BACKGROUND:Adolescents appear to be at increased risk of mental illness during pregnancy and the first year postpartum, although most studies to date are small or limited to depression or self-harm. We aimed to compare the risks of psychiatric disorder diagnoses and adverse psychiatric outcomes during pregnancy and the first year postpartum between adolescents and adults. METHODS:In this retrospective, population-based cohort study, we used health administrative data from Ontario, Canada, to identify all singleton livebirth or stillbirths after 20 weeks of gestation between Jan 31, 2013, and March 31, 2021. We categorised births by the pregnant individual's age at conception: adolescent (aged <20 years) or adult (aged ≥20 years). The main outcomes of interest were any psychiatric diagnosis between conception and 1 year postpartum, based on a physician's diagnosis in an outpatient, emergency department, or inpatient setting, as well as adverse psychiatric outcomes (emergency department visit, inpatient admission, and self-injury). We used modified Poisson regression to compare adolescents and adults on the risk for outcome, generating relative risks (RRs) adjusted for sociodemographic characteristics, medical comorbidities, and parity. Young people with lived experience were involved in the study conduct and interpretation of findings. FINDINGS:The cohort comprised 992 729 births: 27 547 among adolescents and 965 182 among adults. Mean age at conception was 17·9 years (SD 1·2) for adolescents and 30·5 years (4·9) for adults. Adolescents were more likely to have a pre-pregnancy history of a psychiatric diagnosis than adults (12 625 [45·8%] vs 241 934 [25·1%]; standardised difference 0·44). A psychiatric disorder diagnosis in pregnancy or the first year postpartum was recorded in 10 973 (39·8%) adolescents and in 241 043 (25·0%) adults (adjusted RR 1·35 [95% CI 1·33-1·37]). 2485 (9·0%) adolescents and 15 013 (1·6%) adults visited the emergency department for a psychiatric reason during pregnancy or postpartum (adjusted RR 3·63 [95% CI 3·46-3·81]), 616 (2·2%) adolescents and 3795 (0·4%) adults had a psychiatric admission (3·67 [3·33-4·05]), and 320 (1·2%) adolescents and 1091 (0·1%) adults had an episode of self-injury (7·11 [6·12-8·26]). INTERPRETATION:Pregnant and postpartum adolescents are a distinct group at substantially increased risk of psychiatric diagnoses and adverse psychiatric outcomes. Targeted treatments to prevent and treat mental illness are urgently needed to improve outcomes in this population. FUNDING:University of Toronto.

Placenta accreta spectrum (PAS) is an obstetrical complication in which the placenta abnormally invades the uterine wall, increasing the risk of hemorrhage, surgical morbidity, and maternal mortality. Management is often complex and multidisciplinary, particularly when invasion extends beyond the uterus. For this reason, standardized guidelines are essential to support early diagnosis and coordinated care across specialties. Significant variations in clinical practice guidelines (CPGs) remain, especially between countries with differing levels of income. This systematic review evaluates national and international CPGs published within the last decade to identify areas of agreement, disagreement, and insufficient evidence across all stages of PAS care. To identify CPGs related to PAS, a comprehensive search of professional society websites, PubMed, the GIN Library, and the ECRI Guidelines Trust was conducted. Two independent reviewers evaluated the sources to extract relevant clinical recommendations, which were then sent to a panel of 15 to 18 experts who had authored their own PAS guidelines. During 2 rounds of structured feedback, the panel could comment on, clarify, or revise their own guidelines before the committee would evaluate them for consensus and sufficiency of evidence. Each guideline was categorized as demonstrating high agreement, poor consensus, or high levels of insufficient evidence. The data were visualized by quantifying the level of agreement and sorting each guideline into categories of epidemiology, diagnosis, antenatal management, surgical management, and postnatal care. A total of 18 articles from 14 national or international societies were included. There was high agreement on epidemiologic risk factors, diagnostic principles, and key elements of antenatal management. A history of cesarean delivery consistently emerged as a major risk factor, especially in patients with concurrent placenta previa. All guidelines supported ultrasound as the primary diagnostic tool, with most recommending standardized descriptors to enhance accuracy. Targeted second-trimester imaging was widely endorsed, with some guidelines supporting first-trimester screening for high-risk patients. There was also strong consensus surrounding antenatal management and the need for specialized care, emphasizing referral to tertiary centers with multidisciplinary expertise, adequate surgical and transfusion resources, and planned delivery around 34 to 35 weeks. In contrast, surgical and peripartum recommendations showed substantial variability and limited evidence, including uncertainty regarding optimal incision type, use of balloon occlusion catheters, anesthesia approaches, and conservative management strategies. Only 1 guideline offered specific recommendations for low- and middle-income countries. These findings indicate that while some aspects of PAS management, such as diagnosis and antenatal care, have a broad consensus, other areas remain under-investigated and lacking consensus. This is especially true for surgical and conservative management in the peripartum period and indicates a need for comparative research and international collaboration to develop standardization. In addition, PAS management in low- and middle-income countries, which often face resource limitations that require flexible and unique practices, is significantly limited. While further research and discussion are needed, this study provides a roadmap for global improvement in PAS management.

OBJECTIVE:To evaluate trends in hysterectomy case volume for placenta accreta spectrum (PAS) disorder over time and compare maternal outcomes between high- and low-volume centers. Specifically, we examined whether surgical volume influences severe maternal morbidity (SMM) and other key perioperative outcomes. METHODS:We conducted a population-based retrospective cohort study of patients aged 18-50 years who underwent hysterectomy for PAS in Ontario, Canada, from January 1, 2003, to January 1, 2022. Cases were identified using provincial administrative health databases. High-volume centers were defined as institutions performing ≥9 PAS hysterectomies annually, based on probability modeling and receiver operating characteristic analysis. The primary outcome was a validated composite measure of SMM, including massive transfusion, intensive care unit (ICU) admission, surgical complications, readmission, and length of hospital stay. RESULTS:Among 778 patients, 151 were treated at high-volume centers. These patients experienced significantly lower rates of SMM compared to those treated at low-volume centers (45.0% vs. 71.7%; adjusted relative risk [aRR] 0.59, 95% confidence interval [CI]: 0.49-0.72). Risks of massive transfusion (aRR 0.57, 95% CI: 0.47-0.70) and ICU admission (aRR 0.30, 95% CI: 0.15-0.58) were also markedly reduced. Length of hospital stay was shorter at high-volume centers (1.88 vs. 3.90 days; P < 0.0001). Each additional PAS hysterectomy performed in the prior year at a given institution was associated with a 3% reduction in SMM risk (aRR 0.97, 95% CI: 0.96-0.98). CONCLUSION:High-volume centers demonstrate significantly better maternal outcomes for PAS hysterectomy. These findings support centralizing PAS care to improve patient safety and surgical outcomes.

STUDY OBJECTIVE:To identify factors associated with ovarian-conserving surgery in children, to examine population trends in benign ovarian surgeries over 20 years, and to evaluate long-term risk of subsequent ovarian surgeries. METHODS:We conducted a population-based retrospective cohort study of females <18 years undergoing benign ovarian surgery in Ontario, Canada (2003-2022). Factors associated with ovarian-conserving surgery were identified with multivariable log-binomial regression. Surgical trends (ovarian-conserving surgery, laparoscopy, pediatric hospital utilization) were evaluated using the Cochrane-Armitage test. Cumulative incidences of subsequent surgeries were estimated with Kaplan-Meier analysis and compared using log-rank tests. RESULTS:Among 3452 children (median age 15 years), 2827 (81.9%) underwent ovarian-conserving surgeries and 625 (18.1%) oophorectomies. Ovarian-conserving surgery was more likely with laparoscopy (RR 1.40, 95% CI, 1.33-1.47), female surgeons (RR 1.04; 95% CI, 1.01-1.07), and nongynecologist (RR 1.04; 95% CI, 1.01-1.08), and less likely in rural patients (RR 0.93, 95% CI, 0.88-0.98) and younger children (RR 0.84, 95% CI, 0.75-0.94). Although rates of surgery remained stable, there was an increase in laparoscopy (63% to 83%, P < .0001), pediatric hospital use (32% to 56%, P < .0001), and ovarian-conserving surgeries (80% to 87%, P < .0001). Cumulative incidence of subsequent ovarian surgery rose with time after index operation, remaining higher after ovarian-conserving surgery than oophorectomy (P < .0001). CONCLUSIONS:Adoption of minimally invasive techniques and specialized pediatric care is increasing. Persistent risk of reoperation among all patients in this cohort highlights the need for strategies to ensure appropriate follow up for this at-risk group, promoting ovarian preservation, and equitable access to pediatric gynecologic expertise.

Background Ovarian dermoid cysts are benign germ-cell tumors commonly found in pediatric and adolescent patients. Laparoscopic ovarian cystectomy has become the preferred surgical approach over laparotomy due to its benefits of shorter hospital stay, reduced post-operative pain, and quicker recovery. However, there remains concern for higher rates of cyst rupture (and possible peritonitis) and future dermoid cyst recurrence, when compared to laparotomy. This systematic review and meta-analysis evaluates the existing evidence on these surgical methods to assess whether the shift to laparoscopy has led to these unintended outcomes. Methods A comprehensive literature search in five academic medical databases was conducted with an information specialist, using keywords and MeSH terms for ovarian dermoid cysts, laparotomy, laparoscopy, or minimally invasive surgery in children, from database inception to August 29, 2024. This study was exempt from Research Ethics Board (REB) approval. Randomized, quasi-randomized trials, and prospective/retrospective cohort studies were eligible. Two independent authors reviewed titles/abstracts, full texts, and extracted data, resolving conflicts with a third author as required. Risk of bias was assessed with appropriate tools. A meta-analysis using risk ratios with 95% confidence intervals was performed with a Mantel-Haenszel fixed-effect model. Heterogeneity among studies was assessed by I², with I2 > 50% interpreted as high degree of heterogeneity requiring random-effects modelling. Results 1021 title/abstracts were reviewed, with six studies eligible for inclusion (2000 – 2022; Canada, United States, Poland). In total, 492 (58%) patients underwent laparoscopy and 353 (42%) underwent laparotomy. For meta-analysis, five studies were included for cyst rupture and four studies were included for dermoid cyst recurrence. Random-effect meta-analysis (I2=58%) showed a significantly higher risk of cyst rupture with laparoscopy (RR = 2.47, 95% CI 1.40-4.37). Four studies reported on peritonitis, with no cases observed. Fixed-effect meta-analysis (I2 =5%) found no significant difference in dermoid cyst recurrence between laparoscopy and laparotomy (RR = 0.92, 95% CI 0.41-2.08). Conclusions Laparoscopy remains the preferred approach for the surgical management of ovarian dermoid cysts in children. Despite a higher risk of intraoperative cyst rupture, our systematic review highlights thatsubsequent post-operative peritonitis was not clinically observed. Further, dermoid cyst recurrence rates remained similar between laparoscopy and laparotomy, further encouraging the use of laparoscopy when possible. Limitations of our systematic review include the limited number of included studies, all of which were observational studies with small sample sizes, and the presence of unaccounted confounders such as cyst size, patient age and BMI, and varying indications for surgical management.

Importance:Placenta accreta spectrum (PAS) is a complex, life-threatening condition that demands a multidisciplinary approach involving obstetrics, maternal-fetal medicine, and various surgical and medical specialties. Effective management relies on multispecialty collaboration and consensus, supported by standardized protocols, to optimize outcomes, guide informed clinical decisions, and mitigate the risks associated with PAS. Objective:To examine clinical practice guidelines for PAS inclusive of high-income countries and low- to middle-income countries (LMICs) identifying areas of consensus and gaps in guidance. Evidence Review:A comprehensive search of PubMed, GIN Library, and ECRI Guidelines Trust identified all PAS-related clinical practice guidelines published from January 1, 2014, to January 31, 2024. Additional searches included professional societies' designated websites and cited references. Two independent reviewers screened the guidelines, resolving conflicts through cross-referencing. Initially, 2 independent reviewers provided structured review and feedback to refine, correct, or highlight areas of consensus, disagreement, or insufficient evidence. Any instances of nonagreement were adjudicated by majority panel agreement, arising from a panel of 15 to 18 experts, all authors of PAS guidelines. Agreement scores for each recommendation area (eg, epidemiology, diagnosis, and antenatal management) were categorized as high agreement (≥75%), poor consensus (<50% or ≥30% insufficient evidence), and high levels of insufficient evidence (≥50% of recommendations with insufficient evidence) based on a priori score criteria. Findings:A total of 14 guidelines from 18 articles from national and international societies were included. High agreement was noted in areas such as specialized expertise (100%), antenatal management (88.9%), diagnosis (76.9%), and epidemiology (75.0%). Poor consensus characterized cesarean hysterectomy management (38.5% insufficient evidence and 23.0% disagreement), conservative techniques (33.3% insufficient evidence and 11.1% disagreement), and fertility counseling (30.0% insufficient evidence and 10.0% disagreement). Despite the high risk of anemia, consensus was lacking on iron supplementation strategies. Recommendations for thromboembolism prevention varied, with some guidelines favoring pharmacologic interventions and others advocating for nonpharmacologic measures. Hemorrhage management and postnatal management recommendations, including iron supplementation and thromboembolism prevention, were characterized by high levels of insufficient evidence (55.6% and 57.1%, respectively). Only 1 article (5.6%) specifically addressed LMICs, highlighting substantial underrepresentation. Conclusions and Relevance:This systematic review of PAS guidelines identified significant discrepancies and insufficient evidence in key aspects of care. The findings underscore the urgent need for further research and quality measures to enhance standardized approaches and improve patient outcomes. The limited availability of recommendations applicable to LMICs highlights the critical need for tailored guidance that accounts for resource constraints and clinical access challenges unique to these settings.

OBJECTIVES:Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss that interferes with physical, social, emotional, or material quality of life. Several societies, including the Society of Obstetricians and Gynecologists of Canada (SOGC) and North American Society for Pediatric and Adolescent Gynecology (NASPAG), have created algorithms to guide investigations and management. We aim to evaluate the extent to which primary care providers (PCPs) initiate first-tier guideline investigations and management before specialist referral. METHODS:A retrospective review of adolescents referred to pediatric and adolescent gynaecology (PAG) for HMB over a 2-year period was conducted. Patient demographics, investigations, and management initiated by the referring PCPs were extracted. These investigations were compared with SOGC and NASPAG guidelines to assess completion of first-tier investigations. In addition, diagnosis, investigations, and management initiated by the PAG team at the first visit was captured. RESULTS:In total, 242 patients were included for review. The minority of referrals included all first-tier investigations defined by SOGC or NASPAG (34.3% and 16.1%, respectively). Despite this, 80% of adolescents were started on a treatment modality by their PCP. Commonly prescribed treatments included oral combined hormonal contraceptives (44%) and non-steroidal anti-inflammatories (43%). After PAG consultation, the majority of adolescents completed first-tier investigations (SOGC 87% and NASPAG 67%). CONCLUSIONS:The study provides an understanding of how PCPs are investigating, managing, and referring adolescents with HMB and the potential impact on decision-making at first PAG consultation. This serves to inform collaboration between PCPs and PAG providers, with the goal of promoting judicious use of health care resources and timely care.

Background Hormonal Intrauterine Devices (IUDs) are important contraceptives and treatment for adolescent menstrual disorders. However, uptake may be limited in adolescents in the clinic setting for concerns that it may be painful and anxiety-provoking. Pediatric and Adolescent Gynecology at SickKids Hospital offers IUD insertion under anesthetic in the operating room (OR) but wait times are long. The primary goal of this study is to assess the implementation of an out-of-OR sedation program for IUD insertion on wait times. Secondary goals are to assess if a sedation program increases the likelihood of selecting an IUD, reduces anxiety and provides a positive insertion experience. Methods This is a retrospective review of IUD insertions in a tertiary institution in 3 settings: clinic, OR and a sedation clinic. OR cases occurred between June 2022 - June 2023, and sedation cases from June 2023 - June 2024. Wait times (days) were calculated from booking date to procedure date. Data was extracted from the electronic medical record. Patients under age 18 seeking IUD insertion were included. Exclusion criteria for sedation were BMI ≥30 due to anaesthetic limitations, severe developmental disability, and patients consented before roll out of sedation (June 2023). A brief survey is in progress for the sedation and clinic setting, to assess patient experience. Quality Improvement approval was obtained through SickKids Hospital. Descriptive statistics were used to summarize patient characteristics, with p-values ≤0.05 statistically significant. Analysis was performed using SPSS Statistics software. Results 83 patients met inclusion criteria, (N=9 clinic, N=37 OR, and N=37 sedation). There were significant differences between BMI, age, and sexual history for each setting. Due to anaesthetic protocols, BMI in the clinic and the OR was higher than in sedation (p = 0.007). Patients were older in the sedation group (M = 16.05) compared to the OR (M = 15.35), (p =0.044). Most patients in clinic (88.9%) were sexually active, higher compared to OR and sedation (p< 0.001). Procedure wait time was lower in sedation (M = 66.05 days) compared to the OR (M =172.00 days), (p< 0.001). There was no difference in diagnosis for OR vs sedation in terms of menstrual indications for IUD insertion. Primary sedatives were ketamine and midazolam for sedation (97%), and propofol and dexmedetomidine for OR (41%). Complication rates and comorbidities were similar between groups. Survey results are pending. Conclusions The sedation program significantly improves access to care with shorter wait times. This supports broader adoption of sedation programs to enhance gynecologic care for adolescents.

STUDY OBJECTIVE:To compare intraoperative cyst rupture, peritonitis, and cyst recurrence after ovarian dermoid surgery via laparoscopy versus laparotomy in pediatric and adolescent patients. METHODS:A comprehensive systematic review and meta-analysis was conducted following PRISMA guidelines and the Cochrane Handbook for Systematic Reviews. Five bibliographic databases (MEDLINE, Embase, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Web of Science) and 3 clinical trial registries were searched from inception to August 29, 2024. Eligible studies included quasi-randomized trials and prospective/retrospective cohort studies evaluating intraoperative cyst rupture, peritonitis, or cyst recurrence after laparoscopy versus laparotomy for ovarian dermoid surgery. Two authors independently performed title-abstract and full text screening and independently extracted data. Meta-analyses of cyst rupture and cyst recurrence after laparoscopy versus laparotomy for ovarian dermoid surgery were performed and presented in forest plots. Risk ratios for cyst rupture were pooled with a random-effects model, and for cyst recurrence were pooled with a fixed-effect model. Quality assessment was assessed using the Newcastle-Ottawa Scale. RESULTS:A total of 1021 studies were identified, with 6 studies included (2000-2022; Canada, United States, Poland). We included 481 (53.9%) patients who underwent laparoscopy, 353 (39.5%) who underwent laparotomy, and 59 (6.6%) who underwent laparoscopy converted to laparotomy. For meta-analysis, 5 studies were included for cyst rupture, and 4 studies were included for cyst recurrence. Random-effects meta-analysis demonstrated a significantly higher risk of cyst rupture with laparoscopy (RR = 2.47; 95% CI, 1.40-4.37). Fixed-effect meta-analysis found no significant difference in cyst recurrence between laparoscopy and laparotomy (RR = 0.92; 95% CI, 0.41-2.08). No cases of chemical peritonitis were observed. CONCLUSION:For the surgical management of ovarian dermoid cysts in children, laparoscopy may carry a higher risk of intraoperative cyst rupture compared to laparotomy, however our work highlights that subsequent post-operative peritonitis was not clinically observed and recurrence rates remained similar.

Background Leiomyomata are one of the most common causes of abnormal uterine bleeding in adult women. In adolescents however, structural causes of abnormal uterine bleeding are identified as the cause of abnormal bleeding in fewer than 1% of cases. To our knowledge, there have only been 27 cases of leiomyomata reported in the literature in this age group. Case We present two cases of adolescent patients with large leiomyomata. Our first patient presented at age 14 with heavy menstrual bleeding (HMB) and dysmenorrhea. She was also experiencing frequent urination and a sensation of incomplete bladder emptying. She was found to have a 8 cm intramural fundal fibroid and trialed on contraceptive patch, followed by Levonorgestrel (LNG) intrauterine device (IUD) with continued HMB and interval increase of fibroid size to 10.6cm. She underwent open myomectomy at age 16. Pathology revealed benign leiomyoma. Our second patient presented at 15 years old, with PMH of Von Hippel Lindau (VHL). Her chief complaint at this time was frequent menses, which had recently normalized to monthly before her initial consult with gynecology. She also required contraception and had a known small fibroid (1.4cm at presentation), incidentally found on imaging to monitor for solid tumors due to her history of VHL. Had LNG-IUD placed for contraception. Fibroid monitored with serial pelvic imaging, with interval increase to 10.0 cm over 2.5 years. She had a consult with gynecology oncology and decision was made to proceed with open myomectomy at age 18. Pathology revealed benign leiomyoma. Comments While leiomyomata are a rare cause of AUB or dysmenorrhea in adolescents, this case series reviews two patients who had large myomas as pathology. Both had interval growth during follow-up. We continue to believe that in the majority of cases of AUB in adolescents, imaging is not required to establish the diagnosis. However, if a patient has failed multiple lines of medical therapy, it is reasonable to obtain imaging to ensure there is no underlying structural etiology. It is also important to consider co-morbidities such as VHL, as these increase the risk of growing solid tumors such as leiomyomata. Though a rare finding in adolescents, it is reassuring that both cases revealed benign pathology.

Journal of Ultrasound in MedicineEarly View Clinical Letter Prenatal Diagnosis of the Unique Combination of Bilateral Congenital Cataracts With Strabismus Rachael Sampson MD, FACOG, Corresponding Author Rachael Sampson MD, FACOG [email protected] orcid.org/0009-0007-4980-3508 Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, SUNY Upstate Medical University, Syracuse, New York, USA Address correspondence to Rachael Sampson, MD, Clinical Assistant Instructor, SUNY Upstate Medical University, Regional Perinatal Center, Upstate Health Care Center, 90 Presidential Plaza, Syracuse, NY 13202, USA. E-mail: [email protected]Search for more papers by this authorSidney C. Davis BS, Sidney C. Davis BS Department of Obstetrics and Gynecology, Norton College of Medicine, SUNY Upstate Medical University, Syracuse, New York, USASearch for more papers by this authorLisa M. Allen RDMS, RDCS, RVT, FAIUM, Lisa M. Allen RDMS, RDCS, RVT, FAIUM Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, SUNY Upstate Medical University, Syracuse, New York, USASearch for more papers by this author Rachael Sampson MD, FACOG, Corresponding Author Rachael Sampson MD, FACOG [email protected] orcid.org/0009-0007-4980-3508 Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, SUNY Upstate Medical University, Syracuse, New York, USA Address correspondence to Rachael Sampson, MD, Clinical Assistant Instructor, SUNY Upstate Medical University, Regional Perinatal Center, Upstate Health Care Center, 90 Presidential Plaza, Syracuse, NY 13202, USA. E-mail: [email protected]Search for more papers by this authorSidney C. Davis BS, Sidney C. Davis BS Department of Obstetrics and Gynecology, Norton College of Medicine, SUNY Upstate Medical University, Syracuse, New York, USASearch for more papers by this authorLisa M. Allen RDMS, RDCS, RVT, FAIUM, Lisa M. Allen RDMS, RDCS, RVT, FAIUM Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, SUNY Upstate Medical University, Syracuse, New York, USASearch for more papers by this author First published: 02 January 2024 https://doi.org/10.1002/jum.16404Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat Open Research Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Supporting Information Filename Description jum16404-sup-0001-Supplemental_Video.movQuickTime video, 2.7 MB Video S1. At 33 weeks of gestation, the divergence of the cataractous lenses can be appreciated while synchronized movement of the globes is occurring. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. References 1Bell SJ, Oluonye N, Harding P, Moosajee M. Congenital cataract: a guide to genetic and clinical management. Ther Adv Rare Dis 2020; 1: 1–22. Google Scholar 2Bremond-Gignac D, Daruich A, Robert MP, Valleix S. Recent developments in the management of congenital cataract. Ann Transl Med 2020; 8: 1545. 10.21037/atm-20-3033 CASPubMedWeb of Science®Google Scholar 3Qin Y, Zhong X, Wen H, et al. Prenatal diagnosis of congenital cataract: sonographic features and perinatal outcome in 41 cases. Ultraschall Med 2022; 43: e125–e134. 10.1055/a-1320-0799 PubMedWeb of Science®Google Scholar 4Haargaard B, Wohlfahrt J, Fledelius HC, Rosenberg T, Melbye M. A nationwide Danish study of 1027 cases of congenital/infantile cataracts. Ophthalmology 2004; 111: 2292–2298. 10.1016/j.ophtha.2004.06.024 PubMedWeb of Science®Google Scholar 5Khazaeni LM. Ocular complications of congenital infections. NeoReviews 2017; 18: e100–e104. 10.1542/neo.18-2-e100 Google Scholar 6Shiels A, Bennett TM, Hejtmancik JF. Cat-Map: putting cataract on the map. Mol Vis 2010; 16: 2007–2015. CASPubMedWeb of Science®Google Scholar 7Martinez Sanchez M, Whitman MC. Genetics of strabismus. Front Ophthalmol 2023; 3:1233866. https://doi.org/10.3389/fopht.2023.1233866. 10.3389/fopht.2023.1233866 Google Scholar 8AIUM practice parameter for the performance of second-and third-trimester diagnostic obstetric ultrasound examinations. J Ultrasound Med 2019; 38: 3093–3100. 10.1002/jum.15163 PubMedWeb of Science®Google Scholar 9Bronshtein M, Zimmer E, Gershoni-Baruch R, Yoffe N, Meyer H, Blumenfeld Z. First- and second-trimester diagnosis of fetal ocular defects and associated anomalies: report of eight cases. Obstet Gynecol 1991; 77: 443–449. CASPubMedWeb of Science®Google Scholar Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

BackgroundOvarian neoplasms are uncommon in premenarchal children. Amongst this population, the proportion of malignant lesions is higher than rates seen in post-menarchal adolescents. Pediatric Gynecologists are challenged to pre-operatively risk-stratify neoplasms to help identify patients who can safely undergo ovarian sparing therapy. We present the case of a young child with a solid ovarian mass who underwent unilateral salpingoopherectomy. Final pathologic diagnosis revealed an uncommon, benign ovarian lesion with genetic etiology.CaseA 2-year 11-month-old was referred to the Pediatric Gynecology service with an asymptomatic left lower quadrant mass and ultrasound evidence of solid 3.9 × 2.9 × 4.6 cm ovarian lesion. On further history, her family described delayed speech and diagnosis of Autism Spectrum Disorder. They also reported frequent episodes of bloody stool and associated fussiness. MRI was obtained that confirmed a solid, vascular left adnexal mass measuring 4 × 4 × 3.5 cm. There was no internal fat or hemorrhagic components. In addition, a colonic polyp causing colo-colonic intussusception was noted. Tumor markers, including Ca 125, AFP, LDH, HCG, estradiol and inhibin, were within normal range. She was taken to the operating room jointly by Pediatric Gynecology and Gastroenterology. Given the mass had features suggestive of malignancy, we undertook a mini-laparotomy, left salpingoopherectomy and omental biopsy. Gastroenterology performed a colonoscopy with polypectomy. Pathology reported an ovarian vascular lesion most consistent with a capillary-lymphatic-venous malformation with no evidence of malignancy. Colonic polyps were in keeping with juvenile polyps. The patient was sent to Genetics to investigate for an underlying genetic cause. Testing demonstrated a pathogenic mutation in the PTEN gene consistent with a diagnosis of PTEN hamartoma tumor syndrome (PHTS).CommentsWe present the case of an uncommon ovarian neoplasm, colonic polyp and Autism Spectrum Disorder with unifying genetic etiology. PTHS is an autosomal dominant condition characterized by hamartomatous growths. To our knowledge, the ovarian lesion we describe has not previously been reported in a child with PHTS. Pediatric Gynecologists are challenged to build our library of potential ovarian neoplasms within the pediatric population. This will serve to advance our knowledge of potential pathologies and further inform risk-stratifying decision algorithms.

BackgroundHeavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with physical, social, emotional, or material quality of life. Several organizations, including NASPAG, have algorithms to guide initial investigations and management. We aim to evaluate the extent to which primary care providers (PCP) initiate first-tier guideline investigations and management prior to specialist referral.MethodsA retrospective review of adolescents referred to PAG for HMB over a 2-year period was conducted. Patient demographics, investigations and management initiated by the referring PCP were extracted. In addition, diagnosis, investigations, and management initiated by the PAG team at the first visit was captured. A modification of ‘first-tier’ investigations for HMB as per NASPAG Committee Opinion to reflect local practices was utilized, including CBC, ferritin, INR, PTT, and beta HCG for sexually active (SA) teens.ResultsThis is a work in progress. 638 patients were identified for chart review. To date, 258 charts (40%) have been reviewed, 124 patients meet inclusion criteria. Most patients are referred by Pediatricians (73%) or Family Physicians (19%). The average age at PAG consult is 13.8 years, and patients are an average of 2.3 years postmenarchal. Of first-tier recommendations, CBC (74%) and ferritin (56%) are most included. Coagulation testing (INR, PTT) is included in 17% referrals and beta HCG is included for 40% of SA teens. Inclusion of all first-tier investigations is uncommon (12%). Despite not being a recommendation, nearly one-third of referrals include a pelvic ultrasound. 27% of patients are referred with no completed investigations. Nearly two-thirds of patients are started on treatment by PCP prior to referral, most commonly iron supplementation (31%) and NSAIDs (31%). PAG ordered investigations for 38% of patients at first consult. Management of HMB is offered to 68% of patients at their initial visit (83% had at least one first-tier investigation ordered by PCP and 17% had no testing included). The minority of patients (12%) had treatment deferred to future visits after investigations ordered by PAG could be reviewed; of this group, two-thirds had a first-tier test included with referral and one-third no testing included.ConclusionsThe study provides an understanding of how PCP are investigating, managing and referring adolescents with HMB, and the potential impact on decision making at first PAG consultation. This serves to inform collaborative efforts between PCP and PAG providers, with the goal of promoting judicious use of healthcare resources and timely care.

BACKGROUND:Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome describes a spectrum of Mullerian anomalies characterized by uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal anomalies. We report the case of a neonatal complication secondary to OHVIRA syndrome with long-term follow-up, adding to the collective understanding of this syndrome.CASE SUMMARY:We present a 22-day-old female with an acute kidney injury secondary to post-renal obstruction from a large hydrometrocolpos. Multidisciplinary care facilitated timely diagnosis of OHVIRA syndrome and temporizing operative management. The patient was followed serially into her adolescence and ultimately underwent definitive excision of her vaginal septum.DISCUSSION:OHVIRA syndrome encompasses a broad spectrum of anatomical variation with different considerations in prepubertal and postpubertal patients. Multidisciplinary care allows for timely diagnosis and clinical decision-making within this complex patient population.

Pediatric and adolescent ovarian lesions are common and are frequently managed by both pediatric surgeons and pediatric and adolescent gynecologists. During the 2023 American Academy of Pediatric Section on Surgery meeting, an educational symposium was delivered focusing on various aspects of management of pediatric and adolescent benign and malignant masses, borderline lesions, and fertility options for children and adolescents undergoing cancer therapies. This article highlights the discussion during this symposium.

INTRODUCTION:Postnatal management of antenatally diagnosed ovarian cysts is not well-defined. The clinical course, management, and outcomes of patients with antenatally diagnosed ovarian cysts were reviewed. METHODS:Infants <1 year of age with antenatally diagnosed ovarian cyst managed at The Hospital for Sick Children between January 2017 and December 2021 were included. Patient charts were reviewed for postnatal ultrasound (US) images, management, clinical course and complications. Mixed linear regression analysis was used to model the change in cyst size over time. RESULTS:In total, 52 patients were included and 10 patients had no cyst identified at their first postnatal US. Of the remaining cases, 36% were simple/physiologic and 64% had complex features. Two underwent percutaneous aspiration while 40 patients were managed expectantly with most cysts (62%) resolving. The rate of resolution was significantly higher and faster for simple compared to complex cysts (84% versus 52%, p < 0.05). Cysts that persisted at the end of the study period (n = 14) had all decreased in size, with a rate of resolution similar to resolved cysts. Only one patient managed expectantly required urgent laparoscopy for salpingoophorectomy. CONCLUSION:Antenatally diagnosed ovarian cysts exhibit high rates of resolution with expectant management, supporting the safety and efficacy for expectant management for these patients. LEVEL OF EVIDENCE:III.

(Can J Anesth/J Can Anesth. 2023;70:1544–1546) Management of hemorrhage after cesarean delivery or cesarean hysterectomy is complex. Intraoperative red cell salvage (IOCS) is commonly used in other surgical settings and is increasingly used in obstetrics. The potential risks such as amniotic fluid embolism, bacteremia, sepsis, and coagulopathy in obstetrics remain poorly understood. This study assessed the use of IOCS in the management of placenta accreta spectrum (PAS) disorders.