Single or two drug combination therapy as initial treatment for low risk, gestational trophoblastic neoplasia. A Canadian analysis.

INTRODUCTION: Low risk gestational trophoblastic neoplasia, WHO prognostic score of 0 to 6, is highly curable. There is no consensus on the optimal chemotherapy. Common regimens are q2wk actinomycin-D (ACT-D), weekly intramuscular methotrexate (MTX) or multi-day MTX. Combination MTX/ACT-D is rarely used. METHODS: A four centre, retrospective cohort study was carried out comparing commonly used regimens: weekly MTX, q2weekly ACT-D and q2 weekly MTX and ACT-D. RESULTS: 412 patients - 196 MTX/ACT-D, 107 MTX, 109 ACT-D - were treated between October 1994 and January 2019. Initial regimen failure (secondary to resistance or toxicity) occurred in 37% (MTX), 21% (ACT-D) and 5% (MTX/ACT-D). Relapse after completion of primary therapy (initial plus switch to another therapy if needed) was rare (0-5%). All eventually were cured. Mean number of cycles required to achieve remission were 10.1 (MTX), 7 (ACT-D) and 5.6 (MTX/ACT-D) with corresponding mean treatment durations of 3.12, 2.9 and 2.26 months. Dosage reductions occurred in 3% (MTX), 0% (ACT-D) and 29% (MTX/ACT-D). Higher failure rates occurred with WHO prognostic scores of 5 to 6 and HCG levels ≥10,000. SUMMARY: Initial regimen failure ie the need to switch to an alternative treatment was more common with MTX. ACT-D and MTX/ACT-D were similar within prognostic score 0-4 or HCG < 10,000. ACT-D then appears the better initial choice with its superior convenience. Above these levels primary failure rates are less with MTX/ACT-D, making it a better choice.

Confidence in performing normal vaginal delivery in the obstetrics clerkship: a randomized trial of two simulators.

OBJECTIVE: To compare clerkship medical students' confidence in performing a simulated normal vaginal delivery (NVD) after participating in a simulation training session using two different models. METHODS: Medical students were randomized to participate in a simulated NVD session using either an obstetrics mannequin or a birthing pelvis model. Questionnaires were used to assess confidence and evaluate the simulation before and immediately after the session and on the last day of the obstetrics clerkship rotation. RESULTS: One hundred ten students were randomized. At the start of the clerkship, both groups had similar obstetrics exposure and confidence levels. Only 15 students (13.9%) agreed they were ready to attempt a NVD with minimal supervision or independently. This increased significantly to 43 students (39.4%) immediately after the session. At the end of the clerkship, 79 of 81 responding students (97.5%) were confident that they could attempt a NVD with minimal supervision or independently. There were no significant differences noted between simulator groups at any point. The sessions were rated as equally useful and realistic, and this remained unchanged at the end of the clerkship. CONCLUSION: Simulated NVD training using either an obstetrics mannequin or a birthing pelvis model provides clerkship students with a positive experience and increases confidence immediately. It should be implemented early in the rotation, as it appears the clerkship experience also plays a large role in terms of students' confidence. Despite this, students maintain this type of learning is useful. Effective simulation training can easily be incorporated into clerkship training.

Objectif : Comparer la confiance des étudiants de médecine en stage clinique, pour ce qui est de l'exécution d'une simulation d'accouchement vaginal normal (AVN), à la suite de leur participation à une session de formation en simulation au moyen de deux modèles différents. Méthodes : Des étudiants de médecine ont été affectés, au hasard, à une session de simulation d'AVN faisant appel à un mannequin obstétrical ou à une session de simulation faisant appel à un modèle de bassin simulant l'accouchement. Des questionnaires ont été utilisés pour évaluer la confiance et la simulation avant et immédiatement après la session, ainsi qu'au cours de la dernière journée de la rotation en obstétrique. Résultats : Cent dix étudiants ont été affectés au hasard à l'un ou l'autre des groupes de simulation. Au début du stage clinique, les deux groupes présentaient des niveaux de confiance et d'exposition à la pratique obstétricale semblables. Seulement 15 étudiants (13,9 %) étaient d'avis qu'ils étaient prêts à tenter un AVN de façon indépendante ou sous une supervision minimale. Cette proportion a connu une hausse considérable en passant à 43 étudiants (39,4 %) immédiatement après la session de simulation. À la fin du stage clinique, 79 des 81 étudiants répondants (97,5 %) étaient confiants de pouvoir tenter un AVN de façon indépendante ou sous une supervision minimale. Aucune différence significative n'a été constatée entre les groupes de simulation à quelque moment que ce soit. Les sessions ont été évaluées comme étant tout aussi utiles et réalistes les unes que les autres; cette constatation est demeurée la même à la fin du stage clinique. Conclusion : La formation faisant appel à la simulation d'un AVN au moyen d'un mannequin obstétrical ou d'un modèle de bassin simulant l'accouchement offre aux étudiants en stage clinique une expérience positive et accroît immédiatement leur confiance. Une telle formation devrait être mise en œuvre tôt au cours de la rotation, puisqu'il semble que l'expérience vécue au cours du stage clinique joue également un rôle important pour ce qui est de la confiance des étudiants. Peu importe la chronologie de la simulation, les étudiants soutiennent que ce type d'apprentissage leur est utile. Une formation efficace en simulation peut facilement être intégrée au stage clinique.

Indications for, timing of, and modes of delivery in a national cohort of women admitted with antepartum hemorrhage at 22+0 to 28+6 weeks' gestation.

OBJECTIVE: Antepartum hemorrhage is associated with preterm birth and operative delivery. Since the Canadian Perinatal Network records obstetric interventions for women admitted to tertiary care hospitals with antepartum hemorrhage, our objective was to describe the delivery characteristics of this cohort. METHODS: Trained abstractors collected data by chart review from women admitted with antepartum hemorrhage between 22+0 and 28+6 weeks' gestation. We included all women with complete follow-up postpartum and used descriptive statistics to report the indications for, timing of, and modes of delivery. RESULTS: The study cohort included 806 women from 13 tertiary perinatal centres in six provinces. The most common causes of bleeding were placental abruption (n = 256) and placenta previa (n = 171). The median gestational age at delivery was 30 weeks, and 497 (61.7%) births occurred at less than 34 weeks. Over one half of the women began labour spontaneously, and 238 (29.5%) were delivered prior to the onset of labour. Overall, 370 (45.9%) women delivered vaginally, including 98 who had induction of labour. Of the 436 Caesarean sections (54.1%), 345 (79.1%) were emergencies. The most common indications for Caesarean section were placenta previa, abnormal fetal presentation, and placental abruption or vaginal bleeding. CONCLUSION: This inpatient cohort of women with antepartum hemorrhage had high rates of spontaneous labour, preterm birth, and emergency Caesarean section. These results can be used as current Canadian benchmark rates of preterm delivery, induction of labour, and Caesarean section in women admitted to tertiary care centres with antepartum hemorrhage between 22+0 and 28+6 weeks' gestation, and can aid in the counselling of similar women.

Improving resident competence and knowledge regarding tension-free vaginal tape procedure: an educational module.

OBJECTIVE: The purpose of this study was to determine the effectiveness of a teaching module using simulation for the tension-free vaginal tape (TVT) procedure on procedural knowledge and skill. METHODS: Twenty-five gynecology residents participated in a teaching module about the TVT procedure and urinary incontinence, which included a simulated insertion on a training model. Questionnaires using 10-point scales for self-rated competence and knowledge and a written examination were administered before and after the module. A simulated TVT insertion was evaluated at an examination at 7 weeks and at 7 months. RESULTS: A significant median improvement of 44% on the written examination and at least one point on each of the self-rated competence and knowledge scales were observed after the teaching module. Residents performed the insertion well at both examinations (89% and 90%), regardless of surgical experience. More than 94% agreed the module was useful and improved their understanding of the procedure. CONCLUSION: A short teaching module and simulation session can effectively teach residents and improve their perceived competence with the TVT procedure.

A review of therapeutic abortions and related areas of concern in Canada.

OBJECTIVE: To review the legal status of abortion and its prevalence, safety, and accessibility in Canada and to highlight related areas of concern. METHODS: We conducted a review of research literature, published reports, websites, and articles in order to describe abortion services and associated issues such as access, availability, and safety in Canada. RESULTS: Therapeutic abortion is often the result of unintended pregnancy. Even so, emergency contraception may not be accessible for all Canadian women, and effective contraception is underutilized. In Canada, abortion has been decriminalized and is generally safe, but current reports of prevalence and complication rates are inconsistent. Abortion rates appear to be decreasing. Medical or surgical termination of pregnancy is available and often publicly funded. However, barriers related to time, cost, travel, and regional disparities hamper unrestricted access to therapeutic abortion in this country, and although the place of abortion in medical education remains controversial, current curriculum content appears to be inadequate. CONCLUSIONS: The Society of Obstetricians and Gynaecologists of Canada states that comprehensive family planning services, including therapeutic abortion, should be freely available to all. The Canadian Medical Association affirms that induced abortion should be uniformly available to all women. In Canada, the issues related to therapeutic abortion access, availability, and safety must be addressed.