Uterine Perforation Research Articles

Low Socioeconomic Status Leading to Unsafe Abortion-related Complications: A Third-world Country Dilemma.

IntroductionAn unsafe abortion is a persistent, preventable dilemma. It is a procedure where an unintended pregnancy is terminated either by untrained individuals, or in an environment not meeting medical standards, or both, as defined by the World Health Organization (WHO). It endangers women in developing countries, where abortion is restricted either by law and culture or legally permitted but not easily accessible. Induced abortions are usually performed by unqualified and untrained individuals or are self-induced. Such incidents take place in unhygienic conditions and involve inappropriate methods or administration of medications. Even if carried out by medical experts, a clandestine abortion carries an additional risk, medical coverage is not immediately available in an emergency and the woman may not receive appropriate post-abortion attention. Induced abortion-related complications happen and the woman may hesitate to seek medical care. Unsafe abortion-induced complications contribute a major burden, such as increased hospital stay, drug costs, and an unusual delay of other operations on gynecological services in developing countries. The purpose of this study was to seek an association between low socioeconomic status and complications related to unsafe abortion.Materials and methodsA total of 296 female patients of child-bearing age presented between 2012 and 2015 in the emergency department (ED), Nishtar Hospital, Multan, after an unsafe abortion, were included. Spontaneous miscarriages and abortions cases carried out on legal or medical grounds were excluded. Patient or their attendants (who usually present the real picture of incidents leading towards unsafe abortion) were interviewed for determinants leading to unsafe abortion. A detailed clinical assessment of the patient was done and complications like hemorrhage, uterine perforation, and bowel perforation were recorded along with basic demographic information such as age, gestational age, parity, and weight.ResultsThere were 296 female patients in the study with a mean age 28.391 ± 4.57 (Range: 13-40 years). In a majority of patients, gravida and parity were 5-6. The mean weight was 60.283 ± 9.31 kilograms and the mean gestational age was 7.733 ± 2.45 weeks. The determinant in the shape of poor economic status was 71.6%. Hemorrhage was seen in 30.1% of the patients followed by uterine perforation (49.3%) and bowel perforation (45.6%).ConclusionOur results indicate that unsafe abortion is a major cause of maternal morbidity, mostly because the service is being sought from untrained healthcare providers in unhygienic conditions secondary to poor socioeconomic status. Since maternal morbidity due to unsafe abortion is a violation of a woman's basic human right: the right to life, there is a dire need to prevent these unwanted complications by improving the quality of the family planning program and providing safe abortion services.

Decrease in uterine perforations with ultrasound image-guided applicator insertion in intracavitary brachytherapy for cervical cancer: A systematic review and meta-analysis

PurposeTo estimate uterine perforations rates during intracavitary brachytherapy for cervical cancer with and without ultrasound (US) image guidance. Materials and methodsA systematic search of databases (PubMed and EMBASE) was performed. The pooled summary uterine perforation rate (detected by postinsertion CT or MRI) for the un-guided insertion group and the guided insertion group was calculated by using the random-effects model weighted by the inverse variance. ResultsA total of 690 articles were initially found, resulting in 12 studies that met the inclusion criteria. A total of 1757 insertions and 766 patients were included in the meta-analysis. The overall uterine perforation rate per insertion was 4.56% (95%CI: 2.35–8.67) and per patient was 7.39% (95%CI: 3.92–13.50). The pooled perforation rate per insertion without image guidance was 10.54% (95%CI: 6.12–17.57) versus 1.06% (95%CI: 0.41–2.67) with image guidance (p < 0.01). The pooled perforation rate per patient without guidance was 16.67% (95%CI: 10.01–26.45) versus 2.54% (95%CI: 1.21–5.24) with image guidance (p < 0.01). The ratio of perforations in the un-guided/guided groups was 9.94 and 6.56, per insertion and per patient, respectively. The most common sites of perforation were the posterior wall (>47 events) and the uterine fundus (24 events). None of the studies reported significant acute clinical consequences. Prophylactic antibiotic after perforation was used in 3 of the 4 studies that described the management. ConclusionUsing postinsertion CT or MRI to detect the perforation, the rate of uterine perforation per insertion in patients who received US-guided intracavitary brachytherapy insertion is 90% lower than with un-guided insertion.

Peritonitis Due to Perforated Uterine Actinomycosis

Actinomyces spp are commensal anaerobic, gram-negative bacilli that have been infrequently associated with pelvic inflammatory disease due to long-standing intrauterine devices (IUD). Actinomycosis can present with non-specific abdominal pain and progress to peritonitis. We present a case of peritonitis initially attributed to colonic perforation, and later found to have been due to pelvic Actinomycosis with uterine perforation. A 65 year-old female with a history of coronary artery disease, hypertension, and depression presented to the emergency department with a stabbing pain in her pelvis, with radiation to the left lower quadrant. This pain was intermittent over the past six months, and became more constant the day prior to admission. She denied fevers, chills, nausea, vomiting, constipation, diarrhea, hematochezia, melena, vaginal bleeding, chest pain, or dyspnea. On physical exam, vitals were stable. She had abdominal distension, guarding, and rebound tenderness. Laboratory work-up was remarkable for leukocytosis (14.2 x 103/uL) with 80% neutrophils and anemia (Hgb 10.6 g/dL and Hct 34%). A CT abdomen revealed free intraperitoneal air. It was also suggestive of colonic pneumatosis, with small amounts of intraperitoneal fluid. Non-specific findings of low-density material and small amounts of gas in the endometrial canal were also noted. The patient underwent an exploratory laparotomy, which revealed light tan fluid and fibrinous exudate throughout the abdomen. There was no evidence of enteric leak. A punched out, necrotic, 4 mm round full-thickness perforation was found in the anterior uterine fundus. Purulent material was expressed from the defect. A subtotal hysterectomy was performed. Intra-operative pelvic pus cultures grew Actinomyces spp. The patient was discharged on a total of three months of amoxicillin-clavulanate, and has continued to do well on follow-up. It was concluded that Actinomycesspp. were likely introduced to the uterus six months prior, when the patient underwent an endometrial biopsy for evaluation of post-menopausal bleeding. This is in contrast to the association of pelvic actinomycosis with longstanding IUDs. Because the mainstay of treatment is with antibiotics, it is important to recognize actinomycosis as a potential etiology when evaluating peritonitis in a patient with uterine instrumentation.1591 Figure 1. A 4 mm necrotic perforation (arrow) was found in the anterior uterine fundus.

Peritonitis and Pelviperitonitis Following Clandestinal Abortion Received at Sylvanus Olympio Teatching Hospital of Lomé

Introduction: Clandestine induced abortion is responsible for significant morbidity and maternal mortality, most often with peritonitis, which remains a medical and surgical emergency. Even the life-threatening and obstetrical future of the patients is at stake. Objectives: To describe the epidemiological, therapeutic and clinical aspects of patients with post-abortion peritonitis. Material and method: From January 1, 2013 to December 31, 2017, we performed a retrospective study of 42 cases of post-abortion peritonitis divided into 05 pelviperitonitis and 37 peritonitis collected at CHU-SO. Results: One hundred and seventy-six cases of complications of abortion were identified during our study period, of which 42 cases of peritonitis ( 23.86% ). Peritonitis is the most serious complications. The average age of our patients was 25, 61 years old. The most affected age group is the 20-24 age group with a rate of 35.71%, those living in socially disadvantaged conditions (50% female sellers, 16.67% female students), the primiparous (38,10%). Signs of peritoneal irritation associated with malodorous losses were observed in all of our patients. One hundred of the cases benefited from a surgical procedure for drainage washing, intestinal anastomosis resection, uterine perforation suture, anexectomy, hysterectomy and / or placental retention evacuation. The mortality rate was high (14.29%.) Conclusion: Post-abortion peritonitis remains a serious and frequent complication. They are an important predictor of morbidity and mortality in women of childbearing age. The occurrence of these complications can be reduced by the prevention of post-abortion infections and by the information on contraception and the risks run by this practice, which is still clandestine in our countries, but which nevertheless remains frequent.

Analysis of induced abortion-related complications in women admitted to referral health facilities in Kinshasa, Democratic Republic of the Congo.

BackgroundDue to a lack of relevant data on induced abortions in the Democratic Republic of the Congo (DRC), as well as the persistence of maternal deaths in the country, this study aims to analyze the extent and characteristics of induced abortion-related complications in women who were admitted to referral health facilities in Kinshasa, including the duration of hospitalization, the mortality rate due to induced abortion complications and their characteristics, and the deaths that occurred after two days of hospitalization.MethodsThis is a cross-sectional study on 843 obstetric and gynecological patients who were admitted as emergency cases to five referral health facilities in Kinshasa during 2014. These facilities were selected as being representative of five types of districts in Kinshasa, according to their cultural, socioeconomic, and infrastructural characteristics. Patient data were collected from patient records and analyzed.ResultsFrom the 843 patients admitted to receive obstetric and gynecological emergency care services in 2014 at the health facilities surveyed, 14.7% (95% CI: 12.4–17.3%) had complications due to induced abortion. These complications were significantly diagnosed in adolescents (p = 0.003) and in single, separated, divorced, or widowed women (p = 0.03). The median duration of hospitalization was nine days, and this period of time was significantly longer for the patients who underwent surgery for pelvic peritonitis due to uterine perforation compared with the patients who underwent Caesarean section/hysterectomy. Furthermore, it was significantly longer for the patients who were treated for other induced-abortion related complications compared with patients treated for spontaneous abortion. The mortality rate related to induced abortions was 5.6% (95% CI: 2.3–11.3%), with an increase in risk of death in the presence of a postabortive pelvic peritonitis-type complication; 42.9% of deaths occurred after two days of hospitalization.ConclusionThe complications of induced abortions are a major public health problem due to their frequency among patients admitted to Kinshasa's referral health facilities, their mortality, and their poor medical management. Therefore, there is a need to understand the reason for its poor medical management in order to provide an adequate intervention program.

Perforated uterus

Early pregnancy failure is a major health problem worldwide which occurs in 15-20% of pregnancies. During evacuation, uterine perforation is a potential complication. Careful post-evacuation follow-up helps in early detection of perforation. Perforation often requires laparotomy or laparoscopy to repair the defect and evaluate for injury to adjacent organs. Our patient had pregnancy loss at 12 weeks and uterine perforation during a dilatation and curettage procedure. She had laparotomy, evacuation through the perforation site and uterine repair with good outcome.

Imaging findings in Essure-related complications:a pictorial review.

Tubal sterilization with Essure inserts has become a prevalent alternative to laparoscopic sterilization because of its minimal invasiveness. It is a well-tolerated ambulatory procedure that provides reliable permanent contraception without the risks associated with laparoscopic surgery and general anesthesia. Correct positioning of the Essure device is necessary to achieve the fibrotic reaction induced by the polyethylene terephthalate fibers, subsequently resulting in tubal occlusion usually within 3 months. After uneventful procedures with satisfactory bilateral placement, only the correct position of the devices needs to be confirmed at follow-up. The imaging techniques used to asses Essure devices may vary depending on the country and its recommendations. The gold-standard test to ascertain tubal occlusion remains the hysterosalpingography but after uneventful procedures, vaginal-ultrasound proved to be a reliable alternative to confirm the proper position of the inserts. Radiologists have been increasingly confronted to post-procedural evaluations and despite the efficiency rate of the Essure device, its use still exposes to a low risk of complications and malfunctions such as unwanted pregnancies, device misplacement, tubal or uterine perforation, and chronic pelvic pain. Unintended pregnancies are mostly due to patient or physician non-compliance and misinterpretation of post-procedural examinations by radiologists which emphasizes the importance of their training in Essure device assessment. This pictorial review discusses the imaging methods used to asses Essure implants and illustrates the possible complications related to them.

Analysis of induced abortion-related complications in women admitted to the Kinshasa reference general hospital: a tertiary health facility, Democratic Republic of the Congo

BackgroundDue to a lack of relevant data on induced abortions in the Democratic Republic of the Congo (DRC) as well as the persistence of maternal deaths in the country, this study aims to analyse the induced abortion-related complications in women who were admitted to the Kinshasa Reference General Hospital (KRGH).MethodsThis is a cross-sectional study on 368 obstetric and gynecological patients who were admitted, as emergency cases, to the KRGH during 2014. This health facility was selected because it is a tertiary health facility with an obstetric and gynecological emergency unit most used in the city of Kinshasa. Patient data were collected from patient records and analyzed.ResultsFrom the 368 patients admitted to receive obstetric and gynecological emergency care services in 2014 at the KRGH, 12.2% (95% CI: 9.1–16.1%) had complications due to induced abortion that was significantly diagnosed to adolescents (p < 0.001), single or separated or divorced women or widow(p < 0.001), and to patients with history of one or several induced abortions(p < 0.001). The median duration of hospitalization was ten days and this period of time was significantly longer for the patients who underwent surgery for pelvic peritonitis due to uterine perforation(p < 0.001) compared with the group of patients who underwent Caesarean section/hysterectomy.The mortality rate related to them is 37.8% (95% CI: 23.8–53.5%) with an increase of risk of death in the presence of a post-abortive pelvic peritonitis-type complication, 56.3% of deaths occurred after two days of hospitalization.ConclusionThe complications of induced abortions are a major public health problem due to its frequency among patients admitted to the KRGH, as well as the poor medical management, and mortality percentage related to them. Therefore, there is a need to understand the reason for the poor medical management to fill in and provide an adequate intervention package.

Пенетрация сальника, ассоциированная с перфорацией матки при хирургическом прерывании беременности

Пенетрация сальника, ассоциированная с перфорацией матки при хирургическом прерывании беременности

Comparison between Two Types of Copper Bearing Intrauterine Device Cu375 and Cu380Ag Regarding Bleeding Pattern: (Randomized Controlled Trial)

Background: The complications of IUDs are abnormal uterine bleeding, dysmenorrhea, expulsion of the IUD or perforation of the uterus. Due to these complications, 5 to 15 percent of women will stop using the IUD during one year. The most common complication of using IUDs is bleeding that is the cause of 15 to 30 percent of the rejection and exclusion of copper IUDs by the users. Except for progesterone IUDs, all IUDs can lead 50-100 percent increase the amount of menstrual blood than before the insertion. Purpose: To compare between two types of copper IUDs different in shape and size Cu375 & Cu380Ag regarding bleeding pattern. Patients and Methods: This is a randomized controlled clinical trial. The study was conducted at Family Planning Outpatient Clinic at Department of Obstetrics & Gynecology at Ain Shams Maternity Hospital on 220 patients divided into two groups with insignificant differences between two groups as regard age (p-value 0.934). Results: 110 participants recruited in each group. In group A, drop out after 1month was 6 women and only 70 women had subjective changes in bleeding pattern. After 1year, drop out was 8 women. In group B, drop out after 1month was 4 women and only 79 women had subjective changes in bleeding pattern. After 1year, drop out was 5 women. Conclusion: One of the most common complications of IUD users is bleeding. These complications vary in the different types of IUDs. The results of this study showed that the use of the IUD ML CU 375 causes a significant decrease in the rate of bleeding.

Spontaneous perforated pyometra presenting as an acute abdomen: appraisal of three consecutive cases

Introduction: Pyometra is the accumulation of purulent fluid in the uterine cavity caused by impaired drainage of pus due to benign or malignant conditions; rarely with resultant spontaneous uterine perforation brought about by uterine distension.&#x0D; Cases: We report three consecutive cases of spontaneous perforated pyometra in postmenopausal elderly women aged 60 to 70 years who presented with acute abdomen, initially diagnosed as hollow viscus perforation, demonstrated of having significant uterine perforation at laparotomy for which hysterectomy with bilateral salpingo-oophorectomy were done. Histopathological examination revealed features of necrosis of stroma with chronic endometritis without any evidence of malignancy in all the three cases.&#x0D; Conclusion: Spontaneous perforated pyometra, a grave complication necessitating prompt intervention, should always be kept as a possibility in all cases of suspected pyoperitoneum and acute abdomen in elderly postmenopausal women.

Association of Facility Type With Procedural-Related Morbidities and Adverse Events Among Patients Undergoing Induced Abortions

Multiple states have laws requiring abortion facilities to meet ambulatory surgery center (ASC) standards. There is limited evidence regarding abortion-related morbidities and adverse events following abortions performed at ASCs vs office-based settings. To compare abortion-related morbidities and adverse events at ASCs vs office-based settings. Retrospective cohort study of women with US private health insurance who underwent induced abortions in an ASC or office-based setting (January 1, 2011-December 31, 2014). Outcomes were abstracted from a large national private insurance claims database during the 6 weeks following the abortion (date of final follow-up, February 11, 2015). Facility type for abortion (ASCs vs office-based settings, including facilities such as abortion clinics, nonspecialized clinics, and physician offices). The primary outcome was any abortion-related morbidity or adverse event (such as retained products of conception, abortion-related infection, hemorrhage, and uterine perforation) within 6 weeks after an abortion. Two secondary outcomes, both subsets of the primary outcome, were major abortion-related morbidities and adverse events (such as hemorrhages treated with a transfusion, missed ectopic pregnancies treated with surgery, and abortion-related infections that resulted in an overnight hospital admission) and abortion-related infections. Among 49 287 women (mean age, 28 years [SD, 7.3]) who had 50 311 induced abortions, (23 891 [47%] first-trimester aspiration, 13 480 [27%] first-trimester medication, and 12 940 [26%] second trimester or later), 5660 abortions (11%) were performed in ASCs and 44 651 (89%) in office-based settings. Overall, 3.33% had an abortion-related morbidity or adverse event; 0.32% had a major abortion-related morbidity or adverse event; and 0.74% had an abortion-related infection. In adjusted analyses, there was no statistically significant difference between ASCs vs office-based settings, respectively, in the rates of abortion-related morbidities or adverse events (3.25% vs 3.33%, difference, -0.08%; [corrected] 95% CI, -0.58% to 0.43%; adjusted OR, 0.97; 95% CI, 0.81-1.17), major morbidities or adverse events (0.26% vs 0.33%; difference, -0.06%; 95% CI, -0.18% to 0.06%; adjusted OR, 0.78; 95% CI, 0.45-1.37), or infections (0.58% vs 0.77%; difference, -0.16%; 95% CI, -0.35% to 0.03%; adjusted OR, 0.75; 95% CI, 0.52-1.09). Among women with private health insurance who had an induced abortion, performance of the abortion in an ambulatory surgical center compared with an office-based setting was not associated with a significant difference in abortion-related morbidities and adverse events. These findings, in addition to individual patient and individual facility factors, may inform decisions about the type of facility in which induced abortions are performed.

A Retrospective Evaluation of Obstetric Patients Admitted to the Intensive Care Unit: Has Anything Changed in the New Era of Technology?

Objective: Despite the fact that obstetric cases constitute only a small portion of intensive care hospitalizations, maternal mortality still remains an important health problem in the world. In this study, we aimed to evaluate the frequency and reasons of admission of obstetric patients to the intensive care unit (ICU), as well as the ‘advanced’ treatments applied and the clinical outcomes. Materials and Methods: The medical records of 8800 obstetric patients who were admitted to the hospital between 2012-2017 were retrospectively reviewed. The demographic data, reasons for admission to the ICU, concomitant diseases, intensive care interventions (advanced monitoring, extracorporeal therapies, etc.) and clinical outcomes were evaluated. Results: Of the 8800 obstetric patients, 40 (0.45%) patients required intensive care. The mean age was 32.2±5 years. The mean duration of stay in the ICU was 4.3 days. The most common reasons for admission to the ICU were HELLP-Preeclampsia-Eclampsia in 16 (40%) patients and bleeding (due to disseminated intravascular coagulation, uterine perforation, uterine atonia) in 11 (27%) patients. Seventeen patients received invasive mechanical ventilation and 3 patients received non-invasive mechanical ventilation. Two patients received extracorporeal membrane oxygenation (ECMO), 4 patients received plasmapheresis and 5 patients received hemodiafiltration. Three patients died. One patient died of multiorgan failure secondary to HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. Two patients died due to HELLP and intracerebral hemorrhage. Conclusion: Advanced intensive care settings where new-era technological equipment (ECMO, hemodiafiltration, advanced monitoring, etc.) is in-reach and employing a multidisciplinary approach in the ICU may decrease the maternal mortality and morbidity.

ACOG Technology Assessment No. 13 Summary: Hysteroscopy.

Hysteroscopy is performed to view and treat pathology within the uterine cavity and endocervix. Diagnostic hysteroscopy allows visualization of the endocervical canal, endometrial cavity, and fallopian tube ostia. Operative hysteroscopy incorporates the use of mechanical, electrosurgical, or laser instruments to treat intracavitary pathology and perform hysteroscopic sterilization procedures. Selection of a distending medium requires consideration of the advantages, disadvantages, and risks associated with various media as well as their compatibility with electrosurgical or laser energy. A preoperative consultation allows the patient and physician to discuss the hysteroscopic procedure, weigh its inherent risks and benefits, review the patient's medical history for any comorbid conditions, and exclude pregnancy. Known pregnancy, genital tract infections, and active herpetic infection are contraindications to hysteroscopy. The most common perioperative complications associated with operative hysteroscopy are hemorrhage, uterine perforation, and cervical laceration. The procedure is minimally invasive and can be used with a high degree of safety.

Therapeutic approach for the cesarean scar pregnancy.

The aim of this study was to explore the pros and cons of different treatments of cesarean scar pregnancy (CSP).We retrospectively studied 205 cases of CSP that were treated in our hospital from June 2013 to June 2014, 189 of which had surgical operation.The average age of the patients was (32.98 ± 4.56) years. Data from those 189 cases were analyzed.Two hundred five patients from Beijing Obstetrics and Gynecology Hospital.One hundred eighty-nine cases who had operative treatment, 111 of which received curettage under hysteroscopy, 70 of which received curettage under ultrasonography, 8 of which received laparoscopic Cesarean scar resection.Management of 189 ectopic Cesarean scar pregnancy cases discussed in this article was usage of methotrexate (MTX) via the utility of uterine arterial chemotherapy embolization (UACE).All of 189 patients were cured without hysterectomy. Hysteroscopy provides a clear view for us, making it easy to identify the range of affected tissues, and clean the pregnancy tissue. Curettage under ultrasonography is relatively simple and inexpensive. Laparoscopic surgery is more suitable for exogenous CSP patients that can reduce the operation risk and prevent uterine perforation. However, laparoscopic surgery costs much more than those 2 and needs longer time of hospitalization.Treatment options should be personalized according to different situations. Minimal invasion, thorough treatment, quick recovery, low risk of hysterectomy, preserved fertility function, and improved life quality are the principles we have been pursuing for.

Unusual Bowel Perforation Following Dilatation and Curettage in a Case of Endometrial Cancer

We present an unusual case of iatrogenic small bowel perforation in a woman with endometrial cancer. A 57-year-old postmenopausal woman with past history of total colostomy with loop ileostomy for ulcerative colitis, was referred to our department for evaluation and further management of suspected endometrial cancer following dilatation and curettage (D&C) elsewhere. The histopathology showed intestinal element which was attributed to metaplasia; however, no malignancy was identified in the biopsy specimen. Imaging carried out elsewhere after D&C showed thickened endometrium with suspicious small bowel infiltration. The patient was completely asymptomatic with no signs of bowel injury or peritonitis. After a complete evaluation, a class 1 extrafascial hysterectomy and bilateral salpingo-oophorectomy with segmental ileal resection and anastomosis and frozen section were performed. Intraoperatively, small bowel loop was found adherent to the posterior uterine wall extending up to the cervix with no obvious sign of any uterine or bowel perforation. The final histopathology revealed endometrioid adenocarcinoma grade 1, stage IA, with tumor located at the fundus along with cervical isthmic perforation on the posterolateral wall with full thickness ileum perforation. Uterine perforation at D&C is a known complication, but a silent bowel injury presenting with intestinal tissue in endometrial biopsy is very unusual. A high degree of suspicion is required to detect such complications at D&C especially in postmenopausal women with past history of abdominal surgery.

Laparoscopic Ligation of Uterine Vasculature for Fertility-Sparing Management of Postabortal Hemorrhage

Study ObjectiveTo present a surgical video in which bilateral uterine vasculature was ligated laparoscopically in order to preserve the uterus in a patient with postabortal hemorrhage. DesignA case report (Canadian Task Force classification III). SettingA tertiary referral center in New Haven, CT. InterventionsThis is a step-by-step demonstration of laparoscopic ligation of the uterine vasculature in a patient with postabortal hemorrhage. The patient was a 33-year-old Para 4014 woman who presented with postabortal hemorrhage after she underwent an urgent dilation and evacuation for the management of symptomatic placenta accreta at 19 weeks of pregnancy. The patient underwent a physical examination when she presented to the emergency department with postabortal hemorrhage. She was hemodynamically stable, and the examination was negative for cervical or vaginal lacerations. Coagulation studies were negative for any coagulopathy. A pelvic ultrasound did not show any retained products of conception. As per the Society of Family Planning guidelines, uterine massage was performed, and uterotonics (i.e., methylergonovine maleate 0.2 mg intramuscularly and misoprostol 1000 mg per rectum) were given [1]. The postabortal hemorrhage persisted despite medical therapy with an approximate blood loss of 600 mL over 2 hours. An intrauterine tamponade balloon was placed, and the patient then underwent a uterine angiogram and bilateral uterine artery embolization secondary to continued vaginal bleeding despite medical management. She was closely monitored and noted to have another 500 mL of blood loss over 2 hours after completion of uterine artery embolization. At this point, she was resuscitated with 2 U red blood cells because she developed symptoms of hemodynamic instability. Her hematocrit was increased suboptimally after transfusion with stabilization of her vitals. The patient was then counseled on her surgical options because she had failed medical management, intrauterine balloon tamponade, and uterine artery embolization. She stated a strong desire to preserve her uterus. Given her overall hemodynamic stability, laparoscopic ligation of the uterine vessels was proposed, which she agreed on [2]. Risks of the laparoscopic approach were explained to the patient, which included injury to the uterus, ureters, blood vessels, and nerves as well as the possibility of conversion to laparotomy. The surgery started with exploration of the peritoneal cavity. Her uterus was noted to be significantly enlarged with many engorged vessels. In order to decrease the risk of uterine perforation in this bulky and highly vascular uterus, the surgeon decided not to place a uterine manipulator. The retroperitoneum was entered at the right pelvic sidewall. Pararectal and paravesical spaces were then developed. Ureterolysis was performed in order to free its peritoneal and uterine artery attachments. The uterine artery was skeletonized cephalad to the hypogastric bifurcation and was ligated with 5-mm vascular clips. The attention was then turned to the ovarian vessels at the cornu of the uterus. Peritoneal avascular windows were created inferior and superior to the vessels. The blood supply was then ligated with an absorbable suture, and the ligature was secured using the extracorporeal knot tying technique. The same steps were repeated on the left pelvic sidewall. The procedure was completed once excellent hemostasis was assured. Besides the technical steps of the procedure, pelvic anatomic landmarks have also been emphasized in this video for educational purposes. Measurements and Main ResultsLaparoscopic ligation of the uterine vasculature was performed without any complications. The operative time was 65 minutes, and blood loss was minimal. The patient had an uneventful postoperative course and was discharged home the day after her laparoscopic surgery. ConclusionThe uterus was preserved with this minimally invasive approach for the management of postabortal hemorrhage. Laparoscopic ligation of the uterine vessels should be considered in hemodynamically stable patients who desire future fertility when managing postabortal hemorrhage.

Evaluation of a Novel Fluid Monitoring Device for Hysteroscopic Surgery

Objective: To evaluate the performance of a simplified fluid monitoring device for monitoring fluid deficit and uterine perforation during hysteroscopic surgery.Material and Method: A novel fluid deficit monitoring device was developed using a weighing system operated by a microcontroller. The deficit volume in milliliters (mL) is continuously monitored with an updated display every 30 seconds. The deficit LED is preset to begin flashing with an alarm sound if a fluid deficit reaches 750 mL, 1,000 mL, and 2,500 mL. A new algorithm for detection of small uterine perforations was also developed. The device can be loaded with a maximum of four bottles of 1 liter distention media and has two 2 liters collecting canisters. After having passed laboratory testing, the prototype was clinically used in hysteroscopic surgeries.Results: The laboratory testing showed a precision of ±7 mL at 500 mL, with an accuracy of ±8.9% for deficit volume measurement with 100% alarm at the preset levels. The perforation alarm could detect a small uterine perforation with 80.0% accuracy in an average (±standard deviation; S.D.) latency time of 3.2±0.2 minutes with an average (±S.D.) fluid leakage of 472±35 mL. The device performed well in a preliminary series of 42 hysteroscopic surgery cases from October 2014 to February 2016. Deficit-volume detection by the device correlated well with clinical evaluations by operating room personnel (r=0.840, p-value&lt;0.001).Conclusion: The newly developed fluid monitoring device can provide acceptable precision and accuracy for monitoring fluid deficits and detection of small uterine perforations during hysteroscopic surgery.

Uterine perforation following abortion in Tikur Anbessa Hospital, Addis Ababa, Ethiopia: A case series study

AbstractObjective: determine incidence, describe patient characteristics, examine clinicalpresentation, associated complications and describe mode of management of cases withuterine perforation.Methods: Operation registry, abortion care logbook and patients’ clinical records werereviewed in a teaching hospital in Addis Ababa, Ethiopia, between January 1, 1999 andDecember 31, 2000. Cases with laparatomy proven uterine perforation are described.Setting: obstetric and gynecologic department of a tertiary referral and teaching hospitalin Addis Ababa, Ethiopia.Outcome measures: clinical presentation, intraoperative findings, site of perforation,mode of management, associated complications and outcome of treatment.Results: there were a total of 927 abortions of which 25 were laparatomy proven cases ofuterine perforation following unsafe abortion, making the prevalence 27/1000 abortions.Majority were fond to be single, nulliparous, young and dependent member of the family.In 36% (9/25) termination was attempted after 14 weeks of gestation. Plastic and metallicmaterials are used frequently. Eight of the cases came after seven days of interference.The main clinical presentations were: abdominal pain (100%), signs of peritonitis(100%), pallor (96%), fever (76%) and vaginal bleeding (76%). Common intraoperativefindings include abdominal abscess, adhesions, and inflamed ovaries and tubes. Frequentareas of perforation are posterior aspect of the body and cervico-isthmic region of theuterus. Drainage and lavage of the abdominal cavity (80%), hysterectomy (76%) andremoval of adnexa (60%) were mainstays of management. All cases had sepsis andperitonitis, 24 had anemia, nine suffered from adult respiratory distress syndrome andeight developed wound infection. Duration of hospital stay ranged from one to 45 days.The case fatality rate was 32% (8/25). Only six came back for follow up.Conclusion: Uterine perforation is associated with increasing number of complicationsincluding death. Physicians catering the health care of women with unsafe abortion shallexhibit a high index of suspicion for uterine perforation. (Ethiop. J. Repro Health May2007, 1(1):17-27)

Hysteroscopic Diagnosis of Omentum Incarceration Subsequent to an Iatrogenic Uterine Perforation

Study ObjectiveTo present and discuss the hysteroscopic aspects of incarcerated omentum through uterine perforation caused by previous dilation and curettage (D&C) for an incomplete first-trimester abortion. DesignA case report. SettingConstantine University Hospital, Constantine, Algeria. PatientA 40-year-old, gravida 3, para 2 patient, with a history of an incomplete first-trimester spontaneous abortion treated 6 months before by D&C requiring medical assistance because of moderate, chronic pelvic pain. No other clinical or biological alteration was found. The ultrasound showed intracavitary hyperechogenic formation infiltrating the myometrium posteriorly. InterventionsHysteroscopy revealed a fatlike lesion arousing suspicion of a residual trophoblast; the differential diagnosis included intramyometrial fat metaplasia as well [1]. A mechanical cold loop resection was initiated. Instrumental manipulation of the mass released yellow drops, probably of lipid nature, subsequently leading to the discovery of a uterine perforation giving passage to the omentum. Histologic examination confirmed fat tissue. There was immediate resolution of symptoms. Laparoscopic repair was subsequently performed and consisted of suturing the defect. There were no further complications. Measurements and Main ResultsFew cases of omentum incarceration in a perforated uterus diagnosed during laparotomy or by magnetic resonance imaging have previously been reported [2–4]. To our knowledge, this is the first case revealed through hysteroscopy. ConclusionIn women with a history of intracavitary interventions such as D&C, omentum incarceration should be considered when hysteroscopy demonstrates a fatlike formation and yellow droplets released by pressing or mobilizing the formation. Surgeons should be cautious, never using electrosurgery on formations whose origin arouses suspicion.