Uterine Perforation Research Articles

Factors Associated with the Complications of Hysteroscopic Myomectomy.

To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications. A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure. We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French), most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38). Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

Repair of a large uterine dehiscence during the second trimester leading to successful prolongation of the pregnancy

Scar separation during a subsequent pregnancy, of an upper segment hysterotomy or previous uterine rupture, can cause catastrophic intra-abdominal hemorrhage. To avoid this, when dehiscence occurs at a previable gestational age, interruption of the pregnancy is sometimes offered because of the risk of uterine rupture. Hysterotomy during the second trimester is used in fetal surgery, and specialized centers have substantial experience with this approach. Here, we report an innovative technique for uterine repair in an ongoing pregnancy complicated by massive dehiscence from a previous uterine perforation.

The value of ultrasound guidance during IUD insertion in women with RVF uterus: A randomized controlled trial

ObjectiveThe study objective is to evaluate the benefits of using ultrasound guidance during insertion of Intrauterine device IUD in women with retroverted flexed RVF uteri. Study designA randomized controlled trial conducted on 400 women with RVF uteri eligible for IUD insertion. They were randomly divided into 2 groups. Group 1 underwent IUD insertion under ultrasound guidance while in group 2 no ultrasound guidance was used. The primary outcome measure was the(Visual Analogue Scale) VAS pain score reported by the women during insertion. Other outcome included easiness of insertion, the procedure time and occurrence of complications as nausea, vomiting, abdominal cramps, failure of insertion, uterine perforation and bleeding. ResultsThe VAS pain score was significantly lower (2.36 ± 1.77 vs. 4.74 ± 2.35, p < 0.001), the insertion was much easier (score 4.0 ± 0.9 vs. 2.5 ± 1.27, p < 0.001) and the time needed for the procedure was significantly shorter (5.82 ± 2.56 vs. 9.4 ± 4.99 min, p < 0.001) in women within the ultrasound guided group when compared to control group.The total rate of complications was significantly lower (6 vs. 16 %, p 0.001) especially bleeding (2 vs. 9%, p = 0.002), abdominal cramps (10.5 vs. 28 %, p 0.012) and failure of the procedure (0 vs. 3%, p = 005) in ultrasound guided group women when compared to control. ConclusionInsertion of Intrauterine device IUD under ultrasound guidance in women with Retroverted flexed RVF uterus easier and less painful than the blind standard technique.

Intrauterine Contraceptive Device Complication: Migration to the Small Bowl and Ovary Concurrently

Intrauterine Contraceptive Device (IUD) is a useful and reversible contraceptive method. This method has potential complications. Uterine perforation and IUD migration is rare but is a serious complication. Migrated IUD could situate in different organs such as bowel loop, urinary bladder, fallopian tube, or ovary. However, the presence of a displaced IUD simultaneously in the two organs is a rare event. Ultrasonography is an appropriate and initial method for evaluating the IUD location. Abdominopelvic x-ray, computed tomography, and MRI are adjunctive imaging modalities. We present a case with migrated IUD, which was located in the right ovary and small intestine simultaneously.

Assessment of Urea and Creatinine in Vaginal Washing Fluid as a Method for Diagnosis of Premature Rupture of Membranes

Abstract Background: Premature rupture of membranes (PROM) refers to rupture of fetal membranes prior the onset of labor. If it occurs before 37 weeks of pregnancy, it is known as preterm premature rupture of membrane (PPROM). Prolonged duration from PROM till delivery is associated with increased maternal and neonatal morbidities, in term and preterm preg-nancies. This includes chorioamnionitis, fetal and neonatal sepsis, placental abruption, prematurity, umbilical cord pro-lapse, and increased rate of cesarean delivery. Pregnant women with history of vaginal leaking or ultra-sound evidence of diminished amniotic fluid should be care-fully evaluated to avoid adverse pregnancy outcomes. Accurate diagnosis helps obstetricians to optimize maternal and neonatal outcomes by early intervention to decrease morbidities. Diagnosis of PROM is may be easy by inspection of leaking through the cervix or fluid accumulation via speculum examination. However, with small rupture of membrane or rupture bag of hind-water, it is difficult to see amniotic fluid leakage clearly and diagnosis can't be easily made, which might lead to delay in diagnosis and management. Methods of PPROM diagnosis include fern and nitrazine which are two commonly used and traditional tests. They are rapid and easy tests but not completely reliable because of high false positive and negative results, which may be related to technical errors or contamination by blood, semen or cervical mucus. Ultrasound evaluation of amniotic fluid can't differentiate PROM from other causes of oligohydramnios. However, tampon or amnio-dye test is a test of accurate diagnosis through aspiration and dye injection into amniotic fluid under ultrasound guidance. It is an aggressive test with has a risk of bleeding, placental abruption infection, miscarriage, and iatrogenic uterine perforation. The Amnisure test for ROM is accurate but expensive and not available in many centers. Thus, a simple, non-invasive, and inexpensive method of detecting PROM is needed. Urea and creatinine are excreted by kidneys through glomerular filtration. Amniotic fluid also contains these markers and their determination in the vaginal can be used as a diagnostic test for PROM.Aim of Study: This study was conducted to evaluate the diagnostic value of urea and creatinine levels in vaginal wash in patients with suspected PROM. Patients and Method: The study was carried out at Ob-stetrics and Gynecology Department, Zagazig University Hospitals. A total of 228 pregnant women were included in study, between completed 24 weeks to completed 37 weeks' gestation. Divided into two equal groups: Group A with definite PROM, control Group is B. All pregnant women included in this study were subjected to: Full history taking, general, abdominal and speculum examination, fern test and nitrazine test. Vaginal wash urea measurement by enzymatic urease examination method and vaginal wash creatinine measurement by RATE JAFFE method. Results: The study showed that there is statistically significant difference between the two groups regarding vaginal wash urea and creatinine. The best cut-off value of vaginal wash urea in prediction of PROM is >!6.85mg/dl with AUC of 0.958, sensitivity of 98.2%, specificity of 70.2%, PPV of 76.7%, NPV of 97.6% and accuracy of 93%. The best cut-off value of vaginal wash creatinine in prediction of PROM is >!0.465mg/dl with AUC of 0.992, sensitivity of 100%, specificity of 80.7%, PPV of 83.8%, NPV of 100% and accuracy of 90.4%. Combined use of vaginal wash urea and creatinine in prediction of PROM had sensitivity of 98.3%, specificity of 91.2%, PPV of 91.8%, NPV of 98.1% and accuracy of 94.7%. Conclusion: This study concluded that urea and creatinine assay in vaginal fluid is cheaper, faster and more valid test, possible candidate for being a gold standard test for diagnosis of PROM.

Uterine Perforation Due To Unsafe Abortion: A Case Report.

Introduction: An unsafe abortion is defined as a procedure for terminating an unintended pregnancy carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards or both. Majority of these unsafe abortions are carried out in under developing countries, usually by unskilled persons who do not have proper knowledge of the anatomy of reproductive organs and in unhygienic environments thus leading to various complications.&#x0D; Case: We discuss the case of a 40 year old female who presented in septic shock after she underwent an unsafe abortion of 14th weeks pregnancy with uterine wall perforation and bowel injury that required resection.&#x0D; Conclusion: Unsafe abortion is an important public health problem which accounts for a significant cause of maternal mortality and morbidity in resource poor countries.&#x0D; Keywords: Unsafe abortion, Uterine perforation, Intestinal obstruction.&#x0D;

Disseminated Intravascular Coagulation and Hemorrhage After Dilation and Evacuation Abortion for Fetal Death

(Obstet Gynecol. 2019;134:708–713) Second-trimester surgical abortion, or dilation and evacuation (D&amp;E) complications are rare. At a mere 0.7% to 3%, these complications can include cervical laceration, uterine perforation, infection, and hemorrhage [including hemorrhage related to disseminated intravascular coagulation (DIC)]. The possibility of excessive blood loss associated with DIC can even lead to the need for transfusion, or in extreme cases, maternal death. A dearth of well-controlled, large sample size studies evaluating the association of fetal death and abortion-related hemorrhage or DIC makes it difficult to create guidelines for appropriate preoperative preparation and anticipation of needed interventions. This study aimed to determine postabortion risk of hemorrhage for patients with a second trimester fetal death. It sources data from a large cohort at a public, urban abortion clinic.

Complications of Dilation and Evacuation and Induction of Labor for Second-Trimester Fetal Demise [31J

INTRODUCTION: We compared the frequency of complications for dilation and evacuation (D&amp;E) and induction of labor (IOL) for treatment of second-trimester intrauterine fetal demise (IUFD). METHODS: We performed a retrospective cohort study of women with an IUFD between 14-24 weeks who underwent D&amp;E or IOL at a university hospital between June 2009 and June 2019. We defined complications a priori as: 1) infection, 2) uterine atony, 3) retained products of conception, 4) hemorrhage, 5) uterine perforation (D&amp;E only), 6) uterine aspiration (IOL only), 7) cervical laceration (D&amp;E only), 8) uterine rupture, 9) unplanned admission, 10) readmission within 14 days, 11) blood transfusion, 12) intensive care unit admission, 13) removal or injury to an organ, 14) uterine rupture, 15) cardiopulmonary arrest, 16) any other unplanned surgery, and 17) death. We also assessed a composite of major complications, defined as complications 8-17. We assessed differences in composite complication frequency with chi-squared and Fisher’s exact tests. RESULTS: Of the 119 women who met inclusion criteria, 41 underwent D&amp;E and 78 underwent IOL. In our preliminary analysis, 29.2% (12/41) women in the D&amp;E group and 24.4% (19/78) in the IOL group (P=.56) experienced any complication. No women in the D&amp;E group experienced a major complication and 3 women in the IOL group experienced a major complication (3.8%, P=.55). CONCLUSION: D&amp;E and IOL had comparable complication rates for women in our study. Patients should be offered both options in the treatment of a second-trimester IUFD.

A Novel IUD Platform Design Uses a Flexible Nitinol Frame to Deliver Either Copper or Levonorgestrel: Phase 2 Data [03I

INTRODUCTION: Current IUD applicators vary among copper and levonorgestrel devices. We present data on a new intrauterine contraceptive platform that uses a flexible nitinol frame provided in a preloaded applicator with precut strings and a tapered leading edge to deliver either low-dose copper (175 mm2) or a levonorgestrel (52 mg) IUD. METHODS: Two Phase 2 studies provide information, one for copper and the other for the levonorgestrel IUD. Subjects met standard inclusion &amp; exclusion criteria for each IUD, per the CDC. IUD placement occurred any day in the menstrual cycle. The primary outcome for both studies was efficacy, measured by Pearl Index (PI). Secondary outcomes include placement success, ease, and pain as well as overall tolerability and safety. RESULTS: The copper and levonorgestrel IUD studies enrolled 286 and 279 women, respectively; 60.8% and 64.2% were nulliparous. Investigators described IUD placements as “easy” or “very easy” in 91.5% and 88.9%, while participants rated pain as “moderate” or “very painful” in 19.0% and 21.5%, respectively. Placement required cervical dilation in 41 (14.5%) and 42 (15.1%); 99% of placements were successful in both studies. One pregnancy occurred in the Copper IUD study (PI=0.73, 95% CI 0.09-2.65) and none in the levonorgestrel study (PI=0.0, 97.5% confidence upper bound=1.88). We identified no uterine perforations. First year expulsions occurred in 1 (0.4%) and 7 (2.5%) participants. CONCLUSION: This novel IUD platform design successfully delivers both a low dose copper and levonorgestrel IUD with promising efficacy and safety data.

Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications.

The use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery. We conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 236/7 weeks gestation and underwent uterine curettage after the fetus was delivered. Overall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4-4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01-5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01-10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1-3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001). Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.

Safety and effectiveness of medication and aspiration abortion before or during the sixth week of pregnancy: A retrospective multicenter study

ObjectiveTo compare adverse outcomes of medication and aspiration abortion among those with intrauterine pregnancy <43 days gestation versus abortions performed at 43–48 days. Study designWe conducted a multicenter retrospective chart review study to review all medication and aspiration abortion of visualized pregnancy <49 days gestation at Planned Parenthood Columbia Willamette (Oregon) and Planned Parenthood of Orange and San Bernardino Counties (California) in 2014–2015. We identified incident cases by billing codes and performed chart review for adverse outcomes (ED visits, incomplete abortion), need for further interventions, or complications (hemorrhage, infection, and uterine perforation), captured up to 90 days post-abortion. ResultsThe 3930 abortions during the study period at the two sites included 2914 medication abortions and 1016 aspiration abortions, with 1470 medication abortions and 469 aspiration abortions at <43 days gestation. Composite adverse outcomes did not vary by gestation, for either medication abortion (75/1470; 5.1% for <43 days versus 94/1444; 6.5% at 43–48 days, p = 0.10) or aspiration (12/469; 2.6% for <43 days versus 16/547; 2.9% at 43–48 days, p = 0.72). Fewer incomplete abortions (ongoing pregnancy, symptomatic retained tissue, or retained gestational sac) occurred in the earlier gestational group (3.1% for <43 days versus 4.3% at 43–48 days, p = 0.04). Composite adverse outcomes were higher after medication versus aspiration abortion (169/2914; 5.8% versus 28/1016; 2.7%, p < 0.01). ConclusionMedication and aspiration abortion performed either before or during the sixth week of ultrasound-confirmed intrauterine pregnancy have low rates of composite adverse outcomes, including complications or incomplete abortion. However, unplanned interventions are more common after medication compared to aspiration abortions. ImplicationsVery early medication and aspiration abortion are similarly safe and effective before or during the sixth week of ultrasound-confirmed pregnancy, though subsequent interventions are more likely after medication abortion. Patients with early pregnancy can safely initiate abortion with follow-up to ensure complete abortion.

Cost-effectiveness of second curettage for treatment of low-risk non-metastatic gestational trophoblastic neoplasia

ObjectiveLow-risk non-metastatic gestational trophoblastic neoplasia (GTN) has been treated with single agent chemotherapy, but second curettage is emerging as an alternative strategy with reported cure rates of 40%. We sought to estimate the cost-effectiveness of second curettage as the first line treatment of low-risk GTN. MethodsA decision-analytic model was created using TreeAge software to compare costs and outcomes for women with WHO staged low-risk GTN undergoing treatment with 5-day methotrexate (MTX), biweekly pulsed actinomycin-D, or second curettage. Probabilities were derived from the literature. Outcomes of interest included side effects from chemotherapy, need for additional agents, hemorrhage, uterine perforation, and cure rates. Utilities were applied to discounted life expectancy at a rate of 3% to generate quality adjusted life years (QALYs). Sensitivity analyses were then performed in order to assess the robustness of our assumptions. ResultsOf the three treatment arms, MTX was associated with the lowest cost and had similar QALYs to the other studied modalities. Second curettage was associated with 49 additional cures when applied to a theoretic cohort of 1000 women, as well as an additional 83 hemorrhages and 17 uterine perforations. Sensitivity analysis on the cure rate of second curettage revealed that second curettage was not cost-effective over MTX unless its probability of cure was 98%. ConclusionOur study found 5-day MTX was the cost-effective strategy for treatment of women with low-risk, non-metastatic GTN when compared to second curettage and actinomycin-D. In a carefully selected patient population, second curettage may be an additional treatment strategy.

Efficacy, Safety, and Tolerability of a New Low-Dose Copper and Nitinol Intrauterine Device

To assess in parous and nulliparous women, the efficacy, safety, and tolerability of a new, low-dose copper (175 mm) intrauterine contraceptive with a flexible nitinol frame provided in a preloaded applicator. Institutional review boards at 12 U.S. sites approved this commercially funded project. Patients met standard inclusion and exclusion criteria for a copper-based intrauterine device (IUD), generally consistent with the Centers for Disease Control and Prevention's U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. Intrauterine device placement occurred at any day in the eligible patient's menstrual cycle after assuring she was not pregnant. The primary outcome measure assessed efficacy (measured by the Pearl Index) in this 1-year study with a 2-year extension. Secondary outcomes included placement success, ease of placement, safety as measured by adverse events, and tolerability assessed by discontinuation rate and bleeding and spotting patterns. A total of 286 women provided 5,640 cycles evaluable for pregnancy. Patients averaged 27.1 years of age. Nulliparous women represented 60.8% of the patients. Over 36 months of observation, we identified two pregnancies (Pearl Index 0.46 [95% CI 0.06-1.67]) and 10 serious adverse events; none were study-related. Successful placement occurred in 283 participants (99.0%). Median (range) continuation times were 2.7 years (0-3.4). We identified five expulsions (1.8%), zero uterine perforations, and one report of pelvic inflammatory disease. Adverse events prompted 30 women (10.6%) to discontinue early in the first year of use with 23 (8.1%) discontinuing for issues of bleeding, pain, or both. Altogether, 107 (37.8%) completed 36 months of device use. Mean bleeding days per cycle decreased from 7.6 in cycle 1 to 5.2 in cycle 13. The novel, low-dose copper and nitinol IUD demonstrated high efficacy and safety in this phase 2 U.S. Food and Drug Administration trial and warrants further expanded study in a phase 3 clinical trial. ClinicalTrials.gov, NCT02446821. Sebela Pharmaceuticals, Inc.

Value of Ultrasonographic Guidance For Operative Hysteroscopy on the Safety and Outcome of the Procedure: Randomized Control Trial

Abstract Background Hysteroscopy is a minimally invasive intervention that can be used to diagnose and treat many intrauterine and endocervical problems. Hysteroscopic polypectomy, myomectomy are just a few of the commonly performed procedures. Hysteroscopy has nearly replaced standard D&amp;C for the management of abnormal uterine bleeding (AUB), as it allows for direct visualization and diagnosis of intrauterine abnormalities, and it often offers an opportunity for simultaneous treatment. Operative hysteroscopy is a safe procedure resulting in complication in 0.95-3% of cases. The most frequently observed complications include hemorrhage (2.4%), uterine perforation (1.5%), and cervical laceration (1-11%). Another rare complication is excessive fluid absorption with or without resultant hyponatremia. Can use of ultrasound guidance during operative hysteroscopy decrease the rate of the operative complication? Objective To assess the value of ultrasound guidance for operative hysteroscopy on decreasing the complication and improving the success rate of the procedure. Patients and Methods It is estimated that a sample size of 88 patients that were divided to 44 patients in the Ultrasound guidance group and 44 patients in the group that didn’t perform ultrasound. The patients were encountered from those presented at the gynecology clinic of the Ain Shams university hospital or those presented at ECDU with the inclusion criteria in the period between December 2017 to November 2018. The patients were approached to participate on study and a written informed consent was taken from all the patients. Results Comparative study between the 2 groups revealed; highly significant increase in success rate in ultrasound guided hysteroscopy (USH) group; compared to conventional hysteroscopy (CH) group; with highly significant statistical difference (p &amp;lt; 0.01) and non-significant difference as regards failure and complications rates (p &amp;gt; 0.05). Conclusion Our study found that ultrasound assistance for difficult hysteroscopy reported that ultrasound appears to be a safe and reliable method of assistance.

81: Hysteroscopic uterine artery laceration in setting of cervical stenosis: A case study

Discuss management of cervical stenosis and techniques for avoidance of perforation, as well as risks for uterine perforation, sites of potential perforation, and management options in the event of a perforation. Hysteroscopy, while a low-risk procedure, can be associated with significant risks, including creation of a false passage during dilation. This risk is increased in the setting of cervical stenosis. Our video discusses the risks factors for cervical stenosis, the preoperative and intraoperative management techniques of this condition, and demonstrates a case of hysteroscopic uterine perforation in a patient with known cervical stenosis. We identify the potential sites through which a perforation may occur, and management of defects at these sites. In our case study, the perforation occurred through the right broad ligament and lacerated the right uterine artery, which required laparoscopic exploration of the broad ligament and ligation of the uterine artery. This video will provide a thorough review of cervical stenosis as well as uterine perforation, and will discuss the management options in both scenarios, and will demonstrate one such case, in which the uterus was perforated along the right cervical canal into the right broad ligament, lacerating the uterine artery in the process. We also demonstrate the process of identifying the defect and repairing it laparoscopically.

51: Ultrasound-guided hysteroscopy

The purpose of this video is to describe the benefit of ultrasound use during complicated hysteroscopy. Hysteroscopy is a common gynecologic surgery that may be technically complex in situations where anatomic landmarks are distorted, including Asherman’s syndrome, Mullerian anomalies, and leiomyoma. We demonstrate how real-time ultrasound can aide the gynecologic surgeon to make key decisions in this case series. The first patient was diagnosed with hematometria secondary to cervical stenosis. The Seldinger technique (commonly used in vascular and cardiac surgery) was employed to perform cervical dilation. Severe intrauterine adhesions distort normal uterine architecture and increase the risk of uterine perforation. Ultrasound can alert the surgeon to the risk of perforation by providing a transabdominal, global view of the uterus, which is demonstrated with the second patient case in our video. The third patient was diagnosed with a complete uterine septum and duplicated cervices. Care needs to be taken to incise the septum in the lower uterine segment cephalad to the cervices to decrease future complications in pregnancy. In addition, ultrasound can be used to notify the physician as to when the septum has been completely incised to the level of the fundus. Similarly, hysteroscopic myomectomy under ultrasound can provide guidance regarding proximity of hysteroscope to the peritoneal cavity and also prevent staged procedures that may be needed to resect the entire fibroid. In our fourth patient case, we demonstrate how ultrasound can visually verify that the surgeon has excised the entire fibroid. Ultrasound-guided hysteroscopy may decrease the risk of uterine perforation in Asherman’s syndrome, assist in identifying anatomical landmarks in uterine septum incision, and ascertain complete fibroid resection, potentially reducing surgical times, fluid deficits, and the need for multiple staged procedures.

An old drug for a rare disease: The example of celiprolol for vascular Ehlers-Danlos syndrome

Vascular Ehlers-Danlos syndrome (OMIM 130050, 1/150,000birth) is caused by mutations in collagen 3A1gene. It is associated with severe phenotype associating early arterial dissection and rupture, digestive and uterine perforations, and skin and joints fragility. Until recently, no treatment was available. Celiprolol, a beta1antagonist with beta2partial antagonist properties betablocker was tested in a randomized, controlled trial. We could show that this compound was associated with a 3-fold decrease in major events related to the disease. This effect was similar in molecular-proven patients. Administration of celiprolol in a cohort of patients followed routinely in France was accompanied to similar benefit. Celiprolol is unavailable in the USA. The ACER Therapeutics company applied for new drug application (NDA) to the Food and Drug Administration.

Cold scissors ploughing technique in hysteroscopic adhesiolysis: a comparative study.

Intrauterine adhesions (IUAs) can be dissected using hysteroscopic scissors (cold scissors) or other methods, but there is no consensus on which hysteroscopic method is preferable. There is also no consensus on the method of how to deal with the scar tissue on the surface of the intrauterine cavity. From January 2016 to October 2017, 179 patients who had HA met the enrollment criteria (see the text below), and their data were analyzed retrospectively. In addition, all patients were divided into three groups according to the surgical techniques used. The groups were the ploughing group (PG) (using cold scissors to dissect the adhesion and cut the scar tissue using a ploughing technique) (n=81), the traditional group (TG) (using cold scissors to dissect the adhesion, but not deal with the scar tissue) (n=42), and the electrosurgical group (EG) (using a resectoscope to dissect the adhesion with an energy L-hook electrode, and not deal with the scar tissue) (n=56). Safety (surgical complications), feasibility (surgical technique replacement rate), and postoperative efficacy (reduction of AFS score, pregnancy, and live birth rate), were each evaluated between groups. No statistically significant differences between the groups were observed in basic preoperative information (P>0.05), while there were significant differences between PG and TG, as well as PG and EG in postoperative AFS scores (PG vs. TG: P=0.007; PG vs. EG: P<0.001) and pregnancy outcome (PG vs. TG: P=0.039; PG vs. EG: P<0.001). No patients had surgical complications such as uterine perforations, moderate or severe fluid overload, heavy uterine bleeding, nor any surgical technique replacements (for example, transfer to use a resectoscope). Cold scissors ploughing technique in HA is effective, feasible, and safe, and thus worthy of further study.

Emergency Laparoendoscopic Single-Site Surgery for Management of Iatrogenic Uterine Perforation: A Report of 3 Cases

Background: With advancements in surgical techniques and equipment, successful laparoscopic management has been reported in selected cases of iatrogenic uterine perforation. However, management of ...

Emergency hysterectomy in a tertiary care hospital: indications, surgical outcomes and challenges: a 2-year retrospective descriptive cross-sectional study.

Introductionemergency hysterectomy (EH) remains a life-saving procedure in cases of life-threatening obstetric hemorrhage and other gynaecological emergencies. We aim to determine the indications, surgical outcomes and challenges of EH in our tertiary centre.Methodsan ethically approved retrospective descriptive cross-sectional study on all EHs performed at a tertiary hospital during the period of 1st January 2018 to 31st December 2019 was conducted. Medical records of eligible patients were retrieved, reviewed and analysed using frequencies and percentages and then summarized in tables.Resultsthere were 146 EHs over the two year period. The age of participants ranged from 19 to 59 years, with a mean of 34.3 years (SD = 6.06). SD: standard deviation.The main indication for EH was primary postpartum haemorrhage (PPH): 73.28% (n = 110/146). The other indications were uterine perforation with necrosis: 8.9% (n = 13/146), secondary postpartum haemorrhage: 4.8% (n = 7/146), choriocarcinoma and pelvic abscess: 2.74% (n = 4/146) each and broad ligament haematoma: 2.06% (n = 3/146). There were 3.42% (n = 5/146) which were classified as ‘others **’: two cases of ovarian cyst torsion; one case of placental site tumour; one case of incomplete septic abortion; one case of bulky multinodular fibroid uterus with severe unremitting lower abdominal pain.The most common indication for the subgroup of hysterectomy due to PPH was uterine atony 54.20% (n = 60/110), followed by ruptured uterus20.56% (n = 23/110) and then, morbidly adherent placenta 14.95% (n = 16/110). Placenta accreta constituted 62.5% (n = 10/16) of the morbidly adherent placenta.There were 91.78% (n=134/146) total abdominal hysterectomies and 8.22% (n = 12/146) subtotalhysterectomies. About eighty percent 79.45% (n = 116/146) of the surgeries required general anaesthesia, 15.07% (n = 22/146) required regional anaesthesia whilst 5.48% (n = 8/146) were started as regional anaesthesia but were converted to general anaesthesia.There were no associated intraoperative complications in 96.60% (141/146) of the cases. The most frequent intraoperative complications included bowel injury 2.04% (3/146), bladder injury 0.68% (1/146) and maternal death 0.68% (1/146).Twoof the three bowel injuries required bowel resection and anastomosis. Most of the surgeries 89.73% (n = 131/146) were performed by skilled doctors above the level of a Specialist. Major challenges faced include delayed referral of patients to the tertiary centre for prompt management and lack of quick access to blood products.Conclusionemergency hysterectomy is performed in women who are relatively young with primary postpartum haemorrhage as the commonest indication but there are other non-obstetric indications for this emergency surgery. Though a challenging procedure, it is safe in the hands of a skilled surgical team.