Hysteroscopy in Pregnancy-Related Conditions: Descriptive Analysis in 273 Patients

Outpatient hysteroscopic removal of retained products of conception: evaluation of effectiveness, safety and patient satisfaction

OBJECTIVE

To assess effectiveness, safety and patient satisfaction of hysteroscopic removal of retained products of conception using a tissue removal system in the outpatient setting.

STUDY DESIGN

A prospective observational study was carried out in a tertiary care hospital over a 10-month period. Fifty-two women who underwent an outpatient hysteroscopy for removal of retained products of conception were included. Effectiveness was evaluated as complete removal of retained products of conception in a one-time procedure. Safety was determined based on the rate of complications using the Clavien-Dindo classification system. Patient satisfaction and pain were assessed using a visual analogue scale survey completed by patients after the procedure.

RESULTS

Complete removal of retained products of conception in a one-time procedure was achieved in 98.1% of cases. The mean morcellation time was 6.0 min. The complication rate recorded in this study was 9.6%; most complications were mild, but there was one case of uterine perforation. A global satisfaction ratio of 8.9 out of 10 was reported by patients. The study did not find any significant differences in complete removal of retained products of conception based on type of hysteroscope, presence of symptoms or Gutenberg classification. Although not significant, a linear relationship was observed between a higher volume of retained products of conception and a higher Gutenberg classification (p=0.229).

CONCLUSION

Outpatient management of retained products of conception using a tissue removal system is effective and safe, and has a high level of patient satisfaction. The results of this study have the potential to alter the standard approach to the management of retained products of conception.

Hysteroscopic management of molar pregnancy: A series of 36 cases

Background: Hydatidiform Mole (HM) is the most common form of gestational trophoblastic disease. Dilatation and curettage is the classical treatment of this affection. Hysteroscopic resection (HsR) is an alternative for the treatment of intra-uterine pathology.

Objective: To describe the feasibility of HsR for the management of HM.

Result: Case series of patients who had a complete or partial HM confirmed by histological examination of the trophoblastic tissue resected by operative hysteroscopy between 2007 and 2019. After approval of our ethics committee, we evaluated 36 patients who underwent hysteroscopic resection for molar pregnancy. Histological analysis showed partial HM in 28 patients (77.8%) and complete HM in 8 (22.2%). Main surgical complications were uterine perforation in one patient and glycine resorption in 10 patients with two cases of hyponatremia corrected by standard treatment. We performed an ultrasound control 1 month after the intervention in 19 patients (52.8%) as they had slow decrease of HCG or bleeding complaints and found retained product of conception (RPOC) in six patients (16.7%).

Conclusion: This first report on a small number of patients demonstrate that hysteroscopic resection is a feasible procedure for the management of molar pregnancy. Direct visualization of the procedure helps the surgeon to control the resection. Further studies are mandatory to compare this technique with D&C in term of RPOC and fertility outcomes as it remains the standard treatment.

Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique

OBJECTIVE

To evaluate the changes in (1) residual myometrial thickness (RMT), (2) cesarean scar defect (CSD) size, and (3) clinical symptoms, before and after channel-like (360°) hysteroscopic resection for the treatment of CSD.

METHODS

A single-center, observational, prospective, cohort study was carried out enrolling all symptomatic patients of childbearing age, diagnosed with CSD and routinely scheduled for channel-like (360°) hysteroscopic resection from July 2020 to July 2021 at the Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Univeristaria di Bologna. University of Bologna, Italy. The primary outcome was the difference in mean RMT before and after the procedure. Secondary outcomes were the differences before and 4 months after the surgery in: (1) CSD size measured by transvaginal ultrasound, (2) visual analog scale (VAS) scores for the symptoms, and (3) abnormal uterine bleeding (AUB) rate. Lastly, patients' satisfaction was assessed by the global impression of improvement (PGI-I) score.

RESULTS

We found a significant difference before and after the procedure in: (1) mean RMT (+2.0 mm; P < 0.001); mean size of the CSD (base: +1.6 mm; height: -2.5 mm; transverse diameter: -3.2 mm; volume: -263.7 mm³ ; P < 0.001); (2) mean VAS score for dyspareunia (-5.84; P < 0.001), dysmenorrhea (-8.94; P < 0.001), pelvic pain (-2.94; P < 0.001); (3) AUB rate (91% vs. 3%; P < 0.001). Lastly, the mean PGI-I score ± SD was 1.7 ± 0.9.

CONCLUSION

Channel-like (360°) hysteroscopic resection for the treatment of patients with symptomatic CSD may lead to an increase in RMT, decrease in CSD, and improvement of symptoms after the procedure, with high patient satisfaction.

Hysteroscopic Removal of Intrauterine Device in Pregnancy: A Scoping Review to Guide Personalized Care

Background and objectives: Pregnancies that occur with an intrauterine device (IUD) in situ are at increased risk for developing severe conditions which may affect the fetus and the mother. The incidence of such adverse consequences significantly drops after device removal. A scoping review of the literature was performed to highlight the risks, benefits, and outcomes of hysteroscopic removal of intrauterine devices in early pregnancy. Materials and Methods: PubMed, Scopus, and Web of Science were searched. The review included all reports from 1990 to October 2022. The research strategy adopted included different combinations of the following terms: (“hysteroscopy”) AND (“pregnancy”) AND (“intrauterine device” or “IUD”) AND (“intrauterine system” or “IUS”). A scoping review of the hysteroscopic removal of IUDs during pregnancy was performed. All studies identified were listed by citation, title, authors, and abstract. Duplicates were identified by an independent manual screening performed by two researchers and then removed. For the eligibility process, two authors independently screened the titles and abstracts of all non-duplicated papers and excluded those not pertinent to the topic. Results: PRISMA guidelines were followed. Nine manuscripts were detected, accounting for 153 patients. Most IUD removals occurred during the first trimester of pregnancy. Most of the time, the procedure was safe and without consequences. Conclusions: This review highlights the safety and efficacy of operative hysteroscopy as a method of IUD removal in early pregnancy. We recommend using a 3 to 5 mm hysteroscope, avoiding cervical dilation, and maintaining low infusion pressure during the procedure to avoid potential damage to the gestational sac and IUD fragment displacement. Heating the distension media to 30 °C should be considered.

New Efficient Method for Hysteroscopic Isthmoplasty: Four Simple Steps Lead to a Significant Improvement in Bleeding Status

We demonstrate an effective reduction in postmenstrual spotting after our novel hysteroscopic isthmoplasty. This study included 66 patients with isthmocele-related postmenstrual spotting confirmed by sonography and diagnostic hysteroscopy between 2000 and 2017. Our new interventions included the following four steps: (1) make a resection gradient of the distal edge of the isthmocele from the ape of the isthmocele down to the cervical outer orifice; (2) resect the distal and proximal niches of the isthmocele; (3) electrocauterize the distal and proximal sides (not only the niche bottom) of the small cave on the scar side of the isthmocele; (4) manage the isthmocele until it is largely connected to the cavity. In our results, all patients underwent extensive hysteroscopic repair of newly hysteroscopic isthmoplasty without any intra- or postoperative complications. After final hysteroscopic repair modification, prolonged menstrual spotting was significantly decreased in 98.2% (53/54) of the patients, and the total number of bleeding days per menstrual cycle significantly decreased from a mean of 15.38 ± 3.3 days to 6.4 ± 1.9 days postoperatively (p < 0.001). Our four-step hysteroscopic technique successfully resolved prolonged menstrual spotting in over 90% of the patients, exceeding the resolution rates of 60−85% achieved with other hysteroscopic techniques used to treat symptomatic isthmocele. No patients experience recurrence after long-term follow up. Four simple steps led to a significant improvement in bleeding status.

Outpatient hysteroscopic removal of intrauterine devices in early pregnancy: feasibility and outcomes

OBJECTIVE

To describe our experience with outpatient hysteroscopy for removal of intrauterine devices (IUDs) in pregnant patients, along with the pregnancy-related outcomes.

DESIGN

Retrospectively and prospectively collected data between January 2015 and April 2021.

SETTING

Hysteroscopic outpatient clinic (See and Treat Clinic) at a university affiliated, tertiary medical center.

PATIENT(S)

Forty-one patients with an inadvertent but desired pregnancy up to 12 weeks + 6 days gestational age with an IUD in situ, with documented failed attempts of IUD removal.

INTERVENTION(S)

After ultrasonographic confirmation of IUD location, gestational age, and viability, a small-caliber hysteroscope was introduced via a vaginoscopic approach. The uterus was distended using 0.9% normal saline until a clear view was achieved. On visualization, the IUD was grasped by its strings, tail, or lateral arm using a semirigid hysteroscopic grasper. Oral antibiotic prophylaxis was prescribed in all cases.

MAIN OUTCOME MEASURE(S)

The primary outcome of interest was term delivery, from 37 weeks of gestation. Secondary outcomes included patient-reported tolerability and satisfaction, and procedure-related and pregnancy related complications.

RESULT(S)

The procedure was completed successfully in all 41 patients. Thirty-three patients continued their pregnancies, resulting in 32 full-term singleton deliveries and 1 singleton preterm delivery at 33 + 4 weeks. Median gestational age at delivery was 39 weeks, with a median birthweight of 3,450 grams. Eight patients (19.5%) miscarried, 4 of these within a week of the procedure.

CONCLUSION(S)

In cases of desired pregnancy with an IUD, outpatient hysteroscopic removal of the IUD is a safe and effective management option. Broader uptake of outpatient hysteroscopy and development of hysteroscopic skills will allow more clinicians to offer patients this effective solution.

Hysteroscopic management of caesarean scar defects

A caesarean section may lead to a defect of the myometrium at the site of the uterine scar. The association with abnormal uterine bleeding or impaired fertility has been demonstrated. Hysteroscopic remodelling reportedly reduces the symptoms. To review the available literature reporting on hysteroscopic treatment of these defects in symptomatic women with abnormal uterine bleeding or impaired fertility. A systematic search of PubMed and Cochrane databases has been performed until January 2021, including 27 articles. Hysteroscopic remodelling relieved symptoms of abnormal uterine bleeding in 60-100% and 25-100% of women with impaired fertility conceived within the follow up period. No major complications were reported. Hysteroscopic remodelling seems a treatment option in the management of symptomatic caesarean scar defects. Long-term follow-up and larger studies are needed to evaluate the effect on abnormal uterine bleeding as well as on reproductive outcomes.

Hysteroscopy and Retained Products of Conception: An Update

Retained products of conception (RPOC) can occur after early or mid-trimester pregnancy termination and also following vaginal or cesarean delivery. It is frequently associated with continuous vaginal bleeding, pelvic pain, and infection. Late complications include intrauterine adhesions formation and infertility. Conventionally, the management of RPOC has been with blind dilation and suction curettage (D and C); however, hysteroscopic resection of RPOC is a safe and efficient alternative. In this review, we analyze the current available evidence regarding the use of hysteroscopic surgery for the treatment of RPOC comparing outcomes and complications of both traditional curettage and hysteroscopic technique. Data search has been conducted using the following databases MEDLINE, EMBASE, Web of Sciences, Scopus, Clinical Trial. Gov., OVID, and Cochrane Library interrogate all articles related to hysteroscopy and the preserved product of conception, updated through September 2020.

Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review

OBJECTIVE

To evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility.

DATA SOURCES

A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English.

METHODS OF STUDY SELECTION

After the removal of duplicates, 3380 articles were screened for inclusion independently by 2 authors. These 2 authors assessed for studies which focused on women of reproductive age with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least 1 of the goals being fertility restoration.

TABULATION, INTEGRATION, AND RESULTS

A total of 13 studies, comprising of 1 randomized controlled trial, 6 prospective case series, and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodologic quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. A total of 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods. Pregnancy rates in the randomized controlled trial were 21 of 28 (75%) for those treated by hysteroscopy compared with 9 of 28 (32%) for those untreated. Among the studies reporting pregnancy outcomes, 101 of 116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including the risk of reoperation.

CONCLUSION

The results of this systematic review suggest that the surgical treatment of an isthmocele, particularly through hysteroscopy, in patients with residual myometrial thickness of at least 2.5 mm, may be effective in treating isthmocele-associated secondary infertility with a relatively low complication rate. Further high-quality studies are needed because of the small sample sizes and observational nature of most available data.

Video Hysteroscopy in the Diagnosis of Molar Pregnancy in two Challenging Situations: Complete Mole with Normal hCG and Partial Mole with Early Gestational Age

STUDY OBJECTIVE

To present the first hysteroscopic findings of 2 cases of complete hydatidiform mole (CHM) and partial hydatidiform mole (PHM) within the context of the patients' clinical histories.

DESIGN

Presentation of 2 hysteroscopic videos with narration of the intrauterine findings of molar pregnancy (MP) from Rio de Janeiro Gestational Trophoblastic Disease Reference Center.

SETTING

MP is characterized by abnormal fertilization that generates 2 clinical syndromes: CHM and PHM [1].

INTERVENTIONS

In the first case, the patient was aged 50 years, and hysteroscopy was indicated to assess abnormal uterine bleeding in the presence of normal serum human chorionic gonadotropin (hCG) and transvaginal ultrassonography showing an endometrial cavity with heterogeneous content. Hysteroscopy found translucent hydropic structures diagnosed as CHM. The negative hCG value was due to the hook effect (hCG after dilution: 2 240 000 IU/L). In the second case, an 18-year-old patient underwent hysteroscopy to assess the endometrial cavity with retained abortion at 7 weeks in which, during conservative management, the hCG level increased over 4 weeks from 25 000 IU/L to 58 000 IU/L. Hysteroscopy visualized the embryo with its umbilical cord and hydatidiform vesicles diagnosed as PHM.

CONCLUSION

MP can be an incidental finding during hysteroscopy for abnormal uterine bleeding or retained abortion [2-4]. Knowing its morphology during hysteroscopy is helpful for the correct management of this uncommon clinical situation. Hysteroscopy as an adjunct diagnostic tool (not as first-line treatment for MP) can be of significant benefit in challenging clinical scenarios. Further studies should assess the possible risk of spreading molar cells into the peritoneal cavity owing to hysteroscopic fluid.

Corpus luteum score, a simple Doppler examination to prognose early pregnancies

OBJECTIVES

In early pregnancies, miscarriages and inconclusive ultrasound scans considering location and viability are very common. In several previous studies, serum progesterone levels predicted viability of pregnancy and, in recent ones, failed Pregnancies of Unknown Location (PUL), completion of miscarriage and complications. Corpus luteum, secreting progesterone in early pregnancy, was less studied. Some publications showed correlations between corpus luteum aspects and diagnosis of miscarriage but it was not evaluated for other outcomes in early pregnancy, such as failed PUL, completion of miscarriage or complications. We aimed to assess if Doppler examination of corpus luteum could also predict all these outcomes: failed PUL, diagnosis and completion of miscarriages and complications.

STUDY DESIGN

A single operator prospectively described and/or collected pictures of Doppler signal in the wall of the corpus luteum at most consultations in our early pregnancy unit and established a three-level score. All suspected or confirmed non-viable pregnancies with this score or/and serum progesterone levels were registered retrospectively. With logistic regressions, AIC/BIC, likelihood ratios, ROC curves, Mann-Whitney and Fisher exact tests, we evaluated the ability of the score, alone, to predict failed PUL, diagnosis and completion of miscarriages and the complications, and, combined, to improve previously published predictions.

RESULTS

From 277 included pregnancies, 186 (67.1 %) miscarried. Of these, 159/186 (85.5 %) fully evacuated without surgery: 114/186 (61.3 %) within 20 days after the first diagnosis and 45/186 (24.2 %) after more than 20 days. Twenty-seven patients (14.5 %) underwent surgical evacuation, including ten complications, five haemorrhages and five suspected infections. Logistic regression correlated strongly the corpus luteum score with failed PUL (p < 0.0001) and miscarriages (p < 0.0001). Moreover, rates of complications and swift non-surgical completions of miscarriage were respectively 0 % and 92 % with scores of 0, versus 6 % and 44 % with scores of 1, versus 16 % and 0 % with scores of 2. Combined with serum progesterone levels, this score improved most predictions. Adding parity or history of miscarriage in predictive models even increased these performances.

CONCLUSIONS

Corpus luteum score, alone, can predict failed PUL, diagnosis and completion of miscarriages and their complications. Combining this score with other factors (mainly serum progesterone levels) improves most predictions.

Surgical and Reproductive Outcomes after Hysteroscopic Removal of Retained Products of Conception: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the impact of hysteroscopy for retained products of conception (RPOC) removal on surgical and reproductive outcomes.

DATA SOURCES

Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, SciELO, EMBASE, and the Cochrane Central Register of Controlled Trials at the Cochrane Library) were searched from inception to March 2020.

METHODS OF STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Medical Subject Headings terms and text words such as "retained products of conception," "placental remnants," "placenta," and "hysteroscopy" were used for the identification of relevant studies. We included observational and randomized studies that analyzed surgical and/or reproductive outcomes of women who underwent hysteroscopic removal of RPOC. The primary outcome was the complete resection rate after 1 procedure.

TABULATION, INTEGRATION, AND RESULTS

Twenty out of 245 studies were applicable, with data provided for 2112 women. The pooled complete resection rate was 91% (95% confidence interval [CI], 0.83-0.96). The incomplete resection rate evaluated was 7% (95% CI, 0.03-0.14), with a complication rate of 2% (95% CI, 0.00-0.04). Out of 1478 procedures, only 12 cases (0.8%) of postsurgical intrauterine adhesions were reported. Regarding post-therapy fecundity, women attempting postoperative conception had a clinical pregnancy rate of 87% (95% CI, 0.75-0.95), with a live birth rate of 71% (95% CI, 0.60-0.81) and a pregnancy loss rate of 9% (95% CI, 0.06-0.12).

CONCLUSION

Hysteroscopy has a high rate of completely removing RPOC in a single surgical step, with low complication rates. Subsequent fecundity seems reassuring, with appropriate clinical pregnancy and live birth rates. However, standardization of approach and comparative trials of different hysteroscopic approaches are needed.

Hysteroscopy in the Treatment of Myometrial Scar Defect (Diverticulum) Following Cesarean Section Delivery: A Systematic Review and Meta-Analysis

Various management approaches have been developed to treat symptoms and prevent complications of the cesarean diverticulum. This systematic review aims to report the outcomes and fertility-related effects of hysteroscopy on women with myometrial scar defects after the cesarean section. Following the formulation of the patient/population, intervention, comparison, and outcomes (PICO) criteria, a systematic search was conducted on seven databases. Finally, a total of 18 studies were included for this systematic review and meta-analysis. All of the included patients suffered from post-cesarean section scars and presented with abnormal bleeding, pain, or secondary infertility. The overall pooled symptomatic improvement rate was 78.83% (95% CI: 72.46-85.76%); however, there was significant heterogeneity among the analyzed studies (I²=87%; p-value: <0.001) and a significant risk of bias (p-value: <0.001). The overall resolution/improvement rate after adjusting for possible bias was higher, 92.82% (95% CI: 85.17-100%). The overall pregnancy rate was 69.77% (95% CI: 59.03-82.48%), while in the individual studies the rates varied, ranging from 25% to 80%. Nevertheless, there was moderate heterogeneity among the included studies (I²=56%; p-value=0.011). In contrast, there was no significant risk of bias among the included studies (p-value=0.100). Furthermore, the meta-regression analyses did not show any significant effect of different follow-up durations on the overall effect size for both outcomes. In conclusion, there is still a need for high-quality, comparative studies with larger sample sizes and long-term follow-up periods to draw firm conclusions. Moreover, future studies should consider the minimum myometrial thickness that is sufficient to complete a healthy pregnancy.

Optimal Isthmocele Management: Hysteroscopic, Laparoscopic, or Combination

OBJECTIVE

To conduct a systematic review of the literature on the hysteroscopic and laparoscopic repair of isthmocele.

DATA SOURCES

A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. (PROSPERO registration number CRD42020190668).

METHODS OF STUDY SELECTION

Studies from the last 20 years that addressed isthmocele repair were collected. Both authors screened for study eligibility and extracted data. All prospective and retrospective studies of more than 10 women were included.

TABULATION, INTEGRATION, AND RESULTS

The initial search identified 666 articles (Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart) (see Supplemental Fig.). We excluded duplicates, case reports, reviews, video articles, and technique articles. We also excluded studies describing only laparotomy or vaginal repair as these were not in the scope of this review. A total of 31 articles met the inclusion criteria, 21 for hysteroscopic resection and 13 for laparoscopic or combined repair (4 articles tested both modalities and appear in both Tables 1 and 2).For abnormal uterine bleeding, hysteroscopic remodeling relived symptoms in 60% to 100% of cases and laparoscopy in 78% to 94%. Secondary infertility was not evaluated in all studies. After hysteroscopic and laparoscopic treatment, 46% to 100% and 37.5% to 90% of those who wished to conceive became pregnant, after the procedure, respectively. Pain and dysmenorrhea seem to be uncommon. All studies that tested improvement of pain had fewer than 10 women. However, between 66% and 100% of women who complain of pain or dysmenorrhea will note a marked improvement to full resolution.

CONCLUSION

Patients with an isthmocele or cesarean scar defect are usually asymptomatic. For symptomatic women, a repair is a valid option. For those with residual myometrial thickness >2 to 3 mm, hysteroscopic remodeling is the modality of choice with an improvement in abnormal uterine bleeding, secondary infertility, and pain. Women with a residual myometrial thickness <2- to 3-mm laparoscopic repair with simultaneous hysteroscopic guidance show similar results. Because available data are limited, no cutoff for the correct choice between hysteroscopy and laparoscopy can be concluded. We recommend 2.5 mm as the cutoff value based on common practice and expert opinion, although no significance between hysteroscopic and laparoscopic treatment was shown.

Role of hysteroscopy and ultrasound in early identification of post-molar gestational trophoblastic neoplasia

OBJECTIVE

To evaluate the role of hysteroscopy and ultrasound in early identification of gestational trophoblastic neoplasia (GTN) after molar evacuation.

METHODS

This was a prospective study involving 52 women with an ultrasound diagnosis of complete hydatidiform mole, attending a tertiary centre in south India between August 2016 and August 2019. Baseline characteristics such as age, serum beta-human chorionic gonadotropin(β-hCG) level, gestational age, and uterine size were noted. After the evacuation of molar pregnancy, weekly follow-up with β-hCG was performed, until three consecutive values were normal and then monthly for six months. Findings of transvaginal ultrasound and diagnostic hysteroscopy, performed on follow up at three weeks, were noted. Primary outcome was the development of GTN. Area under the curve(AUC) was calculated to assess the usefulness of these methods in early identification of GTN.

RESULTS

Thirteen women (25 %) developed GTN during follow up, within 6 months. Twenty six(50 %) cases had high-risk molar pregnancy. Positive findings on hysteroscopy and ultrasonography were noted in 44.2 % and 19.2 % respectively. AUC was 0.83(95 % CI, 0.70-0.97) for ultrasound and 0.82(95 % CI, 0.72-.92) for hysteroscopy. Sensitivity and specificity were 69.2 % and 97.4 % for ultrasound and it was 92.3 % and 71.8 % respectively for hysteroscopy in identifying those who developed GTN on follow-up.

CONCLUSIONS

Transvaginal ultrasound as well as hysteroscopy may help in early identification of women at risk of developing GTN following a molar evacuation. Being a non-invasive method with similar discriminative value, ultrasonographic evaluation may be used for early identification of women with GTN after validation in future studies.

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis

PURPOSE

To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications.

METHODS

PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology.

RESULTS

We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%).

CONCLUSIONS

We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.

Successful treatment of gestational trophoblastic neoplasia in the uterine cornus with laparoscopic cornuostomy and postoperative methotrexate injection

OBJECTIVE

Management of cornual gestational trophoblastic neoplasia (GTN) has never been reported. Here, we describe the first case of cornual GTN.

CASE REPORT

A 32-year-old woman was diagnosed with left cornual GTN after evacuation of a complete mole. Laparoscopic cornuostomy was performed with intramural vasopression injection and barbed sutures. Histopathology revealed hydropic chorionic villi. Complete hydatidiform mole was diagnosed, and treated with adjuvant methotrexate, to address the poor decline of β-human chorionic gonadotropin levels during follow-up. The β- human chorionic gonadotropin levels declined to < 1 mIU/mL 9 months after cornuostomy. She successfully conceived 16 months after cornuostomy, and underwent cesarean section at 37 gestational weeks due to concomitant severe preeclampsia.

CONCLUSION

Cornual GTN can be successfully managed with laparoscopic cornuostomy and adjuvant methotrexate.

Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar

An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmocele's characteristics and surgeon expertise.

Hysteroscopy in the treatment of uterine cesarean section scar diverticulum: A systematic review

The aim of this paper is to review and to analyze the results of previous studies dealing with hysteroscopic treatment of postcesarean scar defects. A systematic review of publications indexed in MEDLINE/PubMed database identified a total of 11 studies dealing with resectoscopic treatment of postcesarean scar defect. The review was conducted in line with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and the PRISMA statement. In only few studies, patients were qualified for hysteroscopic surgery based on the measurement of the defect depth and thickness of residual myometrium above the pouch. Two principal techniques were used for the hysteroscopic treatment: resection of one edge of the scar diverticulum, and resection of the inferior and superior edges of the defect. Additionally, most authors performed electrocauterization of the niche bottom. Resectoscopic treatment turned out to be highly effective in the case of women with AUB. No complications of the hysteroscopic procedure have been reported. Methodological value of the reviewed studies was relatively low due to non-unified selection/verification criteria and incomplete, non-systematic postoperative assessment. In conclusion, hysteroscopic treatment seems to be a promising option in the management of postcesarean scar defects, but still further research is needed on the problem in question.

A "See and Treat" Office Procedure for Retained Products of Conception Removal After Normal Vaginal Delivery Using Manual Vacuum Aspiration: Preliminary Efficacy and Reproductive Outcomes

STUDY OBJECTIVE

To compare the efficacy and reproductive outcomes of an ultrasound-guided manual vacuum aspiration (MVA) procedure with the widely accepted operative hysteroscopic (OH) procedure in the removal of retained products of conception (RPOCs) after normal vaginal delivery.

DESIGN

A retrospective cohort study (Canadian Task Force classification II-2).

SETTING

A university-affiliated tertiary medical center.

PATIENTS

Eighty-six patients after normal vaginal delivery diagnosed with RPOCs from 2005 through 2015. This study was approved by the local institutional review board.

INTERVENTIONS

Treatment with either MVA or OH for patients diagnosed with RPOCs.

MEASUREMENTS AND MAIN RESULTS

Of 86 patients, 23 underwent remnant removal by ultrasound-guided MVA using a 6- to 7-mm catheter in a "see and treat" office procedure. Sixty-three patients underwent remnant removal using the OH procedure. Follow-up included sonographic examination 3 to 5 weeks after the procedure and long-term follow-up on complications and reproductive outcomes. Successful remnant evacuation and the overall complications rates were similar when comparing the MVA group and the OH group (95.7% vs 96.8% and 4.3% vs 4.7%, respectively). Conception rates and miscarriage rates were comparable in the MVA and OH groups (78.6% vs 72.2% and 9.1% vs 14.8%, respectively).

CONCLUSION

Preliminary results from 23 patients suggest that MVA is an efficient procedure with low complication rates and satisfactory reproductive outcomes. It does not require anesthesia or operating room facilities, allowing an immediate and inexpensive "see and treat" option for RPOCs. Further larger controlled trials are required.

In-office Hysteroscopic Extraction of Intrauterine Devices in Pregnant Patients Who Underwent Prior Ultrasound-guided Extraction Failure

STUDY OBJECTIVE

To determine an effective method of intrauterine device (IUD) retrieval from pregnant women who had previous unsuccessful ultrasound-guided IUD extraction failure.

DESIGN

A retrospective cohort study (Canadian task force classification II-1).

SETTING

A gynecology department of an outpatient clinic.

PATIENTS

Pregnant patients in their first trimester with IUD in situ who underwent prior unsuccessful ultrasound-guided IUD extraction.

INTERVENTIONS

Hysteroscopic IUD extraction guided by transabdominal ultrasound.

MEASUREMENTS AND MAIN RESULTS

Between 2011 and 2014, 7 of 8 pregnant patients who had undergone previous failed attempts at IUD retrieval via ultrasound guidance underwent successful removal via ultrasound-guided hysteroscopy performed without anesthesia. The sole patient with extraction failure was in her 12th week of pregnancy, and the procedure was concluded to avoid risk to the fetus. Minimal vaginal bleeding was experienced by 2 patients after the procedure. Seven of 8 patients delivered at term without any obstetric complications. One patient had a miscarriage in her 8th week of pregnancy, 2 weeks after successful IUD removal.

CONCLUSION

A novel, easy outpatient hysteroscopic technique without anesthesia is presented in case of failure of previous ultrasound-guided IUD removal in early pregnancy. Results are encouraging in this difficult context.

Saline Hysteroscopy for Removal of Retained Intrauterine Contraceptive Devices in Early Pregnancy

OBJECTIVE

Pregnancies complicated by a retained intrauterine device (IUD) are at increased risk for adverse outcomes such as miscarriage and preterm labour. There is limited evidence to guide the management of retained IUDs in pregnancy when the strings are not visible at the external cervical os. We describe a method for IUD retrieval in such cases.

METHODS

Twenty-six patients underwent saline hysteroscopy with or without concurrent ultrasound guidance for retrieval of a retained IUD in early pregnancy between 2002 and 2015. We retrospectively evaluated procedural and pregnancy-related outcomes in this case series.

RESULTS

The average gestational age at the time of the procedure was 11+0 weeks. Successful IUD retrieval occurred in 22 of 26 cases (84.6%). There were 23 live births, including 20 full term and three preterm deliveries. The average gestational age at delivery was 38+4 weeks. There was one miscarriage and one elective termination of pregnancy following the procedure. There were no complications directly related to the procedure.

CONCLUSION

Saline hysteroscopy is a safe and effective method for retrieval of a retained IUD in early pregnancy. It appears that concurrent ultrasound guidance can facilitate IUD localization, but more cases are needed to confirm this. Pregnancy outcomes after IUD retrieval were favourable, with a low rate of miscarriage and preterm labour.

Successful treatment of atypical cesarean scar defect using endoscopic surgery

Background

Cesarean scar syndrome results from a postoperative defect of the uterine isthmus, also known as an isthmocele. Patients present with gynecological symptoms, such as abnormal genital bleeding or infertility, after cesarean delivery. Although the cesarean rate is increasing worldwide, this syndrome is not widely known.

Case presentation

A 43-year-old G2P1 Japanese woman with atypical cesarean scar syndrome had a 3-year history of secondary infertility and postmenstrual brown discharge. Laparoscopic and hysteroscopic exploration revealed a cesarean scar defect connected to a small cavity in the myometrium: this was not an endometrial cavity or a uterine diverticulum. After endoscopic excision of the cavity, the brown discharge resolved, and the patient achieved ongoing pregnancy on her third attempt at intrauterine insemination.

Conclusion

Consensus is still lacking regarding the diagnosis and treatment of cesarean scar defect. However, the gynecologists should be aware that cesarean scar syndrome can have scar defects forming cavities of unusual shapes and features. Surgical correction of these defects will often improve postmenstrual bleeding and subfertility in these cases.