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ABSTRACT: PURPOSE: Demonstrate changes in methods of menstrual suppression in adolescents with developmental disabilities in a recent 5-year cohort compared with an historical cohort at the same hospital. METHODS: Retrospective cohort study of patients with physical and cognitive challenges presenting for menstrual concerns at an Adolescent Gynecology Clinic between 2006 and 2011 compared with a previous published cohort (1998 to 2003). RESULTS: Three hundred patients with developmental disabilities aged 7.3 to 18.5 years (mean 12.1 ± 1.6) were analyzed. Caregiver concerns included menstrual suppression, hygiene, caregiver burden, and menstrual symptoms. Ninety-five percent of patients had cognitive disabilities, 4.4% had only physical impairments. Thirty-two (31.7) percent of patients presented premenarchally. The most commonly selected initial method of suppression was extended or continuous oral contraceptive pill (OCP) (42.3%) followed by patch (20%), expectant management (14.9%), depot medroxyprogesterone acetate (DMPA) (11.6%), and levonorgestrel intrauterine system (LNG-IUS) (2.8%). Published data from 1998 to 2003 indicated a preference for DMPA in 59% and OCP in 17% of patients. The average number of methods to reach caregiver satisfaction was 1.5. Sixty-five percent of initial methods were continued. The most common reasons for discontinuation were breakthrough bleeding, decreased bone mineral density, or difficulties with patch adherence. Second-choice selections included OCP (42.5%), LNG-IUS inserted under general anesthesia (19.2%), DMPA (17.8%), and patch (13.7%). CONCLUSIONS: Since identification of decreased bone mineral density with DMPA and emergence of new contraceptive options, use of extended OCP or patch has surpassed DMPA for menstrual suppression in our patient population. LNG-IUS is an accepted, successful second-line option in adolescents with developmental disabilities.
Journal of Adolescent Health 06/2013; · 3.33 Impact Factor
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ABSTRACT: Objective: To assess the effectiveness of a multidisciplinary team approach to reduce severe maternal morbidity in women with invasive placenta previa. Methods: We conducted a prospective study of 33 women with placenta previa and increta-percreta (diagnosed by ultrasound and/or magnetic resonance imaging) delivering at Mount Sinai Hospital, Toronto, following the introduction in January 2008 of a team-based approach to women with this condition. We included women who delivered by June 2012. We reviewed antenatal outpatient and inpatient records for use of six pre-defined team components by the attending staff obstetrician: (1) antenatal maternal-fetal medicine consultation, (2) surgical gynaecology consultation, (3) antenatal MRI, (4) interventional radiology consultation and preoperative placement of balloon catheters in the anterior divisions of the internal iliac arteries, (5) pre-planned surgical date, and (6) surgery performed by members of the invasive placenta surgical team. Antenatal course, delivery, and postpartum details were recorded to derive a five-point composite severe maternal morbidity score based on the presence or absence of: (1) ICU admission following delivery, (2) transfusion > 2 units of blood, (3) general anaesthesia start or conversion, (4) operating time in highest quartile (> 125 minutes), and (5) significant postoperative complications (readmission, prolonged postpartum stay, and/or pulmonary embolism). Results: All 33 women survived during this time period. Two thirds (22/33) had either five or six of the six components of multidisciplinary care. Increasing use of multidisciplinary team components was associated with a significant reduction in composite morbidity (R2 = 0.228, P = 0.005). Conclusion: Team-based assessment and management of women with invasive placenta previa is likely to improve maternal outcomes and should be encouraged on a regional basis.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 05/2013; 35(5):417-25.
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ABSTRACT: Background: Pregnancy in a rudimentary uterine horn is a rare form of ectopic pregnancy with a high risk of rupture. Management usually involves excision of the rudimentary horn. If diagnosed after the first trimester, it has been managed in the past by laparotomy. Case: A primigravid woman was found on routine ultrasound to have a rudimentary horn pregnancy. The diagnosis was confirmed on MRI, and a thin uterine wall was demonstrated. Management comprised fetal injection of potassium chloride followed by complete laparoscopic excision of the rudimentary horn at 16 weeks' gestation. Conclusion: Laparoscopic management of a mid-trimester rudimentary horn pregnancy is feasible, but expert radiological characterization is required for optimal surgical planning.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 05/2013; 35(5):468-72.
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ABSTRACT: OBJECTIVE: Paediatric and adolescent gynecology (PAG) is an evolving subspecialty, with patients often having to travel large distances to access care. The goal of the present study was to assess whether Telehealth (TH) would be appropriate for PAG services in a tertiary care centre and to determine patient/family interest. METHODS: The present study was a prospective observational study of patients who attended PAG clinics over the course of one year. Patient data collected on each visit included postal code, diagnosis, availability of a local hospital with TH, patient appropriateness for TH and patient/family reasons for accepting TH. Visits were stratified by diagnosis to determine if certain conditions were more amenable to TH. RESULTS: From the total visits through the year (July 15, 2008 to July 15, 2009), 1541 (79.6%) patients were approached for participation; 8 (0.5%) declined. The final sample size was 1533 patient visits. Four hundred sixty-nine visits (30.6%) were potentially appropriate for TH based on geography. According to clinic physicians, only 51 of these 469 visits (10.9%) were appropriate for TH. The main reasons for being inappropriate were the need for physical examination (n=238, 57.0%), imaging (n=57, 13.6%), or issues regarding sexuality/privacy (n=45, 10.8%). Of the 51 appropriate visits, 28 patients/families (55.0%) expressed interest in TH. Of those not interested in TH, the main reasons included the desire for a face-to-face encounter and the need to coordinate with other health care appointments. CONCLUSION: Of the patient visits considered for TH (based on the fact that patients lived a considerable distance from the hospital), 10.9% were deemed appropriate for TH by the PAG team, but 45.0% of families/patients in this group said they would prefer a traditional clinic visit. Currently, TH appears to be appropriate for only a small subset of patients/families.
Paediatrics & child health 02/2012; 17(2):e12-e15. · 0.78 Impact Factor
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ABSTRACT: STUDY OBJECTIVE: To review the medical literature and determine whether testing for von Willebrand disease can be performed in adolescents using combined hormonal contraceptives (CHC). DESIGN: Literature review where Embase and Medline were searched using the key words "von Willebrand factor," "von Willebrand disease," "contraceptive agents," and "menorrhagia." Articles were included in the review if they were controlled trials comparing a current form of CHC versus a control group and testing for von Willebrand factor was performed and reported. MAIN OUTCOME MEASURES: Impact of combined hormonal contraceptives on von Willebrand factor antigen. Secondary outcomes included effects on Factor VIII and von Willebrand factor activity known as the Ristocetin cofactor. RESULTS: Seven articles met inclusion criteria. All seven assessed VWF Ag with CHC use; six of the seven demonstrated no change and one, Gevers Leuven, demonstrated a significant decrease after CHC use. Three studies measured Factor VIII and showed no significant change with use. One study by Kadir assessed the Ristocetin cofactor and also failed to demonstrate change on CHC. CONCLUSION: From the literature it appears that adolescents, assessed for menorrhagia and already on combined hormonal contraceptives, can be tested for von Willebrand disease if this diagnosis is suspected by the physician. By allowing adolescents to remain on combined hormonal contraceptives during testing, one avoids the risk of recurrent and severe menorrhagia which could result in admission and transfusion.
Journal of pediatric and adolescent gynecology 12/2011; · 0.90 Impact Factor
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ABSTRACT: Ovarian torsion is a surgical emergency that can present with a variety of symptoms and hence is difficult to diagnose. We present the first case of a pediatric synchronous bilateral ovarian torsion in ovaries without pathology and review its presentation, diagnosis, treatment, outcome, and the associated literature.
Journal of Pediatric Surgery 12/2011; 46(12):e19-23. · 1.45 Impact Factor
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ABSTRACT: Invasive placentation (placenta accreta, increta, or percreta) presents significant challenges at Caesarean section. Caesarean hysterectomy in such circumstances may result in massive blood loss despite surgical expertise. We reviewed two divergent surgical approaches: planned Caesarean hysterectomy versus a "conserving surgery" in which the placenta is left in situ after Caesarean section.
We conducted a single-centre retrospective review of all patients who delivered with invasive placentation between 2000 and 2009. We included only patients with antenatally diagnosed invasive placentation and planned mode of delivery.
Twenty-six patients met the inclusion criteria. Caesarean hysterectomy was planned in 16 patients and conserving surgery in 10. Intraoperative and postoperative complications were comparable in the two groups. Four of 10 patients initially treated by conservative surgery required a subsequent hysterectomy for severe vaginal bleeding, coagulopathy, or sepsis. No pregnancies were subsequently reported in the conserving surgery group.
An initial conserving surgical procedure is an option in patients with extensive invasive placentation, but it requires further monitoring for potential complications and carries a high subsequent hysterectomy rate.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 10/2011; 33(10):1005-10.
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ABSTRACT: To determine whether there were differences in presentation, imaging, and tumour markers between pediatric and adolescent gynaecology patients with adnexal masses managed expectantly and those managed surgically.
We conducted a retrospective review of patients who presented to the pediatric and adolescent gynaecology service with adnexal masses between January 2003 and January 2006 at Toronto's Hospital for Sick Children. We used t tests, chi-square, and Pearson correlation tests for analysis.
We identified 114 patients with an adnexal mass. Fifty-nine percent had surgery (laparotomy 41.8%, laparoscopy 58.2%) and 41% were managed conservatively. The mean age of patients was 12.7 years (range 7 days to 18 years) and there was no difference in age between management groups (P = 0.59). The most common presenting symptom was abdominal pain (72.8%). Increased abdominal girth was found only in the surgical group (P < 0.01). Size of the mass was the only feature on imaging that differed between groups (11.1 cm surgical vs. 5.3 cm observed, P < 0.001). CT scans were performed in 35 patients, 94.3% of whom had surgery (P < 0.001). Tumour markers were drawn in 41.2% of patients, more often in surgical patients (P < 0.001), and 27% were abnormal, all in the surgical group. Surgical approaches included cystectomy, oophorectomy, or detorsion. Twelve percent of surgeries were for malignancies, representing 7.0% of all adnexal masses, and malignant masses were larger than benign masses (16.1 cm vs. 10.5 cm, P < 0.05). In cases that required only expectant management with serial ultrasound, both simple and complex masses resolved, with or without hormonal suppression.
Larger masses and masses associated with increased abdominal girth or abnormal tumour markers were more likely to be managed by surgical intervention. Surgically managed patients had more investigations. Forty-one percent of masses in patients referred to pediatric and adolescent gynaecology specialists resolved with expectant management.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 09/2011; 33(9):935-43.
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ABSTRACT: At present, there is no gold standard test for the investigation of ovarian function in pre-menopausal breast cancer patients who develop amenorrhea after chemotherapy. Clinical, biochemical and biophysical investigations continue to be utilized in clinical practice, despite concerns regarding their predictive value for menopause. The resulting uncertainty about a woman's actual menopausal status has important consequences for patient management. These include choice of appropriate endocrine therapy, assessment of residual ovarian function and its effect on breast cancer recurrence, fertility issues and the prediction of the likelihood of conception. It is hoped that the development of novel surrogates may allow clinicians to more accurately assess menopausal status and thereby facilitate tailored and individualised therapy for this common group of patients.
Breast (Edinburgh, Scotland) 12/2010; 19(6):545-8. · 2.09 Impact Factor
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ABSTRACT: To determine if repeat screening for sexually transmitted infection is appropriate for adolescent obstetric patients and to identify any risk factors associated with increased risk of contracting a sexually transmitted infection (STI) during pregnancy.
We conducted a retrospective review of the medical records of adolescent obstetric patients seen over a five-year period in the Young Prenatal Program at the Hospital for Sick Children (Toronto, Ontario).
Between January 2003 and December 2007, 201 patients with 211 pregnancies attended the Young Prenatal Program. Of the 211 pregnancies reviewed, all patients had screening at baseline for HIV, syphilis, hepatitis B, chlamydia, gonorrhea, and trichomonas; 173 patients were screened in the third trimester, two were tested at another point in the pregnancy because of symptoms, and 161 were screened at their postpartum visit. In 53 pregnancies, STI was diagnosed either during pregnancy or postpartum. Fourteen patients had multiple sexually transmitted infections for a total of 71 infections. Thirty-four infections were diagnosed at baseline, 15 in the third trimester, two because of symptoms, and seven were diagnosed postpartum. In patients who did not develop an STI during pregnancy, the previous use of contraception (excluding condoms), being in a relationship with the baby's father, and living with their partner were identified as significant protective factors against STI. There was a trend towards significance for contracting an STI in patients with a history of abuse, in those with a higher than average number of sexual partners, and in those with a younger than average age of coitarche.
Sexually transmitted infections were diagnosed in 25.1% of adolescent pregnancies (53/211) in our cohort. Of the 71 sexually transmitted infections diagnosed, 22.5% (16/71) were diagnosed on routine third trimester screening. Because of the high rates of STI and the small number of identified risk factors, routine repeat screening in the third trimester for chlamydia, gonorrhea, and trichomonas is warranted in pregnant adolescents.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 10/2010; 32(10):956-61.
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Lisa Allen
Journal of pediatric and adolescent gynecology 12/2009; 22(6):381-4. · 0.90 Impact Factor
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ABSTRACT: The purpose of the study is to review the surgical technique, complication rate and obstetric outcome associated with the laparoscopic approach to the placement of the cervico-isthmic cerclage.
A prospective cohort study was conducted from 2003-2008 and compared with previously reported cases of cervico-isthmic cerclage by laparotomy and laparoscopy.
Thirty-one patients underwent cerclage placement during pregnancy and 34 patients were not pregnant at the time of the surgery. Seven cases were converted to laparotomy due to complications arising from uterine vessel bleeding or impaired surgical visibility; 2 pregnancies were lost perioperatively. No other complications occurred. The fetal salvage rate (n = 67 pregnancies) was 89% with a mean gestational age of 35.8 +/- 2.9 weeks. Six pregnancies were lost in the second trimester due to the consequences of acute or subacute chorioamnionitis.
Our findings suggest that the cervico-isthmic cerclage placed laparoscopically compares favorably with the traditional laparotomy approach.
American journal of obstetrics and gynecology 10/2009; 201(4):364.e1-7. · 3.28 Impact Factor
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ABSTRACT: Epithelial ovarian neoplasms are uncommon in pediatric and adolescent patients, accounting for approximately 20% to 30% of ovarian tumors in adolescent females and women younger than 25. Tumors of low malignant potential (LMP) account for a significant proportion of epithelial neoplasms in this patient population. This case series describes 5 adolescent patients, with a mean age of 14.4 +/- 2.4 years, diagnosed with ovarian tumors of LMP at one institution. Between November 2001 and January 2006, 5 patients were diagnosed with ovarian tumors of LMP of 126 patients who had surgery for adnexal masses. All patients underwent initial surgery via laparotomy. Two patients underwent ovarian cystectomy, and 3 had at least a unilateral salpingo-oophorectomy. One patient had stage IIIc disease, whereas the other 4 patients, not all completely staged, had presumed stage I disease. Three patients developed recurrent ovarian masses on follow-up. Two had recurrent LMP tumors (one bilateral) and one was a benign mucinous cystadenoma. This case series of 5 adolescent patients with ovarian tumors of LMP highlights the importance of considering epithelial neoplasms in any pediatric or adolescent patient with a pelvic mass and supports conservative management, with staging and fertility-sparing surgery; however, appropriate follow-up is essential, as evidenced by 3 of 5 patients exhibiting recurrent ovarian masses.
Journal of Pediatric Surgery 10/2009; 44(10):2023-7. · 1.45 Impact Factor
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ABSTRACT: Vulvovaginal complaints in the prepubertal child are a common reason for referral to the health care provider. The Cochrane Library and Medline databases were searched for articles published in English from 1980 to December 2004 relating to vulvovaginal conditions in girls. The following search terms were used: vulvovaginitis, prepubertal, pediatric, lichen sclerosis, labial fusion, labial adhesion, genital ulcers, urethral prolapse, psoriasis, and straddle injuries. The objectives of this article are to review the normal vulvovaginal anatomy, describe how to perform an age-appropriate examination, and discuss common vulvovaginal disorders and their management in young girls.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 09/2009; 31(9):850-62.
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ABSTRACT: To evaluate the surgical approach used in the management of ovarian dermoid cysts in the pediatric and adolescent population.
A descriptive retrospective chart review of all cases of ovarian dermoid cyst excision between January 2001 and January 2006.
The Hospital for Sick Children, Toronto, Canada.
Forty-one female children and adolescents who underwent operative management of an ovarian dermoid cyst.
Surgical approach (laparoscopy vs laparotomy), intraoperative cyst rupture, length of hospital stay, and postoperative complications.
The mean age was 12.5 years. All cysts were unilateral. Twenty-three patients (56%) underwent laparoscopic cystectomy, 14 (34%) underwent cystectomy via laparotomy, and 4 (10%) oophorectomies were performed via laparotomy. Cyst size was significantly larger in the laparotomy group compared to the laparoscopy group (mean diameter 14.4 cm vs 7.1 cm, respectively, P < .001). A significantly higher rate of cyst rupture was experienced during laparoscopic cystectomy (100%), compared to excision via laparotomy (27.7%, P < .001). Length of hospital stay was significantly shorter in the laparoscopy group compared to the laparotomy group (median of 0 vs 3 days, respectively, P < .001). A single case in the laparoscopy group sustained a bladder injury and developed postoperative necrotizing fasciitis resulting in a prolonged hospitalization and recovery. There were no operative or postoperative complications related to cyst content spillage, regardless of the surgical approach.
Laparoscopic cystectomy is a safe and effective method of managing ovarian dermoid cysts in the pediatric and adolescent patient population.
Journal of pediatric and adolescent gynecology 07/2009; 22(6):360-4. · 0.90 Impact Factor
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Lisa Allen
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ABSTRACT: Disorders of sex development are medical conditions in which the development of chromosomal, gonadal, or anatomic sex varies from normal and may be incongruent with each other. This article primarily addresses the medical conditions where infants may be born with ambiguous genitalia leading to decisions with regard to gender assignment. The approach to investigations and diagnosis in the newborn period will be stressed within an interprofessional team. Policies with regard to surgery have developed, with techniques evolving and data emerging from long-term outcome studies. Current medical and surgical management are reviewed. Finally, a developmental approach to disclosure is presented.
Obstetrics and Gynecology Clinics of North America 04/2009; 36(1):25-45. · 1.70 Impact Factor
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ABSTRACT: To assess gynaecologists' management of ectopic pregnancies in adolescents.
A survey was sent to Canadian gynaecologists, including pediatric gynaecologists, by mail and email. Pediatric gynaecologists in the United States were surveyed by mail. Variations in preferences and practices in the management of ectopic pregnancy were identified, with specific focus on the use of methotrexate. Some possible determinants of alternative management were described, using both descriptive and inferential statistics.
A total of 209 physicians responded. Of these, 89 (42.6%) had treated adolescents with ectopic pregnancies (the "treatment group"). There were no statistically significant differences in demographic characteristics of the treatment group compared with the non-treatment group, except for the proportion of adolescents in the physicians' practices and whether or not they provided care for pregnant adolescents. In the treatment group, 84.3% had used methotrexate in the management of adolescents with an ectopic pregnancy. Most physicians (57/89, 64%) stated that they do not use different criteria for managing adolescent and adult patients, although across all age categories only 21.3% to 25.8% stated that age is not a relevant factor; 43.9% and 28.8% would definitely not or probably not offer methotrexate to patients less than 13 and 14-16 years of age, respectively, and 4.8% and 6.2% would definitely not or probably not offer methotrexate to patients 17-19 and more than 19 years of age, respectively. Physicians would definitely not or probably not offer methotrexate to a patient with a history of non-compliance with contraception (48.4%) or of substance abuse (45.9%), or to a patient living alone (62.7%).
Physicians do report using methotrexate in managing adolescents with ectopic pregnancies, but consider age and compliance variables in their decision-making.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 04/2009; 31(3):254-62.
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ABSTRACT: Unintentional female genital trauma is a complaint commonly seen and managed through the emergency department. The purpose of this study was to review all unintentional female genital trauma evaluated at The Hospital for Sick Children for 3.5 years to determine the factors associated with gynecologic consultation and need for operative repair.
One hundred five patients were identified by health record coding. Data were extracted to study factors associated with gynecologic consultation and operative repair. Statistical analyses were performed to evaluate the significance of these associations. Surgical choices were also evaluated.
Mean age was 5.60 years. Mean time to presentation was 7.05 hours. Straddle injury was the most common mechanism (81.90%), and only 4.76% injuries were penetrating. Of the 105 patients, 48.57% consulted the gynecology section, 19.05% were taken to the operating room, and 6.66% were treated under conscious sedation. Overall, 20.95% required surgical repair. The most common complication was dysuria. Six patients had other injuries, the most common of which were pelvic fractures related to trauma.Factors significantly associated with gynecologic consultation and operative management included older age, transfer to our institution, shorter time to presentation, laceration-type injury, hymenal injury, and larger size of injury. Straddle injuries were significantly less likely to be taken to the operating room. When cases were stratified by a surgeon, there were no significant differences in management.
Unintentional female pediatric genital traumas most commonly result from straddle injuries. Most injuries are minor, and in this cohort, only 48.57% received gynecologic consultation and 19.05% required operative management. Future prospective studies would be useful to better evaluate the efficacy of surgical choices.
Pediatric emergency care 12/2008; 24(12):831-5. · 0.92 Impact Factor
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Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 05/2008; 30(4):301-2.
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ABSTRACT: Virilization in female newborns typically results from congenital adrenal hyperplasia, requiring immediate diagnosis and treatment. We report a rare cause of virilization, maternal pregnancy luteoma, responsible for virilization of both a newborn and the mother. Luteomas are usually asymptomatic tumour-like ovarian lesions of pregnancy that secrete androgens in only 25% of cases. Many female infants born to masculinized mothers will also be virilized.
A term infant born with ambiguous genitalia was transferred to a referral centre for investigation, diagnosis, and treatment. Assessment identified Prader II-III genitalia, an elevated serum testosterone level, a normal serum 17-hydroxyprogesterone level, and a normal female karyotype (46,XX). The mother had had virilization from the second trimester and was found to have an elevated serum testosterone level. Pelvic ultrasound assessment in the mother showed a complex right ovarian mass. Laparotomy was performed, and the mass was excised. Histopathology examination confirmed a luteoma.
High maternal serum testosterone levels due to a luteoma can result in virilization in the female newborn. This report emphasizes the need to consider possible underlying maternal pathology in evaluating a virilized female infant.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 11/2007; 29(10):835-40.
