All histological specimens as well as data for treatment and follow-up of gestational trophoblastic disease and neoplasia were reviewed. Clinical features, including age, prognostic score and International Federation of Gynecology and Obstetrics (FIGO) stages (in the case of gestational trophoblastic neoplasia), human chorionic gonadotropin (hCG) follow-up, treatment and outcome were reported. RESULTS: The centre registered 354 patients, and these patients presented 156 cases of partial hydatidiform moles, 163 cases of complete hydatidiform moles and 14 cases of gestational trophoblastic neoplasia. During follow-up, 35 gestational trophoblastic neoplasms were diagnosed after hCG persistence. After pathology review, the overall agreement rates between our centre and a participating provider hospital was 82%. Methotrexate was the first line of single-agent chemotherapy for most patients, with resistance rates of 23%. Multi-agent chemotherapy was used as first-line treatment for five patients. None of the patients followed up by the centre died from gestational trophoblastic disease. CONCLUSIONS: This study reflects the activity of the Swiss trophoblastic disease centre from the French-speaking part of Switzerland created in 2009, and its role as local and national reference centre, in terms of global health, for women with gestational trophoblastic disease.

Case Report: Laparoscopic Management of an Ectopic Pregnancy in a Rudimentary Non-communicating Uterine Horn.

Introduction: Ectopic pregnancy in a non-communicating rudimentary uterine horn is a rare gynecological condition associated with a high risk of uterine rupture and important maternal mortality and morbidity. A surgical excision of the rudimentary horn is the standard treatment, usually performed by laparotomy in the second trimester. Methods: A 36-year-old woman, secundigravida and nulliparous, was admitted to the emergency obstetric unit with acute pelvic pain. The ultrasound found an ectopic pregnancy at 15 weeks gestational age with fetal cardiac activity. As her hemodynamic status was stable, a diagnostic laparoscopy was performed and confirmed the development of the pregnancy in a left rudimentary uterine horn. Results: We report a total laparoscopic removal of a pre-ruptured rudimentary uterine horn containing a second trimester ectopic pregnancy, using a vessel-sealer device. To our knowledge, only three other cases of successful laparoscopic treatment of second trimester rudimentary horn pregnancies have been reported in the literature. Conclusion: Laparoscopy is an efficient and safe surgical option for treating rudimentary horn second trimester pregnancy in patients with hemodynamic stability.

Motives influencing students' preferences for obstetrics and gynaecology speciality: A cross-sectional multi-site Swiss study.

OBJECTIVES: Knowing and understanding the reasons why medical students choose postgraduate medical specialities are essential to help influence the workforce for a balanced national healthcare system. The objective of this study was to determine motivating factors for choosing a speciality career in general and, more specifically, for the choice of obstetrics and gynaecology (OBGYN) over surgery or general practice. STUDY DESIGN: This study was based on prospectively collected data from a large research multi-site cross-sectional study. We sent a survey to medical students in the sixth year, which contained questions about demographics, choice of speciality and motives for choosing. We grouped the specialities into families of specialities and motives into motivating factors clustered by principal component analysis. We used a multivariate analysis of variance (MANOVA) test to identify differences between motivating factors in speciality categories and gender. We performed logistic regression analyse to compare the choice of OBGYN to choices of surgery and general practice as well as undecided. RESULTS: A total of 1749 students responded with an average return rate of 56%. Our study revealed four motivating factors: "experiential", "relational", "occupational" and "scientific". Logistic regression analysis showed that the choice of OBGYN was particularly influenced by "experiential factor" (OR 1.5; 95%CI [1.2; 1.9]) and by gender (OR 4.5; 95%CI [2.2; 9.2]). When we compared the motivational profile of OBGYN to other speciality categories, OBGYN appeared to stand between surgery and general practice for the "experiential" and "relational" factors, more like surgery for the "occupational factor" and more like general practice for the "scientific factor". CONCLUSION: This study highlighted the importance of "experiential factor" and gender for choosing OBGYN as a career. OBGYN seemed to stand between surgery and general practice from a Swiss students' point of view. These findings provide useful information for targeted interventions to promote OBGYN at the undergraduate level. Such interventions could include providing more hands-on experiences, improving integration of male students and encouraging student involvement in patient care.

Prevalence of undiagnosed uterine leiomyosarcoma in women undergoing hysterectomy or myomectomy for benign indications.

OBJECTIVE: To determine the prevalence of undiagnosed uterine leiomyosarcoma (LMS) in women undergoing hysterectomy or myomectomy for suspected benign leiomyomas. STUDY DESIGN: Retrospective, single-centre, cohort study. Information for all gynaecological procedures for suspected benign leiomyomas between 1993 and 2016 was extracted from the hospital database. The prevalence of LMS was calculated by surgery type and age group. RESULTS: The prevalence of LMS was 1.7/1000 [one in 603 women; 95% confidence interval (CI) 0.8-3.4] for all procedures combined. The prevalence of LMS was 1.1/1000 (one in 875 women; 95% CI 0.4-2.9) for all hysterectomies combined and 4.2/1000 (one in 240 women; 95% CI 1.4-12.2) for all myomectomies combined. For women aged <50years, the prevalence of LMS was 5.4/1000 (one in 187 women; 95% CI 1.8-15.6) for abdominal hysterectomies, 1.0/1000 (one in 1040 women; 95% CI 0.2-5.4) for laparoscopic hysterectomies, 5.2/1000 (one in 191 women; 95% CI 0.9-29.1) for abdominal myomectomies, 3.0/1000 (one in 332 women; 95% CI 0.5-16.9) for laparoscopic myomectomies and 8.6/1000 (one in 116 women; 95% CI 1.5-47.2) for hysteroscopic myomectomies. CONCLUSIONS: Occult LMS is a rare malignant disease. This study found that the prevalence of LMS was higher in women undergoing myomectomy compared with women undergoing hysterectomy. The highest prevalence of LMS was found in women undergoing hysteroscopic myomectomy.