Most gynecologic procedures carry an identifiable risk of visceral organ injury. These injuries are associated with known risk factors, though not all such injuries are predictable or avoidable. Accurate diagnosis and safe, timely repair of bowel and bladder injuries is crucial in reducing morbidity and, potentially, mortality. Delayed diagnosis of these injuries, particularly in the case of small and large bowel injury, may occur more frequently after laparoscopic surgery with resultant increased patient mortality.1,2 Furthermore, delayed diagnosis and repair of bladder and bowel injuries incurs a higher cost for the health care system.3 Timely and effective repair of these injuries is critical to improving patient outcomes and mitigating litigation risk, as claims relating to intraoperative injury to pelvic organs have high average indemnity payments and more frequently end in payments than do other gynecologic complications. It is essential that gynecologic surgeons have a high suspicion for visceral injury, are prepared to diagnose these injuries intraoperatively, can safely repair injuries with or without consultants, and can follow patients postoperatively in a careful manner.
INCIDENCE AND RISK FACTORS
Obstetric and gynecologic procedures account for 65% of all nonendoscopic iatrogenic bladder injuries across surgical specialties.2 Significantly, injury to the urinary tract occurs during 0.3%–0.8% of all gynecologic procedures; bladder injury rates range from 0.05% to 0.66%.4–6 Urinary tract injuries occur during 0.33% of all benign gynecologic laparoscopies and 0.73%–1.8% of laparoscopic hysterectomies.5,7 Bladder injuries occur during 0.24% of gynecologic laparoscopies, 1.3% of laparoscopic-assisted vaginal hysterectomies, and 1.3% of vaginal hysterectomies.4,8 Composite bladder injury rates during hysterectomies have been reported as high as 3.6%.9
While bladder injury occurs frequently in uncomplicated cases, injuries can be associated with several patient-related and perioperative factors such as the performance of concurrent anti-incontinence procedures or lysis of adhesions.7,9 The presence of endometriosis has been suggested as a risk factor for bladder injury during laparoscopic hysterectomy.10 Several studies have investigated the association of bladder injury and prior cesarean delivery; results are varied based on route of hysterectomy. One composite study of bladder injury during all routes of surgery revealed an association of bladder injury with a history of prior cesarean delivery11; another case-controlled study revealed an increased odds ratio for injury in patients with prior cesarean delivery for all types of hysterectomy combined and for laparoscopically assisted vaginal hysterectomy.12
The incidence of bowel injury during gynecologic surgery is 0.13–0.54%; 75% of such injuries occur to the small bowel.13 One series reported that incidence was highest at laparoscopic hysterectomy, 0.39%.1 Notably, 37.3–55% of all such injuries occur during entry and 38.2% occur during adhesiolysis.1,13 These statistics are comparable with general surgery literature, in which an incidence of laparoscopy-induced gastrointestinal (GI) injury is reported as 13% and laparoscopic entry is a cause of 41% of GI injuries.14
Risk factors for bowel injury include the presence of adhesive disease, small bowel obstruction, and prior laparotomy.14,15 There is no evidence that mechanical bowel preparation prior to gynecologic surgery aids in visualization, operative difficulty, or injury prevention16; however, lower bowel mechanical preparation may be indicated if intraoperative proctoscopy is anticipated due to suspected bowel disease.
BLADDER INJURY PREVENTION AND DIAGNOSIS
In a patient with no prior gynecologic surgery, the urinary bladder is located posterior to the pubic symphysis, medial to the pelvic sidewalls, anterior to the lower uterine segment and vagina, inferior to the obliterated umbilical arteries and urachus, and superior to the anterior cervix. In patients with prior cesarean delivery or other pelvic surgery, these planes may be significantly distorted. Entry through laparotomy requires a finely layered dissection and anticipation of an adherent bladder to anterior peritoneal surfaces as cephalad as the umbilicus. Palpation of the Foley balloon may aid in dissection. Initial laparoscopic insufflation or Hassan entry at the umbilicus seldom poses a risk of urinary tract injury, but accessory suprapubic port placement must be preceded by adequate visualization and bladder decompression in order to avoid bladder injury.
Intraoperative injuries to the urinary bladder during gynecologic surgery may occur during adhesiolysis, during bladder dissection at hysterectomy, or during anterior cul-de-sac entry at vaginal hysterectomy. We recommend sharp instead of blunt bladder dissection to avoid tearing of tissues and to aid in repair if necessary. Retrograde instillation of the bladder may delineate appropriate surgical planes if an adherent bladder is noted at hysterectomy. At laparoscopic hysterectomy, cephalad uterine traction with a manipulator and careful counter-traction on vesicouterine peritoneum facilitates the caudad mobilization of the bladder prior to ligation of uterine arteries. At vaginal hysterectomy, appropriate anterior cul-de-sac entry is facilitated by downward traction on the cervix, sharp dissection at a 45-degree angle, careful palpation of the anterior peritoneal reflection, and retrograde bladder instillation if necessary.
Thermal injury may occur during monopolar or bipolar electrosurgical instrument use during bladder dissection at hysterectomy and requires careful attention. These injuries may present in a delayed fashion as a result of subclinical thermal spread, which extends several millimeters beyond visually desiccated tissue with electrosurgery. This energy should be used in a very deliberate fashion, with low power and voltage settings and for the least amount of time in the vicinity of the bladder.
Intraoperative detection of bladder injury occurs in 85% of cases overall.10 Several agents that stain urine may aid in the intraoperative detection of such injuries. Oral phenazopyridine may be given up to 2 hours preoperatively and works by staining urine orange for several hours. In our experience, this agent provides the effective intraoperative detection of urinary tract injuries. However, this agent must be given in advance; urine staining is delayed at least 30 minutes after administration. Intravenous sodium fluorescein may be given intraoperatively, stains urine green immediately, and is also useful in detecting ureteral patency at cystoscopy.17 Alternatively, the bladder may be retrofilled with methylene blue, sterile infant formula, or saline both to aid in bladder dissection during hysterectomy and to detect injury. Injury may be suspected by efflux of the colored agent into the pelvic cavity. Notably, efflux of a large amount of sodium fluorescein and methylene blue may grossly stain pelvic tissue, impeding further dissection. Furthermore, access to sterile infant formula is often discouraged; an increase in urinary tract infection is suspected based on extrapolation of data from intravesical dextrose instillation. In the absence of conclusive data, we recommend the preoperative administration of phenazopyridine prior to hysterectomy. Bladder injuries may also be detected by visualization of the Foley catheter through bladder mucosa after a defect has been created, or by the presence of blood or carbon dioxide gas in the Foley catheter bag.
Universal cystoscopy is often recommended for urinary tract evaluation after hysterectomy. In one institution, implementation of a universal cystoscopy policy decreased urologic injury rates at hysterectomy from 2.6% to 1.8% and significantly decreased rates of delayed urologic injuries.18 As few as 35.3% of bladder injuries are detected intraoperatively at hysterectomy prior to performing a cystoscopy.9 One systematic review revealed an intraoperative bladder injury detection rate of 94% when universal cystoscopy is employed7; other studies have echoed significantly higher bladder injury detection rates with a routine cystoscopy. Notably, the implementation of routine cystoscopy does not influence postoperative detection rates.19 Furthermore, cystoscopy is associated with an additional cost of $83 per hysterectomy and may have false positive findings in up to 2% of cases.20,21
Most bladder injuries in gynecologic surgery occur at the dome, but careful inspection must occur to ensure that ureteral orifices and the trigone are spared and intact. If the injury involves the trigone, urologic consultation must be considered; repair may involve stenting or re-implantation.
The delayed diagnosis of bladder injuries is an undesirable consequence of missed injury and may occur in up to 15% of cases.10 These may occur after normal or omitted cystoscopy.22 In this situation, urine may extravasate into the retropubic space, peritoneum, or retroperitoneal spaces.23 Routine imaging may reveal evidence of urinary ascites, and a computed tomography (CT) urogram may further delineate the injury. If biochemical analysis of peritoneal fluid is obtained, creatinine values will be elevated in comparison with the patient’s serum values.
BLADDER INJURY REPAIR
All bladder injuries, regardless of location, should be repaired by an experienced surgeon. Injuries involving denuded or necrotic tissue, tissue exposed to radiation, or other complicating factors often require the expertise of a urologic specialist. Notably, very small bladder defects caused by a pneumoperitoneum insufflation needle or suture needle may be managed expectantly and some injuries smaller than 1 cm may be managed with Foley catheter decompression only (Table 1).
All identified full-thickness bladder injuries larger than 1 cm should be primarily repaired. Data have shown that 35% of bladder injuries during gynecologic laparoscopy are repaired by laparoscopic suturing, 19% are repaired vaginally, and 15% of such injuries require a conversion to laparotomy to achieve repair5. The principles of repair are similar for both routes. Repair may occur in one or two layers; most cystotomies larger than 2 cm require two layers for watertight repair. Although there is wide variation in closure techniques, we often employ an initial running, nonlocked layer to incorporate the bladder mucosa and muscularis. The second layer may consist of running or interrupted suture; bladder serosa should be incorporated in an imbricating fashion to add integrity. Occasionally, larger or more complicated injuries may require additional layers of repair or coverage with an omental flap (Table 1).
After repair, retrofill instillation should be performed with at least 300 mL saline with or without dying agent such as methylene blue. If leakage occurs through suture lines, additional layers of imbricating suture should be added as needed. Cystoscopy may also be performed to evaluate closure, though this is not necessary for simple repairs.
Absorbable synthetic suture such as polyglactin or poliglecaprone are often used for bladder repair. Studies have shown that bladder tissue regains its tensile strength approximately 3 weeks after cystotomy repair, making absorbable suture ideal. Permanent suture such as silk should never be used in cystotomy repair, as its presence in contact with the urine can precipitate stone formation.24 Recent case series suggest that the use of a single layer of barbed absorbable suture may provide adequate tension-free cystotomy repair without any additional complications.25
No additional antibiotic prophylaxis is needed at the time of bladder injury diagnosis or repair, unless a urinary tract infection is present.
BLADDER INJURY FOLLOW-UP
Continuous catheter drainage should be performed following any cystotomy repair. To maintain bladder integrity, the duration of drainage and decompression should be approximately 7 days depending on the extent of the initial injury (Table 1). Prophylactic antibiotics are not required for short-term indwelling Foley catheter use in patients with uncomplicated cases.
Many protocols include the routine use of a plain or CT cystogram prior to Foley catheter removal; these studies are designed to ensure the presence of a water-tight and leak-proof repair by instilling retrograde dye into the urinary tract (Fig. 1). Animal studies have shown that re-epithelialization of bladder mucosa and serosa occurs after 3 to 4 days.26,27 Studies in the trauma literature have revealed a low incidence of leakage at the time of cystogram after bladder injury repair and no overall effect of the cystogram on management.28 Conversely, studies examining characteristics of voiding cystourethrograms after urinary tract repair revealed a 2.9% rate of abnormal findings and a change in management in each instance of abnormal voiding cystourethrogram findings.29 In general, we recommend follow-up imaging prior to Foley catheter removal in any large or complex repair, and consideration of this option for simpler repairs.
After bladder repair, patients may develop discomfort or bladder spasm due to the temporary presence of suture and indwelling Foley catheter. This can be managed with anticholinergic agents such as oxybutynin or belladonna-opium suppositories.
BOWEL INJURY PREVENTION AND DIAGNOSIS
Laparoscopic insufflation and Hassan entry carry a risk of inadvertent bowel injury; a large meta-analysis suggests no significant difference in bowel injury rates between these two entry techniques.30 Veress needle insufflation requires careful stabilization and avoidance of inadvertent deep penetration past peritoneum. Patients with a prior vertical laparotomy, pelvic infection, mesh hernia repair or known adhesive disease have a significant risk of the small bowel being fused near the umbilicus. In these patients, we advocate a left or right mid-quadrant Veress needle entry and subsequent visualization of the entry site through an accessory port to rule out occult injury. Laparotomy in patients with extensive surgical history, pelvic infection, or known adhesive disease requires a meticulous layered dissection for safe entry.
Techniques for avoiding bowel injury include effective use of traction and counter-traction principles, careful inspection of each bowel segment following adhesiolysis, the use of combined blunt and sharp dissection, and judicious use of thermal dissection. If significant enterolysis is anticipated or encountered, such as in the case of an obliterated posterior cul-de-sac or in a patient with a significant past pelvic infection, consultation or transfer to a surgeon experienced in such dissection is recommended.
Sharp injuries may occur during adhesiolysis or during dissection of an obliterated posterior cul-de-sac. Careful delineation of planes, use of traction, and surgeon experience help to minimize this risk during laparoscopic and open approaches. Thermal injuries may occur with the use of monopolar or bipolar devices. If electrosurgery must be used in proximity to the bowel, only short bursts of energy with low voltage and power are recommended. Crush injuries may occur with the use of ratcheted instruments directly on bowel; this should always be avoided. Bowel tethering or entrapment may occur during fascial closure; careful inspection and adequate fascial closure will avoid this situation. Finally, the interruption of small bowel vascular supply may occur after inadvertent separation of the mesentery from the bowel wall or by devascularization occurring while achieving hemostasis in the bowel mesentery. In these situations, careful inspection must occur in order to identify healthy margins of bowel; the effect of vascular supply and watershed areas must be considered.
The intraoperative diagnosis of small and large bowel injury is of the utmost importance in optimizing patient safety and, potentially, decreasing mortality. Overall, 41% of bowel injuries at gynecologic laparoscopy are diagnosed in a delayed manner; the mortality rate for these cases is 3.2%.1 Notably, general surgery literature has demonstrated a mortality rate of 3.6% for all laparoscopy-induced bowel injury.14
The diagnosis of sharp bowel injury is self-evident if there is visualization of intraperitoneal spillage of bowel contents or an opening into the bowel lumen is visible. Unfortunately, bowel injury can also be very difficult to diagnose. The “flat tire test” may be considered for intraoperative evaluation of rectosigmoid integrity after adhesiolysis or serosal repair. The sigmoid colon should be occluded proximally with a hand or laparoscopic instrument and saline should be instilled in the pelvis. Using a bulb syringe or proctoscope, air should be progressively instilled into the rectum so that it is visibly dilated. If bubbles are noted, full-thickness injury should be suspected. This test may be similarly employed for evaluation of the small bowel; bowel contents may be squeezed across a suture line with proximal occlusion. It is important to note that injuries caused by thermal damage or devascularization would be unlikely to result in a positive intraoperative test. These injuries may appear as blanched spots on the bowel serosa or may not be immediately visible.
Despite a high index of suspicion, a subclinical bowel injury may occur and go unrecognized. The delayed diagnosis of small or large bowel injury most commonly occurs 2 to 4 days postoperatively. Surgeons must have a high index of suspicion for this diagnosis as signs and symptoms may be insidious, especially in healthy women. Patients may or may not report tolerance of oral intake and normal passage of flatus. A constellation of abdominal pain, tachycardia, tachypnea, leukocytosis, and fever is often but not always noted. Examination may reveal distention and peritonitis. Patients may meet criteria for SIRS or sepsis. Occasionally, leukopenia and hypothermia are noted. It is important to note that the positive predictive value of any single abnormal vital sign or white blood cell count for bowel leak is very low. Most postoperative patients, especially those undergoing bowel resection, are tachycardic or tachypneic at some time in the postoperative period.31 Notably, electrolyte derangements may be severe. Clinicians must be adept at interpreting signs and symptoms within the clinical context. In literature examining morbidity after traumatic bowel perforation, time to surgery is noted to be an independent modifiable risk factor for morbidity.32
Plain films of the abdomen may be used to detect extraluminal air with a sensitivity of only 50–70%.33 However, it is important to note that intra-abdominal CO2 is normally present for up to 2 weeks after open and laparoscopic surgery. Computed tomography imaging with water soluble oral and IV contrast is indicated in most postoperative patients in which bowel injury is suspected. It is important to note that the utility of CT in diagnosing injuries is lowered if oral contrast is not used or does not reach the lower gastrointestinal tract. A water soluble (non–barium-based) lower GI enema and CT series can also be considered if a sigmoid injury is suspected, though occult injuries may still be missed (Fig. 2). Barium should not be used as an oral or rectal contrast agent when ruling out bowel injury given the attendant risks of peritonitis and death. The most specific CT findings for bowel injury include the extravasation of bowel contrast into the peritoneal cavity, bowel wall defects, bowel wall thickening, and pneumoperitoneum.34 Intra-abdominal abscesses may also be noted. Trauma literature has revealed that the presence of pneumoperitoneum may have a low positive predictive value in the presence of other confounding factors.35 Studies have shown that more than 40% of patients with uncomplicated cases have moderate pneumoperitoneum on CT imaging performed within 3 days postoperatively; rates were not significantly different between laparoscopic and open surgery and decreased over time.36
Rarely, delayed gastrointestinal injuries present as fistulae between 1 and 2 weeks postoperatively. A significant proportion of missed rectal injuries may present as rectovaginal fistulae.37 These are diagnosed by performing a fistulogram with dye, followed by a small and large bowel series.
In situations in which clinical deterioration is evident and postoperative suspicion for injury is high, surgical exploration without imaging may be warranted. No imaging modality is 100% sensitive for detecting injury. Severe sepsis and septic shock may prompt multidisciplinary care with critical care providers and anesthesiologists and should be managed according to guidelines with broad-spectrum antibiotic therapy, fluid management with crystalloids, pressors if needed, airway support, and cardiac monitoring.38
BOWEL INJURY REPAIR
Data have shown that 20–58% of bowel injuries during gynecologic laparoscopy are repaired via a minimally invasive approach, which is comparable with the general surgery literature.1,14,39 In recent decades, data have consistently supported the safe and effective repair of enterotomies and rectal injuries laparoscopically.40,41 For any modality of repair, surgeons should have adequate expertise in these repairs and in the management of postoperative breakdown and other complications. For the low-volume gynecologic surgeon encountering a full-thickness injury requiring repair, consultation from a general surgeon or a gynecologic oncologist may be warranted. If a penetrating injury from a Veress needle or other instrument is noted, the instrument should be left in place until the area can be properly grasped or tagged, in order to keep the injury visible.
Small superficial sharp or thermal small bowel injuries to the serosa may be oversewn in an interrupted fashion with 3-0 delayed absorbable suture (such as Vicryl) in a cross-sectional plane. These injuries generally do not require resection. Partial-thickness seromuscular defects that do not penetrate through to the mucosa may be repaired using interrupted 2-0 or 3-0 delayed absorbable suture (Table 2). Even if the plane of the injury is parallel with the bowel plane, repair should occur in a direction perpendicular to the longitudinal plane of the bowel, so as not to potentially decrease the diameter of the bowel lumen (Fig. 3). The surgeon should start at one apex of the defect and suture toward the midline. A single layer of closure is adequate in most cases.
Full thickness small bowel injuries smaller than 1 cm may be closed in one or two layers in a similar manner to partial-thickness injuries. After the first layer, the second layer is performed in an imbricating fashion in the same perpendicular plane as the first. For full-thickness injuries larger than 1 cm, primary repair may occasionally be achieved with a stapling device. Most often, larger full-thickness injuries require resection. Indications for small bowel resection at the time of injury vary depending on the clinical context and may include the presence of thermal injuries without discrete margins, signs of necrosis or overt infection, delayed diagnosis, and the presence of nonviable or devascularized bowel segments. After resection, a primary anastomosis can be performed with or without proximal diversion (Table 2). A stapled technique may be used if no size discrepancy exists between the two lumens, and data have revealed no difference in intra-abdominal complications between stapled and sutured anastomoses.42 Data, including a large Cochrane review, have supported similar rates of anastomotic leak, complications, and mortality between single-layer and double-layer anastomoses.43 Occasionally, primary anastomosis is not possible due to a high risk of anastomotic breakdown. Conditions predisposing to this include the presence of extensive infection, fibrosis, necrosis, prior radiation to the area, immunosuppression, malnourishment, or sepsis.
When repairing injuries to the large bowel, principles are similar to those noted for small bowel injury repair. Margins of resection may be dictated by vascular supply and watershed areas. Systematic reviews have compared primary repair with colostomy diversion for uncomplicated penetrating colon injuries, revealing lower rates of wound infection and infectious complications for primary repair.44 However, diverting colostomy may be indicated if the risk of anastomotic breakdown is high. Risk factors may include the delayed identification of injury, extensive injury, dense adhesions, surrounding inflammation, or immunosuppression. Left-sided colonic anastomoses have a higher rate of postoperative leak; these and rectal injuries requiring resection often require diversion for decompression, especially if the injury is distal or grossly contaminated.45 However, case series have demonstrated successful repair or primary anastomosis without colostomy diversion if adequate rectal tissue is present and the patient does not have severe acidosis, bowel wall edema, or gross evidence of infection.37,46 The lack of a preoperative bowel prep is not, in itself, an indication for diverting colostomy. After any large bowel injury repair or resection, copious pelvic and abdominal irrigation should be performed. Intraoperative testing for leakage of the repair should be performed with proctoscopy or the “flat tire test,” described above. A closed-suction pelvic drain is often placed after large bowel resection in order to monitor for signs of anastomotic breakdown postoperatively, though evidence suggests that drain placement does not decrease the incidence of postoperative complications.47
For small and large bowel injuries repaired intraoperatively, additional antibiotics may not be needed in patients who have already received appropriate prophylaxis. If the bowel lumen is entered and no antibiotics have been administered prior, broad-spectrum antibiotics should be administered intraoperatively and may be continued for 24 hours. There is no evidence that antibiotic use beyond 24 hours postoperatively improves outcomes.48
The repair of delayed-diagnosis small and large bowel injuries almost always involves gross intraperitoneal contamination. Broad-spectrum antibiotics should be continued intraoperatively and for at least 24 hours postoperatively. Repair may be complicated by adhesive disease requiring lysis and varying degrees of necrosis. Repair after a delayed diagnosis requires resection, and often involves diversion with or without anastomosis. The decision regarding fascial closure is based on the surgeon's ability to reapproximate the fascial edges, the degree of intraperitoneal contamination, and the potential for anastomotic breakdown. Delayed closure beyond postoperative day 5 is associated with increased morbidity and should be avoided.45 In some cases of delayed injury diagnosis, avoiding reoperation by initiating bowel rest and parenteral nutrition may be prudent. Primary skin closure is often avoided; evidence has revealed fewer wound infections in patients with gross intraperitoneal contamination after colon injuries in which the skin was left to heal by secondary intention.49 In these cases, the surgeon may loosely approximate skin with staples and place packing in between. Vacuum-assisted closure devices may be used to facilitate wound healing.
BOWEL INJURY FOLLOW-UP
For patients with superficial injuries or injuries less than 1 cm repaired primarily, no postoperative dietary restrictions are necessary. For patients with large bowel injuries, large full-thickness small bowel injuries, or bowel resection, diet should be initiated with clear liquids until bowel function has returned. The prophylactic use of nasogastric tubes is not necessary. In benign gynecologic patients, repair diversion and decompression ostomy are almost always temporary. These patients often undergo ostomy reversal and anastomosis 3 to 6 months after the injury.
The most common complications after bowel repair or anastomosis include leaks, intra-abdominal abscess, or fistulae. Data have revealed that approximately 10% of patients develop complications following small bowel anastomosis, regardless of the technique used intraoperatively.50 These may present with pain, leukocytosis, fever, increased pelvic drain output, and imaging with extraluminal contrast or intraperitoneal fluid collections. Surgeons caring for such patients postoperatively must have a high index of suspicion for these complications in patients whose overall course deteriorates instead of improving.
Gynecologic surgery is not without risks; every gynecologic surgeon should be adept at the diagnosis of injuries to the bowel and bladder. The delayed diagnosis of visceral organ injuries is associated with increased morbidity and mortality. Both education and quality standards should emphasize the importance of intraoperative detection of these injuries whenever possible. While consultants may be called on to repair and manage such injuries, gynecologists should have a basic understanding of mechanisms of repair and tests to ensure integrity. Gynecologists should also be aware of complications of repair, anastomosis, and ostomy formation; perioperative management should reflect an awareness of these risks.
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CME FOR THE CLINICAL EXPERT SERIES
Learning Objectives for “Bowel and Bladder Injury Repair and Follow-up After Gynecologic Surgery”
After completing this learning experience, the involved learner should be able to:
- List ways to minimizing serious patient morbidity and mortality from visceral injury during gynecologic surgery
- Discuss the factors most closely associated with bladder injury during hysterectomy
- Outline the risks of using electrosurgical energy
- Identify the most common location for urologic injuries during gynecologic surgery
Instructions for Obtaining AMA PRA Category 1 Credits™
Continuing Medical Education credit is provided through joint providership with The American College of Obstetricians and Gynecologists.
Obstetrics & Gynecology includes CME-certified content that is designed to meet the educational needs of its readers. This article is certified for 2 AMA PRA Category 1 Credits™ This activity is available for credit through February 28, 2022.
The American College of Obstetricians and Gynecologists is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
AMA PRA Category 1 Credit(s)™
The American College of Obstetricians and Gynecologists designates this journal-based CME activity for a maximum of 2 AMA PRA Category 1 Credits.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.
College Cognate Credit(s)
The American College of Obstetricians and Gynecologists designates this journal-based CME activity for a maximum of 2 Category 1 College Cognate Credits. The College has a reciprocity agreement with the AMA that allows AMA PRA Category 1 Credits™ to be equivalent to College Cognate Credits.
Disclosure of Faculty and Planning Committee Industry Relationships
In accordance with the College policy, all faculty and planning committee members have signed a conflict of interest statement in which they have disclosed any financial interests or other relationships with industry relative to article topics. Such disclosures allow the participant to evaluate better the objectivity of the information presented in the articles.
How to Earn CME Credit
To earn CME credit, you must read the article in Obstetrics & Gynecology and complete the quiz, answering at least 70 percent of the questions correctly. For more information on this CME educational offering, visit the Lippincott CMEConnection portal at https://cme.lww.com/browse/sources/196 to register and to complete the CME activity online. ACOG Fellows will receive 50% off by using coupon code, ONG50.
Hardware/software requirements are a desktop or laptop computer (Mac or PC) and an Internet browser. This activity is available for credit through February 28, 2022. To receive proper credits for this activity, each participant will need to make sure that the information on their profile for the CME platform (where this activity is located) is updated with 1) their date of birth (month and day only) and 2) their ACOG ID. In addition, participants should select that they are board-certified in obstetrics and gynecology.
The privacy policies for the Obstetrics & Gynecology website and the Lippincott CMEConnection portal are available at http://www.greenjournal.org and https://cme.lww.com/browse/sources/196, respectively.
Questions related to transcripts may be directed to email@example.com. For other queries, please contact the Obstetrics & Gynecology Editorial Office, 202-314-2317 or firstname.lastname@example.org. For queries related to the CME test online, please contact email@example.com or 1-800-787-8985.© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.