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Pain Management during Office Hysteroscopy: An Evidence-Based Approach. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081132. [PMID: 36013599 PMCID: PMC9416725 DOI: 10.3390/medicina58081132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Hysteroscopy is a reliable technique which is highly useful for the evaluation and management of intrauterine pathology. Recently, the widespread nature of in-office procedures without the need for anesthesia has been requesting validation of practical approach in order to reduce procedure-related pain. In this regard, we performed a comprehensive review of literature regarding pain management in office hysteroscopic procedures. Materials and Methods: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Global Health, Health Technology Assessment Database and Web of Science, other research registers (for example Clinical Trials database) were searched. We searched for all original articles regarding pain relief strategy during office hysteroscopy, without date restriction. Results have been collected and recommendations have been summarized according to the Appraisal of Guidelines for Research and Evaluation (AGREE) tool. Moreover, the strength of each recommendation was scored following the Grading of Recommendations Assessment (GRADE) system, in order to present the best available evidence. Results: Both pharmacological and non-pharmacological strategies for pain management are feasible and can be applied in office setting for hysteroscopic procedures. The selection of strategy should be modulated according to the characteristics of the patient and difficulty of the procedure. Conclusions: Accumulating evidence support the use of pharmacological and other pharmacological-free strategies for reducing pain during office hysteroscopy. Nevertheless, future research priorities should aim to identify the recommended approach (or combined approaches) according to the characteristics of the patient and difficulty of the procedure.
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Baradwan S, Khalil M, Alshahrani MS, Albouq B, AlSghan R, Khadawardi K, Mohamed DF, Yousef DH, Kamal SHM, Abdel Halim HW, Elhawary MAA, Alkholy EA, Elsharkawy MRM, Abdelhakim AM, Abbas AM, Dahshan SA, Alshawadfy A, Soror GI. Warm saline effectiveness for pain relief in office hysteroscopy: A systematic review and meta‐analysis of randomized controlled trials. J Obstet Gynaecol Res 2022; 48:1523-1530. [DOI: 10.1111/jog.15272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/23/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Saeed Baradwan
- Department of Obstetrics and Gynecology King Faisal Specialist Hospital and Research Center Jeddah Saudi Arabia
| | - Mohamed Khalil
- Department of Obstetrics and Gynecology Faculty of Medicine, Kafrelsheikh University Kafr el‐Sheikh Egypt
| | - Majed S. Alshahrani
- Department of Obstetrics and Gynecology Faculty of Medicine, Najran University Najran Saudi Arabia
| | - Bayan Albouq
- Department of Obstetrics and Gynecology Prince Mohammed Bin Abdulaziz National Guard Hospital Madinah Saudi Arabia
| | - Rayan AlSghan
- Department of Obstetrics and Gynecology Maternity and Children Hospital AlKharj Saudi Arabia
| | - Khalid Khadawardi
- Department of Obstetrics and Gynecology Faculty of Medicine, Umm Al‐Qura University Makkah Saudi Arabia
| | - Doaa F. Mohamed
- Department of Obstetrics and Gynecology Faculty of Medicine for Girls, Al‐Azhar University Cairo Egypt
| | - Doaa H. Yousef
- Department of Obstetrics and Gynecology Faculty of Medicine for Girls, Al‐Azhar University Cairo Egypt
| | - Shaimaa H. M. Kamal
- Department of Obstetrics and Gynecology Faculty of Medicine for Girls, Al‐Azhar University Cairo Egypt
| | - Hala W. Abdel Halim
- Department of Obstetrics and Gynecology Faculty of Medicine for Girls, Al‐Azhar University Cairo Egypt
| | - Mona A. A. Elhawary
- Department of Obstetrics and Gynecology Faculty of Medicine for Girls, Al‐Azhar University Cairo Egypt
| | - Eman A. Alkholy
- Department of Obstetrics and Gynecology Faculty of Medicine for Girls, Al‐Azhar University Cairo Egypt
| | | | | | - Ahmed M. Abbas
- Department of Obstetrics and Gynecology Faculty of Medicine, Assiut University Assiut Egypt
| | - Shaimaa A. Dahshan
- Department of Anesthesia and Intensive care Faculty of Medicine, Suez Canal University Ismaïlia Egypt
| | - Abdelrhman Alshawadfy
- Department of Anesthesia and Intensive care Faculty of Medicine, Suez Canal University Ismaïlia Egypt
| | - Ghada I. Soror
- Department of Obstetrics and Gynecology Faculty of Medicine for Girls, Al‐Azhar University Cairo Egypt
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Gulucu S, Cakmak B. Warm distension fluid reduces pain severity in office hysteroscopy: a randomized controlled trial. Ann Saudi Med 2021; 41:135-140. [PMID: 34085547 PMCID: PMC8176380 DOI: 10.5144/0256-4947.2021.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Abnormal uterine bleeding (AUB) affects approximately 14% to 25% of women of reproductive age. The most common use of office hysteroscopy is to evaluate pathologies related to AUB and reproductive health, but office hysteroscopy can also be used for the diagnosis and treatment of other intrauterine pathologies. OBJECTIVE Investigate the effects of the temperature of the distension fluid on pain severity in patients undergoing diagnostic office hysteroscopy due to AUB. DESIGN Randomized controlled clinical trial. SETTING Tertiary care center in Turkey. PATIENTS AND METHODS One hundred perimenopausal patients with AUB were randomly allocated according to the temperature of the distension fluid used in office hysteroscopy (37°C or 25°C). Pain intensity was assessed using a visual analog scale (VAS). Six VAS measurements were compared over the course of the hysteroscopy: pre-treatment (VAS-1), at vaginal entry (VAS-2), at the cervical ostium transition (VAS-3), while in the cavity (VAS-4), at the end of the procedure (VAS-5), and 30 minutes after the end of the procedure (VAS-6). MAIN OUTCOME MEASURE VAS SAMPLE SIZE: Fifty in each group enrolled, one drop out. RESULTS The VAS-3, VAS-4, and VAS-5 scores were significantly lower for patients in the warm fluid group than in the room temperature group (P<.05), whereas the VAS-1, VAS-2, and VAS-6 scores were similar in both groups. CONCLUSION The application of warm distension fluid in office hysteroscopy reduces pain severity compared with the application of an unheated fluid. LIMITATIONS The main limitations of the study were that a subgroup analysis could not be performed due to an insufficient number of cases, and we were unable to evaluate vasovagal symptoms. CONFLICT OF INTEREST None.
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Affiliation(s)
- Selim Gulucu
- From the Department of Obstetrics and Gynecology, Gaziosmanpasa University, Tokat, Turkey
| | - Bulent Cakmak
- From the Department of Obstetrics and Gynecology, Nigde Omer Halisdemir University, Merkez Nigde, Turkey
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Sorbi F, Fambrini M, Saso S, Lucenteforte E, Lisi F, Piciocchi L, Cioni R, Petraglia F. Office hysteroscopy in pre- and post-menopausal women: a predictive model. Gynecol Endocrinol 2021; 37:206-210. [PMID: 33356672 DOI: 10.1080/09513590.2020.1864316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES To assess the variables associated with success of office hysteroscopy (OH) in pre-menopausal and post-menopausal women and to develop a clinical model for predicting the outcome of OH. METHODS This is a retrospective cohort study of consecutive patients (n = 3181) referred for an OH to a tertiary care university hospital between January 2018 and March 2020. Multivariate logistic regression analysis was used to investigate the variables for predicting the success of OH in all patients and in pre-menopausal and in post-menopausal patients separately. The logistic regression analysis of each variable was applied to develop a predictive model. RESULTS The overall success rate of the procedure was 92.2%; 95.4% in pre-menopausal women and 87.6% in post-menopausal women. In the general population, independent predictors of procedure success were previous vaginally delivery and hysteroscopy, while previous cervical or uterine surgery were associated with incomplete OH. In the pre-menopausal group, the independent predictors of failure were treatment with GnRH, estroprogestins and infertility. In 89% of cases, our developed model was able to predict whether an OH would be successful in a particular patient. ROC analysis showed an area under the curve of 0.8746 (95% CI: 0.85354-0.89557). CONCLUSIONS The present study demonstrates the development of a simple and reliable clinical model for the identification of both pre-menopausal and menopausal patients with a high chance of OH success.
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Affiliation(s)
- Flavia Sorbi
- Department of Biomedical, Experimental and Clinical Sciences - Division of Obstetrics and Gynecology, University of Florence, Careggi University Hospital Florence, Florence, Italy
| | - Massimiliano Fambrini
- Department of Biomedical, Experimental and Clinical Sciences - Division of Obstetrics and Gynecology, University of Florence, Careggi University Hospital Florence, Florence, Italy
| | - Srdjan Saso
- Division of Surgery & Cancer, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Ersilia Lucenteforte
- Department of Neurosciences, Psychology, Pharmacology and Child Health, University of Florence, Careggi University Hospital Florence, Florence, Italy
| | - Federica Lisi
- Department of Biomedical, Experimental and Clinical Sciences - Division of Obstetrics and Gynecology, University of Florence, Careggi University Hospital Florence, Florence, Italy
| | - Luigi Piciocchi
- Department of Obstetrics and Gynecology, Careggi University Hospital, Florence, Italy
| | - Riccardo Cioni
- Department of Obstetrics and Gynecology, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Department of Biomedical, Experimental and Clinical Sciences - Division of Obstetrics and Gynecology, University of Florence, Careggi University Hospital Florence, Florence, Italy
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Vitale SG, Alonso Pacheco L, Haimovich S, Riemma G, De Angelis MC, Carugno J, Lasmar RB, Di Spiezio Sardo A. Pain management for in-office hysteroscopy. A practical decalogue for the operator. J Gynecol Obstet Hum Reprod 2020; 50:101976. [PMID: 33166706 DOI: 10.1016/j.jogoh.2020.101976] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 12/01/2022]
Abstract
Hysteroscopy is known to be the gold standard for evaluation of intrauterine pathologies, pre-menopausal and post-menopausal abnormal uterine bleeding and, in addition to this, it is a crucial examination in the infertility work-up. In-office operative hysteroscopy incorporates the outstanding possibility of seeing and treating an intracavitary pathology in the same examination, eliminating all the risk related to anesthesia and reducing procedure-related costs. By now, performing operative procedures in the office setting is recognized as feasible and safe. Over the last 20 years, many efforts have been made to implement the in-office operative approach worldwide. However, for some women, in-office hysteroscopy is still considered a painful experience, with reported discomfort at different steps of the hysteroscopic procedures. Moreover, uneventful and tedious sensations might be increased by a high level of anxiety for such examination. For this reason, despite the feasibility of the in-office approach, many clinicians are still afraid of provoking pain during the procedure and rather not to perform surgical procedures in the office, postponing the removal of the pathology in the operating room. To date, there is no consensus concerning pain management for in-office hysteroscopy and different approaches, pharmacological and non-pharmacological aids, as well as several procedural tips and tricks are utilized. Our purpose is to provide a feasible practical decalogue for the operator, to supply adequate management of pain during in-office hysteroscopic procedures, performing challenging operations, shrinking discomfort, aiming to upgrade both women's and operator's satisfaction.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
| | | | - Sergio Haimovich
- Hillel Yaffe Medical Center, Technion-Israel Technology Institute, Hadera, Israel
| | - Gaetano Riemma
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, Florida, USA
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Analgesia for Office Hysteroscopy: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 27:1034-1047. [DOI: 10.1016/j.jmig.2020.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/18/2019] [Accepted: 01/14/2020] [Indexed: 12/19/2022]
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Riemma G, Schiattarella A, Colacurci N, Vitale SG, Cianci S, Cianci A, De Franciscis P. Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review. Climacteric 2020; 23:376-383. [PMID: 32396751 DOI: 10.1080/13697137.2020.1754388] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.
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Affiliation(s)
- G Riemma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Schiattarella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - N Colacurci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - S G Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - S Cianci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - A Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - P De Franciscis
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania 'Luigi Vanvitelli', Naples, Italy
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Ghamry NK, Samy A, Abdelhakim AM, Elgebaly A, Ibrahim S, Ahmed AA, Abdelbaky WH, Abdallah KM, Badawy MA, Mohammed AH, Hamza M. Evaluation and ranking of different interventions for pain relief during outpatient hysteroscopy: A systematic review and network meta-analysis. J Obstet Gynaecol Res 2020; 46:807-827. [PMID: 32088931 DOI: 10.1111/jog.14221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/27/2020] [Accepted: 02/08/2020] [Indexed: 11/29/2022]
Abstract
AIM To identify the highest-ranked pharmacological and nonpharmacological interventions for pain relief during outpatient hysteroscopy. METHODS We conducted an online bibliographic search in different databases from inception till July 2019. We included randomized controlled trials assessing effect of pharmacological and nonpharmacological interventions on pain relief during outpatient hysteroscopy. Our main outcomes were pain scores at different endpoints of the procedure. We applied this network meta-analysis based on the frequentist approach using statistical package 'netmeta' (version 1.0-1) in R. RESULTS The review included 39 randomized controlled trials (Women n = 3964). Misoprostol plus intracervical block anesthesia (mean difference [MD] = -3.32, 95% confidence interval [CI] [-6.06, -0.59]), misoprostol (MD = -1.92, 95% CI [-3.04, -0.81]) and IV analgesia (MD = -2.01, 95% CI [-3.27, -0.25]) were effective in reducing pain during the procedure compared to placebo. Ranking probability showed that misoprostol plus intracervical block anesthesia was the highest ranked pharmacological treatment for pain relief during the procedure (P score = 0.92) followed by misoprostol alone (P score = 0.78), and IV analgesia (P score = 0.76). Regarding nonpharmacological treatments, transcutaneous electrical nerve stimulation (TENS) showed a significant pain reduction compared to placebo (MD = -1.80, 95% CI [-3.31, -0.29]). TENS ranked as the best nonpharmacological treatment (P score = 0.80) followed by CO2 distention (P score = 0.65) and bladder distention (P score = 0.60). CONCLUSION Combination of misoprostol plus local anesthesia appears to be the most effective pharmacological approach for pain reduction during and after outpatient hysteroscopy. Nonpharmacological approaches as TENS and bladder distention showed considerable efficacy but should be further investigated.
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Affiliation(s)
- Nevein K Ghamry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Samy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | - Safaa Ibrahim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amal A Ahmed
- Obstetrics and Gynecology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Waleed H Abdelbaky
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Khaled M Abdallah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Mahmoud A Badawy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Ahmed H Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Assiut, Egypt
| | - Mohamed Hamza
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Goswami D, Nisa N, Sharma A, Dadhwal V, Baidya DK, Arora M. Low-Dose Ketamine for Outpatient Hysteroscopy: A Prospective, Randomised, Double-Blind Study. Turk J Anaesthesiol Reanim 2019; 48:134-141. [PMID: 32259145 PMCID: PMC7101193 DOI: 10.5152/tjar.2019.73554] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 05/20/2019] [Indexed: 11/22/2022] Open
Abstract
Objective Outpatient hysteroscopy is often accompanied by pain and discomfort along with frequent occurrence of bradycardia and hypotension. This study aimed to observe if intravenous low-dose ketamine reduces the pain scores along with lowering the incidence of bradycardia and hypotension during hysteroscopy. Methods This prospective, randomised, double-blind trial was conducted in operating rooms in a tertiary care hospital. In this study, we enrolled 72 patients with American Society of Anesthesiologists status I to II undergoing hysteroscopy. We randomised patients into two groups, and both groups received paracervical block. The control group received intravenous pentazocine and promethazine along with saline infusion. The ketamine group received ketamine infusion (0.75 mg kg−1 bolus followed by infusion at the rate of 10 mcg kg−1 min−1). We analysed visual analogue scale (VAS), rescue analgesic consumption, hemodynamic parameters, lowest recorded heart rate, blood pressure, level of sedation, patient’s comfort, surgeon’s satisfaction and nursing staff’s satisfaction. Results Analysis of the data revealed that the pain scores were similar in both the groups (p=0.493, p<0.001). Rescue analgesic was required by 47% patients in control group, compared to only 5.6% patients in ketamine group. Episodes of bradycardia and hypotension were more pronounced in the control group than in the ketamine group [77.4±10.9 vs. 78.4±5.5; 67.6±8 vs. 70.1±6 respectively] (p<0.001). Patient comfort and surgeon’s satisfaction were higher in the ketamine group, but nursing satisfaction was higher in the control group. Disorientation was present in 75% patients in the ketamine group as compared to none in the control group. Conclusion We concluded that low-dose ketamine in day-care hysteroscopy is an effective and safe agent.
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Affiliation(s)
- Devalina Goswami
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Neisevilie Nisa
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Sharma
- Department of Trauma and Emergency (Anaesthesiology) All India Institute of Medical Sciences, Jodhpur, India
| | - Vatsala Dadhwal
- Department of Obstretics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim Kumar Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Mahesh Arora
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Bharathi S, Maurya DK, Keepanasseril A, Kubera NS. Efficacy and safety of Tramadol as an analgesic in women undergoing vaginoscopic hysteroscopy: a randomized placebo-controlled trial. J OBSTET GYNAECOL 2019; 40:678-683. [PMID: 31462117 DOI: 10.1080/01443615.2019.1647525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Pain or discomfort during the hysteroscopy remains a challenge even after the introduction of small calibre instruments and vaginoscopic techniques. Tramadol, a centrally acting analgesic, is one among the medications used to reduce pain; however, the experience with its use in the vaginoscopic technique is limited. This was a randomised double-blind placebo-controlled trial conducted to study the effectiveness of oral Tramadol as an analgesic in 100 women undergoing diagnostic vaginoscopic hysteroscopy. Median pain score assessed by the Visual Analogue Scale was lower in the study group compared to the placebo group during the procedure (7 versus 8; p < .001) and immediately after the procedure (6 versus 7; p < .001) Ease of entry, procedure entry time and the adverse effects were similar in both the groups. Administration of oral Tramadol 50 mg, 1 h prior to the procedure may be a safe and effective analgesic in women undergoing diagnostic vaginoscopic hysteroscopy.Impact statementWhat is already known on this subject? Even with the use of newer hysteroscopes with small calibres and vaginoscopic techniques, pain and discomfort to the patient during negotiation through the cervix remain the main challenge to the surgeon. Among the several medications reported to reduce pain during the procedure, Tramadol a centrally acting drug with dual analgesic action, both by the µ opioid receptor agonist action and by the inhibiting uptake of serotonin and norepinephrine, can be used. However, studies using oral Tramadol during vaginoscopic hysteroscopy are limited.What do the results of this study add? The median pain score assessed by the Visual Analogue Scale was lower in the study group compared to the placebo group during the procedure (7 versus 8; p < .001) and immediately after the procedure (6 versus 7; p < .001). Ease of entry, procedure entry time and the adverse effects were similar in both the groups.What are the implications of these findings for clinical practice and/or further research? This study suggests that administration of oral Tramadol 50 mg, 1 h prior to the procedure, may be used as a safe and effective analgesic in women undergoing diagnostic vaginoscopic hysteroscopy. Future trial with a larger sample size is required to confirm the tolerability of its use, as the incidence of adverse effects was low in the study.
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Affiliation(s)
- Shree Bharathi
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research, Puducherry, India
| | - Dilip Kumar Maurya
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research, Puducherry, India
| | - Anish Keepanasseril
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research, Puducherry, India
| | - N S Kubera
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research, Puducherry, India
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Exalto N, Emanuel MH. Clinical Aspects of HyFoSy as Tubal Patency Test in Subfertility Workup. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4827376. [PMID: 31360713 PMCID: PMC6644241 DOI: 10.1155/2019/4827376] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 06/04/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Tubal patency testing is an essential part of female subfertility evaluation. Traditionally, hysterosalpingography (HSG) was the first step to evaluate tubal patency. However, during the past decade Hysterosalpingo-Contrast Sonography (HyCoSy) was introduced in order to avoid radiation exposure and Hysterosalpingo-Foam Sonography (HyFoSy) has been developed as a safe and less painful alternative. OBJECTIVES AND RATIONALE The aim of this narrative review is to provide an overview of the currently available HyFoSy literature and related clinical aspects. SEARCH METHODS A literature search was conducted using PubMed and Embase from the introduction of HyFoSy to March 2019. Unfortunately, a meta-analysis was not possible due to a too small number of studies, being mutually incomparable for the various subjects of clinical aspects, even for the reliability as a test for tubal patency. OUTCOMES Nine small studies concluded that the accuracy and effectiveness as a test for tubal patency of 2D- and 3D-HyFoSy are comparable or even better than HSG or HyCoSy. With or without using Doppler techniques, 3D-HyFoSy does not seem to offer benefits above real-time 2D-HyFoSy. Five studies reported on pain and discomfort during HyFoSy, concluding that HyFoSy is a well-tolerated, less painful procedure compared to HSG, without a need for the use of analgesics. There are suggestions about an increased pregnancy rate in the first three cycles after the procedure but in no studies pregnancy outcome after HyFoSy was compared with other or no intervention. WIDER IMPLICATIONS HyFoSy is a promising and safe alternative for HSG with regard to accuracy and effectiveness. HyFoSy lacks radiation and iodine exposure and is a well-tolerated and less painful procedure than HSG, without the need for analgesics. However more research is needed to make clear statements regarding a therapeutic effect of HyFoSy.
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Affiliation(s)
- Niek Exalto
- Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Mark Hans Emanuel
- Division of Woman and Baby, Department of Gynaecology and Reproductive Medicine, University Medical Centre, Utrecht, Netherlands
- Department of (Uro)gynaecology, University Hospital, Ghent, Belgium
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Role of Chromohysteroscopy in Evaluation of Endometrial Pathology Using Methylene Blue Dye. J Obstet Gynaecol India 2019; 69:363-368. [PMID: 31391745 DOI: 10.1007/s13224-019-01233-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 04/19/2019] [Indexed: 10/26/2022] Open
Abstract
Background Chromohysteroscopy is expected to help in diagnosing subtle endometrial pathologies which could be missed on conventional hysteroscopy and also help in targeting biopsy from endometrium. Objective To study staining pattern of endometrium in patients undergoing chromohysteroscopy and to evaluate and compare the histopathology of chromohysteroscopy-guided endometrial biopsy with conventional endometrial sampling. Method This was a cross-sectional study conducted during the period of 18 months in Department of Obstetrics and Gynaecology, ESI PGIMSR, New Delhi, India, from September 2016 to February 2018. Totally, 60 women with complaints of infertility, failed intrauterine insemination (IUI), recurrent spontaneous abortions (RSA), heavy menstrual bleeding (HMB), intermenstrual bleeding (IMB) and postmenopausal bleeding (PMB) meeting inclusion criteria were evaluated and enrolled in the study. In patients with normal looking endometrium on hysteroscopy, methylene blue dye was administered through the hysteroscopic inlet. Tissue samples were obtained from stained areas followed by blind endometrial sampling immediately. The results of chromohysteroscopy-guided biopsy from light- and dark-blue-stained areas and blind biopsy were compared. Results Mean age of the study group was 37 years, with mean BMI of 24 kg/m2. There were 24 cases of HMB, 9 of IMB, 7 of PMB, 15 of infertility, 2 of failed IUI and 3 with RSA. On chromohysteroscopy, 39(65%) cases showed light-stained endometrium (group I) and 21(35%) showed dark-stained endometrium (group II). Comparison was done between histopathology obtained through chromohysteroscopy and blind endometrial sampling. The diagnostic accuracy of chromohysteroscopy-guided endometrial biopsy in evaluation of endometrial pathology was 86.67% with sensitivity of 91.67%, specificity of 85.41%, PPV of 61.12% and NPV of 97.61% (P <0.001). Conclusion Chromohysteroscopy was able to detect endometrial pathology which was missed on conventional hysteroscopy and detected more cases of endometrial pathology than blind endometrial sampling.
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Abbas AM, Elzargha AM, Ahmed AGM, Mohamed II, Altraigey A, Abdelbadee AY. Oral Diclofenac Potassium Versus Hyoscine-N-Butyl Bromide in Reducing Pain Perception during Office Hysteroscopy: ARandomized Double-blind Placebo-controlled Trial. J Minim Invasive Gynecol 2019; 26:709-716. [DOI: 10.1016/j.jmig.2018.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/29/2018] [Accepted: 08/01/2018] [Indexed: 10/28/2022]
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New EP, Sarkar P, Sappenfield E, Mikhail E, Plosker S, Imudia AN. Comparison of patients' reported pain following office hysteroscopy with and without endometrial biopsy: a prospective study. ACTA ACUST UNITED AC 2018; 70:710-715. [DOI: 10.23736/s0026-4784.18.04215-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Capmas P, Pourcelot AG, Fernandez H. Are synechiae a complication of laparotomic myomectomy? Reprod Biomed Online 2018; 36:450-454. [DOI: 10.1016/j.rbmo.2018.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 11/16/2022]
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Ahmad G, Saluja S, O'Flynn H, Sorrentino A, Leach D, Watson A. Pain relief for outpatient hysteroscopy. Cochrane Database Syst Rev 2017; (10):CD007710. [PMID: 35611933 PMCID: PMC6485917 DOI: 10.1002/14651858.cd007710.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hysteroscopy is increasingly performed in an outpatient setting. Pain is the primary reason for abandonment of procedure or incomplete assessment. There is no consensus upon routine use of analgesia during hysteroscopy. OBJECTIVES To assess the effectiveness and safety of pharmacological interventions for pain relief in women undergoing outpatient hysteroscopy, compared with placebo, no treatment or other pharmacological therapies. SEARCH METHODS In September 2016 we searched the Cochrane Gynaecology and Fertility (CGF) Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers (ClinicalTrials.gov and WHO ICTRP), together with reference checking and contact with study authors and experts. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing use of pharmacological interventions with other pharmacological interventions and pharmacological interventions versus placebo or no treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our primary outcome was mean pain score. MAIN RESULTS We included 32 RCTS (3304 participants), of which only 19 reported data suitable for analysis. Most studies were at unclear or high risk of bias in most of the domains assessed. The evidence was low or very low quality, mainly due to risk of bias and imprecision. Baseline pain scores were relatively low in all groups. Analgesic versus placebo or no treatment Local anaesthetics Local anaesthetics reduced mean pain scores during the procedure [(SMD) -0.29, 95% CI -0.39 to -0.19, 10 RCTs, 1496 women, I2 = 80%, low-quality evidence)] and within 30 minutes (SMD 0.50, 95% CI -0.67 to -0.33, 5 RCTs, 545 women, I2 = 43%, low-quality evidence). This translates to a difference of up to 7 mm on a 0-10 cm visual analogue scale (VAS) during the procedure and up to 13 mm within 30 minutes, which is unlikely to be clinically meaningful. There was no clear evidence of a difference between the groups in mean pain scores after > 30 minutes (SMD -0.11, 95% CI -0.30 to 0.07, 4 RCTs, 450 women, I2 = 0%, low-quality evidence), or in rates of vasovagal reactions (OR 0.70, 95% CI 0.43 to 1.13, 8 RCTs, 1309 women, I2 = 66%, very low-quality evidence). There was insufficient evidence to determine whether there was a difference in rates of non-pelvic pain (OR 1.76, 95% CI 0.53 to 5.80, 1 RCT, 99 women, very low-quality evidence). Nonsteroidal anti-inflammatory drugs (NSAIDs) There was insufficient evidence to determine whether there was a difference between the groups in mean pain scores during the procedure (SMD -0.18, 95% CI -0.35 to 0.00, 3 RCTs, 521 women, I2 = 81%, low-quality evidence). Pain scores were lower in the NSAIDs group within 30 minutes (SMD -0.25, 95% CI -0.46 to -0.04, 2 RCTs, 340 women, I2=29%, low-quality evidence) and at over 30 minutes (SMD -0.27, 95% CI -0.49 to -0.05, 2 RCTs, 321 women, I2 = 78%, low-quality evidence). This equates to maximum differences of under 7.5 mm on a 0-10 cm scale, which are unlikely to be clinically significant. One RCT (181 women) reported adverse events: there was insufficient evidence to determine whether there was a difference between the groups in vasovagal reactions (OR 0.76, 95% CI 0.20 to 2.94, very low-quality evidence). For other reported adverse events (non pelvic pain and allergic reactions) evidence was lacking. Opioids One RCT utilised sublingual buprenorphine and one utilised oral tramadol. Data on pain scores during the procedure were unsuitable for pooling due to inconsistency. Tramadol was associated with a benefit of up to 22 mm on a 0-10 cm scale (SMD -0.76, 95% CI -1.10 to -0.42, 1 RCT, 140 women). However, the effect estimate for this outcome for sublingual opioids did not support a benefit from the intervention (SMD 0.08, 95% CI -0.22 to 0.39, 164 women). Compared with placebo, the pain score within 30 minutes of the procedure was reduced in the tramadol group, with a difference of up to 17mm on a 0-10cm scale (SMD -0.57, 95% CI -0.91 to -0.23 , 1 RCT, 140 women, low-quality evidence. There was no clear evidence of a difference between the tramadol and placebo groups at over 30 minutes (SMD -0.17, 95% CI -0.51 to 0.16, 1 RCT, 140 women, low-quality evidence). Nausea and vomiting occurred in 39% of the buprenorphine group, and in none of the placebo group (OR 107.55, 95% CI 6.44 to 1796.46) Analgesic versus any other analgesic Some comparisons did not report pain scores at all time frames of interest, and none reported data on adverse events. One RCT (84 women) compared local intracervical anaesthesia versus combined intracervical and paracervical anaesthesia. Pain scores were higher in the group with local intracervical anaesthesia during the procedure (SMD 4.27, 95% CI 3.49 to 5.06, very low-quality evidence), within 30 minutes (SMD 1.55, 95% CI 1.06 to 2.05, very low-quality evidence) and at more than 30 minutes (SMD 3.47, 95% CI 2.78 to 4.15, very low-quality evidence). This translates to a possible benefit in the combined group of up to 12 mm on a 0-10 cm scale during the procedure. Benefits at longer follow-up were smaller. One RCT compared antispasmodic + NSAID versus local paracervical anaesthesia. Pain scores were lower in the NSAID group than in the local anaesthesia group (during procedure: SMD -1.40, 95% CI -1.90 to -0.91; >30 minutes after procedure: SMD -0.87, 95% CI -1.33 to -0.41; 80 women, very low-quality evidence). This suggests a possible benefit of during the procedure of up to 23 mm on a 0-10 VAS scale and up to 11 mm >30 minutes after the procedure. Other comparisons included local intracervical anaesthesia versus combined intracervical, paracervical and topical anaesthesia, and opioid versus NSAIDs. Findings were inconclusive. AUTHORS' CONCLUSIONS There was no consistent good-quality evidence of a clinically meaningful difference in safety or effectiveness between different types of pain relief compared with each other or with placebo or no treatment in women undergoing outpatient hysteroscopy.
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Affiliation(s)
- Gaity Ahmad
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Sushant Saluja
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Helena O'Flynn
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Alessandra Sorrentino
- Pennine Acute Hospitals NHS TrustDepartment of RadiologyNorth Manchester General HospitalManchesterUKM8 5RB
| | - Daniel Leach
- The Royal Oldham Hospital, Pennine Acute Hospitals NHS TrustRochdale RdOldhamUKOL12JH
| | - Andrew Watson
- Tameside & Glossop Acute Services NHS TrustDepartment of Obstetrics and GynaecologyFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
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Optimal Order of Successive Office Hysteroscopy and Endometrial Biopsy for the Evaluation of Abnormal Uterine Bleeding. Obstet Gynecol 2017; 130:565-572. [DOI: 10.1097/aog.0000000000002202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hassan A, Haggag H. Role of oral tramadol 50 mg in reducing pain associated with outpatient hysteroscopy: A randomised double-blind placebo-controlled trial. Aust N Z J Obstet Gynaecol 2016; 56:102-6. [PMID: 26817525 DOI: 10.1111/ajo.12431] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 11/21/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several drugs have been used to reduce hysteroscopy-associated pain. Although the Royal College of Obstetricians and Gynaecologists has recommended against the use of opiates in outpatient hysteroscopy, we wished to investigate if opioids can be used if the appropriate opioid was given in the appropriate dose. AIM To study the effectiveness of tramadol 50 mg in reducing pain associated with outpatient hysteroscopy. MATERIALS AND METHODS A prospective randomised double-blind placebo-controlled trial conducted in the outpatient hysteroscopy clinic at Cairo University Hospital. Main outcome measures were the severity of pain during the procedure, immediately after the procedure and 30 minutes later assessed by a visual analogue scale (VAS). VAS of 0 indicates no pain and VAS of 10 indicates the worst possible pain. RESULTS A total of 140 women who had diagnostic outpatient hysteroscopy were randomised to receive oral tramadol 50 mg or placebo one h before performing outpatient hysteroscopy. There was no difference between the groups in the age, parity, duration of the procedures or indications of hysteroscopy. The median pain score was significantly lower in the tramadol group during the procedure (5 vs 6; P = 0.013), immediately after the procedure (3 vs 4; P < 0.036), and 30 minute later (1 vs 2; P = 0.034). Two women in the tramadol group reported nausea, but this was mild and did not warrant cancelling the procedure. CONCLUSIONS Oral administration of tramadol 50 mg before hysteroscopy reduces the pain evoked by the procedure and the drug was well tolerated by women.
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Affiliation(s)
- AbdelGany Hassan
- Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hisham Haggag
- Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt.,Department of Obstetrics and Gynecology, University of Saarland, Homburg, Germany
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Capmas P, Pourcelot AG, Giral E, Fedida D, Fernandez H. Office hysteroscopy: A report of 2402 cases. ACTA ACUST UNITED AC 2016; 45:445-50. [DOI: 10.1016/j.jgyn.2016.02.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/08/2016] [Accepted: 02/24/2016] [Indexed: 11/15/2022]
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Inoue T, Kitajima M, Taniguchi K, Masuzaki H. Three-dimensional saline-infusion sonohysterography is useful for the identification of endometrial polyp. J Obstet Gynaecol Res 2016; 42:855-9. [DOI: 10.1111/jog.12994] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 01/21/2016] [Accepted: 02/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Tsuneo Inoue
- Department of Obstetrics and Gynecology; Nagasaki University Hospital; Nagasaki Japan
| | - Michio Kitajima
- Department of Obstetrics and Gynecology; Nagasaki University Hospital; Nagasaki Japan
| | - Ken Taniguchi
- Department of Obstetrics and Gynecology; Nagasaki University Hospital; Nagasaki Japan
| | - Hideaki Masuzaki
- Department of Obstetrics and Gynecology; Nagasaki University Hospital; Nagasaki Japan
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Senturk MB, Guraslan H, Babaoğlu B, Yaşar L, Polat M. The Effect of Intrauterine Lidocaine and Rectal Indomethacin on Pain during Office Vaginoscopic Hysteroscopy: Randomized Double-Blind Controlled Study. Gynecol Obstet Invest 2015; 81:280-4. [DOI: 10.1159/000441787] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022]
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Moro F, Knez J, Pateman K, Derdelis G, Foo X, Jurkovic D. Ultrasound-guided retrieval of lost intrauterine devices using very fine grasping forceps: a case series. THE JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2015; 41:205-9. [PMID: 25648937 DOI: 10.1136/jfprhc-2014-101088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/01/2015] [Indexed: 11/03/2022]
Abstract
AIM To assess the efficacy of a novel ultrasound-guided procedure for the retrieval of intrauterine contraceptive devices (IUDs) when the threads are not visible at the external cervical os ('lost threads'). METHODS This was a prospective cohort study of consecutive women referred for ultrasound examination because of lost IUD threads. The procedures were performed under local anaesthesia in the outpatient setting. After injection of local anaesthetic, the anterior cervical lip was grasped with a vulsellum forceps. A 5Fr hysteroscopy grasping forceps was introduced transcervically into the uterine cavity under continuous transabdominal ultrasound guidance. The IUD was then grasped and removed from the uterus. Patients' demographic data, gynaecological history, ultrasound findings, duration of procedure, success rate and pain score were recorded. RESULTS Twenty-three consecutive women were included in the study. Ultrasound examination showed an IUD correctly sited in the centre of the uterine cavity in 20/23 (87%), in 2/23 (9%) it was partially embedded in the myometrium and in 1/23 (4%) the IUD was partially sited in the cervical canal. In 8/23 (35%) women the IUD threads were not visible on ultrasound scan. Removal of the IUD was successful in 22/23 (96%) cases with a median operating time of 3 (interquartile range 1.25-4.75) minutes. 15/23 (65%) women experienced no or minimal pain (pain score ≤3), 4/23 (17%) reported moderate pain (pain score 4-6) and 4/23 (17%) described the pain as severe (pain score 7-10). No complications were recorded during or immediately after the procedure. CONCLUSIONS Ultrasound-guided retrieval of lost IUDs using fine hysteroscopy grasping forceps is a highly successful technique and is well tolerated by women.
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Affiliation(s)
- Francesca Moro
- Clinical Research Fellow, Institute of Women's Health, University College London, London, UK
| | - Jure Knez
- Clinical Research Fellow, Institute of Women's Health, University College London, London, UK
| | - Katie Pateman
- Clinical Research Fellow, Institute of Women's Health, University College London, London, UK
| | - Grigorios Derdelis
- Clinical Research Fellow, Institute of Women's Health, University College London, London, UK
| | - Xulin Foo
- Clinical Research Fellow, Institute of Women's Health, University College London, London, UK
| | - Davor Jurkovic
- Consultant Gynaecologist, Institute of Women's Health, University College London, London, UK
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