Retrospective Review of Management of Antenatally Diagnosed Ovarian Cysts at the Hospital for Sick Children.

INTRODUCTION: Postnatal management of antenatally diagnosed ovarian cysts is not well-defined. The clinical course, management, and outcomes of patients with antenatally diagnosed ovarian cysts were reviewed. METHODS: Infants <1 year of age with antenatally diagnosed ovarian cyst managed at The Hospital for Sick Children between January 2017 and December 2021 were included. Patient charts were reviewed for postnatal ultrasound (US) images, management, clinical course and complications. Mixed linear regression analysis was used to model the change in cyst size over time. RESULTS: In total, 52 patients were included and 10 patients had no cyst identified at their first postnatal US. Of the remaining cases, 36% were simple/physiologic and 64% had complex features. Two underwent percutaneous aspiration while 40 patients were managed expectantly with most cysts (62%) resolving. The rate of resolution was significantly higher and faster for simple compared to complex cysts (84% versus 52%, p < 0.05). Cysts that persisted at the end of the study period (n = 14) had all decreased in size, with a rate of resolution similar to resolved cysts. Only one patient managed expectantly required urgent laparoscopy for salpingoophorectomy. CONCLUSION: Antenatally diagnosed ovarian cysts exhibit high rates of resolution with expectant management, supporting the safety and efficacy for expectant management for these patients. LEVEL OF EVIDENCE: III.

Case Report: Neonate Presenting with Acute Kidney Injury Secondary to Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) Syndrome: Long-Term Follow-Up.

BACKGROUND: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome describes a spectrum of Mullerian anomalies characterized by uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal anomalies. We report the case of a neonatal complication secondary to OHVIRA syndrome with long-term follow-up, adding to the collective understanding of this syndrome. CASE SUMMARY: We present a 22-day-old female with an acute kidney injury secondary to post-renal obstruction from a large hydrometrocolpos. Multidisciplinary care facilitated timely diagnosis of OHVIRA syndrome and temporizing operative management. The patient was followed serially into her adolescence and ultimately underwent definitive excision of her vaginal septum. DISCUSSION: OHVIRA syndrome encompasses a broad spectrum of anatomical variation with different considerations in prepubertal and postpubertal patients. Multidisciplinary care allows for timely diagnosis and clinical decision-making within this complex patient population.

Clinical Review: Prepubertal Bleeding.

BACKGROUND: Prepubertal bleeding is a common presentation in the pediatric office and can be distressing for patients and families. A comprehensive approach to diagnosis and management allows clinicians to identify patients at risk for worrisome pathology and arrange timely care. OBJECTIVE: We aimed to review the key features of clinical history, physical exam, and diagnostic workup of a child presenting with prepubertal bleeding. We reviewed potential pathologies requiring urgent investigations and management, such as precocious puberty and malignancy, as well as more common etiologies, including foreign bodies and vulvovaginitis. CONCLUSION: Clinicians should approach each patient with the goal of excluding diagnoses that require urgent interventions. A thoughtful clinical history and physical exam can inform appropriate investigations to optimize patient care.

Management of Acute Genital Ulcers: A Survey of North American Pediatric and Adolescent Gynecology Care Providers.

INTRODUCTION: Acute genital ulcers are painful ulcerations of the lower vagina and vulva, with limited data to guide management. We aimed to survey care providers to understand the workup and management of acute genital ulcers across North America. METHODS: A cross-sectional survey was distributed to members of NASPAG. Data are presented descriptively, and management practices between care providers are compared using Fisher's exact test. RESULTS: Responses from 100 NASPAG members were included. Common diagnostic tests performed were herpes simplex virus PCR (82%), Epstein-Barr virus serology (56%), and cytomegalovirus serology (47%). Topical steroids were considered by 67% on the basis of the degree of accompanying inflammation. There was no difference in corticosteroid prescriptions according to the type or location of providers (P > .05). DISCUSSION: Collaboration between pediatric and adolescent gynecology care providers is needed to prospectively evaluate the effectiveness of treatment modalities and develop evidence-based guidelines.

Case Report: An Uncommon Etiology of Vulvar Irritation and Swelling in an Adolescent Patient.

INTRODUCTION: Vulvovaginal concerns are common among adolescent patients. In postmenarchal patients, common etiologies include poor hygiene, contact irritants, and infection. CASE: A 14-year-old transgender male presented with concerns of vulvar irritation and significant labial enlargement. Comprehensive workup including tissue biopsies and imaging suggested chronic inflammation. His clinical course was complicated by an episode of methemoglobinemia secondary to local anesthetic toxicity, at which time his care team recognized use of large quantities of Vagisil, which contains benzocaine. Ultimately, vulvar changes were recognized to be secondary to chronic Vagisil use. SUMMARY AND CONCLUSION: This case highlights the potential dangers of off-the-shelf products, such as Vagisil. In patients presenting with vulvovaginal complaints, care providers should carefully screen for use of "hygiene products" as part of exposure history.

Informing the Spectrum of Approaches: Institutional Review of Placenta Accreta Spectrum Disorders Management.

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.

Well-Differentiated Papillary Mesothelioma With Two Synchronous Serous Gynaecologic Carcinomas in a 62-Year-Old Woman: Lessons Learned for the Gynaecologic Surgeon.

BACKGROUND: Well-differentiated papillary mesothelioma (WDPM) is a rare tumor of unknown malignant potential. It is typically diagnosed incidentally during benign gynaecologic surgery. We report the first published case of WDPM in a woman with synchronous serous carcinomas of the gynaecologic tract and highlight lessons learned for general gynaecologists and gynaecologic oncologists alike. CASE: A 62-year-old woman was referred for assessment and management of a pelvic mass. Intraoperatively, metastatic high-grade carcinoma was identified and the patient underwent a successful debulking procedure that identified 3 synchronous tumors: ovarian high-grade serous carcinoma, endometrial serous carcinoma, and 2 foci of pelvic WDPM. CONCLUSION: This case of WDPM with 2 synchronous serous gynaecologic tumors is a novel addition to the reported literature and offers many learning points about the disease. Gynaecologic surgeons should be familiar with WDPM, as it is predominantly found in reproductive-aged women undergoing benign gynaecologic surgery, may be linked with endometriosis, and has an unclear malignant potential. Multidisciplinary care is essential for accurate diagnosis. Further research is needed to clarify the optimal management and surveillance of WDPM.

Mode of Delivery: Development and Implementation of an Obstetrical In Situ Simulation Program.

OBJECTIVE: Simulation is increasingly valued as a learning tool in obstetrical practice. In situ simulation assesses the hands-on and critical thinking skills of a health care team within their clinical setting. We aimed to create an in situ simulation program to promote skills acquisition, enhance teamwork, and identify system limitations. METHODS: Key obstetrical emergencies were identified through a needs assessment. In situ simulations were developed to address these clinical presentations. During simulations, organizers and participants identified latent safety threats. Medical management was evaluated through comprehensive emergency-specific checklists. Leadership attitudes were assessed using the modified Perinatal Emergency Team Response Assessment tool. Following each simulation, team members were debriefed, and qualitative and quantitative feedback was solicited and aggregated by specialty and discipline. RESULTS: Simulations were conducted monthly at two academic centers over 14 months. Participation was interdisciplinary, including learners, staff physicians, nursing, and allied health team members from the departments of obstetrics, anesthesia, emergency medicine, and neonatology. Participants reported their involvement was enjoyable. Participants reported improvements in communication skills, content knowledge, and procedural knowledge. Participants favourably rated the spontaneity of simulations, clinically relevant scenarios, safe environment, and use of realistic equipment. Latent safety threats, related to equipment, medication, personnel, resources, and technical skills, were identified. CONCLUSION: We present the successful implementation of a comprehensive in situ simulation program. In situ simulation allows for deliberate practice of obstetrical emergencies and promotes a culture of patient safety. Lessons learned provide valuable data to identify limitations within our current practices and inform future policy change.