Dilatation And Curettage Research Articles

SURGICAL METHODS FOR ENDOMETRIAL POLYPECTOMY AND ASSOCIATED ENDOMETRIAL INJURY

Intrauterine procedures have the potential for endometrial injury, possibly leading to formation of intrauterine adhesions and infertility. Methods for removal of endometrial abnormalities, such as endometrial polyps, have traditionally been performed with sharp curettage or hysteroscopic scissors, however, the use of hysteroscopic morcellators has become more common in recent years. It is unclear which method, if any, is associated with lower frequency of endometrial injury. Therefore the purpose of our study was to determine if the frequency of endometrial injury differs between methods for removal of endometrial polyps. Retrospective cohort study All pathology samples from polypectomy procedures performed between 2014 and 2019 on women ages 18-50 were included in the study. Because the myometrium is deep to the endometrium and is not itself a target of these procedures, the presence and proportion of myometrium on surgical pathology samples were used to indicate endometrial injury. Pathology samples were re-evaluated by a single, blinded pathologist to measure the primary outcome of presence and proportion of myometrium. Secondary outcomes included operative complications and mention of myometrium on the initial pathology report. Data were evaluated using chi square analysis. Interim analysis of 195 of the 473 (41%) pathology samples demonstrated increased reporting of myometrial tissue on initial surgical pathology with morcellator use (46% of morcellator pathology reports), in comparison to traditional D&C (8%), and hysteroscopic scissors (3%) (p < 0.01). However, blinded pathology review demonstrated no differences in the overall presence of myometrium, presence of isolated myometrium or the proportion of myometrial tissue noted. There was no difference noted in surgical complications between the various methods of polypectomy. Interim analysis demonstrated increased reporting of myometrial tissue on initial surgical pathology with hysteroscopic morcellator use, however, no difference was found in the presence or quantity of myometrium upon blinded re-evaluation of samples.

Frequency, risk factors, and complications of induced abortion in ten districts of Madagascar: results from a cross-sectional household survey

BackgroundMadagascar has restrictive abortion laws with no explicit exception to preserve the woman’s life. This study aimed to estimate the incidence of abortion in the country and examine the methods, consequences, and risk factors of these abortions.MethodsWe interviewed 3179 women between September 2015 and April 2016. Women were selected from rural and urban areas of ten districts via a multistage, stratified cluster sampling survey and asked about any induced abortions within the previous 10 years. Analyses used survey weighted estimation procedures. Quasi-Poisson regression was used to estimate the incidence rate of abortions. Logistic regression models with random effects to account for the clustered sampling design were used to estimate the risk of abortion complications by abortion method, provider, and month of pregnancy, and to describe risk factors of induced abortion.ResultsFor 2005–2016, we estimated an incidence rate of 18.2 abortions (95% CI 14.4–23.0) per 1000 person-years among sexually active women (aged 18–49 at the time of interview). Applying a multiplier of two as used by the World Health Organization for abortion surveys suggests a true rate of 36.4 per 1000 person-year of exposure. The majority of abortions involved invasive methods such as manual or sharp curettage or insertion of objects into the genital tract. Signs of potential infection followed 29.1% (21.8–37.7%) of abortions. However, the odds of potential infection and of seeking care after abortion did not differ significantly between women who used misoprostol alone and those who used other methods. The odds of experiencing abortion were significantly higher among women who had ever used contraceptive methods compared to those who had not. However, the proportion of women with a history of abortion was significantly lower in rural districts where contraception was available from community health workers than where it was not.ConclusionsIncidence estimates from Madagascar are lower than those from other African settings, but similar to continent-wide estimates when accounting for underreporting. The finding that the majority of abortions involved invasive procedures suggests a need for strengthening information, education and communications programs on preventing or managing unintended pregnancies.

Comparison between vacuum aspiration and forceps plus blunt curettage for the evacuation of complete hydatidiform moles

ObjectiveSuction curettage is recommended for molar evacuation rather than sharp curettage because of its safety. However, the superiority of suction curettage with respect to the incidence of gestational trophoblastic neoplasia (GTN) has not been reported. This study aimed to compare the efficacy and safety of two evacuation procedures, vacuum aspiration and forceps/blunt curettage, for complete hydatidiform moles (CHMs) to determine the differences between them. Materials and methodsPatients with androgenetic CHM determined by multiplex short tandem repeat polymorphism analysis were included in this observational cohort study. Patients underwent evacuation with forceps and blunt curettage (forceps group) before March 2013 and with vacuum aspiration (vacuum group) thereafter. GTN was diagnosed based on the International Federation of Gynecology and Obstetrics 2000 criteria. The incidence of GTN and other clinical parameters were compared. ResultsNinety-two patients were diagnosed with androgenetic CHM. The number of patients in the forceps and vacuum groups was 41 and 51, respectively. The incidence of GTN was 12.2% (5/41) and 13.7% (7/51) in the forceps and vacuum groups, respectively, which was not significantly different (P = 1, Fisher's exact test). No major adverse events, such as uterine perforation and blood transfusion, were noted in either group. The median surgery time was shorter in the vacuum group (16 min) than in the forceps group (25 min) (P = 0.05, Mann–Whitney U test). ConclusionThere were no differences in the incidence of GTN between the forceps and vacuum groups for androgenetic CHM. However, vacuum aspiration could have the advantage of a shorter surgery period. The use of vacuum aspiration for molar pregnancy seems to be safer. Therefore, we recommend suction curettage for the first evacuation of hydatidiform moles.

Postabortion Care in Humanitarian Emergencies: Improving Treatment and Reducing Recurrence.

Unsafe abortion contributes to maternal mortality worldwide and disproportionately affects the most disadvantaged women and girls; thus, improving the treatment of complications of abortion is essential. Shifting PAC treatment from sharp dilation and curettage (D&C) to the use of aspiration techniques, notably manual vacuum aspiration (MVA), and medical treatment with misoprostol improves health outcomes. Equally critical is ensuring that women have access to voluntary contraception after an abortion to prevent future unintended pregnancies. In humanitarian settings, access to voluntary family planning to disrupt the cycle of unsafe abortion is even more critical because access to quality services cannot be guaranteed due to security risks, migration, and devastation of infrastructure. Save the Children applied a multipronged postabortion care (PAC) approach in the Democratic Republic of the Congo (DRC), Somalia, and Yemen that focused on capacity building; assurance of supplies and infrastructure; community collaboration and mobilization; and monitoring and evaluation. Program-level data were extracted for each of the 3 countries from the inception of their program through 2017. The sources of information included monthly service delivery reports that tracked key PAC indicators as well as qualitative data from evaluations of community mobilization activities. The number of PAC clients increased in all countries. In the DRC in 2012, 19% of PAC clients requiring treatment received D&C; in 2017 the percentage was reduced to 3%. In 2013, 25% of all PAC clients in Yemen were treated with D&C; this percentage was reduced to 3% in 2017. The proportion of women choosing contraception after an abortion increased. In 2012, only 42% of all PAC clients in the DRC chose a contraceptive method; by 2017, the proportion had increased to 70%. Somalia had substantial increases in PAC demand, with the percentage of all PAC clients electing contraception increasing from 64% in 2012 to 82% in 2017. In Yemen, where the health system has been constrained due to severe conflict, the percentage of PAC clients choosing voluntary contraception rose from 17% in 2013 to 38% in 2017. Uptake and demand for PAC was mobilized through targeted community outreach in each context. These data demonstrate that providers can effectively shift away from D&C as treatment for PAC and that contraceptive uptake by PAC clients can increase substantially, even in settings where the use of contraception after abortion is often stigmatized.

Women's Satisfaction With and Perceptions of the Quality of Postabortion Care at Public-Sector Facilities in Mainland Tanzania and in Zanzibar.

In 2015, the government of Tanzania began to strengthen the quality of postabortion care (PAC). Limited research has been conducted to understand clients' perceptions of public sector provision of PAC. Accordingly, we carried out a mixed-method study between April and July 2016, using client surveys and in-depth interviews, both implemented immediately following PAC. Results were used to help guide the government's initiative. We assessed the quality of PAC in 25 public-sector facilities through a client survey of 412 women. Questions included satisfaction with client-staff interaction, counseling, provider competence, postabortion family planning, accessibility of care, and the facility environment. Based on responses, we developed and validated a scale representing women's overall satisfaction with the quality of care. We conducted bivariate analysis to identify the levels of care associated with clients' ranking of individual and composite measures of the quality of care. We used multivariate ordinal logistic models to assess the relative influence of multilevel factors on clients' overall satisfaction. We coupled our survey with qualitative analysis of in-depth interviews with 30 PAC clients. Clients reported moderately high levels of satisfaction with the quality of PAC, with an overall mean score of 2.6 on a 4-point scale. Bivariate analysis identified several areas for improvement, including family planning counseling and provision, especially at regional hospitals; pain management; and reduced use of sharp curettage. The factors most strongly associated with satisfaction were advanced parity, receiving care at lower-level facilities, brief waiting periods, and manual vacuum aspiration for treatment of incomplete abortion. Qualitative analysis illuminated how client-provider interactions; pain; desire for counseling and information, especially on family planning; and congested facility environments shape clients' perceptions of the care they received. Although clear areas for improvement in public-sector provision of PAC existed at all sites, women were less likely to report satisfaction with care at referral facilities owing primarily to inadequate counseling, delays in receiving PAC treatment after admission, and poor emphasis on postabortion fertility, family planning information, and contraceptive provision. PAC programs should ensure availability of a wide range of contraceptive methods and high-quality family planning counseling, especially at tertiary facilities.

Evaluating the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians: study protocol for a randomized controlled equivalence trial

BackgroundA large proportion of abortion-related mortality and morbidity occurs in the second trimester of pregnancy. The Uganda Ministry of Health policy restricts management of second-trimester incomplete abortion to physicians who are few and unequally distributed, with most practicing in urban regions. Unsafe and outdated methods like sharp curettage are frequently used. Medical management of second-trimester post-abortion care by midwives offers an advantage given the difficulty in providing surgical management in low-income settings and current health worker shortages. The study aims to assess the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians.MethodsA randomized controlled equivalence trial implemented at eight hospitals and health centers in Central Uganda will include 1192 eligible women with incomplete abortion of uterine size > 12 weeks up to 18 weeks. Each participant will be randomly assigned to undergo a clinical assessment and treatment by either a midwife (intervention arm) or a physician (control arm). Enrolled participants will receive 400 μg misoprostol administered sublingually every 3 h up to five doses within 24 h at the health facility until a complete abortion is confirmed. Women who do not achieve complete abortion within 24 h will undergo surgical uterine evacuation. Pre discharge, participants will receive contraceptive counseling and information on what to expect in terms of side effects and signs of complications, with follow-up 14 days later to assess secondary outcomes. Analyses will be by intention to treat. Background characteristics and outcomes will be presented using descriptive statistics. Differences between groups will be analyzed using risk difference (95% confidence interval) and equivalence established if this lies between the predefined range of − 5% and + 5%. Chi-square tests will be used for comparison of outcome and t tests used to compare mean values. P ≤ 0.05 will be considered statistically significant.DiscussionOur study will provide evidence to inform national and international policies, standard care guidelines and training program curricula on treatment of second-trimester incomplete abortion for improved access.Trial registrationClinicalTrials.gov, NCT03622073. Registered on 9 August 2018.

Manual Vacuum Aspiration versus Sharp Curettage for Incomplete Abortion: Which One is Better?

Objective: To acknowledge the effectiveness and safety of MVA compare with SC in management of incomplete abortion below 12 weeks of gestation which compare time to perform procedure, rates of evacuation and infection one week after procedure, and complication during MVA and SC procedure&#x0D; Methods: A prospective study with 62 subjects with complain incomplete abortion came to ER at RSCM, RS Fatmawati and RS Karawang, divided into 31 subjects on MVA group and 31 subjects on SC group. The data was documented on the time of MVA procedure compare to SC, clinical findings on complication during procedure, completed evacuation and infection symptoms one week after procedure.&#x0D; Results: Sixty two subjects (31 each group) with average time of procedure was 17,65 ± 4,128 minutes and SC was 22,26 ± 4,611 minutes with p = 0,00 and 95% CI; -4,513(-6,837 to -2,389 with significant statistically difference. The comparison of completed evacuation one week after procedure was 3,2% (n = 1) on MVA and 6,5% (n = 2) on SC with clinical findings, and p = 0,554, RR = 1,034 and 95% CI 0,924 – 1,158 with no statistically difference. On the other comparison, we didn’t find any infection symptoms one week after procedure and complication during procedure on both of procedures.&#x0D; Conclusion: MVA has more effective than SC on the time of procedure in incomplete abortion with below 12 weeks of gestation. MVA has superiority from completed evacuation but no statistically difference and has equal safety to SC on clinical infection symptoms and complication during procedure.&#x0D; Keywords: Manual Vacuum Aspiration (MVA), sharp curettage (SC), incomplete abortion.&#x0D; &#x0D; Tujuan:Mengetahuiefektifitasdankeamanandari AVM dibandingkan dengan kuret tajam pada penanganan abortusin komplit dibawah usia kehamilan 12 minggu dengan melihatdari lama tindakan, proporsi tingkat kebersihan evakuasi sisa konsepsi 1 minggu pasca tindakan, proporsigejala – gejalainfeksi 1 minggu pasca tindakan dan proporsi komplikasi pada saat tindakan AVM dan kuret tajam.&#x0D; Metode:Penelitian ini merupakan penelitian kohort prospektif (observasional) dengan jumlah sampel 62 subjek yang berkunjung dengan abortusin komplit ke UGD RSCM, RS Fatmawati dan RSUD Karawang terbagi dalam 31 subjek pada kelompok prosedur AVM dan 31 subjek pada kelompok prosedur kuret tajam. Data dikumpulkanmelaluipencatatanwaktu lama prosedur AVM dibandingkankurettajam, pemeriksaan klinis komplikasi selama prosedur berlangsung, pemeriksaan klinis kebersihan sisa konspesi 1 minggu pasca tindakan dan gejala – gejala infeksi 1 minggu pasca tindakan.&#x0D; Hasil:Sebanyak 62 subjek (masing – masing 31 subjek), dimana didapatkan rerata dan simpang baku prosedur AVM 17,65 ± 4,128 menit dan kuret tajam 22,26 ± 4,611 menit dengan p = 0,00 dan IK 95% -4,513(-6,837 s/d -2,389), bermakna secara statistik. Pada perbandingan proporsi tingkat kebersihan evakuasi sisa konsepsi 1 minggu pasca tindakan didapatkan pada AVM 3,2% (n = 1) dan pada kuret tajam 6,5% (n = 2) terdapat sisa konsepsi dengan penilaian klinis, p = 0,554, RR = 1,034 dan IK95% 0,924 – 1,158 tidak memiliki perbedaan bermakna secara statistik. Pada perbandingan lainnya, tidak ditemukan gejala – gejala infeksi 1 minggu pasca prosedur dan komplikasi selama prosedur berlangsung pada prosedur AVM dan kuret tajam.&#x0D; Kesimpulan:.AVM juga memiliki keunggulan dalam kebersihan sisa konsepsi namun tidak bermakna secara statitik dan memiliki keamanan yang setara dengan kuret tajam dari tingkat gejala infeksi dan komplikasi selama prosedur.&#x0D; Kata kunci :Aspirasi Vakum Manual (AVM), kuret tajam, abortusin komplit

Clinical effect of the ultrasound monitoring curettage and balloon placement hemostas in the treatment of cesarean scar pregnancy

Objective To investigate the clinical effect of the ultrasound monitoring curettage and balloon placement hemostas in the treatment of cesarean scar pregnancy. Methods From May 2014 to May 2016, the clinical data of 13 cases with cesarean scar pregnancy in the People's Hospital of Hechuan District were retrospectively analyzed. All 13 cases received methotrexate, ultrasonic monitoring curettage and balloon placement hemostas therapy were observed. Results Of 13 cases, 11 cases were cured, including 9 cases of gestational sac endogenous type and mass type 2 cases. The intraoperative bleeding was (167±101)mL, the operation time was (12.3±6.3)min, the blood HCG dropped to normal time was (37.2±13.8)d. There were 2 cases of failure, all of which were exogenous gestational sac . Conclusion Utrasound monitoring curettage combined with balloon compression is a simple, safe and economical method for the treatment of endogenous type of caesarean scar pregnancy, which is worthy of clinical promotion. Key words: Ultrasonography; Cesarean section; Pregnancy, ectopic; Dilatation and curettage; Hemostatic techniques; Chorionic gonadotropin

Diagnostic value of serum tumor biomarkers for endometrial cancer in elderly women with intrauterine abnormalities on transvaginal ultrasound

Objective To investigate age-related changes in serum tumor markers carbohydrate antigen 125(CA125), CA153 and CA199, and the clinical significance of separate and combined detection of these markers for screening endometrial carcinoma(EC)in elderly women with intrauterine abnormalities on transvaginal ultrasound(TVS). Methods Cross-sectional data of 420 elderly women suspected of having an intrauterine abnormality by TVS and undergone hysteroscopy with dilation and curettage from January 2010 to December 2017 were retrospectively analyzed.Patients were divided into a 60-64 years-old group and a 65-83 years-old group.Aging-related changes in positive rates of CA125, CA153 and CA199 were compared between the two groups.Differences in positive rates of tumor markers were compared between different pathological types.Using postoperative pathological diagnosis as the gold standard for EC, the diagnostic sensitivity, specificity and accuracy of serum CA125, CA153 and CA199 alone or in combination for EC were calculated. Results The positive rates of CA125, CA153 and CA199 were 3.9%(16/412), 0%(0/172)and 5.0%(20/404), respectively.The positive rate of CA125 was higher in the 65-83 years-old group(6.5%, 16/246)than in the 60-64 years-old group(0.0%, 0/166)(P=0.001). The positive rates of CA125 and CA199 in patients with EC were 14.3%(4/28)and 42.9%(12/28), which were higher than those in patients with other pathological types.However, the sensitivity of single and combined detection of CA125 and CA199 was too low for the diagnosis of EC(14%、43%). Conclusions The single and combined detection of CA125, CA153 and CA199 for screening EC is of limited value in elderly women.New tumor markers need to be identified and used in combination with TVS for screening EC in elderly women. Key words: Endometrial neoplasms; Transvaginal sonography; Tumor biomarker

A prospective descriptive study of the management of miscarriages at two tertiary hospitals in Zimbabwe: variations from global trends

Background: Early pregnancy loss is the commonest reason for admission to gynaecological wards for women of reproductive age group.Objective: To assess the current management of incomplete miscarriage at Harare and Parirenyatwa Hospitals and to determine the proportion of patients with incomplete miscarriage managed with Manual Vacuum Aspiration (MVA), sharp curettage or medical evacuation.Design: A prospective descriptive study.Setting: Two teaching hospitals in Zimbabwe.Materials and Methods: Women admitted with incomplete miscarriage, missed, septic incomplete and complete miscarriage were followed up from admission until discharge between for April and May in 2014. Demographic details, management and clinical course was recorded prospectively on a form.Main Outcome Measures: Outcome assessed were method of evacuation, need for transfusion, antibiotic use and hospital stay.Results: Four hundred and eleven (411) women were admitted to the two hospitals. The mean gestation at admission was 12 weeks. Planned pregnancies were 62.3% with 37.8% unplanned. Those who used contraception prior to conception were 22%. Only 5.4% were diagnosed as septic and 2 patients (0.5%) had foreign bodies in the genital tract. The majority of patients had sharp curettage for evacuation of retained products of conception with very few patients being having MVA, suction curettage, expectant management or medical evacuation. Overall only 0.5% of patients had medical evacuation. The mean duration of hospital stay was 27 and 19 hours for Parirenyatwa and Harare respectively and was not statistically significant.Conclusion: We have shown that most patients are still having sharp curettage in theatre despite Zimbabwe being one of the countries to introduce MVA in early 1990s. Management of incomplete miscarriage has not kept up with global trends where suction blunt curettage is the preferred method

Histopathological comprise between hysterectomy and dilatation and curettage results

Histopathological comprise between hysterectomy and dilatation and curettage results

Blighted ovum in subfertile patients undergoing assisted reproductive technology

To explore the incidence and risk factors of blighted ovum in subfertile patients undergoing assisted reproductive technology (ART). This retrospective analysis was conducted among 2378 patients who were pregnant following embryo transfer at our center from January, 2012 to December, 2015, including cases of early pregnancy losses and simultaneous live births. The cases with early pregnancy losses were divided into embryonic pregnancy and blighted ovum groups based on the presence or absence of an embryonic pole before dilation and curettage. The clinical data of the 3 groups were analyzed for comparisons of the maternal age, paternal age, BMI, AFC, basal FSH, bFSH/bLH, duration of infertility, Gn dosage, Gn days, serum estradiol on the day of HCG administration, endometrium thickness, number of oocyte retrieved, proportion of high-quality embryos transferred, serum β-HCG value on the 10th to 14th days of embryo transfer, infertility type and miscarriage times. The incidences of blighted ovum were compared between cases with different cycles, embryo stages, infertile factors and methods of fertilization. Maternal age and paternal age, BMI, duration of infertility, infertility type and miscarriage times differed significantly between cases with blighted ovum and those with live births. Serum β-HCG level was the lowest in blighted ovum group followed by embryonic pregnancy group and then by live birth group. Blastocyst transfer was associated with a significantly higher incidence of blighted ovum as compared with cleavage embryo transfer (11.6% vs 5.6%, P=0.000). No significant difference was found in the other parameters among the 3 groups (P>0.05). Adjusted logistic regression analysis showed that maternal age, β-HCG level and blastocyst transfer were risk factors of blighted ovum. Advanced maternal age, low β-HCG level and blastocyst transfer may increase the risk of blighted ovum possibly in association with gene imprinting errors during the early stage of embryo development.

Risk Factors for Intrauterine Adhesions in a Black African Population - Nigerians

Background: Intrauterine adhesions are associated with certain uterine procedures such as dilatation and curettage, open myomectomy and Cesarean section as well as some infections. Objectives: To determine the most important risk factors for intrauterine adhesions among Black Africans Study design, setting and subjects: This was a retrospective study conducted at Nordica Fertility Center (NFC). A total of 905 patients from three cities - Lagos, Abuja and Asaba, who consulted for infertility related problems and on whom hysteroscopy was performed between January 2005 and November 2014, were studied. Main outcome measures: Performance of different uterine surgeries, type and number of different uterine surgeries performed, and presence or absence of intrauterine adhesions. Results: A total of 905 women on whom hysteroscopy was performed were included in the study among whom 264 (29.2%) were positive for intrauterine adhesions. Women with IUA were significantly older (t=5.34, P-value=0.00001) than those without IUA. IUA was common among women who were Chief Executives (21/52, 40.4%). The overall mean [± sd] number of myomectomy (0.58 [0.66]) and of D&C (1.68 [1.82]) were significantly higher in IUA-positive women than in IUA-negative women (t=10.66, P-value=0.000001; t=4.52, P-value=0.00001). The ratio of D&C per woman was 1.70 per woman in IUA-positive women compared to 1.1 per woman in IUA negative women. Women with IUA were about 2½ times more likely to have had open myomectomy than those without IUA (Crude odds ratio=2.36, 95% CI:1.75, 3.16) and were just about twice as likely to have had D&C compared to those without IUA (Crude odds ratio=1.92, 95% CI:1.42, 2.60). Correlation coefficient study indicates that IUA was significantly (P-value<0.05) associated with performing all uterine and adnexal operations especially D&C (r=0.023, t=4.42), open myomectomy (r=0.017, t=3.45), Cesarean section (r=0.037, t=4.39), ovarian cystectomy (r=0.06, t=4.86) and salpingectomy (r=0.111, t=6.37). When the number of uterine surgeries performed was considered, IUA significantly (P-value<0.05) correlated with age (r=0.097, t=12.42), Body Mass Index (r=0.162, t=15.45), and with the number of D&C performed (r=0.014, t=2.16). Conclusion: Uterine procedures like open myomectomy, Dilatation and Curettage and Caesarean section as well as adnexeal surgeries and the number of times these procedures are carried out are important risk factors for uterine adhesions in infertile black African women. Mitigating these risk factors can help reduce the incidence of intrauterine adhesions in these women and improve their fertility.

'It's a very complicated issue here': understanding the limited and declining use of manual vacuum aspiration for postabortion care in Malawi: a qualitative study.

Malawi has one of the highest maternal mortality ratios in the world. Unsafe abortions are an important contributor to Malawi's maternal mortality and morbidity, where abortion is illegal except to save the woman's life. Postabortion care (PAC) aims to reduce adverse consequences of unsafe abortions, in part by treating incomplete abortions. Although global and national PAC policies recommend manual vacuum aspiration (MVA) for treatment of incomplete abortion, usage in Malawi is low and appears to be decreasing, with sharp curettage being used in preference. There is limited evidence regarding what influences rejection of recommended PAC innovations. Hence, drawing on Greenhalgh et al. 's (2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 82: 581-629.) diffusion of healthcare innovation framework, this qualitative study aimed to investigate factors contributing to the limited and declining use of MVA in Malawi. Semi-structured interviews with 17 PAC providers in a central hospital and a district hospital indicate that a range of factors coalesce and influence PAC and MVA use in Malawi. Factors pertain to four main domains: the system (shortages of material and human resources; lack of training, supervision and feedback), relationships (power dynamics; expected job roles), the health workers (attitudes towards abortion and PAC; prioritization of PAC) and the innovation (perceived risks and benefits of MVA use). Effective and sustainable PAC policy must adopt a broader people-centred health systems approach which considers all these factors, their interactions and the wider socio-cultural, legal and political context of abortion and PAC. The study showed the value of using Greenhalgh et al. 's (2004. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly 82: 581-629.) framework to consider the complex interaction of factors surrounding innovation use (or lack of), but provided more insights into rejections of innovations and, particularly, a low- and middle-income country perspective.

Postabortion Care: 20 Years of Strong Evidence on Emergency Treatment, Family Planning, and Other Programming Components.

Worldwide 75 million women need postabortion care (PAC) services each year following safe or unsafe induced abortions and miscarriages. We reviewed more than 550 studies on PAC published between 1994 and 2013 in the peer-reviewed and gray literature, covering emergency treatment, postabortion family planning, organization of services, and related topics that impact practices and health outcomes, particularly in the Global South. In this article, we present findings from studies with strong evidence that have major implications for programs and practice. For example, vacuum aspiration reduced morbidity, costs, and time in comparison to sharp curettage. Misoprostol 400 mcg sublingually or 600 mcg orally achieved 89% to 99% complete evacuation rates within 2 weeks in multiple studies and was comparable in effectiveness, safety, and acceptability to manual vacuum aspiration. Misoprostol was safely introduced in several PAC programs through mid-level providers, extending services to secondary hospitals and primary health centers. In multiple studies, postabortion family planning uptake before discharge increased by 30-70 percentage points within 1-3 years of strengthening postabortion family planning services; in some cases, increases up to 60 percentage points in 4 months were achieved. Immediate postabortion contraceptive acceptance increased on average from 32% before the interventions to 69% post-intervention. Several studies found that women receiving immediate postabortion intrauterine devices and implants had fewer unintended pregnancies and repeat abortions than those who were offered delayed insertions. Postabortion family planning is endorsed by the professional organizations of obstetricians/gynecologists, midwives, and nurses as a standard of practice; major donors agree, and governments should be encouraged to provide universal access to postabortion family planning. Important program recommendations include offering all postabortion women family planning counseling and services before leaving the facility, especially because fertility returns rapidly (within 2 to 3 weeks); postabortion family planning services can be quickly replicated to multiple sites with high acceptance rates. Voluntary family planning uptake by method should always be monitored to document program and provider performance. In addition, vacuum aspiration and misoprostol should replace sharp curettage to treat incomplete abortion for women who meet eligibility criteria.

Laparoscopic Management of Uterine Rupture After Early Second-Trimester Medical Abortion in a Patient With a Prior Cesarean Section

Study ObjectiveTo show the possibility of laparoscopic management of uterine rupture. DesignVideo with explanations. SettingIn the medical management with misoprostol for termination of pregnancy at any time the risk of uterine rupture may be possible. The risk is likely higher in women with a previous uterus surgery. In a systematic review of available studies, the risk of rupture was .28% among women with a prior cesarean delivery who were undergoing second-trimester misoprostol-induced abortion, meaning if 414 women with a history of cesarean delivery were given misoprostol for second-trimester abortion, 1 would experience uterine rupture. Uterine rupture has only been reported 3 times in first-trimester abortion and only once managed via laparoscopy: a missed abortion reported in 2005, a case of a ruptured unscarred uterus in a women undergoing medical abortion, and a case of a delayed miscarriage at 8 weeks’ gestation after misoprostol managed by laparotomy and sharp curettage. InterventionsTotal laparoscopic management in a patient with uterine tear after misoprostol treatment. ConclusionEarly second-trimester medical abortions with misoprostol can cause uterine rupture. In hemodynamically stable cases, total laparoscopic management is possible approach.

Comparison of Sublingual and Vaginal Misoprostol for Cervical Ripening before Curettage: A Randomized Controlled Trial

Objective: To compare the effectiveness and side effects of misoprostol as a cervical ripening agent through two different routes of administration before curettage. Materials and Methods: The study employed a hospital based prospective randomized controlled trial. A total of 70 patients were simple random divided in two groups for 400 micrograms sublingual and vaginal administration. The drug was administered 6 hours before dilatation and curettage or fractional curettage. Efficacy was assessed on cervical dilatation achieved, pain score and vaginal blood loss. The tolerable limit was noted based on side effects. Results: The sublingual group had significantly more cervical dilatation than the vaginal group (median cervical dilatation 7 mm vs. 5 mm, P < 0.001). Significantly less pain scores (VAS) in sublingual group than vaginal group (3.3 vs. 4.8, P < 0.001). Postoperative vaginal blood loss in the sublingual group was significantly greater than the vaginal group (20 ml vs. 10 ml, P < 0.001). Other side effects such as fever, chill, nausea, vomiting and diarrhea did not differ in both groups. Conclusion: Sublingual misoprostol could be more effective for cervical dilatation, but presents greater postoperative vaginal blood loss than vaginal route.

An Unusual Case of Acquired Uterine Arteriovenous Malformation With Persistent Scar Ectopic Pregnancy Successfully Managed With Uterine Artery Embolization

Uterine arteriovenous malformation (AVM) is a rare entity in gynecology, with fewer than 100 cases reported in the literature. AVM is an abnormal arteriovenous connection lacking an intervening capillary network on histopathological examination. We report an unusual case of acquired AVM after dilatation and curettage of cesarean scar ectopic pregnancy managed with uterine artery embolization and concurrent methotrexate administration for persistently elevated beta-human chorionic gonadotropin levels. J Med Cases. 2016;7(4):143-147 doi: http://dx.doi.org/10.14740/jmc2458w

Cesarean scar pregnancy: role of serial transabdominal ultrasonography in the diagnosis and treatment response following dilation and curettage.

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Effects of retained placenta and membrane patients who complete curettage of uterine cavity with the hysteroscopy when injecting oxytocin in the cervix before operation and shorting the time of single expanding uterus

Objective To investigate the effects on retained placenta and membrane patients who complete curettage of uterine cavity with the hysteroscopy when injecting oxytocin in the cervix before operation and shorting the time of single expanding uterus. Methods Totally 147 patients at the Maternal and Child Health Hospital of Hunan Province were divided into the intervention group (72 cases) and control group (75cases). The intervention group was injected 10u oxytocin in the cervix before hysteroscopy and curettage of uterine cavity, all at once, controlling the time of single expanding uterus (no more than 5 minutes). The control group was not injected oxytocin before hysteroscopy and curettage of uterine cavity, and not limited the time of single expanding uterus (5 minutes to 10 minutes). A series of parameters were compared among two groups, including total expansion uterine time, mean single expansion uterine time, operation time, frequency of hysteroscopy, the amount of bleeding, hemoglobin decline, hemostatic measures use rate, postoperative infection rate, the rate of the second time curettage, and incidence of intrauterine adhesions. Results Compared to the control group, total expansion uterine time, mean single expansion uterine time, and operation time were significantly shorter in the intervention group; at the same time, the amount of bleeding, other hemostatic measure use rate, and incidence of intrauterine adhesions were significantly less in the intervention group (P 0.05). Conclusions Not only the time of operation and the amount of bleeding are decreased but also postoperative infection rate and incidence of intrauterine adhesions are decreased when injecting oxytocin before hysteroscopy and shorting the time of single Expanding uterus. In other words, this method can keep clear vision of operation under direct vision, avoid repeated curettage, tissue trauma, decrease incidence of intrauterine adhesions, increase operative successful rate, and keep healthy and reproductive capacity of patients. Therefore, it is worth promoting. Key words: Oxytocin/AD; Hysteroscopy; Placenta, retained/SU; Dilatation and curettage