Hysteroscopic Resection for Missed Abortion: Feasibility, Operative Technique and Potential Benefit Compared to Curettage

Addition of operative hysteroscopy to vacuum aspiration for the management of early pregnancy loss after in vitro fertilization

OBJECTIVE

To investigate whether operative hysteroscopy in addition to vacuum aspiration for the management of early pregnancy loss effectively increases the success rate of subsequent frozen embryo transfer.

DESIGN

Propensity score-matched cohort study.

SETTING

Academic hospital.

PATIENT(S)

Women with a miscarriage at 5-16 gestational weeks during an in vitro fertilization cycle in Peking University Third Hospital from 2015 to 2022.

INTERVENTION(S)

Hysteroscopy plus vacuum aspiration vs. conventional vacuum aspiration.

MAIN OUTCOME MEASURE(S)

Live birth rate in the subsequent frozen embryo transfer.

RESULT(S)

A total of 347 women who underwent vacuum aspiration plus hysteroscopy and 2,562 women who underwent conventional vacuum aspiration were included in the analysis. After propensity score matching (1:1 ratio), 325 women were included in each group. Compared with women who underwent vacuum aspiration, those who underwent vacuum aspiration plus hysteroscopy were associated with a lower rate of live birth in the propensity score-based matched cohort (22% vs. 30%; adjusted odds ratio, 0.68 [0.47-0.97]). Biochemical, clinical, and multiple pregnancy rates were not significantly different, as was the miscarriage rate. In the overall cohort, 11 women experienced surgery reintervention in the vacuum aspiration group (0.4%), whereas none required surgery reintervention in the vacuum aspiration plus hysteroscopy group.

CONCLUSION(S)

Women who underwent vacuum aspiration plus hysteroscopy may be associated with lower rates of live birth than those who underwent vacuum aspiration. Further studies are necessary to establish this relationship definitively.

Primary Resectoscopic Treatment of First-Trimester Miscarriage

OBJECTIVES

To determine the feasibility and safety of resectoscopic treatment for uterine evacuation of first-trimester miscarriage.

METHODS

A single-centre prospective study performed between April 2021 and October 2021 at a university-affiliated tertiary medical centre. Patients diagnosed with early miscarriage of up to 12 weeks from the last menstrual period were eligible for participation. Recruited patients underwent hysteroscopic uterine evacuation under general anaesthesia by a Versapoint 2 bipolar resectoscope 24Fr (Johnson and Johnson, Germany).

RESULTS

A total of 15 patients were recruited for the study. The procedural characteristics as well as intra- and postoperative adverse events were recorded. The mean duration of the procedure was 14.3 ± 3.7 minutes. The achievement of complete evacuation was recorded in all cases, and no adverse events occurred during any procedure. Post-procedure follow-up 6 weeks after treatment was conducted by office hysteroscopy in 10 women and by ultrasonography in 4 women. One woman had conceived prior to her scheduled follow-up visit. In total, 2 (13.3%) cases of retained products of conception were diagnosed during office hysteroscopy and they were removed by the "see-and-treat" technique without anaesthesia. The diagnosis was confirmed pathologically. No intrauterine adhesions were detected and none of the women required a second hysteroscopy under anaesthesia due to retained products of conception.

CONCLUSIONS

Hysteroscopic evacuation of first-trimester miscarriage by a standard resectoscope is a safe and feasible technique.

Hysteroscopy-assisted suction curettage for early pregnancy loss: does it reduce retained products of conception and postoperative intrauterine adhesions?

OBJECTIVE

To describe the feasibility of hysteroscopy-assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA).

DESIGN

Prospective single-arm cohort study.

SETTING

University-affiliated Department of Obstetrics and Gynecology.

PATIENTS

Women admitted for surgical evacuation of early pregnancy loss were invited to participate in the study.

INTERVENTION

Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, a diagnostic hysteroscopy was performed to identify the pregnancy's implantation wall, followed by ultrasound-guided suction and curettage directed to the implantation wall, and then diagnostic hysteroscopy to verify complete uterine cavity emptying. Postoperative IUA were evaluated by follow-up office hysteroscopy.

MAIN OUTCOME MEASURE

Identification of the pregnancy's implantation wall on hysteroscopy, and intra-, and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic-related restrictions on elective procedures.

RESULTS

Forty patients were included in the study group. Their mean age was 34.0 ± 6.6 years, and their mean gestational age was 8.9 ± 1.6 weeks. The implantation wall was clearly visualized on hysteroscopy in 33 out of 40 cases (82.5%). The mean operative time was 17.2 ± 8.8 min, and no intraoperative complications occurred. Suspected RPOC were diagnosed intraoperatively by hysteroscopy and removed in 4 cases, and the histologic examination confirmed the presence of RPOC in three of them. Follow-up office hysteroscopy was performed in nine women: mild IUA was diagnosed in one case and a normal cavity was confirmed in eight cases. A new pregnancy was reported at the time of follow-up in 15 cases, while 12 women declined to attend the follow-up hysteroscopy and four were lost to follow-up.

CONCLUSIONS

Hysteroscopy-assisted suction curettage for early pregnancy loss is a safe, short, and inexpensive procedure, which allows the identification of the pregnancy's wall in most cases and may reduce the rates of RPOC.

Retained Intrauterine Fetal Bone Fragments Causing Secondary Infertility: A Review

Retained intrauterine fetal bone fragments are emerging as a potential yet often overlooked cause of secondary infertility, posing significant challenges for couples who have previously experienced successful pregnancies. This review article explores the association between retained fetal bone fragments and secondary infertility by delving into their impact on fertility, pregnancy outcomes, and diagnostic challenges. The review highlights the underlying mechanisms of fragment retention, including immune response and inflammation, and their detrimental effects on endometrial receptivity and implantation. The diagnostic difficulties and importance of specialized imaging techniques like hysteroscopy for accurate diagnosis are also discussed. The article also provides insights into available treatment options, such as medical management and surgical interventions, focusing on hysteroscopy as the gold standard for diagnosis and treatment. The implications for clinical practice emphasize early diagnosis and intervention to improve fertility outcomes and reduce the emotional burden of secondary infertility. Furthermore, the review discusses preventive strategies and the potential for future research to refine diagnostic methods and explore novel treatments. By recognizing and addressing the impact of retained fetal bone fragments, this review aims to enhance the understanding and management of this condition, providing valuable support to couples seeking to overcome the challenges of secondary infertility on their journey toward parenthood.

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.

Hysteroembryoscopy and hysteroscopic uterine evacuation of early pregnancy loss: A feasible procedure in selected cases

Hysteroscopic uterine evacuation of early pregnancy loss using tissue removal devices seems to be a safe and feasible procedure in selected cases. The hysteroscopic approach allows the precise localisation of the gestational sac inside the uterine cavity. The endoscopic approach allows one to perform hysteroembryoscopy before uterine evacuation and this technique appears to be more accurate than dilatation & curettage for fetal chromosome karyotyping, with lower maternal cell contamination. This “under vision” procedure may reduce retained products of conception rates and risk of intrauterine adhesions formation.

Clinical Efficacy and Safety Study of Mifepristone with Misoprostol Treatment in Patients with Missed Abortion

Currently, medication abortion is widely used in clinical practice in China. The aim of this study was to investigate the effect of mifepristone with misoprostol treatment on the efficacy of patients with missed abortion (MA) and the safety of this drug regimen. 95 patients with MA treated in our hospital from February 2019 to April 2021 were collected as the subjects of this study, and the patients were divided into the control and the research groups according to different treatment modalities. Among them, 46 cases in the control group were treated by diethylstilbestrol combined with oxytocin and 49 cases in the research group were treated by mifepristone combined with misoprostol, and both groups underwent curettage after medication. The rates of complete abortion, time of embryo expulsion, time of operation, intraoperative bleeding, time of postoperative vaginal bleeding, amount of vaginal bleeding, rate of one-time curettage, the levels of serum estradiol (E2), progesterone (P), β-chorionic gonadotropin (β-hCG), and interleukin-18 (IL-18), and the incidence of adverse effects in the two groups were examined and compared. Alanine transaminase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN), and serum creatinine (Scr) were used as indicators to evaluate the safety of the drug. The results showed that the rates of complete abortion and one-time curettage were significantly higher in the study group than in the control group, while the time of embryo expulsion, operation time, intraoperative bleeding, postoperative vaginal bleeding time, and vaginal bleeding were significantly lower than in the control group. The serum E2, P, and β-hCG levels before curettage in both groups were significantly higher, and IL-18 levels were significantly lower than those at the time of admission, with E2, P, and β-hCG levels increasing more and IL-18 levels decreasing more in the research group. After drug treatment, no abnormal changes in liver and kidney functions were observed in both groups, and the incidence of adverse reactions was at a similar and lower level in both groups. This shows that mifepristone with misoprostol is a safer and more effective drug regimen for the treatment of MA, which can regulate the levels of serum sex hormones and inflammatory factors in the body, promote the shedding of placental tissue, and create conditions for improving the rate of curettage.

A Pilot Study of Guided Conservative Hysteroscopic Evacuation of Early Miscarriage

STUDY OBJECTIVE

To evaluate initial feasibility and experience with guided hysteroscopic morcellation for uterine evacuation of early miscarriage.

DESIGN

A prospective pilot study of 10 cases.

SETTING

A tertiary university hospital in Israel.

PATIENTS

Women with confirmed early miscarriage at a gestational age of below 10 weeks from the last menstrual period.

INTERVENTIONS

From May 2020 to October 2020, the hysteroscopic TruClear tissue removal system (Medtronic, Minneapolis, MN) was used for evacuation of early miscarriage in 10 women. The procedures were recorded.

MEASUREMENTS AND MAIN RESULTS

Data including the length of the procedure, visibility, complete evacuation, bleeding, complications, and follow-up ultrasonography (US) were recorded. The mean duration of the procedure was 24 minutes. Complete evacuation was recorded in all cases. No adverse events were recorded in any of the 10 procedures. Normal uterine cavity without evidence of retained products of conception was documented in follow-up evaluation by US in all cases. Four patients underwent a follow-up office hysteroscopy that demonstrated a normal cavity without evidence of adhesions. In 4 cases (40%), an additional suction curettage was performed immediately after the hysteroscopic procedure owing to obscured visibility or an abnormal US scan at the end of the procedure. However, retained products of conception were found in only 1 of these 4 suction specimens (25%).

CONCLUSION

Hysteroscopic morcellation under vision seems to be a safe and feasible technique for management of early missed abortion. This method may have potential as an innovative treatment of miscarriage in selected cases. Further studies are needed to refine the indications and the surgical technique.