Children with anorectal malformations (ARM) constitute a significant group within a pediatric surgery practice. It is important with female cases of anorectal malformations to consider the ...association of gynecologic anomalies, especially at the time of the definitive repair. However, it is critical to consider the association of such gynecologic anomalies when caring for patients with a cloacal anomaly. If not recognized, an opportunity to diagnose and treat such anomalies may be missed with the possibility of negative implications for future reproductive capacity. With the knowledge of the associated anomalies and long term sequelae, surgeons can provide better care for girls and important counseling for parents. Knowledge of reproductive related issues in females with cloaca allows the pediatric surgeon an opportunity both, to provide optimal surgical management in infancy, childhood, and into young adulthood and to collaborate medically and surgically with an experienced gynecologist in patients with more complex anatomic variations. Appropriate counseling for patients and families about potential reproductive concerns that may develop many years after the definitive surgical repair allows preparation and planning to preserve future fertility.
BACKGROUND AND OBJECTIVES:
Intrauterine devices (IUDs) are increasingly being used in adolescents and nulliparous women for contraception. Levonorgestrel IUDs also have beneficial effects on bleeding ...and pain. Although they are recommended for menstrual suppression in adolescents with disabilities, there are limited data on their use in this population. Our objective is to describe the characteristics and experiences of levonorgestrel IUD use in nulliparous children, adolescents, and young adults with physical, intellectual, and developmental disabilities.
METHODS:
A retrospective chart review was conducted for all nulliparous patients ages ≤22 with physical, intellectual, or developmental disabilities who had levonorgestrel IUDs placed between July 1, 2004, and June 30, 2014, at a tertiary-care children’s hospital. Descriptive statistical analysis and survival analysis were performed.
RESULTS:
In total, 185 levonorgestrel IUDs were placed in 159 patients with disabilities. The mean age was 16.3 (3.3; range of 9–22) years. Only 4% had ever been sexually active; 96% of IUDs were inserted in the operating room. IUD continuation rate at 1 year was 95% (95% confidence interval: 93%–100%) and at 5 years was 73% (95% confidence interval: 66%–83%). The amenorrhea rate was ∼60% throughout the duration of IUD use among those with available follow-up data. Side effects and complications were ≤3%.
CONCLUSIONS:
In this study, we provide evidence for the therapeutic benefit and safety of levonorgestrel IUD use in adolescents and young adults with physical, intellectual, and developmental disabilities. It should be considered as a menstrual management and contraceptive option for this population.
Intrauterine devices (IUDs) are highly effective at preventing pregnancy. Levonorgestrel (LNG) IUDs also have beneficial effects on menstrual bleeding and abdominal and pelvic pain. Although there ...are increasing data on use of IUDs for contraception in adolescents and for medical indications in adults, there are extremely limited data on LNG IUD use for medical indications in adolescents. Our objective is to describe the characteristics and experiences of LNG IUD use in nulliparous adolescents and young women using IUDs for medical indications.
We conducted a retrospective chart review of all nulliparous patients aged 22 years and younger who underwent LNG IUD insertion at a tertiary care children's hospital between July 1, 2004 and June 30, 2014 primarily for noncontraceptive indications. Descriptive statistical analysis was performed.
We identified 231 LNG IUDs placed in 219 nulliparous women for medical indications during this time period. Mean patient age was 16.8 years (±2.2). Only 41% reported ever being sexually active. IUD continuation rate at 1 year was 86%. The amenorrhea rate at 1 year was 51%. Approximately 80% of women reported improvements in menstrual bleeding and abdominal and pelvic pain. Side effects and complications were low.
This study provides evidence that LNG IUDs are effective, well-tolerated, and safe menstrual management options in young nulliparous women, including younger adolescents and those who have never been sexually active. This method is an excellent first-line therapy option for adolescents and young women for both contraceptive and noncontraceptive indications, regardless of age, parity, or sexual activity.
STUDY OBJECTIVELong-term gynecologic data are lacking to inform the care of patients with cloacal malformations. We seek to examine perceived sexual and reproductive health challenges of patients ...born with cloacal anomalies and characterize the experiences of patients as adults.DESIGN AND SETTINGVirtual semi-structured focus groups and single-participant interviews were conducted using an online video platform. Retrospective chart review was performed to abstract available demographics and surgical history.PARTICIPANTSAdult patients were contacted from a database of 143 patients born with cloaca who had been seen at or referred to a tertiary care pediatric colorectal center. Participants were recruited until data collection reached thematic saturation. Twenty patients aged 18-53 years participated in 5 focus groups and 3 single-participant interviews. The hospital IRB determined the research activities to be exempt from IRB review and oversight.INTERVENTIONS AND MAIN OUTCOME MEASURESInterviews and focus groups were transcribed and analyzed using the constant comparative method to identify themes regarding sexual and reproductive health and compared with medical and surgical history abstracted from chart review.RESULTSParticipants reported many perceived barriers to intercourse and intimacy including bowel and bladder continence management. All participants reported discussion of pregnancy and fertility with healthcare providers as important. Other common themes included concerns about independence and transitioning from pediatric to adult providers.CONCLUSIONAnorectal malformations are associated with sexual and reproductive health concerns. Patients seek guidance on family building, intimacy, and transition to adult care. Future quantitative study of these topics is needed to develop best practices for counseling and clinical management of these patients.LEVEL OF EVIDENCELevel VI.TYPE OF STUDYPrognosis Study.
Children with anorectal malformations (ARMs) constitute a significant group within a pediatric surgery practice. In females, the most common ARM is an imperforate anus with a rectovestibular fistula, ...followed by an imperforate anus with a rectoperineal fistula and then cloacal anomalies. Some malformations, such as an imperforate anus with a rectovestibular fistula, may seem straightforward, treated with a posterior sagittal anorectoplasty; however, it is vital to recognize the association with gynecologic anomalies. Girls with the most complex anorectal defect, cloacal malformation, have significant associated urological and gynecologic anomalies, which should be recognized and treated. An opportunity to diagnose and treat such anomalies may be missed in the newborn period or at the definitive surgery, unless the pediatric surgeon is aware of this association. With the knowledge of the associated anomalies and long-term sequelae, surgeons can provide better care for girls and important counseling for parents. Important gynecologic issues to consider may be divided into several categories, such as infancy, puberty, sexual intimacy, and obstetrical concerns. Knowledge of reproductive-related issues in females with ARMs allows the pediatric surgeon and their gynecology colleagues to provide optimal surgical management throughout infancy, childhood, and into young adulthood. Appropriate counseling for patients and families about potential reproductive concerns that may develop many years after the definitive surgical repair allows preparation and planning to preserve future fertility.
•What does this study add to the literature (required).•What is currently known about this topic? A large number of patients with cloacal malformation have associated gynecologic anomalies.•What new ...information is contained in this article? Girls with less complex ARM subtypes (such as rectoperineal and rectovestibular fistulas) have a high incidence of gynecologic anomalies. This incidence is significantly increased in the presence of a VACTERL association.
VACTERL association is defined by the presence of 3 or more anomalies in any of the following systems: vertebral, anorectal, cardiac, trachea-esophageal, renal, or limb. This study hypothesized that the presence of VACTERL association would correlate with an increased risk of gynecologic anomalies in patients with anorectal malformation (ARM).
This study is a cross-sectional, retrospective analysis from the prospectively collected, multicenter registry of the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The 834 female patients with ARM who were enrolled in the registry by January 1, 2020 were included in this study. The relationship of VACTERL association with presence of a gynecologic anomaly was evaluated with Fisher's exact test. The relationship of each VACTERL system with presence of a gynecologic anomaly was assessed in patients with cloaca, rectovestibular fistulas and rectoperineal fistulas. P-values reported were based on a 2-sided alternative and considered significant when less than 0.05.
834 patients with ARM underwent VACTERL screening and gynecologic evaluation with the three most common subtypes being cloaca (n = 215, 25.8%), rectovestibular fistula (n = 191, 22.9%) and rectoperineal fistula (n = 194, 23.3%). A total of 223 (26.7%) patients with ARM had gynecologic anomalies. VACTERL association was seen in 380 (45.6%) of patients with ARM. Gynecologic anomalies were present in 149 (39.1%) vs. 74 (16.3%) of subjects with vs. without VACTERL association (p < 0.001). VACTERL association did not significantly increase the risk of gynecologic anomaly in patients with cloaca and VACTERL (n = 88, 61.5%) vs. cloaca without VACTERL (n = 39, 54.2% p = 0.308). VACTERL association increased the risk of gynecologic anomalies in patients with rectoperineal fistulas (n = 7, 14.9% vs n = 9, 6.1% p = 0.014) and rectovestibular fistulas (n = 19, 31.1% vs. n = 13, 10.0% p<0.001). In patients with ARM who had a VACTERL association, when one of the associated anomalies was renal, there was an even higher risk of having an associated gynecologic anomaly (n = 138, 44.2% vs. n = 85, 16.3% p<0.001).
VACTERL association in patients with rectoperineal and rectovestibular fistulas correlates with an increased risk of gynecologic anomalies. The presence of VACTERL associated findings, especially renal, should prompt a thorough evaluation of the gynecologic system.
III. Retrospective comparative study
Background
Normative data from pelvic ultrasonography (US) of the pediatric female reproductive organs are outdated and limited by sample size.
Objective
The purpose of this study was to report ...normal uterine and ovarian volumes and endometrial stripe thickness in children and young adults and throughout the menstrual cycle in post-menarchal adolescents.
Materials and methods
Females ages 0 through 20 years who underwent pelvic US between January 2010 and May 2014 were identified. After excluding patients with pelvic and/or endocrine pathology, nomograms of uterine and ovarian volumes and endometrial thickness by age year were created. Data for patients ages 12 years and older with a recorded day of last menstrual period were used to create additional nomograms of volumes/thickness throughout the menstrual cycle. Student’s
t
-tests and linear regression were performed to assess differences in measurements between groups and association of volumes/thickness with age.
Results
During our study period, 5,647 patients underwent 6,953 pelvic US examinations. After further review, 907 examinations from 889 patients were included (mean age: 11.3±6.0 years). Mean pelvic US volumes (cm
3
) per organ were 25.5±27.0 (uterus), 4.5±4.7 (right ovary) and 4.0±4.1 (left ovary). Mean endometrial thickness was 4.5±3.7 mm. Right ovarian volume was significantly larger than the left (
P
=0.0126). Uterine volume, ovarian volume and endometrial thickness were significantly associated with age (
P
-values<0.0001). Plots of mean organ measurements with respect to week of menses are provided.
Conclusion
We report normal volumes of the uterus and ovaries and endometrial stripe thickness measured by pelvic US throughout childhood and adolescence with reference to the menstrual cycle. These values are significantly associated with age and vary visually by menstrual cycle week.
Young patients and their parents often are unsure about what represents normal menstrual patterns, and clinicians also may be unsure about normal ranges for menstrual cycle length and amount and ...duration of flow through adolescence. It is important to be able to educate young patients and their parents regarding what to expect of a first period and about the range for normal cycle length of subsequent menses. It is equally important for clinicians to have an understanding of bleeding patterns in girls and adolescents, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate young patients' conditions appropriately. Using the menstrual cycle as an additional vital sign adds a powerful tool to the assessment of normal development and the exclusion of pathological conditions.
Recurrence Rates for Pediatric Benign Ovarian Neoplasms Knaus, Maria E.; Onwuka, Amanda J.; Abouelseoud, Naila M. ...
Journal of pediatric & adolescent gynecology,
April 2023, 2023-Apr, 2023-04-00, Letnik:
36, Številka:
2
Journal Article
Recenzirano
To examine the recurrence rates of pediatric benign ovarian neoplasms
A retrospective review of females up to 21 years of age who underwent surgery for a benign ovarian neoplasm at 8 pediatric ...hospitals from January 2010 through December 2016 was conducted. Data include primary operation details, follow-up imaging, and reoperation details.
Four hundred and twenty-six females were included in our cohort, with a median age of 15 years at the time of the primary operation. Of the patients, 69% had a mature teratoma, 18% had a serous cystadenoma, and 8% had a mucinous cystadenoma. Two-thirds of patients underwent ovarian-sparing surgery. There were 11 pathologically confirmed recurrences (2.6%) at a median follow-up of 12.8 months. The pathologically confirmed recurrence was 10.5 per 100 person-months at 12 months (SE = 5.7) for mucinous cystadenomas and 0.4 months (SE = 0.4) for mature teratomas (P = .001). For half of the patients, the pathologically confirmed recurrences occurred by 12.8 months, and for 75%, they occurred by 23.3 months. There were no differences in reoperation or recurrence on the basis of initial procedure (ovary-sparing surgery vs oophorectomy).
We measured the pathologically confirmed recurrence rate for pediatric benign ovarian neoplasms in a large cohort. Oophorectomy was not protective against recurrence. Mucinous cystadenomas were at a greater risk of pathologically confirmed recurrence.
Müllerian anomalies include a fascinating constellation of congenital malformations. There is significant diversity in anatomic variants and their respective long-term sexual and reproductive ...outcomes. We review the current controversies in classification and management of vaginal, uterine, and fallopian tube anomalies.
Comparative trials of preoperative magnetic resonance imaging (MRI) and laparoscopic intraoperative evaluation have demonstrated a moderately well correlated prediction of anatomic description. Three-dimensional ultrasound technology appears to be equivalent to MRI in detecting uterine anomalies; however MRI is a consistently superior method of evaluating the vaginal and cervical anatomy. Despite advances in both modalities, care at an experienced center is most highly associated with an accurate preoperative diagnosis and a decrease in the number of inappropriate surgical procedures.Large case series continue to be the main vehicle by which treatment and surgical management of these unique anomalies are described and recommended. Case reports continue to provide information on novel approaches to improve operative techniques. In the absence of prospective studies, these series provide the only emerging information on the long-term sexual and reproductive function of women with vaginal and uterine anomalies.
Recent developments in three-dimensional ultrasonography and MRI improve our ability to accurately describe and diagnose female reproductive tract anomalies. With the description of new complex malformations, which do not fall into the recognized American Society of Reproductive Medicine, formerly American Fertility Society (AFS) classification system, questions arise regarding embryologic development upon which this classification system is based and support attempts to devise a new, comprehensive classification. Advances in surgical correction have expanded the options for the reconstructive surgeon when approaching a patient with an anomaly of the reproductive tract.
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