Prise en charge invasive conservatrice pour hémorragie du post-partum : fertilité et devenir obstétrical

High-intensity focused ultrasound as a pretreatment combined with hysteroscopic resection for gestational trophoblastic neoplasia with chemotherapy intolerance: a case report

BACKGROUND

Due to resistance and intolerance to chemotherapy, localized lesion resection may be required in some patients with Gestational trophoblastic neoplasia (GTN), which may lead to massive bleeding. In this case report, we describe the successful use of high-intensity focused ultrasound (HIFU) as an effective pretreatment method for surgical procedure in a patient with GTN to reduce the perioperative risk and the impact on fertility.

CASE PRESENTATION

A 26-year-old woman was diagnosed with high-risk GTN (FIGO Stage III: 12 prognostic scores) after a hydatidiform mole. The fifth chemotherapy cycle was interrupted due to severe chemotherapy toxicity. However, the uterine lesion was still present and the beta-human chorionic gonadotropin (β-hCG) level was not restored to normal. Therefore, ultrasound-guided HIFU was performed as a pretreatment method to shrink the lesion and prevent massive bleeding during localized lesion resection. The effectiveness of ablation was evaluated immediately using contrast-enhanced ultrasound and Color Flow Doppler ultrasonography. One month after HIFU treatment, the uterine lesion was completely resected under hysteroscopic surgery. During the surgery, HIFU was found to have shrunk the lesion and there was minimal bleeding (5 mL). The uterine cavity morphology and menstruation returned to normal after surgery. The patient has showed no signs of recurrence as of one-year follow-up.

CONCLUSION

Ultrasound-guided HIFU ablation may be a new choice for high-risk GTN patients with chemoresistance or chemo-intolerance. As a noninvasive pretreatment method, HIFU can shrink the uterine lesion, and reduce the risk of bleeding with no obvious effect on fertility.

Visual estimation of postpartum blood loss during a simulation training: A prospective study

OBJECTIVE

The objective of our study was to compare visually estimated blood loss (with collector bags and absorbent pads) during postpartum with the real volume during a simulation training.

STUDY DESIGN

This study was conducted from May 23 to December 22, 2017 during training sessions on the theme of postpartum haemorrhage provided by the Elena perinatal network. 137 participants visually estimated the losses contained in 5 graduated collector bags (from 600 to 1800mL) and on 5 absorbent pads (from 200 to 1000mL).

RESULTS

The averages of the visual estimated blood loss were significantly different from the real value, except for absorbent pads containing 400mL of losses. The low volumes are better estimated for either the absorbent pads or collector bags (p<0.001). 57% of the volumes were underestimated with collector bags, 33% of the estimates were accurate to ± 50 mL. With absorbent pads, 51% of the estimates were underestimated, compared to 22%, that were accurate.

CONCLUSION

The simulation training allows to test the capacities of visual estimation of blood loss by health professionals in order to improve them and to improve the maternal care during postpartum haemorrhage.

[Obstetric outcomes after uterine compression suture for treatment of postpartum hemorrhage: Long-term monitoring of 40 cases]

OBJECTIVE

Uterine atony is the first cause of postpartum hemorrhage. In caesarean section, different techniques of uterine compression suture exist when uterotonic drugs fail. Their effectiveness is shown but little data on their effects on subsequent pregnancies are available. The aim of this work is analyze of the obstetrical long-term consequences after uterine compression suture.

PATIENTS AND METHODS

This is a retrospective study of 40 cases of uterine compression suture performed in a level III maternity, between 2004 and 2010. The main objective is the evaluation of the obstetrical prognosis of subsequent pregnancies. The efficacy and safety of surgical techniques, according to their transfixing character or not, were analyzed.

RESULTS

Eleven pregnancies after uterine compression suture were reported among 14 women whishing another pregnancy. The median time to be pregnant was 27 months (6-78 months). Nine pregnancies were conducted at term. One case of intrauterine growth restriction and a moderate prematurity at 32 weeks were observed. There was no significant difference in efficacy and early surgical complications according to the surgical technique; however, both infectious and ischemic complications were observed after transfixing compression suture.

CONCLUSION

The obstetric prognosis after a uterine compression suture is kept. The transfixing techniques may cause more infectious and ischemic complications. An evaluation of surgical techniques depending on their transfixing, or not, character on a large cohort is necessary for the evaluation of the influence of the technique on fertility and postoperative complications.