Previous Pelvic Inflammatory Disease Research Articles

Ovarian tissue biopsy for cryopreservation by vaginal natural orifice transluminal endoscopic surgery: a new approach for a minimal invasive ovarian biopsy

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging surgical procedure that combines the advantages of the vaginal approach with laparoscopic vision and instrumentation [1]. Shorter hospitalization and lower postoperative pain associated to vNOTES [2] may be explained by the advantages of this innovative surgical approach (such as absence of abdominal incisions, shorter operating time, lower insufflation pressure) [2;3]. Ovarian tissue cryopreservation allows to preserve reproductive and endocrine functions in young women with oncological disease at risk of premature ovarian insufficiency (POI) caused by gonadotoxic treatments [4]. Ovarian tissue biopsy for cryopreservation consists of a large biopsy of one or both ovaries [4] that is usually performed by laparoscopy. Then, the removed ovarian tissue is cryopreserved for the future transplant after cancer remission. Volume of ovarian biopsy ranges from 50% of the ovary for women at moderate risk of POI to 70 % or whole ovary for women at high risk [5]. Inclusion criteria for ovarian tissue cryopreservation are women aged less than 35 who cannot delay start of oncological treatments for follicles cryopreservation, with a moderate or high risk of POI and good chance of 5-year survival [6]. Ovarian tissue cryopreservation cannot be performed if tumor treatments include uterine irradiation or for tumors at risk of ovarian metastases (as in case of ovarian cancer, leukemia, neuroblastoma, Burkitt lymphoma) [7]. Despite widespread adoption of vNOTES in gynecology, ovarian biopsy for cryopreservation has never been performed using this route. Step-by-step explanation of the procedure with descriptive text and narrated video footage. Tertiary level referral academic center. A 27-years-old patient recently diagnosed with low grade follicular non-hodgkin lymphoma was referred to our center for ovarian tissue cryopreservation before chemotherapy. The patient included in this study gave informed consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. Due to the nature of the study, IRB approval was not required. Access to peritoneal cavity was created by a 3 cm posterior colpotomy. Peritoneum was then opened using cold scissors and temporarily fixed to the posterior vaginal wall. The Gelpoint Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA, USA), with one 10 mm and two 5 mm trocars, was used as vNOTES port. The inner Alexis ring of the Gelpoint was inserted through the colpotomy into the pouch of Douglas. An hysterometer was placed into the uterine cavity to keep the uterus anteverted during the surgery. A pneumoperitoneum was created to a pressure of 8 mmHg and the operating table was tilted to 20° Trendelenburg position. A 10-mm rigid 30° camera was inserted in the inferior and larger trocar and both the ovaries were visualized. 70 % of the left ovary was removed with cold scissors, in order to minimize trauma on the surgical specimen. After removal of the Gelpoint cap, ovarian biopsy was immediately picked-up by the biologist of our fertility center. The ovary was coagulated with bipolar instrument. Hysterometer was then replaced by a uterine manipulator to perform tubal patency test and blue dye passage through both the salpinges was observed. Finally, the Alexis retractor and the stich on the posterior peritoneum were removed and the vagina was sutured using interrupted stiches. Total operative time was 25 minutes. Ovarian tissue biopsy for cryopreservation by vNOTES. No intraoperative and postoperative complications were reported and the patient was discharged after 24 hours from surgery. VNOTES may be a feasible alternative approach to laparoscopy for ovarian tissue cryopreservation: it allows an easy access to the ovaries and removal of different tissue volumes. Patients undergoing ovarian cryopreservation may benefit of vNOTES approach since a rapid post-operative recovery is crucial to start chemotherapy in a short time. As for other vNOTES surgical procedures, accurate selection of patients seems to be crucial for a successful ovarian tissue cryopreservation [8]. We think that inclusion and exclusion criteria reported for other gynecologic procedures performed through vNOTES may also be valid for ovarian tissue cryopreservation by vNOTES [9]. Women at high risk of pelvic adhesions (such as coexistent endometriosis, previous pelvic surgery or inflammatory pelvic disease), with elevated Body Mass Index or enlarged uterus as well as women with cervical, vaginal or uterine cancer cannot be considered for this approach since all these factors are associated to failure of vNOTES. On the other hand, women with no history of surgery, endometriosis and large myomas may benefit from vNOTES approach and these women represent most of patients who undergo ovarian tissue cryopreservation.

Readmission following methotrexate treatment for tubal pregnancy.

To identify risk factors for readmission following methotrexate treatment for tubal pregnancy. A retrospective study undertaken in two tertiary medical centers, including all individuals with medically treated tubal pregnancy (N = 511), between December 2009 and June 2021. Individuals with and without readmission following methotrexate treatment were compared. The primary outcome was the readmission rate. Secondary outcomes included the rate of post-discharge gynecological emergency department visits, tubal rupture rate, and the eventual need for surgical treatment. Readmission following methotrexate treatment occurred in 224/511 patients (43.8%). Most readmissions were due to abdominal pain or suspicion of treatment failure. Readmitted individuals were more likely to have a history of pelvic inflammatory disease and pretreatment serum human chorionic gonadotropin (hCG) >2000 mIU/mL. Both factors remained significantly associated with higher readmission rates in a logistic regression analysis (adjusted odds ratio [OR] 6.28, 95% confidence interval [CI] 1.30-30.45, and adjusted OR 2.73, 95% CI 1.83-4.07, respectively) after adjustment for age, endometriosis, tubal pathology, abdominal pain, and presence of yolk sac or embryo at diagnosis. A dose-dependent association was observed between pretreatment serum hCG levels and readmission rate (P < 0.001). Pretreatment hCG levels were also associated with tubal rupture and the eventual need for surgical treatment (P < 0.001 for both). A prediction model using hCG was not sufficiently accurate to predict readmission risk. Readmission following methotrexate treatment for tubal pregnancy was independently associated with previous pelvic inflammatory disease and pretreatment serum hCG levels. The latter was also associated with surgical intervention rate.

Awareness of risk factors associated with tubal infertility among female youth corps members in Benin City, Nigeria

Infertility is the inability to achieve pregnancy within one year of regular unprotected coital exposures. It is a common gynecological problem in our environment. The cause of infertility could be of female origin, male origin, a combination of both, or idiopathic. It can be primary when there is no previous pregnancy, or secondary infertility when there is an inability to conceive after a previous conception. In secondary infertility, a tubal factor is the most typical cause globally. In a review of factors associated with tubal factor infertility in a tertiary hospital in southern Nigeria, the tubal aspect constituted 13.5%. It was due to previous post-abortion sepsis, puerperal sepsis, and Pelvic Inflammatory Disease (PID). Awareness of infertility risk factors is an essential first step to safeguard future fertility; however, several studies demonstrated poor knowledge of tubal infertility and its risk factors, especially among infertile couples and couples attending gynecology clinics. This study assesses the knowledge of female youth corps members in Benin City, Edo State, on tubal factor infertility, its risk factors, and management. A cross-sectional analytical study was conducted among female youth corps members in Benin City using a multi-stage sampling technique. A self-administered questionnaire was used for data collection. The data was entered and analyzed using Statistical Package for Social Sciences (SPSS) Version 25.0 (IBM SPSS V 25.0, Chicago, IL, USA) and presented using tables. From this study, there is good knowledge of the burden of tubal infertility and treatment implications (50.4%). However, the knowledge of tubal infertility (34.3%) and its risk factors (27.0%) was poor. Age, marriage, and the medical profession are associated with sound knowledge of the burden of tubal infertility (p=0.02). However, only the medical profession is independently associated with good knowledge of tubal infertility (AOR=2.963, p=0.006, CI=1.370-6.411). There is generally poor knowledge of tubal infertility among females of reproductive age, who are at higher risk of pelvic inflammatory disease being the most typical risk factor for tubal infertility. This calls for more health awareness programs for the youth to help safeguard their future fertility.

Pelvic inflammatory disease and risk of epithelial ovarian cancer: a national population-based case-control study in Sweden

Epithelial ovarian cancer is an insidious disease, and women are often diagnosed when the disease is beyond curative treatment. Accordingly, identifying modifiable risk factors is of paramount importance. Inflammation predisposes an individual to cancer in various organs, but whether pelvic inflammatory disease is associated with an increased risk of epithelial ovarian cancer has not been fully determined. The aim of the present study was to investigate a possible association between clinically verified pelvic inflammatory disease and risk of epithelial ovarian cancer. In this national population-based case-control study, we identified all women in Sweden diagnosed with epithelial ovarian cancer between 1999 and 2020 and ten controls for each, matched for age and residential district. Using several Swedish nationwide registers, we retrieved data on previous pelvic inflammatory disease and potential confounding factors (age, parity, educational level, and previous gynecological surgery). Adjusted odds ratios and 95% confidence intervals were estimated using conditional logistic regression. We performed histotype-specific analyzes for the subgroup of women diagnosed with epithelial ovarian cancer between 2015 and 2020. Hormonal contraceptives and menopausal hormone therapy were also adjusted for in addition to the aforementioned confounders. We included 15,072 women with epithelial ovarian cancer and 141,322 controls. A majority had serous carcinoma (n=9102, 60.4%). In a subgroup of cases diagnosed between 2015 and 2020 we identified high-grade serous carcinoma (n=2319, 60.0%). A total of 1.1% (n=168) of cases and 0.9% (n=1270) of controls were diagnosed with pelvic inflammatory disease. Previous pelvic inflammatory disease was associated with increased risk of epithelial ovarian cancer (adjusted odds ratio, 1.39; 95% confidence interval, 1.17-1.66) and serous carcinoma (adjusted odds ratio, 1.46; 95% confidence interval, 1.18-1.80) for the entire study population. For the subgroup of women diagnosed in 2015-2020, pelvic inflammatory disease was associated with high-grade serous carcinoma (adjusted odds ratio, 1.43; 95% confidence interval, 1.01-2.04). Odds ratios of the other histotypes were as follows: endometrioid (adjusted odds ratio, 0.13; 95% confidence interval, 0.02-1.06); mucinous (adjusted odds ratio, 1.55; 95% confidence interval, 0.56-4.29); and clear cell carcinoma (adjusted odds ratio, 2.30; 95% confidence interval, 0.90-5.86). A dose-response relationship was observed between the number of pelvic inflammatory disease episodes and risk of epithelial ovarian cancer (Ptrend<0.001). A history of pelvic inflammatory disease is associated with an increased risk of epithelial ovarian cancer and a dose-response relationship is evident. Histotype-specific analyzes show an association with increased risk of serous epithelial ovarian cancer and high-grade serous carcinoma, and potentially also with clear cell carcinoma, but no significant association with other histotypes. In conclusion, infection and inflammation of the upper reproductive tract might have serious long-term consequences, including epithelial ovarian cancer.

Intrauterine adhesions, peritubal adhesions and tubal occlusion on hysterosalpingography

Pelvic Inflammatory Disease (PID), Dilatation and Curettage (D&amp;C) and other abdominopelvic surgeries are often presumed to cause female infertility. This can occur through adhesions formation that can result in Intrauterine Adhesions (IUA), Peritubal Adhesions (PTA) and Tubal Occlusion (TO). Hysterosalpingography (HSG) can be used to diagnose IUA, PTA, and TO; and the correlations of these findings with the histories of PID, D&amp;C and other abdominopelvic surgeries statistically tested. The available literature shows very few of such correlation tests. The objective of this study was to document HSG diagnosis of IUA, PTA and TO, and test their correlation with histories of previous PID, D&amp;C and abdominopelvic surgeries among women with secondary infertility. This is a prospective descriptive study of 158 subjects, analyzed with SPSS version 21. For correlation test, p≤0.05 is considered significant. There was history of previous PID in 53 subjects (33.5%), D&amp;C in 114 (72.2%), and abdominopelvic surgery in 80 (50.6%). The important findings included: IUA in 20 subjects (12.7%), TO in 53 (33.5%) and PTA in 30 (19.0%). Significant correlation was found between D&amp;C and PTA, but not between PID and IUA, PID and TO, PID and PTA, D&amp;C and IUA, D&amp;C and TO, abdominopelvic surgery and IUA, abdominopelvic surgery and TO, or abdominopelvic surgery and PTA. Tubal occlusion, followed by PTA and by IUA were detected in that order as the possible causes of infertility in our subjects; and these did not correlate well with the history of PID, D&amp;C and other abdominopelvic surgeries.

Chlamydia infection, PID, and infertility: further evidence from a case–control study in China

BackgroundChlamydia trachomatis infection and pelvic inflammatory disease (PID) are well-known risk factors for female infertility. But there is limited evidence from China. This study aimed to further explore the associations between previous/current chlamydial infection, PID, and infertility in China.MethodsWe performed a 1:2 matched case–control study with two control groups: pregnant controls and non-pregnant controls in China in 2019. Women diagnosed with infertility were selected as cases (n = 255). Controls were selected based on the following criteria: Pregnant women who were documented in the selected hospitals were chosen as Pregnant controls (n = 510), and people who sought health care in Obstetric/Gynecologic clinics, Family Planning clinics, Dermatology and STD Department or Urological department were selected as Non-pregnant controls (n = 510). Infertility induced by male factors and people who used antibiotics in the vagina within two weeks were excluded. The first-stream specimen of urine samples was tested for chlamydia by nucleic acid amplification testing (NAAT). Conditional logistic regression was used to estimate the association.ResultsThe prevalence of previous chlamydial infection and PID were significantly higher in cases (2.4%, 17.3%) than in controls (Non-pregnancy: 0.4%, 3.0%; Pregnancy: 0.4%, 9.0%). The current chlamydial infection rates were 5.9%, 7.3%, and 7.1% in infertile, pregnant, and non-pregnant women, respectively. After adjusting for confounders, PID largely elevated the risk of infertility (using non-pregnant controls: adjusted OR = 2.57, 95% CI 1.51, 4.39; using pregnant controls: adjusted OR = 6.83, 95% CI 3.47, 13.43). And the positive association between PID and tubal infertility was more obvious for both groups. For current chlamydial infection, none of the odds ratios were significant at the 0.05 level, while small sample size limited the evaluation of an association between prior chlamydial infection with infertility.ConclusionsPrevious PID was indicated to largely increase the risk of infertility, especially tubal infertility. And there should be continuing emphasis on highly sensitive and specific biomarker for prior chlamydial infection.

The Effect of Pelvic Inflammatory Disease on Risk of Endometriosis: A Systematic Review and Meta-Analysis

To systematically review the evidence for the association between previous pelvic inflammatory disease (PID) and endometriosis.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Risk Factors and Outcomes of Conversion to Open Surgery in Benign Gynecologic Laparoscopies: A Case-Control Study

To describe cases of conversion from gynecologic laparoscopy to open surgery and to assess risk factors for conversion and conversion outcomes. A retrospective case-control study. Tertiary referral hospital in Melbourne, Australia. Eighty-five cases of conversion from laparoscopy to laparotomy and 170 controls matched by age, surgical date, and gynecologic unit from 2006 to 2017. Demographic, clinical, and surgical data were collected and compared between the study groups. Logistic regression was performed to identify preoperative and intraoperative risk factors for conversion. Rate of conversion during the study period was 0.7%. The most common indication for conversion was unexpected surgical complexity (67% of cases), which included severe adhesive disease, specimen size, severe pathology, and inadequate views. Factors that were significantly associated with risk of conversion in multivariate analysis were previous pelvic inflammatory disease (adjusted odds ratio [aOR] 5.16; 95% confidence interval [CI], 1.35-19.71; p=.02), previous open surgery (aOR 3.62; 95% CI, 1.52-8.58; p <.01), history of endometriosis (aOR 2.96; 95% CI, 1.17-7.50; p=.02), and elevated body mass index (aOR 1.07; 95% CI, 1.01-1.13; p=.02). As compared with current surgery for endometriosis, odds of conversion were higher in surgeries for emergency indications (aOR 5.40; 95% CI, 1.53-18.98; p <.01), uterine pathologies (aOR 3.34; 95% CI, 1.10-10.12; p=.03), and adnexal pathologies (aOR 2.76; 95% CI, 1.19-6.40; p=.02). With the inclusion of intraoperative factors, surgical adhesions were also found to be associated with conversion (aOR 3.19; 95% CI, 1.30-7.85; p=.01). Most skilled laparoscopic surgeon level as defined by the Australasian Gynaecological Endoscopy and Surgery Society was not associated with conversion risk. Conversion to laparotomy was associated with a higher rate of intraoperative and postoperative complications and prolonged length of stay. Conversion to laparotomy is a rare but very important clinical outcome measure of laparoscopic surgery. Understanding the factors contributing to conversion and perioperative outcomes may help clinicians to identify and counsel patients before surgery and to reduce surgical morbidity.

Prevalence of negative sliding sign representing pouch of Douglas obliteration during pelvic transvaginal ultrasound for any indication

Pouch of Douglas (POD) obliteration can be predicted with a high degree of certainty and reproducibility using the dynamic transvaginal ultrasound (TVS) sliding-sign technique. So far, studies on POD obliteration prediction have focused on tertiary-care populations with high prevalence of endometriosis; however, POD obliteration may exist in individuals with asymptomatic endometriosis or other conditions. Our primary aim was to determine the prevalence of a negative sliding sign, representing POD obliteration, in a cohort of patients undergoing TVS for any gynecological indication. This was a prospective observational study of consecutive women with an indication for gynecological TVS, conducted at a high-volume ultrasound practice between July and August 2018. Clinical and surgical history, indication for TVS and TVS findings were documented. The prevalence of TVS-confirmed POD obliteration, determined by interpretation of the sliding sign, was calculated for the entire cohort and for the subgroups of women with and without risk factors for endometriosis. High risk for endometriosis was defined as having (1) a TVS referral for endometriosis-like pelvic pain or endometriosis specifically and/or (2) clinical symptoms or signs suggestive of endometriosis. Low risk was defined as the absence of these characteristics. During the study period, 1043 consecutive women underwent TVS. After excluding those who underwent transabdominal ultrasound, had a history of hysterectomy or with missing data, 909 women were analyzed. The prevalence of a negative sliding sign in the entire cohort was 47/909 (5.2%). A negative sliding sign was observed in 22/639 (3.4%) women with a low risk for endometriosis and 25/243 (10.3%) of those with a high risk for endometriosis (difference in proportions, 6.9% (95% CI 2.8-10.9%); P < 0.001). We have demonstrated an overall prevalence of a negative sliding sign, suggesting POD obliteration, of 5.2% (or 1/20) in women seeking TVS for a gynecological indication. The prevalence of negative sliding sign in low-risk women is not negligible (3.4% or 1/29 women). These women are most likely to have asymptomatic endometriosis or another important etiology of POD obliteration. The prevalence of a negative sliding sign is approximately three-times higher in women with signs and/or symptoms of endometriosis (10.3% vs 3.4%). Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Clinical Study of Ectopic Pregnancy in Al-Zahra Teaching

An ectopic pregnancy is one in which fertilized ovum is implanted at the site other than normal uterine cavity.[1] Incidence of ectopic pregnancy is 1:160 deliveries.[2]Clinical presentation is variable from acute to chronic type. Due to its varied clinical presentation ectopic pregnancy poses great diagnostic difficulty both to obstetrician, physician and surgeons.[3] OBJECTIVE: To find out incidence in our study population and to evaluate symptomatically and clinical presentation in these patients. MATERIALS AND METHODS: Retrospective study of 34 ectopic pregnancies admitted and treated in Al-zahra Teaching Hospital from 2015 to 2020 are included in the study. RESULTS : The incidence of ectopic pregnancy is more between the age group of 21-30years (73.52%) and in Multigravida 64.71%. Infertility and previous tubal surgery are the high risk factors for tubal pregnancy. Pain in abdomen was present in all 34 cases, amenorrhea in 97.05% and bleeding per vagina in 76.47% cases. Syncopal attacks, vomiting were detected in 14.70% cases. Acute ectopic pregnancy was detected in 14.71% and chronic in 85.29% cases. 82.35% cases presented with adnexal mass, 79.41% with cervical motion tenderness, 50% with pallor, 32.35% with abdominal lump and tenderness and 11.76% with fullness in POD. CONCLUSION : Ectopic pregnancy is leading cause of maternal mortality in first trimester. In spite of advanced diagnostic techniques. It poses great diagnostic difficulties due to varied signs and symptoms. Previous tubal surgery pelvic inflammatory disease and infertility are the risk factors of tubal pregnancy. KEYWORDS : Ectopic pregnancy, Salpingectomy, Ovarian pregnancy. DOI: 10.7176/JHMN/81-03 Publication date: October 31 st 2020

Characterization of the Attended Surgical Patients in the Assisted Reproduction Territorial Centre, Cienfuegos 2015-2016

Introduction: Infertility is a health problem that does not cause death, disability or physical pain; however, it is a crisis for couples who see their life plans threatened and suffer not only at the time of diagnosis and during treatments, but in multiple daily situations. Scientific Problem: There are no published studies on the characteristics of the infertile patient who has required surgical treatment, which is attended at the Territorial Center for Assisted Reproduction, Cienfuegos. Objective: To characterize the patients with infertility diagnosis who underwent surgical treatment and were treated at the Territorial Center for the care of the infertile couple in the province of Cienfuegos. Methodological Design: A descriptive, prospective, cross-sectional study of a series of cases was carried out at the Territorial Center for Assisted Reproduction, inserted in the Department of External Consultation of the General University Hospital, Dr. “Gustavo Aldereguia Lima” in Cienfuegos, in the period from January 2015 to December 2016. The variables studied were: age, skin color, pelvic inflammatory disease, personal pathological history, number of pregnancies, number of deliveries, number of abortions, age of the first sexual relations, cause of infertility, time attending the consultation, previous pelvic surgery, preoperative diagnosis, type of surgery, type of treatment and results of the surgery. Results: A predominance of age was obtained between 26 and 35 years of previous pelvic inflammatory disease, Bronchial Asthma as a personal pathological antecedent, previous pelvic surgery, number of pregnancies between 1 and 2, induced abortion among other results.

Epidemiology and Management of Ectopic Pregnancy in Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Southeast, Nigeria

Background: Ectopic pregnancy is a common cause of maternal morbidity and mortality in the 1st trimester of pregnancy; without timely diagnosis and intervention, ruptured ectopic pregnancy can become a life threatening condition. Objective: This study aims to give baseline indices on the incidence, clinical presentation, risk factors and the management of cases of ectopic pregnancy that presented in Alex Ekwueme Federal University Teaching Hospital, Abakaliki over a 5-year period. Materials and Method: This is a 5-year retrospective study of patients who were diagnosed with ectopic pregnancy between January 1st 2012 and December 31st 2016. The statistical analysis was done using SPSS version 22. Result: During the study period, there were 11,932 deliveries while 7725 Gynaecology patients were admitted. Over the same period there were 156 patients diagnosed and managed for ectopic pregnancy, accounting for 1.31% of all deliveries and 2.0% of all Gynaecological admissions. The modal age group was 26 - 30 years 68 (43.6%), 122 (78.2%) were married, while 34 (21.7%) were single. Nulliparous were 41 (26.3%) and primiparous were 33 (21.2%). The commonest presenting complaints were lower abdominal pain and amenorrhea, and the commonest identified risk factor was previous pelvic inflammatory disease. Most of the cases were ruptured prior to presentation and partial salpingectomy was the management in all tubal pregnancy while two cases were unruptured and had salpingostomy and another case was abdominal pregnancy and had exploratory laparotomy only. Out of 156 women that presented with ectopic pregnancy, 8 (5.1%) died before surgery could be done due to late presentation. Fifty-seven women presented in a state of shock and 9 (5.8%) of the cases were complicated with acute renal failure. Conclusion: Ruptured ectopic pregnancy is a major cause of maternal morbidity and early pregnancy loss. Late presentation is a common feature in our environment; hence widespread advocacy on case identification and early presentation is urgently needed.

Comparison of the prevalence of adhesions at the time of diagnostic laparoscopy for infertility between patient who had open myomectomy and those who had no previous pelvic-abdominal surgery or pelvic inflammatory disease.

The aim of this study is to determine the prevalence and patterns of adhesions in infertile women with prior open myomectomy compared with women without prior pelvic-abdominal surgery. A nested case-control study of infertile women who had diagnostic laparoscopy after open myomectomy between January 2008 and June 2015 in Life Institute for Endoscopy Limited, Nnewi Nigeria, was conducted. At diagnostic laparoscopy, the presence, site, and quality (density) of adhesions was noted and recorded. Women with endometriosis and documented prior pelvic infections were excluded. Of the 348 women who were eligible, 121 women had prior open myomectomy (study group) while 227 had none (control group). Of the 121 women, adhesions were detected in 97 women; thus, the prevalence of adhesion after open myomectomy was 80.2% versus 20.3% (46/227) in controls (odds ratio [OR] =15.90; 95% confidence interval [CI] =8.86-28.76; P < 0.001). Compared with controls, adhesions were statistically higher in these sites: uterus (68.6% vs. 14.5%), fallopian tubes (77.7% vs. 16.7%), ovaries (62.8% vs. 20.3%), cul-de-sac (66.1% vs. 16.3%), bladder (45.5% vs. 7.9%), and bowel (53.7% vs. 6.2%) (P < 0.001, for all). Cohesive form of adhesions was also statistically higher, 54 (44.6%) vs. 32 (14.1%) (P < 0.05). In infertile women, post-open myomectomy adhesions have a high prevalence of 80.2% with high predilection in fallopian tubes and uterus, compared with women without prior abdominopelvic surgery at 20.3%. Cohesive form of adhesion predominates.

Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21.

Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21.

Isolated Tubal Torsion With Endometriosis

A 34-year-old woman, gravida 1, para 1, consulted our department because of secondary infertility of 1-year duration. On transvaginal ultrasound, a unilocular hypoechoic cystic mass was observed in the left adnexa measuring 6.70 ! 5.56 cm, suggestive of a paratubal cyst (Fig. 1). She menstruated regularly with dysmenorrhea at a numeric rating scale of 5. She delivered her child vaginally with no other previous operations and pelvic inflammatory disease. Laboratory examination showed her cancer antigen-125 level at 29.6 U/mL. On laparoscopy, there was torsion of the left fallopian tube, twisting around itself 4 times, with its distal end engorged (Fig. 2) containing chocolatelike fluid and adhered to the peritoneum and cul-de-sac. The uterus, right adnexa, and left ovary were grossly normal. Adhesiolysis and left partial salpingectomy were performed. Histopathologic findings revealed tubal endometrioma with hemosiderinladen macrophages, fibrosis, and chronic inflammation.

Assessment of Tubal Patency with Tridimensional Coded Contrast Imaging Hysterosalpingo-Contrast- Sonography Compared with Conventional HyCoSy: A Preliminary Study

ABSTRACT Objective The aim of this preliminary study is to analyze and compare tridimensional coded contrast imaging hysterosalpingocontrast- sonography (3D-CCI HyCoSy) with conventional hysterosalpingo-contrast-sonography (HyCoSy) with saline serum for the evaluation of tubal patency in women with sterility. Materials and methods This was a prospective preliminary observational study performed in the Clinica Universidad de Navarra. Intending to compare 3D-CCI HyCoSy with conventional HyCoSy, we decided and perform conventional HyCoSy between 1st of January 2015 and 15th of February 2015 and 3D-CCI HyCoSy between 16th of February and 15th of April 2015, in different sets of patients. Exclusion criteria were: recent vaginal infection, previous pelvic inflammatory disease, previous salpingectomy or hidrosalpinx diagnosed previously or while performing the ultrasound examination. Results Total number of cases was 22 (12 women underwent conventional HyCoSy and 10 a 3D-CCI HyCoSy). The mean age of patients was 33.8 years (SD: 3.2 range: 23–40 years). Three cases (100%) of Fallopian tube obstruction were detected by 3D-CCI HyCoSy and confirmed by laparoscopic tubal chromopertubation (LTC). Four of the six cases (67%) of obstruction detected by conventional HyCoSy were confirmed by hysterosalpingography/LTC (HSG/LTC). Two cases of severe post-procedure pain were reported in women who underwent conventional HyCoSy. Conclusion The results of the study show that 3D-CCI HyCoSy was better to visualize the entire Fallopian tube and evaluate its patency How to cite this article Alcázar JL, Moya M, Caparros M, Salas A, Errasti T, Ruiz-Zambrana A. Assessment of Tubal Patency with Tridimensional Coded Contrast Imaging Hysterosalpingo-Contrast-Sonography Compared with Conventional HyCoSy: A Preliminary Study. Donald School J Ultrasound Obstet Gynecol 2016;10(1):103-106.

Implications of perihepatic adhesions in women undergoing laparoscopic surgery for ectopic pregnancy

ObjectiveTo establish whether the finding of perihepatic adhesions (PHAs) at laparoscopy for ectopic pregnancy (EP) is associated with poor perioperative and reproductive outcomes. MethodsA retrospective cohort study was undertaken of all cases of EP managed surgically at a teaching hospital in northeast London in 2003–2013. Data for symptoms, reproductive history, ultrasonography findings, blood parameters, and findings at surgery were compared between patients with and without perihepatic adhesions (PHAs) identified at laparoscopy. ResultsAmong 802 women with EP, PHAs were identified during surgery for 60 (7.5%). Compared with women without PHAs, patients with PHAs were significantly more likely to have had previous pelvic inflammatory disease, previous EP, previous tubal surgery, and the finding of abnormal contralateral adnexa or other adhesions during laparoscopy (P≤0.024 for all). They also had higher preoperative hemoglobin concentrations and smaller hemoperitoneum volumes (P≤0.04 for both). ConclusionWomen with PHAs at laparoscopy for EP had lower blood loss than did those without PHAs. The finding of PHAs was associated with an increased rate of recurrent EP, irrespective of a previous history of PID or EP.

INFERTILIDAD POR SALPINGITIS: CARACTERÍSTICAS DEMOGRÁFICAS Y CLÍNICAS DE PACIENTES ATENDIDAS EN EL HOSPITAL ARZOBISPO LOAYZA

OBJETIVO: Determinar las características demográficas y clínicas de las pacientes con infertilidad tubárica. LUGAR: Hospital Arzobispo Loayza, entre enero y junio de 2001. MATERIAL Y MÉTODOS: Se revisó las historias clínicas de 77 pacientes con infertilidad debida a salpingitis. RESULTADOS: Cincuenta y dos (67%) pacientes tenían entre 30 y 39 años; 54 (70%) pacientes iniciaron su actividad sexual después de los 18 años, 31 (40%) tuvieron sólo una pareja sexual y 35 (46%), dos. En 18 (23%) pacientes se encontró un episodio previo de enfermedad pélvica inflamatoria (EPI) y en 30 (39%) se evidenció dolor y/o anexos engrosados al examen pélvico. CONCLUSIONES: la mayoría de pacientes con infertilidad por salpingitis atendidas en el Hospital Arzobispo Loayza no suele tener hábitos de riesgo para EPI ha tenido sintomatología clínica de infección genital, habiéndose realizado el diagnóstico en forma retrospectiva, a través de las secuelas de infertilidad.

ACR appropriateness Criteria® infertility.

Appropriate imaging for women undergoing infertility workup depends upon the clinician's suspicion for potential causes of infertility. Transvaginal US is the preferred modality to assess the ovaries for features of polycystic ovary syndrome (PCOS), the leading cause of anovulatory infertility. For women who have a history or clinical suspicion of endometriosis, which affects at least one third of women with infertility, both MRI and pelvic US can provide valuable information. If tubal occlusion is suspected, whether due to endometriosis, previous pelvic inflammatory disease, or other cause, hysterosalpingogram (HSG) is the preferred method of evaluation. To assess for anatomic causes of recurrent pregnancy loss (RPL) such as Müllerian anomalies, synechiae, and leiomyomas, saline infusion sonohysterography, MRI and 3-D US are most appropriate. Up to 10% of women suffering recurrent pregnancy loss have a congenital Müllerian anomaly. When assessment of the pituitary gland is indicated, MRI is the imaging exam of choice.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.