Evacuation Of Retained Products Of Conception Research Articles

Histopathological examination of products of conception after first-trimester miscarriage

Introduction This study is aimed to determine the value of histopathological examination of tissues obtained from evacuation of retained products of conception (ERPC) procedure. In addition, it is also aimed to determine the correlation between ultrasonically suspected Hydaditiform mole (H Mole) with histopathologically proven H Mole. Methodology In this retrospective study, clinical records of 140 patients who underwent surgical management for early pregnancy loss, from January 2012 to June 2017 were analysed. Their histopathology reports and relevant clinical profiles were collected from medical records. Results The age distribution of studied population ranges from 14 to 52 years. The majority of patients (43.6%) were within 21-30 years. The Molar pregnancy was confirmed in 32.8% samples and the majority (78.3%) were dominated by complete mole. There were 66 patients ultrasonically suspected to have H Mole. Among them 46 patients had either complete or partial mole. Further, this study showed no molar pregnancies were identified from specimens obtained following evacuation of ultrasonically diagnosed missed or incomplete miscarriage where no H Mole was suspected. Conclusion It can be recommended that histopathological examination should be performed in selected instances. Further, it is a hospital-based study and its findings increase the importance of a country wide study to guide the revision of current practice of routine histopathological examination of specimens from miscarriages in this middle-income country.

A comparative study of ketofol and fentafol for evacuation of retained products of conception (ERPC)

Background: Intravenous balanced anesthesia (IVA) is desirable during the evacuation of retained products of conception (ERPC) to avoid the use of inhalational anesthetics agents that may cause uterus relaxation, the possibility of bleeding, and the risk of uterus perforation. Objectives: The aim of this study was to compare the efficacy and safety of ketofol (a mixture of propofol and ketamine) versus fentafol (a mixture of propofol and fentanyl) during the ERPC. Methods: A double-blind, randomized comparative study was conducted among a total of 60 women of childbearing age categorized as grades I and II according to the American Society of Anesthesiologist (ASA), presented for ERPC. The patients were selected and randomized blindly into two groups (K group and F group), with 30 patients in each group. The K group was given ketofol (1ml containing 5mg of propofol and 5mg of ketamine) and F group was given fentafol (1ml containing 5mg propofol and 5mcg fentanyl). An intravenous loading dose of ketofol or fentafol was given slowly, with doses ranging from 1ml to 2ml/10kg, to reach level 5 or 6 of the Ramsay Scale of Sedation (RSS), followed by small incremental doses which were given when RSS dropped to 4. Hemodynamic parameters, success, and side effects were assessed throughout the procedures. Results: K group demonstrated a significant increase in heart rate (HR) and blood pressure (BP), compared to significant decreases in the F group. Decreases in oxygen saturation (SpO 2 ) and respiratory rate (RR) were observed more in the F group. However, no patients developed hypertension, hypotension, apnea, hypoxemia or serious adverse effects. Ketofol showed less propofol consumption and a short recovery time. Conclusions: Both ketofol and fentafol offer optimum conditions for ERPC. Ketofol is characterized by more stable hemodynamic parameters, a smaller dosage and faster recovery. [ Ethiop.J. Health Dev. 2019; 33(2):88-93] Key words: Propofol, ketamine, fentanyl, retained products of conception (RPC), ketofol, fentafol

Prediction of recurrent ectopic pregnancy: A five-year follow-up cohort study

ObjectiveTo evaluate the value of different clinical risk factors in the prediction of recurrent ectopic pregnancies (REP). Study designThis cohort study was carried out at a tertiary-care maternity hospital in Saudi Arabia, between January 2010 and June 2017. All women with a primary ectopic pregnancy (EP) were consecutively recruited, thoroughly assessed and followed up for a minimum duration of five-years (5.6 ± 0.61 years) to diagnose the nature and location of the subsequent pregnancies. The primary outcome measure was the occurrence of REP, while the secondary outcomes included intrauterine pregnancy, the pregnancy of unknown location and infertility rates. ResultsA total of 272 women with a primary ectopic pregnancy (EP) were initially recruited, 217 women were included in the final analysis, among them 41 (18.9%) women had REP. Univariate analysis showed that women who subsequently developed REP had more prevalent prior miscarriages, evacuation of retained products of conception (ERPC), pelvic inflammatory disease (PID) and consanguinity, they also had lower hemoglobin levels at the time of primary EP, and lower prevalence of surgical treatment. Among the 143 surgically treated cases, salpingectomy, when compared to salpingostomy, and laparoscopy, when compared with laparotomy, were found to be associated with a lower risk of REP [RR = 0.32 (95% CI, 0.13–0.77) and 0.40 (95% CI, 0.18–0.86) respectively]. The occurrence of a subsequent delivery at any time after the primary EP was protective against REP [RR = 0.39 (95% CI, 0.22–0.68)], this protection is increased by almost nine folds if this delivery occurred at the descendant pregnancy [RR = 0.04 (95% CI, 0.01–0.17)]. Multivariable binary logistic regression revealed that prior PID, treatment modality and presenting hemoglobin level were independent predictors of REP. Receiver operating characteristic (ROC) curve was plotted using the predicted probability values derived from the multivariable binary logistic regression model, the area under the ROC curve was 0.792 (95% CI, 0.732–0.844). ConclusionCareful consideration of primary ectopic pregnancy data is a valuable tool to predict the potential risk of recurrence in the future.

Prophylactic chemotherapy for hydatidiform mole to prevent gestational trophoblastic neoplasia.

This is an update of the original Cochrane Review published in Cochrane Library, Issue 10, 2012.Hydatidiform mole (HM), also called a molar pregnancy, is characterised by an overgrowth of foetal chorionic tissue within the uterus. HMs may be partial (PM) or complete (CM) depending on their gross appearance, histopathology and karyotype. PMs usually have a triploid karyotype, derived from maternal and paternal origins, whereas CMs are diploid and have paternal origins only. Most women with HM can be cured by evacuation of retained products of conception (ERPC) and their fertility preserved. However, in some women the growth persists and develops into gestational trophoblastic neoplasia (GTN), a malignant form of the disease that requires treatment with chemotherapy. CMs have a higher rate of malignant transformation than PMs. It may be possible to reduce the risk of GTN in women with HM by administering prophylactic chemotherapy (P-Chem). However, P-Chem given before or after evacuation of HM to prevent malignant sequelae remains controversial, as the risks and benefits of this practice are unclear. To evaluate the effectiveness and safety of P-Chem to prevent GTN in women with a molar pregnancy. To investigate whether any subgroup of women with HM may benefit more from P-Chem than others. For the original review we performed electronic searches in the Cochrane Gynaecological Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2012), MEDLINE (1946 to February week 4, 2012) and Embase (1980 to 2012, week 9). We developed the search strategy using free text and MeSH. For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 5, 2017), MEDLINE (February 2012 to June week 1, 2017) and Embase (February 2012 to 2017, week 23). We also handsearched reference lists of relevant literature to identify additional studies and searched trial registries. We included randomised controlled trials (RCTs) of P-Chem for HM. Two review authors independently assessed studies for inclusion in the review and extracted data using a specifically designed data collection form. Meta-analyses were performed by pooling data from individual trials using Review Manager 5 (RevMan 5) software in line with standard methodological procedures expected by Cochrane methodology. The searches identified 161 records; after de-duplication and title and abstract screening 90 full-text articles were retrieved. From these we included three RCTs with a combined total of 613 participants. One study compared prophylactic dactinomycin to no prophylaxis (60 participants); the other two studies compared prophylactic methotrexate to no prophylaxis (420 and 133 participants). All participants were diagnosed with CMs. We considered the latter two studies to be of poor methodological quality.P-Chem reduced the risk of GTN occurring in women following a CM (3 studies, 550 participants; risk ratio (RR) 0.37, 95% confidence interval (CI) 0.24 to 0.57; I² = 0%; P < 0.00001; low-quality evidence). However, owing to the poor quality (high risk of bias) of two of the included studies, we performed sensitivity analyses excluding these two studies. This left only one small study of high-risk women to contribute data for this primary outcome (59 participants; RR 0.28, 95% CI 0.10 to 0.73; P = 0.01); therefore we consider this evidence to be of low quality.The time to diagnosis was longer in the P-Chem group than the control group (2 studies, 33 participants; mean difference (MD) 28.72, 95% CI 13.19 to 44.24; P = 0.0003; low-quality evidence); and the P-Chem group required more courses to cure subsequent GTN (1 poor-quality study, 14 participants; MD 1.10, 95% CI 0.52 to 1.68; P = 0.0002; very low quality evidence).There were insufficient data to perform meta-analyses for toxicity, overall survival, drug resistance and reproductive outcomes. P-Chem may reduce the risk of progression to GTN in women with CMs who are at a high risk of malignant transformation; however, current evidence in favour of P-Chem is limited by the poor methodological quality and small size of the included studies. As P-Chem may increase drug resistance, delays treatment of GTN and may expose women toxic side effects, this practice cannot currently be recommended.

P02.06: Ultrasound based criteria for the selection of women for hysteroscopic removal of retained products rather than conventional suction curettage

Objectives: Conventional evacuation of retained products of conception (RPOC) is a blind technique which may not remove focal RPOC and is associated with perforation and adhesion risks. Ultrasound (USS) guided evacuation of retained products of conception (ERPC) is a commonly used alternative but we hypothesised that for focal retained tissue following miscarriage, termination of pregnancy (TOP) or delivery hysteroscopic removal of tissue under direct visualisation was an effective and safe alternative which allows intraoperative confirmation of an empty uterus. Methods: For 15 months women with small well-defined intrauterine focal mixed hyperechogenic tissue, with or without vascularity, following miscarriage, TOP or delivery were selected for hysteroscopic management. Under general anaesthesia an 8 mm saline resectoscope without an active electrode was used. Operative findings, procedures, complications, repeat USS and histology are reported. Results: 15 patients were identified retrospectively. Initial presentation was miscarriage (6), TOP (3) and post delivery (6). In 4/15 findings followed blind ERPC. Mean AP diameter of tissue was 17.3 mm (range 4.3–29 mm). In 15/15 (100%) USS findings were confirmed by direct visualisation of frond-like pale tissue or an isolated nodule at hysteroscopy. 1/15 (7%) was complicated by uterine perforation. In 15/15 (100%) blood loss was minimal. Histology confirmed RPOC in 12/15 (80%), implantation site reaction in 2/15 (13%) and chronic endometritis in 1/15 (7%). 7/7 who returned for follow up at 8/52 had an empty uterine cavity confirmed. Conclusions: The ultrasound criteria perform well in identifying focal RPOC. The 7% negative histology may be due to false positive USS or sample collection problems. We propose prospective comparison of USS guided ERPC with hysteroscopy.

A review of management of early fetal demise in a single centre over a 2-year period

It is estimated that 15–20% of confirmed pregnancies will spontaneously miscarry. Treatment options for early fetal demise (EFD) include expectant management, medical treatment and surgical intervention in the form of...

Acquired haemophilia a in a postpartum patient: diagnosis and management

Acquired haemophilia A is a potentially life threatening haemorrhagic disorder caused by spontaneous occurrence of autoantibodies directed against coagulation factor VIII. It has a mortality rate of up to 22%. We report a 40-year-old woman, para 5 who presented with 1 day history of painless haematuria. Seventy days earlier the patient experienced secondary postpartum haemorrhage following spontaneous vaginal delivery due to retained placenta, and was discharged well after ERPOC (evacuation of retained products of conception). Clinical examination was normal. Routine coagulation studies confirmed steady prolongation of activated partial thromboplastin time (APTT) up to 112 s with low factor VIII and high titre of factor VIII inhibitor (16.5 Bethesda units). Diagnosis of acquired haemophilia A was confirmed and she was treated with corticosteroid therapy, recombinant factor VII and intravenous immunoglobulin. The haematuria settled after 48 hours with normalisation of APTT and the level of factor VIII. After 2 months, the coagulation factor study revealed normal factor VIII level and disappearance of factor VIII inhibitors.

Chlamydia screening and treatment in patients undergoing evacuation of retained products of conception or vaginal termination of pregnancy: an audit of the Royal College of Obstetricians and Gynaecologists' Guidelines in practice

ObjectiveTo assess compliance with the Royal College of Obstetricians and Gynaecologists Guidelines regarding screening for and treatment of Chlamydia trachomatis before vaginal termination of pregnancy (VTOP) and surgical evacuation of...

Mid-trimester termination of pregnancy by dilatation and evacuation

The object of this study was to evaluate the feasibility and safety of Dilatation and Evacuation (D&E) as a method of termination of pregnancy in the second trimester. We conducted a retrospective analysis of 61 cases. The mean age of women was 25·6 years (range 1545) and the majority of terminations were performed for social reasons. Twelve women (20%) had at least one previous termination of pregnancy. The median gestational age was 16 weeks (range 1322). Except for three multiparous women, they all had Cervagem vaginal pessaries preoperatively and the mean operative time was 26·6 minutes. Most of the operations were performed under ultrasound guidance, but there was no increased risk of complications in the rest of the group. One multiparous woman suffered uterine perforation and severe haemorrhage, for which she underwent hysterectomy. One in four women tested positive for chlamydia infection. Evacuation of retained products of conception (ERPC) was required in four cases. No postoperative analgesia was required in 43% of women and most of the rest required only mild non-opiate analgesia. Except for two women, all were discharged from the hospital either on the same or the day after the operation. This retrospective study shows that surgical evacuation in the second trimester of pregnancy is a quick and well tolerated method of termination, although there is a risk of perforation and hysterectomy.

Evaluation of the Accuracy of Transvaginal Sonography for the Assessment of Retained Products of Conception After Spontaneous Abortion

Transvaginal sonography (TVS) was used to assess uterine contents in 100 consecutive subjects presenting with a diagnosis of spontaneous abortion. TVS assessments were correlated with findings at subsequent evacuation of retained products of conception (ERPC). There was a strong correlation between the weight of the surgical specimen at ERPC with both the sagittal (r = 0.76; p < 0.05) and transverse (r = 0.73; p < 0.05) plane area measurements of the uterine cavity. Combining the 2 sonographic measurements increased the correlation to r = 0.81 (p < 0.05). Fifteen of 25 subjects who had been categorised to have an ‘empty’ uterus had less than 5 g of tissue removed and the other 10 subjects less than 10 g of tissue. In 20 of these 25 cases, the surgeon described the amount of curettings as ‘small or non-significant’. TVS can accurately identify those women who do not have a significant amount of residual uterine tissue following spontaneous abortion.

Spontaneous abortion: short-term complications following either conservative or surgical management.

Spontaneous abortion is a common gynaecological condition. It is a commonly held belief that medical morbidity associated with this condition is low and that routine treatment should be surgical evacuation of the uterus. This study was performed to study the short-term complications of spontaneous abortion and its management. Transvaginal sonography (TVS) was used to determine whether retained products of conception (POCs) were visible inside the uterus in women presenting with spontaneous abortion. If tissue was present, surgical evacuation of retained products of conception (ERPC) was performed. If the uterus was empty, the patients were managed expectantly. Four hundred and seventy women were treated with ERPC and 297 were managed expectantly. The complication rate was 3.0% in those managed expectantly compared with 5.8% for those treated by ERPC. Subjects with no POCs on TVS can therefore be managed expectantly without increasing the risk of morbidity associated with this condition.

A medical approach to management of spontaneous abortion using misoprostol: Extending misoprostol treatment to a maximum of 48 hours can further improve evacuation of retained products of conception in spontaneous abortion

To compare a 48 hour non surgical policy in the management of spontaneous abortion with a policy of routine, universal uterine curettage. A prospective, observational study on 354 women admitted to hospital with spontaneous abortion. Of these, 225 who had retained products of conception were treated with misoprostol for up to 48 hours after 101 were excluded because they had an empty uterus on transvaginal scan (TVS) and another 28 women because they were unsuitable for conservative management. Follow-up was conducted over a 3 week period to assess morbidity. A reference group of 137 women, all of whom had an evacuation of retained products of conception (ERPC) as a routine after they had a TVS documenting retained products of conception (POCs), was used for comparison. Evacuation of the uterus occurred within 24 hours in 107 women and in 148 at 48 hours after misoprostol treatment was started. There were three uterine curettages up to 14 days after discharge from hospital for persistent bleeding and two cases of pelvic infection. An ectopic pregnancy was diagnosed at follow-up in one woman. In the reference group, there were nine women who had complications, four requiring another ERPC and five had infection, an overall complication rate of 6.6% in the reference group and 1.7% in the protocol treatment group. A 48 hour regimen using transvaginal ultrasound and misoprostol for the management of spontaneous abortion was successful in avoiding surgery in 249 out of a possible 354 (70.6%) women with spontaneous abortion, with a low rate of subsequent morbidity.