Green, Isabel

INTRODUCTION: Emergencies during gynecologic office procedures are uncommon. However, knowledge in management of these complications is essential as more gynecologic procedures move from the operating room to the office. Our goal was to develop an interactive curriculum to address a gap in residency training in the management of office-based procedural emergencies. METHODS: A curriculum including management of unanticipated bleeding, anaphylaxis, vasovagal response, and local anesthetic systemic toxicity (LAST) was developed and implemented using a combination of simulated patient sessions, a “choose-your-own-adventure” PowerPoint, and a mock oral board session. Pre and post intervention surveys queried participants’ confidence in recognition and management. The curriculum was delivered as in-person simulation sessions or virtual sessions due to COVID restrictions. Institutional review board (IRB) approval was obtained. Mean pre and post intervention scores were compared using paired t-test. RESULTS: Four accredited obstetrics and gynecology residency programs participated. Twenty-nine trainees completed the curriculum, and 24 submitted pre and post surveys (82.8% response rate). There was significant improvement in confidence scores for management of unanticipated bleeding (mean difference 0.96, P<.001), anaphylaxis (mean difference 1.7, P<.001), vasovagal response (mean difference 1.0, P<.001), and LAST (mean difference 2.5, P<.001). Additionally, significant improvement in confidence scores for identification of risk factors and signs/symptoms of vasovagal response (mean difference 0.96, P<.001, and 0.46, P=.005) and LAST (mean difference 2.3, P<.001, and 2.2, P<.001) was noted. CONCLUSION: Implementation of an office emergencies curriculum significantly increased confidence in identification and management of unanticipated bleeding, anaphylaxis, vasovagal response, and LAST. Future studies evaluating knowledge-based assessments of learners are needed.

INTRODUCTION: Despite the benefits, convenience, and acceptability of office hysteroscopy (OH), 20% of patients find OH unacceptable. In this study we defined acceptability as willingness to undergo office hysteroscopy in the future and investigated whether patients with co-existing pelvic pain disorders were more likely to find OH unacceptable. METHODS: Patients who underwent OH from 12/2016 to 6/2018 were included. Patients were asked to rate acceptability at the time of their procedure. Retrospective chart review was used to identify patients with pelvic pain disorders defined as chronic pelvic pain (CPP), dysmenorrhea, vulvodynia, dyspareunia, or high tone pelvic floor dysfunction (PFD). Patients rating OH as acceptable (Likert scale 4–5) were compared to those rating it as unacceptable (Likert scale 1–2). Comparisons between groups were made using a t-test or Wilcoxon rank sum test for continuous data, and a Chi-square test for categorical data. This study was determined to be exempt from the requirement for IRB approval (IRB #20–009387). RESULTS: Compared to patients in the “acceptable” group (n=929), patients who rated OH as “unacceptable” (n=55) reported higher during and post-procedure pain scores and lower satisfaction rates (P<.001). Prior diagnosis of PFD (P<.001) and dyspareunia (P=.003) were both associated with finding OH unacceptable. Dysmenorrhea, CPP, and vulvodynia were associated with unacceptability but did not achieve significance. CONCLUSION: A preexisting diagnosis of a pelvic pain disorder, specifically PFD and dyspareunia, was associated with unacceptability of OH. Implementing triage criteria for patients to pursue hysteroscopy with sedation or anesthesia could help improve patient satisfaction and warrants additional study.

INTRODUCTION: Nonrelaxing pelvic floor dysfunction (PFD) is a condition characterized by tension of the pelvic floor musculature, often resulting in pelvic pain. The objective of this study was to review patient-reported pain outcomes following treatment of nonrelaxing pelvic floor dysfunction to identify gaps in current evidence. METHODS: A systematic review of the following databases from inception to July 2020 was performed: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Two authors reviewed titles and abstracts for relevance, and full articles were obtained and evaluated for inclusion. Studies were included if they assess interventions for nonrelaxing PFD characterized by pelvic pain. The third author was consulted in instances of disagreement. RESULTS: Of the 1,184 abstracts identified and reviewed, 36 full text articles were reviewed. Treatments for nonrelaxing PFD included biofeedback, botulinum toxin injections, electrical stimulation, intravaginal diazepam, massage, osteopathy, psychiatric interview, physical therapy, sacral nerve stimulation, trigger point injection, and combined therapies. Nineteen studies assessed the effectiveness of treatment based on patient reported pain outcomes. All studies demonstrated an improvement in pelvic pain. Several limitations were identified including varied pre-treatment diagnostic evaluation, small sample size, retrospective and single arm design, heterogeneity in treatment administration within and between studies, lack of standardized pain assessments, and limited long term outcome data. CONCLUSION: Nonrelaxing PFD is a debilitating condition. There is a paucity of high-quality clinical trials evaluating the effectiveness of pelvic floor muscle dysfunction treatments. Although preliminary studies support multi-modal treatment options, robust trials assessing patient-centered outcomes are necessary.

INTRODUCTION: While rare, emergencies encountered during office procedures have the potential for significant morbidity if the team is caught unprepared. The aim of this study was to evaluate current availability of and needs for training in office emergencies in residency programs in the United States. METHODS: This was a cross-sectional survey of residents from accredited obstetrics and gynecology residency programs. Identified programs were those with representation in the American College of Obstetricians and Gynecologists Simulation Working Group (ACOG SWG). A multi-item instrument was developed, designed, and edited by representatives of the ACOG SWG for accuracy and content validity. Participants were asked to rate their level of agreement with statements on importance of training in the recognition and management of obstetrics and gynecology emergencies and their confidence in management of those emergencies. Specific emergencies encountered in the office, gynecologic surgery, and obstetrics were queried. RESULTS: Six programs participated for a total of 116 residents and a response rate of 62% (116/188). Most residents agreed office emergency (97.5%) and obstetric emergency training (94.8%) were important in residency training. While 65.5% were confident in managing a vasovagal episode in the office, 0.9% were confident in managing lidocaine toxicity. In contrast, the majority of residents felt confident in obstetric emergency management across all listed emergencies (hemorrhage, cord prolapse, shoulder dystocia, eclampsia). CONCLUSION: While rated as important to residency training, significant gaps exist within resident preparation for identification and management of office-based emergencies, providing an opportunity for curriculum development and education.

INTRODUCTION: Retained products of conception (POC) following uterine evacuation can lead to adverse sequelae, including hemorrhage, endometritis, intrauterine adhesions, and reoperation. Incidence of retained POC range from 1.5–3.7%. Use of procedural transvaginal sonography (TVUS) in the operating room has been proposed to help decrease this. METHODS: A retrospective review of first trimester uterine evacuation procedures from 1/2015–2/2017 was performed, noting use of transabdominal ultrasonography (TAUS), retained products of conception (sonographic findings requiring surgical or medical intervention), and complications. A practice change was implemented in May 2018, in which intra-procedural TVUS was routinely performed. A second retrospective chart review was conducted to assess for post-implementation incidence of retained POC, reoperation, and associated complications. Fisher's exact test was performed. RESULTS: Prior to implementation, 130 eligible procedures were performed during the specified timeframe, with 9/130 (6.9%) incidence of retained products of conception. TAUS was performed in 59/130 (45.4%) of procedures, and 4/9 (44.4%) of those with retained products. There were eight re-operative procedures in seven patients, and two patients were treated with misoprostol. Complications included hemorrhage, Asherman's and endometritis. Following implementation, 94 first trimester procedures were performed with transvaginal sonography, with 0 (0%) cases of retained POC (P=.01), no incidences of re-operation (P=.02), and one case of Asherman's. TVUS led to additional focused curettage in 20/94 (21.3%) of procedures. The endometrium was measured in 64 procedures, with a mean thickness of 5.5 mm (1–12 mm). CONCLUSION: Implementation of routine TVUS during uterine evacuation appears to reduce the incidence of retained POC and associated reoperation rates.

INTRODUCTION: Bimanual pelvic examination is often performed for symptoms related to uterine fibroids (UF). We evaluated the clinical utility of this exam at the time of UF diagnosis in a community setting. METHODS: Retrospective sample of women diagnosed with UF between 2006 and 2010 in the Rochester Epidemiology Project, a population-based records-linkage system. Cohort includes a sample of women who had a pelvic examination within 12 months of UF diagnosis (n=141). Abnormal pelvic exam was defined as abnormal uterine size or shape, or any adnexal mass or fullness recorded by healthcare provider. We examined clinical and imaging characteristics using chi-squared for categorical and t tests for continuous data. Data reported as percentage or mean ± standard deviation. Volumes of the uterus and largest fibroid were calculated using the prolate ellipsoid formula. RESULTS: Women with UF and a normal pelvic exam (n=73) were younger than women with abnormal exam (n=68) (44.7±7.1 vs 46.9±5.4 years, P=.05), and had a higher BMI (29.4 ± 6.5 vs 26.6 ± 5.0 kg/m2, P=.007). Women with abnormal exam had significantly larger uterine volumes (226.0 ± 151.8 vs 150.9 ± 97.9 cm³, P=.005) and fibroid volumes (61.1±81.1 vs 19.9±52.8 cm³, P=.005). Abnormal examination was more frequently documented by gynecology providers (57.4%) than other providers (42.7%, P=.04). Fibroid symptoms were not associated with abnormal examination. CONCLUSION: Fifty-two percent of women with fibroids had a normal bimanual examination. Thus, a high suspicion of fibroids should prompt imaging. Lower BMI and larger uterine and fibroid dimensions increase fibroid diagnosis on pelvic examination.

BACKGROUND: In 2005, in response to a decline in residency applications in OBGYN, the American College of Obstetrics and Gynecology Presidential Task Force outlined strategies for attracting medical students to OBGYN. Our program implemented interventions across all years of medical school education, increased efforts to “teach the teachers,” and improve faculty and resident relations with students. Application rates increased, but little is still known about which interventions work. METHODS: This qualitative study received IRB approval. Students applying or recently matched into OB GYN residency programs from the Class of 2014–2016 were included. Eleven participants completed a phone interview exploring why they chose OB GYN, focusing on positive and negatives experiences. The survey instrument was designed to include open ended questions and a Likert-type survey. Grounded theory methodology was used for analysis. Participants received a $50 Starbucks card. RESULTS: Preliminary analysis identified the following themes: 1) potential for a “meaningful” job and a future role in women's health, advocacy for women or empowerment of women; 2) first impressions in the clinical clerkship and “welcoming” teams; 3) content and diversity of our field; 4) impact of supportive mentors in career decisions. DISCUSSION: Participants identify important events that even precede medical school, but commonly highlight finding meaning in their work, and identifying with others that share in their interest and goals as guiding them toward OB GYN.