Intrauterine Intervention Research Articles

Antenatal hydronephrosis and fetal urine sampling.

The aim of this study is to evaluate the significance of renal pelvis aspiration (RPA) in the management of antenatal hydronephrosis (AHN). This study enrolled 15 AHN cases (one twin pregnancy) that necessitated RPA for AHN. Chromosomal abnormalities, gene disorders, and additional life-threatening congenital abnormalities were eliminated prior to intrauterine interventions. Urine analysis were performed for the evaluation of renal function. Normal renal function was observed in six neonates/infants (40%) (group 1), whereas impaired renal function and various type of urinary system anomalies were observed in 9 neonates/infants (60%) (group 2) during the short-term and longitudinal follow-up periods. There were statistically significant differences in the oligohydroamniosis rate, mean fetal urine sodium value, mean fetal urine β2-microglobulin, mean gestational week at birth, and mean birthweight values between the groups (P = 0.007, P < 0.001, P = 0.035, P < 0.001, and P = 0.001, respectively). Renal pelvis aspiration and urine analysis were substantial for the management of AHN in necessary cases. β2-microglobulin and sodium are clinically useful markers to detect the presence of severe renal damage due to obstructive uropathy and thus, important adjuvants in the proper selection of fetuses for further antenatal interventions.

VP101 Intrauterine Surgical Interventions: A Rapid Review

IntroductionAdverse conditions during pregnancy, such as myelomeningocele (MMC), fetal-fetal transfusion syndrome (STFF) and congenital heart disease (CHD) not only significantly increase the risk of fetal death, but also increase the occurrence of severe postnatal sequelae.MethodsWe conducted a rapid review of the efficacy and safety of intrauterine interventions in MMC, STFF and DCC in comparison to traditional interventions. We searched Pubmed via Medline, Cochrane Library and Center for Reviews and Dissemination databases using the terms indexed and synonyms for each intervention.ResultsFor STFF, the available scientific evidence indicates that laser ablation is effective and presents better outcomes when compared to other interventions, such as high overall survival rate, better perinatal outcomes and less chance of brain injury. Even though intrauterine interventions in CHD present high rates of live births, high neonatal mortality rates are also reported. Evidence on the efficacy and safety of intrauterine surgical interventions for myelomeningocele and CHD is inconclusive. Regarding myelomeningocele, no significant differences were observed for the outcomes of postnatal mortality, rate of ventriculostomy placement, reversal of posterior brain herniation, motor response and placental rupture.ConclusionsThere is no consensus regarding the efficacy and safety of intrauterine surgical interventions for myelomeningocele and CHD. Regarding STFF, laser ablation is accepted as an effective intervention. It is necessary to conduct prospective studies in order to evaluate the effect of these interventions, considering the specifications of each condition and the ethical aspects.

Морфофункциональное состояние яичников у пациенток с гиперпластическими процессами эндометрия после внутриматочных хирургических вмешательств

Морфофункциональное состояние яичников у пациенток с гиперпластическими процессами эндометрия после внутриматочных хирургических вмешательств

Indications and methods for intrauterine intervention in the surgical correction of cardiac malformations

Indications and methods for intrauterine intervention in the surgical correction of cardiac malformations

POSSIBILITY FOR NON-INVASIVE DIAGNOSIS OF CHRONIC ENDOMETRITIS IN WOMEN AT RISK DURING PREGRAVID PREPARATION

Introduction: Detection and treatment of chronic endometritis (CE) is clinically significant, though involves intrauterine intervention to collect endometrium. The aim: To estimate the possibility to use fertility α2-microglobulin (FAMG) as the marker of the high risk for CE. Materials and methods: 70 women with CE who were planning pregnancy were tested for FAMG in menstrual blood. 40 of them received treatment of CE. The other 30 women refused from the proposed treatment. The control group involved 30 women who had neither CE nor luteal phase deficiency (LPD). Additional group (20 women) had LPD without CE. Results: The decrease of FAMG by 2.4 times was noted in women with CE (16.3 ± 3.9 μg/ml against 39.8 ± 8.3 μg/ml in the controls). In LPD the index was 5.6 times lower. After treatment the level of FAMG was increasing. Conclusions: The decrease of the amount of FAMG in menstrual blood is specific for women both with CE and LPD. Detection of abnormally low rates of FAMG in all women with CE enables, with the exception of absolute hypoprogesteronemia and LPD, using it as a simple method of estimation of the functional state of endometrium. Its application can be very useful both for non-invasive diagnosis of CE and subsequent evaluation of treatment of this pathology.

Peculiarities of high-risk pregnancy management after the IVF procedure: a clinical observation report

This article presents an annotation and discussion of our own clinical observation of a high-risk multiple pregnancy after in vitro fertilization in a patient with tuboperitoneal infertility. We report a case of early prenatal diagnosis of a rare malformation of a single fetus in dichorionic twin pregnancy (pentalogy of Cantrell). The feasibility of cumulative assessment of the risks of assisted reproductive technology complications to determine the tactics of management and intensive observation during pregnancy, as well as the use of invasive intrauterine interventions for multiple pregnancy to reduce perinatal risks is discussed.

Health-Related Quality of Life and Depression in Women following Intrauterine Interventions in Complicated Monochorionic Twin Pregnancies

Introduction: The aim of this study was to explore maternal health-related quality of life (HRQoL) and depression following intrauterine interventions in complicated monochorionic twin pregnancies at the Medical University Graz. Material and Methods: In a cross-sectional questionnaire survey, women with at least one liveborn infant following intrauterine intervention during 2011 and 2015 were matched with uncomplicated monochorionic and dichorionic pregnancies. All completed the 12-Item Short Form Health Survey to measure HRQoL and the Patient Health Questionnaire-9 to measure depression. Results were compared with local normative values. Results: There were no differences in physical and mental HRQoL as compared to those with uncomplicated pregnancy. However, the whole study population had significantly lower HRQoL scores (p < 0.001) than the normative sample. Additionally, 11% of the whole study population experienced moderate (6.2%) or moderately severe (4.6%) depression. Women following uncomplicated dichorionic pregnancy revealed more depressive symptoms compared to women with intervention. Discussion: Women with at least one surviving infant following intervention in complicated monochorionic twin pregnancy do not seem to have an impaired HRQoL as compared to women following uncomplicated monochorionic or dichorionic pregnancies. However, twin pregnancy itself appears to impair HRQoL, at least in the first 4 postnatal years.

Intrauterine Interventions for the Treatment of Twin Anemia-Polycythemia Sequence: A Systematic Review.

Twin anemia-polycythemia sequence (TAPS) is a complication of monochorionic, multiple gestation pregnancies in which blood shunting through placental anastomoses results in chronic anemia in one fetus and chronic polycythemia in another. The outcomes of different treatment modalities for TAPS are not well known. To determine the outcomes of the intrauterine interventions used to treat TAPS. A systematic literature search of MEDLINE, EMBASE, and CENTRAL was performed in June 2016. Primary outcomes were mortality, morbidity, and adverse perinatal outcomes. Data were summarized in the form of weighted means, and statistical difference was determined. Twenty-one articles were identified for inclusion in this review and were composed of 105 cases of TAPS. In the cases presented in the literature, there was no statistically significant difference in mortality, morbidity, or emergent Caesarean section rates between expectant management, intrauterine transfusion (IUT), and laser ablation therapy. Laser ablation therapy and IUT were found to have a significantly lower rate of adverse perinatal outcomes when compared to expectantly managed cases. The literature looking into the treatment of TAPS is very limited, with no randomized controlled trials and only one includable comparative study. Based on the data in the case report and case study literature, there is no mortality difference between any of the treatment modalities. Expectant management may be associated with an increase in adverse perinatal outcomes when compared to laser therapy and IUT. More comparative studies are needed to assist clinicians in adopting an evidence-based approach to the treatment of TAPS.

Outcomes of severe primary fetal hydrothorax treated by prenatal intervention

Objective: To investigate the effect of intrauterine intervention on severe primary fetal hydrothorax. Methods: Twelve cases with severe fetal primary hydrothorax who underwent prenatal intervention from January 2014 to December 2017 in Guangdong Women and Children Hospital were retrospectively reviewed. Results: The median gestational age of prenatal diagnosis was 30.8 weeks (24.0-33.0 weeks) . All cases were excluded congenital chromosomal abnormalities by prenatal diagnosis, and had no complications of pregnancy during prenatal diagnosis and had hydrothorax. Three cases (3/12) were right hydrothorax, the other 9 cases (9/12) were bilateral. Thoracoamniotic shunting was performed in 7 cases (7/12) . Thoracentesis was performed in 5 cases (5/12) , and the hydrothorax reappeared soon after operation in 4 cases, shunt placement was performed again. The hydrothorax was dissolved in 2 cases, released in 6 cases.Tube falling off occurred in 1 case,treatment was abandoned in 1 case and intrauterine fetal death happened in 1 case, and 1 case wasn't rechecked by ultrasonic due to premature birth following thoracentesis. In 10 cases who had deliveries, 5 newborns (5/10) were premature, 6 newborns (6/10) underwent assisted mechanical ventilation, 8 newborns (8/10) underwent thoracic close drainage, all of them were discharged when hydrothorax resolved. Conclusions: Antenatal intervention may improve the chance of survival in severe primary fetal hydrothorax. Thoracoamniotic shunting is the first-choice for the primary severe fetal hydrothorax.

Abnormal uterine bleeding: we diagnose and choose treatment

Abnormal uterine bleeding (AUB) is one of the most common frequent reasons for contacting a gynecologist and conducting intrauterine interventions. AUB causes iron deficiency anemia and a decrease quality of life of women, which in turn is the reason of their social and clinical significance. Based on the analysis of literature and international data recommendations, the review outlines the basic principles of AUB diagnosis, non-hormonal and hormone therapy Advantages of continuous regimen for the administration of progestogens, in particular the LNG-IUS, and COCs containing estradiol valerate, to reduce menstrual flow blood loss are presented in the article. The need for a differentiated approach of choosing the therapy based on age, causes of bleeding, and balance benefits and risks of medicines.

Influence Factors on Contrast Agent Venous Intravasation During Transvaginal 4-Dimensional Hysterosalpingo-Contrast Sonography.

To explore the risk factors on contrast agent venous intravasation during transvaginal 4-dimensional hysterosalpingo-contrast sonography (TVS 4D-HyCoSy). The TVS 4D-HyCoSy imaging data were collected from 276 female infertile patients. The correlation between endometrial thickness, days after menstruation, intrauterine intervention history, fallopian tubal patency degree, and contrast agent venous intravasation, respectively, was analyzed. In our study, the incidence of contrast agent venous intravasation was 13.04%. Endometrial thickness and days after menstruation were significantly associated with venous intravasation (P < .05). However, there was no significance for intrauterine intervention history and fallopian tube patency degree. Contrast agent intravasation during TVS 4D-HyCoSy is not infrequent. Performing TVS 4D-HyCoSy according to endometrial thickness and menstrual period could reduce intravasation incidence to some extent.

Outcomes and morbidities of patients who survive haemoglobin Bart's hydrops fetalis syndrome: 20-year retrospective review.

Haemoglobin Bart's hydrops fetalis syndrome was once considered a fatal condition. However, advances over the past two decades have enabled survival of affected patients. Data relating to their morbidities and outcomes will help medical specialists formulate a management plan and parental counselling. All babies with the syndrome who survived beyond the neonatal period and were subsequently managed long-term in eight public hospitals in Hong Kong from 1 January 1996 to 31 December 2015 were included. Patient and parent characteristics, antenatal care, reasons for continuation of pregnancy, intrauterine interventions, perinatal course, presence of congenital malformations, stem-cell transplantation details, and long-term neurodevelopmental outcomes were reviewed. A total of nine patients were identified, of whom five were female and four male. The median follow-up duration was 7 years. All were Chinese and were homozygous for the Southeast Asian α-thalassaemia deletion. Five of the nine mothers received antenatal care at a public hospital and opted to continue the pregnancy after antenatal diagnosis and counselling. Despite intrauterine transfusions, all babies were born with respiratory depression and required intubation and mechanical ventilation during the neonatal period. Hypospadias was identified in all four male infants. Growth retardation, global developmental delay, and residual neurological deficits were noted in two-thirds of the patients. Haematopoietic stem-cell transplantation was performed in two patients, who became transfusion-independent. Survival of patients with Bart's hydrops fetalis syndrome is possible but not without short- and long-term complications; local epidemiology is comparable to that documented for an international registry. Detailed antenatal counselling of parents with a non-judgemental attitude and cautious optimism are imperative.

Intrauterine interventions with the aid of ultrasonography

Aim: The aim of this study was to research the applicability of the surgical treatment of intrauterine pathologies with the aid of ultrasonography by passing a laparoscopic grasper or scissor through a metal sheath placed in the cervical canal, and compare this method with hysteroscopy, which is considered the gold standard in diagnosis and treatment.Methods: Our study was conducted with 39 cases where intrauterine pathologies were found with transvaginal ultrasonography (TVUSG). The patients were evaluated for endometrial polyp, submucosal leiomyoma/fibroid and uterine malformations using a transvaginal probe in the 6th to 12th days of the menstrual cycle. Patients with endometrial polyps and submucosal leiomyomas/fibroids were excised with a laparoscopic 5 mm grasper. A laparoscopic plain dissection scissor (5 mm) was used instead of a grasper for the uterine septum. In patients undergoing polypectomy and myomectomy, the uterine cavity was reevaluated by TVUSG about one month later (in the follicular phase after the first menstruation). Patients who underwent resection of the septum after the second menstrual bleeding, intrauterine cavity and tubal were evaluated by hysterosalpingography.Results: Considering the presence of intrauterine pathologies, TUSVG has sensitivity of 1 (0.87- 1.0), specificity of 0.56 (0.21-0.86), positive predictive value of 0.87 (0.71-0.96), negative predictive value of 1 (0.48-1.0), accuracy of 0.89 and positive likelihood ratio of 2.25 (1.03-4.5) for the detection endometrial polyps. When endometrial polyps were found as the intrauterine pathology during TUSVG, the chance of having endometrial polyps in hysteroscopic diagnosis was found to be 2.25 times more compared to those with no pathology. According to hysteroscopic diagnosis, TUSVG has sensitivity of 0.90 (0.74-0.98), specificity of 0.56 (0.21-0.86), positive predictive value of 0.87 (0.71-0.96), negative predictive value of 0.63 (0.25-0.92), accuracy of 0.82 and positive likelihood ratio of 2.03 (0.95-4.2) for intrauterine pathology. When the intrauterine pathology was found during TVUSG, the chance of having these pathologies in hysteroscopic diagnosis was found to be 2.03 times more compared to those with no pathology.Conclusion: We think that the surgical treatment of intrauterine pathologies with the aid of ultrasonography can be an alternative for hysteroscopy.

NEOADJUVANT DIAGNOSIS AND MANAGEMENT OF CHRONIC ENDOMETRITIS

Aim. The purpose of this research was informational content assessment of the anamnestic data in diagnosing of chronic endometritis before its histologic confirmation and possibility of the timely beginning of complex therapy of pathology. Materials and methods. To achieve the aim of the retrospective analysis of 303 case reports of patients who underwent endometrium papel biopsy as a part of examination plan before assisted reproductive treatment in 2017. A particular interest, in our case, submitted the special anamnesis including consideration of menstrual, sexual and reproductive functions, past gynecologic diseases and interventions. Results. In the analysis of the received results the most constant signs of chronic endometritis: disorders of menstrual and seсretory functions; the high index of intrauterine interventions, considerable frequency of identification of endometrium polyps and the cervical channel (40,1%), pathological cervical neoplasia (30,8%) were noted. Conclusion. Thus, anamnestic data of patients with the verified endometritis, especially extended one, with inclusion of nonconventional, but relevant at the present stage additional signs, have shown high informational content for neoadjuvant diagnosis of pathology of endometrium of inflammatory character. Only against the background of timely initiated complex therapy, numerous endometrial receptivity parameters are restored, which leads to relief of clinical symptoms and lays the foundation for the successful implementation of reproductive function.

CLINICAL AND MORPHOLOGICAL FEATURES OF CHRONIC ENDOMETRITIS IN INFERTILE WOMEN

Morphofunctional state of the endometrium is one of the key factors determining both the successful implantation and full development of the embryo, including in cycles of «in vitro fertilization» (IVF). The most common cause of the impairment of the structure and function of the endometrium being chronic endometritis (CE), the frequency of its detection in infertile patients varies between 13 and 68%, reaching its maximum in women with tubal peritoneal factor and unsuccessful attempts of IVF in the anamnesis. The increasing prevalence and steady growth of the currently occurrence rate of CE cases in infertility is promoted by an increase in the role of intrauterine contraception and intrauterine interventions, including artificial abortions. On the other hand, happened in the last decades the evolution of the etiologic factor of CE towards the predominance of associations of facultative and obligate anaerobic microorganisms and viruses in the endometrium often leads to the development of erased, sluggish and atypical forms of the disease, which significantly hamper the diagnosis of CE and significantly reduce the effectiveness of traditional schemes of its treatment. CE is a clinically significant nosological form requiring the timely detection and treatment. The complex phased and pathogenetically substantiated therapy of CE in most cases leads to the restoration of the morphofunctional potential of the endometrium and, as a consequence, promotes the successful realization of the reproductive function.

Experience of intrauterine application of anti-adhesive gel based on hyaluronic acid in the prevention of Asherman's syndrome in patients with the pathology of the uterine cavity and severe forms of endometriosis

Introduction. One of the leading problems of modern reproductive surgery is treatment of adhesive disease, and in turn, prevention of intrauterine adhesions after intrauterine interventions is of particular interest.&#x0D; Purpose: to evaluate the effectiveness and safety of anti-adhesive gel “Antiadgesin” for intrauterine use in patients with a combination of pathology of the uterine cavity and severe forms of endometriosis.&#x0D; Materials and methods. The study included 24 patients aged 23 to 39 years with a combination of pathology of the uterine cavity and severe forms of genital endometriosis. The main group consisted of 12 patients to whom the anti-adhesive gel “Antiadhesin” was applied at the end of the laparoscopic and hysteroscopic stages on the region of the ovaries, pelvic peritoneum in the areas of separation of the adhesions, and also inside the uterine cavity. The comparison group included 12 patients who received 0.9% sodium chloride solution (5 ml) on the surgical area. Patients of both groups underwent treatment with gonadotropin-releasing hormone agonists (GnRH-a) 3.75 mg for 4 months after the operation. We performed gynecological ultrasound 4 weeks after operation, 4 weeks after the last injection of GnRH-a, and after the first menstrual bleeding. Assessment of the state of the uterine cavity, diagnosis of intrauterine synechia was performed by hydrosonography.&#x0D; Results. The duration of the operation, the amount of intraoperative blood loss did not differ significantly between the groups. In all patients, no complications of the postoperative period, no allergic or inflammatory reactions associated with the use of “Antiadhesin” were detected. The duration the uterine bleeding after the operation did not differ significantly between the groups. In 2 patients of the comparison group hydrosonography confirmed the adhesive pathology of the uterine cavity. In the main group there were not identified any signs of intrauterine adhesions by ultrasound. Within 12 months after the treatment, pregnancy occurred in 50% of the patients in the main group and in 33.3% of the patients in the comparison group.&#x0D; Conclusion. The results of the study showed that the introduction of the anti-adhesive gel “Antiadgesin” in the uterine cavity after hysteroresectoscopy is a safe and effective method for preventing the formation of intrauterine synechia.

P29.01: Maternal hemodynamic changes and complications following intrauterine interventions for monochorionic twin pregnancies

P29.01: Maternal hemodynamic changes and complications following intrauterine interventions for monochorionic twin pregnancies

Prenatal diagnosis and pregnancy outcomes in 42 fetuses with pleural effusion

Objective To investigate the value of prenatal diagnosis in identifying the etiology and predicting the prognosis of fetal pleural effusion (FPE). Methods Forty-two cases of FPE were recruited in this study from January 2012 to September 2016. Ultrasound scan and genetic tests were performed on all fetuses. Seven fetuses with severe FPE were given pleurocentesis. Pregnancy outcomes of all the fetuses were followed up. Results FPE was commonly accompanied with other abnormalities, such as ascites, hydrops, hydramnion, hygroma colli, abnormal posturing, joint contractures, arrhythmia and micromandible. Chromosomal abnormality was detected in 11 fetuses (26.2%), of which ten were further confirmed by karyotype analysis, including six with 45,X, three trisomy 21 and one trisomy 18, and one was detected with a 9.83 Mb uniparental disomy (UPD) located at 12q24.21q24.31 by gene chip. One fetus was diagnosed with --SEA/--SEA thalassemia. All of the 12 families decided to terminate the pregnancies after genetic counseling. Among the other 30 fetuses, seven with severe FPE and normal karyotype underwent pleurocentesis. Five of the seven cases were with favorable outcomes, one with progressive hydrops was aborted and one neonate with severe hydrops died after birth. Spontaneous regression of FPE with good outcome was found in two cases. Parents of the other 21 fetuses chose to terminate the pregnancies. Conclusions Prenatal diagnosis is important to identify the etiology and predict the outcome of FPE. Chromosomal abnormality is a relatively common cause of FPE, and 45,X and trisomy 21 are the most common abnormalities. Intrauterine intervention is beneficial for FPE without chromosomal or other definite genetic abnormalities. Genetic test may be of great value for pregnant counseling. Key words: Pleural effusion; Prenatal diagnosis; Pregnancy outcome

Cardiac Etiologies of Hydrops Fetalis.

Cardiac etiologies of hydrops fetalis have been a topic of concern due to challenging perinatal management. The common cardiac etiologies leading to hydrops fetalis include structural cardiac anomalies, cardiac dysrhythmias, cardiac tumors, cardiomyopathy and myocarditis. The mechanisms of cardiogenic hydrops fetalis may be: 1) elevation of atrial pressure and volume overload, 2) decrease of cardiac output, and 3) development of congestive heart failure. The diagnosis of hydrops fetalis was usually made at 19-36 gestational weeks, when ultrasound is a highly effective diagnostic method. Intrauterine interventions for certain congenital heart defects, maternal transplacental or direct fetal medications and fetal pacing placement for cardiac arrhythmias, and fetal or postnatal tumor resections are important progressions of etiologic treatment for hydrops fetalis. Treatment strategies for hydrops fetalis per se are usually ultrasound-guided pericardiocentesis and feto-amniotic shunting, whereas reaccumulation may require further interventions in utero or postnatally. Hydrops fetalis often carries a poor prognosis, and mortality remains high. Current developments in the management of hydrops fetalis should encourage physicians to attempt further fetal interventions.

Pathogenetic features of the macrotypes of chronic endometritis

Aim. To expand the understanding of the pathogenesis of chronic endometritis based on the study of reception and markers of cell proliferation/apoptosis in its various macrotypes depending on the nature of microbial colonization.Methods. We prospectively examined a group of 345 women with early reproductive losses (history of missed miscarriage, spontaneous abortion, artificial abortion, in vitro fertilisation failures during up to 6 months after intrauterine intervention), who had histologically verified chronic endometritis. A microbiological study of cervical discharge, aspirate from the uterus, identification of the pathogens with PCR, hysteroscopic and pathomorphological study of the endometrium (paypel biopsy) were performed. Identification of hysteroscopic hyperplastic, hypoplastic and mixed macrotypes was carried out on the basis of groups of features characterizing the thickness, color and the structure of the mucous membrane, intensity of vascular pattern in the presence of chronic inflammatory process. Immunohistochemistry of endometrium was performed to determine endometrial receptors for estrogen, progesterone («Dako», Denmark), proliferative activity of endometrial epithelial cells; the intensity of the expression of Ki-67 marker, that marks the cell nucleus at G1-, G2- and S-phase of the mitotic cycle, was taken into account. Apoptosis activity in endometrial biopsies was evaluated on the basis of expression of CPP32 proteins.Results. Structural and functional disintegration of the endometrium in chronic endometritis is presented as disorders of strictly determined submicroscopic features of the cellular elements of the glandular epithelium and stroma of the endometrium, however, each of the macrotypes has its own characteristic disturbances of homeostasis and homeokinesis of endometrial tissue.Conclusions. Further study of the markers of signaling pathways regulating proliferative cascades at the endometrial level matched with endometrial response to the invasion of a pathogen and morphological transformations will allow optimizing the diagnosis and treatment of chronic endometritis and restoration of reproductive potential after reproductive losses.