Uterine Curettage Research Articles

English

Placenta percreta and uterine rupture are associated with possible massive intraperitoneal bleeding, which can be fatal if not recognised. We describe a case of a 40-year-old multigravida with a history of two instances of placenta percreta and three instances of uterine rupture, previous artificial abortion, and uterine curettage. The patient’s uterus had been preserved after undergoing an emergency uterus repair operation and a scheduled caesarean within 5 years. This case report aimed to contribute to the knowledge of the early diagnosis of placenta percreta and highlights the advantages of uterus preservation, including psychological reasons and the ability to bear children in the future. In summary, it is clear that the steadily increasing rate of deliveries may result in an increased number of abnormal placentation cases. Abnormal placentation is one of the most important risk factors of severe obstetric complications, including perinatal massive haemorrhage. Therefore, prenatal diagnosis and identification of abnormal placentation are vital in order to plan appropriately the date, place, and mode of delivery, as well as to ensure the availability of highly qualified specialists in the field of obstetrics and anaesthesia and ensure availability of a sufficient amount of blood products and blood substitutes. Key words: Placenta percreta, uterine rupture, pregnancy.

Preliminary study on the application of abdominal aortic balloon occlusion in the treatment of cesarean scar pregnancy

Objective: To explore the clinical value by analyzing the application of abdominal aortic balloon occlusion in the uterine curettage treatment for patients with cesarean scar pregnancy (CSP). Methods: Totally 42 CSP patients in the first Affiliated Hospital of Zhengzhou University were analyzed retrospectively, 21 cases in the observation group, placing the balloon catheter to the abdominal aorta under the renal artery under the digital substraction angiography(DSA), conducting curettage under hysteroscopy or uterine laparoscopy immediately, and making intermittent blockage in abdominal aorta blood flow during the surgery;21 patients in the control group, conducting uterine artery embolization (UAE) before operation, conducting curettage under hysteroscopy or uterine laparoscopy after 1-3 days. The fluoroscopy time under DSA, body surface radiation dose, intraoperative blood loss, operation time, incidence of postoperative adverse reactions, hospitalization time and follow-up menstruation were comparatively analyzed. Results: All patients operated and retained the uterus successfully. In the control group, all 21 patients had different degrees of fever, pain and other symptoms after UAE. In the observation group and control group, the fluoroscopy time and body surface radiation dose under DSA respectively were (7.4±1.4) s, (5.4±1.1) mGy and (1 142.8±315.5) s, (1 442.0±300.0) mGy (both P<0.01);the average amount of intraoperative blood loss were (22±15), (19±14) ml (P>0.05), the time of uterine curettage were (37±20), (42±19) minutes (P>0.05);hospitalization time were (5.0±0.9), (7.7±1.3) days (P<0.01). The follow-up period was more than 3 months, no adverse reactions were observed in the observation group; 4 cases of menstrual reduction and 1 case of intrauterine adhesions were found in the control group. Conclusion: Abdominal aortic balloon occlusion and UAE could effectively reduce intraoperative bleeding in uterine curettage for patients with CSP; abdominal aortic balloon occlusion has significant reduction of the X-ray dose, shorter hospitalization time, and fewer adverse events comparing to UAE.

Clinical characteristics and treatment of different types of cesarean scar pregnancy.

The purpose of this study was to evaluate the clinical characteristics and compare the treatment efficacy of different types of cesarean scar pregnancy (CSP). We performed a retrospective chart review of 66 women (69 cases) with CSP who received treatment with mifepristone/methotrexate (MTX) plus curettage, uterine artery embolization (UAE) plus curettage, additional MTX, or laparotomy, and compared the clinical characteristics, treatment efficacy, and occurrence of complications among 3 types of CSP (partial, complete, and mass type). Review of the 69 cases revealed a considerable increase of gestational duration(p < 0.001), sac/lesion size(p < 0.001) and vaginal bleeding (p < 0.05) in patients with mass-type CSP compared to that of other types. All CSP cases were successfully treated, 4 cases of mass-type received laparotomy and none of the cases required a hysterectomy. Severe bleeding was observed in 2 cases of partial-type and complete-type, respectively, and 3 cases for mass-type. Moreover, bleeding occurred during initial treatment with mifepristone plus curettage in partial-type cases, but not with UAE plus curettage. UAE plus curettage is a more effective treatment option for partial- and complete-type of CSP than mifepristone plus curettage. The cases of mass-type often need surgery and are prone to have longer gestational duration, larger lesions, and more vaginal bleeding.

Puerperal Sepsis Caused by Clostridium Innocuum in a Patient with Placenta Accreta and Literature Review

Puerperal Sepsis Caused by Clostridium Innocuum in a Patient with Placenta Accreta and Literature Review

Efficacy of different treatment of 134 cases of cesarean scar pregnancy

The aim of this study was to compare the clinical efficacy of different methods for treating cesarean scar pregnancy (CSP). The clinical data of 134 patients diagnosed with CSP in the Third Affiliated Hospital of Guangzhou Medical University were retrospectively analyzed. Grouped by treatment plan: pretreatments +ultrasound guided Curettage group (group A), pretreatments+ laparotomy (group B). Group A was sub-grouped according to the pretreatments: ultrasound guided uterine evacuation (A1), uterine arterial embolism (UAE) + ultrasound guided uterine evacuation (A2), high-intensity focused ultrasound (HIFU) + ultrasound guided uterine evacuation (A3); group B was sub-groups according to pretreatments: laparotomy (B1), UAE + laparotomy (B2). The success rates of treatment in groups A and B were 72.73%-100%, and it was statistically significant (P<0.05) There were no statistically significant in the blood loss and the degree of decrease of β-hCG in these two group (P>0.05). The operation time, length of stay and cost were statistically significant between curettage group and laparotomy group (P<0.05); there was no significant difference in the degree of β-HCG decrease (%) and surgical bleeding volume. The success rate in group A1-A3 was 64.10%, 96.52% and 100% respectively, which was statistically significant (P<0.05). No statistically significant were showed in operation time, Length of stay and the degree of decrease of β-hCG within 5 days after operation in A1-A3 group (P>0.05). The blood loss and cost between A1 and A3 groups were statistically significant (P<0.05). The success rate in group B1-B2 were both 100%, with no statistically significant (P>0.05). There were no statistically significant in operation time, blood loss, degree of decrease of β-hCG, length of stay between the two groups (P>0.05). The cost between the two groups was statistically significant (P<0.05). Ultrasound-guided uterine Curettage can be used as a better treatment for type I and II scar pregnancy. UAE or HIFU before Curettage can reduce uterine bleeding, while UAE before the laparotomy did not reduce uterine bleeding.

Uterine body placenta accreta spectrum: A detailed literature review

Placenta accreta spectrum (PAS) is a major obstetrical problem whose incidence is rising. Current guidelines recommend screening of all women with placenta previa and risk factors for PAS between 20 and 24 weeks. Risk factors, diagnosis, and management of previa PAS are well established, but an apparently normal location of the placenta does not exclude PAS. Literature data are scarce on uterine body PAS, which carries a high risk of maternal and neonatal adverse outcome, but is still easily missed on prenatal ultrasound. We conducted a comprehensive review to identify possible risk factors, clinical presentations, and diagnostic modalities of uterine PAS. A total of 133 cases were found during a 70-year period (1949–2019). The vast majority of them presented with signs of uterine rupture, even prior to the viability threshold of 24 weeks (up to 45%). Major risk factors included previous cesarean delivery, uterine curettage, uterine surgery, Asherman's syndrome, manual removal of the placenta, endometritis, high parity, young maternal age, in vitro fertilization, radiotherapy, uterine artery embolization, and uterine leiomyoma. Diagnosis was pre-symptomatic in only 3% of cases. Future studies should differentiate between previa PAS and uterine body PAS.

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

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

Clinical assessment of uterine artery embolization combined with curettage when treating patients with cesarean scar pregnancy: A retrospective study of 169 cases.

Recent years have witnessed an elevated incidence of cesarean scar pregnancy (CSP). However, the clinical complications and consequences of uterine artery embolization (UAE) and curettage treatment for CSP patients are not clear. We aimed to assess menstrual recovery and other clinically pertinent factors after UAE and curettage treatment in CSP patients. A total of 169 CSP patients who underwent UAE combined with curettage between August 2013 and August 2017 were enrolled in this study. The menstruation recovery was recorded, and the factors that potentially affected menstrual blood volume (MBV) were analyzed. Among the 169 CSP cases, 36 had asymptomatics (21.3%), 133 vaginal hemorrhage (78.7%) and 19 lower abdominal pain (11.2%). The success rate of treatment was 96.4% with six patients undergoing further treatment. The follow-up assessment was performed in 139 of 169 patients. About 83 of 139 (59.7%) patients had reduced MBV, and 2 patients (1.4%) had amenorrhea. There was a significant difference in numbers of abortions between the decreased and normal MBV group (P = 0.0276). Importantly, 16 of 42 cases who were planning on having babies became pregnant, with 8 from the decreased (8/27) and normal MBV (8/15) group each. UAE combined with curettage treatment in CSP patients demonstrates a favorable success rate, which can also reduce MBV and proceeding pregnancy rate.

Acute Miliary Tuberculosis and Pelvic Tuberculosis after In vitro Fertilization

Nearly one-fourth of the world's population is infected with Mycobacterium tuberculosis (MTB). Female genital tuberculosis (TB) is a common cause of infertility in both developing and undeveloped countries. Furthermore, assisted reproduction treatments and pregnancy potentially increase the risk of TB infection and reactivation. In this study, we present the case of a 28-year-old infertile female without a history of TB who developed an acute miliary TB and pelvic TB after in vitro fertilization–embryo transfer (IVF-ET). Elevated serum estrogen levels during controlled ovarian hyperstimulation and T-lymphocyte function inhibition during pregnancy are the risk factors for MTB infection and reactivation. In her 7th week of gestation, the patient developed fever and spontaneously aborted. Her chest computed tomography images revealed classical miliary TB. Uterine curettage tissue and vaginal secretion samples as well as Gene X-pert MTB/rifampicin (RIF) and TB-RNA test results were positive for MTB. Histological examination of the uterine curettage tissue confirmed the diagnosis of endometrial TB. Treatment with isoniazid, RIF, pyrazinamide, amikacin, and levofloxacin was selected based on the patient's diagnosis, complications, and test results. Currently, the patient is undergoing anti-TB treatment, and her condition is stable. It is important to rule out the presence of TB in infertile patients before performing IVF-ET to avoid TB dissemination during pregnancy.

The effect of laparoscopic salpingectomy for ectopic pregnancy on ovarian reserve.

Salpingectomy may damage ovarian reserve by direct vascular interruption to the ovary or thermal vascular injury from electrosurgery. It is plausible that this risk may increase in the context of salpingectomy conducted for ectopic pregnancy due to the distension of the fallopian tube and vascular changes associated with pregnancy. To report anti-Müllerian hormone (AMH) concentrations before and after laparoscopic salpingectomy for ectopic pregnancy as an indicator of change in ovarian reserve. Women aged 18-44years scheduled for salpingectomy for tubal ectopic pregnancy were prospectively recruited. Serum AMH concentrations were measured immediately prior to surgery, then repeated four months post-operatively. In all cases, salpingectomy was conducted laparoscopically using bipolar electrosurgery and mechanical scissors. A group of women scheduled for uterine curettage for first trimester miscarriage was recruited to ensure any observed change in AMH concentration in the women undergoing salpingectomy was secondary to surgery, rather than an effect of pregnancy. Paired pre- and post-operative serum AMH concentrations were obtained from 32 women with tubal ectopic pregnancy. The mean age of the women was 33.6±4.6years. There was no significant difference in the median pre- and post-operative AMH concentrations (13.00pmol/L (range 5-67pmol/L) vs 15.25pmol/L (range 3-96pmol/L), P=0.575). Median AMH concentrations also remained stable in women experiencing a first trimester miscarriage (10.40pmol/L (range 3.9-37.8pmol/L) vs 13.67pmol/L (range 2.8-30.5pmol/L), P=0.185). Laparoscopic salpingectomy using electrosurgery and mechanical scissors does not damage ovarian reserve. AMH concentrations do not fluctuate from baseline in the first trimester of pregnancy.

Use of hysteroscopy in diagnosis and follow-up of acquired uterine enhanced myometrial vascularity

To describe the role of hysteroscopy in diagnosis and subsequent follow-up of uterine enhanced myometrial vascularity (EMV). Uterine EMV, previously known as arteriovenous malformation (AVM), is a rare but cannot-miss finding often associated with prior pregnancy or uterine surgery and is typically suspected when a vascular mass is found on ultrasound. Color Doppler imaging will demonstrate high-velocity, low-impedance flow, with more significant shunts demonstrating higher peak systolic velocity (PSV). If not already diagnosed by ultrasound, accurate recognition during hysteroscopy is mandatory prior to any uterine instrumentation, as biopsy or curettage can lead to unanticipated massive hemorrhage. While many cases of EMV may resolve spontaneously, actively bleeding patients may require treatment with embolization, a procedure that may decrease ovarian reserve and impair fertility, though favorable reproductive outcomes have been reported. Others have reported success with hysteroscopic management using a bipolar electrosurgical loop. Case report. Academic hospital system. We describe a 22-year-old G2P1011 who presented to the emergency department with heavy vaginal bleeding and a negative urine human chorionic gonadotropin 9 weeks following a first-trimester termination of pregnancy. Her ultrasound demonstrated a heterogeneous 2.6×2.3×2.6 cm vascular mass in the endometrial canal that was initially interpreted as retained products of conception. Unfortunately, PSV in the lesion was not measured. During observation, bleeding continued, and her hemoglobin dropped from 8.3 g/dL to 6.9 g/dL the next morning. She was transfused 2 units of blood and taken to the operating room for hysteroscopic evaluation and possible uterine curettage. Hysteroscopy revealed a large pulsating 2cm bluish vascular mass that was recognized as a uterine EMV and the procedure was terminated with the plan for embolization. Given fertility concerns, the diagnosis was confirmed with MRI/MRA, which identified a 2.7cm mass-like process with early post-contrast enhancement in the arterial phase. An angiogram demonstrated bilaterally enlarged tortuous uterine arteries perfusing a hypervascular EMV that was treated with selective bilateral uterine artery embolization. Further bleeding or evidence of EMV. Follow-up office hysteroscopy at 2 weeks demonstrated a 2 cm raised area of tissue without pulsations. At 6 weeks post-procedure, bleeding had ceased, and office hysteroscopy revealed only a small 0.5 cm calcified nodule with a circumferential pseudo-decidual reaction. Hysteroscopy may be used to diagnose EMV when ultrasound is not conclusive. Recognition of the pulsating vascular appearance of EMV on hysteroscopy is critical in preventing hemorrhage from inappropriate curettage. Resolution of the lesion following embolization can be readily demonstrated with office hysteroscopy.

Rate of Significant Endometrial Pathology in Women at Low Risk for Endometrial Hyperplasia or Cancer Presenting with Abnormal Uterine Bleeding.

Background and ObjectivesTo determine the rate of significant endometrial abnormalities in premenopausal women at low risk for endometrial hyperplasia and cancer presenting with abnormal uterine bleeding (AUB).Patients and MethodsThis descriptive study was conducted from January 1, 2016 to March 31, 2019. The inclusion criteria were premenopausal women, 35–50 years, presenting with AUB, low risk for endometrial hyperplasia or endometrial cancer, and having undergone endometrial sampling or uterine curettage. Nulliparous, obesity, diabetes mellitus, polycystic ovary syndrome, chronic anovulation, infertility, tamoxifen therapy and/or a family history of uterine, ovarian, breast and colon cancer were excluded. Data regarding baseline characteristics were collected, and histopathology reports were reviewed.ResultsDuring the study period, 644 subjects were recruited, 557 of whom had adequate endometrial tissue for histopathology study. The pathology demonstrated benign in most cases (96%). The rate of significant abnormal endometrial pathology was 4% (23 cases) including 19 cases of endometrial hyperplasia without atypia (3.3%), and 4 cases of endometrial cancer (0.7%).ConclusionThe rate of significant abnormal endometrial pathology in premenopausal women at low risk for endometrial hyperplasia or endometrial cancer presenting with AUB was very low. This information should be incorporated into the counseling process regarding the risks and benefits of endometrial sampling.

Evaluation of prognostic value of cesarean section scar pregnancy after uterine arterial chemoembolization with cesarean section by ultrasonography

Objective To assess the clinical value of uterine curettage ultrasound in the evaluation of cesarean section scar pregnancy (CSP) after uterine arterial chemoembolization (UAE). Methods Retrospective analysis were performed in 42 patients who took uterine curettage within 24-48 hours after UAE treatment in the Second Affiliated Hospital of Harbin Medical University from January 2015 to June 2018. The ultrasonic manifestations were graded and classified before UAE. The intraoperative and postoperative complications, time of β-human chorionic gonadotrophin declined to normal limits were evaluated, and the formation of hematoma and hematoma absorption time were followed up by ultrasound. Results UAE was performed successfully in all patients. The ultrasound-guided scar pregnancy was successfully completed. The uterus was successfully retained in all patients.Among the 42 patients, 18 cases were 3 scores group, and 24 cases were 4 scores group according to the ultrasonic scoring system. Two cases were type Ⅰgroup, 25 cases were type Ⅱ group, and 15 cases were type Ⅲ group according to the ultrasonic classification. The amount of intraoperative complications, postoperative mass formation and absorption time were significantly different between 3 scores group and 4 scores group (P 0.05). Conclusions Ultrasonography has clinical application value in evaluating the prognosis of CSP treated with UAE. Ultrasonic scoring system can evaluate the efficacy and is helpful for predicting clinical outcome of CSP. Key words: Ultrasonography; Cesarean scar pregnancy; Uterine artery embolization; Curettage

Management of placenta percreta. A case report

The placenta accreta designates an abnormality of the placental insertion characterized, on the anatomopathological level, by an absence of deciduous deciduous between the placenta and the myometrium. This insertion anomaly may interest all or only part of the placenta. We distinguish within this terminology the terms of - placenta accreta when the placenta is simply attached to the Myometrium. - placenta increta when the placenta invades the myometrium. - placenta percreta when the placenta enters the serosa uterine, or even the neighboring organs (bladder, peritoneum, etc.) [1]. Placentas accretas are a high-risk situation for severe postpartum hemorrhage and its inherent complications such as disseminated intravascular coagulation, hemostasis hysterectomy, surgical wounds to the ureters, bladder, multiple organ failure, or even maternal death, particularly in the case of placenta percreta [2,3]. Risk factors for placenta percreta include a history of cesarean, uterine curettage or manual removal of placenta, presence of placenta previa, endometriosis, high parity and advanced maternal age [4]. We report the case of a 30-year-old woman, IIGIIP, who had a previous cesarean section during her first pregnancy and who had a placenta percreta and who underwent hysterectomy without cystectomy and without ligation of the hypogastric arteries.

Embolization of acquired uterine arteriovenous fistula and pseudoaneurysm as a definitive uterine-sparing treatment

Background: Uterine curettage after spontaneous pregnancy loss may result in complications, including acquired arteriovenous fistula (AVF), and most cases settle spontaneously with conservative or medical management. Persisting symptoms require more definitive treatment and this is usually with hysterectomy. This report shows that the embolization as a uterine-sparing surgical alternative can offer a definitive endovascular treatment strategy. Case presentation: A 34-year-old lady presented with anemia from recurrent per-vaginal bleeding which persisted for 3 months after curettage for failed early pregnancy. Ultrasound showed AVF and a large pseudoaneurysm. Angiography and embolization was performed using gelatin sponge which was able to successfully treat the vascular lesions. At 2 years follow-up, she had complete symptom resolution and preserved her uterus. Conclusion: There are only a small number of case reports in the literature to support embolization as a minimally invasive surgical alternative as a definitive treatment.

Prevalence of uterine curettages at Instituto da Mulher Dona Lindu in 2014 - Manaus - AM, Brazil

Prevalence of uterine curettages at Instituto da Mulher Dona Lindu in 2014 - Manaus - AM, Brazil

1147: The role of ultrasound in the management of third stage of second trimester delivery

The use of intraoperative sonographic guidance for second trimester elective dilation and curettage (D & E) procedure reduces the incidence of uterine perforation. Nevertheless, the role of intraoperative sonographic guidance during curettage procedure following second trimester medical induction has not been evaluated. We aim to evaluate the effect of intraoperative sonographic guidance during curettage procedure following second trimester uterine evacuation. A retrospective cohort study performed in a Gynecology department at a tertiary university-affiliated medical center including patients undergoing second trimester medical induction up to 23 6/7 weeks estimated gestational age who underwent uterine curettage after delivery of the fetus. Women undergoing curettage procedure under continuous ultrasound guidance were compared with those undergoing curettage without ultrasound guidance One hundred ninety four patients underwent a curettage without intraoperative sonographic guidance, while 79 underwent the procedure utilizing intraoperative sonographic guidance. The overall rate of composite adverse outcome was higher among those undergoing curettage under intraoperative sonographic guidance as compared with no sonographic guidance (39.2% vs. 20.6%, P=0.002). Placental morbidity (12.6% vs. 5.6%, P=0.04) and infectious complications (7.5% vs. 2.5%. P=0.05) were more frequent among those undergoing curettage using intraoperative sonographic guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with an adverse outcome (P=0.001). Procedure time was longer when ultrasound guidance was used; 9:52 min. vs. 6:58 min. (P< 0.001). Intraoperative ultrasonography guidance during curettage after second trimester uterine evacuation is associated with a higher complication rate than no guidance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Nitroglycerin for treatment of retained placenta: A randomised, placebo-controlled, multicentre, double-blind trial in the UK.

Retained placenta following vaginal delivery is a major cause of postpartum haemorrhage. Currently, the only effective treatments for a retained placenta are the surgical procedures of manual removal of placenta (MROP) and uterine curettage, which are not universally available, particularly in low- and middle-income countries. The objective of the trial was to determine whether sublingual nitroglycerin spray was clinically effective and cost-effective for medical treatment of retained placenta following vaginal delivery. A randomised, placebo-controlled, double-blind trial was undertaken between October 2014 and July 2017 at 29 delivery units in the UK (Edinburgh, Glasgow, Manchester, Newcastle, Preston, Warrington, Chesterfield, Crewe, Durham, West Middlesex, Aylesbury, Furness, Southampton, Bolton, Sunderland, Oxford, Nottingham [2 units], Burnley, Chertsey, Stockton-on-Tees, Middlesborough, Chester, Darlington, York, Reading, Milton Keynes, Telford, Frimley). In total, 1,107 women with retained placenta following vaginal delivery were recruited. The intervention was self-administered 2 puffs of sublingual nitroglycerin (800 μg; intervention, N = 543) or placebo spray (control, N = 564). The primary clinical outcome was the need for MROP, assessed at 15 minutes following administration of the intervention. Analysis was based on the intention-to-treat principle. The primary safety outcome was measured blood loss between study drug administration and transfer to the postnatal ward or other clinical area. The primary patient-sided outcomes were satisfaction with treatment and side-effect profile, assessed by questionnaires pre-discharge and 6 weeks post-delivery. Secondary clinical outcomes were measured at 5 and 15 minutes after study drug administration and prior to hospital discharge. There was no statistically significant or clinically meaningful difference in need for MROP by 15 minutes (primary clinical outcome, 505 [93.3%] for nitroglycerin versus 518 [92.0%] for placebo, odds ratio [OR] 1.01 [95% CI 0.98-1.04], p = 0.393) or blood loss (<500 ml: nitroglycerin, 238 [44.3%], versus placebo, 249 [44.5%]; 500 ml-1,000 ml: nitroglycerin, 180 [33.5%], versus placebo, 224 [40.0%]; >1,000 ml: nitroglycerin, 119 [22.2%], versus placebo, 87 [15.5%]; ordinal OR 1.14 [95% CI 0.88-1.48], p = 0.314) or satisfaction with treatment (nitroglycerin, 288 [75.4%], versus placebo, 303 [78.1%]; OR 0.87 [95% CI 0.62-1.22], p = 0.411) or health service costs (mean difference [£] 55.3 [95% CI -199.20 to 309.79]). Palpitations following drug administration were reported more often in the nitroglycerin group (36 [9.8%] versus 15 [4.0%], OR 2.60 [95% CI 1.40-4.84], p = 0.003). There were 52 serious adverse events during the trial, with no statistically significant difference in likelihood between groups (nitroglycerin, 27 [5.0%], versus placebo, 26 [4.6%]; OR 1.13 [95% CI 0.54-2.38], p = 0.747). The main limitation of our study was the low return rate for the 6-week postnatal questionnaire. There were, however, no differences in questionnaire return rates between study groups or between women who did and did not have MROP, with the patient-reported use of outpatient and primary care services at 6 weeks accounting for only a small proportion (approximately 5%) of overall health service costs. In this study, we found that nitroglycerin is neither clinically effective nor cost-effective as a medical treatment for retained placenta, and has increased side effects, suggesting it should not be used. Further research is required to identify an effective medical treatment for retained placenta to reduce the morbidity caused by this condition, particularly in low- and middle-income countries where surgical management is not available. ISRCTN.com ISRCTN88609453 ClinicalTrials.gov NCT02085213.

Ведення вагітних з прееклампсією після пологів

Pre-eclampsia found only in humans during the second half of pregnancy or the postpartum period, is known to be featured by the development of arterial hypertension and multiple organ failure syndrome. Almost a third of eclampsia is known to occur in the postpartum period. The pre-eclamptic patients require thorough monitoring of blood pressure and administration of antihypertensive drugs in the puerperium. The pathogenesis and tactics of the developed de novo postpartum pre-eclampsia have not been sufficiently studied. The greatest risk of stroke after delivery remains for 10 days. In the case of postpartum pre-eclampsia, it is very important to start using antihypertensives in a timely manner. First-line drugs should be used not later than 30-60 minutes from the time of severe pre-eclampsia diagnosing to prevent intracranial hemorrhage. Labetalol or hydralazine should be used in order to reduce blood pressure. Sublingual administration of nifedipine may also be considered as first-line therapy. The use of magnesium sulfate is necessary for the prevention of seizures in patients with severe preeclampsia. In the case of eclampsia, a solution of magnesium sulfate is administered intravenously at a loading dose of 4-5 g for 15-20 minutes and then continued infusion at a dose of 1 g per hour throughout the day. Uterine curettage is also a possible measure of reducing blood pressure in women with pre-eclampsia. Uterine curettage reduced blood pressure in pre-eclamptic patients, but without adequate reporting of harms of perforation and infection dissemination, so it cannot currently be recommended. However, curettage should be done during a caesarean section of women with preeclampsia. The own case of a systemic inflammatory response syndrome that occurred in a postpartum woman with mild pre-eclampsia is given. Postpartum endomyometritis, which was caused by group B streptococcus, should have played a triggering role in the progression of preeclampsia. The problem of polychemical resistance has led to the inability of traditional antimicrobial agents to prevent the dissemination of infection after curettage. The systemic inflammatory response syndrome has contributed to the increased severity of preeclampsia and the development of multiple organ failure. Key words: preeclampsia, postpartum period, antihypertensive drugs.

State-of-the-Art Workup and Initial Management of Newly Diagnosed Molar Pregnancy and Postmolar Gestational Trophoblastic Neoplasia.

Gestational trophoblastic disease refers to a series of interrelated tumors arising from the placenta, including benign molar pregnancies as well as the malignant conditions termed gestational trophoblastic neoplasia (GTN). GTN most commonly follows a molar pregnancy but may develop after any gestation. The wide availability of first trimester ultrasound and serum human chorionic gonadotropin (hCG) measurement has changed the presentation of molar pregnancy in recent decades from a second trimester to a first trimester disease, such that most patients have few symptoms at diagnosis. With identification of molar pregnancy at earlier gestations, accurate diagnosis increasingly relies on expert histopathology coupled with ancillary molecular and genetic techniques. However, earlier diagnosis has not changed the risk of postmolar GTN. Although most molar pregnancies are treated with dilation and curettage, hysterectomy may be appropriate in select cases when future fertility is not desired. After treatment of molar pregnancy, close surveillance with serial hCG monitoring is essential to diagnose GTN and identify the need for chemotherapy. Physicians following hCG levels should understand the performance characteristics of the test, including common causes of false-positive and false-negative results. After a diagnosis of postmolar GTN is made, selection of single-agent or multiagent chemotherapy depends on accurate assignment of the clinical stage and risk stratification by the International Federation of Gynecology and Obstetrics (FIGO) prognostic scoring system. Surgical treatment of postmolar low-risk GTN, including both second uterine curettage and hysterectomy, may decrease subsequent need for or duration of chemotherapy. Cure rates for postmolar low-risk GTN approach 100%, and subsequent pregnancy outcomes for patients reflect those of the general population.