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1.
CMAJ ; 193(36): E1423, 2021 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-34518343
2.
J Perinatol ; 2021 Aug 18.
Artigo em Inglês | MEDLINE | ID: mdl-34408259

RESUMO

OBJECTIVE: To evaluate the diagnostic and screening utility of Kleihauer-Betke (KB) testing as a triage tool in predicting adverse fetal outcomes associated with fetomaternal hemorrhage (FMH). STUDY DESIGN: Single center retrospective cohort study evaluated a primary composite outcome of fetal complications associated with FMH between KB-negative and KB-positive test groups. Screening tests for sensitivity, specificity, positive predictive value and negative predictive value were determined. RESULTS: 641 women (97%) had KB-negative and 22 (3%) had KB-positive tests. The primary composite outcome between KB-negative and KB-positive pregnancies was similar (30% vs. 36%, p = 0.54). Screening exhibited high specificity (97%), however, test sensitivity was poor (4%) with only moderate positive and negative predictive values (36.4 and 69.7%). CONCLUSION: Fetal outcomes associated with FMH were not significantly different between KB-positive and KB-negative test cohorts; KB testing offers no diagnostic precision in the emergency triage evaluation of women with suspected FMH.

3.
Obstet Gynecol ; 138(1): 16-20, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34259459

RESUMO

OBJECTIVE: To quantify the effect of a resident's reputation on the assessment of their laparoscopic skills. METHODS: Faculty gynecologists were randomized to receive one of three hypothetical resident scenarios: a resident with high, average, or low surgical skills. All participants were then asked to view the same video of a resident performing a laparoscopic salpingo-oophorectomy that differed only by the resident description and provide an assessment using a modified OSATS (Objective Structured Assessment of Technical Skills) and a global assessment scale. RESULTS: From September 6, 2020, to October 20, 2020, a total of 43 faculty gynecologic surgeons were recruited to complete the study. Assessment scores on the modified OSATS (out of 20) and global assessment (out of 5) differed significantly according to resident description, where the high-performing resident scored highest (median scores of 15 and 4, respectively), followed by the average-performing resident (13 and 3), and finally, the low-performing resident (11 and 3) (P=.008 and .043, respectively). CONCLUSION: Faculty assessment of residents in gynecologic surgery is influenced by the assessor's knowledge of the resident's past performance. This knowledge introduces bias that artificially increases scores given to those residents with favorable reputations and decreases scores given to those with reputed surgical skill deficits. These data quantify the effect of such bias in the assessment of residents in the workplace and serve as an impetus to explore systems-level interventions to mitigate bias.


Assuntos
Avaliação Educacional , Preconceito , Ginecologia/educação , Humanos , Internato e Residência , Laparoscopia/educação
4.
CMAJ ; 193(18): E663, 2021 May 03.
Artigo em Francês | MEDLINE | ID: mdl-33941529
5.
Acad Med ; 96(9): 1353-1365, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33883396

RESUMO

PURPOSE: Performing a gynecological exam is an essential skill for physicians. While interventions have been implemented to optimize how this skill is taught in medical school, it remains an area of concern and anxiety for many medical students. To date, a comprehensive assessment of these interventions has not been done. The authors conducted a systematic review of the literature on interventions that aim to improve medical student education on gynecological exams. METHOD: The authors searched 6 databases (Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL Plus, Scopus, Web of Science Core Collection, and ERIC [Proquest]) from inception to August 4, 2020. Studies were included if they met the following criteria: focus on medical students, intervention with the purpose of teaching students to better perform gynecological exams, and reported outcomes/evaluation. Extracted data included study location, study design, sample size, details of the intervention and evaluation, and context of the pelvic exam. All outcomes were summarized descriptively; key outcomes were coded as subjective or objective assessments. RESULTS: The search identified 5,792 studies; 50 met the inclusion criteria. The interventions described were diverse, with many controlled studies evaluating multiple methods of instruction. Gynecological teaching associates (GTAs), or professional patients, were the most common method of education. GTA-led teaching resulted in improvements in student confidence, competence, and communication skills. Physical adjuncts, or anatomic models and simulators, were the second most common category of intervention. Less resource-intensive interventions, such as self-directed learning packages, online training modules, and video clips, also demonstrated positive results in student comfort and competence. All studies highlighted the need for improved education on gynecological exams. CONCLUSIONS: The literature included evaluations of numerous interventions for improving medical student comfort and competence in performing gynecological exams. GTA-led teaching may be the most impactful educational tool described, though less resource-intensive interventions can also be effective.


Assuntos
Competência Clínica , Exame Ginecológico/psicologia , Ginecologia/educação , Aprendizagem Baseada em Problemas/métodos , Estudantes de Medicina/psicologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Simulação de Paciente , Relações Médico-Paciente
6.
BMC Womens Health ; 21(1): 122, 2021 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-33757512

RESUMO

BACKGROUND: Though cervical cancer is one of the leading causes of cancer-related death globally, its incidence is nearly entirely preventable. Young people have been an international priority for screening as this population has historically been under-screened. However, in both high-income and low-income countries, young people have not been screened appropriately according to country-specific guidelines. The aim of this systematic review was to systematically characterize the existing literature on barriers and facilitators for cervical cancer screening (CCS) among adolescents and young people globally. METHODS: We conducted a systematic review following PRISMA guidelines of three key databases: Medline-OVID, EMBASE, and CINAHL. Supplementary searches were done through ClinicialTrials.Gov and Scopus. Databases were examined from 1946 until the date of our literature searches on March 12th 2020. We only examined original, peer-reviewed literature. Articles were excluded if they did not specifically discuss CCS, were not specific to individuals under the age of 35, or did not report outcomes or evaluation. All screening, extraction, and synthesis was completed in duplicate with two independent reviewers. Outcomes were summarized descriptively. Risk of bias for individual studies was graded using an adapted rating scale based on the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices. RESULTS: Of the 2177 original database citations, we included 36 studies that met inclusion criteria. The 36 studies included a total of 14,362 participants, and around half (17/36, 47.2%) of studies specifically targeted students. The majority of studies (31/36, 86.1%) discussed barriers and facilitators to Pap testing specifically, while one study analyzed self-sampling (1/36, 2.8%), one study targeted HPV DNA testing (1/36, 2.8%), and the remainder (4/36, 11.1%) were not specified. Our systematic review found that there are three large categories of barriers for young people: lack of knowledge/awareness, negative perceptions of the test, and systemic barriers to testing. Facilitators included stronger relationships with healthcare providers, social norms, support from family, and self-efficacy. CONCLUSION: There are unique barriers and facilitators that affect CCS rates in adolescents and young people. Health systems and healthcare providers worldwide should address the challenges for this unique population.


Assuntos
Neoplasias do Colo do Útero , Adolescente , Estudos Transversais , Detecção Precoce de Câncer , Feminino , Pessoal de Saúde , Humanos , Programas de Rastreamento , Neoplasias do Colo do Útero/diagnóstico
8.
J Obstet Gynaecol Can ; 43(5): 596-600, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33493679

RESUMO

OBJECTIVES: To determine the rates of residual anal sphincter defect following primary repair of obstetrical anal sphincter injury (OASIS), and to assess symptomatology in these patients. METHODS: A retrospective observational study of patients who underwent primary repair of an OASIS sustained at Mount Sinai Hospital from January 2016 to June 2017. Records were reviewed for demographic and obstetrical data, symptoms of anal incontinence (AI), and the results of endoanal ultrasonography (EA-US). RESULTS: One hundred and one women sustained an OASIS during the study period, of whom 53 had EA-US performed at Mount Sinai Hospital; 4 women were excluded from this analysis. There were 42 third-degree tears and 7 fourth-degree tears. EA-US revealed residual defects in 22 patients with third-degree tears and 5 patients with fourth-degree tears (52% vs. 71%; P = 0.44).  Twelve patients with third-degree tears and 4 patients with fourth-degree tears reported AI (29% vs. 57%; P = 0.20). EA-US revealed no evidence of a tear in 14 patients clinically diagnosed with third-degree tears and 1 patient clinically diagnosed with a fourth-degree tear (33% vs. 14%). CONCLUSION: These data demonstrate deficiencies in diagnosis and repair of OASIS. Continued training for health care providers on identification and effective repair of OASIS may improve outcomes for women who experience this complication.


Assuntos
Canal Anal/lesões , Incontinência Fecal/epidemiologia , Lacerações/cirurgia , Complicações do Trabalho de Parto/cirurgia , Adulto , Canal Anal/diagnóstico por imagem , Canal Anal/cirurgia , Canadá/epidemiologia , Parto Obstétrico , Feminino , Humanos , Lacerações/diagnóstico por imagem , Lacerações/etiologia , Complicações do Trabalho de Parto/diagnóstico por imagem , Complicações do Trabalho de Parto/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Período Pós-Parto , Gravidez , Estudos Retrospectivos
9.
Fam Cancer ; 20(2): 103-110, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32964297

RESUMO

Women at risk of developing ovarian cancer because of a BRCA1 or BRCA2 pathogenic variant are candidates for prophylactic bilateral salpingo-oophorectomy (BSO). While BSO surgeries are routinely performed, to our knowledge there are no studies that have examined patient-reported experiences following laparoscopic BSO performed in an ambulatory care setting. The objective of this study was to examine whether women undergoing prophylactic laparoscopic BSO felt they were adequately informed about post-operative outcomes. A telephone interview was conducted among 46 women undergoing laparoscopic BSO to collect detailed information regarding surgical outcomes, complications, symptoms, and time to return to daily activities. The average age at surgery was 45.0 years (range 34-66) and 67% of women underwent BSO prior to age 50. The mean reported hospital stay was 7.2 h (range 4-12 h) and at time of discharge, 78% of the women felt well enough to go home. None of the women required a readmission to hospital. Forty-three percent (n = 20) of the women did not feel well informed about what to expect post-operatively. Most of the patient-reported outcomes (including pain, vaginal bleeding, and nausea/vomiting) were expected and patient-reported menopausal symptoms were more common among women who were premenopausal at surgery. In terms of returning to regular activities, premenopausal women (n = 36) resumed sexual activity on average at 43 days (range 2-365), which is later than postmenopausal women (n = 15) at 19 days (range 7-30). On average, women returned to full-time work in 16 days (range 1-56 days). Despite patients receiving pre-surgery counselling, our findings suggest that there is a need to provide supplemental, reinforcing patient materials in preparing patients for what to expect after surgery.

10.
J Obstet Gynaecol Can ; 43(3): 306-312, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33127379

RESUMO

OBJECTIVE: Rates of cesarean delivery are increasing, and these procedures carry potential complications, like the risk of invasive placentation, which increases with each cesarean. A trial of labour after cesarean (TOLAC) is a viable option for patients; however, it has been associated with uterine rupture, a complication with maternal and fetal risks. To better counsel patients considering TOLAC, we aimed to determine local uterine rupture rates and maternal and neonatal outcomes with TOLAC and compare these with outcomes related to invasive placentation. METHODS: A 4-year retrospective chart review was conducted at our tertiary centre of all patients with a history of a previous cesarean delivery. We assessed rates of TOLAC, vaginal delivery after cesarean (VBAC), and uterine rupture, as well as maternal and neonatal outcomes associated with invasive placentation. Cases of uterine rupture from 1988 to the present were also reviewed, and their outcomes were compared with those of invasive placentation. RESULTS: Our uterine rupture rate was 0.44% and VBAC rate was 73.8%. We identified 8 cases of uterine rupture since 1988 and 67 invasive placentas during the 4-year chart review. Invasive placentation was associated with a significantly increased risk of neonatal respiratory morbidity, hysterectomy, maternal complications, and longer length of maternal hospital stay when compared with uterine rupture. CONCLUSION: While uterine rupture remains a potential complication of TOLAC, it is rare with overall excellent maternal and neonatal outcomes. Invasive placentation, the risk of which increases with cesarean delivery, carries potentially higher complication rates than uterine rupture. Local complication data is important for individual sites offering TOLAC. The implications of invasive placentation cannot be overlooked when counselling patients considering TOLAC.


Assuntos
Aconselhamento , Placentação , Prova de Trabalho de Parto , Ruptura Uterina/etiologia , Nascimento Vaginal Após Cesárea/efeitos adversos , Adulto , Cicatriz/complicações , Feminino , Humanos , Avaliação de Resultados em Cuidados de Saúde , Gravidez , Estudos Retrospectivos , Nascimento Vaginal Após Cesárea/estatística & dados numéricos
11.
J Obstet Gynaecol Can ; 43(4): 490-496, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33373695

RESUMO

OBJECTIVE: Obstetricians and gynaecologists are among the highest risk specialties for burnout. There is growing evidence that physician burnout can be both prevented and reduced. We sought to characterize the evidence base for interventions related to the prevention and treatment of burnout in obstetrics and gynaecology DATA SOURCES: We conducted a scoping review following PRISMA guidelines of 5 databases: (Medline-OVID, EMBASE, CINAHL, ClinicalTrials.gov, and PsycInfo) from inception to March 17, 2020. Citations of relevant articles were hand-searched to maximize sensitivity. STUDY SELECTION: All interventional study designs were included. The target study population was obstetrics and gynaecology residents, learners, or staff. Published conference posters, papers, and abstracts were eligible for inclusion. DATA EXTRACTION AND SYNTHESIS: All extraction and descriptive analysis was completed by two independent reviewers. Outcomes were summarized descriptively. Appraisal was completed using the Cochrane Risk of Bias tool and Risk of Bias Assessment tool for Non-randomized Studies. RESULTS: Of the 1540 original database citations, 20 studies met our inclusion criteria. A total of 589 obstetrics/gynaecology participants were included. While there was an overall a lack of research in the field, there were several promising interventions that target residents. There were a combination of preventative interventions (e.g. yoga, nutritional programs, or narrative medicine initiatives) as well as treatments (e.g. counselling appointments or debrief sessions). The vast majority of these interventions focused on individual-specific interventions rather than structural changes. In addition, the majority of interventions appeared to be "proof of concept" and feasability-related studies, with many studies published as conference abstracts rather than peer-reviewed journal publications. CONCLUSIONS: Institutions should continue to implement interventions that address burnout in obstetrics and gynaecology. Further research is required on long-term outcomes of interventions as well as structural strategies.


Assuntos
Esgotamento Psicológico , Ginecologia , Obstetrícia , Estresse Ocupacional , Médicos/psicologia , Adaptação Psicológica , Feminino , Humanos , Saúde Mental , Gravidez , Resiliência Psicológica
12.
CMAJ ; 192(50): E1830, 2020 Dec 14.
Artigo em Francês | MEDLINE | ID: mdl-33318100
14.
Fertil Steril ; 113(6): 1330-1332, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32386869

RESUMO

OBJECTIVE: To review tuboplasty techniques for alleviating fallopian tube blockage. DESIGN: A step-by-step explanation of the techniques that comprise tuboplasty-fimbrioplasty, salpingo-ovariolysis, and salpingostomy-with surgical video footage. SETTING: Academic medical center. PATIENT: A 28-year-old G0 female patient with primary infertility and bilateral fallopian tube occlusion wanting to avoid in vitro fertilization. INTERVENTION(S): Tuboplasty and its component techniques of fimbrioplasty, salpingo-ovariolysis, and salpingostomy are demonstrated in a stepwise fashion for a case of mild tubal disease. Fimbrioplasty includes identifying the agglutinated or phimosed fimbrial end and gently opening it with fine forceps and blunt microdissection. Salpingo-ovariolysis is demonstrated with video and comprises: 1) surveying the anatomy; 2) applying traction to delineate the adhesions; and 3) transecting the adhesions with microsurgical scissors or electrosurgery. Finally, the steps of a salpingostomy are demonstrated, including: 1) identifying the length of the fallopian tube; 2) performing chromotubation to delineate tubal obstruction; 3) creating a salpingostomy at the terminal end; and 4) suturing open the salpingostomy site circumferentially to evert the edges. MAIN OUTCOME MEASURE(S): Successful restoration of normal tubal anatomy and identification of the location of tubal occlusion to guide salpingostomy site placement. RESULT(S): The fallopian tubes were assessed bilaterally and noted to have mild tubal disease and therefore were appropriate for tuboplasty. Normal tubal anatomy was restored bilaterally through salpingo-ovariolysis. Subsequent identification of the area of tubal occlusion bilaterally and salpingostomy were performed to create a patent fallopian tube able to pick up an oocyte from the ovary and facilitate fertilization. CONCLUSION(S): Tubal reconstructive surgery remains an important option to offer patients who want to avoid in vitro fertilization and who have mild tubal disease.


Assuntos
Doenças das Tubas Uterinas/cirurgia , Laparoscopia , Salpingectomia , Salpingostomia , Adulto , Doenças das Tubas Uterinas/diagnóstico por imagem , Feminino , Humanos , Técnicas de Sutura , Resultado do Tratamento
15.
J Minim Invasive Gynecol ; 27(7): 1545-1551, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31982585

RESUMO

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.


Assuntos
Competência Clínica , Ginecologia/educação , Laparoscopia/educação , Salpingo-Ooforectomia/educação , Gravação em Vídeo , Adulto , Competência Clínica/normas , Competência Clínica/estatística & dados numéricos , Feminino , Ginecologia/métodos , Humanos , Internato e Residência/métodos , Laparoscopia/métodos , Laparoscopia/normas , Masculino , Obstetrícia/educação , Ontário , Salpingo-Ooforectomia/métodos , Cirurgiões/educação , Ensino
17.
J Obstet Gynaecol Can ; 41(9): 1268-1275.e4, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31155501

RESUMO

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.


Assuntos
Ginecologia/organização & administração , Internato e Residência/estatística & dados numéricos , Obstetrícia/organização & administração , Médicos , Atitude do Pessoal de Saúde , Canadá , Competência Clínica , Estudos Transversais , Humanos , Médicos/psicologia , Médicos/normas , Médicos/estatística & dados numéricos , Inquéritos e Questionários
20.
J Obstet Gynaecol Can ; 40(11): 1497-1510, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30473125

RESUMO

OBJECTIVE: This Committee Opinion outlines the gynaecologic management recommendations for women diagnosed with hereditary breast and ovarian cancer syndrome (HBOC) with respect to screening, contraception, chemoprophylaxis, fertility considerations, risk-reducing surgery, and post-oophorectomy care. INTENDED USERS: This Committee Opinion is designed for gynaecologic oncologists, general gynaecologists, family physicians, genetic counsellors, registered nurses, nurse practitioners, residents, and health care providers. TARGET POPULATION: Adult women (18 years and older) with a pathogenic germline variant in the BRCA1, BRCA2, and other ovarian cancer-associated genes. EVIDENCE: While reviewing evidence, databases searched include Medline, Cochrane, and PubMed. Medical Subject Heading search terms used include BRCA AND gynaecology management, hormone replacement therapy, risk reduction, chemoprophylaxis, fertility from 01/2010 and 10/2017. Literature search was begun 07/2017 and finalized 10/2017. In total 183 studies were identified, and 101 were used. VALIDATION METHODS: The content and recommendations were drafted and agreed upon by the principal authors. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework (Table 1). The interpretation of strong and conditional (weak) recommendations is described in Table 2. The Summary of Findings is available upon request. BENEFITS, HARMS, AND COSTS: We may expect a risk reduction of up to 90% in women predisposed to HBOC who undergo risk-reducing bilateral salpingo-oophorectomy. The harms of iatrogenic premature menopause are offset by the benefits of risk reduction. By minimizing potential tubal/ovarian/peritoneal cancers, we can expect savings to the health care system. GUIDELINE UPDATE: Evidence will be reviewed 5 years after publication to decide whether all or part of the opinion should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. SPONSORS: This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada.


Assuntos
Neoplasias da Mama , Neoplasias Ovarianas , Adulto , Proteína BRCA1 , Proteína BRCA2 , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/genética , Neoplasias da Mama/terapia , Detecção Precoce de Câncer , Feminino , Aconselhamento Genético , Humanos , Pessoa de Meia-Idade , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/genética , Neoplasias Ovarianas/terapia , Gravidez
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