Predicting adverse outcomes in pregnant patients positive for SARS-CoV-2: a machine learning approach- a retrospective cohort study.

BACKGROUND: Pregnant people are particularly vulnerable to SARS-CoV-2 infection and to ensuing severe illness. Predicting adverse maternal and perinatal outcomes could aid clinicians in deciding on hospital admission and early initiation of treatment in affected individuals, streamlining the triaging processes. METHODS: An international repository of 1501 SARS-CoV-2-positive cases in pregnancy was created, consisting of demographic variables, patient comorbidities, laboratory markers, respiratory parameters, and COVID-19-related symptoms. Data were filtered, preprocessed, and feature selection methods were used to obtain the optimal feature subset for training a variety of machine learning models to predict maternal or fetal/neonatal death or critical illness. RESULTS: The Random Forest model demonstrated the best performance among the trained models, correctly identifying 83.3% of the high-risk patients and 92.5% of the low-risk patients, with an overall accuracy of 89.0%, an AUC of 0.90 (95% Confidence Interval 0.83 to 0.95), and a recall, precision, and F1 score of 0.85, 0.94, and 0.89, respectively. This was achieved using a feature subset of 25 features containing patient characteristics, symptoms, clinical signs, and laboratory markers. These included maternal BMI, gravidity, parity, existence of pre-existing conditions, nicotine exposure, anti-hypertensive medication administration, fetal malformations, antenatal corticosteroid administration, presence of dyspnea, sore throat, fever, fatigue, duration of symptom phase, existence of COVID-19-related pneumonia, need for maternal oxygen administration, disease-related inpatient treatment, and lab markers including sFLT-1/PlGF ratio, platelet count, and LDH. CONCLUSIONS: We present the first COVID-19 prognostication pipeline specifically for pregnant patients while utilizing a large SARS-CoV-2 in pregnancy data repository. Our model accurately identifies those at risk of severe illness or clinical deterioration, presenting a promising tool for advancing personalized medicine in pregnant patients with COVID-19.

What is the Role of Video-Based Assessment of Laparoscopic Surgical Skill in Residency Training? A Qualitative Study of Trainee and Faculty Perspectives.

OBJECTIVES: Surgical training programs are starting to experiment with video-based assessment (VBA) of residents' technical skills. VBA may limit the effect of interpersonal bias on assessment scores. However, before VBA is implemented widely, stakeholders' perceptions ought to be explored, including potential benefits and challenges. METHODS: Using the qualitative methods of hermeneutical phenomenology, the authors explored both trainee and faculty educators' perspectives on VBA using semi-structured interviews. Participants were recruited from the Department of Obstetrics and Gynecology at the University of Toronto. Data underwent thematic analysis and was validated by the investigator and theoretical triangulation. RESULTS: The authors interviewed 9 physicians (5 faculty and 4 residents). Four dominant themes were identified, including advantages compared to traditional methods, the role of feedback and coaching, challenges integrating VBA, and considerations for implementation. CONCLUSIONS: Surgical trainees and faculty feel that VBA is a worthy tool to advance equity and fairness in assessment, but felt it was better as a vehicle for feedback and coaching. VBA cannot be used as a standalone assessment metric without additional evidence for its validity. If implemented, residency programs can use VBA as an adjunct to other evaluation measures to facilitate coaching, provide asynchronous feedback, and limit assessment bias.

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.

Pregnancy and childbirth during incarceration: A qualitative systematic review of lived experiences.

BACKGROUND: Incarcerated individuals who experience pregnancy or childbirth in correctional facilities face unique considerations for obstetric care and consequently are at greater risk of adverse maternal and fetal outcomes. OBJECTIVES: To characterise patient experiences regarding pregnancy and childbirth during incarceration via qualitative synthesis. SEARCH STRATEGY: Medline-OVID, EMBASE, CINAHL, Sociological Abstracts, Social Work Abstracts, Web of Science, Scopus and PsycInfo were systematically searched from inception to 24 December 2020. Supplementary searches were performed using the Scopus database. SELECTION CRITERIA: Only original, peer-reviewed literature was examined. Eligible studies were assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. RESULTS: After screening 4173 original database citations, 24 studies that met inclusion criteria were included and analysed via thematic analysis. The 24 studies included perspectives from 645 female patients who had experienced incarceration, 69 healthcare providers and 70 prison staff. Key patient-reported concerns for the well-being of pregnant individuals during incarceration included mental health challenges, dehumanisation of prenatal care and delivery, lack of privacy, stigma, psychological trauma, lack of emotional support and shackle usage during pregnancy and/or labour. The studies reported a lack of support for patients to access female correctional officers or guards, privacy during intimate examinations, timely medical care and support for breastfeeding. Above all, the psychological trauma of separation from one's newborn after birth was of utmost devastation. CONCLUSIONS: Our systematic review highlights the dire need for accountability and interventions to improve pregnancy and childbirth care for incarcerated individuals. TWEETABLE ABSTRACT: This systematic review describes lived experiences of pregnancy & childbirth during incarceration, including dehumanisation, psychological trauma, and use of shackles.

Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review.

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.

Residual Defects of the Anal Sphincter Complex Following Primary Repair of Obstetrical Anal Sphincter Injuries at a Large Canadian Obstetrical Centre.

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.

Interventions to Prevent and Treat Burnout in Obstetrics/Gynaecology: A Scoping Review.

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.

Counselling Patients for Trial of Labour after Cesarean (TOLAC) and Invasive Placentation: Are We Missing the Mark? The Importance of Local Data and Informed Choice.

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.

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.

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.

Arteriovenous Malformation Following Conservative Management of Cervical Pregnancy.

BACKGROUND: Medical management using potassium chloride feticide and methotrexate is often the first-line approach to cervical pregnancies. CASE: A 25-year-old woman presenting with a cervical ectopic pregnancy was unsuccessfully managed with conservative therapy, resulting in an arteriovenous malformation requiring a laparoscopic hysterectomy. CONCLUSION: Conservative management of ectopic pregnancies is the treatment of choice for young women looking to preserve fertility. However, medical management is not without risk, and this case illustrates one such complication.

Implementation of a Same-Day Discharge Protocol Following Total Laparoscopic Hysterectomy.

OBJECTIVE: Previous studies have demonstrated that outpatient total laparoscopic hysterectomy (TLH) is both safe and feasible. Our objective was to decrease length of stay for patients undergoing TLH by implementing a same-day discharge protocol at two Canadian teaching hospitals. METHODS: We conducted a prospective cohort study assessing length of stay (primary outcome), perioperative complications, and readmission rates over a 12-month period following implementation of a same-day discharge protocol for TLH. These data were compared with pre-intervention baseline data collected retrospectively over a 12-month period immediately before protocol introduction. Our protocol consisted of patient education, instructions for perioperative care, and close follow-up. RESULTS: In the year prior to our protocol, 256 TLHs were performed. Forty-seven patients (18.3%) were discharged the same day, 191 patients (74.5%) were discharged on the first postoperative day, and 18 patients (7%) were admitted for 2 or more days. In the year following implementation, 215 patients underwent TLH of which 129 were enrolled in our study. The overall outpatient hysterectomy rate during that time period was 62% (134/215 patients). Among study participants, 102 patients (79.1%) were discharged the same day, 22 patients (17.0%) were discharged on the first postoperative day, and 5 patients (3.9%) were admitted for 2 or more days. There were no significant differences in perioperative complications or readmission rates and patient satisfaction scores were high. CONCLUSION: Implementation of a same-day discharge protocol successfully increased the rate of outpatient TLH without impacting patient safety. This protocol was acceptable to both surgeons and patients and can be easily adapted for use at other centres.