Niches after cesarean section in a population seeking hysteroscopic sterilization

OBJECTIVE

To study the prevalence of hysteroscopically evaluated disruptions of the integrity of the uterine wall ('niches') in women with and without a previous cesarean section.

STUDY DESIGN

A prospective cohort study was performed in a teaching hospital in the Netherlands. Women seeking hysteroscopic sterilization were included. A hysteroscopic evaluation of the anterior wall of the uterus and cervix to identify the existence of disruptions (niches) was performed in a standard manner. Primary outcome was the presence of a uterine niche, defined as any visible defect, disruption, or concavity (gap) in the anterior wall. Secondary outcome was to develop a registration form of niche features for hysteroscopic evaluation.

RESULTS

In total, 713 women were included, 603 without and 110 with a previous cesarean section. In women with a previous cesarean Section 83 (75%) niches were observed using hysteroscopy. Anterior wall disruptions were not observed in women without a cesarean section. The following niche features were identified and incorporated in a registration form: polyps, cysts, myometrium defect, fibrotic tissue, (abnormal) vascular pattern, lateral branches, mucus production inside the defect, and bleeding.

CONCLUSION

In a prospective cohort study among women undergoing hysteroscopic sterilization, a uterine niche could be detected by hysteroscopy in 75% of women with a previous cesarean section.

The Effect of Perioperative E-Health Interventions on the Postoperative Course: A Systematic Review of Randomised and Non-Randomised Controlled Trials

BACKGROUND

E-health interventions have become increasingly popular, including in perioperative care. The objective of this study was to evaluate the effect of perioperative e-health interventions on the postoperative course.

METHODS

We conducted a systematic review and searched for relevant articles in the PUBMED, EMBASE, CINAHL and COCHRANE databases. Controlled trials written in English, with participants of 18 years and older who underwent any type of surgery and which evaluated any type of e-health intervention by reporting patient-related outcome measures focusing on the period after surgery, were included. Data of all included studies were extracted and study quality was assessed by using the Downs and Black scoring system.

FINDINGS

A total of 33 articles were included, reporting on 27 unique studies. Most studies were judged as having a medium risk of bias (n = 13), 11 as a low risk of bias, and three as high risk of bias studies. Most studies included patients undergoing cardiac (n = 9) or orthopedic surgery (n = 7). All studies focused on replacing (n = 11) or complementing (n = 15) perioperative usual care with some form of care via ICT; one study evaluated both type of interventions. Interventions consisted of an educational or supportive website, telemonitoring, telerehabilitation or teleconsultation. All studies measured patient-related outcomes focusing on the physical, the mental or the general component of recovery. 11 studies (40.7%) reported outcome measures related to the effectiveness of the intervention in terms of health care usage and costs. 25 studies (92.6%) reported at least an equal (n = 8) or positive (n = 17) effect of the e-health intervention compared to usual care. In two studies (7.4%) a positive effect on any outcome was found in favour of the control group.

CONCLUSION

Based on this systematic review we conclude that in the majority of the studies e-health leads to similar or improved clinical patient-related outcomes compared to only face to face perioperative care for patients who have undergone various forms of surgery. However, due to the low or moderate quality of many studies, the results should be interpreted with caution.

Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development

Caesarean section (CS) results in the occurrence of the phenomenon 'niche'. A 'niche' describes the presence of a hypoechoic area within the myometrium of the lower uterine segment, reflecting a discontinuation of the myometrium at the site of a previous CS. Using gel or saline instillation sonohysterography, a niche is identified in the scar in more than half of the women who had had a CS, most with the uterus closed in one single layer, without closure of the peritoneum. An incompletely healed scar is a long-term complication of the CS and is associated with more gynaecological symptoms than is commonly acknowledged. Approximately 30% of women with a niche report spotting at 6-12 months after their CS. Other reported symptoms in women with a niche are dysmenorrhoea, chronic pelvic pain and dyspareunia. Given the association between a niche and gynaecological symptoms, obstetric complications and potentially with subfertility, it is important to elucidate the aetiology of niche development after CS in order to develop preventive strategies. Based on current published data and our observations during sonographic, hysteroscopic and laparoscopic evaluations of niches we postulate some hypotheses on niche development. Possible factors that could play a role in niche development include a very low incision through cervical tissue, inadequate suturing technique during closure of the uterine scar, surgical interventions that increase adhesion formation or patient-related factors that impair wound healing or increase inflammation or adhesion formation.

The involvement of gynaecological patients in the development of a clinical guideline for resumption of (work) activities in the Netherlands

CONTEXT

Most initiatives for patient involvement in guideline development have been carried out for chronic diseases. The involvement of patients with incidental and non-threatening diseases is more complicated. Little knowledge is available on how these patient groups can successfully be involved in guideline development.

OBJECTIVE

To assess the effectiveness of the involvement of gynaecological patients in the guideline development for resumption of (work) activities after surgery.

DESIGN

At three different stages patients were involved in the process: (i) three focus group discussions (FGDs) were organized, (ii) patients were involved for the instruction video, and (iii) patients tested the patient version of the clinical guideline. To assess the effectiveness, an evaluation framework was used. The guideline development process was divided into two parallel trajectories in which patients and professionals were consulted separately. Patients were primarily consulted for the development of the patient version, although their input also influenced the recommendations for resumption of (work) activities after surgery. Professionals were mainly involved in the development of the recommendations of the clinical guideline.

DISCUSSION AND CONCLUSIONS

The involvement of gynaecological patients in the guideline development for resumption of (work) activities after surgery was successful in many respects. Consultation of individual patients by means of FGDs and with regular feedback moments has been rather effective for a guideline development process related to an incidental, non-threatening disease for which there is no patient organization. Patients' input contributed to applicability of the clinical guideline in daily practice. Increased patient involvement could be achieved by integration of the two parallel trajectories with additional participatory activities, such as a dialogue meeting.

The use of 3D power Doppler ultrasound in the quantification of blood vessels in uterine fibroids: feasibility and reproducibility

BACKGROUND

To evaluate the interobserver agreement and discriminating value of three-dimensional power Doppler ultrasound (3D PDUS) in patients with fibroids.

METHODS

An observational prospective cohort study in 19 patients with fibroids. 3D PDUS was performed by one examiner and evaluated by three independent examiners in order to evaluate various vascular parameters: vascular index (VI), flow index, and vascular flow index of the fibroid, the vascular capsule and of its highest vascular area, using both manual and automatic contour modes. The intraclass correlation coefficient and discriminating values were calculated. The correlation between VI and volume was studied using Kendall's Tau test.

RESULTS

In the manual contour mode, the VIs of the fibroid and of the vascular capsule had the highest interobserver agreements (intraclass correlation coefficients of 0.89 and 0.87, respectively). Both parameters seem to have good discriminating values, given the large range of these parameters between different fibroids, independent of their volume. The vascularity of the fibroid and capsule was related. VI was not related to the volume of the fibroid.

CONCLUSIONS

VI assessed using 3D PDUS is a reproducible parameter in the assessment of fibroid vascularization with discriminating abilities. Additional studies are needed to further evaluate its validity and clinical relevance.

Reproducibility of three-dimensional ultrasound for the measurement of a niche in a caesarean scar and assessment of its shape

OBJECTIVE

To evaluate the inter- and intraobserver agreement for measurement of the size and volume of a niche and assessment of the shape, with the use of three-dimensional (3D) ultrasound.

STUDY DESIGN

In this reproducibility study, 20 3D ultrasound volumes of uteri with a niche were selected, based on complete visualisation of the uterus and niche in both the longitudinal and transversal plane. Niche measurements were performed off-line twice by one observer and once by another observer. Niche measurements and assessment of shape were performed in the longitudinal and transversal plane, and niche volume in the longitudinal plane. The mean difference, 95% limits of agreement, the intraclass correlation coefficient (ICC) and Cohen's kappa were calculated to assess the inter- and intraobserver agreement.

RESULTS

The interobserver agreement was excellent for all niche measurements (ICC >0.86), including depth and residual myometrial thickness (RMT), except for width at niche base in the transversal plane (ICC 0.74) and niche volume (ICC 0.79), which were classified as good agreement. Wide limits of agreement and a high mean difference were found for maximal width in the transversal plane. The intraobserver agreement was excellent for all measurements (ICC >0.80), except for RMT in the longitudinal and transversal plane, which were classified as good agreement (ICC 0.73 and 0.62, respectively). Wide limits of agreement were found for maximal width and width at niche base in the transversal plane. The overall agreement in the transversal plane was lower than in the longitudinal plane, but still all in the range of good agreement. The inter- and intraobserver agreement was good to poor for the assessment of niche shape.

CONCLUSION

Using 3D ultrasound, various niche parameters, including depth (both perpendicular to niche base and maximal depth), maximal width, width at niche base, RMT and volume, can be measured with a high level of agreement, in particular if measured in the longitudinal plane.

Process evaluation of a multidisciplinary care program for patients undergoing gynaecological surgery

PURPOSE

This study describes the process evaluation of an innovative multidisciplinary care program for patients undergoing benign gynaecologic surgery. This care program aims at improving recovery and preventing delayed return to work and consists of two steps: (1) an interactive e-health intervention for all participants, and (2) integrated clinical and occupational care management for those participants whose sick leave exceeds 10 weeks.

METHODS

Eligible for this study were employed women aged between 18-65 years scheduled for a laparoscopic adnexal surgery and/or hysterectomy. Data were collected from patients, their supervisors and their gynaecologists, by means of electronic questionnaires during a 6 month follow-up period and an automatically generated, detailed weblog of the patient web portal ( www.ikherstel.nl ). Investigated process measures included: reach, dose delivered, dose received, and fidelity. In addition, attitudes towards the intervention were explored among all stakeholders.

RESULTS

215 patients enrolled in the study and accounted to a reach of 60.2 % (215/357). All intervention group patients used their account at least once and total time spent on the patient web portal was almost 2 h for each patient (median 118 min, IQR 64-173 min). Most patients visited the website several times (median 11 times, IQR 6-16). Perceived effectiveness among patients was high (74 %). In addition, gynaecologists (76 %) and employers (61 %) were satisfied with the web portal as well. Implementation of the second step of the intervention was suboptimal. Motivating patients to consent to additional guidance and developing an accurate return-to-work-prognosis were two important obstacles.

CONCLUSIONS

The results of this study indicate good feasibility for implementation on a broad scale of the e-health intervention for patients undergoing benign gynaecological surgery. To enhance the implementation of the second step of the perioperative care program, adaptations in the integrated care protocol are needed.

Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review

OBJECTIVE

To review systematically the medical literature reporting on the prevalence of a niche at the site of a Cesarean section (CS) scar using various diagnostic methods, on potential risk factors for the development of a niche and on niche-related gynecological symptoms in non-pregnant women.

METHODS

The PubMed and EMBASE databases were searched. All types of clinical study reporting on the prevalence, risk factors and/or symptoms of a niche in non-pregnant women with a history of CS were included, apart from case reports and case series.

RESULTS

Twenty-one papers were selected for inclusion in the review. A wide range in the prevalence of a niche was found. Using contrast-enhanced sonohysterography in a random population of women with a history of CS, the prevalence was found to vary between 56% and 84%. Nine studies reported on risk factors and each study evaluated different factors, which made it difficult to compare studies. Risk factors could be classified into four categories: those related to closure technique, to development of the lower uterine segment or location of the incision or to wound healing, and miscellaneous factors. Probable risk factors are single-layer myometrium closure, multiple CSs and uterine retroflexion. Six out of eight studies that evaluated niche-related symptoms described an association between the presence of a niche and postmenstrual spotting.

CONCLUSIONS

The reported prevalence of a niche in non-pregnant women varies depending on the method of detection, the criteria used to define a niche and the study population. Potential risk factors can be categorized into four main categories, which may be useful for future research and meta-analyses. The predominant symptom associated with a niche is postmenstrual spotting.

Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding

OBJECTIVE

To study the prevalence of niches in the caesarean scar in a random population, and the relationship with postmenstrual spotting and urinary incontinence.

DESIGN

A prospective cohort study.

SETTING

A teaching hospital in the Netherlands.

POPULATION

Non-pregnant women delivered by caesarean section.

METHODS

Transvaginal ultrasound (TVU) and gel instillation sonohysterography (GIS) were performed 6-12 weeks after caesarean section. Women were followed by questionnaire and menstruation score chart at 6-12 weeks, 6 months, and 12 months after caesarean section.

MAIN OUTCOME MEASURES

Prevalence of a niche 6-12 weeks after caesarean section, using TVU and GIS.

SECONDARY OUTCOMES

relation to postmenstrual spotting and urinary incontinence 6 and 12 months after caesarean section; and niche characteristics, evaluated by TVU and GIS.

RESULTS

Two hundred and sixty-three women were included. Niche prevalence was 49.6% on evaluation with TVU and 64.5% with GIS. Women with a niche measured by GIS reported more postmenstrual spotting than women without a niche (OR 5.48, 95% CI 1.14-26.48). Women with residual myometrium at the site of the uterine scar measuring <50% of the adjacent myometrial thickness had postmenstrual spotting more often than women with a residual myometrial thickness of >50% of the adjacent myometrial thickness (OR 6.13, 95% CI 1.74-21.63). Urinary incontinence was not related to the presence of a niche.

CONCLUSIONS

A niche is present in 64.5% of women 6-12 weeks after caesarean section, when examined by GIS. Postmenstrual spotting is more prevalent in women with a niche and in women with a residual myometrial thickness of <50% of the adjacent myometrium.

Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding

OBJECTIVE

To study the prevalence of niches in the caesarean scar in a random population, and the relationship with postmenstrual spotting and urinary incontinence.

DESIGN

A prospective cohort study.

SETTING

A teaching hospital in the Netherlands.

POPULATION

Non-pregnant women delivered by caesarean section.

METHODS

Transvaginal ultrasound (TVU) and gel instillation sonohysterography (GIS) were performed 6-12 weeks after caesarean section. Women were followed by questionnaire and menstruation score chart at 6-12 weeks, 6 months, and 12 months after caesarean section.

MAIN OUTCOME MEASURES

Prevalence of a niche 6-12 weeks after caesarean section, using TVU and GIS.

SECONDARY OUTCOMES

relation to postmenstrual spotting and urinary incontinence 6 and 12 months after caesarean section; and niche characteristics, evaluated by TVU and GIS.

RESULTS

Two hundred and sixty-three women were included. Niche prevalence was 49.6% on evaluation with TVU and 64.5% with GIS. Women with a niche measured by GIS reported more postmenstrual spotting than women without a niche (OR 5.48, 95% CI 1.14-26.48). Women with residual myometrium at the site of the uterine scar measuring <50% of the adjacent myometrial thickness had postmenstrual spotting more often than women with a residual myometrial thickness of >50% of the adjacent myometrial thickness (OR 6.13, 95% CI 1.74-21.63). Urinary incontinence was not related to the presence of a niche.

CONCLUSIONS

A niche is present in 64.5% of women 6-12 weeks after caesarean section, when examined by GIS. Postmenstrual spotting is more prevalent in women with a niche and in women with a residual myometrial thickness of <50% of the adjacent myometrium.

A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: results of a multicentre randomised trial

OBJECTIVE

To evaluate the effectiveness of an eHealth intervention on recovery and return to work, after gynaecological surgery.

DESIGN

Randomised multicentre trial that ran from March 2010 until September 2011.

SETTING

Secondary care in seven general and university hospitals in The Netherlands.

POPULATION

A cohort of 215 women (aged 18-65 years) who had a hysterectomy and/or laparoscopic adnexal surgery for a benign indication.

METHODS

The women were randomly assigned to the intervention group (n = 110) or the control group (n = 105). The intervention group received an eHealth programme that provided personalised tailor-made pre- and postoperative instructions on the resumption of daily activities, including work, and tools to improve self-empowerment and to identify recovery problems. The control group was provided with access to a control website.

MAIN OUTCOME MEASURES

The primary outcome was the duration of sick leave until a full sustainable return to work. Secondary outcome measures were quality of life, general recovery, and pain intensity.

RESULTS

In intention-to-treat analysis the eHealth intervention was effective on time to return to work (hazard ratio 1.43; 95% confidence interval 1.003-2.040; P = 0.048). The median duration of sick leave until a full sustainable return to work was 39 days (interquartile range 20-67 days) in the intervention group and 48 days (interquartile range 21-69 days) in the control group. After 26 weeks pain intensity was lower (visual analogue scale, cumulative odds ratio 1.84; 95% confidence interval 1.04-3.25; P = 0.035) and quality of life was higher (Rand-36 health survey, between-group difference 30, 95% confidence interval 4-57; P = 0.024) in the intervention group, compared with the control group.

CONCLUSIONS

The use of the eHealth intervention by women after gynaecological surgery results in a faster return to work, with a higher quality of life and less pain.

Real-time elastography for assessment of uterine disorders

OBJECTIVES

Sonoelastography is an ultrasound-imaging technique that measures tissue strain. The aim of this study was to define, in a systematic manner, specific sonoelastographic characteristics of the myometrium, fibroids and adenomyosis, to evaluate the feasibility of sonoelastography in patients with suspected gynecological pathology and to compare the results with histology and/or magnetic resonance imaging (MRI)-based diagnoses.

METHODS

We performed a prospective observational cohort study between 2009 and 2011. Two-hundred and eighteen women with suspected gynecological pathology underwent routine transvaginal ultrasound and additional real-time sonographic elastography. Sixty-nine of the 218 women underwent MRI and/or histological examination and were included in the final analysis. Acquisition of elastographic images was standardized. We analyzed the elastographic characteristics of myometrium, fibroids and adenomyosis. An independent observer, unaware of clinical, histological or MRI findings, evaluated the recorded elastographic images and cineloops. These elastographic-based diagnoses were compared with histology and/or MRI diagnoses.

RESULTS

With elastography, the uterus was well delineated from the surrounding bowel. The myometrium was uniform in color in 49% of the cases, with a main color of purple or dark blue, indicating stiffer tissue. Fibroids and adenomyosis had different elastographic characteristics and different color patterns. In general, fibroids were darker and adenomyosis was brighter than adjacent myometrium. The agreement between elastography-based diagnosis of fibroids and adenomyosis with MRI-based diagnosis was excellent; with histology-based diagnosis, agreement was substantial for fibroids and adenomyosis.

CONCLUSIONS

Elastography is able to identify clear discriminating characteristics of the uterus, fibroids and adenomyosis, and elastography-based diagnoses are in excellent agreement with those of MRI. Agreement between elastography-based diagnosis of adenomyosis and histology is substantial but not optimal.

Diagnostic and clinical value of 3D gel installation sonohysterography in addition to 2D gel installation sonohysterography in the assessment of intrauterine abnormalities

OBJECTIVE

To study the diagnostic value of three-dimensional gel instillation sonography (3D GIS) in addition to two-dimensional (2D) GIS in the assessment of intrauterine abnormalities. Secondly, the clinical value of 3D GIS in the planning for hysteroscopic procedures was evaluated.

STUDY DESIGN

A prospective cohort study was performed from 2008 till 2010. All women with a suspected intrauterine abnormality on 2D GIS suitable for hysteroscopic resection or with recurrent postmenstrual bleeding were planned for a hysteroscopic procedure. Diagnostic accuracy tests were calculated for the detection of fibroids and polyps with both histology and hysteroscopy as the reference standard. For the assessment of type and size of fibroids hysteroscopy was used as the reference standard. We compared the planning for type of hysteroscopy based on 2D GIS findings with the combined 2D-3D GIS findings.

RESULTS

In total 110 patients were analysed. In comparison to histology, addition of 3D GIS did not change sensitivity or specificity substantially in the discrimination between fibroids and polyps. In comparison to hysteroscopy, sensitivity increased for detecting fibroids and polyps, without major interference with the specificity. Despite an improved accuracy after the addition of 3D GIS, the planning for hysteroscopic procedures did not improve substantially.

CONCLUSION

In daily practice, the addition of 3D GIS to 2D GIS improved the accuracy for the detection of polyps and fibroids compared to hysteroscopy, but only marginally improved the planning of hysteroscopic procedures, and therefore the clinical relevance seems to be limited.

Prediction of time to return to work after gynaecological surgery: a prospective cohort study in the Netherlands

OBJECTIVE

To measure the impact of the level of invasiveness of gynaecological procedures on time to full Return to Work (RTW) and to identify the most important preoperative sociodemographic, medical and work-related factors that predict the risk of prolonged sick leave.

DESIGN

Prospective cohort study.

SETTING

Dutch university hospital.

POPULATION

A total of 148 women aged 18-65 years scheduled for gynaecological surgery for benign indications.

METHODS

A questionnaire regarding the surgical procedure as well as perioperative and postoperative complications was completed by the attending resident at baseline and 6 weeks after surgery. All other outcome measures were assessed using self-reported patient questionnaires at baseline and 12 weeks post-surgery. The follow-up period was extended up to 1 year after surgery in women failing to return to work. Surgical procedures were categorised into diagnostic, minor, intermediate and major surgery.

MAIN OUTCOME MEASURES

Time to RTW and important predictors for prolonged sick leave after surgery.

RESULTS

Median time to RTW was 7 days (interquartile range [IQR] 5-14) for diagnostic surgery, 14 days (IQR 9-28) for minor surgery, 60 days (IQR 28-101) for intermediate surgery and 69 days (IQR 56-135) for major surgery. Multivariable analysis showed a strongest predictive value of RTW 1 year after surgery for level of invasiveness of surgery (minor surgery hazard ratio [HR] 0.51, 95% CI 0.32-0.81; intermediate surgery HR 0.20, 95% CI 0.12-0.34; major surgery HR 0.09, 95% CI 0.06-0.16), RTW expectations before surgery (HR 0.55, 95% CI 0.36-0.84), and preoperative functional status (HR 1.09, 95% CI 1.04-1.13). A prediction model regarding the probability of prolonged sick leave at 6 weeks was developed, with a sensitivity of 89% and a specificity of 86%.

CONCLUSIONS

RTW often takes a long time, especially after intermediate and major surgery. This study reveals important predictors for prolonged sick leave and provides a prediction model for the risk of sick leave extending 6 weeks after benign gynaecological surgery in the Netherlands.

Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome

BACKGROUND

Approximately 15-20% of all clinically confirmed pregnancies end in a miscarriage. Intrauterine adhesions (IUAs) are a possible complication after miscarriage, but their prevalence and the contribution of possible risk factors have not been elucidated yet. In addition, the long-term reproductive outcome in relation to IUAs has to be elucidated.

METHODS

We systematically searched the literature for studies that prospectively assessed the prevalence and extent of IUAs in women who suffered a miscarriage. To be included, women diagnosed with a current miscarriage had to be systematically evaluated within 12 months by hysteroscopy after either spontaneous expulsion or medical or surgical treatment. Studies that included women with a history of recurrent miscarriage only or that evaluated the IUAs after elective abortion or beyond 12 months after the last miscarriage were not included. Subsequently, long-term reproductive outcomes after expectant (conservative), medical or surgical management were assessed in women with and without post-miscarriage IUAs.

RESULTS

We included 10 prospective studies reporting on 912 women with hysteroscopic evaluation within 12 months of miscarriage and 8 prospective studies, including 1770 women, reporting long-term reproductive outcome. IUAs were detected in 183 women, resulting in a pooled prevalence of 19.1% [95% confidence interval (CI): 12.8-27.5%]. The extent of IUAs was reported in 124 women (67.8%) and was mild, moderate and severe respectively in 58.1, 28.2 and 13.7% of cases. Relative to women with one miscarriage, women with two or three or more miscarriages showed an increased risk of IUAs by a pooled OR of 1.41 and 2.1, respectively. The number of dilatation and curettage (D&C) procedures seemed to be the main driver behind these associations. A total of 150 congenital and acquired intrauterine abnormalities were encountered in 675 women, resulting in a pooled prevalence of 22.4% (95% CI: 16.3-29.9%). Similar reproductive outcomes were reported subsequent to conservative, medical or surgical management for miscarriage, although the numbers of studies and of included women were limited. No studies reported long-term reproductive outcomes following post-miscarriage IUAs.

CONCLUSIONS

IUAs are frequently encountered, in one in five women after miscarriage. In more than half of these, the severity and extent of the adhesions was mild, with unknown clinical relevance. Recurrent miscarriages and D&C procedures were identified as risk factors for adhesion formation. Congenital and acquired intrauterine abnormalities such as polyps or fibroids were frequently identified. There were no studies reporting on the link between IUAs and long-term reproductive outcome after miscarriage, while similar pregnancy outcomes were reported subsequent to conservative, medical or surgical management. Although this review does not allow strong clinical conclusions on treatment management, it signals an important clinical problem. Treatment strategies are proposed to minimize the number of D&C in an attempt to reduce IUAs.

Surgical versus expectant management in women with an incomplete evacuation of the uterus after treatment with misoprostol for miscarriage: the MisoREST trial

Background

Medical treatment with misoprostol is a non-invasive and inexpensive treatment option in first trimester miscarriage. However, about 30% of women treated with misoprostol have incomplete evacuation of the uterus. Despite being relatively asymptomatic in most cases, this finding often leads to additional surgical treatment (curettage). A comparison of effectiveness and cost-effectiveness of surgical management versus expectant management is lacking in women with incomplete miscarriage after misoprostol.

Methods/Design

The proposed study is a multicentre randomized controlled trial that assesses the costs and effects of curettage versus expectant management in women with incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage.

Eligible women will be randomized, after informed consent, within 24 hours after identification of incomplete evacuation of the uterus by ultrasound scanning. Women are randomly allocated to surgical or expectant management. Curettage is performed within three days after randomization.

Primary outcome is the sonographic finding of an empty uterus (maximal diameter of any contents of the uterine cavity < 10 millimeters) six weeks after study entry. Secondary outcomes are patients’ quality of life, surgical outcome parameters, the type and number of re-interventions during the first three months and pregnancy rates and outcome 12 months after study entry.

Discussion

This trial will provide evidence for the (cost) effectiveness of surgical versus expectant management in women with incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage.

Trial registration

Dutch Trial Register: NTR3110

eHealth program to empower patients in returning to normal activities and work after gynecological surgery: intervention mapping as a useful method for development

BACKGROUND

Full recovery after gynecological surgery takes much longer than expected regardless of surgical technique or the level of invasiveness. After discharge, detailed convalescence recommendations are not provided to patients typically, and postoperative care is fragmented, poorly coordinated, and given only on demand. For patients, this contributes to irrational beliefs and avoidance of resumption of activities and can result in a prolonged sick leave.

OBJECTIVE

To develop an eHealth intervention that empowers gynecological patients during the perioperative period to obtain timely return to work (RTW) and prevent work disability.

METHODS

The intervention mapping (IM) protocol was used to develop the eHealth intervention. A literature search about behavioral and environmental conditions of prolonged sick leave and delayed RTW in patients was performed. Patients' needs, attitudes, and beliefs regarding postoperative recovery and resumption of work were identified through focus group discussions. Additionally, a literature search was performed to obtain determinants, methods, and strategies for the development of a suitable interactive eHealth intervention to empower patients to return to normal activities after gynecological surgery, including work. Finally, the eHealth intervention was evaluated by focus group participants, medical doctors, and eHealth specialists through questionnaires.

RESULTS

Twenty-one patients participated in the focus group discussions. Sufficient, uniform, and tailored information regarding surgical procedures, complications, and resumption of activities and work were considered most essential. Knowing who to contact in case of mental or physical complaints, and counseling and tools for work reintegration were also considered important. Finally, opportunities to exchange experiences with other patients were a major issue. Considering the determinants of the Attitude-Social influence-self-Efficacy (ASE) model, various strategies based on a combination of theory and evidence were used, resulting in an eHealth intervention with different interactive functionalities including tailored convalescence recommendations and a video to communicate the most common pitfalls during the perioperative period to patients and employers. Fifteen patients in the focus groups, 11 physicians, and 3 eHealth specialists suggested points for improvement to optimize the usability of the eHealth intervention and judged it an approachable, appropriate, and attractive eHealth intervention to empower gynecological patients.

CONCLUSIONS

The IM protocol was a useful method to develop an eHealth intervention based on both theory and evidence. All patients and stakeholders judged the eHealth intervention to be a promising tool to empower gynecological patients during the perioperative period and to help them to return to normal activities and work.

Perioperative outcomes using LigaSure™ compared to conventional bipolar instruments in laparoscopic salpingo-oophorectomy: a randomized controlled trial

BACKGROUND

The aim of this study was to compare the effects of LigaSure™ versus conventional bipolar techniques on operating time and blood loss during laparoscopic salpingo-oophorectomy in a randomized controlled trial.

METHODS

In three teaching hospitals, 100 women undergoing a laparoscopic salpingo-oophorectomy were randomized for LigaSure or conventional bipolar instruments. Primary outcome was operating time (from initial skin incision to removal of the specimen). Secondary outcome measures were total operating time (from initial skin incision to skin closure), time to dissect the ovarian and infundibulopelvic ligaments, intraoperative blood loss, and subjective judgment of the instrument used.

RESULTS

There were no differences in operating time and total operating time using LigaSure versus conventional bipolar instruments: 41.0 vs. 39.2 min (p = 0.78; 95 % CI = -10.9 to 14.5) and 54.6 vs. 58.6 min (p = 0.46; 95 % CI = -14.8 to 6.8), respectively. The mean blood loss using LigaSure versus conventional bipolar instruments was 38 vs. 33 mL (p = 0.73; 95 % CI = -22.7 to 32.2). Various subjective efficacy and instrument handling parameters of the two instruments varied among participating centers.

CONCLUSION

There were no significant differences in operating time and blood loss with the use of LigaSure compared to conventional bipolar instruments during laparoscopic salpingo-oophorectomy, even after correction for potential confounders.

Standardized approach for imaging and measuring Cesarean section scars using ultrasonography

Incomplete healing of the scar is a recognized sequel of Cesarean section (CS) and may be associated with complications in later pregnancies. These complications can include scar pregnancy, a morbidly adherent placenta, scar dehiscence or rupture. To date there is uncertainty relating to the factors that lead to poor scar healing and how to recognize it. In recent years, there has been an increase in studies using ultrasound that describe scars as deficient, or poorly, incompletely or inadequately healed with few data to associate the morphology of the scar with the functional integrity of the lower segment of the uterus. There have been multiple attempts to describe CS scars using ultrasonography. Different terminology, methods and results have been reported, yet there is still no consensus regarding the prevalence, clinical significance or most appropriate method to describe the appearances of these scars. Developing a test that can predict the likelihood of women having problems associated with a CS scar is becoming increasingly important. On the other hand, understanding whether the ultrasound appearances of the scar can tell us anything about its integrity is not well supported by the research evidence. In this article we present an overview of ultrasound-based definitions and methods used to describe CS scars. We also present information relating to the performance of alternative techniques used to evaluate CS scars. Having examined the current evidence we suggest a standardized approach to describe CS scars using ultrasound so that future studies can be meaningfully compared.

Effectiveness of abdominal cerclage placed via laparotomy or laparoscopy: systematic review

Preterm delivery remains a primary cause of neonatal morbidity and mortality. One cause of preterm birth is cervical incompetence. In women with a shortened or absent cervix or in those in whom previous vaginal cerclage failed, abdominal cerclage may be recommended. We performed a systematic literature search of PubMed, EMBASE, and the Cochrane database. Thirty-one eligible studies were selected. Six studies (135 patients) reported on the laparoscopic approach, and 26 (1116 patients) on the abdominal approach. Delivery of a viable infant at 34 weeks of gestation or more varied from 78.5% (laparoscopic) to 84.8% (abdominal). Second-trimester fetal loss occurred in 8.1% (laparoscopic) vs 7.8% (abdominal), with no reported third-trimester losses (laparoscopic) vs 1.2% (abdominal). We conclude that abdominal cerclage is associated with excellent results as treatment of cervical incompetence, with high fetal survival rates and minimal complications during surgery and pregnancy. Further studies are needed to differentiate which method is superior.

Multidisciplinary convalescence recommendations after gynaecological surgery: a modified Delphi method among experts

OBJECTIVE

To generate structured detailed uniform convalescence recommendations after gynaecological surgery by a modified Delphi method amongst experts and a representative group of physicians.

DESIGN

Modified Delphi study.

SETTING

Expert physicians recruited by their respective medical boards and employed at different hospitals, doctor's surgeries and healthcare services.

POPULATION

Twelve experts (five gynaecologists, two general practitioners [GPs] and five occupational physicians [OPs]) and a representative sample of 63 medical doctors.

METHODS

Multidisciplinary detailed recommendations for graded resumption of relevant activities after uncomplicated hysterectomy (laparoscopic supracervical, total laparoscopic/laparoscopic-assisted, vaginal and abdominal hysterectomies) and laparoscopic adnexal surgery were developed. Recommendations were based on a literature review and a modified Delphi procedure among 12 experts, recruited in collaboration with the participating medical boards of gynaecologists, GPs and OPs.

MAIN OUTCOME MEASURES

A multidisciplinary consensus of at least 67% on the relevant detailed convalescence recommendations in relation to hysterectomy and laparoscopic adnexal surgery.

RESULTS

Out of initially 65 activities, the expert panel judged 38 activities relevant for convalescence recommendations. Consensus for all activities was achieved after four Delphi rounds and two group discussions. The recommendations were judged as feasible by a representative sample of 26 gynaecologists, 19 GPs and 18 OPs.

CONCLUSIONS

Consensus between gynaecologists, GPs and OPs was achieved on all relevant convalescence recommendations regarding hysterectomy (abdominal, vaginal and laparoscopic) and laparoscopic adnexal surgery.