External Cervical Os Research Articles

Uterine tumors resembling ovarian sex cord tumors: A retrospective analysis of 7 cases from a single institution.

To investigate the clinicopathological features, diagnosis, surgical treatment and prognosis of uterine tumors similar to ovarian sex cord tumors (UTROSCT). The clinical data, surgical approach, histopathological, and immunohistochemical features of 7 cases of UTROSCTs were retrospectively reviewed and followed up. All 4 patients were premenopausal women. The most common clinical presentation was menorrhagia (n = 4) followed by postmenopausal lower abdominal mass (n = 2) and postmenopausal bleeding (n = 1). Gynecological ultrasonography suggested uterine fibroids in 4 cases, adenomyosis with uterine fibroids in 2 cases, and an intrauterine mass in 1 case. Pelvic MRI was performed preoperatively in only 2 cases, and both indicated uterine fibroid degeneration, including 1 patient with suspected malignancy. Preoperative serum tumor markers were measured in 6 patients, and only 1 patient had elevated CA125 levels, up to 158 U/mL. Total hysterectomy with bilateral adnexectomy or salpingectomy was the most common treatment pattern (n = 6). The tumors were located within the myometrium (n = 4), submucosa (n = 1), and isthmus to external cervical os (n = 1), with a range of 2 to 12 (mean = 8) cm. Edema and degeneration were observed in 2 cases, and necrosis in 1 case. Postoperative follow-up ranged from 31 to 82 (mean = 43) months. Unfortunately, 1 patient died at 54 months of follow-up without undergoing hysterectomy. The remaining 6 cases showed no tumor recurrence or metastasis after surgery. Histological examination revealed a tumor composed of epithelioid tumor-like cells arranged in cords, trabeculae, and nests. All 7 tumors showed expression of 2 sex cord differentiation markers. Furthermore, all tumors expressed the smooth muscle marker, while epithelial marker CK (4/7). endometrial stromal marker CD10(0/7). The Ki-67 proliferation index was found to be <5% (5/7). The option of total hysterectomy may be considered for women who do not have any fertility requirements. However, for young women who desire to maintain their reproductive capacity, surgery to preserve the uterus may be an alternative, although it necessitates careful postoperative monitoring. In terms of follow-up monitoring, MRI is more suitable than ultrasound. The diagnosis of UTROSCT heavily relies on histopathological examination and immunohistochemical analysis.

Elasticity of the Cervix in Relation to Uterus Position.

Strain elastography allows the evaluation of tissue elasticity. Background/Objectives: Tissue elasticity depends on the content and distribution of collagen fibers and is shaped by the applied tensile forces that may differ in uteri with a different angle of flexion of the corpus on the cervix. The objective was to investigate whether the angle of uterine flexion is related to cervical tissue elasticity. Methods: The anterior angle between the longitudinal axis of the uterus corpus and that of the cervix was measured in 275 non-pregnant young women by transvaginal ultrasonography and considered both as an absolute value or categorized as ≤150°, between >150° and ≤210°, and >210°. Strain elastography was used to assess tissue elasticity by placing the probe in the anterior vaginal fornix. Tissue elasticity was evaluated in the middle of the anterior cervical compartment (ACC), in the middle of the posterior cervical compartment (PCC), in the middle portion of the cervical canal (MCC), and at the internal cervical os (ICO). In a sagittal plane MCC was evaluated across the cervical canal, and ACC and PCC at a distance equal between the cervical canal and the outer anterior or posterior part of the cervix. MCC, ACC and PCC were evaluated at equal distance between the ICO and the external cervical os. Elasticity was expressed as a color score ranging from 0.1 (low elasticity) to 3 (high elasticity). Results: The angle of uterine flexion show a negative linear relation with the elasticity of the ACC (p = 0.001) and MCC (p = 0.002) and a positive relation with the elasticity of the PCC (p = 0.054). In comparison to uteri with an angle of flexion of <150°, those with an angle of flexion of >210° had lower elasticity of the ACC (p = 0.001) and MCC (p = 0.001) and higher elasticity of the PCC (p = 0.004). The ACC/PCC and PCC/MCC elasticity ratios were also significantly different (p = 0.001). Conclusions: The angle of uterine flexion is associated with changes in cervix elasticity. Retroflexion is associated with stiffer ACC and MCC and a more elastic PCC. Differences in tissue elasticity suggest structural changes of the cervix that may have implication in variate obstetric and gynecological conditions.

Clinical analysis of uterine parameters evaluated by preoperative magnetic resonance imaging in patients treated by hysteroscopic approach with previous cesarean scar defect-related abnormal uterine bleeding: a retrospective cohort study.

As the cesarean delivery rate continues to rise globally, the treatment of previous cesarean scar defects (PCSD) remains challenging. This study aimed to analyze the variables that may influence the clinical cure rate of patients with PCSD-related abnormal uterine bleeding (AUB) as determined by preoperative magnetic resonance imaging (MRI) following hysteroscopic therapy. Women who underwent hysteroscopic surgery for PCSD-related AUB at the Gynecology Department of Third Xiangya Hospital of Central South University from 2018 to 2022 were recruited to this retrospective cohort investigation. A total of 147 patients were enrolled in this study and underwent follow-up over 6 months. The significance of clinical characteristics linked to the clinical cure rate of AUB was examined by logistic regression. There were 64 clinically cured (43.5%) and 83 non-clinically cured (56.5%) patients in the study. There were no significant differences in the age, menstrual duration, gravidity, parity, number of cesarean sections, time since the previous cesarean section, uterus position, width, depth, and thickness of the remaining muscle layer of the defect by MRI T2-weighted images (T2WI) before hysteroscopic surgery between the 2 groups. MRI T2WI of the myometrial thickness adjacent to the defect [P=0.038, odds ratio (OR) =2.095, 95% confidence interval (CI): 1.047-4.261] and the distance from the defect to the external cervical os (P=0.021, OR =2.254, 95% CI: 1.136-4.540) before hysteroscopic surgery are risk factors for the clinical cure rate. The myometrial thickness adjacent to the defect and the distance from the defect to the external cervical os in preoperative MRI are risk factors for clinical cure rate in patients with PCSD-related AUB after hysteroscopic treatment, which is helpful for evaluating the prognosis of disease.

Protruding vs. visible prolapsed fetal membranes adversely affects the outcome of cervical insufficiency.

This study aimed to determine how prolapsed fetal membranes (PFM) affect perinatal outcomes in cases of cervical insufficiency undergoing emergency cerclage or expectant management. This retrospective study analyzed perinatal outcomes in 100 pregnant women with cervical insufficiency, including those with visible PFM at the cervical external os and those with protruding PFM to the vagina. The participants were subjected to either expectant management involving prescribed bedrest or emergency cerclage. In the study population, 41 (41%) preferred bedrest, while 59 (59%) chose emergency cerclage. Among those managed expectantly, 10 (10%) had visible PFM, and 31 (31%) had protruding PFM. Among those who underwent emergency cerclage, 32 (32%) had visible PFM, and 27 (27%) had protruding PFM. Delivery after 32 weeks of gestation showed similar rates between women with visible and protruding PFM, regardless of the management approach chosen. These rates were significantly higher compared to those with protruding PFM managed with bed rest and emergency cerclage. Prolongation of pregnancy in protruding-cerclage and protruding-bedrest groups was 42.3±34 and 17.9±22 days, respectively. Our findings provide support for considering emergency cerclage as a viable option when addressing cases involving a visible form of PFM, although the recommendation is somewhat less robust in instances of protruding PFM. The implementation of an emergency cerclage procedure has the potential to extend the time frame between diagnosis and delivery, enhance neonatal survival rates, and increase the likelihood of births occurring after 28 weeks of gestation. However, it does not seem to significantly affect the rate of births taking place after 32 weeks of gestation. This could potentially lead to complications associated with premature births and extended stays in the postnatal neonatal intensive care unit. Therefore, it is crucial to offer families detailed information regarding the pros and cons of emergency cerclage.

Addition of Cervical Elastosonography to Cervical Length to Predict Preterm Birth in Pregnancy Women with Prior Preterm Birth: A preliminary prospective study.

To investigate the characteristics of cervical elastosonography in pregnancies and establish an ultrasound-based combing predictor for improving the prediction in pregnant women with prior-preterm birth who might ultimately undergo preterm birth (PTB). 169 singleton pregnancies with prior-preterm birth were examined by cervical elastography from January to November of 2021. According to the ultrasound image and result of the following-up, the patients were separated into preterm groups and full-term groups with or without cerclage. There were five elastographic parameters: Elasticity Contrast Index (ECI), Cervical hard tissue Elasticity Ratio (CHR), External Cervical os Strain rate (ES), Closed Internal Cervical os Strain rate (CIS), CIS/ES ratio and CLmin. Multivariable logistic regression was used to screen out the most significant predictors. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the ability of prediction. The PTB group without cerclage showed significantly softer cervix stiffness, while those with cerclage showed significantly harder. CHRmin with P < 0.05 in the univariate logistic regression analysis was screened as a more valuable cervical elastosonography parameter than other ones. The combination of CLmin and CHRmin in un-cerclage and integrating CHRmin, maternal age and pre-pregnancy BMI in cerclage presented good predictive value. The results of AUC were higher than CLmin, respectively (0.775 vs 0.734, 0.729 vs 0.548). The addition of cervical elastography parameters (such as CHRmin) might improve the ability to predict preterm birth in pregnant women with previous preterm delivery, which was better than using CL alone.

Hematometra Ec Stenosis Of The Cervix Of The Uterus: A Case Report

Background : Cervical stenosis has been defined as a narrowing of the endocervical canal preventing passage of a 2.5-mm Hegar or Pratt dilator. Stenosis of the external cervical os has been described as an external os diameter of less than 4.5mm. Symptoms of cervical stenosis are dependent on the degree of endocervical canal obstruction and the patient's menopausal status. Those patients with severe or complete obstruction of the endocervical canal can experience hematometra with scant or sporadic menstrual flow, amenorrhea, dysmenorrhea, chronic pelvic pain, and infertility.Case Report : A 16-year-old woman was consulted from Pediatric with cervix stenosis with haematometra wich had been noticed since a month ago. Menarche at the age 13 years, regular and slightly pain menstruation every month. The result of MRI examination represented bilateral hematometra and hematocolpos ec suspected cervical stenosis. The management of this case was cervical dilatation and cervical tube installation. Conclusion : Cervical stenosis is a caused of menstrual complaint which is characterized by slightly pain while menstruation, hematometra and hematocolpos.Â

Evaluation of the stiffness of normal cervix and its change with different factors using transvaginal two-dimensional shear wave elastography under strict quality control

BackgroundThe usefulness of transvaginal two-dimensional shear wave elastography (2D SWE) for cervical lesions is still uncertain. This study was to explore the value of transvaginal 2D SWE in the evaluation of the stiffness of normal cervix and its change with different factors under strict quality control (QC).MethodsTwo hundred patients with normal cervix were included in this study and were examined using quantitative 2D SWE to evaluate cervical stiffness and its change with different factors under strict QC.ResultsIntra-observer concordance of transvaginal 2D SWE parameters in midsagittal planes were acceptable with intraclass correlation coefficients higher than 0.5. Transvaginal 2D SWE parameters were significantly higher than the corresponding transabdominal parameters. 2D SWE parameters of internal cervical os were significantly higher than the corresponding parameters of external cervical os in a transvaginal midsagittal plane. 2D SWE parameters of external cervical os increased significantly over 50 years old, while these parameters of internal cervical os didn’t change significantly with increasing age. 2D SWE parameters of internal cervical os of horizontal position cervix were significantly higher than those of vertical position cervix. SWE parameters of normal cervix did not change according to different menstrual cycles, parities and human papilloma virus test results.ConclusionsTransvaginal 2D SWE under strict QC could provide quantitative, repeatable and reliable cervical stiffness information. Internal cervical os was stiffer than external cervical os. Menstrual cycles, parities and human papilloma virus test results wouldn’t affect cervical stiffness. However, age and cervical positions should be taken into condition while interpreting 2D SWE results of cervical stiffness.

Value and influencing factors of preoperative MRI evaluation for previous cesarean scar defect associated abnormal uterine bleeding in patients undergoing laparoscopic surgery.

As the cesarean section rate increases year by year, the treatment of previous cesarean scar defects (PCSD) poses a significant challenge. This study aims to evaluate the clinical value of preoperative magnetic resonance imaging (MRI) technology and analyze relevant influencing factors for patients with abnormal uterine bleeding (AUB) associated with cesarean scar defects who underwent laparoscopic surgery. A retrospective cohort analysis was performed on women who underwent laparoscopic surgery for PCSD-related AUB at the Department of Gynecology, the Third Xiangya Hospital of Central South University from 2018 to 2022. A total of 57 patients who underwent laparoscopic surgery for the treatment of AUB associated with PCSD were divided into 2 groups based on their postoperative clinical cure status: The clinically-cured group (n=28, 49.1%) and the non-clinically-cured group (n=29, 50.9%). After a postoperative follow-up period of 3 months for all participants, logistic regression analysis was conducted to explore the correlation between the clinical cure rate of AUB associated with cesarean scar defects treated by laparoscopic surgery and various factors. These factors included patient age, clinical symptoms, obstetric history, history of cesarean section, basic clinical information, preoperative MRI parameters, and postoperative menstrual conditions. There were no significant differences in many aspects, including the patient's age at the time of previous cesarean section, number of pregnancy, time since the previous cesarean section, the uterus position assessed by preoperative T2 signal MRI, defect length, defect width, residual muscle layer thickness, adjacent uterine muscle layer thickness, and distance from the defect to the external cervical os between the 2 groups (all P>0.05). However, the time of onset of AUB symptoms (P=0.036, OR=1.019, 95% CI 1.002 to 1.038) and the depth of the defect on the preoperative MRI (P=0.010, OR=5.793, 95% CI 1.635 to 25.210) were identified as risk factors affecting the clinical cure rate. The time of onset of AUB symptoms and the depth of the defect on preoperative MRI are risk factors that influence the clinical cure rate of laparoscopic surgery for the treatment of AUB associated with PCSD, which could be helpful for evaluating the prognosis of disease.

Vaginal Isonicotinic Acid Hydrazide Prior to Diagnostic Office Hysteroscopy in Primarily Infertile Patients: A Randomized Double-Blinded Clinical Trial

Objective: The aim of this research was to learn if 900 mg of vaginal isonicotinic acid hydrazide (INH) reduced pain and improved insertion ease during diagnostic outpatient hysteroscopy (DOH) in nulliparous infertile patients, when administered 12 hours before DOH. Materials and Methods: A double-blinded, randomized, controlled study was carried out at a university teaching hospital. Primary infertile women (150) were allocated randomly to receive 900 mg of INH vaginally or a placebo 12 hours before DOH for infertility assessment. Patients were requested to assess the intensity of their pain on a visual analogue scale ranging from 1 to 10 during the DOH, which was the study's primary objective. Secondary outcomes were the time it took to insert the hysteroscope via the external cervical os and to view the uterus, patient satisfaction, postprocedural analgesic needs, and the ease with which DOH was performed. Results: Both groups shared baseline features. The INH group had a reduced mean pain score during DOH (3.9 ± 0.8 versus 5.8 ± 0.8; p < 0.001). DOH was easier in the INH group; ease of insertion score in the INH group was lower than in the placebo group (5.3 ± 0.1 versus 7.3 ± 1.1; p < 0.001). The INH group had greater satisfaction (7.6 ± 1.3 versus 5.1 ± 0.9; p < 0.001) and needed less analgesia (p = 0.02) than the placebo group. Both groups had comparable adverse effects. Conclusions: In nulliparous infertile women, 900 mg of vaginal INH 12 hours before DOH reduces perceived pain more effectively than a placebo, facilitating easier hysteroscope insertion and improving patient satisfaction. (J GYNECOL SURG 39:43)

Laparoscopic Repair of a Deep Cesarean Scar Defect Guided by Hysteroscopy: Surgical Technique

<h3>Study Objective</h3> To show a uterus-preserving surgical technique in a patient with a deep cesarean scar defect. <h3>Design</h3> A technical video showing a laparoscopic isthmoplasty guided by hysteroscopy. <h3>Setting</h3> A tertiary referral hospital. For surgery, the patient was placed in dorsal modified lithotomy position. The surgeon was on the patient's left side, the first assistant on the right, and the second assistant between the patient's legs to perform the hysteroscopy. <h3>Patients or Participants</h3> A 41-year-old woman, with a history of two cesarean sections, was referred to our gynecological department for symptomatic isthmocele with abnormal uterine bleeding and abdominal pain. At MRI examination, it was identified a cesarean scar defect of 34 mm length x 34mm depth x 48mm of transverse diameter, with a residual myometrial thickness of 1.7 mm. <h3>Interventions</h3> The procedure started with the resection of adhesions between the uterus and the abdominal wall, followed by cautious mobilization of the bladder below the external cervical os. The cesarean scar was excised until healthy myometrium was identified, guided by transillumination with hysteroscopy. Afterwards, an hysterometer was used to facilitate the myometrial repair, which was performed with two layers of interrupted 2-0 absorbable multifilament suture. An hysteroscopic control was done, using physiological solution with methylene blue as distensor media, which ensured, with a laparoscopic view, that there were no leaks. Finally, the uterine plastic was covered by a peritoneal flap. <h3>Measurements and Main Results</h3> Operating time was of 140 minutes. The postoperative course was uneventful, and the patient was discharged on the first postoperative day. The patient reported resolution of postmenstrual spotting and abdominal pain. <h3>Conclusion</h3> Laparoscopic repair of a deep cesarean scar defect guided by hysteroscopy, is a feasible surgery and it should be considered as an alternative to hysterectomy in women who want to preserve the uterus.

The Role of Amnioreduction in Emergency Cervical Cerclage with Bulging Membranes: A Retrospective Comparative Study.

The purpose of this study was to investigate the role of amnioreduction in patients who underwent emergency cervical cerclage (ECC) with bulging membranes during the second trimester. This retrospective comparative study included 46 singleton pregnant women who had cervical dilation at least 1 cm with bulging membranes beyond the external cervical os and underwent ECC at the Third Affiliated Hospital of Sun Yat-sen University between December 2016 and December 2021. Cases were categorized as amnioreduction group (n = 16) and non-amnioreduction group (n = 30) according to whether amnioreduction was performed prior to ECC. The gestational age and cervical dilation at cerclage, operative time, prolongation of pregnancy, and outcomes of pregnancy were compared between the two groups. All 46 patients underwent successful ECC excepted one case with intraoperative rupture of membrane in non-amnioreduction group. In the amnioreduction group, the cervical dilation at cerclage was larger than that in the non-amnioreduction group (4.5 ± 2.2 vs. 2.2 ± 1.2 cm, P < 0.001), and had more patients with cervical dilation ≥4 cm (50.0% vs. 10.0%, P = 0.004). However, the gestational age at cerclage, operative time, prolongation of pregnancy, gestational age at delivery were not significantly different between the two groups (22.9 ± 2.8 vs. 22.9 ± 3.2 weeks, 31.1 ± 9.2 vs. 27.9 ± 11.4 min, 21.3 ± 21.5 vs. 38.7 ± 40.2 days, 25.9 ± 4.5 vs. 28.4 ± 6.1 weeks; P > 0.05). The rates of delivery ≥28 weeks, ≥32 weeks, and live birth were 20.0% vs. 80.0%, 12.5% vs. 26.7%, 56.3% vs. 66.7% (P > 0.05) in amnioreduction group and non-amnioreduction group, respectively. In conclusion, even in cases with larger cervical dilation, the application of amnioreduction with ECC is possible to get the acceptable pregnancy outcomes. These findings suggested that amnioreduction may be a safe and feasible option to be applied before ECC, especially for those with advanced cervical dilation and bulging membranes.

Achievement of a 136-day delayed-interval delivery of a second twin with minimum intervention

The rate of multiple pregnancies in the past three decades has increased dramatically. Twin pregnancies have a higher risk of pregnancy loss owing to premature birth. Although the premature delivery of the first twin is usually followed by spontaneous birth of the second twin, there are ways to delay the delivery of the second twin to enhance survival and neonatal outcomes. However, there is insufficient evidence to support the role of any interventions such as cerclage, hospitalization, tocolytics, and/or antibiotics. As a result, the management of delayed interval for the delivery of the second twin varies depending on each case. The purpose of this study was to report the obstetric components of a successful delayed-interval delivery, with an emphasis on the current conflicts around the active management of the delayed interval delivery of the second twin. A case of a 40-year-old, G5P4, woman who had three cesarean sections is presented. She got pregnant with a dichorionic diamniotic twin. At 17 weeks of gestation, she developed sudden severe lower abdominal pain, vaginal bleeding, and spontaneous expulsion of the first fetus weighing 179 g. After delivery of the first twin, the vaginal bleeding became minimal, and the cervix was reconstituted soon, so cervical cerclage was not offered. The umbilical cord of the first fetus was cut at the level of the external cervical os, and the placenta was retained. She received intravenous fluids, anti-D prophylaxis, paracetamol, and antibiotics. The patient was keen to continue with the pregnancy and was informed about the risks and benefits. The management was mainly an outpatient basis after an initial short hospital stay of 6 days before being discharged (upon her request); during the follow-up, she did not develop any clinical manifestations of maternal infection. She was subjected to ANC at the outpatient clinic every 2 weeks, where vaginal culture, complete blood count, prothrombin time, and C-reactive protein levels and serial ultrasonography were checked consistently. The fetus showed adequate growth. After 136 days, she delivered by elective cesarean section a male baby weighing 2850 g at 37 weeks of gestation with good recovery. In certain situations, delayed delivery of the second twin of diamniotic dichorionic twin pregnancy may be a safe, simple with less interventions, and effective option to improve pregnancy outcome.

Effect of endometrial scratching on unassisted conception for unexplained infertility: a randomized controlled trial

To investigate whether endometrial scratching increases the chance of live birth in women with unexplained infertility attempting to conceive without assisted reproductive technology. Randomized, placebo-controlled, participant-blind, multicenter international trial. Fertility clinics. Women with a diagnosis of unexplained infertility trying to conceive without assistance. Participants were randomly assigned to receive an endometrial biopsy or a placebo procedure (placement of a biopsy catheter in the posterior fornix, without inserting it into the external cervical os). Both groups performed regular unprotected intercourse with the intention of conceiving over three consecutive study cycles. The primary outcome was live birth. A total of 220 women underwent randomization. The live birth rate was 9% (10 of 113 women) in the endometrial-scratch group and 7% (7 of 107 women) in the control group (adjusted OR, 1.39; 95% CI, 0.50-4.03). There were no differences between the groups in the secondary outcomes of clinical pregnancy, viable pregnancy, ongoing pregnancy, and miscarriage. Endometrial scratching was associated with a higher pain score on a 10-point scale (adjusted mean difference, 3.07; 95% CI, 2.53-3.60). This trial did not find evidence that endometrial scratching improves the live birth rate in women with unexplained infertility trying to conceive without assistance. Australian New Zealand Clinical Trials Registry ACTRN12614000656639.

Safety and Efficacy of an Atraumatic Uterine Cervical Traction Device: A Pilot Study.

Introduction: Alignment of the uterine cervix with the vaginal canal is often required during insertion of an intrauterine contraceptive device (IUD). Currently available instruments are traumatic tenacula, which can cause pain and bleeding and represent an obstacle for certain patients to pursue their medical follow-up. A novel investigational cervical vacuum tenaculum, enables atraumatic traction of the cervix using a semi-circular suction pad, designed to conform to the anatomical shape of the external cervical os. Suction is generated by manually pulling out a sliding tube in a vacuum chamber.Methods: We performed a single arm non-comparative pilot study to assess the safety and efficacy of the cervical vacuum tenaculum in 13 women receiving an IUD. Data on procedural efficacy, safety, patient-reported pain scores at specific time points during IUD insertion procedure and patient satisfaction were collected prospectively.Results: Insertion of IUD was successful with use of the study device in 7 of the 13 enrolled patients (54%). No bleeding or only limited ecchymosis were caused by the device. No adverse events were reported. Participants reported very little pain (mean Visual Analog Scale <10) when applying the device. Participants who achieved IUD insertion with the device reported strong overall satisfaction with the procedure.Conclusions: The suction-based atraumatic tenaculum can be used to manipulate the cervix during IUD insertion with satisfactory efficacy and safety. The results of this pilot study support further studies of this device in larger populations comparing with standard single-tooth tenaculum.Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT 04441333.

A new technique for emergency cerclage: Guard suture method

Objective The aim of this study was to introduce a novel technique to treat midtrimester cervical insufficiency with prolapsed membranes.Material and methods This retrospective study included patients with singleton pregnancies between 16 and 28 gestational weeks that underwent emergency cervical cerclage in a tertiary center. Patients were divided into two groups as McDonald method and guard suture method group according to the procedure they underwent. The following variables were recorded and evaluated: gestational age at cerclage, cervical length between the suture and external cervical os measured by transvaginal ultrasound on postoperative 1st and 7th day, gestational age at delivery, time between the procedure and delivery, intraoperative complications, newborn intensive care unit (NICU) admission, Apgar scores of neonates, and discharged alive newborns.Results During the study period, 38 patients underwent emergency cerclage procedure. Twenty-three were included in the McDonald group and 15 were in the guard suture group. The mean gestational age at the time of cerclage was 22.1 (17 -27) weeks and the mean gestational age at delivery was 33.9 (26- 38) weeks. Prolongation time between cerclage and delivery was 80.42 (1 - 140) days. Significantly higher 1st and 5th minutes Apgar scores and significantly lower NICU admission was found in the guard suture group (p = 0.04, p = 0.01 and p = 0.02, respectively).Conclusion In cases with cervical insufficiency and prolapsed membranes, emergency cerclage may prevent premature birth by prolonging pregnancy. Guard suture method is safe, effective, and easily applicable and can help obstetricians achieve better fetal and neonatal outcomes.

Emergency cervical cerclage in twin and singleton pregnancies with 0‐mm cervical length or prolapsed membranes

Cervical cerclage is controversial in twin pregnancies, although recent data from the USA supports its use where "physical examination-indicated". Limited data exist, however, in the extreme situation of 0-mm ultrasound-measured cervical length or even prolapsed membranes. This research compares the success of emergency cervical cerclage in multiple and singleton pregnancies. This is a retrospective cohort study of all such cerclages performed at a tertiary hospital over a 15-year period. "Emergency" was where transvaginal ultrasound-assessed cervical length was 0mm, with amniotic membranes at or beyond the external cervical os. Exclusion criteria were clinical or biochemical evidence of infection, regular contractions, bleeding, ruptured membranes, or gestation beyond 24+0 weeks. The primary outcome, or "success", was defined as birth >27+6 weeks of gestation, with the neonate alive 28days later with no markers of adverse outcome (seizures, periventricular leukomalacia, intracranial hemorrhage more than Grade 2, or necrotizing enterocolitis). Demographic and cerclage variables were assessed against the primary outcome. Variables correlated with success were analyzed between multiple and singleton pregnancies. Comparison of all adverse outcomes was then adjusted using logistic regression. A total of 135 pregnancies were included (107 singletons and 28 multiples [all twins]). Success was achieved in 79 (58.5%; 57.9% in singletons, 60.7% in twins). Nulliparity, in utero transfer, symptoms, prolapsed membranes, and dilation more than 3cm were predictors of failure, but twin pregnancy was not. After controlling for potential confounding variables, there was no significant difference in measures of success between singleton and twin pregnancies, apart from higher rates of neonatal unit admission. Emergency cervical cerclage, even in extreme situations, is as effective in twin pregnancies as it is in singletons.

Two successful embryo transfers of mini‐donkey embryos in Brazilian Northeastern jennies using an alternative method: Case report

AbstractPregnancy rates after embryo transfer (ET) are disappointing in donkey species. This study aims to report two successful ET of mini‐donkey embryos using Brazilian Northeastern jennies as recipients. Eighteen embryo flushes were performed 9 days post‐ovulation in two non‐pregnant mini‐donkeys jennies (11 and 7 cycles per jenny). Eleven embryos (61%, 11/18) were collected and transferred to Brazilian Northeastern jennies 4–6 days post‐ovulation by conventional (n = 6) or an alternative (n = 5) technique. The alternative method consisted of inserting a Polansky equine vaginal speculum smeared with lubricant in the vagina of the recipient jenny. The arms of the speculum were extended to allow the visualization of the cervix. Then, using an adapted crafted, elongated, toothed tissue grasping forceps, the external cervical os was held, and the cervix was gently pulled backward, aiming to straight the cervical canal. The ET gun was inserted through the vagina and cervix by visual inspection, and the embryo was released into the uterine lumen. All embryos collected were Grade 1 and classified as Expanded Blastocysts. No jennies become pregnant after conventional ET (0/6), whereas two recipient jennies (40%, 2/5) become pregnant and delivered offspring in the following year after ET using the alternative technique. In conclusion, Brazilian Northeastern jennies can be used as embryo recipients using the alternative method proposed in the present study. However, further investigations are needed to improve the knowledge and results of ET in donkey species.

Misplaced IUCD

The intra uterine device (IUD) is a popular family planning method worldwide. Some of the complications associated with the insertion of an IUD are well described in the literature. The frequency of IUD perforation is estimated to be between 0.05 &amp; 1B per 1000 insertions. There are many reports of migrated intrauterine devices, but for fewer reports of IUDs which have penetrated into the rectum. Among the options available the multi-year cost of the copper T380A. IUD makes it one of the most cost-effective contraceptive options available. According to the World Health Organization Medical Eligibility Criteria, an IUCD can be inserted in the 48 hours postpartum, referred to here as Postpartum IUCD (PPIUCD), or after four weeks following a birth. With increased use of intra-uterine devices (IUDs) for contraception, an increase in the number of related problems are reported. A frequent clinical problem is the loss of filament at the external cervical os, the ‘lost tail’. The disappearance of the string or marker heralds potential problems such as retracted or turn off tail, misplacement within the cavity, intra-mural penetration or extra-uterine location.

P–746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Abstract Study question The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus. Summary answer The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os. What is known already Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os. Study design, size, duration This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 –2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment. Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups. Main results and the role of chance There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P = 0.002) and history of RPL (P = 0.017) in the study group. There was significant lower incidence of tubal factors infertility (P = 0.005) and endometriosis (P = 0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P = 0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P = 0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P = 0.000), and delivery by CS (69.6% vs 41.2%; P = 0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P = 0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively. Limitations, reasons for caution A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed. Wider implications of the findings: Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri. Trial registration number Not applicable

P-746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Abstract Study question The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus. Summary answer The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os. What is known already Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os. Study design, size, duration This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 -2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment. Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups. Main results and the role of chance There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P=0.002) and history of RPL (P=0.017) in the study group. There was significant lower incidence of tubal factors infertility (P=0.005) and endometriosis (P=0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P=0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P=0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P=0.000), and delivery by CS (69.6% vs 41.2%; P=0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P=0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively. Limitations, reasons for caution A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed. Wider implications of the findings Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri. Trial registration number Not Applicable