Postpartum Curettage Research Articles

Predicting risk of postpartum hemorrhage associated with vaginal delivery of twins: A retrospective study.

Many studies have only focused on the risk factors for postpartum hemorrhage (PPH) in singleton vaginal deliveries and twin cesarean deliveries. We analyzed the factors of influencing PPH occurrence in twin vaginal deliveries and developed a nomogram for clinical application. This retrospective study included 274 pregnant women with twin pregnancies who were hospitalized for delivery from January 2014 to December 2018. The patients opted for vaginal delivery and experienced spontaneous labor. Univariate analysis of PPH risk factors was performed. Multivariate analysis was performed using the least absolute shrinkage and selection operator (LASSO) to obtain relevant factors and build a prediction model, which was presented as a nomogram. The model was internally validated by bootstrap self-sampling method. Model accuracy was evaluated with the concordance index (C-index). There were 36 (13.14%) and 238 (86.9%) patients in the PPH and no PPH groups, respectively. Univariate analysis identified twin chorionicity, hypertensive disorders complicating pregnancy (HDCP), anemia in pregnancy, delivery mode of the second twin, oxytocin use during labor, postpartum curettage, cervical laceration, intrapartum fever, fibrinogen degradation products (FDP), and platelet count (PLT) as significant PPH factors. On multivariate analysis, HDCP, anemia in pregnancy, intrapartum fever, oxytocin use during labor, fetal distress, PLT, direct bilirubin, and FDP were noted as significant PPH factors and were included in the prediction model. A C-index of 0.816 was noted after internal validation, and the calibration curve showed good consistency. We developed a model to predict PPH risk in the vaginal delivery of twin pregnancies and visualized it with a nomogram that can be applied clinically to assess PPH risk and aid PPH prevention.

Outpatient management of preterm prelabor rupture of membranes before 34 weeks: Maternal and neonatal outcomes.

To evaluate the maternal, fetal, and neonatal outcomes of pregnant women complicated with preterm prelabor rupture of membranes (PPROM) eligible for outpatient care. This study included a retrospective cohort of patients with singleton pregnancies with PPROM between 23+0 to 34+0 weeks who remained pregnant after the first 72 h. Outpatient management was considered in women with clinical, ultrasound and analytical stability, and easy access to hospital. Maternal, fetal, and neonatal results were compared between women managed as inpatients versus those managed as outpatients. Women eligible for the outpatient management had a better prognostic profile (no anhydramnios, longer cervical length, less intraamniotic infection, and clinical, ultrasound, and analytical stability) and presented a lower gestational age at admission and longer latency to delivery, resulting in a similar gestational age at delivery as the inpatient group. Postpartum curettage, uterine atony, respiratory distress syndrome, and bronchopulmonary dysplasia were less frequent in the outpatient group. Composite maternal-fetal morbidity and mortality outcomes were similar in both groups, while composite neonatal morbidity and mortality outcomes were significantly lower in the outpatient group. Outpatient management may be an option for women presenting stable PPROM before 34 weeks when adequate selection criteria are fulfilled. Differences in perinatal outcomes in the outpatient group compared with the inpatient group are probably attributable to baseline characteristics. Further prospective randomized studies are needed to confirm the benefits of outpatient management in PPROM.

The impact of epidural analgesia on third stage of labor disorders

To evaluate whether epidural analgesia (EA) is associated with complications of the third stage of labor. In this retrospective population-based cohort study, all women who delivered between the years 1996-2016 in a large tertiary medical center were divided to those who used EA during labor (study group) and those who did not (comparison group). We excluded from the analysis women with multiple pregnancies, congenital malformations, women who underwent a cesarean section, those complicated with uterine rupture in the index pregnancy and those lacking prenatal care. Clinical, demographical and obstetrical characteristics were collected and pregnancy complications and adverse perinatal outcomes were compared between the groups. Univariate analysis was followed by a multivariate analysis to control for confounders. A p-value of < 0.05 was considered statistically significant. During the study period, 209,096 patients met the inclusion criteria. Of these, 43,413 (20.7%) delivered with EA. Significantly higher rates of postpartum hemorrhage (PPH), need for blood transfusions and anemia (Hemoglobin less than 10gr/dl) were noted in the study group. A composite of placental complications (including retained placenta, adherent placenta, need for manual removal of the placenta, postpartum curettage, revision of the uterine cavity) was not found to be significantly different between the groups. In a multivariate analysis, after controlling for maternal age, vacuum delivery, polyhydramnios and previous cesarean delivery, EA was found to be an independent risk factor for a composite hemorrhagic outcome (including PPH, need for blood transfusion and anemia). EA was significantly associated with hemorrhagic complications (PPH, need for blood transfusions and anemia) independent of third stage of labor placental complications.

Retraction Note: Does immediate postpartum curettage of the endometrium accelerate recovery from preeclampsia-eclampsia? A randomized controlled trial.

Retraction Note: Does immediate postpartum curettage of the endometrium accelerate recovery from preeclampsia-eclampsia? A randomized controlled trial.

Stem cell therapy in the treatment of organic and dysfunctional endometrial pathology.

Intrauterine adhesions caused by postpartum curettage, spontaneous abortions, interrupted pregnancies, endometrial ablations, infections and inflammations, can lead to a loss of endometrial function, with consequent hypomenorrhea and infertility in women of reproductive age. In a non-negligible percentage of cases, the available surgical methods and hormone therapy, with sequential administration of estrogen and progesterone, are ineffective. In fact, severe damage to the basal layer of the endometrium causes the loss of endometrial cell precursors and leads to the failure of regeneration of the functional layer to which the endometrium is cyclically exposed. Today, many researchers are evaluating the use of stem cells of different origins as a potential therapy to restore endometrial function. Our interest has been focused on adipose-derived stromal/stem cells (ADSCs) obtained by collecting subcutaneous adipose tissue and subsequently treating it with the MilliGraft® method. This procedure produces a cell suspension, the stromal vascular fraction (SVF), which includes ADSCs and soluble factors such as proteins and extracellular vesicles (exosomes). The SVF thus obtained was characterized in its cellular composition and its functional factors. Our clinical protocol for the future use of adipose tissue in endometrial regeneration in its different phases is presented. The data obtained, even though they still require further support and implementation, show the regenerative properties of SVF obtained from adipose tissue using a mechanical method. These findings can contribute to the development of cell therapies using stem cells of different derivations which are increasingly being utilized in the treatment of endometrial lesions from adherent or dysfunctional pathologies.

Acute Sheehan’s syndrome manifesting initially with diabetes insipidus postpartum: a case report and systematic literature review

PurposeAcute Sheehan’s syndrome is a rare, but potentially life-threatening, obstetric event that can be complicated by diabetes insipidus. Little information on the diagnosis and treatment of Sheehan’s syndrome with diabetes insipidus is available. We report on a 28-year-old patient who developed acute Sheehan’s syndrome with diabetes insipidus after giving birth, and on a systematic review of similar cases.MethodsWe performed a systematic review of the literature cataloged in PubMed and Google Scholar using the keywords “Sheehan syndrome” OR “Sheehan's syndrome” AND “diabetes insipidus” to identify relevant case reports published between 1990 and 2021. Eight Reports met the inclusion criteria (English-language abstracts available, onset in the puerperium, information about the day of the onset).ResultsIn the present case, postpartum curettage was necessary to remove the residual placenta. The total amount of blood loss was severe (2500 ml). On the second day postpartal, the patient developed polyuria. Laboratory analysis revealed hypernatremia with increased serum osmolality and decreased urinary osmolality. Hormone analysis showed partial hypopituitarism involving the thyroid, corticotropic, and gonadotropic axes. The prolactin level was elevated. Brain magnetic resonance imaging showed pituitary gland infarction. Desmopressin therapy was initiated and resolved the polyuria. Hormone replacement therapy was administered. Four months later, the patient was well, with partial diabetes insipidus. The literature review indicated that this case was typical in terms of symptoms and disease onset. Most reported cases involve hypotension and peripartum hemorrhage, but some patients without hemorrhage also develop Sheehan’s syndrome. Elevated prolactin levels are uncommon and associated with poor prognosis in patients with Sheehan’s syndrome.ConclusionAcute Sheehan’s syndrome with diabetes insipidus involves nearly all pituitary hormone axes, indicating severe disease. Prolactin elevation could suggest that a case of Sheehan’s syndrome is severe.

Postpartum retained products of conception: Is it possible to avoid postpartum curettage?

Removal of retained products of conception (RPOC) by suction curettage or hysteroscopy may be required in the postpartum period, possibly causing intrauterine adhesions. We investigated whether rates of suction curettage, hysteroscopy, and postoperative intrauterine adhesions have changed over time. Parturients considered at risk for RPOC were followed in a specialized postpartum clinic with sequential ultrasound scans. We compared the rates of women requiring surgical procedures for RPOC removal and rates of postoperative intrauterine adhesions between two 2-year periods: 2011-2012 ("early period") and 2016-2017 ("late period"). The overall rates of women requiring a surgical procedure for removal of RPOC did not differ between the early and late periods (38/762 [5.0%] vs 41/732 [5.6%], respectively, P=0.595). However, removal of RPOC by suction curettage decreased significantly over time whereas removal by hysteroscopy increased (P=0.022). Intrauterine adhesions were diagnosed in 7 of 38 women (18.4%) who underwent a surgical procedure for RPOC removal in the early period, but none of the patients operated on in the late period developed intrauterine adhesions (P=0.004). Removal of RPOC in postpartum women may be completed by hysteroscopy in most cases, significantly reducing the need for postpartum curettage and the rates of postoperative intrauterine adhesions.

Collection of umbilical cord blood and the risk of complications in postpartum women after natural labour in the context of the possibility of umbilical cord stem cells usage in clinical practice.

Comparison of changes in peripheral blood venous morphology and the frequency of select complications in patients who underwent umbilical cord blood collection during the third stage of labour by in the utero method compared to patients who did not undergo this procedure. Presentation of current therapeutic possibilities of cord blood stem cells. The study involved 248 patients who had a vaginal delivery and had umbilical cord blood taken by in utero method during the third stage of labour. The control group consisted of the first 400 patients who gave vaginal delivery starting in 2019. Each patient had a venous peripheral blood count taken before delivery and 18 hours after delivery. Changes in the results of laboratory tests and the occurrence of adverse outcomes, such as postpartum curettage, postpartum haemorrhage and manual removal of placenta, in the 3rd and 4th stage delivery periods, were analysed. In the blood donor group there were significantly lower haemoglobin (11.32 g/L vs 11.61 g/L, p = 0.004) and haematocrit (32.83% vs 33.82% p = 0.001) concentrations after delivery. Umbilical cord donors had a greater difference in haemoglobin (postpartum minus prepartum) (-1.4 g/L vs -0.9 g/L, p = 000), and haematocrit (-4.05% vs -2.5% , p = 0.000). The study group had a higher percentage of patients with postpartum anaemia (haemoglobin concentration < 10 g/L) (15.9% vs 10.64%, p = 0.05), but the result were borderline significant. The groups did not differ in terms of the percentage of postpartum curettage, PPH, manual removal of placenta, percentage of severe anaemia (Hb < 7g/L) or transfusion requirement. Collection of umbilical cord blood during the 3rd stage of labour using the in utero method is associated with a statistically significant increase of blood loss and a higher probability of postpartum anaemia. The observed changes are minor and may have little clinical significance in otherwise healthy patients.

A Rare Case of Intrauterine Adhesion Caused by Intrauterine Fallopian Tube Incarceration

Hysteroscopy is widely used for the detection and treatment of intrauterine adhesion. Such technique, however, sometimes has limitations and even second damages. We report a rare case of severe intrauterine adhesion caused by uterine perforation with a fallopian tube incarceration. A 24-year-old woman underwent severe intrauterine adhesion and secondary infertility caused by fallopian tube incaceration into the uterine cavity after postpartum curettage. First hysteroscopy created a false passage through the previous uterine perforation, entered into the cavity of incarcerated fallopian tube, and led to iatrogenic hydrosalpinx. Secondary hysteroscopy combined with laparoscopy revealed a connection between the right tubal lumen and the uterine cavity by the false passage, released the adhesion, and reconstructed the uterine cavity. Early recognition of uterine perforation or tissue incarcerarion is significant in preventing further damage.

Maternal and fetal outcomes of patients referred from primary health-care facilities to a tertiary hospital: A cross-sectional study

INTRODUCTION: There is insufficient local data on the maternal and fetal morbidity and mortality of cases seen initially at the primary health-care facility (PHCF) and subsequently referred to a tertiary hospital for acute management. This study aimed to determine the maternal and fetal outcomes of such patients using the World Health Organization maternal near miss, mortality, and neonatal mortality rates. MATERIALS AND METHODS: A cross-sectional study was done that involved obstetric patients beyond 20-week gestation and in the immediate postpartum who were initially managed at the PHCF then referred to a tertiary hospital for management. RESULTS: There were 485 deliveries (85.5%) with a primary cesarean section rate of 16.6%. One patient underwent exploratory laparotomy for uterine rupture with extraction of a stillborn baby and hysterectomy. Eighteen cases (3.2%) necessitated other forms of surgical interventions including hysterectomy (6), transverse compression suture (3) with bilateral uterine or hypogastric artery ligation, uterine repositioning (1), evacuation of vaginal hematoma (4), balloon pack insertion (2), postpartum curettage (1), and removal of retained suture needle (1). The maternal near-miss rate is 46.7/1000 live births (46.7%). There were three intensive care unit admissions and 5 cases required ventilatory support. The maternal mortality rate is 10.6 maternal deaths per 1000 live births (1.06%). Majority of the babies had good APGAR scores at birth. Twenty-two babies (4.5%) required intensive neonatal management. The neonatal mortality rate is 0.42% or 4.2/1000 live births. CONCLUSIONS: Almost 40% of referred cases were primigravidas and have preexisting medical problems that should not have been seen at the primary care level but directed to secondary or tertiary center at the outset. It cannot be understated that education of the populace, more training, and monitoring the performance of base health facility workers should be done to prevent maternal and fetal catastrophes.

Asherman syndrome: Audit of a single-operator cohort of 423 cases.

BackgroundThe diagnosis of Asherman syndrome, or ‘intra‐uterine adhesions’ is often overlooked when the symptoms of amenorrhea and hematometra are missing.AimsThis audit reviews the clinical data of a large cohort of patients treated by a single operator.Materials and MethodsFrom July 1998 till the end of December 2017, 423 patients with intra‐uterine adhesions were treated by a single operator. Clinical information was obtained by review of the medical files and phone interviews.ResultsAmenorrhea was recorded in 163/423 patients (38.5%), 225/423 (53.2%) patients did not have amenorrhea and for 35/423 (8.3%) patients the information was missing. A hematometra was documented in 19/423 (4.5%) patients. Pregnancy was achieved in 215/246 (87.4%). Patients with stage II disease did best with a pregnancy rate of 94.5% (P = 0.029).ConclusionAsherman syndrome should be considered in any woman with a history of miscarriage or postpartum curettage who then fails to conceive again.

Third stage of labor placental complications and placenta-associated syndromes

Objective To evaluate the association between third stage placental complications and placental insufficiency associated disorders, also known as, placenta associated syndromes. Study design A population-based retrospective cohort study comparing placental-related perinatal outcomes of parturient with (study group) and without third stage placental complications, defined as a composite of retained placenta, adherent placenta, placenta accrete, need for manual removal of the placenta, postpartum curettage and revision of the uterine cavity. A univariate analysis was followed by a multivariable logistic regression model. Results During the study period, 263,023 deliveries met inclusion criteria, of which, 10,281 (3.9%) experienced placental complications during the third stage of labor. Parturient in the study group had significantly higher rates of placental insufficiency associated disorders which included among others: hypertensive disorders of pregnancy (6.5 versus 5.6%, p < .001), stillbirth (1.9 versus 0.7%, p < .001) and preterm delivery (9.9 versus 7.7%, p < .001). Using a multivariable regression model, while controlling for confounders such as maternal age and induction of labor, third stage placental complications were independently associated with placental insufficiency associated disorders. Conclusion Our findings suggest that placental associated adverse pregnancy outcomes and third stage placental complications may represent different manifestations of a common pathological or inadequate placentation process.

Effects of postpartum uterine curettage in the recovery from Preeclampsia/Eclampsia. A randomized, controlled trial.

To evaluate if postpartum uterine curettage improved the clinical and laboratory parameters in patients with preeclampsia or eclampsia. A total of 442 patients with preeclampsia/eclampsia were randomized to postpartum curettage (223) or no procedure (219). Systolic and diastolic blood pressure were recorded and analyzed at hours 6, 12, 24 and 48. Also, several laboratory values and diuresis were evaluated. No statistical differences were found between groups (curettage vs. no procedure) in regards to systolic [155.74(15.43) vs. 156.81(15.58)] and/or diastolic blood pressure [101.51(11.44) vs. 101.70(11.20)] before and after the allocated procedure, starting at hour 6 [SBP: 134.19(13.11) vs. 136.65(15.36); DBP: 87.20(9.42) vs. 88.57(10.98)] and up to 48 h after delivery [SBP: 126.59(15.54) vs. 128.21(13.85); DBP: 81.86(9.92) vs. 81.67(11.33)]. No statistical differences between groups were found in the rate of recovery of laboratory values, as well as in the need for additional antihypertensive medications in the postpartum period. These results applied to patients with severe preeclampsia (210 patients in both arms) and eclampsia (13 vs. 9). There were no cases of postpartum eclampsia or acute renal failure after delivery in any of the groups. To perform a postpartum uterine curettage does not present an advantage in the patient with preeclampsia/eclampsia. The procedure dos not improve clinical or laboratory values.

Role of Postpartum Curettage in the Control of Hypertension in Severe Preeclampsia

Role of Postpartum Curettage in the Control of Hypertension in Severe Preeclampsia

Asherman’s syndrome after an uncomplicated cesarian section

Intrauterine adhesions (IUAs) and their worst form, the Asherman’s syndrome, are the result of endometrium basal layer damage, leading to partial or complete obliteration of the uterine cavity by fibrous bridges between the uterine walls. We present the case of a 30 years old woman, gravida 1, para 1 that suffers from secondary amenorrhea and infertility resulted from IUAs formation after an uncomplicated cesarean section, which she underwent 2 years before. Although she never breastfed, she did not start menstruating again after the cesarean section. Clinical and hormonal examinations were in normal ranges and the transvaginal ultrasound revealed an eccentric echogenic endometrium. Hysterosalpingography showed multiple intrauterine filling defects and bilateral tubal occlusion. The operative hysteroscopy revealed multiple intrauterine adhesions originating from the former caesarean incision site and extending to the entire uterine cavity. In spite of hysteroscopic adhesiolysis, intrauterine device insertion and hormonal therapy being provided, the patient never regained fertility. Patients with Asherman’s syndrome usually present infertility, recurrent pregnancy loss, amenorrhea or hypomenorrhea. The main cause is known to be the endometrium damage following pregnancy-related curettage. Less common etiologic factors are represented by caesarean section, hysteroscopic procedures, myomectomy and histerotomy. Around 2-2.8% of the patients develop IUAs after cesarian section, more likely as a result of chorioamnionitis, postpartum endometritis, postpartum curettage or uterine compression sutures for postpartum hemorrhage. Severe intrauterine adhesions are a challenging gynecological pathology. The particularity of the case is due to an unusual extensive endometrium damage following uncomplicated caesarian section.

Does Immediate Postpartum Curettage of the Endometrium Accelerate Recovery From Preeclampsia–Eclampsia? A Randomized Controlled Trial

To evaluate the effect of immediate postpartum curettage on rapid resolution of clinical and laboratory indices in pre-eclampsia and eclampsia women. A randomized controlled study, comprised of 420 pre-eclamptic or eclamptic women with singleton pregnancy 24 weeks gestation and more. Patients were divided into two groups: 220 patients underwent immediate postpartum curettage and 200 patients as a control group. The clinical and laboratory prenatal parameters showed no statistical significant differences between both groups. The follow-up for the postnatal clinical and laboratory data showed significant improvement for the mean arterial blood pressure in the curettage group over 6, 12, and 24 h after delivery and significant improvement in the platelet count as well. The average time required for MAP to reach 105 mmHg or less was significantly shorter (P < 0.05) in the curettage group (40 ± 3.15 h) than the control group (86 ± 5.34 h). Two patients in the curettage group developed convulsions versus 11 patients in the control group within the first 24 h after delivery. No maternal mortalities were reported in both groups. Immediate postpartum curettage is a safe and effective procedure and can accelerate recovery from pre-eclampsia or eclampsia.

English

OBJECTIVE: To access the ability of immediate postpartum curettage to accelerate maternal recovery from severe pre eclampsia and eclampsia. MATERIAL AND METHODS: 100 patients with severe pre-eclampsia and eclampsia where assigned to postpartum curettage following delivery or to have no curettage. RESULTS: subjects who underwent immediate curettage had a decreased MAP at each fourth hourly for the first 24 hrs compared to those who were not curetted. The urine output after uterine curettage was significantly greater in the first four hours of 24hrs of postpartum period compared with controls. Platelet counts increased in 24hrs following a curettage where as controls exhibited at unchanged platelet count for 12 to 24hrs. CONCLUSION: Immediate postpartum curettage of the parturient in severe pre eclampsia and eclampsia appears to accelerate the recovery of the disease with no apparent adverse sequel.

RETRACTED ARTICLE: Does immediate postpartum curettage of the endometrium accelerate recovery from preeclampsia–eclampsia? A randomized controlled trial

To evaluate the effect of immediate postpartum curettage on rapid resolution of clinical and laboratory indices in pre-eclampsia and eclampsia women. A randomized controlled study, comprised of 420 pre-eclamptic or eclamptic women with singleton pregnancy 24 weeks gestation and more. Patients were divided into two groups: 220 patients underwent immediate postpartum curettage and 200 patients as a control group. The clinical and laboratory prenatal parameters showed no statistical significant differences between both groups. The follow-up for the postnatal clinical and laboratory data showed significant improvement for the mean arterial blood pressure in the curettage group over 6, 12, and 24 h after delivery and significant improvement in the platelet count as well. The average time required for MAP to reach 105 mmHg or less was significantly shorter (P < 0.05) in the curettage group (40 ± 3.15 h) than the control group (86 ± 5.34 h). Two patients in the curettage group developed convulsions versus 11 patients in the control group within the first 24 h after delivery. No maternal mortalities were reported in both groups. Immediate postpartum curettage is a safe and effective procedure and can accelerate recovery from pre-eclampsia or eclampsia.

Puerperal curettage after cesarean section delivery

To analyze the clinical situations that leads us to carry out curettage after cesarean section, the ultrasound prior surgery, intraoperative, and pathological findings. A retrospective study of all cases of postpartum curettage after cesarean section in a level 3 maternity unit. There were 42 curettages to women with cesarean sections (1.6% of all cesarean sections). The indications for curettage were: fever: 21, methrorraghia: 11, and residual trophoblastic tissue: 10. In the previous ultrasound, all indicated curettages for retained trophoblastic tissue showed it, and in a lower proportion those indicated for fever (66.6%) or methrorraghia (22.2%). A total of fourteen curettages (35%) were performed without suspect image of retained tissue, and in all cases the surgeon described to obtain small amount of tissue. From material submitted to pathologic evaluation trophoblastic tissue was found in 64.7%, and there were no differences as curettage indication. When the previous ultrasound do not showed retained tissue, the surgeon did not remove retained material. When extracted there were always in small amounts. Therefore, it could be concluded that after cesarean section the curettage should be indicated only in the presence of evident ultrasound image of retained products.

Is immediate post-partum curettage of the endometrium accelerate recovery from Preeclampsia–Eclampsia? Five Years Experience in Mansoura University

Is immediate post-partum curettage of the endometrium accelerate recovery from Preeclampsia–Eclampsia? Five Years Experience in Mansoura University