Medical treatment for early pregnancy loss following in vitro fertilization compared to spontaneous pregnancies

BACKGROUND

Misoprostol is a well-studied medical treatment for early pregnancy loss (EPL), with success rates ranging between 70 and 90%. However, treatment failure is associated with major patient discomfort, including the need for surgical intervention to evacuate the uterus. It was previously reported that medical treatment was especially successful among women who conceived after in vitro fertilization (IVF). We aimed to study if there is a difference in rates of medical treatment failures for EPL between pregnancies conceived by IVF and spontaneous pregnancies.

METHODS

In this retrospective cohort study, we included all women who underwent medical treatment for EPL at our institute between 07/2015 and 12/2020. Treatment outcome was compared between IVF and spontaneous pregnancies. Treatment failure was defined as a need for surgical intervention, namely, dilation & curettage (D&C) and/or hysteroscopy, due to retained products of conception, which was defined as a gestational sac or endometrial thickness greater than 15 mm in a TVS scan.

RESULTS

Overall, 775 patients were included, of which 195 (169/775 = 25.1%) ultimately required surgical intervention. There was no difference between the study groups in the rate of treatment failure. However, among IVF pregnancies, the rate of emergency D&C was lower (3.6% vs. 9.8%, p = 0.001), compared to spontaneous group.

CONCLUSION

In cases of medical treatment for EPL, IVF pregnancies had no differences in rates of treatment failure compared to spontaneous pregnancies. That being said, IVF pregnancies have lower chances to undergo emergency D&C, compared to spontaneous pregnancies.

Failure Rate of Medical Treatment for Miscarriage Correlated with the Difference between Gestational Age According to Last Menstrual Period and Gestational Size Calculated via Ultrasound

Objective: To study whether the interval between gestational age calculated using the last menstrual period (GA-LMP) and gestational age calculated via ultrasound (GA-US) is correlated with the success rate of medical treatment in cases of miscarriages. Methods: This was a retrospective cohort study conducted in a gynecology unit in a tertiary medical center. Women who underwent medical treatment with Misoprostol for miscarriage at the Edith Wolfson Medical Center between 07/2015 and 12/2020 were included. Incomplete or septic miscarriages, multiple pregnancies, patients with irregular periods, and cases of missing data were excluded. Failure of medical treatment was defined as the need for surgical intervention due to a retained gestational sac, severe bleeding or retained products of conception. The cohort study was divided into two groups: patients with successful treatment and patients for whom surgical intervention was eventually needed. We performed both a univariate and multivariate analysis in order to identify whether a correlation between GA-LMP and GA-US interval is indeed a factor in the success rate of a medical abortion. Results: Overall, 778 patients were included in the study. From this cohort 582 (74.9%) had undergone a successful medical treatment, while 196 (25.1%) required surgical intervention due to the failure of medical treatment, as defined above. The GA-LMP to GA-US interval (in weeks) was 2.6 ± 1.4 in the success group, while the GA in the failure group was 3.1 ± 1.6 (p < 0.001). After performing a multivariant regression analysis, we were able to show that the GA-LMP to GA-US interval was found to be independently correlated with an increase in the treatment failure rate (aOR = 1.24, CI 95% (1.01-1.51), p = 0.03). Conclusions: In cases of miscarriage, longer GA-LMP to GA-US interval has been shown to be an independently correlated factor to lower success rate of the medical treatment option.

Surgical intervention after medical treatment for early pregnancy loss according to gestational size

OBJECTIVE

To study the rate of surgical intervention for unsuccessful medical treatment in early pregnancy loss (EPL), according to gestational size by ultrasound (GS-US).

METHODS

This was a retrospective cohort study. All women who were treated with misoprostol for EPL between July 2015 and December 2020 were included. The cohort was divided according to GS-US: group 1: gestational sac without an embryonic pole; group 2: an embryonic pole with crown-rump length (CRL) compatible with <7 weeks; group 3: CRL compatible with 7⁺⁰ -7⁺⁶ weeks; group 4: CRL compatible with 8⁺⁰ -8⁺⁶ weeks; group 5: CRL compatible with ≥9 weeks. We compared the rate of any surgical intervention due to treatment failure.

RESULTS

Overall, 783 patients were included: group 1, 236 (30.1%); group 2, 319 (40.7%); group 3, 115 (14.7%); group 4, 78 (10.0%); and group 5, 35 (5.0%) patients. The rate of any surgical intervention was significantly lower in groups 1-4 (54, 22.9%; 85, 26.6%; 28, 24.3%; and 22, 28.2%, respectively) compared with group 5 (17, 48.6%; P = 0.030). On multivariant analysis, GS-US greater than 9 weeks was independently associated with the need for surgical intervention (adjusted odds ratio 1.23, 95% confidence interval 1.01-1.51; P = 0.040).

CONCLUSION

When treating EPL medically, GS-US greater than 9 weeks increases the risk of undergoing additional surgical intervention compared with younger weeks.

P-351 Medical treatment for missed abortion- difference in gestational age based on menstrual dating and on ultrasound criteria, and the correlation to failure

Study question

Does the difference in gestational age based on menstrual dating and on ultrasound criteria correlate with failure rate of medical treatment in missed abortions?

Summary answer

In missed abortions, the difference in gestational age based on menstrual dating and on ultrasound is inversely correlated with failure rate of medical treatment.

What is known already

A number of factors have been reported as predictors for Misoprostol treatment failure, including assisted reproductive treatment, primigravity, and vaginal bleeding prior to treatment.

Increased rates of failure with medical management were also reported with delaying treatment after diagnosis.

Study design, size, duration

This was a retrospective cohort study.

Overall, 778 patients who underwent medical treatment with Misoprostol for missed abortion at our institute, between 07/2015 and 12/2020 were included.

Participants/materials, setting, methods

Inclusion criteria were either anembryonic gestation or embryonic death, as long as pregnancy age, as measured by transvaginal sonography , correlated with 12 weeks gestation or less.

Exclusion criteria included incomplete or septic abortions, multiple pregnancies, and cases that had either irregular period, missing data, or were lost to follow up.

The primary outcome was treatment failure, defined as any need for surgical intervention (elective or emergency Dilation & curettage, or operative hysteroscopy).

Main results and the role of chance

Five hundred and eighty two patients (74.9%) had successful medical treatment, while 196 (25.1%) required surgical intervention.

The gestational age based on menstrual dating and on ultrasound difference (in weeks) was 2.6±1.4 in the success group and 3.1±1.6 in the failure group (p &lt; 0.001).

On multivariant regression analysis, gestational age based on menstrual dating and on ultrasound difference was found to be independently correlated with treatment failure (aOR=1.24, CI 95% (1.01-1.51), p = 0.03).

Limitations, reasons for caution

We did not analyze long term consequences, such as the amount of bleeding, and time to future fertility.

Moreover, patients who were treated at our institute may have been diagnosed and treated for treatment failure in neighboring hospitals and hence lost to follow-up.

Wider implications of the findings

The current study has shown that the difference between gestational age based on menstrual dating and on ultrasound is directly corelated with medical treatment failure.

This data should be taken into account when counseling patients regarding the optimal treatment for first trimester missed abortion.

Trial registration number

not applicable

The effect of preemptive local anesthesia on postoperative pain following vaginal hysterectomy: A randomized controlled trial

OBJECTIVE

We aimed to study the effect of preemptive local anesthetic without adrenaline on postoperative pain following vaginal hysterectomy and concomitant trans obturator tape (TOT).

STUDY DESIGN

This was a double-blinded, randomized, controlled trial. Women who undergone elective vaginal hysterectomy were included. Solutions of either Bupivacaine-Hydrochloride 0.5%, or Sodium-Chloride 0.9% as a placebo, were prepared prior to surgery, according to randomization. The chosen solution was injected before incision, in a circumferential manner, to the cervix. The amount of fluid administered was 10 ml. When colporrhaphy was also performed, an additional 5 ml of solution were injected in the midline of the vaginal wall prior to each incision line. We conformed to the CONSORT recommendations. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. We estimated that the intervention would cause a 25% reduction in the primary outcome. The required total sample size was calculated to be 30 patients women for each group. We used ANOVA for continuous variables and the Chi-square or Fisher exact tests for categorical variables.

RESULTS

A total of 30 women were included in each group. The level of postoperative pain, as assessed by VAS, was not significantly different between the groups, in all points of time. In addition, there was no difference between the groups in opioid based analgesics during recovery, nor in postoperative analgesic use.

CONCLUSION

Preemptive local anesthesia was not shown to be efficient in reducing postoperative pain after vaginal hysterectomy and TOT.

Misoprostol treatment for early pregnancy loss: an international survey

RESEARCH QUESTION

What is the global variability in misoprostol treatment for the management of early pregnancy loss (EPL)?

DESIGN

An international web-based survey of fertility specialists and obstetrics and gynaecology clinicians was conducted between August and November 2020. The survey consisted of 16 questions addressing several aspects of misoprostol treatment for EPL.

RESULTS

Overall, 309 clinicians from 80 countries participated in the survey, of whom 67.3% were fertility specialists. Nearly one-half (47.9%) of the respondents let the patient choose the first line of treatment (expectant management, misoprostol treatment or surgical aspiration) according to her own preference. The 248 respondents who administer misoprostol in their daily practice were asked further questions; 59.7% of them advise patients to take the medication at home. The most common dose and route of administration is 800 µg administered vaginally. Only 28.6% of participants use mifepristone pretreatment. Variation in the timing of the first follow-up visit after misoprostol administration was wide, ranging from 24 h to 1 week in most clinics. In case of incomplete expulsion, only 42.3% of the respondents routinely administer a second dose. The timing of the final visit and the definition of successful treatment also differed greatly among respondents.

CONCLUSIONS

There is large variability in the use of misoprostol for the management of EPL. High-quality research is necessary to examine several aspects of the treatment. Particularly, the timing and effectiveness of a second dose administration and the criteria to decide on treatment failure or success deserve more research in the future.

Reproductive outcome after early pregnancy loss treated with misoprostol versus surgical aspiration

RESEARCH QUESTION

Does long-term reproductive outcome after early pregnancy loss (EPL) differ between women who are treated with misoprostol and surgical aspiration.

DESIGN

A historic cohort study of all women who were diagnosed with early pregnancy loss (≤12 weeks), in a single medical centre, between September 2016 and August 2017, was conducted. The women were treated with either misoprostol or surgical aspiration according to their own preferences. Women who were lost to follow-up or did not attempt to conceive again were excluded. The primary outcome measure was the cumulative pregnancy rate within 12 months from intervention.

RESULTS

Baseline characteristics were comparable between women who received misoprostol (n = 163) and women who underwent surgical aspiration (n = 122). Women who received misoprostol had a higher rate of interventions for retained products of conception (11.0% versus 3.3%, respectively; P = 0.015). The misoprostol and the surgical aspiration groups did not differ in rate of repeated miscarriages (17.8% versus 21.3%, respectively; P = 0.45), or pregnancy rate within 6 months (58.3% versus 50.0%, respectively; P = 0.16), 12 months (78.5% versus 78.7%, respectively; P = 0.97) and 24 months (92.0% versus 91.8%, respectively; P = 0.94). Live birth rate within 24 months was comparable (62.0% versus 58.2%, respectively; P = 0.52), as well as gestational age at birth (38.5 versus 38.6 weeks, respectively; P = 0.81) and birthweight (3295 versus 3161 g, respectively; P = 0.07).

CONCLUSIONS

Long-term reproductive outcomes are comparable in women with EPL who are treated with either misoprostol or surgical aspiration. Our findings may help counselling patients facing EPL who have concerns about their future reproduction.

Expression of Heparanase in uterosacral ligaments of women with or without uterine prolapse

OBJECTIVE

Pelvic organ prolapse (POP) is a global health problem for which the pathophysiological mechanism remains unclear. The loss of extracellular matrix proteins is considered an important molecular basis for this pathology. Heparanase is a heparin sulfate degrading endoglycosidase that has an important role in various biological processes and is a key component of extracellular matrix. The aim of this study was to compare expression of Heparanase in connective tissue of uterosacral ligaments in women with or without uterine prolapse.

STUDY DESIGN

Thirty-nine women who underwent hysterectomy for benign reasons were enrolled in the study. Twenty-three women with uterine prolapse (stage ≥3) who underwent vaginal hysterectomy (VH) - POP group, were compared to sixteen women without uterine prolapse who underwent abdominal hysterectomy (stage <2) - control group. Uterosacral ligaments (USL) biopsies were obtained from all uterine specimens near their origin. All tissue samples were analyzed by immunohistochemistry and tested for the presence of Heparanase using antiheparanse antibody 733.

RESULTS

Heparanse positive staining was more common in the connective tissue of uterosacral ligaments in women with uterine prolapse. Positive staining was seen in 17/23 (73.9 %) women with uterine prolapse compared to 4/16 (25 %) without uterine prolapse (p = 0.003). On multivariate logistic regression analysis, positive staining displayed a trend for an independent association with POP, after controlling for menopausal status and parity (OR 13.57, 95 %CI 0.82-224.4, p = 0.06).

CONCLUSION

Heparanase expression is more common in the connective tissue of uterosacral ligaments in women with uterine prolapse compared to women with no prolapse.

Clinical Characteristics of Women with Isolated Fallopian Tube Torsion Compared with Adnexal Torsion

BACKGROUND

Isolated fallopian tube torsion (IFTT) is a rare gynecological entity and its diagnosis is challenging.

OBJECTIVES

To compare clinical characteristics, sonographic findings, surgical management, and outcomes of women with surgically verified IFTT compared to those diagnosed with adnexal torsion.

METHODS

A retrospective case-control study in a university hospital was conducted. Thirty-four women with surgically verified IFTT between March 1991 and June 2017 were compared to 333 women diagnosed with adnexal torsion within the same time period.

RESULTS

Both groups presented primarily with abdominal pain, which lasted longer prior to admission among the IFTT group (46.8 ± 39.0 vs. 30.0 ± 39.4 hours, P < 0.001). Higher rates of abdominal tenderness with or without peritoneal signs were found in the adnexal torsion group (90.3% vs. 70.6%, P < 0.001). Sonographic findings were similar; however, an increased rate of hydrosalpinx was found among the IFTT group (5.9% vs. 0.0%, P = 0.008). Suspected adnexal torsion was the main surgical indication in only 61.8% of IFTT cases compared with 79.0% in the adnexal torsion group (P = 0.02). Salpingectomy with or without cystectomy was more commonly performed in the IFTT group (35.3% vs. 1.5%, P < 0.001). The leading pathological findings among the IFTT group were hydrosalpinx and paraovarian cysts.

CONCLUSIONS

The clinical signs and symptoms of IFTT and adnexal torsion are similar. Although sonographic imaging demonstrating a paraovarian cyst or hydrosalpinx may be helpful in diagnosing IFTT, it is rarely done preoperatively.

Comparison of Emergent and Elective Surgeries of Endometriomas: Is Adnexal Torsion a Concern?

BACKGROUND

When a woman with an endometrioma presents with acute abdominal pain, it is unclear whether ovarian torsion should be suspected.

OBJECTIVES

To compare patient characteristics, imaging results, and surgical management of endometriomas in elective versus emergent surgeries.

METHODS

This retrospective cohort study included women treated at our institution during the period 1990-2015 who presented with histologically verified endometrioma and who underwent either planned surgery or emergent surgery due to suspected adnexal torsion.

RESULTS

Of 225 surgeries performed, 174 were elective and 51 emergent. Patients in the emergent group were significantly younger (33.9 ± 11.1 vs. 39.01 ± 10.9 years, P = 0.004). Abdominal pain was the main complaint of all the emergent surgery patients and the leading complaint in 21% of the elective surgery patients (P < 0.001), with right-sided predominance in both groups. Sonographic parameters were similar in both groups. Bilateral ovarian cysts were noted in 11.7% and 11.0% of emergent and elective patients, respectively (P = 0.87). Laboratory evaluation was notable for a higher white blood cell count and CA125 levels among emergent patients. All patients in the emergent group and 93% of patients in the elective group were managed laparoscopically. No cases of torsion were noted. The rate of intra-pelvic adhesions was similar in both groups (56.8% vs. 66.6%, P = 0.19).

CONCLUSIONS

Endometrioma may present with acute abdominal pain. However, adnexal torsion in these patients is rare. These cases can be managed using a minimally invasive approach, assuming an optimal surgical setting.

Clinical and Sonographic Findings in Suspected Retained Trophoblast: Correlation with Histological Findings

BACKGROUND

Different clinical and sonographic parameters have been suggested to identify patients with retained products of conception. In suspected cases, the main treatment is hysteroscopic removal.

OBJECTIVES

To compare clinical, sonographic, and intraoperative findings in cases of hysteroscopy for retained products of conception, according to histology.

METHODS

The results of operative hysteroscopies that were conducted between 2011 and 2016 for suspected retained products of conception were evaluated. Material was obtained and evaluated histologically. The positive histology group (n=178) included cases with confirmed trophoblastic material. The negative histology group (n=26) included cases with non-trophoblastic material.

RESULTS

Patient demographics were similar in the groups, and both underwent operative hysteroscopy an average of 7 to 8 weeks after delivery/abortion. A history of vaginal delivery was more common among the positive histology group. The main presenting symptom in all study patients was vaginal bleeding, and the majority of cases were diagnosed at their routine postpartum/abortion follow-up visit. Sonographic parameters were similar in the groups. Intraoperatively, the performing surgeon was significantly more likely to identify true trophoblastic tissue as such than to correctly identify non-trophoblastic tissue (P < 0.001).

CONCLUSIONS

Suspected retained trophoblastic material cannot be accurately differentiated from non-trophoblastic material according to clinical, sonographic, and intraprocedural criteria. Thus, hysteroscopy seems warranted in suspected cases.

Expression of the epithelial sodium channel (ENaC) in the endometrium - Implications for fertility in a patient with pseudohypoaldosteronism

Pseudohypoaldosteronism type 1 (PHA) is a syndrome of unresponsiveness to aldosterone. The severe form of this disease results from mutations in the genes that encode for the epithelial sodium channel subunits, SCNN1A, SCNN1B, and SCNN1G. A PHA patient under our care failed to conceive after many years and IVF trials. Our earlier studies had shown that ENaC is expressed in the female reproductive tract. We hypothesized that a defective ENaC expression may be responsible for the infertility of the patient. To test this hypothesis we examined ENaC expression in endometrial Pipelle biopsy samples from three healthy women and the PHA patient with an Arg508X mutation in the SCNN1A gene. The formalin fixed samples were reacted with anti-ENaCA (alpha subunit) antisera, followed by secondary antibodies to visualize ENaC expression by immunofluorescence. Confocal microscopy imaging of the samples showed strong ENaC immunofluorescence along the luminal border (apical membrane) of the epithelial cells in Pipelle samples from healthy women. In contrast, none of the samples from the PHA patient showed ENaC immunofluorescence. The Arg508X mutation interrupts the transport of ENaC subunits to the cell surface, yet it would not be expected to disrupt ENaC localization in the cytoplasm. In contrast to endometrium where ENaC is localized in the apical membrane of the epithelial cells, in keratinocytes ENaC is expressed in cytoplasmic pools. Therefore, we examined ENaC immunofluorescence in plucked hair follicles. As expected, ENaC immunofluorescence was detected in the cytoplasm of keratinocytes of both normal and PHA samples. Our results support the hypothesis that lack of expression of ENaC on the endometrial surface may be responsible for the infertility of the PHA patient.

The Impact of Salpingectomy on Anti-Mullerian Hormone Levels and Ovarian Response of In Vitro Fertilization Patients

BACKGROUND

Laparoscopic salpingectomy is strongly related to successful in vitro fertilization (IVF) treatments.

OBJECTIVES

To compare the ovarian reserve, including anti-mullerian hormone (AMH) levels, in patients who underwent salpingectomy before IVF to IVF patients who had not been salpingectomized.

METHODS

In this retrospective study, medical records of women who were treated by the IVF unit at our institute were reviewed. We retrieved demographic data, surgical details, and data regarding the ovarian reserve. Details of 35 patients who were treated by IVF after salpingectomy were compared to 70 IVF patients with no history of salpingectomy treatment. Nine women underwent IVF treatment before and after having salpingectomy, and their details were included in both groups.

RESULTS

The levels of AMH, follicular stimulating hormone (FSH), estradiol, and progesterone were not significantly different in the groups. The antral follicular count (AFC), number of oocytes retrieved, amount of gonadotropin administered for ovarian stimulation, and number of embryos transferred (ET) were also not significantly different.

CONCLUSIONS

Salpingectomy does not seem to affect ovarian reserve in IVF patients.

Single versus repeat doses of misoprostol for treatment of early pregnancy loss-a randomized clinical trial

STUDY QUESTION

Does repeat administration of misoprostol for early pregnancy loss increase the treatment success rate?

SUMMARY ANSWER

Repeat administration of misoprostol does not increase the treatment success rate, and is associated with more analgesics use.

WHAT IS KNOWN ALREADY

Misoprostol reduces the need for surgical evacuation and shortens the time to complete expulsion in patients with early pregnancy loss. However, the impact of repeat doses of misoprostol is not clear.

STUDY DESIGN, SIZE, DURATION

A randomized clinical trial was conducted in a single tertiary hospital, recruiting women with early pregnancy loss (<12 weeks), seeking medical treatment, between August 2015 and June 2016. A sample size of 160 patients was sufficient to detect a 30% decrease in treatment success.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants received 800 μg of misoprostol vaginally on Day 1, and were then randomly assigned into two groups: Patients in the single-dose group were evaluated on Day 8. Patients in the repeat-dose group were evaluated on Day 4, when they were given a repeat dose if required, and scheduled for re-evaluation on Day 8. If complete expulsion was not achieved on Day 8 (endometrial thickness >15 mm or the presence of gestational sac on transvaginal sonography), participants underwent surgical evacuation. The primary outcome was treatment success, defined as no need for surgical intervention up to Day 8.

MAIN RESULTS AND THE ROLE OF CHANCE

Final analysis included 87 participants in the single-dose group and 84 participants in the repeat-dose group, out of whom 41 (48.8%) received a second dose. Treatment succeeded in 67 (77%) patients in the single-dose group and 64 (76%) patients in the repeat-dose group (RR 0.98; 95% CI 0.83-1.16; P = 0.89). Patients in the repeat-dose group reported more use of over the counter analgesics (82.1% versus 69.0%, P = 0.04).

LIMITATIONS, REASONS FOR CAUTION

The study was not blinded and our definition of complete expulsion may be debated. Follow-up time was not equal in all participants, since some had a complete expulsion on Day 4 and some underwent emergent D&C before Day 8. This, however, should not affect the primary outcome.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest that a single-dose protocol is superior to a repeat-dose protocol due to a comparable success rate and more favorable outcomes regarding the need for analgesic drugs.

STUDY FUNDING/COMPETING INTEREST(S)

We did not receive funding for this study and we declare no conflict of interest.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT02515604).

TRIAL REGISTRATION DATE

2 August 2015.

DATE OF FIRST PATIENT'S ENROLMENT

19 August 2015.

Is There a Difference in the Outcome of Mid-Urethral Sling Operations Performed by Urogynecologists Compared with Supervised Residents?

STUDY OBJECTIVE

To compare the operative results of midurethral sling (MUS) surgeries for stress urinary incontinence (SUI) performed by residents under the guidance of an attending specialist in urogynecology and those performed by attendings.

DESIGN

Retrospective chart review (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

A retrospective analysis of all MUS surgeries performed at a single public tertiary medical center between January 2009 and December 2013 was carried out. A total of 257 patients underwent transobturator tape (TOT) placement during the study period, including 136 (52.9%) placed by an attending specialist in urogynecology (group A) and 121 (47.1%) placed by a resident, under the guidance of an attending (group B).

MEASUREMENTS

The efficacy of treatment was evaluated in terms of early postoperative course, reoperation, and symptom improvement, as based on the Pelvic Floor Distress Inventory short form (PFDI-20) questionnaire. The primary outcome was patient-reported symptoms of SUI, as assessed with the PFDI-20 questionnaire, as well as absence of surgical retreatment for SUI.

RESULTS

Immediate postoperative complications were comparable in the 2 groups, as were subjective failure and self-reported SUI. The primary outcome-moderate and severe symptoms of SUI-were reported by 23.7% of the patients in group A and 23.6% of those in group B (p = .91). At a mean follow-up of 40 months in both groups, symptoms, as assessed using the urinary scale and prolapse scale of the PFDI-20, were also similar in the 2 groups. The rate of reoperation with repeated sling for SUI was 5% in both groups.

CONCLUSION

The operative results of TOT surgery for SUI performed by residents under the guidance of an attending specialist in urogynecology did not differ significantly from those performed by the attendings themselves.

Ovarian reserve following cesarean section with salpingectomy vs tubal ligation: a randomized trial

BACKGROUND

Epithelial ovarian cancer is assumed to derive from the fallopian tube. Salpingectomy has been previously demonstrated to reduce the risk of ovarian cancer, and may be used as a means of sterilization.

OBJECTIVE

We aimed to compare short-term ovarian reserve and operative complications in cases of salpingectomy and tubal ligation during cesarean section.

STUDY DESIGN

Study patients who underwent elective cesarean section at our institution and requested sterilization were randomized to bilateral salpingectomy or tubal ligation. Prior to surgery, blood samples were obtained for antimüllerian hormone. Surgical course was noted, including overall time, complications, and postoperative hemoglobin. Repeat antimüllerian hormone samples were obtained from patients 6-8 weeks following surgery.

RESULTS

In all, 46 patients were recruited for participation, of whom 33 completed a follow-up visit, and for whom repeat antimüllerian hormone levels were available. Patients in the salpingectomy group were slightly older (37.0 ± 3.9 vs 34.3 ± 4.1 years, P = .02). No differences were noted in patient parity, body mass index, or gestational age between the groups. Pregnancy and postdelivery antimüllerian hormone levels were not significantly different between the groups, with an average increase of 0.58 ± 0.98 vs 0.39 ± 0.41 ng/mL in the salpingectomy and tubal ligation groups, respectively (P = .45). Surgeries including salpingectomy were longer by an average 13 minutes (66.0 ± 20.5 vs 52.3 ± 15.8 minutes, P = .01). No difference was demonstrated between the groups regarding surgical complications and postoperative hemoglobin decrease.

CONCLUSION

Sterilization by salpingectomy appears to be as safe as tubal ligation regarding operative complications and subsequent ovarian reserve. As salpingectomy offers the advantage of cancer risk reduction, it may be offered in the settings of elective preplanned surgeries.

Unexpected Significant Uterine Pathological Findings at Vaginal Hysterectomy Despite Unremarkable Preoperative Workup

BACKGROUND

Several studies have addressed the issue of undetected uterine pathology in women undergoing hysterectomy for pelvic organ prolapse (POP). However, these studies differ largely with respect to the incidence of malignancy found, study population, and preoperative evaluation.

OBJECTIVES

To assess the risk of unexpected pre-malignant and malignant uterine pathological findings after vaginal hysterectomy for POP repair, in a single medical center in Israel.

METHODS

A retrospective study was performed of all patients who underwent vaginal hysterectomy due to symptomatic POP between January 1990 and April 2015 in a single tertiary medical center. Selected clinical and pathological data were retrieved from the computerized medical records. All specimens were routinely sent for histopathological assessment. All women were managed according to a uniform protocol that required the presence of a preoperative normal Pap smear, and included preoperative transvaginal sonography and endometrial biopsy when indicated. Patients in whom premalignant or malignant lesions were found preoperatively were not included in the study.

RESULTS

The study comprised 667 patients. The overall rate of malignant or significant premalignant pathologies (6 cases) was 0.89%, including one (0.14%) case of endometrial carcinoma. All premalignant and malignant pathologies were found only in post-menopausal patients. The rate of significant endometrial pathological lesions found in asymptomatic post-menopausal women was only 0.35%.

CONCLUSIONS

The rate of preoperatively undetected abnormal histopathological findings in patients who undergo vaginal hysterectomy due to POP is very low, and therefore more extensive preoperative evaluation is not warranted in them.

Different routes of misoprostol for cervical priming in first trimester surgical abortions: a randomized blind trial

PURPOSE

To compare effectiveness and patient satisfaction of different routes of misoprostol for short-term (same day) cervical priming in first trimester surgical abortions.

METHODS

In a blind randomized trial, patients undergoing surgical abortion at a gestational age of 6 + 0-14 + 6 were administered oral, vaginal, or sub-lingual 400 mcg misoprostol, 1.5 to 4 h prior to procedure. Surgeons blinded to patient allocation evaluated cervical priming. The primary outcome was initial cervical dilatation. Secondary outcomes were cervical consistency, ease of dilation, patient discomfort, and side effects.

RESULTS

From July 2015 through May 2016, 120 patients were randomized as follows: 40 to oral, 40 to vaginal, and 40 to sublingual misoprostol administration. No differences were noted in patient age, gestational age, curettage indication (termination/delayed miscarriage), past vaginal delivery, and administration to procedure interval. Initial cervical dilatation was similar between the groups, as were cervical consistency and ease of dilation. Patients noted the greatest discomfort and side effects with sublingual administration. The followings were found to be independently associated with cervical dilatation in a linear regression analysis: sublingual administration, gestational age, missed abortion, and previous vaginal delivery. Side effects and administration to procedure interval were found non-significant.

CONCLUSION

The same day cervical priming for first trimester surgical abortion is similarly achieved with all routes of misoprostol administration. In cases of termination of pregnancy with no prior vaginal delivery, sublingual administration may be considered, but entails a higher rate of side effects and patient discomfort.

Different Routes of Misoprostol for Same-Day Cervical Priming Prior to Operative Hysteroscopy: A Randomized Blinded Trial

STUDY OBJECTIVE

To compare the effectiveness of and patient satisfaction with different routes of misoprostol administration for short-term cervical priming before operative hysteroscopy.

DESIGN

Randomized blinded trial (Canadian Task Force classification I).

SETTING

University hospital.

PATIENTS

One hundred and twenty patients undergoing operative hysteroscopy.

INTERVENTIONS

Patients were randomly assigned to receive 400 μg of misoprostol administered orally (n = 40), vaginally (n = 40), or sublingually (n = 40) for cervical priming at 1.5 to 4 hours before undergoing operative hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was preoperative cervical dilatation. Secondary outcomes included cervical consistency, ease of dilation and time of dilation, patient discomfort, and side effects. No differences were noted among the 3 groups in terms of patient age, parity, previous vaginal delivery, menopausal status, and time interval from preparation to procedure. Patients in the 3 groups reported similar discomfort and side effects. Initial mean cervical dilatation was 6.1 ± 2.0 mm in the oral group, 6.4 ± 2.1 in the vaginal group, and 6.4 ± 1.8 mm in the sublingual group (p = .75). Cervical consistency and ease of dilation were similar among the groups. The mean time of dilation was 37.2 ± 30.6 seconds in the oral group, 31.7 ± 29.0 seconds in the vaginal group, and 31.5 ± 21.7 seconds in the sublingual group (p = .59). Additional subanalyses according to menopausal status and parity did not demonstrate any differences among the groups.

CONCLUSION

Same-day cervical priming for operative hysteroscopy is achieved equally with all routes of misoprostol administration, with similar patient satisfaction and side effects.

The association between umbilical cord abnormalities and the development of non-reassuring fetal heart rate leading to emergent cesarean deliveries

OBJECTIVE

To study the contribution of umbilical cord (UC) abnormalities in emergent cesarean deliveries (ECDs) for non-reassuring fetal heart rate (NRFHR) and to explore their association with placental histopathology and neonatal outcome.

STUDY DESIGN

Data from 530 ECDs for NRFHR were reviewed for the occurrence of UC abnormalities. Those included the presence of UC entanglements, the number and location of loops, true knots and short cord (<50 cm). Multiple UC entanglements were defined as ⩾ 2 UC loops. Results were compared with 530 vaginal deliveries (VD group) matched for maternal age, parity and gestational age. Additionally, we compared neonatal outcome and placental histopathology in cases of ECDs with a single vs multiple UC entanglements. Neonatal outcome consisted of low Apgar score (⩽ 7 at 5 min), cord blood pH ⩽ 7.1 and composite neonatal outcome that was defined as one or more of respiratory distress, necrotizing enterocolitis, sepsis, transfusion, ventilation, seizure, hypoxic-ischemic encephalopathy, phototherapy or death. Placental lesions were classified as: lesions related to maternal vascular supply, lesions related to fetal vascular supply (consistent with fetal thrombo-occlusive disease), and maternal and fetal inflammatory responses.

RESULTS

UC entanglements, true knots and short cords were all more common in the ECD group compared with the VD group, P<0.001, P=0.002, P=0.004, respectively. The rate of one loop entanglement did not differ between the groups. The rate of multiple UC entanglements was higher in the ECD group compared with the VD group, 20.6% vs 6.4%, respectively, P<0.001. ECDs with multiple compared with single UC entanglement had higher rate of adverse neonatal outcome, P=0.031, and more placental fetal vascular lesions 19.3% vs 8.1%, P=0.027, respectively.

CONCLUSION

Multiple UC entanglements, true knots and short cords were more common in ECDs for NRFHR, suggesting their role in the development of fetal placental vascular lesions and adverse neonatal outcome.

Candida glabrata Chorioamnionitis following in vitro Fertilization: Review of the Literature

AIM

To review all past reports of Candida glabrata chorioamnionitis in the literature while noting their correlation with in vitro fertilization (IVF).

METHODS

We checked MEDLINE, PubMed and Google scholar (January 1970 to December 2014) for articles using the search terms 'Candida', 'Torulopsis', 'glabrata', 'chorioamnionitis', 'congenital', 'perinatal' and 'infection'. Case reports were included if they described a verified intrauterine infection with C. glabrata. The authors reviewed the articles and abstracted the data. 20 cases were compared, including a case reported from our institution shortly described in this article.

RESULTS

13 of 20 cases (65%) involved pregnancies achieved by IVF; 3 patients underwent amniocentesis during their pregnancy. Of the 7 cases with no history of IVF, 2 involved a history of cerclage and 2 a history of intrauterine device use. Only 6 infants survived, delivered prematurely by cesarean section.

CONCLUSIONS

Review of literature demonstrated a high prevalence of IVF-assisted pregnancies among the few C. glabrata chorioamnionitis cases previously described, typically occurring during the second trimester. Additional cases were notable for additional instrumentation/invasive procedure. The prognosis was mostly grim, entailing a high incidence of stillbirth or rapid neonatal death.

Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy

PURPOSE

The aim of our study was to assess the clinical and obstetric outcomes of laparoscopic surgeries performed during advanced pregnancy compared to those performed in early pregnancy.

METHODS

We retrospectively reviewed all cases of patients who underwent laparoscopic surgery during pregnancy in our institution between 1996 and 2013.

RESULTS

We reviewed cases of 117 pregnant women who underwent laparoscopic surgery during the study period. There were no conversions to laparotomy. 71 surgeries were performed in the first trimester (group 1, mean gestational age 7.7 ± 1.9 weeks) and 46 were performed in the second and third trimesters (group 2, mean gestational age 18.1 ± 4.3 weeks). More patients in group 1 underwent surgery for suspected adnexal torsion (p < 0.001), while more patients in group 2 underwent surgery for presumptive cholecystitis (p = 0.014) and persistent ovarian mass (p = 0.011). The interval between admission and surgery differed significantly between the groups and was longer in group 2 compared to group 1 (18.2 ± 24.0 vs. 6.8 ± 10.6 h, p = 0.001). No difference was found between the two groups regarding surgical complications, histopathological findings and pregnancy outcomes.

CONCLUSION

In our experience, laparoscopic surgery in advanced pregnancy was found to be feasible and safe as in early pregnancy, without any adverse effects on pregnancy outcome.

Laminaria vs. vaginal misoprostol for cervical preparation before second-trimester surgical abortion: a randomized clinical trial

OBJECTIVE

To compare the efficacy and tolerability of vaginal misoprostol and laminaria for cervical preparation before second-trimester surgical abortion.

STUDY DESIGN

We performed a prospective, randomized trial comparing midnight administration of misoprostol 600 mcg vaginally to midnight placement of laminaria, before surgical abortions among women at 13-20 weeks of gestation. The primary outcome was preoperative cervical dilation. Secondary outcomes were the need for further dilation, procedure duration and difficulty, immediate complications and side effects.

RESULTS

Eighty-four women were randomized, with a median gestational age of 16.5 weeks. The mean time interval between misoprostol and laminaria placement and dilatation and evacuation initiation was 11.0±2.9 and 11.2±2.0h, respectively (p=.17). Cervical dilation was not greater in the laminaria group as compared to the misoprostol group (12.8 vs. 12.4mm, respectively; p=.32). No difference was demonstrated regarding the need for additional dilation or the difficulty of the procedure. Procedures performed after laminaria insertion were 1 min longer (median 11 vs. 10 min, p=.04). Participants found laminaria placement more uncomfortable than vaginal misoprostol placement. Other than pain, additional side effects occurred only in the misoprostol group, primarily nausea and vomiting. One participant in the misoprostol group experienced fetal expulsion during the night before the intended procedure.

CONCLUSION

Either vaginal misoprostol or laminaria provides adequate dilation for second-trimester surgical abortion. Laminaria causes more pain at insertion and misoprostol causes more side effects.

IMPLICATIONS STATEMENT

We found that cervical preparation in an inpatient setting for approximately 11h with misoprostol 600 mcg vaginally is comparable to 11h of laminaria. However, given the potential for spontaneous expulsion and more side effects with misoprostol, laminaria is likely a better general option in such a setting.

Endometrial nerve fibre density in patients undergoing IVF: a pilot study

The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. Presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. This prospective pilot study assessed the presence of nerve fibres in endometrium of women undergoing IVF due to various causes and examined the correlation between the presence of nerve fibres and IVF success. A total of 32 IVF patients underwent endometrial biopsy during days 21-23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Correlations between the presence and density of nerve fibres and aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. Presence of nerve fibres was not correlated with cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without correlation to presence of nerve fibres in the endometrium. Nerve fibres were identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. The presence of nerve fibres does not appear to interfere with implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research. The presence of nerve fibres in the functional layer of the endometrium has been strongly associated with endometriosis. The presence of nerve fibres in the endometrium of women undergoing IVF has not been previously assessed. Our aim was to assess the presence of nerve fibres in endometrium of women with various causes of infertility undergoing IVF and to examine the association between the presence of nerve fibres in the endometrium and IVF success. In a prospective study, 32 IVF patients underwent endometrial biopsy during days 21-23 of the menstrual cycle. Nerve fibres were identified by immunohistochemical staining. Associations between the presence and density of nerve fibres and the aetiology of infertility and IVF success were measured. Nerve fibres were identified in the endometrium of 10/31 (32.3%) women with a satisfactory biopsy. No association was found between the presence of nerve fibres and the cause of infertility. Clinical pregnancy was achieved in 12/32 (37.5%) patients, without association with the presence of nerve fibres in the endometrium. Nerve fibres can be identified in a substantial percentage of women undergoing IVF, possibly reflecting underdiagnosis of endometriosis in this population. Their presence does not interfere with embryo implantation. The significance of nerve fibres in the endometrium of IVF patients warrants further research.

Differences between adnexal torsion in pregnant and nonpregnant women

STUDY OBJECTIVE

To compare the clinical manifestation, management, and outcome of adnexal torsion in pregnant and nonpregnant women.

DESIGN

Retrospective case-control study (Canadian Task Force classification II-3).

SETTING

Tertiary care university hospital.

PATIENTS

Sixty-four pregnant women and 198 nonpregnant women with episodes of adnexal torsion.

INTERVENTIONS

Surgery to treat proved adnexal torsion.

MEASUREMENTS AND MAIN RESULTS

The mean (SD) gestational age in the pregnant group was 11.5 (7.7) weeks. Thirty six episodes of adnexal torsion in the pregnant group (56%) developed after treatment for infertility, compared with only 14 such episodes (7%) in the nonpregnant group (p < .001). A repeated episode of torsion occurred more frequently in the pregnant group (14% vs 4%; p = .03). Sonographic demonstration of multicystic ovaries was more common in pregnant women with recurrent torsion than in women with a single episode of torsion (86% vs 31%; p = .009). Tissue preservation was achieved more frequently in pregnant than in nonpregnant patients (95% vs 77%; p < .001), and the duration of surgery was 15 minutes shorter in the pregnant women (p < .001).

CONCLUSION

Pregnancy after treatment for infertility is a risk factor for adnexal torsion. Recurrence of ovarian torsion occurs more frequently in pregnant patients, and in particular in enlarged multicystic ovaries.

Can we rely on blind endometrial biopsy for detection of focal intrauterine pathology?

OBJECTIVE

To compare the diagnostic power of random endometrial biopsy with hysteroscopy for intrauterine lesions.

STUDY DESIGN

A retrospective cohort study of 639 women evaluated by diagnostic office hysteroscopy and endometrial biopsy (Novak curette) was carried out between 10/1997-6/2000. Reasons for evaluation were postmenopausal bleeding, abnormal uterine bleeding, ultrasound or hystero-salpingography findings, intrauterine device removal, suspected retained products of conception, infertility, late abortions and recurrent abortions.

RESULTS

The women's mean age was 43.4+/-13.3 years (range, 18-88). The most prevalent indication for investigation was abnormal uterine bleeding (n=218, 34.1%), followed by sonographic or hystero-salpingographic findings (n=167, 26.1%). Hysteroscopy revealed a normal uterine cavity in 367 (57.4%) women. Endometrial polyps and submucosal fibroids were the most common hysteroscopic findings (in 151 [23.6%] and 72 [11.3%], respectively). The hysteroscopic findings were compared with the pathology results in 558 cases. The sensitivity of the Novak curette for detection of endometrial polyps and submucosal fibroids was only 8.4% and 1.4%, respectively. The positive predictive value (30.9%) and the negative predictive value (57.9%) for both lesions were likewise low. On the other hand, hysteroscopy was not effective in diagnosing the 27 cases of hyperplasia (26 simple and one complex) all without atypia.

CONCLUSION

Random endometrial sampling alone is not effective for diagnosing focal lesions of the uterine cavity and should be combined with other modalities, preferably diagnostic hysteroscopy.

A New Approach to Office Hysteroscopy Compared With Traditional Hysteroscopy

OBJECTIVE

To compare a "no touch" approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3%.

METHODS

A total of 130 women undergoing diagnostic hysteroscopy were included in the study and were randomized, using a computer-generated randomization list to one of two treatment groups in a ratio of 2:1. Eighty-three women underwent hysteroscopy without speculum, tenaculum, or anesthesia. Forty-seven women received intracervical anesthesia with 10 mL of 3% mepivacaine hydrochloride solution injected at two sites (3:00 and 9:00 positions) and underwent traditional hysteroscopy. Hysteroscopy was performed using a rigid 3.7-mm hysteroscope and a medium of 0.9% saline, and the image was transmitted to a screen visible to the patient. A visual analog scale (VAS) consisting of a 10-cm line was used to assess the intensity of pain experienced during and after the procedure. Overall patient satisfaction was assessed during, immediately after, 15 minutes later, and 3 days after hysteroscopy.

RESULTS

The mean pain score was significantly lower in the group without the use of speculum, tenaculum, or anesthesia (VAS1: 3.8+/-2.7 versus 5.34+/-3.23, P=.01; VAS2: 3.02+/-2.50 versus 4.57+/-3.30, P=.008). Patient satisfaction rate was similar in both groups.

CONCLUSION

Patients reported significantly less pain with the altered approach to diagnostic hysteroscopy compared with patients undergoing the traditional procedure with anesthesia. This new approach can therefore be considered as a useful hysteroscopic technique.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00319410

Endometrial Carcinoma After Endometrial Resection for Dysfunctional Uterine Bleeding

BACKGROUND

Endometrial destruction is an accepted conservative surgical approach for women with dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. The possibility exists that endometrial carcinoma may develop even years after such procedure.

CASE

We report on a case of endometrial carcinoma, which was diagnosed 3 years after hysteroscopic resection of the endometrium for dysfunctional uterine bleeding in a patient with no risk factors.

CONCLUSION

Endometrial carcinoma after hysteroscopic endometrial ablation is still a possibility even when strict selection criteria are applied.

Laparoscopic Management of Extremely Large Ovarian Cysts

OBJECTIVE

To assess the feasibility and outcome of laparoscopic surgery for the management of extremely large ovarian cysts.

METHODS

From July 2000 to December 2003, 21 patients with extremely large ovarian cysts were managed laparoscopically. The masses were cystic or complex, reached the umbilicus or higher, and were not associated with ascites or enlarged pelvic or para-aortic lymph nodes on computed tomography scan. Serum CA 125 levels were within the normal range or mildly elevated (< 130 mIU/mL). The mean and median ages of the patients were 45 +/- 20 and 46 years, respectively (range 17-89 years). Seven women were postmenopausal and the rest were premenopausal. The patients underwent cystectomy or adnexectomy depending on each patient's age and obstetric history.

RESULTS

Two laparoscopies were converted to laparotomy, one because of ovarian malignancy and the second because of technical difficulties related to morbid obesity and severe intra-abdominal adhesions. The postoperative recovery was uneventful in all women.

CONCLUSION

With proper patient selection, the size of an ovarian cyst is not necessarily a contraindication for laparoscopic surgery.

Improved Patient Compliance using Pediatric Cystoscope during Office Hysteroscopy

STUDY OBJECTIVE

To evaluate the use of a pediatric cystoscope in office diagnostic hysteroscopy.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

Maccabi Outpatient Women's Health Center.

PATIENTS

One thousand three hundred and thirty-five women; 959 (71.8%) premenopausal and 376 (28.2%) menopausal.

INTERVENTION

Office diagnostic hysteroscopy using 2.3-mm diameter pediatric cystoscope, without premedication or anesthesia.

MEASUREMENTS AND MAIN RESULTS

Hysteroscopy was successfully completed in 1298 patients (97.3%). The main reason for failure was cervical stenosis. Menopausal status was the only statistically significant factor correlating with increased failure rate. The analysis demonstrates that for every year of age, the OR for success decreases by 0.965, and success rises by 1.29 for every delivery the woman had. In menopausal women, the OR for success decreases by 0.45. Dilatation of the cervix was required in six women (0.46%), and local anesthesia was needed in only two women. One uterine perforation was recorded, and eight women (0.006%) developed vasovagal reflex or severe abdominal cramps. Post procedural oral analgesia was needed in 108 (8%) of the women.

CONCLUSION

The combination of a very small diameter continuous flow pediatric cystoscope, together with its ability to deliver high-quality images of the uterine cavity, make this instrument an excellent option for office diagnostic hysteroscopy.

Vaginal removal of prolapsed pedunculated submucous myoma: a short, simple, and definitive procedure with minimal morbidity

OBJECTIVE

Our objective was to evaluate the outcome of vaginal removal of prolapsed pedunculated submucous myomas over a 10-year period.

STUDY DESIGN

Retrospective observational study. Fifty-two patients were admitted with the diagnosis of prolapsed pedunculated submucous myoma. Six patients were excluded because of an a priori decision for abdominal hysterectomy. In 46 patients an attempt for vaginal myomectomy under general anesthesia was done.

RESULTS

Vaginal myomectomy was successful in 44 patients (95.6%). There were no immediate complications. Histological diagnosis of leiomyoma was confirmed in 34 cases (73.9%) and in the remainders intrauterine pathology was endometrial polyp. Total abdominal hysterectomy was performed in additional 6 patients (13.7%) 3 months to 5 years following vaginal myomectomy.

CONCLUSIONS

Vaginal myomectomy is the treatment of choice for prolapsed pedunculated submucous myoma. The associated morbidity is minimal.

Role of sonography in the diagnosis of retained products of conception

OBJECTIVE

To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings.

METHODS

This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty-one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor.

RESULTS

Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false-positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false-positive rates were 28.9% and 51.5%, respectively.

CONCLUSIONS

Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false-positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

Reproductive Performance following Midtrimester Termination of Pregnancy

The aim of the study was to determine the impact of midtrimester abortion with extra-amniotic PGE(2) on future fertility and reproduction. Two hundred and fifteen women were enrolled. The mean induction-to-abortion interval was 21.3 h. The complication rate was 11.7%. Twenty women (9.3%) were lost to follow-up, 82 patients (38.1%) used contraception. Spontaneous pregnancy occurred in 110 out of 113 women who desired fertility (97%). Three patients were defined as infertile but conceived following treatment. The average time between the abortion and the next conception was 15.9 months (range 1-77 months). Seventy patients (63.7%) delivered at term. Premature delivery occurred in 18 patients (16.4%). Eighteen women aborted spontaneously in the first and 3 in the second trimester. One extrauterine pregnancy occurred. Second-trimester abortion with extra-amniotic PGE(2) is a safe procedure with a low rate of complication. Apparently it does not affect future fertility, but may be associated with an increased rate of premature deliveries in future gestations.

Extra-amniotic prostaglandin E2 for midtrimester termination of pregnancy in live fetuses vs. fetal demise

This study compared the course of midtrimester termination of pregnancies with fetal demise and those with a viable fetuses by extra-amniotic prostaglandin (PG) E(2). A total of 275 women who underwent second trimester abortion with extra-amniotic PGE2(2) were divided into two groups: 95 patients (35%) with fetal demise and 180 women (65%) with a live fetuses. Extra-amniotic PGE2(2) was administered in doses of 200 micro g every 2 h up to 20 doses. Bumm curettage was performed in the majority of the patients. We compared the duration and complication rate between the groups. The median induction to abortion interval was significantly shorter in the fetal demise group (13 vs. 21 h) than in the live fetus group. Mean gestational ages and complication rates were similar. Midtrimester termination of pregnancy with extra-amniotic PGE2(2) is a safe method with a low complication rate. In cases of pregnancy with fetal demise extra-amniotic PGE2(2) is associated with a significantly shorter induction to abortion interval than with a live fetus.