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Breastfeeding at work is recommended by pediatric society guidelines and is protected by employment and human rights law in many countries. Despite this, previous studies have found that residents report important structural barriers to breastfeeding at work.We administered a cross-sectional, electronic, multicenter survey of all women residents in Alberta who were parents in 2017. The study aimed to characterize respondents' experiences of breastfeeding, including duration, goals, barriers, and support from colleagues.There were 110 respondents, of whom 53 individuals had breastfed 83 children during residency. While nearly all felt that breastfeeding was important to them, only 69.2% reported meeting their breastfeeding duration goal. Surgical residents were less likely to meet their breastfeeding duration goal than residents in other disciplines (40.0% (n = 6/15) compared to 80.0% of non-surgical (n = 28/35) and 80.0% of family medicine residents (n = 12/15)). Residents reported stopping breastfeeding earlier than they desired due to lack of adequate space (48.7%, n = 19) and lack of time (57.1%, n = 24). Twelve participants (10.9%) reported hearing a derogatory comment from a staff physician about their breastfeeding.Women residents face barriers to breastfeeding at work which require systems-level intervention. Residents from surgical programs may be the most vulnerable to these barriers. Program directors, residency wellness committees, and hospital administrators should prioritize addressing these barriers for women residents returning to work after maternity leave. Examples of interventions that may address these barriers include policies, designation of lactation spaces, and flexible return-to-work schedules.

Highlights • Malignancy should be considered as a possible cause of a Caesarean scar defect. • Gestational trophoblastic neoplasia can be present despite negative hCG. • Limited evidence on fertility-sparing treatment of epithelioid trophoblastic tumor., Background Epithelioid trophoblastic tumor is a rare form of gestational trophoblastic neoplasia. We present the first known case of this rare malignancy presenting as a Caesarean scar defect. Case A patient with 3 prior Caesarean sections presented with vaginal bleeding 2 months following management of retained products of conception. Her hCG was negative. She underwent surgical repair of a Caesarean scar defect, and pathology was consistent with epithelioid trophoblastic tumor. Conclusion This case highlights the possibility of malignancy presenting to the general gynecologist as a Caesarean scar defect. The diagnosis of gestational trophoblastic neoplasia should always be considered in the differential diagnosis of a patient with postpartum vaginal bleeding. Limited evidence on fertility conserving treatment of epithelioid trophoblastic tumors does not seem favorable.

OBJECTIVE Cervical tissue samples of limited adequacy but with pathological features of squamous intraepithelial lesions (SIL) may not be gradable and result in a diagnosis of ungraded SIL (SILQ). SILQ outcome, clinico-pathological correlates, and the predictive role of biomarker staining are unknown. MATERIALS AND METHODS Among 17,551 colposcopy attendees, 478 (2.7%) had SILQ. Glass slides of 472 were reviewed. Positive [high SIL (HSIL), adenocarcinoma in situ (AIS), or carcinoma] and negative [negative for intraepithelial lesion or malignancy (NILM) or low SIL (LSIL)] outcomes were based on the worst pathology in 24 months of follow-up. p16 and Ki67 immunohistochemistry of 80 random SILQ and 149 controls (44 NILM, 15 LSIL, 75 HSIL, and 15 AIS) was scored as unsatisfactory, positive, or negative. Biomarker and outcome status were correlated, and sensitivity, specificity positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS Of the total cases, 332 (1.9%) were reviewed as SILQ, and follow-up for 329 was positive in 134 (41%). Atypical glandular cells, AIS, atypical squamous cells (cannot exclude HSIL), HSIL referral Pap test (70% vs. 47%, p < .001), and HSIL colposcopic impression (33% vs. 19%, p < .001) were more frequent among positive compared with negative outcomes. Best SILQ sensitivity (89%) and NPV (77%) occurred with combined biomarkers, and best specificity (52%) and PPV (58%) occurred with Ki67. All 4 performance metrics among the controls were high. CONCLUSIONS The 2% frequency and 41% positive outcome highlight the clinical importance of SILQ. The referral Pap test and colposcopic impression could prioritize follow-up colposcopy for some SILQ, and negative staining with both biomarkers could eliminate further colposcopy in others.

Background The loop electrosurgical excision procedure (LEEP) is commonly used to treat cervical dysplasia and has few procedural risks. We report a rare complication: vesicovaginal fistula (VFF). Case A 47-year-old G3P1 woman with a previous LEEP underwent a second procedure 9 years later and was diagnosed as having microinvasive cervical cancer. Subsequently, at the time of her scheduled robotic-assisted laparoscopic total hysterectomy, examination under anaesthesia revealed a VFF, confirmed with cystoscopy. A joint VFF repair and total abdominal hysterectomy bilateral salpigo-oophorectomy subsequently ensued with an uncomplicated postoperative course. Conclusion VFF is a rare but recognized complication of LEEP, particularly in women with risk factors, such as a prior LEEP. Examination under anesthesia prior to commencing surgery facilitated recognition and appropriate management of this case.

Objective To strengthen the national framework for care of adolescents and women affected by female genital cutting (FGC) in Canada by providing health care professionals with: (1) information intended to strengthen their knowledge and understanding of the practice; (2) directions with regard to the legal issues related to the practice; (3) clinical guidelines for the management of obstetric and gynaecological care, including FGC related complications; and (4) guidance on the provision of culturally competent care to adolescents and women with FGC. Evidence Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and keywords (e.g., female genital mutilation, clitoridectomy, infibulation). We also searched Social Science Abstracts, Sociological Abstracts, Gender Studies Database, and ProQuest Dissertations and Theses in 2010 and 2011. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values 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).

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.

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.

Objective To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting. Options The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed. Outcomes Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception. Evidence Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed. Values The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1). Benefits, Harms, and Costs These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC. Sponsor The Society of Obstetricians and Gynecologists of Canada.

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.

To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed.Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception.Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed.The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1).These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC.The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1. Hormonal emergency contraception may be effective if used up to 5 days after unprotected intercourse. (II-2) 2. The earlier hormonal emergency contraception is used, the more effective it is. (II-2) 3. A copper IUD can be effective emergency contraception if used within 7 days after intercourse. (II-2) 4. Levonorgestrel emergency contraception regimens are more effective and cause fewer side effects than the Yuzpe regimen. (I) 5. Levonorgestrel emergency contraception single dose (1.5 mg) and the 2-dose levonorgestrel regimen (0.75 mg 12 hours apart) have similar efficacy with no difference in side effects. (I) 6. Of the hormonal emergency contraception regimens available in Canada, levonorgestrel-only is the drug of choice. (I) 7. A pregnancy that results from failure of emergency contraception need not be terminated (I) Recommendations 1. Emergency contraception should be used as soon as possible after unprotected sexual intercourse. (II-2A) 2. Emergency contraception should be offered to women if unprotected intercourse has occurred within the time it is known to be effective (5 days for hormonal methods and up to 7 days for a copper IUD). (II-2B) 3. Women should be evaluated for pregnancy if menses have not begun within 21 days following emergency contraception treatment. (III-A) 4. During physician visits for periodic health examinations or reproductive health concerns, any woman in the reproductive age group who has not been sterilized may be counselled about emergency contraception in advance with detailed information about how and when to use it. (III-C).

A 20-year-old primigravida was found on ultrasound to have monochorionic monoamniotic twins. One twin had multiple anomalies, including no identifiable heart and a single umbilical artery with reversed flow (Figure 1). The second twin had normal anatomy. With a diagnosis of twin reversed arterial perfusion (TRAP) syndrome, radiofrequency ablation of the abnormal twin’s cord vessels was performed. The patient delivered a healthy baby and the perfused twin (Figure 2) at term.

N avons constate, au moment de l’echographie, qu’une primigravide de 20 ans presentait des jumeaux monozygotes monoamniotiques. Un des jumeaux presentait de multiples anomalies, y compris l’absence d’un cœur identifiable et la presence d’une seule artere ombilicale a circulation inversee (Figure 1). Le deuxieme jumeau presentait une anatomie normale. A la suite de l’etablissement d’un diagnostic de syndrome de perfusion arterielle inversee gemellaire (ou syndrome TRAP pour twin reversed arterial perfusion), l’ablation par radiofrequence des vaisseaux du cordon du jumeau anormal a ete menee. La patiente a accouche d’un enfant sain et du jumeau perfuse (Figure 2) a terme.