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Background Abdominal cerclage is indicated for some women with cervical insufficiency. Long-term complications from cerclage are rare. Case Here we report the case of a patient who presented with recurrent urinary tract infection and hematuria 5 years after laparoscopic abdominal cerclage. Cystoscopy revealed bladder stones surrounding a foreign body. Another cystoscopy 3 months later showed complete erosion of the cerclage into the bladder. Conclusion This case reminds us that differential diagnosis of urinary symptoms in women who have undergone cervical cerclage should include suture erosion into the bladder. Cerclage removal can be offered to women who have completed childbearing to prevent this rare complication.

Objective The incidence of placenta accreta spectrum (PAS) has risen over the past decades, primarily in response to increasing Caesarean section rates. The surgical management of PAS is associated with significant morbidity, including hemorrhage and intensive care unit (ICU) admission. This study sought to evaluate the surgical outcomes of a PAS operative approach. Methods A single-centre retrospective chart review of all Caesarean hysterectomies for PAS by an assigned surgeon over a 16-year period was performed. Surgical outcomes were described (Canadian Task Force Classification II-2). Results The described surgical approach involves a midline skin incision, high midline hysterotomy, a rapid single-layer uterine closure with no placental removal attempt, constant cephalad uterine traction, and liberal choice of subtotal hysterectomy. A total of 47 patients were included: 19 (40.4%) with placenta accreta, 14 (29.8%) with placenta increta, and 14 (29.8%) with placenta percreta. Mean estimated blood loss was 1416 ± 699 mL, and mean operative time was 112 ± 49 minutes. Overall, 16 patients (34.0%) required blood transfusion, and 4 patients (8.5%) required ICU admission. The average hospitalization was 5.2 days, with no re-admission within 30 days. The use of internal iliac balloons did not result in a difference in blood loss or operative time (P > 0.05). Patients with placenta percreta had significantly more blood loss (P = 0.02) and longer operative time (P = 0.007) compared with those with placenta accreta and increta. Conclusion The current surgical model for planned Caesarean hysterectomy for PAS exhibits a low complication rate. Further research is needed for developing a standardized approach to the management of PAS.

Resume Contexte Les troubles du spectre du placenta accreta (TSPA) constituent une complication de la grossesse potentiellement mortelle et exigent une coordination des soins interdisciplinaires afin d'ameliorer la possibilite d'une issue favorable. La hausse de la frequence des cas est due a l'augmentation du nombre d'interventions chirurgicales uterines, notamment a l'augmentation de la frequence des grossesses apres cesarienne. Objectif Fournir des directives cliniques factuelles courantes sur les methodes optimales pour depister, diagnostiquer et prendre en charge les TSPA de facon efficace. Methode Les membres du comite sur les directives cliniques ont ete selectionnes en fonction de leur milieu de pratique et de leur expertise actuelle en matiere de prise en charge de cette maladie au Canada. Le comite a revu toutes les donnees probantes disponibles dans la litterature medicale en anglais, y compris des lignes directrices publiees ainsi que des tests de diagnostic, des interventions chirurgicales et les issues cliniques evaluees. Donnees probantes La litterature publiee jusqu'en mars 2018, y compris les directives cliniques, a ete puisee dans les bases de donnees Medline et Cochrane Library au moyen d'un vocabulaire controle et de mots cles. Les resultats sont limites aux analyses systematiques, aux essais cliniques randomises et aux etudes observationnelles rediges en anglais. Les recherches ont ete mises a jour regulierement, et les resultats ont ete incorpores a la directive clinique jusqu'en juillet 2018. Criteres La qualite des donnees probantes dans le present document a ete evaluee en fonction des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. Resultats Le present document passe en revue les donnees probantes relatives aux techniques diagnostiques et chirurgicales utilisees pour favoriser la prise en charge optimale des femmes chez qui l'on suspecte un TSPA, notamment l'anesthesie et les considerations cliniques de la prestation de soins interdisciplinaires. Avantages, prejudices et couts La mise en application des recommandations de la presente directive clinique ameliorera la sensibilisation a cette maladie et augmentera la proportion des femmes atteintes recevant des soins interdisciplinaires dans des centres regionaux. Conclusion La prestation de soins par une equipe interdisciplinaire qui assure de bons services diagnostiques, la planification concertee et les interventions chirurgicales securitaires fournissent des soins qui ameliorent les issues cliniques comparativement aux autres modes de prise en charge. DECLARATIONS SOMMAIRES 1La frequence des troubles du spectre du placenta accreta est en hausse constante dans de nombreux pays, vraisemblablement en raison de l'augmentation de la proportion de femmes qui deviennent enceintes apres avoir subi une ou plusieurs interventions chirurgicales uterines, notamment des cesariennes multiples. 2Les troubles du spectre du placenta accreta dans un contexte d'antecedents de cesarienne decoulent de l'implantation de la grossesse dans la niche au niveau de la cicatrice pres de la jonction cervico-isthmique de l'uterus. Diverses methodes echographiques permettent de diagnostiquer la manifestation precoce d'une « grossesse sur cicatrice de cesarienne ». 3L'echographie peut servir a depister et a diagnostiquer les grossesses avec un placenta praevia anterieur complique par un trouble du spectre du placenta accreta. L'efficacite de l'echographie dans ce contexte depend de la connaissance des facteurs de risque cliniques, de la qualite de l'imagerie, de l'experience de l'echographiste, de l'âge gestationnel, des modalites d'imagerie et du volume vesical adequat. 4L'imagerie par resonance magnetique peut appuyer l'echographie multimodale dans le diagnostic et la classification des troubles du spectre du placenta accreta; cependant, la contre-indication relative de l'utilisation du gadolinium comme agent de contraste limite actuellement son efficacite. 5Les troubles du spectre du placenta accreta sont potentiellement mortels et necessitent la prestation de soins par une equipe interdisciplinaire regionale afin de maximiser les chances d'issue favorable pour la mere et le nourrisson. RECOMMANDATIONS 1Il y a lieu de diriger les femmes enceintes qui presentent un placenta praevia anterieur et des facteurs de risque cliniques des troubles du spectre placenta accreta a l'echographie obstetricale de 18-20 semaines vers des services d'imagerie specialisee afin de diagnostiquer ou d'exclure cette maladie (II-2A). 2Il y a lieu de diriger les femmes qui ont recu un diagnostic de troubles du spectre du placenta accreta vers un centre regional designe a la prise en charge interdisciplinaire de cette maladie (II-3A). 3Les soins interdisciplinaires rattaches a un protocole qui s'etend du diagnostic a l'intervention chirurgicale optimiseront les issues a la fois peroperatoires et postoperatoires (II-3A). 4L'admission prenatale dans un centre de prise en charge regional designe peut etre indiquee, surtout a la suite d'une hemorragie ante partum, ou en fonction de contraintes geographiques ou de transport (III-B). 5Chez les femmes autrement en sante dont l'historique de grossesse ne comporte aucun saignement vaginal, le meilleur moment pour proceder a la cesarienne planifiee se situe entre 34 et 36 semaines de grossesse (II-3B). Il convient d'envisager d'effectuer l'intervention plus tot en cas d'episodes repetes d'hemorragie ante partum ou de contractions afin de reduire le risque d'intervention chirurgicale d'urgence non planifiee; on doit aussi idealement administrer une corticotherapie pour favoriser la maturation pulmonaire fœtale si l'intervention a lieu avant 35+0 semaines de grossesse (II-2A). 6L'anesthesie regionale peut s'averer plus securitaire que l'anesthesie generale etant donne qu'elle est liee a une perte sanguine moindre et que les patientes et leur partenaire la prefere (II-2A). Un protocole de transfusion massive doit etre en place afin de pouvoir reagir en cas de perte sanguine importante (III-B). 7Il y a lieu d'administrer de l'acide tranexamique par voie intraveineuse au debut de l'intervention parce qu'elle diminue la perte sanguine peroperatoire (I-A). 8Il convient de realiser l'intervention chirurgicale en position de lithotomie modifiee, au moyen d'une incision mediane assez haute pour extraire le fœtus sans pratiquer d'incision dans le placenta; l'echographie pre- ou peroperatoire peut etre utilisee afin de determiner l'incision uterine optimale (III-B). Si le placenta ne montre aucun signe de decollement, il convient de ne pas tenter de l'extirper en raison de l'hemorragie importante qui peut en decouler (III-B). 9A l'heure actuelle, il n'y a pas suffisamment de donnees probantes pour recommander ou non l'administration de medicaments uterotoniques apres l'extraction du fœtus (III-C). 10A l'heure actuelle, il n'y a pas suffisamment de donnees probantes pour recommander une methode ou une autre (insertion preoperatoire de ballonnets ou ligature peroperatoire) visant a reduire le debit sanguin des arteres iliaques internes avant l'hysterectomie (II-1C). 11Une atteinte centrale focale peut se preter a la resection cuneiforme (wedge) avec retrait complet du placenta et reparation de l'uterus (triple-P) (II-3B). 12La cesarienne classique avec abandon du placenta envahissant constitue une methode d'accouchement acceptable, mais elle prolongerait le temps de recuperation et presente un risque persistant d'hysterectomie (II-3B). 13Il convient de recommander aux femmes qui demeurent fertiles apres un diagnostic de trouble du spectre de placenta accreta d'obtenir une echographie aupres d'un specialiste tot dans toute grossesse subsequente de sorte que toutes les options de prise en charge demeurent sur la table en cas de grossesse sur cicatrice de cesarienne (III-B). 14Le diagnostic prenatal des formes les plus graves de troubles du spectre du placenta accreta, designees comme des grossesses sur cicatrice de cesarienne, peut rendre possible une prise en charge au moyen de techniques chirurgicales a effraction minimale (II-3D). 15Bien que bon nombre de femmes presentant un trouble du spectre du placenta accreta recoivent des soins securitaires dans les pays bien outilles, il faut pousser la recherche et favoriser le transfert de connaissances encore davantage pour offrir efficacement toutes les options de prise en charge a la population (III-B).

Background Placenta accreta spectrum (PAS) disorders are a potentially life-threatening complication of pregnancy that demand coordinated interdisciplinary care to achieve safer outcomes. The rising incidence of this disease is due to a growing number of uterine surgical procedures, including the rising incidence of pregnancy following Caesarean section. Objective To provide current evidence-based guidelines on the optimal methods used to effectively screen, diagnose, and manage PAS disorders. Methods Members of the guideline committee were selected on the basis of their ongoing expertise in managing this condition across Canada and by practice setting. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated diagnostic tests, surgical procedures, and clinical outcomes. Evidence Published literature, including clinical practice guidelines, was retrieved through searches of Medline and The Cochrane Library to March 2018 using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized controlled trials, and observational studies written in English. Searches were updated on a regular basis and incorporated in the guideline to July 2018. Values The quality of evidence in this document was graded using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Results This document reviews the evidence regarding the available diagnostic and surgical techniques used for optimal management of women with suspected PAS disorders, including anaesthesia and practical considerations for interdisciplinary care. Benefits, Harms, and Costs Implementation of the guideline recommendations will improve awareness of this disease and increase the proportion of affected women receiving interdisciplinary care in regional centres. Conclusions Interdisciplinary team-based care providing accurate diagnostic services, coordinated planning, and safer surgery deliver effective care with improved clinical outcomes in comparison with alternative management. Summary Statements 1The incidence of placenta accreta spectrum disorders is steadily rising in many countries, likely due to the increasing proportion of women becoming pregnant following a variety of surgical procedures to the uterus, including multiple Caesarean sections. 2Placenta accreta spectrum disorders in the setting of prior Caesarean section deliveries arises from pregnancy implantation within the niche created by this surgery near the cervicoisthmic junction of the uterus. This early presentation as a "Caesarean section scar pregnancy" may be diagnosed by ultrasound methods. 3Ultrasound may be used to screen for, and to diagnose, pregnancies with anterior placenta previa that are complicated by placenta accreta spectrum disorders. The effectiveness of ultrasound in this context depends upon awareness of clinical risk factors, imaging quality, operator experience, gestational age, imaging modalities, and adequate bladder filling. 4Magnetic resonance imaging may complement multimodal ultrasound in the diagnosis and staging of placenta accreta spectrum disorders, though its effectiveness is currently limited by the relative contraindication to the use of a gadolinium contrast enhancing agent. 5Placenta accreta spectrum disorders are potentially life-threatening and demand regional interdisciplinary team-based care to deliver the safest outcomes for mothers and infants. Recommendations 1Pregnant women with clinical risk factors for placenta accreta spectrum disorders and anterior placenta previa at the 18–20-week fetal anatomical ultrasound should be referred for specialist imaging to diagnose or exclude this disorder (II-2A). 2Women with a diagnosis of placenta accreta spectrum disorder should be referred to a regional centre dedicated to the interdisciplinary management of this condition (II-3A). 3Protocol-based interdisciplinary care from diagnosis to surgery will optimize both intraoperative and postoperative outcomes (II-3A). 4Antenatal admission to a designated regional management centre may be indicated, especially following an antepartum hemorrhage, or based on considerations of geography or transport conditions (III-B). 5For otherwise healthy women with no history of vaginal bleeding, the optimal timing of elective Caesarean section delivery is around 34–36 weeks gestation (II-3B). Surgery should be considered earlier for repeated episodes of antepartum hemorrhage or contractions to reduce the risks of emergent unplanned surgery and should ideally be preceded by a course of corticosteroids to enhance fetal lung maturation if prior to 35+0 weeks gestation (II-2A). 6Regional anaesthesia may be safer than general anaesthesia as it is associated with reduced blood loss and is preferred by patients and their partners (II-2A). A massive transfusion protocol should be in place to respond to significant blood loss (III-B). 7Intravenous tranexamic acid should be administered at the commencement of surgery because it reduces intraoperative blood loss (I-A). 8Surgery should be performed in the modified lithotomy position, using midline access, sufficiently high so as to deliver the fetus without incising through the placenta; preoperative or intraoperative ultrasound can be used to guide the optimal uterine incision (III-B). No attempt should be made to remove the placenta if it shows no signs of separation as this may cause substantial hemorrhage (III-B). 9Presently there is insufficient evidence to recommend giving or withholding uterotonic drugs after delivery of the fetus (III-C). 10Presently there is insufficient evidence to recommend either approach (preoperative balloon placement or intraoperative ligation) designed to arrest blood flow from the internal iliac arteries prior to hysterectomy (II-1C). 11Focal central disease may be amenable to wedge resection, with complete removal of the placenta and repair of the uterus (the triple-P procedure) (II-3B). 12Classical Caesarean section and non-removal of the invasive placenta is an acceptable method of delivery but is associated with a protracted course of recovery and a persistent risk of hysterectomy (II-3B). 13Women who retain their fertility following a diagnosis of placenta accreta spectrum disorder should be instructed to access specialist ultrasound early in any future pregnancy so that all management options are available should a Caesarean section scar pregnancy be found (III-B). 14Prenatal diagnosis of the more severe forms of placenta accreta spectrum disorder, expressed as a Caesarean section scar pregnancy, may permit management using minimally invasive surgical techniques (II-3B). 15Though many women with placenta accreta spectrum disorder in well-resourced countries receive safe care, more research and knowledge translation are needed to effectively deliver all management options at the population-based level (III-B).

Objective To evaluate how hysterectomy affects the prescription of analgesic, psychotropic and neuroactive drugs in women with endometriosis using population‐based nationwide registers. Design Nationwide cohort study. Setting Swedish national registers, from 1 January 2009 to 31 December 2018. Population Women with benign disease undergoing a total hysterectomy during the 4‐year period of 2012–2015. Women with endometriosis (n = 1074) were identified and compared with women who did not have endometriosis (n = 10 890). Methods Prospectively collected data from two population‐based registers were linked: the Swedish National Quality Register of Gynaecological Surgery and the Swedish National Drug Register. Multivariate logistic regression was used as the main statistical method. Main outcome measures Changes in drug prescription over time for 3 years prior to and 3 years after hysterectomy. Results The frequency of prescription of analgesics was higher in women with endometriosis compared with women without endometriosis (OR 2.2, 95% CI 1.7–2.9). Among women with endometriosis, the prescription of analgesics (OR 1.0, 95% CI 0.8–1.2) did not decrease 3 years after hysterectomy compared with the 3 years prior to surgery. There was also a significantly higher rate of prescription of psychoactive (OR 1.6, 95% CI 1.4–2.0) and neuroactive drugs (OR 1.9, 95% CI 1.3–2.7) in the long term postoperatively. Conclusions In women undergoing hysterectomy, endometriosis was associated with a higher prescription rate of analgesics. In the endometriosis group the prescription of analgesic, psychoactive and neuroactive drugs did not decrease when comparing prescription rates for the 3 years prior to and the 3 years after surgery. Tweetable abstract In women with endometriosis, the long‐term prescription of analgesics did not decrease after hysterectomy., Tweetable abstract In women with endometriosis, the long‐term prescription of analgesics did not decrease after hysterectomy.

Although gynaecologists may be most familiar with the Pfannenstiel and midline laparotomy incisions, the Cherney and Maylard incisions are two alternative transverse abdominal incisions with unique advantages. Both provide superior pelvic exposure compared with the Pfannenstiel incision and offer significant benefits over a midline incision, such as decreased postoperative pain and improved wound healing. These incisions can be used for a multi-fibroid uterus, large pelvic masses, endometriosis, or when access to the retropubic or other pelvic spaces is needed. This video reviews surgically relevant anatomy of the anterior abdominal wall and provides a stepwise approach for performing both the Maylard and Cherney incisions using narrated illustrations and video footage. Surgical technique and anatomical considerations are highlighted throughout the video. This educational tool can be used as a reference for gynaecologists when performing these less commonly used incisions. When a laparotomy is indicated, the Maylard or Cherney incision can be considered as alternative approaches to a midline laparotomy in gynaecologic surgery, as both result in less postoperative morbidity while still providing excellent pelvic access.

Background The insertion of intrauterine devices (IUDs) is associated with a small increased risk of pelvic inflammatory disease and ascending infection, particularly in patients with risk factors. However, the risk of sepsis and toxic shock syndrome after insertion of an IUD is a rare event, described only through case reports in the literature. Case This report describes the case of a 40-year-old woman who presented with high fever, myalgias, and abdominal pain 2 days following the insertion of a levonorgestrel-releasing IUD. She was found to have group A Streptococcus infection in the vagina that led to a diagnosis of streptococcal toxic shock syndrome and required admission to the intensive care unit. Conclusion Toxic shock syndrome is a rare but potentially catastrophic complication after the insertion of an IUD. Health care providers should be conscious of this complication, particularly among patients presenting with fever and sepsis soon after IUD insertion.

Video abstract summary When a Pfannenstiel incision does not provide adequate exposure, the Maylard and Cherney incisions may be considered as alternatives to midline laparotomy due to their unique advantages. Both provide superior pelvic exposure compared to the Pfannenstiel incision while offering significant benefits over a midline incision such as lower post operative pain scores, decreased pulmonary complications, abdominal adhesions and improved cosmesis. These incisions can be used for a multi-fibroid uterus, endometriosis, or when access to the retropubic or other pelvic spaces is needed. This video reviews the surgically relevant anatomy of the anterior abdominal wall and provides a stepwise approach for performing both the Maylard and Cherney incisions using narrated illustrations and video footage. When a laparotomy is indicated, a Maylard or Cherney incision should be considered as both provide excellent pelvic exposure with all the benefits of a transverse abdominal incision.

Although uterine artery embolization has been established as a less invasive alternative to hysterectomy or myomectomy for the treatment of uterine leiomyomas, it is not devoid of life-threatening complications.We present the case of a 44-year-old patient who developed a severe systemic inflammatory response and acute respiratory distress syndrome 5 weeks after uterine artery embolization of a large multileiomyomatous uterus. Deterioration of her clinical status prompted an emergency hysterectomy that led to rapid improvement.Although fatalities from septicemia after uterine artery embolization have been reported, aseptic inflammatory responses to uterine degeneration can also lead to multiorgan failure. With recent studies refuting uterine size and leiomyoma location as risk factors, further research is needed to help select appropriate uterine artery embolization candidates.

Objectives To evaluate the surgical outcomes of a placenta accrete spectrum (PAS) operative approach at our institution. Methods A single-center retrospective chart review of all caesarean hysterectomies for PAS by an assigned surgeon over a 16-year period was performed. Surgical outcomes were described. Results The described surgical approach involves a midline skin incision, high midline hysterotomy, a rapid single-layer uterine closure with no placental removal attempt, constant cephalad uterine traction, and liberal choice of subtotal hysterectomy. A total of 47 patients were included: 19 (40.4%) accreta, 14 (29.8%) increta, and 14 (29.8%) percreta. The mean estimated blood loss was 1416±699cc and the mean operative time was 112±49min. Overall, 16 patients (34.0%) required blood transfusion and 4 patients (8.5%) required ICU admission. The average hospitalization was 5.2days, with no readmission within 30days. The use of internal iliac balloons did not result in a difference in blood loss or operative time (p> 0.05). Patients with placenta percreta had significantly more blood loss (p=0.02) and longer operative time (p=0.007) compared to both accreta and increta. Conclusions A simple, reproducible surgical model for planned caesarean hysterectomy for PAS is safe and exhibits a low complication rate. Further research is needed for developing a safe, reproducible, and standardized approach to the management of PAS.

The objective of this study was to evaluate the prevalence and extent of intra-abdominal adhesions at cesarean deliveries (CS) and their clinical relevance. We studied 490 cases of primary CS, 430 first repeat, and 106 cases of second or third repeat CS. Using a standard scoring system, the prevalence, extent, and consistency of adhesions were evaluated prospectively. We also examined the incision–delivery interval and the total operating time. At repeat CS, adhesions were found mainly between the uterus and the bladder or the abdominal wall. Dense adhesions to the bladder and to the abdominal wall were significantly more after ≥2 CSs (46.3% and 48.2%) than after one CS (29.8% and 25.6%). The adhesions on these areas were also more severe after ≥2 CSs than after one CS. There was a significant correlation between the adhesion score and the interval between the incision and delivery (r = 0.23, P

Background Prior to Caesarean section (CS) for morbidly adherent placenta (MAP), endovascular balloons are often placed prophylactically to minimize hemorrhage. However, there have been few reports describing complications of this intervention. Case A 41-year-old woman with a diagnosis of placenta percreta had endovascular balloon catheters placed before CS. Intraoperatively the right internal iliac artery ruptured, requiring vascular repair, multiple transfusions of blood and plasma, and admission to the intensive care unit. Conclusion Prophylactic placement of endovascular balloons to reduce maternal hemorrhage at CS for MAP may result in complications. Until more evidence becomes available supporting their use, safety guidelines must be instated in centres using them.

Objective Postpartum hysterectomy is an uncommon yet serious obstetric procedure associated with maternal morbidity and mortality. The objectives of our study were to assess the incidence of and indications for PH and to identify predictors of massive hemorrhage and coagulopathy. Methods We conducted a retrospective cohort study on all cases of PH performed at the Jewish General Hospital, McGill University, between 1992 and 2011. Data were collected from individual patient charts and logistics regression models were used to evaluate predictors of adverse events. Results Over a 20-year study period, there were 76 938 live births and 67 postpartum hysterectomies for an overall incidence of 0.87/1000. Although overall PH rates increased over time predominantly because of increasing rates of planned PH for placental abnormalities, there was a decrease in unplanned emergency postpartum hysterectomies. The main indications for PH were abnormal placentation (64.2%) and postpartum hemorrhage (26.9%). In adjusted analysis, the risk of requiring massive blood transfusion was increased when PH was performed after vaginal delivery or Caesarean section (OR 102.1; 95% CI 4.22 to 2468) and in association with postpartum hemorrhage (OR 9.1; 95% CI 1.3 to 64.3). The risk of massive hemorrhage was lower if occlusive balloons were placed antenatally in the uterine arteries (OR 0.13; 95% CI 0.03 to 0.68) and if PH was performed by a dedicated experienced surgeon (OR 0.23; 95% CI 0.06 to 0.86). Conclusion Although overall rates of PH are increasing, antenatal recognition of placental pathologies have resulted in fewer postpartum hysterectomies being done as emergencies. The use of occlusive balloons in the uterine arteries and having the procedure performed by a dedicated surgeon skilled in performing postpartum hysterectomy can reduce overall serious morbidity.

OBJECTIVE: To evaluate knowledge of vaginal atrophy among postmenopausal women (aged 55-65 years), using the Vaginal Health: Insights, Views a Attitudes (VIVA) survey. METHODS: An independent research organization conducted a quantitative Internet-based survey, to obtain information from 3520 women who were living in the UK, the USA, Canada, Sweden, Denmark, Finland or Norway. Findings from Canada are presented (n = 500). RESULTS: Almost half of Canadian respondents had experienced vaginal discomfort since they had stopped menstruating, most commonly (88%) vaginal dryness; over half (56%) reported having experienced symptoms for three years or longer. Seven percent would have attributed vaginal symptoms to vaginal atrophy. Eighty-two percent of women felt that vaginal discomfort would have a negative impact on various aspects of their lives, most notably sexual intimacy (72%), 'having a loving relationship with a partner' (39%) and 'overall quality of life' (30%). While the majority of women (66%) who had experienced vaginal atrophy eventually sought the assistance of a health-care professional, a considerable proportion (34%) did not. Most women (58%) had tried lubricating gels and creams to treat their symptoms, but many were less aware of specific means of treating the underlying cause. However, compared with systemic hormone replacement therapy, more women indicated that they would consider local estrogen therapy (e.g. vaginal tablets or creams). CONCLUSIONS: These data indicate that many postmenopausal women in Canada have a low understanding of vaginal atrophy. Medical practitioners should proactively initiate dialogue about this chronic condition with their patients, and discuss appropriate treatment options.

The decision to retain or remove the cervix when performing laparoscopic hysterectomy remains a topic of debate. A 38-year-old woman with multiple sclerosis underwent laparoscopic supracervical hysterectomy (LASH) for menometrorrhagia. Two weeks later, she was seen at our institution with septic shock. She underwent an exploratory laparotomy and was found to have cervical stump necrosis and peritonitis. Trachelectomy was performed. The postoperative course was prolonged by persistent fever, pleural effusion, and abscess collections. Although rare, cervical stump necrosis is a possible complication of LASH.

To describe the gynecologic history of women with inflammatory bowel disease.Questionnaires were sent to the 1000 women age 20-60 who had been hospitalized for inflammatory bowel disease at the Cleveland Clinic Foundation during 1989-1993. There were 692 responses, and those from 662 women who had undergone surgery for inflammatory bowel disease were analyzed. Of the 117 women who had undergone hysterectomy, 85 responded to follow-up questionnaires.Three hundred sixty women had Crohn disease, 251 had ulcerative colitis, and 51 had inflammatory bowel disease of indeterminate or unknown type. Menstrual abnormalities were reported by 58%. Symptomatic vaginal discharge, reported by 40%, was more likely to occur in those with Crohn disease than with ulcerative colitis (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.47-2.99; P.001). Infertility was reported by 25% of the women in this series. Abdominal pain with sexual intercourse (50% overall) was more common in women with Crohn disease than in those who had ulcerative colitis (OR 1.64, 95% CI 1.13-2.40; P = .01), but pain with penetration (55% overall) did not differ statistically by type of inflammatory bowel disease. Half of the women reported the loss of pleasure or desire for sex. Ovarian cysts had been diagnosed in 39% of women and resulted in surgical treatment in 57% of these. One hundred seventeen women (18%) had undergone hysterectomy, 52 (44% of total) at age 35 or younger.Gynecologic conditions are common in women with inflammatory bowel disease, including menstrual abnormalities, vaginal discharge, infertility, and gynecologic surgery. All physicians providing care for women with inflammatory bowel disease should be familiar with the frequency and nature of concurrent gynecologic conditions.

Objective We sought to evaluate postsurgical adhesions in women of different races with or without keloids. Study Design This was a prospective study evaluating postsurgical adhesions after a cesarean delivery in 429 women with or without keloids. The outcome measures were the prevalence and extent of adhesions in women of different races with or without keloids. Results There was no difference in the prevalence of adhesions and adhesion score in various sites among women of different races. Compared with whites (0.5%), keloids were significantly more common in African Americans (7.1%; P = .007; odds ratio, 16.5) and in Asians (5.2%; P = .02; odds ratio, 11.9). Women with keloids were found to have more dense adhesions between the uterus and the bladder ( P = .028; 95% confidence interval, 0–12) and between the uterus and the anterior abdominal wall ( P Conclusion The prevalence and degree of postsurgical adhesions in women of different races are comparable. Women with keloids on the cesarean scar have increased adhesions between the uterus and the bladder and between the uterus and the abdominal wall.