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A 32-year-old woman presented with painless hematuria at 24 weeks of gestation. Cystoscopy revealed placenta percreta involving the maternal bladder.

Malinowski and Murji present several facts about iron deficiency and iron deficiency anemia. Iron deficiency and iron deficiency anemia are common during pregnancy and are associated with adverse outcomes. Prenatal iron deficiency occurs in more than 30% of pregnancies in Canada. It has been linked with low birth weight, small for gestational age size, preterm birth, need for blood transfusion for the mother, postpartum hemorrhage and long-term neurocognitive effects in childhood.

To determine the proportion of patients undergoing hysterectomy for a benign indication who have unexpected malignancy (UM) on postoperative pathology and characterize the nature of UMs. This was a multi-center, retrospective study of patients undergoing hysterectomy for a benign indication from July 2016 to December 2019 at 7 Ontario, Canada hospitals (4 academic, 3 community). Hysterectomies for invasive placentation, malignant, and premalignant indications were excluded. Primary outcome was rate of unexpected malignancy as defined by the number of patients with malignancy on final pathology divided by the total number of hysterectomy cases. Data was extracted from health records and electronic charts. Patient, surgical, and surgeon characteristics were compared between benign and UM groups using bivariate methods. Associations between UM status and perioperative variables were assessed using bivariate logistic regression. In the study period, 2779 hysterectomies were performed. UM incidence was 1.8% (51 malignancies/2779 cases), with one patient having two malignancies (total UMs = 52). The most common UM types were endometrial (27/52, 51.9%) and sarcoma (13/52, 25%). Patients with UM were older (57.2 ± 11.4 years vs. 52.8 ± 12.5 years, p = .015), had more previous laparotomies (2 (1.25, 2.0) vs. 1 (1.0, 1.0), p < .001), and higher BMI (29.7 ± 7.2 kg/m2 vs. 28.0 ± 5.9 kg/m2, p = .049) and ASA class (p < .028). Regarding surgical factors, patients with UM had more adhesions (p = .001), transfusions (p = .020), and blood loss (p = .006) compared to those with benign pathology. Patient characteristics most strongly associated with UM were age (OR 2.57, 95% CI 1.78-3.72, p < .001) and preoperative diagnosis of pelvic mass (OR 2.76, 95% CI 1.11-6.20, p = .019). Incidence of UM at hysterectomy for benign indication was 1.8%. Several perioperative variables are associated with an increased chance of UM.

Importance Approximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms. Objective To achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition. Design, Setting, and Participants A consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022. Main Outcomes and Measures Definition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche. Results In total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis. Conclusions and Relevance In this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.

Introduction A symptomatic uterine niche is a long‐term complication after a cesarean section (CS). A group of international niche experts reached consensus on a standardized definition of a disorder caused by a symptomatic niche, named cesarean scar disorder (CSDi). However, the prevalence of this disorder is unclear. The aim of this study was to assess the prevalence of CSDi in patients 3 years after a first CS. Material and Methods A secondary analysis was performed on the 3‐year follow‐up results of the 2Close study. The 2Close study was a multicenter randomized controlled trial that evaluated single‐ versus double‐layer uterine closure at CS in 32 hospitals in the Netherlands and included 2292 patients (registered in Dutch trial register: [NTR5480]). Patients, aged ≥18 years, undergoing a first CS were included. Three months after their CS, transvaginal ultrasonography was performed to evaluate the uterine scar for the presence of a niche. Three years after their CS, a digital questionnaire was sent to evaluate the primary and secondary symptoms of CSDi. For this secondary analysis, patients were excluded if they were pregnant, breastfeeding, or using hormonal contraception. The primary outcome of the study was the prevalence of CSDi. Results Of the 1648 participants who completed the 3‐year questionnaire, patients were excluded due to pregnancy or breastfeeding (n = 305), use of hormonal contraception (n = 509), missing ultrasound evaluations (n = 76), and incomplete responses (n = 88). Of the 670 patients included in this analysis, 543 (81.0%) had a uterine niche visible on ultrasound and 127 (19.0%) were without a niche. The prevalence of CSDi at 3 years following a first CS was 42.5% (285/670). Most reported symptoms were chronic pelvic pain (35.0%), postmenstrual spotting (32.8%), and abnormal vaginal discharge (23.2%). Conclusions Our study found a high prevalence of CSDi 3 years following their first CS. Symptoms were self‐reported and the exclusion criteria of pregnancy, breastfeeding, or hormonal contraception use could have introduced selection bias. Therefore, this percentage could be an overestimation of the actual prevalence. However, this high prevalence should be included in counseling patients with a scheduled CS. Three years following a first caesarean section 42.5% of all patients develop Caesarean Scar Disorder. Most reported symptoms within the Caesarean Scar Disorder are chronic pelvic pain, postmenstrual spotting and abnormal vaginal discharge. The long‐term consequences of a Caesarean Section on patients’ health should be structurally investigated.

Endometriosis is characterized by the presence of functional endometrial glands and stroma outside of the uterus. This common condition affects up to 10% of women of reproductive age, most often involving the ovaries and utero sacral ligaments. Gastrointestinal involvement occurs in up to 34% of women with pelvic endometriosis.2 The diagnosis of gastrointestinal endometriosis may be difficult to establish be - cause its symptoms are relatively nonspecific. Patients may present with abdominal pain, bloating, tenesmus, dyschezia (painful bowel movements), rectal bleeding, diarrhea, constipation or obstruction.3 The differential diagnosis is often broad; the main considerations include appendicitis, diverticulitis, inflammatory bowel disease, irritable bowel syndrome and malignant disease. The incidence of endometriosis causing bowel obstruction is unknown, although complete obstruction occurs in less than 1% of pa - tients with gastrointestinal endometriosis.4 Adding to the challenge of diagnosing gastrointestinal endometriosis is the often falsenegative result of endoscopic biopsies. The biopsies tend to be superficial and miss the foci of endometriosis that are located in the deeper bowel layers. When deeply infiltrating gastrointestinal endometriosis is suspected clinically, trans vaginal ultrasonography and MRI may prove valuable in reaching the diagnosis. With a sensitivity of 91% and a specificity of 97%, transvaginal ultrasonography is the first-line imaging modality for such patients.7,8 Likewise, MRI detects invasive intestinal endometriosis with a sensitivity of 88% and a specificity of 93%, and it may be useful when the results of ultrasonography are equivocal.9 Although CA- 125 levels may be elevated in endometriosis, the test is primarily used as a tumour marker, with a sensitivity of 80% for advanced ovarian cancer. However, it has poor specificity and may be elevated in several benign and malignant conditions, including endometriosis and colon cancer.10 A clinical presentation of an abdominal mass and bowel obstruction in the context of worsening gastrointestinal symptoms and equivocal diagnostic tests frequently raises the sus picion of gastrointestinal cancer. Negative findings on colonoscopy do not necessarily rule out malignant disease, because primary extraluminal neoplasms and neoplastic changes arising from endometriosis (endometrioid adenocarcinoma and clear-cell adenocarcinoma) frequently involve only the outermost layers of the colon. The differential diagnosis of intramural gastrointestinal lesions causing large bowel obstruction is shown in Table 1.8,11,12 Although primary colorectal lymphoma may also present as an extraluminal mass, mucosal involvement often can be seen with colonoscopy.11

Data from observational studies of pregnant survivors of nuclear disasters and experimental studies on animals have shown that, in the first two weeks after conception, the main risk is radiationinduced pregnancy termination, which can occur at a radiation dose of 100-200 mGy. From two weeks after conception until term, a minimum fetal radiation dose of 350-500 mGy is required to cause adverse outcomes such as pregnancy loss, fetal malformations, growth restriction and developmental delay.1 Practice guidelines from the American Congress of Obstetricians and Gynecologists suggest a more conservative threshold of 50 mGy or less during pregnancy to avoid adverse events.2 Typical fetal radiation doses from common examinations are shown in Appendix 1 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.140901/-/DC1).3 For example, the fetal dose from chest radiographs is less than 0.01 mGy. More than 5000 such radiographs in pregnancy are required to exceed the 50-mGy threshold. By comparison, the fetal dose during a transatlantic flight is 0.01 mGy, and naturally occurring background radiation during pregnancy is 1 mGy. In case-control studies,4 in utero exposure to medical diagnostic radiation was associated with a discernable increase in relative risk of childhood leukemia. Given the low baseline rate of childhood cancer, the absolute increased risk from ionizing radiation is small. For example, an antenatal fetal dose of 20 mGy translates to 0.8 additional childhood cancers per 100 babies.4

Background Answering telephone calls and pagers is common distraction in the operating room. We sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance. Methods We conducted a randomized crossover study of obstetrics and gynecology residents. After studying a patient sign-out list, subjects performed a virtual salpingectomy. They were randomized to a distraction phase followed by quiet phase or vice versa. In the distraction phase, a pager beeped and subjects were asked questions based on the sign-out list. Accuracy of responses and the number of unsafe responses were recorded. In the quiet phase, trainees performed the task uninterrupted. Measures of surgical performance were successful task completion, time to task completion and operative blood loss. Results The mean score for correct responses to clinical questions during the distracted phase was 80 % (SD ±14 %). Nineteen residents (63 %) made at least 1 unsafe clinical decision while operating on the simulator (range 0–3). Subjects were more likely to successfully complete the surgical task in the allotted time under the quiet compared to distraction condition (OR 11.3, p  = 0.03). There was no difference between the conditions in paired analysis for mean time (seconds) to task completion [426 (SD 133) vs. 440 (SD 186), p  = 0.61] and mean operative blood loss (mL) [73.14 (SD 106) vs. 112.70 (SD 358), p  = 0.47]. Conclusions Distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents’ ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.