Placenta Accreta Spectrum Disorders: A National Survey.

OBJECTIVES: Describe the current practice of Canadian obstetricians-gynaecologists in managing placenta accreta spectrum (PAS) disorders from suspicion of diagnosis to delivery planning and explore the impact of the latest national practice guidelines on this topic. METHODS: We distributed a cross-sectional bilingual electronic survey to Canadian obstetricians-gynaecologists in March-April 2021. Demographic data and information on screening, diagnosis, and management were collected using a 39-item questionnaire. The survey was validated and pretested among a sample population. Descriptive statistics were used to present the results. RESULTS: We received 142 responses. Almost 60% of respondents said they had read the latest Society of Obstetricians and Gynaecologists of Canada clinical practice guideline on PAS disorders, published in July 2019. Nearly 1 in 3 respondents changed their practice following this guideline. Respondents highlighted the importance of 4 key points: (1) limiting travel to thereby remain close to a regional care centre, (2) preoperative anemia optimization, (3) performance of cesarean-hysterectomy leaving the placenta in situ (83%), (4) access via midline laparotomy (65%). Most respondents recognized the importance of perioperative blood loss reduction strategies such as tranexamic acid and perioperative thromboprophylaxis via sequential compression devices and low-molecular-weight heparin until full mobilization. CONCLUSIONS: This study demonstrates the impact of the Society of Obstetricians and Gynaecologists of Canada's PAS clinical practice guideline on management choices made by Canadian clinicians. Our study highlights the value of a multidisciplinary approach to reducing maternal morbidity in individuals facing surgery for a PAS disorder and the importance of regionalized care that is resourced to provide maternal-fetal medicine and surgical expertise, transfusion medicine, and critical care support.

No. 383-Screening, Diagnosis, and Management of Placenta Accreta Spectrum Disorders.

BACKGROUND: Placenta accreta spectrum (PAS) disorders are a potentially life-threatening complication of pregnancy that demand coordinated interdisciplinary care to achieve safer outcomes. The rising incidence of this disease is due to a growing number of uterine surgical procedures, including the rising incidence of pregnancy following Caesarean section. OBJECTIVE: To provide current evidence-based guidelines on the optimal methods used to effectively screen, diagnose, and manage PAS disorders. METHODS: Members of the guideline committee were selected on the basis of their ongoing expertise in managing this condition across Canada and by practice setting. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated diagnostic tests, surgical procedures, and clinical outcomes. EVIDENCE: Published literature, including clinical practice guidelines, was retrieved through searches of Medline and The Cochrane Library to March 2018 using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized controlled trials, and observational studies written in English. Searches were updated on a regular basis and incorporated in the guideline to July 2018. VALUES: The quality of evidence in this document was graded using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. RESULTS: This document reviews the evidence regarding the available diagnostic and surgical techniques used for optimal management of women with suspected PAS disorders, including anaesthesia and practical considerations for interdisciplinary care. BENEFITS, HARMS, AND COSTS: Implementation of the guideline recommendations will improve awareness of this disease and increase the proportion of affected women receiving interdisciplinary care in regional centres. CONCLUSIONS: Interdisciplinary team-based care providing accurate diagnostic services, coordinated planning, and safer surgery deliver effective care with improved clinical outcomes in comparison with alternative management. SUMMARY STATEMENTS: RECOMMENDATIONS.

Use of Audio Computer-Assisted Self-Interviews to Gather Information on Risk Behaviors in a Population of Pregnant Adolescents.

In a prospective study comparing the use of the Audio Computer-Assisted Self-Interview (ACASI) with a traditional clinical interview in 40 pregnant adolescents, there was significantly greater disclosure of violence with the ACASI method. Better identification of high-risk behaviors may help to optimize care and programing for pregnant adolescents.

Obstetric and Anaesthesia Checklists for the Management of Morbidly Adherent Placenta.

OBJECTIVE: To develop an integrated checklist for the management of patients with suspected morbidly adherent placenta (MAP). METHODS: A checklist process was developed incrementally by clinicians in the disciplines of maternal-fetal medicine, gynaecology, medical imaging, and anaesthesia for management of women with suspected MAP. RESULTS: Over a five-year period of debriefing after individual cases, a comprehensive checklist system was developed. The checklist is activated upon referral if MAP is suspected at an initial maternal-fetal medicine consultation; the process is subsequently guided by a clinical nurse specialist, leading to a standardized program of care. CONCLUSIONS: Having a checklist process facilitates standardized care and optimal communication between specialists, providing team-based care for women with this potentially serious complication of pregnancy.

Simulated impact of pelvic MRI in treatment planning for pediatric adnexal masses.

BACKGROUND: There are no studies on utility of MRI in management of pediatric adnexal masses. OBJECTIVE: To determine the diagnostic and therapeutic impact of pelvic MRI in adnexal masses in children and adolescents. MATERIALS AND METHODS: We included 32 females age 18 years and younger who had adnexal masses and who underwent both pelvic ultrasound (US) and MRI. A radiologist retrospectively reviewed US and MR images and created a standard radiologic report for each patient. In a prospective theoretical fashion, two pediatric gynecologists reviewed the clinical data and US report for each patient and indicated conservative versus surgical management; in surgical cases the options were laparoscopy versus laparotomy, midline versus Pfannenstiel incision, and oophorectomy versus cystectomy. Subsequently, the gynecologists were presented the MRI report and were asked to indicate their treatment options again. A binomial test was conducted to determine the effect of adding MRI findings to the management plan. RESULTS: The addition of MRI significantly changed management in 10 of 32 patients (P=0.0322), with a change in surgical versus conservative treatment in 5, a change in laparotomy vs. laparoscopy in 2, and a change from oophorectomy to cystectomy along with change in incision in 3 cases. This was based on additional information provided by MRI regarding the nature of the mass in 8 cases and origin of the mass in 2 cases. CONCLUSION: Preoperative pelvic MRI findings might change the surgical management of pediatric patients with adnexal masses, so it is a valuable addition to the conventional workup in the clinical management.

Postoperative Ovarian Morphology on Ultrasound after Ovarian Torsion-Effect of Immediate Surgery: A Retrospective Cohort Study.

STUDY OBJECTIVE: Our objective was to determine if ovarian surgery at the time of ovarian detorsion is associated with impaired short-term ovarian function as indicated by ovarian morphology on ultrasound when compared with detorsion alone. DESIGN: Retrospective cohort study SETTING: The Hospital for Sick Children, Toronto PARTICIPANTS: Patients ≤ 18 years old with confirmed ovarian torsion from January 1, 2004, to December 31, 2018, with ovarian-sparing surgery. MAIN OUTCOME MEASURES: Data were collected on demographics, procedure, intraoperative findings, and postoperative ultrasound. To determine ovarian function, we compared the morphology on the postoperative ultrasound between those with surgery to the ovary and those without surgery to the ovary at the time of detorsion. We also compared the ovarian volume of affected and contralateral ovaries after detorsion and surgery to the affected ovary. RESULTS: One hundred and nineteen patients met the inclusion criteria, of whom 67 (56%) had detorsion with surgery to the ovary and 52 (44%) had detorsion alone. There was no statistically significant difference in appearance on the postoperative ultrasound between these groups (P =.446). There was also no statistically significant difference on the postoperative ultrasound of affected and contralateral ovarian volumes after detorsion and surgery to the affected ovary (P = .69). Patients who underwent surgery to the ovary experienced a lower rate of recurrence; however, this did not reach statistical significance, with a P value of 0.080. CONCLUSION: Our study demonstrates that surgery, eg cystectomy to the ovary at the time of ovarian detorsion, does not appear to impact ovarian function when compared with detorsion alone, as indicated on postoperative imaging. There was also no difference in volume of the affected and contralateral ovaries in those cases that underwent surgery at the time of initial detorsion. This evidence would support that immediate cystectomy at the time of initial ovarian detorsion is not associated with impaired ovarian function, thus avoiding the need for an interval cystectomy.

Comparing estrogen-based hormonal contraceptives and hormone therapy on bone mineral density in women with premature ovarian insufficiency: a systematic review.

IMPORTANCE: Premature ovarian insufficiency (POI) is a condition associated with estrogen deficiency which leads to decreased bone mineral density and an increased risk of osteoporosis and fractures. Estrogen-based hormone therapy is an integral component of treatment; however, to date the ideal hormone formulation for optimizing bone health has not been established. OBJECTIVE: To assess the effects of estrogen-based oral contraceptives (OCP) versus hormone therapy (HT) on bone mineral density (BMD) in women with POI. EVIDENCE REVIEW: A systematic review of Ovid MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was conducted from conception until December 2020. Randomized controlled trials (RCTs) and observational studies that met inclusion criteria were included in the analysis. Risk of bias was assessed with the Newcastle-Ottawa Quality Assessment Scale for cohort studies and the Cochrane Risk of Bias for RCTs. The study protocol was registered with the International Prospective Register of Systematic Reviews and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. FINDINGS: Our search yielded 1,227 studies; 3 RCTs and 2 observational cohort studies met inclusion criteria and were included in our study. The largest subpopulation was Turner Syndrome (n = 625), followed by idiopathic POI (n = 146). Of the four studies that assessed changes in BMD, two studies reported a significant increase in lumbar spine BMD with HT compared with OCP (+0.050 g/cm2, P < 0.025; +0.019 g/cm2, P < 0.01), one study found similar improvement in lumbar spine BMD across treatments (HT -0.003 g/cm2, P = 0.824), and one study did not directly compare treatments. Effects on bone turnover markers were inconsistent across three studies that evaluated this outcome. CONCLUSIONS AND RELEVANCE: This is the first systematic review to include studies that directly compared OCP and HT on bone outcomes in POI. While two studies reported increased lumbar spine BMD with HT, this result was not consistently found across studies. There were important differences in POI etiology, treatment regimens and formulations, and risk of bias was high in many of the studies. These results indicate future, larger-scale trials are needed to further understand the optimal hormone therapy for bone density in POI.

Safer outcomes for placenta accreta spectrum disorders: A decade of quality improvement.

OBJECTIVE: To describe the evolution and evaluation of protocol-based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders. METHODS: A single-center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009-2011 (initial period) and 2017-2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization. RESULTS: Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 ml in the initial period to 1000 ml in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days). CONCLUSION: These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders.

Prenatal 3-dimensional imaging techniques in the sonographic evaluation of an oral mass: comparison with postnatal imaging modalities.

Historically, published reports of 3-dimensional (3D) sonographic evaluation of fetal oral masses have been limited to the surface-rendering mode. This report demonstrates the clinical potential of various 3D imaging techniques in the evaluation of fetal epignathus. A comparison is made among the images generated from 3D data sets, postnatal magnetic resonance imaging and computed tomographic scans, and the excised surgical specimen. The diagnostic value and limitations of several 3D imaging techniques in the evaluation of an oral mass are explored.

Müllerian duct anomalies and mimics in children and adolescents: correlative intraoperative assessment with clinical imaging.

Müllerian duct anomalies (MDAs) are congenital entities that result from nondevelopment, defective vertical or lateral fusion, or resorption failure of the müllerian (paramesonephric) ducts. MDAs are common, although the majority are asymptomatic, and have been classified by the American Society of Reproductive Medicine according to clinical manifestations, prognosis, and treatment. Accurate diagnosis of an MDA is essential, since the management approach varies depending on the type of malformation. In females, when a müllerian duct becomes obstructed, the patient may present with an abdominal mass and dysmenorrhea. If the patient is not treated in a timely fashion, the consequences can be severe, extending even to infertility. When an MDA is suspected, ultrasonography (US) should be performed initially to delineate any abnormalities in the genital tract. However, US cannot help identify the type of MDA. In contrast, magnetic resonance imaging is a valuable technique for noninvasive evaluation of the female pelvic anatomy and accurate MDA classification. If obstruction is present, surgical correction of the MDA may be required, and further counseling of the patient with regard to reproductive possibilities becomes important. Supplemental material available at http://radiographics.rsnajnls.org/cgi/content/full/29/4/1085/DC1.

Retrospective review of unintentional female genital trauma at a pediatric referral center.

UNLABELLED: Unintentional female genital trauma is a complaint commonly seen and managed through the emergency department. The purpose of this study was to review all unintentional female genital trauma evaluated at The Hospital for Sick Children for 3.5 years to determine the factors associated with gynecologic consultation and need for operative repair. METHODS: One hundred five patients were identified by health record coding. Data were extracted to study factors associated with gynecologic consultation and operative repair. Statistical analyses were performed to evaluate the significance of these associations. Surgical choices were also evaluated. RESULTS: Mean age was 5.60 years. Mean time to presentation was 7.05 hours. Straddle injury was the most common mechanism (81.90%), and only 4.76% injuries were penetrating. Of the 105 patients, 48.57% consulted the gynecology section, 19.05% were taken to the operating room, and 6.66% were treated under conscious sedation. Overall, 20.95% required surgical repair. The most common complication was dysuria. Six patients had other injuries, the most common of which were pelvic fractures related to trauma.Factors significantly associated with gynecologic consultation and operative management included older age, transfer to our institution, shorter time to presentation, laceration-type injury, hymenal injury, and larger size of injury. Straddle injuries were significantly less likely to be taken to the operating room. When cases were stratified by a surgeon, there were no significant differences in management. CONCLUSIONS: Unintentional female pediatric genital traumas most commonly result from straddle injuries. Most injuries are minor, and in this cohort, only 48.57% received gynecologic consultation and 19.05% required operative management. Future prospective studies would be useful to better evaluate the efficacy of surgical choices.

The Utility of Routine Ultrasound in the Diagnosis and Management of Adolescents with Abnormal Uterine Bleeding.

STUDY OBJECTIVE: Despite the fact that most cases of abnormal uterine bleeding (AUB) in adolescence are due to an immature hypothalamic-pituitary-ovarian (HPO) axis, the current approach to investigating adolescents who present with AUB often includes pelvic ultrasound to exclude rare structural causes. The aim of this study was to determine whether an ultrasound ordered for the investigation of AUB in adolescents detects any significant anatomic pathology or alters diagnosis and management. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS: A retrospective chart review of 230 patients younger than 18 years of age who presented with AUB to the gynecology clinic at the Hospital for Sick Children in Toronto, Canada between January 2010 and December 2012 was completed. MAIN OUTCOME MEASURES: Findings on pelvic ultrasound and any further imaging as well as management choices for these patients were examined. RESULTS: Of all patients, 67.8% (156/230) had ultrasound done as part of their AUB workup. The most common diagnosis for the patients who received ultrasound examinations and the patients who did not was AUB due to an immature HPO axis. Of the patients who received an ultrasound examination, 72.4% (113/156) had normal findings; incidental findings were identified in 17.9% (28/156) and polycystic ovary syndrome morphology in 6.4% (10/156). Structural causes of AUB were found in only 2 (1.3%) of the adolescents imaged. No patient had a change in her AUB management plan because of ultrasound findings. CONCLUSION: Our results strongly suggest that pelvic ultrasound examination is not required in the initial investigation of AUB in the adolescent population because it did not alter treatment in any of our patients.

Rates and Technique for Oophoropexy in Pediatric Ovarian Torsion: A Single-Institution Case Series.

STUDY OBJECTIVE: Ovarian torsion (OT) is uncommon, but can result in loss of reproductive function. Traditionally managed using adnexectomy, torsed adnexae are now being conserved, increasing the potential for recurrent OT. As a result, some experts suggest oophoropexy (OP) to prevent recurrence. We report on a series of 11 patients who underwent OP. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective case series was conducted from 2004 to 2013 to identify patients younger than the age of 18 years with OT. From this, data for patients with OP were extracted for detailed review. RESULTS: We identified 97 patients with OT; 6 of 97 (6.2%) had recurrent OT. The rate of recurrence was higher (14.8%, 4/27) in the group with torsion without an adnexal mass. Eleven of 97 patients (11.3%) underwent OP. The mean age of patients with OP was 8.8 years. Nine patients had normal adnexae at initial torsion. Five of 11 had OP during their initial procedure. OP was most commonly performed for long utero-ovarian ligaments (n = 6), recurrence (n = 4), or bilateral OT (n = 2). Eight of 8 patients with follow-up ultrasound imaging after torsion showed at least 1 marker of normal ovarian function. One of 11 patients (9%) had a recurrence of OT of an oophoropexied ovary. There were no complications due to the OP portion of the procedure. CONCLUSION: In our series of OT, a small percentage of patients underwent prophylactic OP. Recurrence might still occur after OP. It seems reasonable to offer OP to patients at higher risk of recurrent OT although level 1 evidence is lacking. Future research should focus on techniques and long-term outcomes of OP.

Uterine Length in Adolescents with Developmental Disability: Are Ultrasound Examinations Necessary before Insertion of the Levonorgestrel Intrauterine System?

STUDY OBJECTIVE: (1) To determine if there are any differences in uterine length between adolescents with developmental disability (DD) compared with their normally developing (ND) peers that might necessitate ultrasonography before insertion of levonorgestrel intrauterine system (LNG-IUS) in patients with DD; and (2) to characterize the LNG-IUS insertion procedure in adolescents with disabilities. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS: This was a retrospective cohort study of 223 female adolescents with or without DDs. Seventy-five adolescents had DD; 33 underwent intrauterine system insertion in the operating room and 42 did not. A comparative cohort of 148 ND adolescents who had pelvic ultrasound examinations for abnormal uterine bleeding were included. The study period was between January 2006 and July 2013 at the Hospital for Sick Children, Toronto, Canada. Cases were identified from surgical databases and medical records. MAIN OUTCOME MEASURES: Mean uterine length on pelvic ultrasound, demographic characteristics (age, age at menarche, time from menarche to ultrasound, weight), and descriptive statistics on intrauterine system insertion. RESULTS: There was a statistically significant difference (P = .03) in uterine length between adolescents with and without DD (6.7 vs 7.1 cm). However, this was not a clinically significant difference because insertion of the LNG-IUS in patients with DD was successful in patients with uteri more than 5 cm long. There was no difference (P = .97) in uterine length of adolescents with DD whether they had LNG-IUS insertion or not (6.7 cm). Adolescents with DD were younger than adolescents without DD at time of ultrasound examination (P = .01). However, among patients with DD, those who underwent intrauterine system insertion were older (P = .001). Incidence of uterine anomaly in patients with DD is low (2.7%) and was the same as in ND adolescents. Rates of complications and expulsions were low and there were no failures of LNG-IUS insertion in adolescents with DD. CONCLUSION: Routine pelvic ultrasound examinations are not necessary before insertion of the LNG-IUS for menstrual suppression in adolescents with DD. Renal abnormalities, obstructive symptoms, and very small stature might necessitate imaging. Insertion using anesthesia is often straightforward and successful with minimal complications.

Menstrual and contraceptive issues among young women with developmental delay: a retrospective review of cases at the Hospital for Sick Children, Toronto.

OBJECTIVES: To define the clinical characteristics of, and management options offered to, young women with developmental delay referred to The Hospital for Sick Children gynecology clinic in Toronto for menstrual suppression and contraception. To review the primary caregiver concerns and preferences with regards to menstruation and contraception. METHODS: A retrospective chart review of hospital records of young women with developmental delay referred to the gynecology clinic at The Hospital for Sick Children, Toronto from 1998 to 2003. RESULTS: A total of 72 charts were reviewed from clinic visits between 1998 to 2003. Ages range from 8 to 17 years with an unknown cause of their cognitive disability in 44% and medium to high support needs in the majority. Forty-three percent were still premenarcheal when first brought to the gynecology clinic by their families or caregivers. The main reason for consult was menstrual-related in 90%, with concerns related to hygiene and problems coping. CONCLUSIONS: Caregivers often approach physicians for menstrual suppression prior to menarche with a primary concern of personal hygiene. Medical suppression of menstruation can be successfully achieved. Depo-Provera was the most commonly prescribed and accepted method of menstrual suppression within our population.

A rare case of inguinolabial lipoblastoma in a 13-month-old female.

Lipoblastoma is a rare, rapidly growing, benign mesenchymal tumor composed of various stages of maturing adipocytes that most often occurs in children under the age of 3. The common locations are the extremities and the trunk. Presentation in the genitoinguinal area is rare. We report a case of a 13-month-old female infant with a 4-month history of a progressively enlarging left labial mass that encompassed her left labium majora and inguinal region. Pelvic MRI confirmed growth from previous ultrasound size of 3 × 2 × 1 cm to 7 × 2 × 2 cm. Composition was suggestive of adipose tissue. The mass was excised through a left inguinal incision. The final pathology results described a lipoblastoma. Six year follow-up has not revealed any signs or symptoms of recurrence. Circumscribed lipoblastomas should be distinguished from their infiltrative counterpart, diffuse lipoblastoma or lipoblastomatosis, which can be more difficult to excise and thus, more likely to recur. Lipoblastoma should also be distinguished from myxoid liposarcoma, which has malignant features, carries a high risk of recurrence, and requires a more aggressive management protocol. Although rare, lipoblastoma should be considered as part of the differential diagnosis of a rapidly growing vulvar mass in prepubertal children.