Reducing patient's perception of postoperative vaginal bleeding after laparoscopic hysterectomy via independent closure of the vaginal cuff angles (RCT)

STUDY OBJECTIVE

Determine if independently suturing the vaginal cuff angles in addition to running barbed suture has an effect on patients' perception of postoperative bleeding after laparoscopic hysterectomy.

DESIGN

Randomized controlled trial.

SETTING

University-based medical center.

PATIENTS

Females ages 18-60 undergoing laparoscopic hysterectomy.

INTERVENTIONS

Patients were randomly assigned to either cuff closure via single layer of barbed suture (control) vs adding figure-of-eight stitches at each angle (intervention). A survey was given between 10 and 25 days after surgery inquiring about bleeding and dyspareunia. A second survey was given between postoperative days 90-114. Chart review was performed to record emergency room visits, complications, infections, and reoperations during the first 90 postoperative days.

RESULTS

n = 117 patients were analyzed. 62 (control) and 55 (intervention). Groups were similar in terms of age (42.92 v 44.29p =.35), BMI (33.79 v 34.06p =.85), diabetes (5.26 % (3/55) v 15.09 % (8/53) p =.08) p =.97). Bleeding was decreased in intervention arm (24.19 % (15/62) v 9.09 % (5/55) p =.03). Median (IQR) pelvic pain score was similar (2.0 (0-5.0) v 2.0 (0-4.0) p =.26). Median total operative time (IQR) (129 min (102, 166) v 139 min (120, 163) p =.39) and median EBL (IQR) (50 mL (30-75) vs 50 mL (20-75) p =.43) were similar. Cuff closure in seconds (IQR) was higher in intervention group (373 sec (323, 518) v 571 sec (520, 715) p <.01). 8/60 control patients visited the ED (13.33 %) v 7/54 (12.96 %) p =.95. Readmissions (1.67 % (1/60) v 1.85 % (1/55) p = 1), re-operations (0 % (0/60) v 1.85 % (1/55) p =.47) and postoperative infections (5.0 % (3/60) v 1.85 % (1/54) p =.62) were similar. Secondary survey showed no significant difference in bleeding (15.38 % (4/26) v 4.35 % (1/23) p =.35) and SF-36 results were similar.

CONCLUSION

Independently suturing the vaginal cuff angles reduces patients' perception of vaginal bleeding in the early postoperative period. Incidence of complications, reoperations, and long-term quality of life are similar.

Adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding associated with uterine leiomyomas

BACKGROUND

Uterine leiomyomas and adenomyosis are both common and often associated with abnormal uterine bleeding (AUB), including the symptom of heavy menstrual bleeding (HMB). Understanding the prevalence of adenomyosis in women with uterine leiomyomas could inform clinicians and patients in a way that may improve therapeutic approaches.

OBJECTIVE

To explore the prevalence of adenomyosis in a group of women who underwent hysterectomy for AUB-L, to determine the prevalence of submucous leiomyomas, and to examine the utility of preoperative ultrasound to detect the presence of adenomyosis.

METHODS

The Kaiser Permanente Hysterectomy Database (KPHD) was searched for women aged 18-52 undergoing hysterectomy for leiomyoma-associated chronic AUB (AUB-L) in 2018 and 2019. A target sample of 400 comprised those with at least 3 years in the Health System. Radiologists evaluated preoperative pelvic ultrasound images to determine leiomyoma size and level 2 FIGO type (submucous or other), and the linked electronic medical record abstracted for clinical features, including histopathological evidence of adenomyosis.

RESULTS

Of the 370 subjects that met the study criteria, adenomyosis was identified via histopathology in 170 (45.9%). There was no difference in the adenomyosis prevalence with (47.1%) and without (43.0%) at least one submucous leiomyoma. Subgroup analysis of ultrasound images by an expert radiologist for the presence of adenomyosis demonstrated a positive predictive value of 54.0% and a negative predictive value of 43.4%.

CONCLUSIONS

Adenomyosis was present in almost half of this AUB-L cohort undergoing hysterectomy and was equally prevalent in those with and without submucous leiomyomas as determined by sonographic evaluation. The imaging findings are in accord with prior investigators and demonstrate that 2-D ultrasound is insensitive to the presence of adenomyosis when the uterus is affected by leiomyomas. Further research is necessary to determine the impact of various adenomyosis phenotypes on the presence and severity of the symptom of HMB.

Sharp Versus Electric Suction Curettage in Gynecologic Patients Undergoing Evaluation for Abnormal Uterine Bleeding

STUDY OBJECTIVE

Suction curettage is preferred over sharp curettage in obstetric settings. We compare the quality of operative tissue sampling between sharp curettage and suction curettage using electric vacuum aspiration for nonobstetric abnormal uterine bleeding in reproductive-aged women.

DESIGN

A retrospective cohort study.

SETTING

Community hospital in Long Island, New York.

PATIENTS

Women ages 21 to 45 years (n = 257) who underwent operative curettage procedure for nonobstetric abnormal uterine bleeding.

INTERVENTIONS

Independent ratings of specimens from suction curettage using electric vacuum aspiration and sharp curettage by 2 pathologists blinded to method of tissue collection.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was percentage of organized tissue, indicative of a higher-quality pathology specimen. Specimens obtained by electric suction curettage (p <.001) had a significantly higher percentage of organized tissue (M = 66.28, SD = 20.33) than sharp curettage (M = 55.51, SD = 24.17). There were no differences between the curettage groups for operative time, blood loss, intraoperative complications, or pathology diagnosis.

CONCLUSION

Specimens obtained with suction curettage contained more organized tissue with similar pathologist satisfaction and confidence scores than sharp curettage. We suggest clinicians consider electric suction curettage in the diagnostic workup of abnormal uterine bleeding in reproductive-aged women. In addition, patient-centered benefits include no increase in operative time, blood loss, or complication rate compared with sharp curettage.

Adenomyoma recurrence 7 years after laparoscopic supracervical hysterectomy: A case report and literature review

RATIONALE

Adenomyosis, a gynecological condition characterized by endometrial tissue within the uterine myometrium, often leads to menstrual pain and heavy bleeding, significantly affecting the quality of life. The primary treatment for adenomyosis and leiomyomas is hysterectomy. However, in rare instances, these conditions can recur in the cervical stump following a hysterectomy.Here, we present a case of cervical adenomyoma development after a prior laparoscopic supracervical hysterectomy.

PATIENT CONCERNS

A 47-year-old woman sought medical attention due to increased vaginal bleeding.

DIAGNOSES

She had undergone a laparoscopic supracervical hysterectomy 7 years earlier to address uterine myoma and adenomyosis. Just 1 month posthysterectomy, a pelvic ultrasound revealed the presence of a cervical stump measuring approximately 4.0 × 4.0 cm. Subsequent follow-up ultrasounds documented the gradual growth of the cervical mass. Two years ago, a recurrent myoma was identified, and the patient experienced intermittent vaginal bleeding. Over 7 years, the cervical mass increased from 4 to 7 cm. Preadmission pelvic ultrasonography confirmed the existence of cervical adenomyoma measuring 7 × 6 cm.

INTERVENTIONS

Consequently, the patient underwent a laparoscopic trachelectomy. Intraoperatively, an enlarged cervix, approximately 7 × 6 cm in size, containing adenomyoma was observed. A gross examination of the specimen indicated hypertrophic muscle tissue and hemorrhagic foci. Subsequent histopathological examination confirmed the presence of adenomyoma.

OUTCOMES

Remarkably, the patient exhibited no recurrence over the subsequent 8 months.

LESSONS

The case presented here highlights the potential occurrence of cervical adenomyoma following a supracervical hysterectomy. Management options include hormone therapy and surgical excision. Furthermore, annual follow-up comprising ultrasound and pap smear evaluations is recommended for patients with supracervical hysterectomies to detect and address possible recurrences.

A case of delayed postoperative bleeding after excision of endometrial polyp using resectoscope in an infertile woman with von Willebrand disease:a case report and literature review

Von Willebrand disease (VWD) is a bleeding disorder caused by a congenital quantitative reduction, deficiency, or qualitative abnormality of the von Willebrand factor (VWF). Here, we report a case of delayed postoperative bleeding in an infertile woman with endometrial polyps complicated by VWD. The patient was a 39-year-old infertile woman with type 2A VWD. At 38 years of age, she was referred to our hospital for infertility and heavy menstrual bleeding. Hysteroscopy revealed a 15-mm polyp lesion in the uterus. The patient was scheduled for transcervical resection (TCR) of the endometrial polyp. Gonadotropin-releasing hormone agonists were preoperatively administered to prevent menstruation. The VWF-containing concentrate was administered for 3 days according to guidelines. The patient was discharged on postoperative day 3 after confirming the absence of uterine bleeding. Uterine bleeding began on postoperative day 6. The patient was readmitted on postoperative day 7 and treated with VWF-containing concentrate for 5 days, after which hemostasis was confirmed. TCR surgery for endometrial lesions is classified as a minor surgery, and guidelines recommend short-term VWF-containing concentrate replacement. However, it should be kept in mind that only short-term VWF-containing concentrate replacement may cause rebleeding postoperatively.

Diagnostic considerations and surgical techniques for a large prolapsing submucosal myoma

OBJECTIVE

To review important diagnostic considerations for accurate identification of a prolapsing submucosal myoma and to highlight surgical techniques for minimally invasive and uterine-sparing combined vaginal and hysteroscopic myomectomy. Submucosal myomas can present with various symptoms, including vaginal bleeding, pelvic pain, and abnormal discharge, and can also contribute to infertility. This type of myoma has the potential to prolapse through the cervical canal, and prompt identification and management are essential to avoid serious sequelae, including hemorrhage, infection, and sepsis.

DESIGN

A case report. Patient consent was received to publish. This publication received an exemption from institutional review board approval from the institution as this was a case report. The investigators have no conflicts of interest.

SETTING

Academic medical center.

PATIENTS

We present a 33-year-old G5P2032 patient with pelvic pain and vaginal bleeding. Her clinical course involved multiple encounters with inaccurate diagnoses, leading to worsening symptoms. She was found ultimately to have a large, prolapsing submucosal myoma. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, and others), and other applicable sites.

INTERVENTION(S)

Given the severity of her symptoms and her desire for uterine preservation for future fertility, the patient was counseled on the need for surgical intervention and elected to proceed with a combined vaginal and hysteroscopic myomectomy.

MAIN OUTCOME MEASURE(S)

Preoperative considerations discussed in this video include common mimics of this condition, the importance of a thorough pelvic examination and preoperative imaging, as well as recommendations for surgical management.

RESULT(S)

We reviewed the following surgical techniques: (1) adequate exposure; (2) clamping of the myoma stalk; (3) morcellation "cone" technique; (4) use of intracervical vasopressin; (5) hysteroscopic evaluation; and (6) insertion of an intrauterine balloon.

CONCLUSION(S)

Prolapsing submucosal myomas can present as common gynecologic complaints but can lead to serious sequelae when timely diagnosis and treatment are not performed. Appropriate evaluation, accurate diagnosis, preoperative imaging, and knowledge of surgical techniques are critical for optimizing patient outcomes and avoiding complications in patients with a prolapsed myoma.

Acquired uterine arteriovenous malformation in a patient with cornual pregnancy: A case report

INTRODUCTION

Acquired uterine arteriovenous malformation (uAVM) is a rare disease and could occur after dilation and curettage, cesarean section, or neoplastic processes.

PATIENT CONCERNS

A 29-year-old female presented with acute right lower abdominal pain and positive beta human chorionic gonadotropin (β-hCG).

DIAGNOSIS

A 6 cm ectopic right cornual pregnancy was found on ultrasound examination.

INTERVENTIONS

She underwent a laparoscopic resection of the cornual ectopic pregnancy. She returned with extensive vaginal bleeding 6-month post surgery, and eventually diagnosed with arteriovenous malformation at the previous surgical site by Color Dopplor endovaginal ultrasound. Percutaneous transcatheter uterine artery embolization (UAE) was attempted, however, vaginal bleeding continued. She was taken to the operation room for a hysteroscopic ablation of uAVM.

OUTCOMES

Complete cessation of the bleeding was achieved without hysterectomy.

CONCLUSION

We report an extremely unusual case of acquired uAVM after a wedge resection of cornual pregnancy. Ultrasound evaluation of patients with post-operative persistent bleeding should be considered for evaluation of a possible arteriovenous malformation.

Evaluation of the Efficacy and Adverse Reactions of Mirena Combined with Hysteroscopic Surgery When Treating AUB: Based on a Retrospective Cohort Study

Objective

A case-control study was performed to explore the efficacy and adverse reactions of Mirena combined with hysteroscopy when treating AUB.

Methods

108 patients with perimenopausal AUB treated in our hospital from June 2019 to December 2021 were enrolled, and their clinical data were collected and analyzed retrospectively. According to the mode of treatment, the patients were assigned into control group (54 cases) and study group (54 cases). The therapeutic effects were compared. Visual analog score (VAS) was adopted to evaluate the degree of incision pain, Barthel index score was adopted to evaluate the ability of daily living, quality of life scale was adopted to investigate the quality of life before and after treatment, and the changes of sex hormone levels, endometrial thickness, and menstruation were detected before and after treatment. The incidence of adverse reactions was calculated.

Results

In terms of the therapeutic effects, 46 cases were cured, 6 cases were effective, and 2 cases were ineffective in the study group, and the effective rate was 96.30%; in the control group, 32 cases were cured, 10 cases were effective, and 12 cases were ineffective, and the effective rate was 77.78%; the effective rate of the study group was higher than that of the control group (P < 0.05). In terms of VAS score, the VAS score decreased after treatment, and the VAS score in the study group was significantly lower than that in the control group at 1 week, 2 weeks, 1 month, and 3 months after treatment. With regard to the Barthel index scores after treatment, the Barthel index scores increased, and the Barthel index scores of the study group at 1 week, 2 weeks, 1 month, and 3 months after treatment were higher compared to the control group (P < 0.05). In terms of the Barthel index scores after treatment, the Barthel index scores increased, and the Barthel index scores of the study group at 1 week, 2 weeks, 1 month, and 3 months after treatment were higher compared to the control group (P < 0.05). Compared with those before treatment, the levels of FSH, LH, and E2 in both groups decreased remarkably (all P < 0.05). In terms of the changes of endometrium and menstruation, the endometrial thickness, menstrual time, and menstrual volume were significantly improved after treatment (P < 0.05). After treatment, the endometrial thickness, menstrual time, and menstrual volume in the study group were better than those in the control group (P < 0.05). With regard to the scores of qualities of life, the scores of qualities of life decreased after treatment. Compared between the two groups, the scores of physiological function, psychological function, social function, and health self-cognition in the study group were lower compared to the control group. Regarding the incidence of adverse reactions, in the study group, there were 1 case of breast pain, 2 cases of vaginal bleeding, and no dizziness and nausea, and the incidence of adverse reaction was 5.56%; In the control group, there were 1 case of dizziness, 2 cases of breast pain, 4 cases of nausea, and 3 cases of vaginal bleeding, and the incidence of adverse reactions in the study group was 18.52%. The incidence of adverse reactions in the study group was lower compared to the control group (P < 0.05).

Conclusion

Hysteroscopy combined with Mirena when treating perimenopausal AUB can remarkably enhance the related symptoms, regulate the level of sex hormones, and remarkably reduce the amount of menstrual bleeding. The curative effect is better than hysteroscopy combined with dydrogesterone tablets, which is worth popularizing in clinic.

[Clinical effect and influencing factors of focused ultrasound ablation surgery combined with suction curettage for the treatment of mass-type cesarean scar pregnancy]

Objective: To investigate the clinical effect of focused ultrasound ablation surgery (FUAS) combined with suction curettage for mass-type cesarean scar pregnancy (CSP) and to analyze the influencing factors of vaginal bleeding and readmission. Methods: From January 2014 to December 2020, 88 patients with mass-type CSP were treated by FUAS combined with suction curettage in the Third Xiangya Hospital of Central South University. The clinical results and the influencing factors of bleeding and readmission for mass-type CSP were analyzed. Results: All the patients underwent one time FUAS treatment successfully. Immediately after FUAS treatment, color Doppler ultrasound showed obvious necrosis and no perfusion area in all lesions, and the blood flow in the mass-type CSP tissue significantly decreased. The median volume of blood loss in the procedure was 20 ml (range: 5-950 ml). Thirteen patients (15%, 13/88) had vaginal bleeding≥200 ml, and 15 patients (17%, 15/88) were hospitalized again. The average time for menstruation recovery was (28±8) days (range: 18-66 days). The average time needed for serum human chorionic gonadotropin-beta subunit to return to normal levels was (22±6) days (range: 7-59 days). The risk of large vaginal bleeding of patients were related to the blood supply of the mass (OR=5.280, 95%CI: 1.335-20.858, P=0.018) and the largest diameter of the mass (OR=1.060, 95%CI: 1.010-1.120, P=0.030). The risk of readmission were related to the largest diameter of the mass (OR=1.055, 95%CI: 1.005-1.108, P=0.030) and the depth of the uterus cavity (OR=1.583, 95%CI: 1.015-2.471, P=0.043). No serious complications such as intestinal and nerve injury occurred during and after FUAS treatment. Conclusions: FUAS combined with suction curettage is safe and effective in treating patients with mass-type CSP through this preliminary study. The volume of vaginal bleeding are associated with the blood supply of the mass and the largest diameter of the mass, the risk of readmission are related to the largest diameter of the mass and the depth of the uterus cavity.

Transcervical radiofrequency ablation of fibroids that are 5 cm or larger in women with abnormal uterine bleeding

INTRODUCTION

Fibroids are the most common benign uterine tumors. Transcervical radiofrequency ablation with the Sonata® System offers a minimally invasive, incisionfree, organ-preserving therapy, with intraoperative visualization of fibroids using intrauterine ultrasound guidance. To demonstrate the effectiveness of transcervical radiofrequency ablation of fibroids that are 5 cm or larger using the Sonata® System, this retrospective analysis was collected.

METHOD

151 patients have been treated with this method in our department up to the time of this analysis. Only patients with at least one fibroid of ≥5 cm and with bleeding symptoms, who were treated with the Sonata® System were included in this retrospective study. A total of 50 patients were included in the study and 57 fibroids were treated.

RESULTS

A total of 57 fibroids were detected and treated, however FIGO 1 and 2 fibroids (in total three fibroids were excluded). The smallest fibroid was 4 cm and the largest fibroid was 12 cm. A single ablation was performed in 18 cases, two ablation steps in 16 cases, three ablation steps in 13 cases, and more than three ablation steps in three cases. Depending on ablation steps, the shortest ablation time was 3 min 15 s and the longest ablation time was 25 min 6 s, with an average time of 9 min 12 s. 86% of patients reported an improvement of symptoms Conclusion: Thus, the Sonata® System is a simple, minimally invasive, rapid and successful method that shows significant improvement of symptoms even in large myomas from ≥5 cm.

Risk of More Advanced Lesions at Hysterectomy after Initial Diagnosis of Non-Atypical Endometrial Hyperplasia in Patients with Postmenopausal Bleeding and Oral Anticoagulant Treatment

Background and Objectives: Endometrial hyperplasia (EH) is a precursor lesion to endometrial cancer (EC), and when cellular atypia is present, in 40% of cases, they are diagnosed with EC on hysterectomy. Usually, EH is clinically manifested by uterine bleeding. In patients with oral anticoagulant therapy (OAT), the uterus is the second most common source of bleeding. The aim of the study was to show that uterine bleeding in postmenopausal patients undergoing OAT may reveal precancerous endometrial lesions with atypia, or neoplastic lesions in patients with an initial diagnosis of endometrial hyperplasia without atypia (non-atypical endometrial hyperplasia, NAEH) on dilation and curettage (D&C). We will be able to estimate the risk of a postmenopausal female patient with uterine bleeding during an OAT to have a precancerous endometrial lesion. Materials and Methods: The subjects of the study were 173 female patients with uterine bleeding, who have had total hysterectomy with bilateral salpingoovarectomy, of whom 99 underwent an OAT. There were 101 female patients initially diagnosed with NAEH, of which 60 did not have anticoagulant treatment (mean age 57.36 ± 6.51) and 41 had anticoagulant treatment (mean age 60.39 ± 7.35) (p = 0.006). From the pathology diagnosis moment, the surgery was performed at 42.09 ± 14.54 days in patients without OAT and after 35.39 ± 11.29 days in those who received such treatment (p = 0.724). Results: Initial diagnosis of NAEH established at D&C was changed at the final diagnosis after hysterectomy in EH with cellular atypia (atypical endometrial hyperplasia AEH) or EC in 18.18% of patients without OAT, and in 40.54% of patients who received this treatment. Conclusions: Based on a logistic regression model, it is estimated that female patients with an initial histopathological diagnosis of NAEH and who underwent OAT have, on average, 4.85 times greater odds (OR = 4.85, 95% CI 1.79–14.06) than the others of being identified postoperatively with more advanced lesions.

Solution to prevent tumor spillage in minimally invasive radical hysterectomy using the endoscopic stapler for treating early-stage cervical cancer: Surgical technique with video

Gynecologic oncologists had originally preferred minimally invasive surgery (MIS) over laparotomic surgery for patients with early-stage cervical cancer until the Laparoscopic Approach to Cervical Cancer (LACC) trial reported a worse prognosis and more loco-regional recurrence in patients treated with MIS. Although some controversy remains, experts suggested that tumor cell spillage and aggravation may have been caused by intra-corporeal colpotomy, usage of uterine elevators, maintenance of Trendelenburg position, and tumor irritation by capnoperitoneum during surgery. Thus, we introduce a surgical procedure with some steps added to the conventional MIS radical hysterectomy for preventing tumor spillage during the surgery, which is currently being evaluated in terms of safety and efficacy through a prospective, multicenter, single-arm, phase II study, entitled "Safety of laparoscopic or robotic radical surgery using endoscopic stapler for inhibiting tumor spillage of cervical neoplasms (SOLUTION trial: NCT04370496)".

Clinicopathological analysis of ovarian sertoli-leydig cell tumor with postmenopausal vaginal bleeding as the first symptom: A case report

RATIONAL

Ovarian sertoli-leydig cell tumor (OSLCT) is extremely rare. We reported a OSLCT case in whom postmenopausal vaginal bleeding was the first symptom.

PATIENT CONCERNS

The patient came to our hospital due to postmenopausal vaginal bleeding.

DIAGNOSES

Serum tumor markers and color Doppler ultrasound for her pelvic cavity were negative. The patient was finally diagnosed with left OSLCT by pathology. It was difficult to make a definite diagnosis before operation, the diagnosis of OSLCT required postoperative pathology in the patients.

INTERVENTIONS

the patient underwent laparoscopic hysterectomy+bilateral adnexectomy+lysis of pelvic adhesions.

OUTCOMES

Postoperative laboratory examinations were normal. The patient was discharged from our hospital on the seventh day after operation and came to our hospital for follow-up check in April 2020. Physical and laboratory examinations were normal.

LESSONS

OSLCT can show different endocrine abnormalities, which are related to the various types of tumor tissues. Missed diagnosis and misdiagnosis are likely to occur in the patients who only have elevated serum testosterone. For the menopausal women with elevated serum testosterone, ovarian tumor shoule be highly suspected after excluding adrenal gland-related diseases.

Outpatient uterine assessment and treatment unit in patients with abnormal uterine bleeding: an economic modelling study

BACKGROUND

Most often in Canada, the evaluation and management of abnormal uterine bleeding occurs under general anesthesia in the operating room. We aimed to assess the potential cost-effectiveness of an outpatient uterine assessment and treatment unit (UATU) compared with the current standard of care when diagnosing and treating abnormal uterine bleeding in women.

METHODS

We performed a cost-effectiveness analysis and developed a probabilistic decision tree model to simulate the total costs and outcomes of women receiving outpatient UATU or usual care over a 1-year time horizon (Apr. 1, 2014, to Mar. 31, 2017) at a tertiary care hospital in Ontario, Canada. Probabilities, resource use and time to diagnosis and treatment were obtained from a retrospective chart review of 200 randomly selected women who presented with abnormal uterine bleeding. Results were expressed as overall cost and time savings per patient. Costs are reported in 2018 Canadian dollars.

RESULTS

Compared with usual care, care in the UATU was associated with a decrease in overall cost ($1332, 95% confidence interval [CI] -$1742 to -$1008) and a decrease in overall time to treatment (-75, 95% CI -89 to -63, d). The point at which the UATU would no longer be cost saving is if the additional cost to operate and maintain the UATU is greater than $1600 per patient.

INTERPRETATION

From the perspective of Canada's health care system, an outpatient UATU is more cost effective than usual care and saves time. Future studies should focus on the relative efficacy of a UATU and the total budget required to operate and maintain a UATU.

Prognostic Factors for the Failure of Endometrial Ablation: A Systematic Review and Meta-analysis

OBJECTIVE

To provide an overview of prognostic factors predicting failure of second-generation endometrial ablation.

DATA SOURCES

MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov were systematically searched from 1988 until February 2019. The search was conducted without language restrictions using the following search terms: "endometrial ablation," "prognosis," "predict," "long term," "late onset," "outcome."

METHODS OF STUDY SELECTION

The literature search provided a total of 990 studies. All types of studies reporting about prognostic factors of second-generation endometrial ablation failure were included.

TABULATION, INTEGRATION, AND RESULTS

After screening for eligibility, 56 studies were included in this review, of which 21 were included in the meta-analysis. In these 56 studies, 157,830 women were included. We evaluated 10 prognostic factors: age, myomas, history of tubal ligation, body mass index, parity, preexisting dysmenorrhea, caesarean delivery, bleeding pattern, uterus position, and uterus length. Meta-analysis was performed for the primary outcome (surgical reintervention) to estimate summary treatment effects. Younger age (aged 35 years or younger, odds ratio [OR] 1.68, 95% CI 1.19-2.36; aged 40 years or younger, OR 1.58, 95% CI 1.30-1.93; aged 45 years or younger OR 1.63, 95% CI 1.28-2.07), prior tubal ligation (OR 1.46, 95% CI 1.23-1.73), and preexisting dysmenorrhea (OR 2.12, 95% CI 1.41-3.19) were associated with an increased risk of surgical reintervention. Studies investigating the prognostic factors myomas and obesity showed conflicting results.

CONCLUSION

Younger age, prior tubal ligation and preexisting dysmenorrhea were found to be associated with failure of endometrial ablation. Obesity and the presence of large submucous myomas may be associated with failure, as well, though more research is necessary to estimate the influence of these factors. It is important to take the results of this review into account when counselling women with heavy menstrual bleeding.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019126247.

The surgical treatment of idiopathic abnormal uterine bleeding: An analysis of 88 000 patients from the French exhaustive national hospital discharge database from 2009 to 2015

Objective

The objective of the study was to compare success rates, complications and management costs of different surgical techniques for abnormal uterine bleeding (AUB).

Methods

This was a retrospective analysis of the French national hospital discharge database. All hospital stays with a diagnostic code for AUB and an appropriate surgical procedure code between 2009 and 2015 inclusive were identified, concerning 109,884 women overall. Outcomes were compared between second generation procedures (2G surgery), first-generation procedures (1G surgery), curettage and hysterectomy. Clinical outcomes were treatment failure and complications during the follow-up period. Costs were attributed using standard French hospital tariffs.

Results

7,863 women underwent a 2G procedure (7.2%), 39,935 a 1G procedure, (36.3%), 38,923 curettage (35.4%) and 23,163 hysterectomy (21.1%). Failure rates at 18 months were 9.9% for 2G surgery, 12.7% for 1G surgery, 20.6% for curettage and 2.8% for hysterectomy. Complication rates at 18 months were 1.9% for 2G surgery, 1.5% for 1G surgery, 1.4% for curettage and 5.3% for hysterectomy. Median 18-month costs were € 1 173 for 2G surgery, € 1 059 for 1G surgery, € 782 for curettage and € 3 090 for hysterectomy.

Conclusion

Curettage has the highest failure rate. Hysterectomy has the lowest failure rate but the highest complication rate and is also the most expensive. Despite good clinical outcomes and relatively low cost, 1G and 2G procedures are not widely used. Current guidelines for treatment of AUB are not respected, the recommended 2G procedures being only used in <10% of cases.

A new surgical technique "cervical internal os plasty" in cesarean delivery for placenta previa accreta: A case-control study

Placenta previa accreta is an obstetrical complication that severely affects the heath of the fetus and the mother due to massive hemorrhage during pregnancy. This study reported a new suture technique called "cervical internal os plasty" to control obstetrical hemorrhage in cesarean delivery for patients with placenta previa accreta and retrospectively evaluated the safety and effectiveness of the new technique.From January 2012 to May 2018, we collected 56 patients with this new suture technique, which repaired the damaged weak area with bleeding from the placental attachment site in the lower uterine segment, and restored the damaged anatomic internal os of the cervix. Meanwhile, we compared it with 60 cases with other conservative methods described by other obstetricians with the same qualifications. The perioperative outcomes (blood loss, blood transfusion, operative time, other applied medical technology, and so on) between the 2 groups were recorded in this report.There were no significant differences between 2 groups among age, gravidity, parity, gestational age, and previous dilatation and curettage techniques (P > .05). Of the patients with placenta previa accrete, 77.6% (90/116) had previous dilatation and curettage. The comparison between study group and control group on the rate of postpartum hemorrhage, blood transfusion, and mean operative time, average hospitalization days after cesarean delivery, expenses was not statistically significant (P > .05). Compared with the control group, other applied supplementary techniques (including uterine tamponade, pelvic arterial embolization, or emergency hysterectomy) for the bleeding from the the placental attachment site is fewer significantly in the study group. No operative accident and hemorrhea-related complication occurred in the 2 groups.Cervical internal os plasty is useful in patients with placenta previa accreta due to its simplicity, utility, and effectivity as well as its capacity for preserving fertility.

Clinical analysis of uterine artery embolization combined with double balloon catheter plus curettage for patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester: Three case reports

RATIONALE

It is very difficult to treat patients with placenta previa who underwent pregnancy termination and suffered antenatal massive hemorrhage in the 2nd trimester.

PATIENT CONCERNS

In this study, case 1 was with fetal malformation of 18-trisomy syndrome at gestation of 19 weeks + 2 days, case 2 was with fetal malformation of 18-trisomy syndrome at gestation of 22 weeks + 1 day, and case 3 was for intrauterine fetal death at gestation of 27 weeks. All the 3 cases were completely placenta previa.

DIAGNOSES

For the 3 patients, completely placenta previa was confirmed by ultrasound examination after hospitalization and underwent pregnancy termination for fetal death or fetal malformation in the 2nd trimester.

INTERVENTIONS

The 3 patients with placenta previa underwent pregnancy termination by mifepristone combined with ethacridine lactate in the 2nd trimester for intrauterine fetal death or fetal malformation from June 2017 to May 2018, and suffered antenatal massive hemorrhage during termination. Uterine artery embolization (UAE) was immediately performed to achieve hemostasis, then double balloon catheter (DBC) was carried out to promote cervical ripen, at last curettage was implemented with the help of ultrasound. After all these procedures, the clinical outcomes were observed.

OUTCOMES

The antenatal bleeding volume of these 3 patients were about 500, 600, and 550 mL. After implementing the combined treatment, all patients completed the abortion. The UAE-DBC time interval and DBC-curettage time interval were 58.4 and 6.0 hours, respectively, for case 1, whereas almost 0 (i.e., immediately) for cases 2 and 3. Case 1 had a fever lasting for 3 days, and the maximum body temperature was up to 39°C after UAE. Moreover, the blood culture was positive for Escherichia coli after curettage in case 1, whereas it was negative in the other 2 cases.

LESSONS

The UAE-DBC-curettage combined treatment is safe and effective for patients with placenta previa who undergo pregnancy termination and suffered massive antenatal hemorrhage in the 2nd trimester. Future studies are needed to advance our observation.

The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus

BACKGROUND

There are currently sparse data on the relationship between surgeon- and patient-related factors and perioperative morbidity in the setting of elective hysterectomy for the larger uterus.

OBJECTIVE

We sought to evaluate the impact of surgeon case volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for uteri >250 g.

STUDY DESIGN

This is a retrospective cohort study of all women who underwent total vaginal, total laparoscopic, laparoscopic-assisted vaginal, or robotic-assisted total laparoscopic hysterectomy from January 2014 through July 2016. Hysterectomy was performed for: fibroids, pelvic pain, abnormal uterine bleeding, or prolapse. Patients were identified by Current Procedural Terminology codes and the systemwide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon case volume was defined as the mean number of minimally invasive hysterectomy cases performed per month by each surgeon during the study period.

RESULTS

In all, 763 patients met inclusion criteria: 416 (54.5%) total laparoscopic hysterectomy, 196 (25.7%) robotic-assisted total laparoscopic hysterectomy, 90 (11.8%) total vaginal hysterectomy, and 61 (8%) laparoscopic-assisted vaginal hysterectomy. Mean (±SD) age was 47.3 ± 6.1 years, and body mass index was 31.1 ± 7.4 kg/m². In all, 66 surgeons performed minimally invasive hysterectomy for uteri >250 g during the study period, and the median rate of minimally invasive hysterectomy cases for large uteri per month was 3.4 (0.4-3.7) cases/month. The median (IQR) uterine weight was 409 (308-606.5) g. The rate of postoperative adverse events Dindo grade >2 was 17.8% (95% confidence interval, 15.2-20.7). The overall rate of intraoperative adverse events was 4.2% (95% confidence interval, 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% confidence interval, 4.0-7.4). There was no significant difference in adverse event rates between the routes of minimally invasive hysterectomy cases (25.6% vs 17.5% vs 18.0% vs 14.8% for total laparoscopic hysterectomy, robotic-assisted laparoscopic hysterectomy, total vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy, respectively, P = .2). In a logistic regression model controlling for age, body mass index, uterine weight, operating time, and history of laparotomy, higher monthly minimally invasive hysterectomy volume was significantly associated with the likelihood that a patient would experience a postoperative adverse event (adjusted odds ratio, 1.1 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.0-1.3). When controlling for the same variables, a higher incidence of intraoperative complications was significantly associated with monthly minimally invasive hysterectomy case volume (adjusted odds ratio, 1.5 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.20-2.08). Increasing age was associated with a lower incidence of complications (adjusted odds ratio, 0.9 for each additional year; 95% confidence interval, 0.8-0.9). Higher monthly minimally invasive hysterectomy volume was associated with a lower rate of conversion from a minimally invasive approach to laparotomy (adjusted odds ratio, 0.4 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 0.2-0.5).

CONCLUSION

The overall rate of serious adverse events associated with minimally invasive hysterectomy for uteri >250 g was low. Higher monthly minimally invasive hysterectomy case volume was associated with a higher rate of intraoperative and postoperative adverse events but was associated with a lower rate of conversion to laparotomy.

Oral contraceptive pills as an option for non-surgical management of retained products of conception - a preliminary study

Many Patients with persistent retained products of conception prefers to avoid surgical interventions, such as a dilatation and curettage (D&C) that might pose an additional future risk to their already compromised fertility or obstetric performance. The aim of this study was to the possibility of induced withdrawal bleeding following oral contraceptive administration as a non-surgical treatment for patients with persistent retained products of conception (RPOC). A retrospective study of patients presenting with retained products of conception (RPOC) after failed expectant management or after treatment with PGE1 was performed. Twelve women presenting with RPOC at ≤8 weeks gestation with minimal to mild vaginal bleeding and no signs of infection were treated with oral contraceptive pill (OCP) containing 0.03 mg ethinylestradiol and 0.15 mg of desogestrel for 3 weeks. Out of the 12 patients treated, nine women (75%) successfully expelled the RPOC after completing the three-week course of OCPs. The three cases (25%) that did not resolve following OCP treatment had pregnancy products with positive blood flow on Doppler examination. We conclude that OCPs may be a useful medical treatment option for persisting RPOC in selected patients with absence blood flow on Doppler examination wishing to avoid surgical intervention.

Laparoscopic Ligation of Uterine Vasculature for Fertility-Sparing Management of Postabortal Hemorrhage

STUDY OBJECTIVE

To present a surgical video in which bilateral uterine vasculature was ligated laparoscopically in order to preserve the uterus in a patient with postabortal hemorrhage.

DESIGN

A case report (Canadian Task Force classification III).

SETTING

A tertiary referral center in New Haven, CT.

INTERVENTIONS

This is a step-by-step demonstration of laparoscopic ligation of the uterine vasculature in a patient with postabortal hemorrhage. The patient was a 33-year-old Para 4014 woman who presented with postabortal hemorrhage after she underwent an urgent dilation and evacuation for the management of symptomatic placenta accreta at 19 weeks of pregnancy. The patient underwent a physical examination when she presented to the emergency department with postabortal hemorrhage. She was hemodynamically stable, and the examination was negative for cervical or vaginal lacerations. Coagulation studies were negative for any coagulopathy. A pelvic ultrasound did not show any retained products of conception. As per the Society of Family Planning guidelines, uterine massage was performed, and uterotonics (i.e., methylergonovine maleate 0.2 mg intramuscularly and misoprostol 1000 mg per rectum) were given [1]. The postabortal hemorrhage persisted despite medical therapy with an approximate blood loss of 600 mL over 2 hours. An intrauterine tamponade balloon was placed, and the patient then underwent a uterine angiogram and bilateral uterine artery embolization secondary to continued vaginal bleeding despite medical management. She was closely monitored and noted to have another 500 mL of blood loss over 2 hours after completion of uterine artery embolization. At this point, she was resuscitated with 2 U red blood cells because she developed symptoms of hemodynamic instability. Her hematocrit was increased suboptimally after transfusion with stabilization of her vitals. The patient was then counseled on her surgical options because she had failed medical management, intrauterine balloon tamponade, and uterine artery embolization. She stated a strong desire to preserve her uterus. Given her overall hemodynamic stability, laparoscopic ligation of the uterine vessels was proposed, which she agreed on [2]. Risks of the laparoscopic approach were explained to the patient, which included injury to the uterus, ureters, blood vessels, and nerves as well as the possibility of conversion to laparotomy. The surgery started with exploration of the peritoneal cavity. Her uterus was noted to be significantly enlarged with many engorged vessels. In order to decrease the risk of uterine perforation in this bulky and highly vascular uterus, the surgeon decided not to place a uterine manipulator. The retroperitoneum was entered at the right pelvic sidewall. Pararectal and paravesical spaces were then developed. Ureterolysis was performed in order to free its peritoneal and uterine artery attachments. The uterine artery was skeletonized cephalad to the hypogastric bifurcation and was ligated with 5-mm vascular clips. The attention was then turned to the ovarian vessels at the cornu of the uterus. Peritoneal avascular windows were created inferior and superior to the vessels. The blood supply was then ligated with an absorbable suture, and the ligature was secured using the extracorporeal knot tying technique. The same steps were repeated on the left pelvic sidewall. The procedure was completed once excellent hemostasis was assured. Besides the technical steps of the procedure, pelvic anatomic landmarks have also been emphasized in this video for educational purposes.

MEASUREMENTS AND MAIN RESULTS

Laparoscopic ligation of the uterine vasculature was performed without any complications. The operative time was 65 minutes, and blood loss was minimal. The patient had an uneventful postoperative course and was discharged home the day after her laparoscopic surgery.

CONCLUSION

The uterus was preserved with this minimally invasive approach for the management of postabortal hemorrhage. Laparoscopic ligation of the uterine vessels should be considered in hemodynamically stable patients who desire future fertility when managing postabortal hemorrhage.

Economic Evaluation of Global Endometrial Ablation Versus Inpatient and Outpatient Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Every year, abnormal uterine bleeding (AUB) exacts a heavy toll on women's health and leads to high costs for the US health care system. The literature shows that endometrial ablation results in fewer complications, shorter recovery and lower costs than more commonly performed hysterectomy procedures. The objective of this study was to model clinical-economic outcomes, budget impact, and cost-effectiveness of global endometrial ablation (GEA) versus outpatient hysterectomy (OPH) and inpatient hysterectomy (IPH) procedures. A decision tree, state-transition (semi-Markov) economic model was developed to simulate 3 hypothetical cohorts of women who received surgical treatment for AUB (GEA, OPH, and IPH) over 1, 2, and 3 years to evaluate clinical and economic outcomes for GEA vs. OPH and GEA vs. IPH. Two versions of the model were created to reflect both commercial health care payer and US Medicaid perspectives, and analyses were conducted for both payer types. Total health care costs in the first year after GEA were substantially lower compared with those for IPH and OPH. Budget impact analysis results showed that increasing GEA utilization yields total annual cost savings of about $906,000 for a million-member commercial health plan and about $152,000 in cost savings for a typical-sized state Medicaid plan with 1.4 million members. Cost-effectiveness analysis results for both perspectives showed GEA as economically dominant (conferring greater benefit at lower cost) over both OPH and IPH in the 1-year commercial scenario. This study demonstrates that, for some patients, GEA may prove to be a safe, uterus-sparing, cost-effective alternative to OPH and IPH for the surgical treatment of AUB.

Agreement of histopathological findings of uterine curettage and hysterectomy specimens in women with abnormal uterine bleeding

Objectives:

To examined the diagnostic value of dilatation and curettage (D&C) in patients with abnormal uterine bleeding (AUB) by conducting a histopathological examination of endometrial tissues by D&C and hysterectomy.

Methods:

In this retrospective study, the medical records of 163 women who had been hospitalized in the Obstetrics and Gynecology Ward, Amir-al-Momenin Hospital, Semnan, Iran between 2010 and 2015 for diagnostic curettage due to AUB and who had undergone hysterectomy were investigated. The patients’ characteristics and histopathologic results of curettage and hysterectomy were extracted, and sensitivity and specificity and positive and negative predictive values of curettage were calculated.

Results:

The mean ± standard deviation age of the patients was 49.8±7.8 years. The sensitivity values of D&C in the diagnosis of endometrial pathologies was 49.1%, specificity 84.5%, positive 60.5%, and negative predictive 77.5%. The sensitivities of D&C in the diagnosis of various endometrial hyperplasia was 62.5%, disordered proliferative endometrium 36.8%, and endometrial cancer 83.3%. Of 6 patients with endometrial polyps on performing hysterectomy, no patient was diagnosed by curettage.

Conclusions:

Dilatation and curettage has acceptable sensitivity in the diagnosis of endometrial cancer, low sensitivity in the diagnosis of endometrial hyperplasia, and very low sensitivity in the diagnosis of disordered proliferative endometrium and endometrial polyps.

Abnormal Uterine Bleeding Control by Sequential Application of Hysteroscopic Lesion Morcellation and Endometrial Ablation

OBJECTIVE

To assess the efficacy and safety of combined hysteroscopic morcellation/endometrial ablation for treating abnormal uterine bleeding (AUB).

STUDY DESIGN

Prospective case series from 5 U.S. gynecology clinics. Women with intrauterine polyps and/or type-0 myomas and transformed Uterine Fibroid Symptom and Health-Related Quality-of-Life (UFS-HRQoL) symptom severity score ≥47 points (100 possible) underwent hysteroscopic morcellation (MyoSure) of intrauterine pathologies before endometrial radiofrequency ablation (NovaSure). Outcome measures were amenorrhea rate, UFS-HRQoL scoring, AUB retreatment/reintervention, bleeding days, and perioperative adverse events, through 12 months.

RESULTS

Of 26 enrolled women, 24 were available through study completion. Lesions were 27% myomas and 73% polyps. Procedure room time was 19±13 minutes. Complete lesion eradication occurred in 96% of women. At 12 months, amenorrhea prevalence was 46% (p<0.0001 vs. baseline), and 87% of women reported either no bleeding or normalized bleeding. Bleeding/spotting days decreased from 15.7±7.4 to 3.1±4.2 days/month (p<0.0001), symptom severity decreased from 75±13 to 12±18 points (p<0.0001), and QoL scores increased from 29±18 to 88±23 points (p<0.0001). Three women required additional AUB intervention. Perioperative adverse events were minor nausea (n=1) and abdominopelvic cramping (n=2) without sequelae.

CONCLUSION

Sequential hysteroscopic morcellation and endometrial radiofrequency ablation of intrauterine lesions in women with AUB increases amenorrhea rate, alleviates bleeding symptoms, and improves quality of life, with an acceptable safety profile.

Resectoscopic myomectomy

Hysteroscopic myomectomy currently is the "gold standard" procedure for treating submucous myoma and represents an effective and safe solution to abnormal uterine bleeding and infertility myoma-related. Several studied have shown that, in the case of submucous myomas, resectoscopic myomectomy has several advantages compared with the traditional surgical treatment of myomectomy by laparotomy, in terms of reduced myometrial trauma, shorter hospitalization times and decreased risk of postoperative adhesion formation. The aim of this paper was to describe the alternative techniques, currently available, of resectoscopic myomectomy. The choice of the procedure mostly depends on the intramural extension of the myoma, as well as on personal experience and available equipment.

The Role of Surgery in the Management of Gestational Trophoblastic Neoplasia The Hungarian Experience

OBJECTIVE

To review the role of surgery in the management of gestational trophoblastic neoplasia (GTN) over the past 38 years in our national trophoblastic disease center.

STUDY DESIGN

Between January 1, 1977, and December 31, 2014, 371 patients with low-risk GTN and 190 patients with high-risk GTN were treated with chemotherapy, surgical interventions, or both. The indications for hysterectomy included excision of large uterine tumor masses, uterine hemorrhage or sepsis, or a drug-resistant uterine focus. Metastases were excised due to the presence of drug-resistant foci or complications of disease such as hemorrhage.

RESULTS

Over the period of 1977-2014 74 hysterectomies, 15 resections of vaginal metastases, 3 omentectomies, 13 adnexectomies, 9 lung resections, I nephrectomy, 1 lung resection and nephrectomy, and 2 craniotomies were performed among our patients. While hysterectomy was performed in 51 (26.8%) of 190 high-risk patients, hysterectomy was performed in only 23 (6.2%) of 371 low-risk patients (p < 0.01). From 1977-2006 metastases were resected in 18.3% (26/142) and from 2007-2014 in 16.7% (8/48) of high-risk patients.

CONCLUSION

In our center surgery, particularly in the form of hysterectomy, still plays a valuable role in the management of both low- and high-risk GTN.

Adverse obstetric symptoms and rural-urban difference in cesarean delivery in Rupandehi district, Western Nepal: a cohort study

BACKGROUND

The burden of maternal morbidity is high in developing countries including Nepal. This study investigated obstetric complications and rural-urban difference in cesarean delivery rate in Western Nepal.

METHODS

A community-based cohort study was conducted in the Rupandehi district of Western Nepal during January-October, 2014, by interviewing 735 mothers within one month postpartum. The prevalence of obstetric complications was reported via frequency distribution, while factors associated with cesarean delivery were assessed using logistic regression analysis.

RESULTS

The prevalence of adverse obstetric symptoms during antenatal, intranatal and postnatal periods were 19.7%, 27.8% and 21.6%, respectively. In total, 81 (11.0%) mothers reported having stillbirths. The cesarean delivery rate was 14.1% overall but was four times higher in the urban (23.0%) than in the rural areas (5.8%). Prolonged labor (19.0%) and heavy bleeding (16.7%) were common among rural women. Logistic regression analysis confirmed that cesarean section was more likely for mothers residing in urban areas than in rural areas (adjusted odds ratio 3.41; 95 % confidence interval 2.01 to 5.78).

CONCLUSIONS

About one in five mothers reported some adverse obstetric symptoms. Obstetric problems were more common in the rural areas, whereas cesarean delivery rate was much higher in the urban areas. Further investigations are required to determine whether these cesarean sections are medically warranted or provider induced.

[Medical termination of pregnancy by mifepristone and misoprostol - evaluation of succes rate, complications and satisfaction of patients]

OBJECTIVE

The purpose of this study was to evaluate the success rate and complications of medical termination of pregnancy up to 49 days of amenorrhea and present the outcome of our phone questionaire of satisfaction of patients.

DESIGN

Retrospective analysis.

SETTING

Department of Obstetrics and Gynecology Masaryk University and University Hospital Brno.

METHODS

The analysis of 111 patients, who underwent medical termination of pregnancy at the Department of Obstetrics and Gynecology Masaryk University and University Hospital Brno from 1. 6. 2014 to 30. 6. 2015 using 600 mg of mifepristone (Mifegyne) and 400 µg of misoprostol (Mispregnol). In our set of patients we monitored subjective perception of medical termination of pregnancy (pain, nausea, vomiting, satisfaction with this method) and objective process (hospitalisation, surgical intervention). The view of patients was found out by the phone questionnaire

RESULTS

Complete abortion without a surgical intervention underwent 103 patients. Nausea, pelvic pain, and intensity of bleeding were evaluated as suitable. Only 1 patient (0.9%) was hospitalised for nausea and 1 patient (0.9%) was hospitalised in case of need for an emergency curretage and transfusions. Some kind of contraception after the medical termination of pregnancy started using 98.0% of women. The satisfaction rate of this method was high - 101 patients declared themselves satisfied - 66.7% very satisfied, 24.3% rather satisfied.

CONCLUSION

Medical termination of pregnancy has good efficiency, we consider it safe with minimum side-effects and is well evaluated by patients.

Cost-Effectiveness of Global Endometrial Ablation vs. Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives

Cost-effectiveness modeling studies of global endometrial ablation (GEA) for treatment of abnormal uterine bleeding (AUB) from a US perspective are lacking. The objective of this study was to model the cost-effectiveness of GEA vs. hysterectomy for treatment of AUB in the United States from both commercial and Medicaid payer perspectives. The study team developed a 1-, 3-, and 5-year semi-Markov decision-analytic model to simulate 2 hypothetical patient cohorts of women with AUB-1 treated with GEA and the other with hysterectomy. Clinical and economic data (including treatment patterns, health care resource utilization, direct costs, and productivity costs) came from analyses of commercial and Medicaid claims databases. Analysis results show that cost savings with simultaneous reduction in treatment complications and fewer days lost from work are achieved with GEA versus hysterectomy over almost all time horizons and under both the commercial payer and Medicaid perspectives. Cost-effectiveness metrics also favor GEA over hysterectomy from both the commercial payer and Medicaid payer perspectives-evidence strongly supporting the clinical-economic value about GEA versus hysterectomy. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.

Evaluation and Management of Adolescents with Abnormal Uterine Bleeding

The International Federation of Gynecology and Obstetrics and the American Congress of Obstetricians and Gynecologists support the use of new terminology for abnormal uterine bleeding (AUB) to consistently categorize AUB by etiology. The term AUB can be further classified as AUB/heavy menstrual bleeding (HMB) (replacing the term "menorrhagia") or AUB/intermenstrual bleeding (replacing the term "metrorrhagia"). Although many cases of AUB in adolescent women are attributable to immaturity of the hypothalamic-pituitary-ovarian axis, underlying bleeding disorders should be considered in women with AUB/HMB. This article reviews the new terminology for AUB, discusses important relevant features of history and examination, presents the laboratory evaluation of HMB, and describes hormonal (oral contraceptive pills, progestin-only methods, long-acting reversible contraceptives including intrauterine systems), hematologic (tranexamic acid and desmopressin), and surgical management options for AUB/HMB.

[Hysteroscopic polypectomy, treatment of abnormal uterine bleeding]

OBJECTIVES

To evaluate the effectiveness of the hysteroscopic polypectomy in terms of the decrease of the abnormal uterine bleeding.

METHODS

A cross-sectional and analytical study was done with patients to whom a hysteroscopic polypectomy was done for treating the abnormal uterine bleeding, between January 2009 and December 2013. The response to the treatment was evaluated via a survey given to the patients about the behavior of the abnormal uterine bleeding after the procedure and about overall satisfaction.

RESULTS

The results were obtained after a hysteroscopic polypectomy done to 128 patients and were as follows. The average time from the polypectomy applied until the survey was 30.5 months, with a standard deviation of 18 months. 67.2% of the patients reported decreased abnormal uterine bleeding and the 32.8% reported a persistence of symptoms. On average 82.8% of the. patients were satisfied with the treatment. Bivariate and multivariate analysis showed no association between the variables studied and no improvement of abnormal uterine bleeding after surgery (polypectomy). There were no complications.

CONCLUSION

Hysteroscopic polypectomy is a safe surgical treatment, which decreases on two of three patients the abnormal uterine bleeding in the presence of endometrial polyps, with an acceptable level of satisfaction.

Radiology Case of the Month:Diagnosis and Treatment of an Acquired Uterine Arteriovenous Malformation in a 26-Year-Old Woman presenting with Vaginal Bleeding

Arteriovenous malformations (AVMs) are a rare source of potentially life-threatening uterine bleeding, and should be suspected in patients presenting with metromenorrhagia. Histologically, AVMs are characterized as having both arterial and venous tissues without an intervening capillary network.1 The etiology may be either congenital or acquired secondary to prior uterine surgery or uterine malignancy.2 Congenital lesions are thought to result from arrested vascular development and contain a nidus of multiple feeding arteries anastomosed to multiple draining veins. In contrast, acquired lesions contain small fistulas between a single feeding artery and draining vein.4 While angiography is considered the gold standard for diagnosing AVMs, its limitations include exposure to contrast and radiation and the inability to accurately detect the degree of pelvic extension.5 As a result, ultrasound (US) with color Doppler is the imaging modality of choice in suspected AVM and can be confirmed noninvasively with magnetic resonance imaging (MRI).6 Angiography remains the preferred method of imaging when there is a high index of suspicion of AVM in a patient who may potentially undergo embolization as treatment.3 Historically, the definitive treatment for AVMs has been either hysterectomy or uterine artery ligation. However, embolotherapy has become a well-recognized alternative to surgery since the first reported case in 1982.5 One of the advantages of embolotherapy is the preservation of reproductive structures. Currently, treatment for AVMs is based on the patient's desire to maintain fertility. The objective of this study was (1) to describe the diagnostic features of an AVM on Doppler ultrasound in a patient who presented with vaginal bleeding and (2) discuss the treatment and outcome of this patient using uterine artery embolization.

[Cervical ectopic pregnancy. Hysteroscopy treatment, case report]

The cervical ectopic pregnancy is extremely rare accounting for approximately 0.1% of all ectopic pregnancies. The incidence is estimated at 1:2500-1:98,000 pregnancies. Before the decade of the 80s, the diagnosis is usually performed to made curettage for incomplete abortion likely secondary to uncontrollable bleeding culminating in hysterectomy, is extremely dangerous, as the trophoblast uterine vessels can reach through the thin wall cervical and cause serious and intractable bleeding that usually ends even today in mutilating surgeries to limit future playback. Currently exist no clear criteria in the literature to help decision-making. We report a case of cervical pregnancy successfully treated by operative hysteroscopy ablation and proposes criteria that could help in the future to address this devastating disease.

[Cervical ectopic pregnancy of 16 weeks gestation. Block with preventive hysterectomy surgical technique for massive pelvic hemorrhage. Case report]

Obstetric hemorrhage remains the leading cause of maternal death, we continue to insist on preventive management of patients at high risk of massive pelvic bleeding, uterine dearterialization selective, significantly reduces the morbidity and mortality of the patient, on this ocassion we report the case of a 33-year-old with a diagnosis of cervical ectopic pregnancy of 13 gestational weeks, treated with selective dearterialization of hypogastric arteries with excellent results, without postoperative complications.

Massive haemorrhage secondary to placenta percreta in the first trimester: a case report

Placenta percreta detected in the first trimester is a very rare condition. It is a known obstetric condition leading to serious maternal morbidity and mortality. High index of clinical suspicion and anticipation of placenta percreta is highly essential in early pregnancy as it is difficult to diagnose. The authors report on a patient who presented with heavy pervaginal bleeding in week 9 of pregnancy. Pelvic examination showed a 12-week sized uterus. Ultrasonography revealed a non-viable fetus. The subsequent emergency curettage performed was complicated by massive haemorrhage which required an abdominal hysterectomy performed as a life-saving procedure.

EMERGENCY PERI PARTUM HYSTERECTOMY--A LIFE SAVING PROCEDURE

BACKGROUND

Sub-total abdominal hysterectomy is a surgical procedure in which body of the uterus is removed while ovaries and cervix are preserved. The study was done with the objectives of assessing the frequency of peripartum hysterectomies, common indications and risk factors associated with this surgery. The postoperative complications including the severity of andemia in these patients and need for blood transfusion and use of blood products like fresh frozen plasma and platelet concentrates were also studied.

METHODS

The study was based on the review of the records of Gynae 'A' Unit, Ayub Teaching Hospital, Abbottabad from January 2011 till December 2012. Data was collected from the unit record and patient's personal files. All the patients who underwent emergency peripartum hysterectomy were included in the study.

RESULTS

During this study period there were 6535 total deliveries in the unit, 2153 vaginal deliveries and 1786 caesarean sections. Emergency perpartum hysterectomy was needed in 72 patients. In the majority of the patients the gestational age was at term. The commonest indications for this operation was haemorrhage (placental abruption) 26 patients (36% ) followed by ruptured uterus in 18 patients (25%), prolonged and obstructed labour promoted uterine atony needing hysterectomy in 13 patients (18%). Placenta previa major degree needed hysterectomy in 9 patients (12.5%) while placenta increta and chorioamnionitis each accounted for 3 cases (4.2%). At admission the majority of the patients were severely anaemic 31 patients (43.05%). The most important risk factor identified was hypertensive disorders of pregnancy 26 patients (36%), followed by uterine atony in 13 patients (18.05%).

CONCLUSION

High risk obstetric patients, prone to peripartum hysterectomy, should be identified by health personnel working in the rural areas and should be timely referred to the hospitals where appropriate facilities are available for the management of such patients.

Arterial hemorrhage from cesarean scar: a rare cause of recurring massive uterine bleeding and successful surgical management

Abnormal uterine bleeding and other gynecologic complications associated with a previous cesarean section scar are only recently being identified and described. Herein we report a rare case of a woman with recurring massive uterine bleeding after 2 cesarean sections. Curettage and hormone therapy were unsuccessfully used in an attempt to control the bleeding. After she was transferred to our hospital, she had another episode of vaginal bleeding that was successfully managed with oxytocin and hemostatic. Diagnostic hysteroscopy performed under anesthesia revealed an abnormal transected artery in the cesarean section scar with a thrombus visible. In the treatment at the beginning of laparoscopic management, we adopted temporary bilateral uterine artery occlusion with titanium clips to prevent massive hemorrhage. Secondly, with the aid of hysteroscopy, the bleeding site was opened, and then the cesarean scar was wedge resected and stitched interruptedly with 1-0 absorbable sutures. The postoperative recovery was uneventful. It would seem that the worldwide use of cesarean section delivery may contribute to the risk of gynecologic disturbances including some unrecognized and complex conditions as seen in this case.

Emergency peripartum hysterectomy in a low resource setting: a 5-year analysis

BACKGROUND

Emergency peripartum hysterectomy (EPH) is an important life saving surgical procedure often necessitated by life threatening obstetric haemorrhage. The indications for peripartum hysterectomy differs between develop and developing countries and may reflect the level of obstetric practice in a region.

PATIENTS AND METHODS

This was a 5-year retrospective study. The medical records of patients who had emergency peripartum hysterectomy at the University of Port Harcourt Teaching Hospital were reviewed and relevant data were retrieved and analyzed.

RESULTS

Sixty two cases of peripartum hysterectomy were performed giving a prevalence rate of 0.38% out of 16,113 total deliveries. Being unbooked was significantly associated with peripartum hysterectomy (x2 = 85.29, p = 0.0000). Peripartum hysterectomy was performed for 20.3% of nulliparous women. Subtotal hysterectomy accounted for 55.9% while total hysterectomy was performed for 44.1% of cases. The commonest indication for peripartum hysterectomy was uterine rupture (57.6%). There was no case of ureteric injury Unbooked mothers were 28 times more likely to die than booked mothers. Unbooked status was significantly associated with maternal mortality (p = 0.00008) and perinatal mortality (p = 0.00000).

CONCLUSION

Emergency peripartum hysterectomy still remains indispensible in obstetric practice in low resource setting. Labour and delivery when well supervised will reduce the need for emergency peripartum hysterectomy. Training of specialist in the skill of internal iliac artery ligation is recommended.

Outpatient endometrial biopsy with Pipelle vs diagnostic dilatation and curettage

BACKGROUND

Pipelle is a silastic curette which does not require a tenaculum or straightening of the cervical fundus axis because of its flexibility and does not require general anaesthesia, whereas Dilatation and curettage (D&C) requires hospitalization and general anaesthesia along with the problem of postoperative pain. The objective of the study was to assess the effectiveness of Pipelle sampling in terms of adequate specimen collection and patients' knowledge and perception about Pipelle and compare it D&C.

METHODS

In this randomized control trial, 203 women presenting with abnormal uterine bleeding were enrolled. The patients were randomly assigned to one of the two procedures. In group A 102 patients were subjected to Pipelle endometrial sampling and in group B 101 patients were enrolled for D&C. Frequencies of adequacy of histopathology reports and cost effectiveness of both groups were compared. Patient's knowledge, perception, pain and acceptability of the procedure of both groups were also assessed and compared.

RESULTS

The mean age of the patients was 46.3 ± 4.45 years. Tissue obtained for histopathology was 100% adequate when the procedure was D&C while it was 98% in Pipelle group. In group-A 92% patients experienced no discomfort, with only 2% experiencing severe pain and 6% mild pain. On the other hand in group-B, 45% patients experienced moderate and 5% experienced severe pain up to 9 on visual analogue scale (VAS) postoperatively arid requiring post-operative analgesia. The acceptability for the Pipelle suction curette was 98% and for the D&C group was 34%. Regarding previous knowledge of procedure none of patients (100%) knew about Pipelle procedure but 98% patients were aware of D&C procedure. Pipelle was eight times more cost effective as compared to D&C.

CONCLUSIONS

The results of obtained by endometrial sample by Pipelle and D&C are compareable. Pipelle significantly produced less pain than D&C.

Management of bleeding uterine arteriovenous malformation with bilateral uterine artery embolization

PURPOSE

To evaluate the technical feasibility and clinical outcome of bilateral uterine artery embolization (UAE) as a first-line therapeutic option for bleeding uterine arteriovenous malformation (AVM).

MATERIALS AND METHODS

Between 2002 and 2012, 19 patients were diagnosed with acquired uterine AVM clinically and through imaging studies. The clinical characteristics, angiographic features, technical success rate of embolization, procedure-related complications, imaging, and clinical follow-up data were assessed. Clinical success was defined as immediate symptomatic resolution with disappearance of vascular abnormality on subsequent imaging studies.

RESULTS

A total of 20 bilateral UAE, with or without embolization of extra-uterine feeders, were performed as the first-line treatment. Technical and clinical success rate was 90.0% (18/20) and 89.5% (17/19), respectively. Embolization was incomplete in two patients who had residual extra-uterine fine feeders to the AVM or a procedure- related complication (ruptured uterine artery); the former showed slow regression of the vascular malformation during the observation period, while the latter underwent a successful second bilateral UAE. Immediate clinical success was achieved in the remaining 17 patients after a single session and no recurrence of bleeding was found. Recovery to normal menstrual cycle was seen in all 17 patients with clinical success within one or two months, two of whom subsequently had uneventful intrauterine pregnancies carried to term.

CONCLUSION

Bilateral UAE is a safe and effective first-line therapeutic option for the management of bleeding uterine AVMs. However, incomplete embolization due to unembolizable feeders or difficult access into the uterine artery may lead to suboptimal treatment.

[Clinical study on 57 cases with caesarean scar pregnancy]

OBJECTIVE

To investigate treatment of caesarean scar pregnancy (CSP) and associated problem.

METHODS

From January 2011 to January 2013, 57 cases with CSP undergoing treatment in Affiliated Hospital of Hebei University were studied retrospectively. Among 57 patients, it was divided into 12 cases treated by curettage (curettage group); 22 cases treated by uterine artery embolization(embolization group);8 cases treated by laparotomy(laparotomy group) and 15 cases treated by transvaginal debridement(transvaginal group).

RESULTS

(1)Successful rate of curettage group, embolization group, laparotomy group and transvaginal group were 12/12, 86% (19/22), 7/8, 13/15. (2) The intraoperative blood loss and the hospital stay were 20 (17-28) ml,(5.1 ± 1.9) days in curettage group, 10 (5-15) ml, (10.2 ± 3.2) days in embolization group, 200 (80-300) ml, (11.3 ± 3.3) days in laparotomy group, 50 (45-100) ml, (6.8 ± 1.2) days in transvaginal group. There was statistically different between curettage group and embolization group (P < 0.05). There was statistically different between laparotomy group and transvaginal group (P < 0.05).

CONCLUSIONS

Curettage, uterine artery embolization, abdominal and transvaginal scar debridement surgery can be used in treatment of the CSP. It should be carefully chosen with surgical intervention, if myometrium was implanted greater than 1/2, or near to serosa.It should be carefully chosen with vaginal surgery, if the blood flow signals was rich around the lesion.

Uterine angioleiomyoma causing severe abnormal uterine bleeding

BACKGROUND

Angioleiomyoma or angiomyoma or vascular leiomyoma is an unusual benign mesenchymal neoplasm. The authors present a rare case of large uterine angioleiomyoma causing severe abnormal uterine bleeding.

CASE

The patient, a 53-year-old, gravida 2, para 2, premenopausal Greek woman presented with a complaint of severe abnormal uterine bleeding. On gynecologic examination there was a palpable pelvic mass. Preoperative computer tomography (CT) of the abdomen and pelvis revealed an intra-abdominal mass 25 x 15 cm with abnormally increased vascularization. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, total omentectomy and elective pelvic lymph node dissection. Histopathology revealed uterine angioleiomyoma. Follow up 84 months after initial surgery showed no evidence of recurrence.

CONCLUSION

Despite the type of surgery, patients with uterine angioleiomyoma have very low risk of recurrence and excellent prognosis.

Conservative management of cervical pregnancy: a report of two cases

BACKGROUND

Cervical ectopic pregnancy is a rare form of ectopic pregnancy. Treatment of this clinical condition is controversial. Previously, hysterectomy was the mainstay of treatment, but in the recent past various conservative management approaches have been applied to preserve fertility. We report 2 such cases in which conservative approach was implemented.

CASES

Case 1 was an early, nonviable cervical pregnancy in which systemic methotrexate was used with success. Case 2 was a viable, advanced cervical pregnancy (at 11 weeks) in which a combination of uterine artery embolization and systemic methotrexate was used. Ultimately this patient required hysterectomy due to sudden massive hemorrhage on day 22 of intervention.

CONCLUSION

On reviewing our results and the literature, we conclude that uterine artery embolization with methotrexate is effective in reducing the ectopic cervical mass. However, there is always a risk of hemorrhage, which can be treated by either repeat uterine artery embolization alone or uterine artery embolization followed by curettage. Hysterectomy should be the last resort if all conservative methods fail.

Emergency department management of vaginal bleeding in the nonpregnant patient

Abnormal uterine bleeding is the most common reason women seek gynecologic care, and many of these women present to an emergency department for evaluation. It is essential that emergency clinicians have a thorough understanding of the underlying physiology of the menstrual cycle to appropriately manage a nonpregnant woman with abnormal bleeding. Evidence to guide the management of nonpregnant patients with abnormal bleeding is limited, and recommendations are based mostly on expert opinion. This issue reviews common causes of abnormal bleeding, including anovulatory, ovulatory, and structural causes in both stable and unstable patients. The approach to abnormal bleeding in the prepubertal girl is also discussed. Emergency clinicians are encouraged to initiate treatment to temporize an acute bleeding episode until timely follow-up with a gynecologist can be obtained.