Olga Bougie

Hysteroscopic management of a stenotic cervix

OBJECTIVEnTo demonstrate an approach to the hysteroscopic management of a stenotic cervix.nnnDESIGNnStep-by-step explanation of the techniques using video and animation (educational video).nnnSETTINGnAcademic tertiary level referral center.nnnPATIENT(S)nPatients with cervical stenosis, inclusive of both reproductive age and postmenopausal women. Gynecologists require intrauterine access for many procedures, but a stenotic cervix can obstruct surgery. Blind dilation of a stenotic cervix can lead to a cervical laceration or uterine perforation, with concomitant complications.nnnINTERVENTION(S)nThe hysteroscopic management of a stenotic cervix includes optimizing the surgical environment, performing vaginoscopy and no-touch hysteroscopy, and revision of the cervical canal. Revision can be performed using microscissors, micrograspers, or a cutting loop electrode. Partial cervical canal excision to aid in hysteroscopy access should be reserved in women who are not interested in future pregnancy or those who are postmenopausal. Outpatient hysteroscopy uses smaller instruments and shows operative success with patient satisfaction. Although these techniques are demonstrated in an outpatient hysteroscopy setting, they can be adapted for use in an operating theater.nnnMAIN OUTCOME MEASURE(S)nThe individual steps and approach are emphasized.nnnRESULT(S)nIntrauterine access can be achieved with various techniques.nnnCONCLUSION(S)nThe see-and-treat approach demonstrated in this video can allow access into the uterine cavity despite a stenotic cervix.

Sténose urétérale à la suite de l'excision de lésions d'endométriose profonde

Un dysfonctionnement mictionnel et de la douleur au flanc droit ont été signalés à la suite de la chirurgie; une échographie réalisée trois mois après l’intervention a révélé la présence d’une hydronéphrose droite. Une prise en charge conservatrice de la sténose urétérale a été tentée au moyen d’une endoprothèse, mais un pyélogramme rétrograde a montré un rétrécissement dans un segment de l’uretère distal. La patiente a subi une réimplantation urétérale sept mois après la chirurgie initiale.

Le Dalkon Shield : oublié, mais toujours pas disparu

ne femme multigravide de 69 ans nous a ete envoyee a Ucause d’une masse uterine. Apres avoir recu un diagnostic de cancer du sein, elle a subi une tomodensitometrie de l’abdomen et du pelvis qui a revele un canal uterin largement anormal et epaissi. La patiente a nie souffrir de douleur pelvienne ou de saignements vaginaux. Elle a mentionne avoir utilise un dispositif intra-uterin (DIU) autrefois, mais elle croyait qu’on le lui avait retire. Les caracteristiques d’un dispositif Dalkon Shield (figure 1, fleche), au profil particulier (figure 2), ont ete relevees lors de l’examen des tomodensitogrammes. La patiente a choisi de ne pas se faire enlever le DIU, car elle ne souffrait d’aucun symptome et preferait se concentrer sur son traitement pour le cancer du sein.

Dalkon Shield: Forgotten but Not Yet Gone

69-year-old multigravid woman was referred because Aof a uterine mass. After a diagnosis of breast cancer, she underwent a CT scan of the abdomen and pelvis, which showed a grossly abnormal and thickened uterine canal. The patient denied any pelvic pain or vaginal bleeding. She noted that she had used an intrauterine device in the past but believed it had been removed. Review of the CT images showed characteristics of a Dalkon shield IUD (Figure 1, arrow), which has a unique outline (Figure 2). The patient elected not to have the IUD removed because she was asymptomatic and focused on her breast cancer treatment.

Critical Appraisal Skills Among Canadian Obstetrics and Gynaecology Residents:How Do They Fare?

OBJECTIVESnEvidence-based medicine has become the standard of care in clinical practice. In this study, our objectives were to (1) determine the type of epidemiology and/or biostatistical training being given in Canadian obstetrics and gynaecology post-graduate programs, (2) determine obstetrics and gynaecology residents level of confidence with critical appraisal, and (3) assess knowledge of fundamental biostatistical and epidemiological principles among Canadian obstetrics and gynaecology trainees.nnnMETHODSnDuring a national standardized in-training examination, all Canadian obstetrics and gynaecology residents were invited to complete an anonymous cross-sectional survey to determine their levels of confidence with critical appraisal. Fifteen critical appraisal questions were integrated into the standardized examination to assess critical appraisal skills objectively. Primary outcomes were the residents level of confidence interpreting biostatistical results and applying research findings to clinical practice, their desire for more biostatistics/epidemiological training in residency, and their performance on knowledge questions.nnnRESULTSnA total of 301 of 355 residents completed the survey (response rate=84.8%). Most (76.7%) had little/no confidence interpreting research statistics. Confidence was significantly higher in those with increased seniority (OR=1.93), in those who had taken a previous epidemiology/statistics course (OR=2.65), and in those who had prior publications (OR=1.82). Many (68%) had little/no confidence applying research findings to clinical practice. Confidence increased significantly with increasing training year (P<0.001) and with formal epidemiology training during residency (OR=2.01). The mean score of the 355 residents on the knowledge assessment questions was 69.8%. Increasing seniority was associated with improved overall test performance (P=0.02). Poorer performance topics included analytical study method (9.9%), study design (36.9%), and sample size (42.0%). Most (84.4%) wanted more epidemiology teaching.nnnCONCLUSIONnCanadian obstetrics and gynaecology residents may have the biostatistical and epidemiological knowledge to interpret results published in the literature, but lack confidence applying these skills in clinical settings. Most residents want additional training in these areas, and residency programs should include training in formal curriculums to improve their confidence and prepare them for a lifelong practice of evidence-based medicine.

Endometrial ossification causing secondary infertility.

J Obstet Gynaecol Can 2014;36(6):473 A 39-year-old woman presented for assessment of secondary infertility. She had previously had a term delivery and a first trimester miscarriage. Pelvic ultrasound revealed a foreign body, and subsequent diagnostic hysteroscopy showed the presence of two foreign bodies in the uterus, consistent with bone fragments (Figure 1). Histologic assessment identified the presence of bone in the endometrium, consistent with osseous endometrial metaplasia (Figure 2).