Publications by authors named "Mara Sobel"

38 Publications

Endometrial cancer.

CMAJ 2021 Sep;193(36):E1423

Department of Obstetrics & Gynaecology (Sobel), Sinai Health System; Department of Obstetrics & Gynaecology (Sobel), Women's College Hospital; Department of Obstetrics & Gynaecology (Sobel, Simpson, Ferguson), University of Toronto; Department of Obstetrics & Gynaecology (Simpson), St. Michael's Hospital/Unity Health Toronto; Li Ka Shing Knowledge Institute (Simpson), Unity Health Toronto; Division of Gynecologic Oncology (Ferguson), University Health Network/Sinai Health System, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.202731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8443285PMC
September 2021

Diagnostic accuracy of Kleihauer-Betke (Kb) testing to predict fetal outcomes associated with fetomaternal hemorrhage: a retrospective cohort study.

J Perinatol 2021 Aug 18. Epub 2021 Aug 18.

Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada.

Objective: To evaluate the diagnostic and screening utility of Kleihauer-Betke (KB) testing as a triage tool in predicting adverse fetal outcomes associated with fetomaternal hemorrhage (FMH).

Study Design: Single center retrospective cohort study evaluated a primary composite outcome of fetal complications associated with FMH between KB-negative and KB-positive test groups. Screening tests for sensitivity, specificity, positive predictive value and negative predictive value were determined.

Results: 641 women (97%) had KB-negative and 22 (3%) had KB-positive tests. The primary composite outcome between KB-negative and KB-positive pregnancies was similar (30% vs. 36%, p = 0.54). Screening exhibited high specificity (97%), however, test sensitivity was poor (4%) with only moderate positive and negative predictive values (36.4 and 69.7%).

Conclusion: Fetal outcomes associated with FMH were not significantly different between KB-positive and KB-negative test cohorts; KB testing offers no diagnostic precision in the emergency triage evaluation of women with suspected FMH.
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http://dx.doi.org/10.1038/s41372-021-01185-5DOI Listing
August 2021

Effects of a Resident's Reputation on Laparoscopic Skills Assessment.

Obstet Gynecol 2021 Jul;138(1):16-20

Department of Obstetrics and Gynecology, University of Toronto, and the Department of Obstetrics and Gynaecology, Sinai Health System, Toronto, Ontario, the Department of Obstetrics and Gynaecology, Cumberland Regional Health Care Centre, Amherst, Nova Scotia, and the Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada.

Objective: To quantify the effect of a resident's reputation on the assessment of their laparoscopic skills.

Methods: Faculty gynecologists were randomized to receive one of three hypothetical resident scenarios: a resident with high, average, or low surgical skills. All participants were then asked to view the same video of a resident performing a laparoscopic salpingo-oophorectomy that differed only by the resident description and provide an assessment using a modified OSATS (Objective Structured Assessment of Technical Skills) and a global assessment scale.

Results: From September 6, 2020, to October 20, 2020, a total of 43 faculty gynecologic surgeons were recruited to complete the study. Assessment scores on the modified OSATS (out of 20) and global assessment (out of 5) differed significantly according to resident description, where the high-performing resident scored highest (median scores of 15 and 4, respectively), followed by the average-performing resident (13 and 3), and finally, the low-performing resident (11 and 3) (P=.008 and .043, respectively).

Conclusion: Faculty assessment of residents in gynecologic surgery is influenced by the assessor's knowledge of the resident's past performance. This knowledge introduces bias that artificially increases scores given to those residents with favorable reputations and decreases scores given to those with reputed surgical skill deficits. These data quantify the effect of such bias in the assessment of residents in the workplace and serve as an impetus to explore systems-level interventions to mitigate bias.
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http://dx.doi.org/10.1097/AOG.0000000000004426DOI Listing
July 2021

Diagnostic et traitement de l’adénomyose.

CMAJ 2021 May;193(18):E663

Département d'obstétrique et de gynécologie (Dason), Université de Toronto; Département d'obstétrique et de gynécologie (Sobel, Chan), Hôpital Mount Sinai, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.201607-fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8112635PMC
May 2021

Improving Medical Student Comfort and Competence in Performing Gynecological Exams: A Systematic Review.

Acad Med 2021 09;96(9):1353-1365

M. Sobel is assistant professor, Department of Obstetrics & Gynaecology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Purpose: Performing a gynecological exam is an essential skill for physicians. While interventions have been implemented to optimize how this skill is taught in medical school, it remains an area of concern and anxiety for many medical students. To date, a comprehensive assessment of these interventions has not been done. The authors conducted a systematic review of the literature on interventions that aim to improve medical student education on gynecological exams.

Method: The authors searched 6 databases (Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL Plus, Scopus, Web of Science Core Collection, and ERIC [Proquest]) from inception to August 4, 2020. Studies were included if they met the following criteria: focus on medical students, intervention with the purpose of teaching students to better perform gynecological exams, and reported outcomes/evaluation. Extracted data included study location, study design, sample size, details of the intervention and evaluation, and context of the pelvic exam. All outcomes were summarized descriptively; key outcomes were coded as subjective or objective assessments.

Results: The search identified 5,792 studies; 50 met the inclusion criteria. The interventions described were diverse, with many controlled studies evaluating multiple methods of instruction. Gynecological teaching associates (GTAs), or professional patients, were the most common method of education. GTA-led teaching resulted in improvements in student confidence, competence, and communication skills. Physical adjuncts, or anatomic models and simulators, were the second most common category of intervention. Less resource-intensive interventions, such as self-directed learning packages, online training modules, and video clips, also demonstrated positive results in student comfort and competence. All studies highlighted the need for improved education on gynecological exams.

Conclusions: The literature included evaluations of numerous interventions for improving medical student comfort and competence in performing gynecological exams. GTA-led teaching may be the most impactful educational tool described, though less resource-intensive interventions can also be effective.
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http://dx.doi.org/10.1097/ACM.0000000000004128DOI Listing
September 2021

Barriers and facilitators for cervical cancer screening among adolescents and young people: a systematic review.

BMC Womens Health 2021 03 23;21(1):122. Epub 2021 Mar 23.

Department of Obstetrics and Gynecology, Sinai Health System, Toronto, ON, Canada.

Background: Though cervical cancer is one of the leading causes of cancer-related death globally, its incidence is nearly entirely preventable. Young people have been an international priority for screening as this population has historically been under-screened. However, in both high-income and low-income countries, young people have not been screened appropriately according to country-specific guidelines. The aim of this systematic review was to systematically characterize the existing literature on barriers and facilitators for cervical cancer screening (CCS) among adolescents and young people globally.

Methods: We conducted a systematic review following PRISMA guidelines of three key databases: Medline-OVID, EMBASE, and CINAHL. Supplementary searches were done through ClinicialTrials.Gov and Scopus. Databases were examined from 1946 until the date of our literature searches on March 12th 2020. We only examined original, peer-reviewed literature. Articles were excluded if they did not specifically discuss CCS, were not specific to individuals under the age of 35, or did not report outcomes or evaluation. All screening, extraction, and synthesis was completed in duplicate with two independent reviewers. Outcomes were summarized descriptively. Risk of bias for individual studies was graded using an adapted rating scale based on the Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices.

Results: Of the 2177 original database citations, we included 36 studies that met inclusion criteria. The 36 studies included a total of 14,362 participants, and around half (17/36, 47.2%) of studies specifically targeted students. The majority of studies (31/36, 86.1%) discussed barriers and facilitators to Pap testing specifically, while one study analyzed self-sampling (1/36, 2.8%), one study targeted HPV DNA testing (1/36, 2.8%), and the remainder (4/36, 11.1%) were not specified. Our systematic review found that there are three large categories of barriers for young people: lack of knowledge/awareness, negative perceptions of the test, and systemic barriers to testing. Facilitators included stronger relationships with healthcare providers, social norms, support from family, and self-efficacy.

Conclusion: There are unique barriers and facilitators that affect CCS rates in adolescents and young people. Health systems and healthcare providers worldwide should address the challenges for this unique population.
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http://dx.doi.org/10.1186/s12905-021-01264-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989022PMC
March 2021

Diagnosis and treatment of adenomyosis.

CMAJ 2021 Feb;193(7):E242

Department of Obstetrics and Gynaecology (Dason), University of Toronto; Department of Obstetrics and Gynaecology (Sobel, Chan), Mount Sinai Hospital, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.201607DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034338PMC
February 2021

Residual Defects of the Anal Sphincter Complex Following Primary Repair of Obstetrical Anal Sphincter Injuries at a Large Canadian Obstetrical Centre.

J Obstet Gynaecol Can 2021 May 22;43(5):596-600. Epub 2021 Jan 22.

Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON; Division of Urogynaecology, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON.

Objectives: To determine the rates of residual anal sphincter defect following primary repair of obstetrical anal sphincter injury (OASIS), and to assess symptomatology in these patients.

Methods: A retrospective observational study of patients who underwent primary repair of an OASIS sustained at Mount Sinai Hospital from January 2016 to June 2017. Records were reviewed for demographic and obstetrical data, symptoms of anal incontinence (AI), and the results of endoanal ultrasonography (EA-US).

Results: One hundred and one women sustained an OASIS during the study period, of whom 53 had EA-US performed at Mount Sinai Hospital; 4 women were excluded from this analysis. There were 42 third-degree tears and 7 fourth-degree tears. EA-US revealed residual defects in 22 patients with third-degree tears and 5 patients with fourth-degree tears (52% vs. 71%; P = 0.44).  Twelve patients with third-degree tears and 4 patients with fourth-degree tears reported AI (29% vs. 57%; P = 0.20). EA-US revealed no evidence of a tear in 14 patients clinically diagnosed with third-degree tears and 1 patient clinically diagnosed with a fourth-degree tear (33% vs. 14%).

Conclusion: These data demonstrate deficiencies in diagnosis and repair of OASIS. Continued training for health care providers on identification and effective repair of OASIS may improve outcomes for women who experience this complication.
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http://dx.doi.org/10.1016/j.jogc.2021.01.011DOI Listing
May 2021

Interventions to Prevent and Treat Burnout in Obstetrics/Gynaecology: A Scoping Review.

J Obstet Gynaecol Can 2021 Apr 26;43(4):490-496. Epub 2020 Dec 26.

Department of Obstetrics & Gynecology, Sinai Health System, Toronto, ON.

Objective: Obstetricians and gynaecologists are among the highest risk specialties for burnout. There is growing evidence that physician burnout can be both prevented and reduced. We sought to characterize the evidence base for interventions related to the prevention and treatment of burnout in obstetrics and gynaecology DATA SOURCES: We conducted a scoping review following PRISMA guidelines of 5 databases: (Medline-OVID, EMBASE, CINAHL, ClinicalTrials.gov, and PsycInfo) from inception to March 17, 2020. Citations of relevant articles were hand-searched to maximize sensitivity.

Study Selection: All interventional study designs were included. The target study population was obstetrics and gynaecology residents, learners, or staff. Published conference posters, papers, and abstracts were eligible for inclusion.

Data Extraction And Synthesis: All extraction and descriptive analysis was completed by two independent reviewers. Outcomes were summarized descriptively. Appraisal was completed using the Cochrane Risk of Bias tool and Risk of Bias Assessment tool for Non-randomized Studies.

Results: Of the 1540 original database citations, 20 studies met our inclusion criteria. A total of 589 obstetrics/gynaecology participants were included. While there was an overall a lack of research in the field, there were several promising interventions that target residents. There were a combination of preventative interventions (e.g. yoga, nutritional programs, or narrative medicine initiatives) as well as treatments (e.g. counselling appointments or debrief sessions). The vast majority of these interventions focused on individual-specific interventions rather than structural changes. In addition, the majority of interventions appeared to be "proof of concept" and feasability-related studies, with many studies published as conference abstracts rather than peer-reviewed journal publications.

Conclusions: Institutions should continue to implement interventions that address burnout in obstetrics and gynaecology. Further research is required on long-term outcomes of interventions as well as structural strategies.
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http://dx.doi.org/10.1016/j.jogc.2020.12.011DOI Listing
April 2021

Grossesse intramurale fundique.

CMAJ 2020 Dec;192(50):E1830

Département d'obstétrique et de gynécologie (Chaikof, Hobson, Sobel), Université de Toronto; Département d'obstétrique et de gynécologie (Hobson, Sobel), Hôpital Mount Sinai, Toronto (Ont.).

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http://dx.doi.org/10.1503/cmaj.200181-fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759108PMC
December 2020

Counselling Patients for Trial of Labour after Cesarean (TOLAC) and Invasive Placentation: Are We Missing the Mark? The Importance of Local Data and Informed Choice.

J Obstet Gynaecol Can 2021 Mar 6;43(3):306-312. Epub 2020 Aug 6.

Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Faculty of Medicine, University of Toronto, Toronto, ON; Mount Sinai Hospital, Toronto, ON.

Objective: Rates of cesarean delivery are increasing, and these procedures carry potential complications, like the risk of invasive placentation, which increases with each cesarean. A trial of labour after cesarean (TOLAC) is a viable option for patients; however, it has been associated with uterine rupture, a complication with maternal and fetal risks. To better counsel patients considering TOLAC, we aimed to determine local uterine rupture rates and maternal and neonatal outcomes with TOLAC and compare these with outcomes related to invasive placentation.

Methods: A 4-year retrospective chart review was conducted at our tertiary centre of all patients with a history of a previous cesarean delivery. We assessed rates of TOLAC, vaginal delivery after cesarean (VBAC), and uterine rupture, as well as maternal and neonatal outcomes associated with invasive placentation. Cases of uterine rupture from 1988 to the present were also reviewed, and their outcomes were compared with those of invasive placentation.

Results: Our uterine rupture rate was 0.44% and VBAC rate was 73.8%. We identified 8 cases of uterine rupture since 1988 and 67 invasive placentas during the 4-year chart review. Invasive placentation was associated with a significantly increased risk of neonatal respiratory morbidity, hysterectomy, maternal complications, and longer length of maternal hospital stay when compared with uterine rupture.

Conclusion: While uterine rupture remains a potential complication of TOLAC, it is rare with overall excellent maternal and neonatal outcomes. Invasive placentation, the risk of which increases with cesarean delivery, carries potentially higher complication rates than uterine rupture. Local complication data is important for individual sites offering TOLAC. The implications of invasive placentation cannot be overlooked when counselling patients considering TOLAC.
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http://dx.doi.org/10.1016/j.jogc.2020.07.009DOI Listing
March 2021

Fundal intramural ectopic pregnancy.

CMAJ 2020 Oct;192(41):E1211

Department of Obstetrics and Gynecology (Chaikof, Hobson, Sobel), University of Toronto; Department of Obstetrics and Gynecology (Hobson, Sobel), Mount Sinai Hospital, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.200181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7588244PMC
October 2020

Patient reported experiences following laparoscopic prophylactic bilateral salpingo-oophorectomy or salpingectomy in an ambulatory care hospital.

Fam Cancer 2021 04 23;20(2):103-110. Epub 2020 Sep 23.

Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Room 6423, Toronto, ON, M5S 1B2, Canada.

Women at risk of developing ovarian cancer because of a BRCA1 or BRCA2 pathogenic variant are candidates for prophylactic bilateral salpingo-oophorectomy (BSO). While BSO surgeries are routinely performed, to our knowledge there are no studies that have examined patient-reported experiences following laparoscopic BSO performed in an ambulatory care setting. The objective of this study was to examine whether women undergoing prophylactic laparoscopic BSO felt they were adequately informed about post-operative outcomes. A telephone interview was conducted among 46 women undergoing laparoscopic BSO to collect detailed information regarding surgical outcomes, complications, symptoms, and time to return to daily activities. The average age at surgery was 45.0 years (range 34-66) and 67% of women underwent BSO prior to age 50. The mean reported hospital stay was 7.2 h (range 4-12 h) and at time of discharge, 78% of the women felt well enough to go home. None of the women required a readmission to hospital. Forty-three percent (n = 20) of the women did not feel well informed about what to expect post-operatively. Most of the patient-reported outcomes (including pain, vaginal bleeding, and nausea/vomiting) were expected and patient-reported menopausal symptoms were more common among women who were premenopausal at surgery. In terms of returning to regular activities, premenopausal women (n = 36) resumed sexual activity on average at 43 days (range 2-365), which is later than postmenopausal women (n = 15) at 19 days (range 7-30). On average, women returned to full-time work in 16 days (range 1-56 days). Despite patients receiving pre-surgery counselling, our findings suggest that there is a need to provide supplemental, reinforcing patient materials in preparing patients for what to expect after surgery.
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http://dx.doi.org/10.1007/s10689-020-00208-yDOI Listing
April 2021

Laparoscopic tuboplasty for mild distal tubal disease.

Fertil Steril 2020 06 5;113(6):1330-1332. Epub 2020 May 5.

Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Objective: To review tuboplasty techniques for alleviating fallopian tube blockage.

Design: A step-by-step explanation of the techniques that comprise tuboplasty-fimbrioplasty, salpingo-ovariolysis, and salpingostomy-with surgical video footage.

Setting: Academic medical center.

Patient: A 28-year-old G0 female patient with primary infertility and bilateral fallopian tube occlusion wanting to avoid in vitro fertilization.

Intervention(s): Tuboplasty and its component techniques of fimbrioplasty, salpingo-ovariolysis, and salpingostomy are demonstrated in a stepwise fashion for a case of mild tubal disease. Fimbrioplasty includes identifying the agglutinated or phimosed fimbrial end and gently opening it with fine forceps and blunt microdissection. Salpingo-ovariolysis is demonstrated with video and comprises: 1) surveying the anatomy; 2) applying traction to delineate the adhesions; and 3) transecting the adhesions with microsurgical scissors or electrosurgery. Finally, the steps of a salpingostomy are demonstrated, including: 1) identifying the length of the fallopian tube; 2) performing chromotubation to delineate tubal obstruction; 3) creating a salpingostomy at the terminal end; and 4) suturing open the salpingostomy site circumferentially to evert the edges.

Main Outcome Measure(s): Successful restoration of normal tubal anatomy and identification of the location of tubal occlusion to guide salpingostomy site placement.

Result(s): The fallopian tubes were assessed bilaterally and noted to have mild tubal disease and therefore were appropriate for tuboplasty. Normal tubal anatomy was restored bilaterally through salpingo-ovariolysis. Subsequent identification of the area of tubal occlusion bilaterally and salpingostomy were performed to create a patent fallopian tube able to pick up an oocyte from the ovary and facilitate fertilization.

Conclusion(s): Tubal reconstructive surgery remains an important option to offer patients who want to avoid in vitro fertilization and who have mild tubal disease.
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http://dx.doi.org/10.1016/j.fertnstert.2020.02.106DOI Listing
June 2020

Effect of a Surgical Teaching Video on Resident Performance of a Laparoscopic Salpingo-oophorectomy: A Randomized Controlled Trial.

J Minim Invasive Gynecol 2020 Nov - Dec;27(7):1545-1551. Epub 2020 Jan 23.

Department of Obstetrics and Gynaecology, University of Toronto (Drs. Norris, Gagnon, Jacobson, Sobel, and Shore); Department of Obstetrics and Gynaecology, Division of Gynecologic Surgery and Pelvic Medicine, St. Michael's Hospital (Dr. Shore), Toronto, Ontario. Electronic address:

Study Objective: To assess the effect of a surgical teaching video on junior resident knowledge and performance of a laparoscopic salpingo-oophorectomy (LSO).

Design: Randomized controlled trial.

Setting: Urban tertiary care academic obstetrics and gynecology department.

Patients: First- and second-year gynecology residents.

Interventions: Access to an education video on LSO for 1 week before performing this surgery in the operating room.

Measurements And Main Results: Twenty-four junior residents were recruited and randomized to either the educational video group or traditional residency training group. All participants completed a demographic survey and knowledge questionnaire before performing an LSO, which was video-recorded. Video recordings of surgical performance were analyzed using the Objective Structured Assessment of Technical Skills (OSATS; 20 points) and an LSO-specific tool (30 points). Participants completed a self-assessment questionnaire before completing the procedure. The primary outcome measure was the difference in OSATS scores. The secondary outcomes were the knowledge questionnaire scores and self-assessed confidence scores. There were no significant differences between demographic variables of the 2 groups. The primary outcome revealed no significant differences in mean (standard deviation) OSATS scores (10.64 [2.05] vs 11.55 [1.85], p = .3) or LSO-specific tool scores (16.45 [2.68] vs 17.85 [2.63], p = .24). However, there was a significant difference in mean knowledge scores between the video and the traditional training (8.42 [0.79] vs 7.11 [1.36], p = .01) groups. In addition, residents in the video group had more confidence in their knowledge of pelvic anatomy (3.83 [0.39] vs 3.00 [1.00] out of 5.00, p = .04).

Conclusion: For junior learners, the use of an LSO video improved knowledge and confidence in anatomy but did not translate to improved surgical performance in the operating room. Surgical videos are a useful adjunct and complement hands-on technical teaching.
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http://dx.doi.org/10.1016/j.jmig.2020.01.010DOI Listing
February 2021

Management of ovarian cancer risk in women with pathogenic variants.

CMAJ 2019 08;191(32):E886-E893

Department of Obstetrics and Gynaecology (Walker), University of Toronto; Department of Obstetrics & Gynaecology (Walker, Jacobson, Sobel), Women's College Hospital; Department of Obstetrics & Gynaecology (Jacobson, Sobel), Sinai Health System, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.190281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6690830PMC
August 2019

Graduating Obstetrics and Gynaecology Residents' Readiness for Practice: A Cross-Sectional Survey Study.

J Obstet Gynaecol Can 2019 Sep 31;41(9):1268-1275.e4. Epub 2019 May 31.

Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.

Objective: This study sought to evaluate the self-reported and program director-reported comfort of graduating Canadian obstetrics and gynaecology residents in independently performing various surgical skills.

Methods: A Web-based survey was distributed to four cohorts of graduating obstetrics and gynaecology residents across Canada (2014-2017). Residents were asked to indicate their comfort level with independently performing 34 core surgical procedures by using a five-point Likert-type scale. A similar survey was sent to program directors. Comfort scores for residents and program directors were compared using quantitative and qualitative methods as appropriate (Canadian Task Force Classification II-3).

Results: Resident and program director survey response rates were 168 of 320 (52.5%) and 20 of 48 (41.7%), respectively. Residents were "comfortable" or "very comfortable" performing 7 of 13 (54%) gynaecology and 4 of 6 (67%) obstetrics List A procedures independently. Program directors reported that residents were "comfortable" or "very comfortable" performing 10 of 13 (77%) gynaecology and 4 of 6 (67%) obstetrics List A procedures. Compared with program directors, residents reported lower comfort with certain minimally invasive and obstetrics List A procedures (P < 0.05). Differences in comfort when performing several List A procedures were related to training program size and plans to pursue fellowship. Qualitative analysis revealed several major and minor themes supporting the dichotomy between residents' lack of comfort and program directors' expectation of comfort.

Conclusion: Graduating residents were not comfortable performing many core surgical procedures independently. Additionally, program directors believed that trainees were more comfortable than they reported, and comfort varied according to program size and future fellowship plans. The new competency-based curriculum is an opportunity to address this gap.
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http://dx.doi.org/10.1016/j.jogc.2019.03.001DOI Listing
September 2019

N 366 - Prise en charge gynécologique du cancer du sein et de l'ovaire héréditaire.

J Obstet Gynaecol Can 2018 11;40(11):1511-1527

Toronto (Ont.).

Objectif: La présente opinion de comité énumère les recommandations pour la prise en charge gynécologique des femmes ayant reçu un diagnostic de syndrome du cancer du sein et de l'ovaire héréditaire (CSOH) en ce qui a trait au dépistage, à la contraception, à la chimioprophylaxie, aux facteurs à considérer pour la fertilité, à la chirurgie de réduction du risque et aux soins post-ovariectomie.

Utilisateurs Cibles: La présente opinion de comité s'adresse aux gynécologues oncologues, aux gynécologues généralistes, aux médecins de famille, aux conseillers en génétique, aux infirmières autorisées, infirmières praticiennes, aux résidents et aux autres fournisseurs de soins.

Population Cible: Les femmes adultes (18 ans et plus) présentant une mutation des gènes BRCA1 ou BRCA2 ou d'autres gènes associés au cancer de l'ovaire. DONNéES: Pour la revue de la littérature, les bases de données Medline, Cochrane et PubMed ont entre autres été interrogées. Les termes de recherche des Medical Subject Headings utilisés ont été BRCA ET gynaecology management [prise en charge gynécologique], hormone replacement therapy [hormonothérapie substitutive], risk reduction [réduction des risques], chemoprophylaxis [chimioprophylaxie] et fertility [fertilité], et les recherches ont ciblé les articles publiés entre janvier 2010 et octobre 2017. La recherche de publications s'est déroulée de juillet à octobre 2017. Au total, 183 études ont été sélectionnées, et 101 ont été utilisées.

Valeurs: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs principaux. Le Conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version finale avant publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) [tableau 1]. L'interprétation des recommandations fortes et conditionnelles (faibles) est décrite dans le tableau 2. Le résumé des conclusions peut être fourni sur demande. AVANTAGES DéSAVANTAGES, ET COûTS: Nous pouvons nous attendre à une diminution des risques allant jusqu'à 90 % chez les femmes prédisposées au CSOH qui subissent une salpingo-ovariectomie bilatérale de réduction du risque. Les méfaits associés à la ménopause précoce iatrogène sont compensés par les avantages découlant de la réduction du risque. En réduisant l'occurrence de cancers des trompes, de l'ovaire et du péritoine, nous pouvons nous attendre à des économies dans le système de santé. MIS à JOUR: Une revue des données probantes sera menée cinq ans après la publication de la présente opinion afin de déterminer si une mise à jour complète ou partielle s'impose. Cependant, si de nouvelles données probantes importantes sont publiées avant la fin du cycle de cinq ans, le processus pourrait être accéléré afin que certaines recommandations soient mises à jour rapidement.

Commanditaire: Cette directive clinique a été élaborée à l'aide de ressources financées par la Société des obstétriciens et gynécologues du Canada.
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http://dx.doi.org/10.1016/j.jogc.2018.09.001DOI Listing
November 2018

No. 366-Gynaecologic Management of Hereditary Breast and Ovarian Cancer.

J Obstet Gynaecol Can 2018 11;40(11):1497-1510

Toronto, ON.

Objective: This Committee Opinion outlines the gynaecologic management recommendations for women diagnosed with hereditary breast and ovarian cancer syndrome (HBOC) with respect to screening, contraception, chemoprophylaxis, fertility considerations, risk-reducing surgery, and post-oophorectomy care.

Intended Users: This Committee Opinion is designed for gynaecologic oncologists, general gynaecologists, family physicians, genetic counsellors, registered nurses, nurse practitioners, residents, and health care providers.

Target Population: Adult women (18 years and older) with a pathogenic germline variant in the BRCA1, BRCA2, and other ovarian cancer-associated genes.

Evidence: While reviewing evidence, databases searched include Medline, Cochrane, and PubMed. Medical Subject Heading search terms used include BRCA AND gynaecology management, hormone replacement therapy, risk reduction, chemoprophylaxis, fertility from 01/2010 and 10/2017. Literature search was begun 07/2017 and finalized 10/2017. In total 183 studies were identified, and 101 were used.

Validation Methods: The content and recommendations were drafted and agreed upon by the principal authors. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework (Table 1). The interpretation of strong and conditional (weak) recommendations is described in Table 2. The Summary of Findings is available upon request.

Benefits, Harms, And Costs: We may expect a risk reduction of up to 90% in women predisposed to HBOC who undergo risk-reducing bilateral salpingo-oophorectomy. The harms of iatrogenic premature menopause are offset by the benefits of risk reduction. By minimizing potential tubal/ovarian/peritoneal cancers, we can expect savings to the health care system.

Guideline Update: Evidence will be reviewed 5 years after publication to decide whether all or part of the opinion should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

Sponsors: This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada.

Recommendations:
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November 2018

Diagnosing ovarian cancer.

CMAJ 2018 10;190(42):E1259

Department of Obstetrics and Gynecology (Walker, Sobel), Faculty of Medicine, University of Toronto; Department of Obstetrics and Gynecology (Walker, Sobel), Mount Sinai Hospital, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.180499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6199160PMC
October 2018

Anémie gravidique se manifestant par une glossite aiguë.

J Obstet Gynaecol Can 2019 Apr 21;41(4):406. Epub 2018 Sep 21.

Université de Toronto, Toronto (Ont.).

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http://dx.doi.org/10.1016/j.jogc.2018.01.034DOI Listing
April 2019

Anemia in Pregnancy Presenting as Acute Glossitis.

J Obstet Gynaecol Can 2019 04 21;41(4):405. Epub 2018 Sep 21.

University of Toronto, Toronto, ON.

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http://dx.doi.org/10.1016/j.jogc.2017.12.014DOI Listing
April 2019

Evaluation of Obstetrics & Gynecology Ultrasound Curriculum and Self-Reported Competency of Final-Year Canadian Residents.

J Obstet Gynaecol Can 2018 12 13;40(12):1580-1585. Epub 2018 Sep 13.

Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON.

Objective: Ultrasonography in obstetrics and gynaecology (OB/GYN) is a vital component of patient assessment, diagnosis, and management. Standards for Canadian obstetrician-gynecologists' ultrasound skills are limited and vague. The primary objective was to audit the current curriculum administered to Canadian OB/GYN residents. The secondary objective was to understand self-perceived competency of final-year residents in performing OB/GYN ultrasound. We also sought to identify perceived barriers to incorporation of ultrasound into practice.

Methods: A cross-sectional questionnaire, distributed to two cohorts of final-year Canadian OB/GYN residents, asked about ultrasound training they received and their perceived competency with respect to specific ultrasound skills. Respondents also answered questions on possible perceived obstacles to independently using ultrasound after graduation.

Results: All Canadian residency programs were represented among the 81 respondents out of the possible 167 participants (49%). Ultrasound training varied in its delivery and quantity. The majority of training time was dedicated to obstetrics, with minimal focus on gynaecology. Self-reported competency for obstetric ultrasound was high, whereas that for gynaecologic ultrasound was variable. The main barrier to incorporating ultrasound into future practice was lack of adequate training.

Conclusions: Canadian OB/GYN programs lack standardisation of ultrasound training. The imbalance in training between OB/GYN ultrasound may influence the low levels of self-reported competency in gynaecologic skills in residents. Standardization of ultrasound education and increasing gynaecologic ultrasound training in residency are the necessary first steps in preparing OB/GYN graduates to use ultrasound.
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December 2018

Arteriovenous Malformation Following Conservative Management of Cervical Pregnancy.

J Obstet Gynaecol Can 2018 09 11;40(9):1186-1189. Epub 2018 Jul 11.

Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, ON; Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON. Electronic address:

Background: Medical management using potassium chloride feticide and methotrexate is often the first-line approach to cervical pregnancies.

Case: A 25-year-old woman presenting with a cervical ectopic pregnancy was unsuccessfully managed with conservative therapy, resulting in an arteriovenous malformation requiring a laparoscopic hysterectomy.

Conclusion: Conservative management of ectopic pregnancies is the treatment of choice for young women looking to preserve fertility. However, medical management is not without risk, and this case illustrates one such complication.
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http://dx.doi.org/10.1016/j.jogc.2018.02.018DOI Listing
September 2018

Adnexal torsion.

CMAJ 2018 06;190(25):E769

Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.180020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6019344PMC
June 2018

Implementation of a Same-Day Discharge Protocol Following Total Laparoscopic Hysterectomy.

J Obstet Gynaecol Can 2018 01 18;40(1):29-35. Epub 2017 Aug 18.

Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON.

Objective: Previous studies have demonstrated that outpatient total laparoscopic hysterectomy (TLH) is both safe and feasible. Our objective was to decrease length of stay for patients undergoing TLH by implementing a same-day discharge protocol at two Canadian teaching hospitals.

Methods: We conducted a prospective cohort study assessing length of stay (primary outcome), perioperative complications, and readmission rates over a 12-month period following implementation of a same-day discharge protocol for TLH. These data were compared with pre-intervention baseline data collected retrospectively over a 12-month period immediately before protocol introduction. Our protocol consisted of patient education, instructions for perioperative care, and close follow-up.

Results: In the year prior to our protocol, 256 TLHs were performed. Forty-seven patients (18.3%) were discharged the same day, 191 patients (74.5%) were discharged on the first postoperative day, and 18 patients (7%) were admitted for 2 or more days. In the year following implementation, 215 patients underwent TLH of which 129 were enrolled in our study. The overall outpatient hysterectomy rate during that time period was 62% (134/215 patients). Among study participants, 102 patients (79.1%) were discharged the same day, 22 patients (17.0%) were discharged on the first postoperative day, and 5 patients (3.9%) were admitted for 2 or more days. There were no significant differences in perioperative complications or readmission rates and patient satisfaction scores were high.

Conclusion: Implementation of a same-day discharge protocol successfully increased the rate of outpatient TLH without impacting patient safety. This protocol was acceptable to both surgeons and patients and can be easily adapted for use at other centres.
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January 2018

Surgical Management Algorithm for Caesarean Scar Pregnancy.

J Obstet Gynaecol Can 2017 Aug 7;39(8):619-626. Epub 2017 Jun 7.

Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON.

Objectives: To report our experience with the management of Caesarean scar pregnancy (CSP) in the first trimester and to develop a unique treatment algorithm allowing physicians to customize their management based on clinical patient characteristics.

Methods: A retrospective review of 12 patients diagnosed with CSP between December 2012 and June 2016 was conducted in a tertiary care hospital in Toronto. All patients were diagnosed with CSP by transvaginal ultrasound using radiologic criteria. Patients were initially treated with an ultrasound-guided embryocidal injection when fetal heart activity was present. Next, patients underwent medical management with systemic multidose methotrexate (MTX) or surgical management using a laparoscopic or transcervical approach depending on CSP characteristics.

Results: The mean age at diagnosis was 35.6 years. The median number of previous CSs was one. The mean serum human chorionic gonadotropin level was 59 938 IU/L. The mean GA at presentation was 8+1 weeks. Two-thirds of patients received medical management with systemic multidose methotrexate. Of these, 50% required additional surgical treatment for the resolution of their CSP. One-third of patients underwent primary surgical treatment, resulting in complete resolution of CSP with no complications. Given the improved outcomes of surgical management in our series, we suggest a treatment algorithm that tailors the surgical approach, either laparoscopic or transcervical, to the characteristics of the CSP.

Conclusion: This constitutes the largest case series of CSP in Canada. Based on our results, CSP can be safely and effectively managed using the suggested surgical algorithm, which accounts for individual patient characteristics.
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August 2017

Selective progesterone receptor modulators (SPRMs) for uterine fibroids.

Cochrane Database Syst Rev 2017 Apr 26;4:CD010770. Epub 2017 Apr 26.

Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, 700 University Ave - 3rd Floor, Toronto, ON, Canada, M5G 1Z5.

Background: Uterine fibroids are smooth muscle tumours arising from the uterus. These tumours, although benign, are commonly associated with abnormal uterine bleeding, bulk symptoms and reproductive dysfunction. The importance of progesterone in fibroid pathogenesis supports selective progesterone receptor modulators (SPRMs) as effective treatment. Both biochemical and clinical evidence suggests that SPRMs may reduce fibroid growth and ameliorate symptoms. SPRMs can cause unique histological changes to the endometrium that are not related to cancer, are not precancerous and have been found to be benign and reversible. This review summarises randomised trials conducted to evaluate the effectiveness of SPRMs as a class of medication for treatment of individuals with fibroids.

Objectives: To evaluate the effectiveness and safety of SPRMs for treatment of premenopausal women with uterine fibroids.

Search Methods: We searched the Specialised Register of the Cochrane Gynaecology and Fertility Group, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and clinical trials registries from database inception to May 2016. We handsearched the reference lists of relevant articles and contacted experts in the field to request additional data.

Selection Criteria: Included studies were randomised controlled trials (RCTs) of premenopausal women with fibroids who were treated for at least three months with a SPRM.

Data Collection And Analysis: Two review authors independently reviewed all eligible studies identified by the search. We extracted data and assessed risk of bias independently using standard forms. We analysed data using mean differences (MDs) or standardised mean differences (SMDs) for continuous data and odds ratios (ORs) for dichotomous data. We performed meta-analyses using the random-effects model. Our primary outcome was change in fibroid-related symptoms.

Main Results: We included in the review 14 RCTs with a total of 1215 study participants. We could not extract complete data from three studies. We included in the meta-analysis 11 studies involving 1021 study participants: 685 received SPRMs and 336 were given a control intervention (placebo or leuprolide). Investigators evaluated three SPRMs: mifepristone (five studies), ulipristal acetate (four studies) and asoprisnil (two studies). The primary outcome was change in fibroid-related symptoms (symptom severity, health-related quality of life, abnormal uterine bleeding, pelvic pain). Adverse event reporting in the included studies was limited to SPRM-associated endometrial changes. More than half (8/14) of these studies were at low risk of bias in all domains. The most common limitation of the other studies was poor reporting of methods. The main limitation for the overall quality of evidence was potential publication bias. SPRM versus placebo SPRM treatment resulted in improvements in fibroid symptom severity (MD -20.04 points, 95% confidence interval (CI) -26.63 to -13.46; four RCTs, 171 women, I = 0%; moderate-quality evidence) and health-related quality of life (MD 22.52 points, 95% CI 12.87 to 32.17; four RCTs, 200 women, I = 63%; moderate-quality evidence) on the Uterine Fibroid Symptom Quality of Life Scale (UFS-QoL, scale 0 to 100). Women treated with an SPRM showed reduced menstrual blood loss on patient-reported bleeding scales, although this effect was small (SMD -1.11, 95% CI -1.38 to -0.83; three RCTs, 310 women, I = 0%; moderate-quality evidence), along with higher rates of amenorrhoea (29 per 1000 in the placebo group vs 237 to 961 per 1000 in the SPRM group; OR 82.50, 95% CI 37.01 to 183.90; seven RCTs, 590 women, I = 0%; moderate-quality evidence), compared with those given placebo. We could draw no conclusions regarding changes in pelvic pain owing to variability in the estimates. With respect to adverse effects, SPRM-associated endometrial changes were more common after SPRM therapy than after placebo (OR 15.12, 95% CI 6.45 to 35.47; five RCTs, 405 women, I = 0%; low-quality evidence). SPRM versus leuprolide acetate In comparing SPRM versus other treatments, two RCTs evaluated SPRM versus leuprolide acetate. One RCT reported primary outcomes. No evidence suggested a difference between SPRM and leuprolide groups for improvement in quality of life, as measured by UFS-QoL fibroid symptom severity scores (MD -3.70 points, 95% CI -9.85 to 2.45; one RCT, 281 women; moderate-quality evidence) and health-related quality of life scores (MD 1.06 points, 95% CI -5.73 to 7.85; one RCT, 281 women; moderate-quality evidence). It was unclear whether results showed a difference between SPRM and leuprolide groups for reduction in menstrual blood loss based on the pictorial blood loss assessment chart (PBAC), as confidence intervals were wide (MD 6 points, 95% CI -40.95 to 50.95; one RCT, 281 women; low-quality evidence), or for rates of amenorrhoea (804 per 1000 in the placebo group vs 732 to 933 per 1000 in the SPRM group; OR 1.14, 95% CI 0.60 to 2.16; one RCT, 280 women; moderate-quality evidence). No evidence revealed differences between groups in pelvic pain scores based on the McGill Pain Questionnaire (scale 0 to 45) (MD -0.01 points, 95% CI -2.14 to 2.12; 281 women; moderate-quality evidence). With respect to adverse effects, SPRM-associated endometrial changes were more common after SPRM therapy than after leuprolide treatment (OR 10.45, 95% CI 5.38 to 20.33; 301 women; moderate-quality evidence).

Authors' Conclusions: Short-term use of SPRMs resulted in improved quality of life, reduced menstrual bleeding and higher rates of amenorrhoea than were seen with placebo. Thus, SPRMs may provide effective treatment for women with symptomatic fibroids. Evidence derived from one RCT showed no difference between leuprolide acetate and SPRM with respect to improved quality of life and bleeding symptoms. Evidence was insufficient to show whether effectiveness was different between SPRMs and leuprolide. Investigators more frequently observed SPRM-associated endometrial changes in women treated with SPRMs than in those treated with placebo or leuprolide acetate. As noted above, SPRM-associated endometrial changes are benign, are not related to cancer and are not precancerous. Reporting bias may impact the conclusion of this meta-analysis. Well-designed RCTs comparing SPRMs versus other treatments are needed.
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http://dx.doi.org/10.1002/14651858.CD010770.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478099PMC
April 2017

Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety.

Surg Endosc 2016 10 19;30(10):4499-504. Epub 2016 Feb 19.

Department of Obstetrics and Gynecology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.

Background: Answering telephone calls and pagers is common distraction in the operating room. We sought to evaluate the impact of distractions on patient care by (1) assessing the accuracy and safety of responses to clinical questions posed to a surgeon while operating and (2) determining whether pager distractions affect simulation-based surgical performance.

Methods: We conducted a randomized crossover study of obstetrics and gynecology residents. After studying a patient sign-out list, subjects performed a virtual salpingectomy. They were randomized to a distraction phase followed by quiet phase or vice versa. In the distraction phase, a pager beeped and subjects were asked questions based on the sign-out list. Accuracy of responses and the number of unsafe responses were recorded. In the quiet phase, trainees performed the task uninterrupted. Measures of surgical performance were successful task completion, time to task completion and operative blood loss.

Results: The mean score for correct responses to clinical questions during the distracted phase was 80 % (SD ±14 %). Nineteen residents (63 %) made at least 1 unsafe clinical decision while operating on the simulator (range 0-3). Subjects were more likely to successfully complete the surgical task in the allotted time under the quiet compared to distraction condition (OR 11.3, p = 0.03). There was no difference between the conditions in paired analysis for mean time (seconds) to task completion [426 (SD 133) vs. 440 (SD 186), p = 0.61] and mean operative blood loss (mL) [73.14 (SD 106) vs. 112.70 (SD 358), p = 0.47].

Conclusions: Distractions in the operating room may have a profound impact on patient safety on the wards. While multitasking in a simulated setting, the majority of residents made at least one unsafe clinical decision. Pager distractions also hindered surgical residents' ability to complete a simulated laparoscopic task in the allotted time without affecting other variables of surgical performance.
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October 2016

Angiogenic response of placental villi to heparin.

Obstet Gynecol 2011 Jun;117(6):1375-1383

From the Department of Obstetrics and Gynecology and the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Canada.

Objective: To estimate the angiogenic effect of heparin on human umbilical vein endothelial cells cultured in conditioned media from normal and severely pre-eclamptic human placental villi.

Methods: Normal first- and second-trimester floating placental villi were explanted in control conditions and increasing concentrations of heparin (unfractionated and low molecular weight heparin) across the clinical prophylactic and therapeutic range (0.025-25 units/mL). At 96 hours, the placenta-conditioned media was tested for angiogenic activity in a human umbilical vein endothelial cell in vitro angiogenesis assay. Total capillary-like tube length and number of branch points were determined from photographs that did not contain information about experimental conditions. The response of placenta-conditioned media from preterm severely preeclamptic pregnant women exposed to low molecular weight heparin also was assessed and compared with both preterm and term control groups.

Results: Unfractionated heparin significantly promoted angiogenesis (0.25 units/mL compared with control: relative branch points 185±32% [mean±standard error of the mean], P<.05), whereas low molecular weight heparin had no significant effect. Addition of unfractionated or low molecular weight heparin to first- and second-trimester placenta-conditioned media significantly promoted angiogenesis with the response to low molecular weight heparin more than double that of unfractionated heparin (low molecular weight compared with unfractionated heparin at 2.5 units/mL: relative branch points 930±158% compared with 398±90%, P<.05). Placenta-conditioned media from pregnancies with severe preeclampsia arrested angiogenesis in comparison with both preterm and term pregnancies and was not significantly restored by the addition of low molecular weight heparin.

Conclusion: Unfractionated and low molecular weight heparin promote in vitro angiogenesis in healthy first- and second-trimester placenta-conditioned media. The nonanticoagulant actions of heparin may be relevant to the prevention of severe preeclampsia.
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June 2011
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