With football season in its full glory, many of us may watch more than 100 huddles every weekend. The modern-era football huddle’s origin was traced back to Paul Hubbard, a quarterback for Gallaudet University, a school for the blind and deaf. To keep his team’s plays secret, Hubbard gathered his team off the line of scrimmage. Although secrecy was the stated reason, I would like to think enhanced communication amongst interested parties may have improved outcomes. Huddles became so important in football that just this year, Patrick Mahomes, Kansas City Chiefs’ Super Bowl–winning quarterback, honored Len Dawson, the recently deceased all-time great quarterback for the Chiefs, by recreating Dawson’s trademark “choir huddle.” Dawson, who is featured in the Pro Football Hall of Fame, is best known for his enhancement of an established communication tool.

Although communication is important in football, it is critical in the enhancement of patient safety. The safety huddle, defined by the Institute for Healthcare Improvement, is a short meeting involving interdisciplinary health care team members (no more than 10-15 minutes in duration) that proactively enables teams to focus on patient safety, thereby facilitating communication.

 The safety huddle is a key element of highly reliable health care systems. As anyone who regularly attends safety huddles can tell you, there is always a tendency for operational issues, more related to efficiency than safety, to creep into the safety huddle. Why wouldn’t all aspects of an operation be improved by enhanced team communication? Because of this, operational efficiency can be enhanced by a formal daily check-in.

When effectively used in the outpatient setting, huddles help to define
the following

Patients or procedures that might require extra time outside the standard appointment template

Optimization of resources, both human and technology

There are multiple ways to run a huddle. But to have buy-in from your teams to initiate the process, articulating anticipated value from the process will create the appropriate momentum. Oleg Tumarkin, director of Global Performance Improvement Inc, published a piece titled “The Effective Huddle,” estimating a 25% to 40% boost in productivity with the use of an effective huddle.

 Although the number seems optimistic, the theoretical advantages of an effective huddle should yield significant gains in every aspect of safety and operational efficiency. Tumarkin cites 3 ways a huddle can be impactful:

1. Performance: Individuals are forced to be thoughtful, plan ahead, analyze completed work, and share with team members. Huddles reduce workflow interruptions and are a foundation to the process of continuous
quality improvement.

2. Support for a learning environment: All organizations aspire to be considered a learning organization. In huddles, everyone learns from others’ experiences and learns to assess their own work—hopefully in a
safe environment.

3. Transparency: This is a characteristic often associated with effective teams and organizations. Huddles build trust through systematic interactions on a frequent basis. This trust allows an honest and effective evaluation
of performance.

There are 2 more intangible benefits to the daily huddle. The first is the ability to identify leaders, especially those who are introverted. Unlike standard meetings where some may participate out of proportion to the value of their contribution, the huddle, by nature of its structured process, allows all to participate equally. This not only allows but also mandates that all members share their ideas and performance outcomes. It also allows identification of those individuals, with the ability to address and solve problems in a timely manner. The second is using the brief amount of time to inspire your team. Although this may seem like a soft activity, it can be unifying. Again, let’s go back to the football paradigm. Most football huddles end with a clap of the hands or a single word, such as “team.” End your huddle with a few words of inspiration or gratitude.

As we move through a suggested template, keep in mind 2 things:

1. Skeptics might say we do this every day in an informal manner, but the truth is that anything less than a formal huddle will lead to missed issues, which could impact your operations;

2. There is no single best practice that will serve each setting equally.

Having observed huddles in both the inpatient and outpatient arenas across several sites in a single health care system, I would estimate approximately 90% of huddle content is identical with the remaining content tailored to the need of the individual site. As a matter of fact, one of the principles in the development of a huddle is to not be afraid to experiment in content, structure, and personnel.

1. Get physician/executive leadership buy-in. The team will not take the process seriously if they feel it is not worthy of the leader’s time.

2. Schedule the huddle for the same time every day. The huddle will not be credible or effective as an operational tool if it is often canceled, missed,
or ignored.

3. Do not let the huddle interfere with the work that needs to be done. Keep it short. In the present environment, everyone is likely busy. If the huddle takes 40 minutes and only decreases work by 20 minutes, it will fail. People must quickly recognize that the huddle makes their life easier.

4. Establish a leader. This does not always have to be the senior person in the room. Maybe a medical assistant or an ultrasound technician leads the huddle. Just make sure the huddle leader knows their role prior to the start of the huddle.

5. Leave time for emerging issues and ad hoc reports. Maybe you only need a weekly report on productivity or efficiency metrics.

6. Regularly reevaluate the huddle’s effectiveness. Again, this does not need to be the executive team, but representatives from all disciplines in your office. The frequency of evaluation should decrease as you discover what works for your office.

The huddle can be an efficient way to communicate across your entire office or department. This communication will create both a safer and more efficient environment. 

1. Shaikh U. Improving patient safety and team communication through daily huddles. Institute for Healthcare Improvement. January 29, 2020. Accessed November 8, 2022. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles

2. Stewart EE, Johnson BC. Improve office efficiency in mere minutes. 

3. The effective huddle. Global Performance Improvement Inc. 2022. Accessed November 8, 2022. https://gpicorporation.com/en/knowledge/huddle/

Articles

Not only for football and safety but also for productivity and efficiency.

The importance of huddles

Endometriosis is a poorly understood condition in which endometrial-like–tissue implants outside the uterus. The disease affects 10% of reproductive-age women and 90% of patients with chronic pelvic pain and infertility.1 The mechanism of implantation and associated pain development is still incompletely described.1 Stage and pain do not correlate well because pelvic pain can be inflammatory and neuropathic in nature, with a component of central sensitization of the nervous system.

 Patients with pelvic pain exhibit enhanced anterior insula glutamatergic neurotransmission and connectivity with the prefrontal cortex, meaning that even with full excision of disease, pain may persist.

Although expert opinion suggests that early diagnosis of endometriosis is key, diagnostic challenges in combination with the requirement for a surgical procedure for diagnosis contribute to a significant delay in treatment. In 2008, US health care costs for endometriosis were estimated at $4000 annually per affected patient.

 Delays in surgical diagnosis are thought to contribute to this high cost because patients without answers seek further care and expensive testing. 

Endometriosis can have serious effects on patients’ quality of life and fertility, leading to lost wages and lack of productivity. The average delay in diagnosis is approximately
7 years, preventing early treatment that can reduce chronic pain and stress on mental and emotional health.

One must remember that chronic pelvic pain can be multifactorial, so a comprehensive evaluation for all causes of the disease must be undertaken, not only gynecologic causes, but also other organ systems, including musculoskeletal, gastrointestinal, genitourinary, and psychological. Infectious diseases as well as immunological diseases, in which the contribution to pain is more poorly understood, must also be considered. Many of these can be identified using a careful history and physical to identify a “source” organ and
through imaging.

Because of the range of etiologies for pelvic pain, a broader work-up should always be performed to rule out other causes. However, when endometriosis is suspected, further action should be taken. Although advances in imaging (eg, MRI and gel-contrast dynamic ultrasound) and the development of predictive algorithms might help with a clinical diagnosis of endometriosis, no current technology can predict all stages of the disease.

 Laparoscopy for endometriosis began in the 1970s and remains the gold standard for diagnosis and treatment of endometriosis.

Given that medical therapies are generally well tolerated, most national organizations recommend a trial of medical therapy to give patients a shorter time to pain relief. Studies have shown that combined hormonal contraceptives, progestins, and gonadotropin-releasing hormone agonists are very effective at reducing pain related to endometriosis.

However, the study authors recommend having a low threshold for surgical evaluation. For persistent pain despite a short course of medical therapy (3-6 months), surgical therapy and reevaluation of other causes of pelvic pain is indicated. 

Careful patient assessment, physical examination findings, and imaging can help guide surgical management. Structural abnormalities such as adenomyosis, ovarian endometriomas, and deeply infiltrating endometriosis nodules indicate advanced disease and should expedite surgical referrals.

A comprehensive discussion regarding the limitations of surgery and continuing medical therapy and multidisciplinary treatments for pain after surgery should be had with the patient as part of preoperative counseling. Further, a discussion should take place that the finding of no endometriosis on laparoscopy and biopsy can help the physician and patient focus on identifying and treating other pain generators. The vast options for the medical suppression of endometriosis and the treatment of chronic pelvic pain are outside the scope of this manuscript but are nonetheless exceedingly important in the comprehensive management of the patient.

Both excision and ablation of endometriosis as a means of surgical treatment remain debated. A Cochrane systematic review showed an unclear benefit with excision vs ablation, although studies were extremely heterogeneous.

 Another systematic review showed significantly greater improvement in dysmenorrhea, dyschezia, and chronic pelvic pain with excision compared with ablation procedures.

A recent study looking at complete peritoneal excision resulted in a high level of pain relief for patients with and without endometriosis.

 Although this study is new and not comparable with patients who did not undergo surgery, the findings may shed light on the physiologic reasons why excision of the peritoneum can result in some level of pain decrease. The authors recommend performing excision surgery, with the goal being histologic diagnosis and full excision of deeply infiltrative endometriosis.

 Because lesions appear heterogeneous or can be microscopic in nature, a true diagnosis cannot be made without a biopsy. With deeply infiltrative endometriosis, the lesions extend beyond the surface of the peritoneum and require a full excision to remove.

The location and depth of lesions impact the excisional technique and the procedures performed. Endometriotic lesions are commonly found on the uterosacral ligaments, posterior cul-de-sac, and rectovaginal septum.9 The typical appearance of an endometriosis lesion is a superficial “powder-burn” implant that can be black, dark brown, or red hemorrhagic spots. Deeply infiltrating endometriosis (DIE) invades greater than 5 mm into the surrounding organ or peritoneal surface.

Because implants can be associated with underlying fibrosis, adhesions, and distortion of adjacent anatomy, resection must be performed with a clear understanding of anatomic structures and relevant anatomic planes, including the pararectal, paravesical, rectovaginal, retrorectal, and retropubic spaces 

The surgeon should be comfortable with retroperitoneal dissection and both blunt and sharp dissection, with and without energy sources for lesions that lie on vital structures. Note: Because of the contractile nature of endometriosis, even early-stage disease may come close to retroperitoneal structures, including the ureter 

Complete resection results in decreased pain and recurrence compared with incomplete resection of lesions. Complete resection, however, is associated with increased complication rates, so cases involving advanced disease require meticulous technique by surgeons with substantial experience in complex endometriosis

Cul-de-sac lesions are common in patients diagnosed with endometriosis, especially DIE. The cul-de-sac or the pouch of Douglas is the peritoneal cavity between the rectum and the posterior uterus. Partial obliteration of the cul-de-sac can occur when fibrotic endometriosis has fused the rectum to the posterior vagina, or complete obliteration can occur when fibrotic endometriosis obscures the plane between the cervicovaginal junction and the rectum, usually involving the uterosacral ligaments 

Careful dissection is needed to avoid damaging the rectum and ureters. Opening the pararectal spaces on both sides can help in dissection and restoration of normal anatomy. To open the pararectal space, an incision can be made either medially or laterally to the infundibulopelvic ligament. The ureter can be found most superficially at the bifurcation of the common internal iliac artery, and starting the dissection at the pelvic brim—where the anatomy is less distorted—can be beneficial. Early identification of anatomic structures and pelvic vasculature allows the surgeon to limit bleeding and complications.

To resect lesions deep in the posterior cul-de-sac, the rectovaginal space can be entered at the uterosacral ligaments and generously developed below the fibrotic adhesions before attempting to divide them. The plane between the vagina and the rectum is avascular and can be separated with a combination of blunt and sharp dissection, up to the levator ani if necessary. Creating this plane allows the surgeon to identify the safest place to sharply divide the adhesions between the rectum and the cervix. Dilute vasopressin solution injected into the cervix and uterus prior to dissection can limit bleeding. Once the rectum has been carefully separated, the surgeon can focus on removing endometriotic implants from the vagina and cervix with electrosurgical devices 

Ovarian endometriomas occur in 17% to 44% of patients with endometriosis.

 When treating endometriomas, the goals are to reduce pain, exclude malignancy, improve fertility, and preserve ovarian function.

Endometriomas occur when menstrual debris builds up and becomes encapsulated within ovarian tissue. The cyst does not have an epithelial lining and is considered a pseudocyst, which can make removal more difficult. Options for treatment include drainage, ablation, cystectomy, and oophorectomy. Aspiration and fenestration with ablation are surgical options; however, because of high recurrence rates with aspiration and lower effectiveness at reducing pain and improving fertility with fenestration, excision is preferred.

For women who desire ovarian conservation, ovarian cystectomy is favored. Use of vasopressin, hemostatic agents, and suturing to achieve hemostasis results in decreased collateral damage to surrounding ovary compared with electrosurgical methods. Oophorectomy is primarily performed if patients have recurrent cysts, are postmenopausal, or there is concern for malignancy. It is important to consider that bilateral oophorectomy without hormone replacement in those younger than 50 years plays a role in increasing risks of cardiovascular disease and all-cause mortality.

Endometriosis can affect the urinary system, and the bladder is the most affected site. In 36% of cases, the endometriosis is localized only to the bladder. Lesions generally evolve from the serosal surface to the mucosa, and the trigone and the dome are the most affected areas.

Prior to surgical management, it is important to rule out vesical malignancy and identify the specific location of the lesion, including distance from the ureter. Complete resection of these lesions has been associated with decreased recurrence and significant reduction of pain.

Treatment for the gynecologist typically involves partial cystectomy with full thickness incision. For lesions near the trigone, ureteral stents should be employed. Mobilization of the retropubic space can aid in visualization of the borders of the lesion. Closure of the cystotomy depends on the size of the lesion; however, as with repair of an inadvertent bladder injury, 2-layer closure using a 3-0 delayed absorbable suture can generally be utilized.

When endometriosis involves the rectosigmoid colon, the depth of invasion should be assessed. Disease severity can vary greatly, from superficial adhesions to full-thickness disease that penetrates the mucosa. When gastrointestinal involvement is suspected, MRI, gel-contrast ultrasonography, and colonoscopy with endoscopic ultrasound can help assess colonic involvement. For severe disease—including cases with multiple bowel implants, sigmoid involvement, lesions greater than 3 cm, and lesions that involve greater than 50% of the bowel circumference, or in cases with bowel stenosis—resection with reanastomosis is beneficial.

For more superficial cases, a shaving technique or discoid resection can be performed. A shaving technique can be implemented with sharp dissection of the implant down to the level of the muscularis. The bowel can then be oversewn perpendicular to the incision to avoid constriction of the bowel lumen. Barbed suture has been shown to be safe when suturing the bowel; however, traditional delayed absorbable sutures can also be used.

 In patients with smaller nodules that involve the mucosa, discoid resection can be considered, with closure in the same fashion.

In one study comparing the shaving technique, discoid resection, and segmental resection, the shaving group had a higher rate of recurrence of dysmenorrhea and dyspareunia, with similar rates of postoperative complications.

Lesions greater than 3 cm were associated with an increased risk of requiring bowel resection.

Integrity of the bowel after a rectovaginal dissection or bowel resection should be confirmed. In a “bubble test,” air is injected retrograde into the rectum, the sigmoid is occluded at the sacral promontory, and the pelvis is filled with sterile irrigant. Observing bubbles indicates an opening that must be addressed to prevent postoperative bowel leakage into the peritoneal cavity.

Endometriosis of the abdominal wall is rare but expected to increase with rising cesarean section rates.

 In most studies, cesarean section was the inciting surgery; however, cases following laparotomy and port-site endometriosis have also been described, as well as cases in patients with no history of prior abdominal surgery. Some studies show concurrent pelvic endometriosis, whereas others describe cases with no associated pelvic lesions.

Excision of the implant with complete margins is recommended to decrease risk of recurrence. Surgery may be booked with a general surgeon for closure if a large fascial defect is anticipated. Preoperative radioisotope injection to clearly identify small lesions has been described but is not well studied.

Extrapelvic endometriosis is a rare condition, representing 8.9% of endometriotic cases. The most common sites include the gastrointestinal tract, urinary tract, and distant organs including the lung, abdominal wall, liver, gallbladder, and pancreas. Thoracic endometriosis syndrome, although rare, is the most frequent extrapelvic type of endometriosis. Catamenial pneumothorax (recurrent pneumothorax associated with menstruation) is a possible manifestation. Video-assisted thoracoscopic surgery to remove all endometriotic lesions and pleurectomy or pleurodesis are recommended
treatment strategies.

Although surgical management of endometriosis is considered the gold standard for diagnosis and treatment of the disease, it should not be considered curative of all chronic pelvic pain. Pelvic pain can be both neuropathic and inflammatory in nature, with central sensitization of the nervous system and prefrontal cortex remodeling leading to continued pain even after excision of all endometriosis.

Discouragingly, 30% of patients have chronic pain that is not responsive to surgery, and 50% develop recurrent symptoms within 5 years of treatment.5 One study found high pain recurrence rates after operative laparoscopy in patients aged 19 to 29 years, despite having no identifiable lesions on
repeat surgery.

Patients with continued pain after surgery need comprehensive multidisciplinary management for their symptoms, including continued medical suppression of menses, consultations with pelvic floor physical therapists and pain interventionalists, and referrals to other subspecialists for the other organ systems involved.

To improve diagnosis of endometriosis and preoperative planning, imaging with an experienced sonographer can identify areas of endometriotic disease through site-specific tenderness, fixed ovaries, a negative “sliding sign,” and evidence of DIE nodules in the anterior and posterior compartments.

Further, advances in MRI-acquisition protocols have improved diagnosis for DIE and enhancing lesions.

 Improved imaging can be diagnostic and also provide guidance for the surgeon in removing all the disease.

Endometriosis is a heterogeneous disease that inflicts a significant quality-of-life and cost burden on patients. Laparoscopy remains the gold standard for diagnosis and treatment. Although it is not curative for all chronic pelvic pain, laparoscopy should be a start in the approach to patients with suspicious symptoms. We recommend a comprehensive work-up for all causes of pelvic pain, and when endometriosis is suspected, preoperative planning with imaging, when applicable, and excision of all disease. When DIE is suspected, treatment should include referral to a subspecialist with experience in complex endometriosis. 

Zondervan KT, Becker CM, Missmer SA. Endometriosis. 

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As-Sanie S, Kim J, Schmidt-Wilcke T, et al. Functional connectivity is associated with altered brain chemistry in women with endometriosis-associated chronic pelvic pain. 

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Nnoaham KE, Hummelshoj L, Kennedy SH, Jenkinson C, Zondervan KT; World Endometriosis Research Foundation Women’s Health Symptom Survey Consortium. Developing symptom-based predictive models of endometriosis as a clinical screening tool: results from a multicenter study. 

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Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton-Smith P. Laparoscopic excision versus ablation for endometriosis-associated pain: an updated systematic review and meta-analysis. 

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Misal M, Girardo M, Wasson M. Improved pain and quality of life after complete pelvic peritonectomy. 

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Lee HJ, Park YM, Jee BC, Kim YB, Suh CS. Various anatomic locations of surgically proven endometriosis: a single-center experience. 

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Cao Q, Lu F, Feng WW, Ding JX, Hua KQ. Comparison of complete and incomplete excision of deep infiltrating endometriosis. 

Zanelotti A, Decherney AH. Surgery and endometriosis. 

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Levy B, Barbieri R. Endometriosis: management of ovarian endometriomas. UpToDate. Accessed October 12, 2022. 

https://www.uptodate.com/contents/endometriosis-management-of-ovarian-endometriomas

Maccagnano C, Pellucchi F, Rocchini L, et al. Diagnosis and treatment of bladder endometriosis: state of the art. 

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Atlas of Pelvic Anatomy and Gynecologic Surgery

Chamsy D, King C, Lee T. The use of barbed suture for bladder and bowel repair. 

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Afors K, Centini G, Fernandes R, et al. Segmental and discoid resection are preferential to bowel shaving for medium-term symptomatic relief in patients with bowel endometriosis. 

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Laparoscopy remains the gold standard for diagnosis and treatment of the disease.

Surgical treatments for endometriosis

Uterine anomalies are associated with higher rates of pregnancy complications, including spontaneous abortion, ectopic pregnancy, preterm labor, malpresentation, and abruption. Obstetricians should understand the embryology, incidence, classifications, and management of patients with uterine anomalies during pregnancy.

The process of uterine and vaginal development begins in the first trimester. The bilateral müllerian (paramesonephric) ducts develop into the uterus, fallopian tubes, cervix, and proximal vagina. These ducts fuse and internal canalization of each duct will produce 2 channels divided by longitudinal septum. The septum will typically resorb throughout the second trimester. The urogenital sinus will also separate into the distal vagina and urethra. Resorption anomalies represent persistence of the longitudinal uterine or vaginal septum. Transverse anomalies include obstructing vaginal septa or
cervical atresia.

Classification and diagnosis of uterovaginal anomalies

The American Society for Reproductive Medicine (ASRM) Müllerian Anomalies Classification (MAC) system, updated in 2021,

 categorizes the range of anomalies by descriptive terms and includes müllerian agenesis, cervical agenesis, unicornuate uterus, uterus didelphys, bicornuate uterus, septate uterus, longitudinal vaginal septum, transverse vaginal septum, and complex anomalies. An online interactive classification is available online. To view the ASRM MAC 2021 online, please scan the QR code.

To differentiate uterine anomalies, imaging or direct visual examination of the contour of external uterus and the endometrial cavity is required. To differentiate the bicornuate from septate from arcuate uterus, ideally, a line can be drawn from cornua to cornua. If the external contour indents more than 10 mm, the uterus is bicornuate. If there is less than 10-mm external contour indentation and less than a 10-mm fundal cavitary indentation with the leading angle of the indentation greater than 90°, the diagnosis is arcuate uterus. If the indentation extends more than 10 mm into the cavity and the leading angle is less than 90°, the diagnosis is septate uterus.

Optimal tests include 3D transvaginal ultrasound, MRI, saline sonohysterography, or laparoscopy or laparotomy combined with hysteroscopy or hysterosalpingogram (HSG; 

 Less sensitive diagnostic tests include 2D transvaginal ultrasound, clinical assessment at cesarean section, as well as hysteroscopy or HSG without external uterine contour evaluation.

 A pregnancy will alter the contour of the uterine fundus and repeat imaging after resolution of the pregnancy is more likely to result in an accurate diagnosis.

Studies using optimal imaging have identified uterine anomalies in
5.5% to 9.8% of the general population, in 16.7% of those with recurrent miscarriage, and in 24.5% of those with a history of miscarriage and infertility.

 A study of uterine evaluation during cesarean sections noted that 5% were found to have a uterine anomaly: 71.0% were septate uteri, 19.4% were bicornuate uteri, 6.4% were unicornuate uteri, and 3.2% were didelphic uteri.

Anorectal, cardiac, limb, ear, skeletal, and especially renal anomalies have all been commonly associated with müllerian anomalies. Obstetricians should have a low threshold to consider renal imaging, as they may be present in
30% of those with fusion anomalies.

Arcuate uterus is the most common anomaly identified, but it does not appear to be associated with a higher rate of infertility or miscarriage by prospective studies.

 In general, the arcuate uterus is considered a benign variant; however, the remaining uterine anomalies confer a significantly higher risk of obstetric complications. The incidence of preterm birth before
37 weeks is approximately 40% for patients with known uterine anomalies. The highest risk of preterm labor is associated with uterine didelphys (56%), unicornuate uterus (43%), bicornuate uterus (39%), and septate uterus (31%).

 Congenital uterine anomalies are also associated with increased risk of first and second trimester loss, cervical insufficiency, premature rupture of membranes, fetal malpresentation, fetal growth restriction, placental abruption, placenta previa, retained placenta, and cesarean birth
(

 For this reason, consultation with a maternal-fetal medicine specialist during pregnancy is recommended.

Limited data suggest that cervical length screening for short cervix (< 25 mm) and fetal fibronectin screening may be useful for predicting preterm birth in those with septate uteri. The data have not shown a consistent predictive benefit for those with unicornuate, didelphic, or bicornuate uteri.

Most studies of 17-hydroxyprogesterone caproate (17-OHPC) for prevention of premature birth did not include those with a history of congenital uterine anomalies. In a small retrospective cohort study of 48 women with congenital uterine anomalies, there was an equally high rate of recurrent preterm birth in those who received 17-OHPC and those who did not. 17-OHPC has not been demonstrated to prolong pregnancy in women with uterine malformations or prenatal diethylstilbestrol exposure.

Patients with a history of cervical atresia may have had reconstructive surgery to create a patent cervix. In those who can become pregnant, case reports have suggested that abdominal cerclage with planned cesarean delivery is warranted.

 There are limited data to suggest that cerclage may decrease the rate of preterm delivery in those with bicornuate uteri with cervical incompetence.20

Historically, hysteroscopic uterine septum resection has been recommended for those with a history of recurrent pregnancy loss, preterm labor, and infertility.

 In case control studies, hysteroscopic metroplasty has been associated with a higher live birth rate and lower spontaneous abortion rate but has also been associated with higher rates of preterm delivery, cesarean section, and fetal malpresentation compared with those with uterine septum who did not have surgery.

A multinational multicenter trial randomly assigned 80 women with a septate uterus to septum resection or expectant management. Live births occurred in 31% who had septum resection compared with 35% who did not have surgery.

 It appears that uterine septum resection may benefit select patients with recurrent fetal loss, but their risk of obstetric complications is still significantly elevated. If the septum extends into the cervix, resection of the cervical component has not been typically recommended due to concern for an increased risk of cervical incompetence.

The incidence of cesarean delivery in those with uterine anomalies is significantly higher, likely because of a combination of higher rates of abruption, preterm labor, and malpresentation. The risks of abruption and failure of external cephalic version (ECV) may be higher in patients with uterine anomalies; however, there have been case reports of successful ECV.

If a longitudinal vaginal septum is identified during a pregnancy, the septum can be resected prior to labor in the operating room or during the first stage or early second stage of labor prior to pushing. Clamping and resecting the intervening septal tissue should be done with extreme care to avoid the bowel, urethra, and the cervices. Use of the LigaSure device (Medtronic) has also been described.

 After vaginal delivery, the vagina should be carefully inspected, hemostasis assured, and gaps in the mucosa should be reapproximated using absorbable suture.

Many patients with obstructive uterovaginal anomalies will present in adolescence or prior to puberty. Some patients may have had vaginal septum resection for a transverse vaginal septum or may have had a vaginal pull-through procedure for distal vaginal atresia. Interposition vaginal grafts, including buccal mucosa or bowel grafts, may have been used to bridge the gap between the upper and lower vagina. 

In these situations where interposition grafts or residual septal tissue is present, and there is a concern for vaginal obstruction, planned cesarean delivery is recommended. Additionally, for those who have had anorectal malformations with a history of anoplasty or reconstructive urological procedures where continence may be negatively impacted by vaginal delivery, planned cesarean delivery should be offered. For any patient with a uterovaginal anomaly, aberrant urologic anatomy, including pelvic kidneys and ectopic and duplicate ureters, are common. Obstetricians should be vigilant during operative deliveries to avoid injury to the urinary system.

Obstetricians should be prepared for an increased rate of retained placenta after vaginal delivery in patients with uterine anomalies. Ultrasound-guided management of instrumentation during removal of retained placental tissue is recommended

Management of therapeutic and spontaneous abortion

For those with 2 cervices, a history of vaginal septum resection, or long interposition vaginal grafts, uterine evacuation can be challenging, with increased difficulty visualizing and dilating 1 or both cervices. For those with a uterine septum, bicornuate uterus, or uterine didelphys, care must be taken to avoid inadvertent instrumentation of the wrong cervix and uterine horn. For those with congenital reproductive tract anomalies, procedures should be performed with ultrasound guidance.

 Operative hysteroscopy may facilitate guided entry into the cavity if dilation with ultrasound guidance alone is not successful.

 Although rare, there are case reports of ectopic pregnancies occurring in asymmetric or noncommunicating uterine horns. MRI may be useful if a pregnancy is visualized by ultrasound but is not accessible through uterine instrumentation and cannot be visualized through hysteroscopy.

Uterine anomalies are common in the general population and are associated with a higher risk of obstetric complications. Optimal imaging is recommended for accurate diagnoses. Consultation with a maternal-fetal medicine specialist is recommended during pregnancy. 

Pfeifer SM, Attaran M, Goldstein J, et al. ASRM müllerian anomalies classification 2021.

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Clinical pearls for assessment and management of the pregnant patient with a uterovaginal anomaly.

Vol 67 No 12

The importance of huddles

Surgical treatments for endometriosis

Uterine anomalies in pregnancy

Leadership in the new reality

Prevalence of Candida species with IUD placement