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OBJECTIVES: Rates of severe maternal morbidity have highlighted persistent and growing racial disparities in the United States (US). We aimed to contrast temporal trends in peripartum hysterectomy by race/ethnicity and quantify the contribution of changes in maternal and obstetric factors to temporal variations in hysterectomy rates. METHODS: We conducted a population-based, retrospective study of 5,739,569 US residents with a previous cesarean delivery, using National Vital Statistics System's Natality Files (2011-2021). Individuals were stratified by self-identified race/ethnicity and classified into four periods based on year of delivery. Temporal changes in hysterectomy rates were estimated using odds ratios (ORs) and 95% confidence intervals (CIs). We used sequential logistic regression models to quantify the contribution of maternal and obstetric factors to temporal variations in hysterectomy rates. RESULTS: Over the study period, the peripartum hysterectomy rate increased from 1.23 (2011-2013) to 1.44 (2019-2021) per 1,000 deliveries (OR 2019-2021 vs. 2011-2013 = 1.17, 95% CI 1.10 to 1.25). Hysterectomy rates varied by race/ethnicity with the highest rates among Native Hawaiian and Other Pacific Islander (NHOPI; 2.73 per 1,000 deliveries) and American Indian or Alaskan Native (AIAN; 2.67 per 1,000 deliveries) populations in 2019-2021. Unadjusted models showed a temporal increase in hysterectomy rates among AIAN (2011-2013 rate = 1.43 per 1,000 deliveries; OR 2019-2021 vs. 2011-2013 = 1.87, 95% CI 1.02 to 3.45) and White (2011-2013 rate = 1.13 per 1,000 deliveries; OR 2019-2021 vs. 2011-2013 = 1.21, 95% CI 1.11 to 1.33) populations. Adjustment ranged from having no effect among NHOPI individuals to explaining 14.0% of the observed 21.0% increase in hysterectomy rates among White individuals. CONCLUSION: Nationally, racial disparities in peripartum hysterectomy are evident. Between 2011-2021, the rate of hysterectomy increased; however, this increase was confined to AIAN and White individuals.
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Cesárea , Histerectomía , Periodo Periparto , Adulto , Femenino , Humanos , Embarazo , Adulto Joven , Cesárea/estadística & datos numéricos , Cesárea/tendencias , Estudios de Cohortes , Etnicidad/estadística & datos numéricos , Histerectomía/estadística & datos numéricos , Histerectomía/tendencias , Grupos Raciales/estadística & datos numéricos , Estudios Retrospectivos , Estados Unidos , Nativos de Hawái y Otras Islas del Pacífico , Indio Americano o Nativo de Alaska , BlancoRESUMEN
OBJECTIVE: Placenta accreta spectrum (PAS) is a condition defined by abnormal adherence of the placenta. Cesarean hysterectomy is the preferred management, but practice patterns vary based on local resources and expertise. We retrospectively reviewed the clinical course of patients diagnosed antenatally with PAS who underwent surgical management in our centre. METHODS: We conducted a retrospective records review involving patients with an antenatal diagnosis of PAS between 2014 and 2019. The primary outcome was a composite score of maternal morbidity, and secondary outcomes were total estimated blood loss and composite neonatal morbidity. Patients were stratified based on the presence or absence of PAS on final pathology. Antenatal diagnosis by ultrasound and magnetic resonance imaging (MRI) was compared with final histologic diagnosis. RESULTS: A total of 34 patients were diagnosed with PAS antenatally and managed at our institution. Final histology confirmed PAS in 29 patients. The overall composite morbidity rate was 44%, with no significant difference between patients with and without PAS on pathology (P = 0.355). Intraoperative blood loss was similar between the 2 groups (2374 ± 2212 mL vs. 1080 ± 852 mL; P = 0.232). The rate of composite neonatal morbidity was 47%. Ultrasound achieved a high positive predictive value in the diagnosis of PAS (96%) and more accurately predicted pathology than MRI. CONCLUSIONS: PAS is associated with high rates of morbidity. Dissemination of our local experience serves to inform best practices in the management of this complex condition.
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Placenta Accreta , Cesárea , Femenino , Humanos , Histerectomía , Recién Nacido , Placenta , Placenta Accreta/diagnóstico por imagen , Placenta Accreta/epidemiología , Embarazo , Estudios RetrospectivosRESUMEN
Ovarian torsion (OT) is a gynecological emergency that requires prompt treatment and management. It is associated with risk factors such as ovarian cysts and prior pelvic surgery. Diagnosis and treatment require surgery to examine the adnexa, correct the torsion, and determine if cystectomy or oophorectomy are required. We reported the case of a 34-year-old woman who presented 9 days after a dermoid cystectomy with sudden onset abdominal pain. An ultrasound showed abnormal blood flow to the ovary. She then underwent a repeat laparoscopy revealing a necrotic and twisted ovary on the same side that had a cystectomy. The surgeons proceeded with a right oophorectomy. Following surgery, the patient reported no concerns with no ongoing bleeding or pain. OT can present in the short-term postoperatively to an ovarian cystectomy, likely as a result of mechanical forces secondary to structural changes of the ovary. The role for prophylaxis against OT is unclear in those with significant risk factors for torsion.
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OBJECTIVE: To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery. TARGET POPULATION: All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications. OPTIONS: The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars. OUTCOMES: Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery. EVIDENCE: We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A). INTENDED AUDIENCE: Surgeons performing laparoscopic gynaecological surgery. SUMMARY STATEMENTS: RECOMMENDATIONS.
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Procedimientos Quirúrgicos Ginecológicos/normas , Laparoscopía/métodos , Laparoscopía/normas , Canadá , Femenino , Ginecología , Humanos , Laparoscopía/efectos adversos , Obstetricia , Sociedades Médicas , Instrumentos QuirúrgicosRESUMEN
OBJECTIF: Aider les médecins qui pratiquent la chirurgie gynécologique dans leur processus décisionnel relatif aux indications bénignes de l'hystérectomie. PUBLIC CIBLE: Médecins, y compris gynécologues, obstétriciens, médecins de famille, chirurgiens généralistes, urgentologues; infirmières, y compris les infirmières autorisées et les infirmières praticiennes; apprentis en médecine, y compris étudiants de médecine, résidents, stagiaires (fellows); et autres fournisseurs de soins de santé. POPULATION CIBLE: Femmes adultes (18 ans et plus) qui devront subir une hystérectomie pour une indication gynécologie bénigne. OPTIONS: La présente directive clinique examine les différentes voies d'abord de l'hystérectomie et l'utilité des interventions chirurgicales concomitantes. DONNéES PROBANTES: Pour la présente directive clinique, des recherches ont été effectuées dans les bases de données PubMed, Medline et Cochrane Library pour trouver des études pertinentes. Les recherches ont été effectuées parmi les publications des cinq dernières années (2012-2017) au moyen des termes de recherche MeSH suivants ainsi que leurs variations : vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy et total vaginal hysterectomy. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs principaux et membres du comité de pratique clinique - gynécologie. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes utilisées dans le présent document a été évaluée au moyen des critères du cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) (tableau 1, tableau 2). Le résumé des conclusions est disponible sur demande. AVANTAGES, PRéJUDICES ET COûTS: Bien que l'hystérectomie soit commune, la pratique chirurgicale varie grandement chez les médecins spécialisés en gynécologie. La présente directive expose les facteurs pré- et périopératoires à prendre en compte pour améliorer la qualité des soins prodigués aux femmes qui doivent subir une chirurgie pour une affection gynécologique bénigne. MISE à JOUR DE LA DIRECTIVE CLINIQUE: La présente directive clinique de la Société des obstétriciens et gynécologues du Canada sera automatiquement passée en revue cinq ans après sa publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de cinq ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière. PROMOTEURS: La présente directive clinique a été élaborée au moyen de ressources financées par la Société des obstétriciens et gynécologues du Canada. DéCLARATIONS CONDENSéES: RECOMMANDATIONS.
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OBJECTIVE: To assist physicians performing gynaecologic surgery in decision making surrounding hysterectomy for benign indications. INTENDED USERS: Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers. TARGET POPULATION: Adult women (18 years and older) who will undergo hysterectomy for benign gynaecologic indications. OPTIONS: The approach to hysterectomy and utility of concurrent surgical procedures are reviewed in this guideline. EVIDENCE: For this guideline relevant studies were searched in the PubMed, Medline, and Cochrane Library databases. The following MeSH search terms and their variations for the last 5 years (2012-2017) were used: vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy, and total vaginal hysterectomy. VALIDATION METHODS: The content and recommendations were drafted and agreed upon by the principal authors and members of the Gynaecology Committee. 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 (Tables 1 and 2). The Summary of Findings is available upon request. BENEFITS, HARMS, AND COSTS: Hysterectomy is common, yet surgical practice still varies widely among gynaecologic physicians. This guideline outlines preoperative and perioperative considerations to improve the quality of care for women undergoing benign gynaecologic surgery. GUIDELINE UPDATE: This Society of Obstetricians and Gynaecologists of Canada clinical practice guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. SPONSORS: This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: RECOMMENDATIONS.
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Histerectomía/normas , Enfermedades Uterinas/cirugía , Canadá , Toma de Decisiones Clínicas , Femenino , Ginecología , Humanos , Histerectomía/métodos , Guías de Práctica Clínica como AsuntoRESUMEN
BACKGROUND: Uterine rupture due to a morbidly adherent placenta is a rare obstetrical cause of acute abdominal pain in the pregnant patient. We present a case to add to the small body of published literature describing this diagnosis. CASE: A 32-year-old G5T2P1A1L2 with multiple prior cesarean sections presented at 21+3 weeks' gestation with abdominal pain and presyncope. Ultrasound showed a large volume of complex intraabdominal free fluid and a heterogenous placenta with irregular lacunae and increased vascularity extending to the posterior bladder wall. Exploratory laparotomy identified a uterine defect and a hysterectomy was performed due to significant bleeding. Pathology confirmed a diagnosis of placenta percreta. CONCLUSION: Early recognition and management of uterine rupture due to a morbidly adherent placenta are essential to prevent catastrophic hemorrhage.
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RATIONALE: The repeated coadministration of the kappa opioid receptor agonist U69593 with the D2/D3 dopamine (DA) agonist quinpirole (QNP) potentiates locomotor sensitization induced by QNP. Behavioral evidence has implicated both pre- and postsynaptic changes as being involved in this augmentation. OBJECTIVES: The objectives of this study were to obtain supporting molecular evidence of pre- and/or postsynaptic alterations in the DA system with U69593/QNP cotreatment and to examine the relationship of such changes to locomotor sensitization. MATERIALS AND METHODS: Gene expression of D1 and D2 receptors (D1R and D2R), the DA transporter, as well as the endogenous opioid prodynorphin (DYN), in the basal ganglia was examined by in situ hybridization in rats after one or ten drug injections. RESULTS: After one injection, changes that were specific to U69593/QNP cotreatment were decreased D1R and D2R messenger RNA (mRNA) in the nucleus accumbens (Acb) shell and increased DYN mRNA in the dorsal striatum (STR). After ten injections, U69593/QNP-specific changes were decreased D2R mRNA in substantia nigra (SN) and increased DYN mRNA in STR and Acb core. Only in U69593/QNP rats was the sensitized locomotor performance on injection ten positively correlated with DYN mRNA levels in Acb and STR. CONCLUSIONS: Distinct alterations of D2R and DYN mRNA levels in SN and Acb/STR, respectively, strengthen the evidence implicating pre- and postsynaptic changes in augmented locomotor sensitization to U69593/QNP cotreatment. It is suggested that repeated U69593/QNP cotreatment may augment locomotor sensitization to QNP by activating D1R-expressing DYN neurons and attenuating presynaptic D2R function.