Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstétrique et gynécologie du Canada : JOGC
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J Obstet Gynaecol Can · Mar 2015
Practice GuidelineVulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis.
To review the evidence and provide recommendations on screening for and management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis. ⋯ The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Vulvovaginal candidiasis affects 75% of women at least once. Topical and oral antifungal azole medications are equally effective. (I) 2. Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year. (II-2) 3. Trichomonas vaginalis is a common non-viral sexually transmitted infection that is best detected by antigen testing using vaginal swabs collected and evaluated by immunoassay or nucleic acid amplification test. (II-2) 4. Cure rates are equal at up to 88% for trichomoniasis treated with oral metronidazole 2 g once or 500 mg twice daily for 7 days. Partner treatment, even without screening, enhances cure rates. (I-A) 5. Current evidence of the efficacy of alternative therapies for bacterial vaginosis (probiotics, vitamin C) is limited. (I) Recommendations 1. Following initial therapy, treatment success of recurrent vulvovaginal candidiasis is enhanced by maintenance of weekly oral fluconazole for up to 6 months. (II-2A) 2. Symptomatic vulvovaginal candidiasis treated with topical azoles may require longer courses of therapy to be resolved. (1-A) 3. Test of cure following treatment of trichomoniasis with oral metronidazole is not recommended. (I-D) 4. Higher-dose therapy may be needed for treatment-resistant cases of trichomoniasis. (I-A) 5. In pregnancy, treatment of symptomatic Trichomonas vaginalis with oral metronidazole is warranted for the prevention of preterm birth. (I-A) 6. Bacterial vaginosis should be diagnosed using either clinical (Amsel's) or laboratory (Gram stain with objective scoring system) criteria. (II-2A) 7. Symptomatic bacterial vaginosis should be treated with oral metronidazole 500 mg twice daily for 7 days. Alternatives include vaginal metronidazole gel and oral or vaginal clindamycin cream. (I-A) 8. Longer courses of therapy for bacterial vaginosis are recommended for women with documented multiple recurrences. (I-A).
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J Obstet Gynaecol Can · Mar 2015
Newborn outcomes in british columbia after caesarean section for non-reassuring fetal status.
To assess the incidence in British Columbia of severe morbidity in neonates delivered by Caesarean section for non-reassuring fetal status, and to examine the accuracy of Apgar score and umbilical cord gas values in predicting severe neonatal morbidity. ⋯ The incidence of abnormal Apgar score and abnormal umbilical cord gas values is very low among neonates in British Columbia delivered by Caesarean section for non-reassuring fetal status. Apgar score at one minute < 7 is a good predictor of severe neonatal morbidity. Electronic fetal monitoring remains a non-specific method for detection of fetal compromise in the intrapartum period.
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The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities. ⋯ The quality of evidence in this document was rated using the criteria described in the Report of the Caadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Uterine fibroids are common, appearing in 70% of women by age 50; the 20% to 50% that are symptomatic have considerable social and economic impact in Canada. (II-3) 2. The presence of uterine fibroids can lead to a variety of clinical challenges. (III) 3. Concern about possible complications related to fibroids in pregnancy is not an indication for myomectomy except in women who have had a previous pregnancy with complications related to these fibroids. (III) 4. Women who have fibroids detected in pregnancy may require additional maternal and fetal surveillance. (II-2) 5. Effective medical treatments for women with abnormal uterine bleeding associated with uterine fibroids include the levonorgestrel intrauterine system, (I) gonadotropin-releasing hormone analogues, (I) selective progesterone receptor modulators, (I) oral contraceptives, (II-2) progestins, (II-2) and danazol. (II-2) 6. Effective medical treatments for women with bulk symptoms associated with fibroids include selective progesterone receptor modulators and gonadotropin-releasing hormone analogues. (I) 7. Hysterectomy is the most effective treatment for symptomatic uterine fibroids. (III) 8. Myomectomy is an option for women who wish to preserve their uterus or enhance fertility, but carries the potential for further intervention. (II-2) 9. Of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. (II-3) 10. Newer focused energy delivery methods are promising but lack long-term data. (III) Recommendations 1. Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. (III-D) 2. Treatment of women with uterine leiomyomas must be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the therapist. (III-B) 3. In women who do not wish to preserve fertility and/or their uterus and who have been counselled regarding the alternatives and risks, hysterectomy by the least invasive approach possible may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-2A) 4. Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (II-3A) 5. Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with the help of appropriate imaging. (III-A) 6. When morcellation is necessary to remove the specimen, the patient should be informed about possible risks and complications, including the fact that in rare cases fibroid(s) may contain unexpected malignancy and that laparoscopic power morcellation may spread the cancer, potentially worsening their prognosis. (III-B) 7. Anemia should be corrected prior to proceeding with elective surgery. (II-2A) Selective progesterone receptor modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. (I-A) 8. Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be considered. (I-A) 9. Uterine artery occlusion by embolization or surgical methods may be offered to selected women with symptomatic uterine fibroids who wish to preserve their uterus. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted. (II-3A) 10. In women who present with acute uterine bleeding associated with uterine fibroids, conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention may be considered, but hysterectomy may become necessary in some cases. In centres where available, intervention by uterine artery embolization may be considered. (III-B).
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J Obstet Gynaecol Can · Jan 2015
Technical update on tissue morcellation during gynaecologic surgery: its uses, complications, and risks of unsuspected malignancy.
To review the use of tissue morcellation in minimally invasive gynaecological surgery. ⋯ The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. (Table 1) BENEFITS, HARMS, AND COSTS: Gynaecologists may offer women minimally invasive surgery and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine sarcoma or endometrial cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Appropriate training and safe practices should be in place before offering tissue morcellation. SUMMARY STATEMENTS: 1. Uterine sarcomas may be difficult to diagnose preoperatively. The risk of an unexpected uterine sarcoma following surgery for presumed benign uterine leiomyoma is approximately 1 in 350, and the rate of leiomyosarcoma is 1 in 500. (II-2) This risk increases with age. (II-2) 2. An unexpected uterine sarcoma treated by primary surgery involving tumour disruption, including morcellation of the tumour, has the potential for intra-abdominal tumour-spread and a worse prognosis. (II-2) 3. Uterus-sparing surgery remains a safe option for patients with symptomatic leiomyomas who desire future fertility. (II-1) RECOMMENDATIONS: 1. Techniques for morcellation of a uterine specimen vary, and physicians should consider employing techniques that minimize specimen disruption and intra-abdominal spread. (III-C) 2. Each patient presenting with uterine leiomyoma should be assessed for the possible presence of malignancy, based on her risk factors and preoperative imaging, although the value of these is limited. (III-C) 3. Preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is recommended. (II-2A) 4. Hereditary cancer syndromes that increase the risk of uterine malignancy should be considered a contraindication to uncontained uterine morcellation. (III-C) 5. Uterine morcellation is contraindicated in women with established or suspected cancer. (II-2A) If there is a high index of suspicion of a uterine sarcoma prior to surgery, patients should be advised to proceed with a total abdominal hysterectomy, bilateral salpingectomy, and possible oophorectomy. (II-2C) A gynaecologic oncology consultation should be obtained. 6. Tissue morcellation techniques require appropriate training and experience. Safe practice initiatives surrounding morcellation technique and the use of equipment should be implemented at the local level. (II-3B) 7. Morcellation is an acceptable option for retrieval of benign uterine specimens and may facilitate a minimally invasive surgical approach, which is associated with decreased perioperative risks. Each patient should be counselled about the possible risks associated with the use of morcellation, including the risks associated with underlying malignancy. (III-C).
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This guideline reviews the evidence relating to the effects of parvovirus B19 on the pregnant woman and fetus, and discusses the management of women who are exposed to, who are at risk of developing, or who develop parvovirus B19 infection in pregnancy. ⋯ The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Recommendations 1. Investigation for parvovirus B19 infection is recommended apart of the standard workup for fetal hydrops or intrauterine fetal death. (II-2A) 2. Routine screening for parvovirus immunity in low-risk pregnancies is not recommended. (II-2E) 3. Pregnant women who are exposed to, or who develop symptoms of, parvovirus B19 infection should be assessed to determine whether they are susceptible to infection (non-immune) or have a current infection by determining their parvovirus B19 immunoglobulin G and immunoglobulin M status. (II-2A) 4. If parvovirus B19 immunoglobulin G is present and immunoglobulin M is negative, the woman is immune and should be reassured that she will not develop infection and that the virus will not adversely affect her pregnancy. (II-2A) 5. If both parvovirus B19 immunoglobulin G and immunoglobulin M are negative (and the incubation period has passed), the woman is not immune and has not developed the infection. She should be advised to minimize exposure at work and at home. Absence from work should be considered on a case-by-case basis. (II-2C) Further studies are recommended to address ways to lessen exposure including the risk of occupational exposure. (III-A) 6. If a recent parvovirus B19 infection has been diagnosed in the woman, referral to an obstetrician or a maternal-fetal medicine specialist should be considered. (III-B) The woman should be counselled regarding risks of fetal transmission, fetal loss, and hydrops and serial ultrasounds should be performed every 1 to 2 weeks, up to 12 weeks after infection, to detect the development of anemia (using Doppler measurement of the middle cerebral artery peak systolic velocity) and hydrops. (III-B) If hydrops or evidence of fetal anemia develops, referral should be made to a specialist capable of fetal blood sampling and intravascular transfusion. (II-2B).