Uterine Perforation Research Articles

A Framework Approach for Hysteroscopic Uterine Septum Incision: Partial and Complete

<h3>Study Objective</h3> To demonstrate safe and efficient techniques for hysteroscopic partial and complete uterine septum incision with electrocautery. <h3>Design</h3> Video instruction of hysteroscopic uterine septum incision techniques. <h3>Setting</h3> Academic hospital setting. <h3>Patients or Participants</h3> One patient with a partial uterine septum and one patient with a complete uterine septum. <h3>Interventions</h3> Hysteroscopic partial and complete uterine septum incision with the monopolar knife. <h3>Measurements and Main Results</h3> Surgical techniques that can be used to safely and efficiently incise a uterine septum and to determine when the incision is complete. For a partial uterine septum, these techniques include 1) alignment of the tubal ostia to maintain a horizontal incision plane, 2) uterine septum shortening, 3) uterine septum thinning, and 4) measurement of the residual septum length with the operating instrument to determine when the incision is complete. For a complete uterine septum, we additionally demonstrate how to make a window through the septum at the level of the internal os to incise the uterine portion while preserving the cervical portion inferiorly. <h3>Conclusion</h3> Uterine septum incision is typically a short procedure that can be successfully performed with operative hysteroscopy. However, if a systematic approach is not followed, the surgeon can quickly and unknowingly become disoriented which can lead to inadvertent uterine perforation, incomplete septum incision, or excessive septum incision causing myometrial thinning which has been shown to increase the risk of uterine rupture during pregnancy. The use of the techniques presented in this video help to maintain intra-operative orientation and provide a framework to guide adequate removal of the septum without causing injury to the myometrium. Review of these techniques may be particularly helpful for a surgical trainee or a less experienced hysteroscopic surgeon.

Hysteroscopic Approach to a Morbidly Adherent Placenta in the Postpartum Period

<h3>Study Objective</h3> Morbidly adherent placenta (MAP) is associated with major maternal morbidity and mortality with risk factors most frequently related to previous uterine surgery. In rare occasions, retained products of conception (RPOC) could complicate low risk births or first trimester termination of pregnancy, resulting in abnormal bleeding patterns or infectious morbidity. We present a case of unsuspected focal (MAP) that was diagnosed two months after a cesarean delivery. Uterine Sparing treatment was accomplished by a 2-stage hysteroscopic resection without complications. <h3>Design</h3> Case Report Video. <h3>Setting</h3> Surgical Suite. <h3>Patients or Participants</h3> A 35-year-old G1 P0 woman had a cesarean delivery at 37 weeks and 4 days due to persistent fetal breech presentation and premature rupture of the membranes. The cesarean delivery was complicated by estimated blood loss of 1019mL with no mention of any precipitating factors. The patient presented with history of prolonged vaginal spotting while on Depot Provera. Office hysteroscopy and Pelvic MRI were utilized for diagnosis and evaluation. Uterine Sparing treatment was accomplished by a 2-stage hysteroscopic resection without complications. <h3>Interventions</h3> 2-stage hysteroscopic resection was performed. The first stage was approached by a mechanical morcellation device that resolved the main bulk of the RPOC. The second stage was approached with a Resectoscopic approach to the deep myometrial nodule that persisted on follow up imaging after the index procedure. <h3>Measurements and Main Results</h3> Complete resection of the RPOC and deep myometrial nodule was accomplished without complication. <h3>Conclusion</h3> Retained products of conception should be considered in the differential diagnosis of patients who present with abnormal uterine bleeding after birth. Treatment can be accomplished with hysteroscopic resection. Resectoscopic approach is more challenging and has a higher risk of uterine perforation yet has the ability to reach the deep-seated lesions. Provider's understanding of the limitations of each method and appropriate referral to an expert surgeon is key for optimal results.

586 Peri-Pancreatic Migration of Lost Intra Uterine Device: Case Report and Review of Literature

Abstract Intra uterine devices (IUDs) is one of the most effective form of contraception available today. Uterine perforation and IUD migration is a rare but serious complication and is reported to occur in 0.05 to 13 cases out of 1000 IUCD placements. Migration of IUD to pelvis and lower abdominal organs following uterine perforation has been reported widely in literature. However far migration into the upper abdomen in very rare. Here we report a case asymptomatic peri-pancreatic migration of IUD. A 65-year-old lady being investigated for pneumonia was picked up to have an asymptomatic IUD lying in front of the pancreas. The patient recalled having a hormonal Mirena coil placed 12 years previously for menopausal symptoms. Routine 3-year general practitioner follow-up failed to detect the IUD on vaginal examination. The patient denied spontaneous IUD discharge. However, three subsequent pelvic ultrasound scans did not detect any retained IUD and she was discharged as unrecognized IUD expulsion. She remained asymptomatic for the next 12 years with no abdominal symptoms though she did report to the General Practitioner, multiple episodes of new onset hot flushes when opening bowels - which was managed conservatively with reassurance. It was decided to surgically remove the IUD. Intraoperatively, the IUD was found densely adherent to the lesser omentum close to the pancreas and stomach and was removed safely laparoscopically. The patient made a good postoperative overnight recovery and was discharged. Intra-abdominal migration of IUDs is a very rare complication of IUD insertion and when detected should be promptly treated with Laparoscopic removal.

Survey on spontaneous miscarriage and induced abortion surgery safety at less than 12 weeks of gestation in Japan.

In Japan, dilatation and curettage (D&C) is a common procedure for spontaneous miscarriage and induced abortion, and its safety has long been an issue. Electric vacuum aspiration (EVA) is also common, but manual vacuum aspiration (MVA) was introduced recently, with medical abortions using mifepristone or misoprostol which are not yet legally accepted. This nationwide retrospective study surveyed the surgical methods and complications associated with spontaneous miscarriage and induced abortion at less than 12 weeks of gestation in Japan to assess their safety, in comparison with a similar survey for induced abortions in 2012. Questionnaires were sent to 4176 facilities with a license for induced abortion surgeries in 2019. The questions included were the methods used, number of spontaneous miscarriages and induced abortions, and number of complications (uterine perforation, incomplete abortion, and gross bleeding requiring blood transfusion). Responses were received from 1706 facilities (40.9%). Although EVA with sharp curettage was the most common surgical method, which was used for 11 953 spontaneous miscarriages (28.9%) and 24 045 induced abortions (37.3%), the most common surgical method per facility was D&C, and the rates of D&C for spontaneous miscarriages (38.4%) and induced abortions (44.7%) performed in general hospitals were significantly higher than those in clinics (24.1% and 22.0%, respectively). There was no significant difference in the complication incidence rate among surgical methods for spontaneous miscarriages. However, in induced abortion surgery, the total complication and incomplete abortion incidence rates for D&C were significantly higher than those for EVA without sharp curettage (47/15 162 [0.31%] vs. 29/18 693 [0.16%], p=0.00362, 45/15 162 [0.30%] vs. 27/18 693 [0.14%], p= 0.00285, respectively). There was no significant difference in the complication incidence rate between MVA and other surgical methods for each abortion surgery. In Japan, especially in general hospitals, D&C is still widely used for miscarriage and induced abortion surgery. Its complication-incidence rates significantly decreased compared with that of the nationwide survey in 2012, but were still significantly higher than EVA without sharp curettage. Few facilities used MVA, but its complication rate was comparable with those of other surgical methods.

Complications after interval postpartum intrauterine device insertion

BACKGROUND:In the United States, up to 57% of women report resumption of sexual activity by the 6 week postpartum visit. Effective contraception should be addressed and provided at that time, to avoid unintended pregnancies and optimize interpregnancy intervals. Long-acting reversible contraceptives are the most effective forms of reversible contraception and are increasingly popular during the postpartum period. However, timing of postpartum intrauterine device (IUD) placement varies among providers and many delay insertion due to concerns for uterine perforation or expulsion of the IUD.OBJECTIVE:This study aimed to evaluate uterine perforation and expulsion rates with IUD insertion at 4–8 weeks postpartum vs 9–36 weeks postpartum.STUDY DESIGN:We performed a retrospective cohort study using the Kaiser Permanente Southern California electronic medical record from 2010 to 2016. We calculated the proportion of perforations and expulsions with IUD insertion at 4–8 weeks vs 9–36 weeks postpartum. Our primary outcome was the perforation rate. Secondarily, we evaluated the expulsion rate. For our minimum sample size calculation, to detect a difference of 0.5% in the perforation rate, with a baseline perforation rate of 0.5% for the 9–36 week postpartum IUD placement group, 80% power, and 5% alpha error rate, we would need at least 4221 participants per group, 8442 in total.RESULTS:A total of 24,959 patients met inclusion criteria (n=13,180 in the 4–8 week group, n=11,777 in the 9–36 week group). Of 430 patients with a confirmed complication, 157 uterine perforations and 273 IUD expulsions were identified. Perforation rates were significantly higher with placement at 4–8 weeks than at 9–36 weeks (0.78% vs 0.46%; P=.001). After adjusting for race and ethnicity, breastfeeding, IUD type, provider type, parity, most recent delivery, and body mass index, the odds of perforation remained higher with placement at 4–8 weeks than at 9–36 weeks (adjusted odds ratio, 1.92; 95% confidence interval, 1.28–2.89). Our Kaplan-Meier survival curve showed that the risk of uterine perforation remained elevated until approximately 22–23 weeks postpartum. Expulsion rates were similar between the 2 groups (1.02 vs 1.17; P=.52).CONCLUSION:Uterine perforation after interval postpartum IUD insertion is greater at 4–8 weeks than at 9–36 weeks, although perforation rates remain low at <1%. Expulsion rates did not differ between the groups. Because overall rates of uterine perforation are low, women can safely be offered IUDs at any interval beyond 4 weeks with minimal concern for perforation.

Mifepristone prior to osmotic dilators for dilation and evacuation cervical preparation: A randomized, double-blind, placebo-controlled pilot study

ObjectivesTo evaluate mifepristone impact on osmotic dilator placement and procedural outcomes when given 18 to 24 hours before dilator placement for dilation and evacuation (D&E) at 18 weeks 0 days to 23 weeks 6 days gestation. Study DesignWe performed a randomized, double-blind, placebo-controlled trial from April 2019 through February 2021, enrolling participants undergoing osmotic dilator (Dilapan) placement for a planned, next-day D&E. Participants took mifepristone 200 mg or placebo orally 18 to 24 hours before dilator placement. We used a gestational age-based protocol for minimum number of dilators. Our primary outcome was the proportion of participants for whom 2 or more additional dilators could be placed compared to the minimum gestational age-based standard. We secondarily evaluated cervical dilation after dilator removal in the operating room, subjective procedure ease, and complication rates (cervical laceration, uterine perforation, blood transfusion, infection, hospitalization, or extramural delivery). ResultsOf the planned 66 participants, we enrolled 44 (stopped due to coronavirus disease 2019-related obstacles), and 41 (19 mifepristone; 22 placebo) completed the study. We placed 2 or more additional dilators compared to standard in 7 (36.8%) and 3 (13.6%) participants after mifepristone and placebo, respectively (p = 0.14). We measured greater median initial cervical dilation in the mifepristone (3.2 cm[2.6−3.6]) compared to placebo (2.6 cm[2.2−3.0]) group, p = 0.03. Surgeon's perception of procedure being “easy” (8/19[42.1] vs 9/22[40.9], respectively, p = 1.00) and complication rate (3/19[15.8%] vs 3/22[13.6], respectively, p = 1.00) did not differ. ConclusionOur underpowered study did not demonstrate a difference in cervical dilator placement, but mifepristone 18 to 24 hours prior to dilators increases cervical dilation without increasing complications. ImplicationsMifepristone 18 to 24 hours prior to cervical dilator placement may be a useful adjunct to cervical dilators based on increased cervical dilation at time of procedure; however, logistical barriers, such as an additional visit, may preclude routine adoption without definite clinical benefit.

ASSESSMENT OF EFFICACY OF ELECTRONIC VACUUM ASPIRATION WITH INTRAVENOUS ANALGESIA

Objective: To assess efficacy of elecrtonic vacuum aspiration in evacuation of retained product of conception with intravenous analgesia.&#x0D; Study Design: A prospective observational study.&#x0D; Place and Duration of Study: Department of Gynaecology and Obstetrics, Pakistan Naval Ship Shifa Hospital, Karachi Pakistan, from Jan to Jun 2018.&#x0D; Methodology: All patients who were intended to undergo Electronic Vacuum Aspiration due to retained products of conception, early fetal demise, septic induced abortions and molar (all upto 12 weeks of gestation) were enrolled in this study after obtaining informed consent. Outcome measures of study were efficacy (defined as completeness of the evacuation procedure confirmed by ultrasound), occurrence of complications like uterine perforation, excessive bleeding &gt;200ml and sepsis (diagnosed clinically or biochemically).&#x0D; Results: A total of 1080 patients underwent Electronic Vacuum Aspiration during the study period. Complete evacuation was achieved in 1026 (95%) cases. Four (&lt;1%) patients experienced post procedure infection while none had uterine perforation. Average blood loss was &lt;100ml while 18 (1.6%) patients had blood loss of &gt;200ml.&#x0D; Conclusion: Electronic vacuum aspiration is a safe and efficacious method of uterine evacuation. It does not require special equipment. It is easy to learn and is readily available as well as cost effective. Hence it’s a very lucrative alternative to manual vacuum aspiration using I pass or medical termination of pregnancy in resource poor settings.

Intrauterine devices migrated into the bladder: two case reports and literature review

BackgroundIntrauterine devices (IUD) are widely used all over the world. One of the most serious complications is uterine perforation, and it is very rare for the IUD to penetrate the bladder after perforation. Here we report two cases of IUD migration into the bladder, and review the literature to analyze the possible causes and solutions of such complications.Case presentationCase NO. 1 is a 37-year-old female who presented lower urinary tract symptoms for a year. Cystoscopy showed that a strip of metal penetrated into the bladder, and the surface was covered with stones. The patient underwent cystotomy and foreign body removal under general anesthesia. Case NO. 2 is a 46-year-old woman who previously inserted an IUD in 1998, but she had an unexpected pregnancy in 1999. Her doctor believed that "the IUD had spontaneously expulsed" and a new IUD was inserted after her pregnancy was terminated. Her CT scan showed an IUD on the left side of the bladder and another IUD in the uterus. Her foreign body was removed by cystotomy.ConclusionPatients with IUD should be suggested to check the device regularly, and those who with a missed IUD have to rule out the possibility of IUD migration. For patients with IUD combined with lower urinary tract symptoms, it is necessary to be aware of whether IUD perforation affects the bladder.

Hysteroscopic Myomectomy for Submucosal Myoma: Literature Review

Uterine myomas are usually asymptomatic, although, most women with submucous myoma have severe symptom including abnormal uterine bleeding and infertility. Hysteroscopic myomectomy is a minimally invasive surgery and is a key benefit to patient care. Patient with submucous myoma no longer requires hysterotomy. Hysteroscopic myomectomy became the gold standard treatment in women who desire to preserve fertility. Complete removal of myoma in one-step procedure should be considered. Pre-operative optimization with cervical ripening agents including osmotic dilators such as laminaria tents and prostaglandin such as misoprostol and dinoprostone is important and decrease the risk of cervical trauma as well as uterine perforation. During the procedure, low viscosity isotonic conductive media such as normal saline are recommended to use with bipolar resectoscope and mechanical morcellator, and fluid deficit should be closely monitored at a minimum of 10-minute intervals. Resectoscope is usually used with slicing technique for resection of myoma. Morcellator can be used as it is easy to use, reduces risk of perforation, and reduces non-electrical currents. However, there is a limited utility in type 2 myoma. In addition, hyaluronic acid and polyethylene oxidesodium carboxymethylcellulose gel may reduce intrauterine adhesion after hysteroscopic myomectomy. Keywords: Hysteroscopy; Morcellation; Myoma; Uterine myomectomy

Causes and Management of Uterine Perforation- A Review

Uterine perforation is an intrauterine problem that can occur with any therapy. It is a rare but possibly dangerous consequence of uterine manipulation, evacuation of retained products of conception or pregnancy termination (TOP), hysteroscopic treatments, and coil implantation. Injury to blood arteries or viscera, such as the bladder or the intestine, might be related. Severe bleeding or infection may ensue if not discovered at the time of surgery; nevertheless, the most majority of uterine drilling is subclinical and safe without treatment, with no substantial long-term damage. Perforation can be caused by cervical stenosis during trans-cervical operations or by a reduction in myometrial wall strength during pregnancy or menopause. Uterine abnormalities, infection, recent pregnancy, and postmenopause are all factors that raise the chance of uterine perforation. The treatment of uterine perforation is determined by the operation and the equipment employed. Admission to the hospital, intravenous antibiotics, and close supervision are required following a uterine perforation and any accompanying injuries. In this paper, we overview common causes and updated management of uterine perforation. Data was collected during a period of 6 months searching Pubmed, EPISCO, Web of science data bases to include studies with relative topics.

Uterine Perforation in Postmenopausal Woman – Case Report

Rupture of uterus occurring spontaneously is a rare occurrence. Here we are presenting a case of spontaneous postmenopausal rupture of uterus caused by pyometra. This can be associated with high morbidity if generalized peritonitis and sepsis occurs. The symptoms will be like acute abdomen similar to that caused by ruptured bowel or gastric perforation. In case of postmenopausal rupture like ours, gynaecological symptoms are very less. Hence the diagnosis becomes difficult and challenging. Here we report a rare case of uterine rupture that occurred in a postmenopausal woman because of pyometra. The patient landed up in the surgical department as case of acute abdomen. Definitive diagnosis was made at the time of laparotomy only when exploration was done and gynaecologist called.

Laparoscopic Retrieval of Migrated Intrauterine Contraceptive Device (IUCD)

Background: IUCD remains a popular, effective and a long-term reversible method of contraception that enjoys wide acceptability globally. One of the most serious complications of its insertion is uterine perforation and its migration into the pelvic/peritoneal cavity including the broad ligament. This rare complication can happen where the insertion was done by an inexperienced health personnel. Case Presentation: A case of a 41 year old multiparous woman who had Mirena intrauterine device insertion in the hands of an inexperienced health personnel, who later developed lower abdominal pain and migration of the Mirena IUD into the pelvic cavity (left broad ligament). The thread of the migrated IUD could not be visualized or felt at pelvic examination. An Abdominopelvic ultrasound scan showed a normal sized uterus with a rounded opacity in the lower uterine portion and also a faint posterior acoustic shadow outside the uterus above the uterine fundus. The myometrial echotexture was normal. She had a 2-port laparoscopy under general anaesthesia and had the Mirena removed. Patient was discharged home the following day with no complications. Conclusions: IUCD remains one of the most effective, safe and widely available long-term contraceptive method. However, rare complication such as uterine perforation can occur especially when inserted by an inexperienced health personnel or where it was inserted in a uterus with anatomic abnormality.

PO-1278 Uterine Perforation During Image-Guided Adaptive Brachytherapy in Cervical Cancer Patients

PO-1278 Uterine Perforation During Image-Guided Adaptive Brachytherapy in Cervical Cancer Patients

Safety and Efficacy of a Novel Barrier Film to Prevent Intrauterine Adhesion Formation after Hysteroscopic Myomectomy: The PREG1 Clinical Trial

To evaluate the safety and potential efficacy of a novel degradable polymer film (DPF) designed to act as a 7-day barrier to prevent intrauterine adhesions (IUAs) after hysteroscopic myomectomy. A prospective single-arm, first-in-human clinical study. Multicenter study involving 6 centers in France, Belgium, and the Netherlands. Women aged 40 years or older with no plans to conceive who qualified for hysteroscopic myomectomy (at least 1 10-mm type 0, 1, or 2 myoma) and had a sounded length of the uterine cavity (fundus to exocervix) ranging between 6 cm and 9 cm were considered eligible for the study. The DPF was inserted after hysteroscopic transcervical myoma resection. The women were followed up by a telephone call at 30 days and second-look hysteroscopy 4 to 8 weeks after the procedure. The chosen safety outcome measures were uterine perforation or cervical trauma at the time of the DPF insertion and unexpected fever, pain, or bleeding beyond 48 hours and up to 30 days after insertion, whereas the outcome measure for efficacy was the absence of IUAs on second-look hysteroscopy. A total of 23 women participated in the study. There were no incidents of uterine perforation or cervical trauma at the time of the DPF insertion. There were no reported adverse effects attributable to the DPF. On second-look hysteroscopy, 20 (87%) of the 23 women had no IUAs. The DPF is a novel, easy-to-apply, and acceptable device to prevent IUAs, with very promising initial safety and efficacy data.

Hysteroscopic incision of the incomplete uterine septum using 5-French scissors with marking strategies: a modified hysteroscopic technique

To demonstrate an easier surgical strategy by using the marking technique for hysteroscopic incision of the uterine septum using 5-French cold scissors. A step-by-step surgical video demonstration. Gynecologic department of the affiliated hospital. A 33-year-old woman presented with a 4-year history of primary infertility. She previously had undergone transcervical resection of (uterine) septum owing to the presence of a complete uterine septum and double cervices. Postoperative 3-dimensional ultrasound revealed a 1.2-cm residual uterine septum, and the outline of the uterine fundus was flat. A second surgery for resection of the residual septum was recommended before invitro fertilization and embryo transfer. We used the Campo hysteroscope (4.4-mm outer sheath) and 5-French scissors with our modified marking strategy to incise the incomplete uterine septum. There were several critical strategies for this approach. After fully exposing 2 fallopian tube ostia, a 3-5-mm mark was made on each side of the uterine fundus where the septum ended, and the marks were parallel to the fallopian tubal ostia. The septum then was incised along the line between the two previously marked points that served as the endpoints. Care was taken to avoid incising myometrial blood vessels during incision, and the 5-French bipolar electrode was used for coagulation when necessary. At the end of the surgery, the distension pressure was gradually decreased to 80 mm Hg to confirm hemostasis of the wound before withdrawing the hysteroscope. Description of a modified hysteroscopic technique. The overall operation time was 10 minutes, and the estimated blood loss was 5 mL. The residual septum was resected successfully while maintaining optimal hysteroscopic visualization. There were no short-term complications, such as uterine perforation or fluid overload. Hysteroscopic evaluation performed 3 months after surgery revealed that the uterine cavity was nearly normal, with no intrauterine adhesion appreciated. There are several advantages to this innovative and practical hysteroscopic surgical approach. Marking the lateral limits of the uterine septum means that a shorter reference line is obtained to incise the septum effectively rather than using the bilateral ostia as reference points. At the same time, marking the bilateral endpoint of the uterine septum incision at the beginning of the surgery might be helpful when bilateral tubal ostia are invisible because of quick absorption of the distension media, which causes insufficient distention pressure at the end of the surgery. Use of the narrow 5-French scissors allowed for instrumentation without prior cervical dilation. Moreover, with this "see and treat" strategy, a clear visualization of the surgical field was maintained without inserting and withdrawing the hysteroscope. The endometrium sustained minimal damage because of the "cold scissors" technique. Our hysteroscopic marking strategy allows the surgeon's intraoperative judgment to be efficient and safe during incision of the uterine septum and ensures that the incision is adequate. It is an improved and valid surgical strategy for hysteroscopic incision of the uterine septum.

Conservative cesarean scar pregnancy treatment: local methotrexate injection followed by hysteroscopic removal with hysteroscopic tissue removal system

To describe a conservative cesarean scar pregnancy (CSP) treatment in a patient with the desire for future pregnancy. To date, there is no gold standard for the management of a viable CSP. There is a wide range of treatment options that include major surgery and minimally invasive procedures. Moreover, after a minimally invasive treatment, the gestational sac may be visible at ultrasound for >6 months. The described technique may be useful to avoid complications related to the use of energy with a large reduction in operative times. Description of the technique with narrated video footage. Academic tertiary hospital. A 31-year-old woman with a previous cesarean section was referred to our clinic with lower abdominal pain. Transvaginal ultrasound revealed a gestational sac with a viable embryo located in the anterior isthmic region, suggestive of CSP at 9 weeks of gestation. Appropriate counseling describing the two diametrically opposite clinical management options was performed, and the patient decided to terminate the pregnancy. Informed consent was obtained from the patient. Hysteroscopy was performed under local anesthesia in an outpatient setting, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope (Karl Storz, Tuttlingen, Germany) with a 4.3-mm inner sheath and 5F instruments. A 3.7F needle (Deflux metal needle; Oceana Therapeutics, Edison, NJ) was pushed into the myometrial tissue surrounding the implantation site of the gestational sac at four different points. Six additional injections were performed into the gestational sac, and 50-mg methotrexate was injected. The appropriate follow-up was performed to determine the success of the procedure. β-Human chorionic gonadotropin was dosed weekly until negative. After 6 weeks, to remove the avascular trophoblastic remnants found at ultrasound evaluation, the patient underwent hysteroscopic removal with a 6-mm TruClear hysteroscopic tissue removal system (Medtronic Parkway, Minneapolis, MN). A contemporary transabdominal ultrasound was performed to minimize surgical risks. Complete and conservative CSP treatment with the absence of surgical complications. Conservative cesarean scar pregnancy treatment was performed successfully with primary local methotrexate injection followed, after 6 weeks, by hysteroscopic removal of the CSP remnants with the TruClear hysteroscopic tissue removal system. The first procedure lasted 6 minutes, whereas hysteroscopic removal of the CSP lasted 5 minutes. Both procedures were performed in an outpatient setting, and no complications were detected during and after the treatments. The patient reported good health at the 1-month follow-up visit, and the ultrasound showed an empty isthmocele (Fig.1). Primary local methotrexate injection followed by hysteroscopic removal of the CSP remnants with the hysteroscopic tissue removal system may be a valuable treatment for women who desire pregnancy in the near future. This combined technique may avoid potential complications, such as thermal-induced myometrial injuries or uterine perforation. Moreover, the operator has the possibility to perform an under-vision procedure with a lower incidence of intraoperative and postoperative bleeding. Because it does not reduce fertility/pregnancy rate, this technique should be a valid option in patients who desire future pregnancy.

Standardizing abortion research outcomes (STAR): Results from an international consensus development study

ObjectiveTo develop a minimum data set, known as a core outcome set, for future abortion randomized controlled trials. Study designWe extracted outcomes from quantitative and qualitative systematic reviews of abortion studies to assess using a modified Delphi method. Via email, we invited researchers, clinicians, patients, and healthcare organization representatives with expertise in abortion to rate the importance of the outcomes on a 9-point Likert scale. After 2 rounds, we used descriptive analyses to determine which outcomes met the predefined consensus criteria. We finalized the core outcome set during a series of consensus development meetings. ResultsWe entered 42 outcomes, organized in 15 domains, into the Delphi survey. Two-hundred eighteen of 251 invitees (87%) provided responses (203 complete responses) for round 1 and 118 of 218 (42%) completed round2. Sixteen experts participated in the development meetings. The final outcome set includes 15 outcomes: 10 outcomes apply to all abortion trials (successful abortion, ongoing pregnancy, death, hemorrhage, uterine infection, hospitalization, surgical intervention, pain, gastrointestinal symptoms, and patients’ experience of abortion); 2 outcomes apply to only surgical abortion trials (uterine perforation and cervical injury), one applies only to medical abortion trials (uterine rupture); and 2 apply to trials evaluating abortions with anesthesia (over-sedation/respiratory depression and local anesthetic systemic toxicity). ConclusionUsing robust consensus science methods we have developed a core outcome set for future abortion research. ImplicationsStandardized outcomes in abortion research could decrease heterogeneity among trials and improve the quality of systematic reviews and clinical guidelines. Researchers should select, collect, and report these core outcomes in future abortion trials. Journal editors should advocate for core outcome set reporting.

Fallopian Tube Prolapse Through the Internal Cervical os: A Rare Complication of Uterine Perforation

Fallopian tube prolapse (FTP) is a rare complication described after hysterectomy without salpingectomy [1,2]. Symptoms reported by patients with FTP include abdominal/pelvic pain, postcoital bleeding, and vaginal discharge [3]. Uterine perforation is the most common complication in patients undergoing dilation and curettage (D&C) [4]. We report a rare case of fallopian tube prolapsed through the internal cervical os into the endocervical canal presenting as a late complication in a patient with undiagnosed uterine perforation.

Comparison of two levonorgestrel-releasing intrauterine systems for the treatment of heavy menstrual bleeding: a randomised, controlled, phase 3 trial

Purpose To evaluate the levonorgestrel-releasing intrauterine system Donasert® (also known as Levosert®) compared with the reference product Mirena® for the alleviation of heavy menstrual bleeding (HMB). Materials and methods A phase 3 multicentre, non-inferiority, active-controlled study in non-menopausal women with HMB (menstrual blood loss [MBL] ≥ 80 mL) as the primary symptom randomised to either Donasert® or Mirena® and followed for 6 months. MBL was evaluated using a validated, modified version of the Wyatt pictogram. Results Overall, 312 were randomised (158 to Donasert® and 154 to Mirena®). The mean (standard deviation) absolute change in MBL from baseline to 6 months in the per-protocol population (N = 300) was −130 (71.8) mL and −127 (67.3) mL in the Donasert® and Mirena® groups, respectively; non-inferiority of Donasert® was confirmed (p-value <0.0001). Successful treatment of HMB (MBL <80 mL) and a decrease to ≤50% of baseline MBL was achieved in 139/154 (90.3%) and 126/146 (86.3%) participants in the Donasert® and Mirena® groups, respectively and the between-treatment difference was non-significant. Most adverse events were mild in severity. Only two device expulsions occurred in the study and there were no uterine perforations. Conclusions Donasert® has equivalent efficacy and safety during the first 6 months foralleviation of HMB compared to the reference device, Mirena®. Trial registration number 348 (Clinical Trials Registry of the Ministry of Health of the Russian Federation, http://grls.rosminzdrav.ru/default.aspx)

Imaging evaluation of uterine perforation and rupture.

Uterine perforation and rupture, denoting iatrogenic and non-iatrogenic uterine wall injury, respectively, are associated with substantial morbidity,and at times mortality. Diverse conditions can result in injury to both the gravid and the non-gravid uterus, and imaging plays a central role in diagnosis of such suspected cases. Ultrasound (US) is the initial imaging modality of choice, depicting the secondary signs associated with uterine wall injury and occasionally revealing the site of perforation. Computed tomography can be selectively used to complement US findings, to provide a more comprehensive picture, and to investigate complications beyond the reach of US, such as bowel injury. In certain scenarios, magnetic resonance imaging can be an important problem-solving tool as well. Finally, catheter angiography is a valuable tool with both diagnostic and therapeutic capability, with potential for fertility preservation. In this manuscript, we will highlight the clinical and imaging approach to uterine perforation and rupture, while emphasizing the value of various imaging modalities in this context. In addition, we will review the multi-modality imaging features of uterine perforation and rupture and will address the role of the radiologist as a crucial member of the management team. Finally, a summary diagrammatic depiction of imaging approach to patients presenting with uterine perforation or rupture is provided.