Vacuum Aspiration Research Articles

Rescue treatment with tPA for refractory thromboembolism during stent-assisted coiling of a ruptured intracranial aneurysm: A case report

Thromboembolic complications during stent-assisted coiling of ruptured intracranial aneurysms are major complications that can cause serious neurological deficits. Management strategies include medical thrombolysis, mechanical thrombectomy with suction aspiration or stent retrieval, and rescue stenting. The existing literature suggests that tissue plasminogen activator agents should be used cautiously because of the high risk of severe bleeding at the aneurysm. We present the case of a ruptured anterior communicating artery aneurysm. Acute in-stent thrombosis occurred during the stent-assisted coiling of the aneurysm. Rescue therapy with tirofiban, suction aspiration, and rescue stenting was attempted; however, these methods failed. Finally, tissue plasminogen activator infusion was performed, which successfully dissolved the thrombus and restored blood flow. Follow-up brain computed tomography revealed no increase in hemorrhage volume.

Hysteroscopic morcellation vs. curettage for removal of retained products of conception: a multicenter randomized controlled trial

To study the comparison between hysteroscopic morcellation (HM) of retained products of conception (RPOC) with ultrasound (US)-guided electric vacuum aspiration in terms of intrauterine adhesion (IUA) formation, efficacy, and complications. A randomized controlled, nonblinded trial. Three teaching hospitals and one university hospital from April 2015 to June 2022. A total of 133 women with RPOC on US, ranging from 1-4 cm, were randomized to receive either HM or electric vacuum aspiration. Hysteroscopic morcellation was performed with the TruClear System (Medtronic, Minneapolis, MN, USA). Electric vacuum aspiration was performed using an 8- or 10-mm flexible plastic Karman cannula under US guidance. Women allocated to vacuum aspiration underwent the procedure as soon as possible. In the HM group, an office diagnostic hysteroscopy was planned a minimum of 6 weeks after the end of pregnancy, followed by retained product of conception removal at least 8 weeks after the end of the pregnancy. Postoperatively, an office second-look hysteroscopy was scheduled to assess the primary outcome of IUAs. Postoperative IUAs were seen in 14.3% (9/63) of patients in the HM group and 20.6% (13/64) of patients in the vacuum aspiration group (-6% [-19.1% to 7.1%]). Significantly more RPOC were removed completely by HM compared with vacuum aspiration (95.2% vs. 82.5% (-14% [-24.9% to -3.1%]), and additional operative hysteroscopy was less frequently necessary in the HM group (12.5%) compared with the vacuum aspiration group (31.3%) (-20.1% [-34.3% to -6%]). The median operating time was shorter for vacuum aspiration compared with HM (5.80 minutes vs. 7.15 minutes). No differences were observed between HM and vacuum aspiration for the occurrence of intraoperative or postoperative complications (5.5% vs. 5.0% and 2.7% vs. 1.3%, respectively). In our randomized controlled trial, no significant differences were found in the occurrence of IUAs and complications. However, the RPOC were more often completely removed by HM than vacuum aspiration, and the HM group required fewer additional hysteroscopic treatments. NTR4923 (https://trialsearch.who.int/Trial2.aspx?TrialID=NTR4923). Date of registration: November 23, 2014, date of initial participant enrollment: January 1, 2015.

"I will never wish this pain to even my worst enemy": Lived experiences of pain associated with manual vacuum aspiration during post-abortion care in Kenya.

In Kenya, where abortion is legally restricted, most abortions are induced using unsafe procedures, and lead to complications treated in public health facilities. The introduction of Manual Vacuum Aspiration (MVA) to treat incomplete abortion has improved the management of abortion complications. However, this technology comes with pain whose management has been a challenge. This paper explores the lived experiences of pain (management) during MVA to document the contributing factors. We used an ethnographic approach to explore girls and healthcare providers' experiences in offering and accessing post-abortion care in Kilifi County, Kenya. The data collection approach included participant observation and informal conversations in public health facilities and neighboring communities, as well as in-depth interviews with 21 girls and young women treated for abortion complication and 12 healthcare providers. Our findings show that almost all patients described the MVA as the most painful procedure they have ever experienced. The unbearable pain was explained by various factors, including the lack of preparedness of health facilities to offer PAC services (i.e. lack of pain medicine, lack of training, inadequate knowledge and grasp of pain medication guidelines, and malfunctioning MVA kits). Moreover, the attitudes of healthcare providers and facilities management toward the MVA device limited the supply and replacement of MVA kits. Moreover, the scarcity of pain medicines also gave some providers the opportunity to abuse patients guided by their values, whereby they would deny patients pain medication as a form of "punishment" if they were suspected of inducing their abortion, especially adolescent girls. The study findings suggest the need for clearer guidelines on pain medication, value clarification and attitude transformation training for providers, systematizing the use of medical uterine evacuation using medical abortion drug and strengthening the supply chain of pain medication and MVA kits to reduce the pain and improve the quality of post-abortion care.

MANUAL VACUUM ASPIRATOR (MVA)- A SAFE AND EFFECTIVE ALTERNATIVE TO CONVENTIONAL CURETTAGE IN THE SURGICAL MANAGEMENT OF 1ST TRIMESTER MISCARRIAGES

Objective: To compare the efficacy of manual vacuum aspiration and conventional evacuation & curettage (ENC) for first-trimester miscarriage management. Materials and Methods: This quasi-experimental study was carried out at the Department of Gynecology and Obstetrics, Khyber Teaching Hospital, Peshawar, Pakistan from October 2022 to March 2023 including 150 patients with first trimester miscarriage dividing them into two groups (MVA and ENC) having equal number of patients. Efficacy in both groups was compared. Results: The mean age in the MVA group (group A) was 27.81±6.31years while in the ENC group (group B) it was 26.50±6.27 years. The mean gestational age in group A was 5.82±2.82 weeks while in group B it was 5.95±2.9 weeks. MVA was effective in 88% of participants while ENC was effective in 93.33% of participants (p-value, 261), which is not statistically significant. Conclusion: Surgical uterine evacuation utilizing MVA under local anesthetic is safe and successful, and it should be considered to minimize a lengthy hospital stay. MVA can be a viable alternative to surgical curettage like ENC. It is safe, cost-effective, and simple to conduct, eliminating general anesthetic, the requirement for theatre access, and an unnecessary hospital stay. Keywords: Manual Vacuum Aspiration, Evacuation, Curettage, miscarriage, efficacy.

Clinical efficacy and risk factors for suction curettage and hysteroscopy in patients with type I and II cesarean scar pregnancy.

To investigate the clinical efficacy and evaluate risk factors for suction curettage (SC) and hysteroscopy in the treatment of type I and II cesarean scar pregnancy (CSP). This was a retrospective study including 100 women diagnosed with type I/II CSP. Patients were treated with either ultrasound-guided SC (SC group) or hysteroscopy resection (surgery group). The success rates, mean operation time, hospitalization duration, hospitalization cost, risk factors, adverse events, and complications were analyzed. The success rate of the SC and surgery groups were 85% and 100%, respectively, and the difference was statistically significant (P = 0.032). There was one case of type I CSP and eight cases of type II CSP that failed SC treatment. No failed cases were found in the surgery group. Analysis of the causes of treatment failure revealed that diameter of the gestational sac was a risk factor for SC failure (odds ratio, 19.66 [95% confidence interval {CI}, 1.70-227.72], P = 0.017). Comparing the clinical outcomes between the SC and surgery groups, although the mean operation time of the SC group was significantly shorter than the surgery group (15 [CI, 15-20] vs. 30 [CI, 27-40], P = 0.001), the cost and duration of hospitalization were significantly lower in the surgery group than that in the SC group. No significant differences were observed for adverse events and complications between the two groups (P > 0.05). Hysteroscopy is an effective and economical method for treating type I/II CSP. Moreover, SC is not recommended for patients with type I/II CSP with a gestation age ≥8 weeks.

Correlation between Manual Vacuum Aspiration and Endometrial Cell Sampler in Abnormal Uterine Bleeding

Objective: Office endometrial biopsy using an endometrial cell sampler is an accepted method of obtaining endometrial tissue for histopathologic evaluation in women with abnormal uterine bleeding (AUB). Manual vacuum aspiration (MVA) is considered an alternative method, but data specific to the use of MVA is limited. This study aimed to evaluate the efficacy of MVA compared to endometrial cell sampler for diagnosing causes of AUB. Materials and Methods: This prospective study enrolled women aged ≥35 years who presented with AUB during August 2015 to June 2016. For each patient, endometrial biopsy using an endometrial cell sampler was first performed followed by MVA. Correlation of endometrial histopathology between methods were analyzed using Kappa statistic. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated. Results: Of the 162 patients enrolled, the data from 151 women were analyzed. Correspondence of histopathologic finding between tissue obtained from endometrial cell sampler and MVA was 72.8% (Kappa: 0.51). Correspondence of histopathologic finding between tissue obtained from MVA and the final most severe pathology used for treatment decision was 84.1% (Kappa: 0.72). MVA diagnosed all cases of malignancy, but endometrial cell sampler missed one case of malignancy. The overall sensitivity, specificity, PPV, and NPV of MVA was 84.5%, 100%, 100%, and 91.2%, respectively. Conclusion: The histopathologic findings of MVA were in good agreement with those of endometrial cell sampler, and MVA had high accuracy for diagnosing endometrial pathology. MVA is suggested as a reliable alternative procedure for endometrial biopsy in women with AUB.

Imaging in gynecological disease (25): clinical and ultrasound characteristics of intramural pregnancy.

To describe the clinical and sonographic characteristics of intramural pregnancy, as well as the available management options and treatment outcomes. This was a retrospective single-center study of consecutive patients with a sonographic diagnosis of intramural pregnancy between November 2008 and November 2022. An intramural pregnancy was diagnosed on ultrasound when a pregnancy was implanted within the uterine corpus, above the level of the internal cervical os and separate from the interstitial section of the Fallopian tube, and extended beyond the decidual-myometrial junction. Clinical, ultrasound, relevant surgical and histological information and outcomes were retrieved from each patient's record and analyzed. Eighteen patients were diagnosed with an intramural pregnancy during the study period. Their median age was 35 (range, 28-43) years and the median gestational age at diagnosis was 8 + 1 (range, 5 + 5 to 12 + 0) weeks. Vaginal bleeding with or without abdominal pain was the most common presenting symptom, recorded in eight patients. Nine (50%) patients had a partial and nine (50%) had a complete intramural pregnancy. Embryonic cardiac activity was present in eight (44%) pregnancies. The majority of pregnancies (n = 10 (56%)) were initially managed conservatively, including expectant management in eight (44%) cases, local injection of methotrexate in one (6%) and embryocide in one (6%). Conservative management was successful in nine of the 10 (90%) pregnancies, with a median time to serum human chorionic gonadotropin resolution of 71 (range, 35-143) days. One patient with an ongoing live pregnancy had an emergency hysterectomy for a major vaginal bleed at 20 weeks' gestation. No other patient managed conservatively experienced any significant complication. The remaining eight (44%) patients had primary surgical treatment, comprising transcervical suction curettage in seven (88%) of these cases, while one patient presented with uterine rupture and underwent emergency laparoscopy and repair. We describe the ultrasound features of partial and complete intramural pregnancy, demonstrating key diagnostic features. Our series suggests that, when intramural pregnancy is diagnosed before 12 weeks' gestation, it can be managed either conservatively or by surgery, with preservation of reproductive function in most women. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Conservative surgical management of a heterotopic scar pregnancy: A case report

Introduction: The cesarean scar pregnancy is on rise and the objective of this case study is to highlight a different, bold but conservative approach to an unusual challenging case of eight weeks heterotopic cesarean scar pregnancy, which was threatening to rupture. Case Report: A 31-year-old G3P2L1 previous two cesarean sections presented with lower abdominal pain and bleeding. She was hemodynamically stable, and ultrasonography (USG) and magnetic resonance imaging (MRI) revealed heterotopic pregnancy, eight weeks (gestational sacs > 32 mm) intrauterine and caesarean scar pregnancy, which was threatening to rupture. Since the scar pregnancy was large, BHcG was > 200,000 iu, there was evidence of imminent scar dehiscence; and she was stable and had good blood parameters. The authors decided to take cautious but bold decision of suction evacuation under USG guidance, following the uterine artery embolism. The procedure was smooth and lower segment scar sacculus bleeding was controlled by compression with help of Foley’s balloons inside uterine cavity as well as in bladder. There was no evidence of extrauterine bleeding. She made a good post-operative recovery. Follow-ups consisted of serial BHcG and USG to monitor the regress. Conclusion: This case study implies that cesarean scar pregnancy, even with imminent scar dehiscence can be managed by USG-guided suction evacuation by experienced hands. Prior uterine artery embolization (UAE) added the safety of bleeding control. This case also emphasizes the importance of a patient monitoring and relying on failing BHcG, and a symptom free patient; and not on mass in CS scar alone which was slow to resolve.

Effectiveness of Self-Managed Medication Abortion Between 9 and 16 Weeks of Gestation.

To evaluate abortion completion after self-managed medication abortion in pregnancies at or beyond 9 weeks of gestation. We conducted a prospective observational cohort study in which we recruited callers to three abortion-accompaniment groups in Argentina, Nigeria, and Southeast Asia who were initiating a self-managed medication abortion. Participants completed a baseline survey over the phone before taking pills and then two follow-up phone surveys 1 and 3 weeks after taking pills. The primary outcome was abortion completion; secondary outcomes included physical experiences and health care seeking and treatment. Between 2019 and 2020, we enrolled 1,352 participants, 19.5% (264/1,352) of whom self-managed a medication abortion at 9 or more weeks of gestation: 75.0% (198/264) at 9-11 weeks, 19.3% (51/264) at 12-14 weeks, and 5.7% (15/264) at 15-22 weeks. Participants were aged 26 years on average (SD 5.6 years); 56.4% (149/264) used the combined regimen (mifepristone+misoprostol), and 43.6% (115/264) used misoprostol only. At the last follow-up, 89.4% (236/264) had a complete abortion without procedural intervention, 5.3% (14/264) had a complete abortion with manual vacuum aspiration or dilation and curettage procedure, 4.9% (13/264) had an incomplete abortion, and 0.4% (1/264) participants did not report an abortion outcome. Some participants (23.5%, 62/264) sought health care during or after the self-managed medication abortion, most commonly to confirm completion (15.9%, 42/264); 9.1% (24/264) needed further medical intervention (procedural evacuation, antibiotics, additional misoprostol, intravenous fluids, blood transfusion, or overnight stay in the facility). Those who were 12 or more weeks pregnant were more likely to seek care at a clinic or hospital than those who were 9-11 weeks pregnant (adjusted relative risk 1.62, 95% CI 1.3-2.1). People who self-managed an abortion with medication between 9 and 16 weeks of gestation had high levels of abortion completion and accessed health care to confirm completion or to treat potential complications. ISRCTN, ISRCTN95769543.

Features of therapeutic tactics for the failure of gastrointestinal anastomosis in patients with morbid obesity after Roux-en-Y gastric bypass

Background: Roux-en-Y gastric bypass is the main type of bariatric surgery. The most formidable and severe complication in morbid obesity patients after gastric bypass is gastrojejunostomy leak. Aim: to study the possibilities of improving treatment outcomes of obese patients during gastrojejunostomy leak after gastric bypass surgery using new minimally invasive methods. Methods: This retrospective cohort descriptive study included all patients with gastrojejunostomy leak after gastric bypass treated in the Department of Surgery of the Federal State Budgetary Institution Federal Scientific and Practical Center of the Federal Medical and Biological Agency of Russia in 20192022. In total, 445 gastric bypasses were performed during this period, and seven patients (1.6%) developed HEA failure in the postoperative period. Results: The results of treatment of gastroenteroanastomotic leaks during gastric bypass in patients with morbid obesity are presented. The early diagnosis of gastroenteroanastomosis failure in this category of patients was difficult. All doubts in the diagnosis of anastomotic failure should be completed by revision laparoscopy with intraoperative esophagogastroscopy. Minimally invasive techniques (surgical, endoscopic), drug therapy, and adequate nutritional support are crucial for managing patients with anastomotic leaks. Conclusion: The use of an endoscopic intraluminal vacuum aspiration system in the treatment of gastroenteroanastomotic insufficiency avoids the spread of inflammation in the abdominal cavity, accelerates the reparative process in the area of insufficiency, and, in most cases, avoids programmed sanitation, significantly improving the treatment results.

Antibiotic Recommendations After Postpartum Uterine Exploration or Instrumentation.

Multiple postpartum scenarios require uterine exploration or instrumentation. These may introduce bacteria into the uterus, increasing the risk of endometritis. Data on the use of antibiotics in these scenarios is limited, resulting in few guidelines and divergent care. To describe postpartum scenarios requiring uterine exploration and/or instrumentation, review data on antibiotic prophylaxis, and delineate antibiotic recommendations for each scenario. Original articles were obtained from literature search in PubMed, MEDLINE, and OVID; pertinent articles were reviewed. These recommendations are based on published evidence and professional society guidelines. Antibiotic prophylaxis following manual placenta removal should include 1-time combination of ampicillin 2 g intravenously (IV) or cefazolin 1 g IV, plus metronidazole 500 mg IV. Antibiotic prophylaxis before postpartum dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade should include 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. If the patient in any of the above scenarios has received group B Streptococcus prophylaxis, then only metronidazole is recommended. Further randomized clinical trials are needed to optimize these regimens. Uterine exploration or instrumentation increases the risk of postpartum endometritis and requires antibiotic prophylaxis. For manual placenta removal, we recommend 1-time combination of ampicillin 2 g IV or cefazolin 1 g IV, plus metronidazole 500 mg IV. For dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade, we recommend 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. For patients who already received antibiotic prophylaxis for group B Streptococcus, we recommend 1-time dose of metronidazole 500 mg IV. Providers can utilize our guidelines to prevent postpartum endometritis in these scenarios requiring postpartum uterine exploration and/or instrumentation.

Surgical evacuation of cesarean scar ectopic pregnancies.

Cesarean scar ectopic pregnancy is associated with significant maternal morbidity, including severe hemorrhage, need for the blood transfusion and hysterectomy. Early diagnosis is therefore key in ensuring timely management, with consensus being that treatment before 9 weeks of gestation leads to reduced morbidity. There is no universally adopted management protocol for cesarean scar ectopic pregnancy, but surgical management generally has a higher success rate than medical management. The primary surgical treatment modalities are suction evacuation versus resection of the pregnancy via multiple routes. Adjuncts that have been shown to successfully minimize bleeding with surgical management include cervical cerclage, balloon catheter, and uterine artery embolization. However, there remains a lack of high-quality evidence regarding what is the best surgical treatment option for cesarean scar ectopic pregnancy, and therefore it is essential that clinicians provide tailored management to patients considering the presenting symptoms and local expertise with various surgical techniques.

A Comparative Study of Improvised Manual Vacuum Aspiration Versus Pipeline Sampling for Endometrial Sampling

Objective: To compare the safety and efficacy of Improvised S2Q manual vacuum aspiration and Pipelle sampling as a diagnostic procedure for the evaluation of women presenting with abnormal uterine bleeding.
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Department of Obstetrics and Gynecology, Combined Military Hospital, Lahore Pakistan, from Oct 2021 to Aug 2022.
 Methodology: A total of 148 females over 35 years of age with abnormal uterine bleeding, who needed endometrial sampling, were divided into two groups of 74 participants each. Group-A underwent endometrial sampling by Improvised S2Q manual vacuum aspiration, while Group-B underwent endometrial sampling by Pipelle sampler.
 Results: Mean age of patients was 47.36±8.34 years in Group-A and 48.20±8.96 years in Group-B, while the mean BMI was 30.59±4.67 kg/m2 and 27.39±2.50 kg/m2 in Groups A and B, respectively. The volume of specimen obtained was found to be higher in the Improvised S2Q manual vacuum aspiration-Group as compared to the pipeline sampling-Group. The operating time in the Improvised S2Q manual vacuum aspiration-Group was 3.37±0.49 minutes, while in the pipeline sampling-Group, it was 3.20±0.55 minutes. No difference was found in the two procedures for side effects (tachycardia, pain/cramps) and complications (significant blood loss, perforation, infection), added analgesia or histopathology report.
 Conclusion: Improvised S2Q manual vacuum aspiration can be used as an alternative low-cost procedure for endometrial sampling in women with abnormal uterine bleeding.Keywords: Biopsy, Curettage, Endometrium, Manual vacuum aspiration, Pipeline sampling.

P-625 Artificial intelligence-enabled analysis of endometrial CD138 positive plasma cells in infertility-associated conditions; Polycystic ovary syndrome (PCOS) and recurrent implantation failure (RIF)

Abstract Study question Can artificial intelligence (AI) algorithm identify CD138+ cells in the endometrial stroma, and is the expression altered in PCOS and RIF? Summary answer CD138+ cell detection by AI shows high accuracy. The cell count in controls was comparable to that in PCOS cases but differed in RIF patients. What is known already Immunohistochemical (IHC) staining for CD138+ plasma cells has been applied to detect endometrial inflammation; however, due to a lack of cost-effective and reliable tools, there is no golden standard for CD138+ analysis. PCOS is a common endocrine disorder characterized by irregular menstrual cycles and hyperandrogenism. The women are also affected by systemic low-grade inflammation, and the PCOS endometrium shows dysregulated immune profile. RIF is one of the main causes of a low IVF success rate, and chronic endometrial inflammation has been detected in women with RIF. To date, AI technology has been applied in the diagnostics of various clinical conditions. Study design, size, duration In this study, AI analysis was done for CD138+ cells in a total of 193 endometrial biopsy samples: 73 were obtained from healthy and fertile controls, 91 from women with PCOS (ovulatory samples; n = 78, anovulatory samples; n = 13, Rotterdam criteria), and 29 samples from RIF patients on day five after the initiation of P4 administration. Participants/materials, setting, methods The biopsy samples were collected by suction curette (Pipelle), and endometrial receptivity was assessed by gene expression profiling (beREADY test). The tissues were stained with CD138 antibody, and the AI algorithm, AITAH, was trained with 150 whole slide images (WSIs) to segment epithelium and stroma and segregate CD138- and CD138+ cells in the stroma. AITAH was validated by three external pathologists. The cell counts were compared according to cycle phases, ovulatory status, and endometrial receptivity. Main results and the role of chance The performance of AITHA was excellent, as the final training error for CD138+ cells was 3.23%, and the decisions for the cells between pathologists and AITAH were in complete agreement. The CD138+ cell percentages were higher in the proliferative phase (PE) endometrial tissue than in the ones obtained in the secretory phase (PCOS, p <0.001 or control, p <0.001), regardless of PCOS diagnosis. Similar CD138+ cell percentages were observed between PE endometrium and anovulatory endometrium in PCOS cases (p <0.001). The count of CD138+ plasma cells was negatively correlated with the endometrial thickness (PCOS, p =0.001 or control, p =0.009) and P4 (PCOS, p =0.001 or control, p =0.003), and positive correlations between the cell counts and gonadotropin levels were observed in ovulatory PCOS samples (FSH, p =0.001 and LH, p =0.031). More CD138+ cells were seen in RIF patients compared to the controls at the receptive stage (p = 0.046); however, there was no difference between RIF samples of three different receptivity statuses (p =0.426). Limitations, reasons for caution Further validation for AITAH using confirmed chronic endometritis cases as positive controls is required. And further analysis using control samples obtained during the hormone replacement treatment is required. The small number of anovulatory PCOS subjects may explain the absence of correlations between the CD138+ plasma cell counts and clinical characteristics. Wider implications of the findings AI-enabled analysis tools could improve histological examination of endometrial immune cells by analyzing high amounts of whole tissue slides within a short time with a high pixel resolution, thus overcoming many current impediments in manual microscopic evaluation. Trial registration number NA

Urine transfer devices may impact urinary particle results: a pre-analytical study.

Well-standardized procedures in the pre-analytical phase of urine diagnostics is of utmost importance to obtain reliable results. We investigated the effect of different urine collection methods and the associated urine transfer tubes on urine test strip and particle results. In total, 146 selected urine samples were subdivided into three different collection containers and subsequently transferred into its accompanying transfer tube (BD, Greiner, Sarstedt vacuum and Sarstedt aspiration). As reference, the original urine sample was directly measured on the analyser. Both chemical test strip analysis (Sysmex UC-3500) and fluorescence flow cytometry particle analysis (Sysmex UF-5000) were performed on all samples. No statistically significant differences in test strip results were found between the studied transfer methods. On the contrary, transfer of urine samples to the secondary tubes affected their particle counts. Clinically significant reductions in counts of renal tubular epithelial cells and hyaline casts were observed using the BD and Greiner transfer tubes and in counts of pathological casts using the BD, Greiner and Sarstedt vacuum tubes. The results of this study indicate that the use of urine transfer tubes may impact counts of fragile urine particles. Clinical laboratories need to be aware about the variation that urine collection methods can induce on urine particle counts.

Examining reuse and replacement procedures for Ipas manual vacuum aspiration and cannulae in nine countries.

To determine how many times Ipas manual vacuum aspiration (MVA) instruments are reused, for what reasons, when the instruments are replaced and/or discarded, and what the barriers are to replacing them. We conducted a mixed-methods cross-sectional study of health care providers who provide MVA services and key stakeholders in the supply chain to understand reuse and replacement of Ipas MVA aspirators and cannulae. Qualitative interviews focused on procurement and replacement of Ipas MVA instruments. The authors interviewed 352 health care providers from nine countries from 2019 to 2021. Providers reported reusing MVA instruments an average of 34.4 times (standard deviation, 45). The reuse averages ranged from one time (Democratic Republic of the Congo) to 500 times (India), with figures varying between providers within the same country. Instrument malfunctioning rather than a specific number of uses drove reuse and subsequent replacement. The decision to replace was most commonly made by the provider during use. Half of the providers said that they knew of no issues with the supply chain, and 85% said they were always able to replace Ipas MVA instruments when needed. Tracking reuse of MVA instruments was uncommon at participating providers' health facilities. Providers' estimates revealed great variability in reuse frequency and tracking procedures.

A Rare Case of Placental Site Trophoblastic Tumor

Placental site trophoblastic tumor (PSTT) is a rare entity of malignant gestational trophoblastic neoplasia (GTN) with an incidence of 0.23 to 3% of all gestational trophoblastic diseases (GTD). They originate from intermediate trophoblastic cells of the placenta. They are slow-growing tumors and less chemo sensitive. Per vaginal bleeding following a miscarriage is not uncommon, however malignant variants of gestational trophoblastic neoplasia also could be a possibility. We are reporting a 24-year-old who was an otherwise healthy female who presented with persistent per vaginal bleeding following the first-trimester miscarriage in her second pregnancy. Initial histology of suction evacuation for her miscarriage has shown a partial mole. Since she continues to have per vaginal bleeding even a month later, repeat evacuation was done and beta hCG was high (2132mIU/ml), she was treated with a methotrexate regime. During follow up there was a slow rising of beta hCG level and hysterectomy was carried out due to the suspicions of invasive mole or PSTT. Histology confirmed a placental site trophoblastic tumor and her recovery and follow-up were uneventful.

Transcatheter vacuum aspiration of valvular and lead related infective endocarditis

BackgroundTranscatheter aspiration is utilized for removal of thrombi and vegetations in inoperable patients and high-risk surgical candidates where medical therapy alone is unlikely to achieve desired outcome. A number of case reports and series have been published since the introduction of AngioVac system (AngioDynamics Inc., Latham, NY) in 2012 where this technology was used in the treatment of endocarditis. However, there is a lack of consolidated data reporting on patient selection, safety and outcomes. MethodsPubMed and Google Scholar databases were queried for publications reporting cases where transcatheter aspiration was used for endocarditis vegetation debulking or removal. Data on patient characteristics, outcomes and complications from select reports were extracted and systematically reviewed. ResultsData from 11 publications with 232 patients were included in the final analyses. Of these, 124 had lead vegetation aspiration, 105 had valvular vegetation aspiration, and 3 had both lead as well as valvular vegetation aspiration. Among the 105 valvular endocarditis cases, 102 (97 %) patients had right sided vegetation removal. Patients with valvular endocarditis were younger (mean age 35 years) vs. patients with lead vegetations (mean age 66 years). Among the valvular endocarditis cases, there was a 50–85 % reduction in vegetation size, 14 % had worsening valvular regurgitation, 8 % had persistent bacteremia and 37 % required blood transfusion. Surgical valve repair or replacement was subsequently performed in 3 % and in-hospital mortality was 11 %. Among patients with lead infection, procedural success rate was reported at 86 %, 2 % had vascular complications and in-hospital mortality was 6 %. Persistent bacteremia, renal failure requiring hemodialysis, and clinically significant pulmonary embolism occurred in about 1 % each. ConclusionsTranscatheter aspiration of vegetations in infective endocarditis has acceptable success rates in vegetation debulking as well as rates of morbidity or mortality. Large prospective multi-center studies are warranted to determine predictors of complications, thus helping identify suitable patients.

Cesarean scar pregnancy: a practical overview and our series of combined double step procedure management.

Cesarean scar pregnancy (CSP), a rare iatrogenic form of ectopic pregnancy (EP), cause of severe maternal morbidity. Each subtype of CSP needs different treatment and there is no consensus about this topic. Despite improvements, the lack of universally accepted therapeutic management and discordance present in literature indicates that treatment has been mainly based on experiences reported. A case series of our double combined approach with methotrexate (MTX) administration followed by vacuum aspiration or resectoscopic approach was reported, with an overview of literature. Eleven patients with CSP underwent a double-step treatment: systemic MTX therapy followed by vacuum aspiration or by resectoscopy, if the gestational sac was embedded deeply in myometrium. For CSP type 1, according to Delphi sonographic classification, with minor potentially risk of complications with a myometrial thickness >3.5 mm, we preferred to adopt vacuum aspiration, while type 2-3 of CSP and myometrial thickness ≤3.5mm were managed with resectoscopy. The average gestational age was 59.1±7.22 days. On the seventh day after MTX administration, the serum β hCG levels decreased in 80% of all patients. After the MTX injection, the CSP mass did not disappear in any patient. MTX therapy was followed by vacuum aspiration in six and by resectoscopy in five cases. In one case bleeding was controlled by Foley balloon treated with vacuum. In type II-III, CSP was performed UAE (uterine artery embolization) followed by resectoscopy procedure. Compared with the results in previous studies, MTX administration followed by suction curettage was more effective than dilatation and curettage and systemic MTX in treatment of CSP. We consider very useful this procedure in case of slow absorption and when the camera was embedded deeply in myometrium (CSP2-3), because that hysteroscopy evaluation of uterine cavity under direct vision is highly accurate in identifying the real cleavage of the gestational camera. We have only used vacuum aspiration in CSP type 1 for minor risk of bleeding.

EE410 The Insurance Payer Perspective on Management Options for Early Pregnancy Loss in the United States

Vacuum aspiration is the current standard for surgical management of early pregnancy loss (EPL). Traditionally performed in a hospital, no reductions in efficacy and safety have been reported for lower-acuity settings. We analyzed how shifting the site of service for surgical management of EPL might impact payer budgets.