Uterine Size Research Articles

Differences in Route of Benign Hysterectomy in Black Patients for Abnormal Uterine Bleeding with Exclusion of Fibroid Diagnosis

<h3>Study Objective</h3> To investigate whether racial disparities still exist in rates of minimally invasive hysterectomy (MIH) performed for abnormal uterine bleeding (AUB) when fibroid diagnosis is excluded. <h3>Design</h3> Cross-sectional survey with a target population of all ambulatory discharges in the United States. <h3>Setting</h3> 2019 Nationwide Ambulatory Surgery Sample (NASS) and National Inpatient Sample (NIS). <h3>Patients or Participants</h3> Female patients age ≥18 years undergoing hysterectomy for primary indication of abnormal uterine bleeding (AUB), excluding malignancy and uterine fibroids. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> A multivariate logistic regression model with appropriate weighting, primary sampling units and strata was utilized. Primary outcome was odds ratio (OR) of abdominal hysterectomy (AH) vs MIH (vaginal/endoscopic) in Black patients compared to white patients. Of 487,008 (SE=11,530) hysterectomies performed for benign indications, 64,681 (SE=1,483) were AH (13.3%), 422,327 (SE=10,047) were MIH (86.7%). After filtering the survey design dataset for hysterectomies performed primarily for AUB using the international classification of diseases 10^th edition, and further excluding those with an associated code for uterine fibroids, the sample size was 75,838 (SE=2,103). Of these, MIH: 68,206 (SE=1,812) (89.9%) and AH: 7,632 (SE=291) (10.1%). After controlling for comorbidities, demographic data, hospital, regional and payer factors, the OR for a Black patient to undergo AH vs MIH for all benign diagnoses was 2.7 (CI-2.44,2.98; p<0.001). For Black patients undergoing benign hysterectomy for AUB excluding fibroids, this trend persisted though was less extreme with OR=1.38 (CI-1.12,1.70; p<0.001). <h3>Conclusion</h3> For the primary indication of AUB excluding malignancy and fibroids, Black patients were still 38% more likely than white patients to undergo AH. It has previously been proposed that rates of MIH are lower in Black patients due to a larger prevalence of fibroids, and by extension, larger uterine sizes. Given that we excluded fibroids and still found a difference in MIH rates, our study suggests there may be other factors leading to disparity in surgical route.

Effect of Low-Frequency Electrical Stimulation Combined with Tonifying Kidney and Blood Pills on Uterine Rejuvenation after Abortion.

Objective This study aimed to observe the clinical efficacy of low-frequency electrical stimulation therapy combined with tonifying the kidney and activating blood pills to promote uterine recovery after abortion and its effect on heat-shock protein (HSP)70 and HSP90. Methods All cases were women with early pregnancy who underwent an abortion at the Third Affiliated Hospital of Nanchang University from September 2019 to September 2020. They were divided into two groups in accordance with the principle of patient voluntariness: 237 cases in the experimental group and 143 cases in the control group. Patients in both groups were given low-frequency electrical stimulation after surgery. In addition, patients in the experimental group began to take the Dingkun pill orally (one pill per time, two times per day) from the first day of surgery and continued to take it until their menstruation returned to normal. Abdominal pain, the duration of vaginal bleeding, and the amount of bleeding were observed in both groups. Uterine size, endometrial thickness, and urinary human chorionic gonadotropin (HCG) status were also observed at 2 weeks postoperatively to determine preoperative and postoperative HSP70 and HSP90 serum levels. The time of menstrual resumption, menstrual period, and menstrual volume were observed and compared with preoperative menstruation. The occurrence of complications, such as a residual uterine cavity, uterine effusion, menstrual irregularities, and reproductive tract infections, during the follow-up period was also recorded in both groups. Results Comparison of the endometrial thickness (mm) and uterine size (sum of the three diameters) on uterine adnexal ultrasound at 2-week postoperative review was better in the experimental group than in the control group (p < 0.05). No statistically significant difference was found between the two groups in terms of residual uterine cavity and blood accumulation in the uterine cavity and the results of the urine pregnancy test (p > 0.05). Serum HSP70 and HSP90 levels were significantly higher in the control group than in the experimental group 2 weeks after surgery (p < 0.05). Postoperative HSP70 and HSP90 levels were significantly higher than preoperative levels in both groups (p < 0.05). The degree of postoperative abdominal pain in the experimental group was less severe than that in the control group, and the duration was shorter (p < 0.05). No statistically significant differences were observed when comparing the duration of postoperative vaginal bleeding and the amount of bleeding (p > 0.05). The time of the first menstrual resumption and menstrual volume were more satisfactory in the experimental group than in the control group (p < 0.05). No adverse reactions occurred in either group of patients receiving treatment. ConclusionLow-frequency electrical stimulation combined with tonifying the kidney and invigorating blood pills could effectively promote uterine rejuvenation after abortion, conducive to improving patients' postoperative abdominal pain, promoting menstrual recovery and maintaining menstrual flow.

A CASE STUDY ON MANAGEMENT OF GARBHASAYA GRANTHI WITH REFERENCE TO UTERINE FIBROID

Uterine fibroid is the most common benign pelvic tumour in women of reproductive age. Leiomyomas, also called fibroids, have a 70-80% cumulative incidence in childbearing age due to their abundant fibrotic tissue. Most of the time, it remains asymptomatic, and the fibroids are diagnosed accidentally. The patient came with the complaint of lower abdomen pain during menses and a few days before the onset of menses for ten years. The pain is in the lower abdomen, lower back region and thigh. The character of the pain is spasmodic. On examination, multiple fibroid uterus measuring 2.1x1.8 cm fibroid noted in the anterior wall, and 4.9x4.4 cm fibroid pointed out in the posterior wall. The case was diagnosed as garbhasaya granthi. There is vitiation of tridosha with a predominance of vata kapha dosha and dushya like rasa, raktha, mamsa, and medas. Hence kapha medohara chikitsa has been given. Medicines like dashamoola kashayam, varunadi kashayam, kanchanara guggulu, saptasara kashayam, dhanwantara gulika, kanchanara guggulu have been administered. Tikshna, ushna, lekhana, chedana, and srotoshodana dravya can reduce uterine fibroid symptoms and size. The patient shows a significant reduction in pain in the lower abdomen and thigh region with the above-mentioned oral medications.

A novel intrauterine barrier for preventing the recurrence of IUA after TCRA procedure

Intrauterine adhesion (IUA) is the result of abnormal endometrium repair after trauma and infection that damages the basal layer of the endometrium, which is then replaced by scar tissue. In such instances, the endometrium partially or completely loses the ability to conceive the embryo. Even after surgery-based comprehensive treatment, a high rate of adhesion remains. A thin endometrium, poor blood supply, and poor function may also lead to refractory infertility, resulting in a poor reproductive prognosis even when the uterine cavity has been completely restored to normal. Therefore, two key points of postoperative management are the use of an intrauterine barrier to prevent re-adhesion and medicine to promote endometrial repair. However, there is currently no clinically applicable barrier that can meet the personalized dimensions of uterine cavity shape and size or effectively separate the wound wall. We have designed an intrauterine barrier that consists of a unique uterine-shaped, estrogen-release intrauterine device (IUD), which can be combined with an injectable, temperature-sensitive hydrogel. For this study, we will insert an estrogen-release IUD into the uterine cavity following transcervical resection of adhesion (TCRA) surgery, at the same time injecting 3–5 mL of liquid hydrogel at room temperature into the uterine cavity via the cervical channel. Due to its temperature sensitivity, the hydrogel will gradually solidify into a jellylike consistency, filling the uterine cavity with a solid barrier and completely preventing contact with the wounded wall to avoid the recurrence of adhesion. The estrogen-release IUD will be wrapped in the hydrogel barrier, which has many pores that allow sustainable estrogen release to promote endometrial regeneration and repair. This protocol can meet the needs of postoperative management of TCRA, but experimental and clinical studies are still needed to demonstrate its effectiveness. If patients in the study group have a lower adhesion recurrence and higher pregnancy rate compared to controls, our hypothesis will be confirmed that this barrier will prove a clinical application to help the functional repair of the endometrium and achieve a good reproductive prognosis.

Analysis of Different Routes of Hysterectomy Based on a Prospective Algorithm and Their Complications in a Tertiary Care Institute.

Introduction Hysterectomy is the most common gynaecological operation worldwide. The objective of the study is to analyze the various routes of hysterectomy and its complications when the decision of route is based on using a prospective algorithm tree. Methodology. It is an observational study to analyze the route of hysterectomy based on using a prospective algorithm. The decision tree is based on pelvic pathology, uterine size, vaginal access, pelvic adhesion, competency of the surgeon, choice of the patient, and complication of different routes of hysterectomy. Data were collected from preoperative, intraoperative, and postoperative records. Demographic factors, indications, routes of hysterectomy, and complications were recorded and analyzed by using SPSS software version 22. Observation. Among the malignant or suspected malignant pathology groups, TAH was performed in 89 cases and TLH was performed in 3 cases. Among the benign disease groups, VH was performed in 137(38.2%) cases, TAH was performed in 118(32.9%) cases, and TLH was performed in 104 (28.9%) cases. Operative time and a number of blood transfusions were significantly less with VH (p value < 0.0001 and 0.004) compared to abdominal and total laparoscopic hysterectomy. Postoperative complication such as fever was more with abdominal hysterectomy (<i>p-</i>value<0.00001) compared to VH and TLH. Vaginal discharge was more with VH and TLH compared to TAH (p value −0.004) and wound infection was more in the abdominal route (p value 0.001). Conclusion The abdominal route was the route of choice for surgery in malignancy or suspected malignant pathology. In benign pathology, VH was the most common and preferable route of surgery. Complications were found to be minimal with vaginal hysterectomy.

Investigation of the 12-month efficacy and safety of low-dose mifepristone in the treatment of painful adenomyosis

Objective: To study the 12-month effects and possible mechanisms of low-dose mifepristone in the treatment of adenomyosis. Methods: Patients included in this retrospective study had painful adenomyosis and previously received 5 mg mifepristone daily (group A, n = 45) or 5 mg mifepristone daily with a poor-effect levonorgestrel-releasing intrauterine device (group B, n = 13) for 12 months. Uterine size, serum CA125 levels, estradiol levels, Visual Analogue Scale (VAS) score, endometrial thickness, and hemoglobin levels were compared before and after treatment and investigated again at 3 to 6 months after drug withdrawal. Another 8 patients with adenomyosis (group C, n = 8) who underwent surgery for severe dysmenorrhea during the same period were only used as a control group for immunohistochemical research. Endometrial biopsy results and expression of nerve growth factor (NGF), cyclooxygenase-2 (COX-2), and nuclear-associated antigen Ki-67 (Ki-67) in endometrial tissues and adenomyotic lesions were also analyzed. Results: The VAS scores in both experimental groups at all time points during treatment and follow-up were significantly lower (P &lt;0.001) than those before treatment. The uterine size was significantly reduced, and endometrial thickness was distinctly thicker after 12 months of treatment than that before treatment in group A receiving 5 mg/d mifepristone. The immunohistochemical expression of NGF and COX-2 decreased in both eutopic and ectopic endometrium after treatment, whereas that of Ki-67 slightly increased in eutopic endometrium after treatment and rapidly recovered to the baseline value after stopping mifepristone. There were no signs of hyperplasia, atypical hyperplasia, or malignancy in the endometrial biopsies. Conclusions: The results suggested that a daily dose of 5 mg mifepristone for 12 months down-regulated the expression of NGF and COX-2 and was effective in treating painful adenomyosis with few side effects.

Comparison of the effectiveness and safety of treatment of incomplete second trimester abortion with misoprostol provided by midwives and physicians: a randomised, controlled, equivalence trial in Uganda

SummaryBackgroundTo address the knowledge gaps in the provision of post-abortion care by midwives for women in the second trimester, we investigated the effectiveness and safety of treatment for incomplete second trimester abortion with misoprostol, comparing care provision by midwives with that provided by physicians in Uganda.MethodsOur multicentre, randomised, controlled, equivalence trial undertaken in 14 health facilities in Uganda recruited women with incomplete abortion of uterine size 13–18 weeks. We randomly assigned (1:1) women to clinical assessment and treatment by either midwife or physician. The randomisation sequence was computer generated, in blocks of four to 12, and stratified for study site. Participants received sublingual misoprostol (400 μg once every 3 h for up to five doses). The study was not concealed from the health-care providers and study participants. Primary outcome was complete abortion within 24 h that did not require surgical evacuation. Analysis was per-protocol and intention to treat; the intention-to-treat population consisted of women who were randomised, received at least one dose of misoprostol, and reported primary outcome data, and the per-protocol population excluded women with unexplained discontinuation of treatment. We used generalised mixed-effects models to obtain the risk difference. The predefined equivalence range was –5% to 5%. The trial was registered at ClinicalTrials.gov, NCT03622073.FindingsBetween Aug 14, 2018, and Nov 16, 2021, 1191 eligible women were randomly assigned to each group (593 women to the midwife group and 598 to the physician group). 1164 women were included in the per-protocol analysis, and 530 (92%) of 577 women in the midwife group and 553 (94%) of 587 women in the physician group had a complete abortion within 24 h. The model-based risk difference for the midwife versus physician group was –2·3% (95% CI –4·4 to –0·3), and within our predefined equivalence range (–5% to 5%). Two women in the midwife group received blood transfusion.InterpretationClinical assessment and treatment of second trimester incomplete abortion with misoprostol provided by midwives was equally effective and safe as when provided by physicians. In low-income settings, inclusion of midwives in the medical management of uncomplicated second trimester incomplete abortion has potential to increase women's access to safe post-abortion care.FundingSwedish Research Council and THRiVE-2.

Indications and surgical route for hysterectomy for benign disorders: a retrospective analysis in a large Australian tertiary hospital network.

Hysterectomy is a common but expensive and morbid procedure. Alternative treatments for heavy menstrual bleeding (HMB) are effective in up to 80% of cases, but there is substantial variation in surgical approach and pre-operative management of HMB. This study aims to assess the approach to hysterectomies for benign indications including alternative treatments and route of operation. We retrospectively collected patient and surgical data on all hysterectomies for benign indications from 1/4/2018 to 31/6/2020 at our tertiary-led hospital network. Hysterectomies were performed in 582 women at a median age of 49(44-56) with a median BMI of 27.9(24.5-33.3)kg/m2 and 251(43%) were referred from private rooms. Hysterectomies for HMB were performed laparoscopically (TLH)(156, 51.7%) more often than abdominally (TAH)(133, 44%) or vaginally (4.3, 13%), with wide variation between sites. Approach was predicted by a history of previous abdomino-pelvic surgery and uterine size but not by other patient factors (BMI, parity or comorbidities). Referral source, on the other hand, was a significant predictor of route of hysterectomy. In women with HMB without uterine abnormalities, 45% tried a levonorgestrel intrauterine device and 25% tried endometrial ablation before proceeding to surgery. The use of alternative therapies pre-operatively did not vary between sites or referral sources. The variations in route of hysterectomy that are unexplained by patient factors suggest room for improvement and raises the question whether some of the patients undergoing a TAH may have been candidates for less invasive surgery. Uptake of alternative management strategies for HMB could also be improved.

Chopstick technique versus cross technique in LESS hysterectomy (CCLEH study): a prospective randomized controlled trial

BackgroundThe traditional cross technique can be used to complete most laparoendoscopic single-site surgery (LESS) procedures, but some relatively precise operations, such as vaginal stump suturing, are challenging. In practice, we have introduced a novel technique named the chopstick technique and applied it to more complex operations, such as cervical cancer operations, and found that it contributes to performing delicate surgery. The efficacy and safety of two different surgical techniques in LESS hysterectomy remain to be validated.MethodsPatients who undergo total hysterectomy will be enrolled in this RCT. Stratified randomization will be performed according to uterine size (< 10 cm, 10–15cm, ≥ 15 cm). The participants will be divided into the chopstick technique group or cross technique group to undergo laparoendoscopic single-site total hysterectomy (LESS-TH), and then the perioperative and postoperative data, including the total operation time and other times, transfer rates, estimated blood loss, surgeon fatigue, intraoperative and postoperative complications (within 8 weeks after surgery), health-related quality of life (EQ-5D) scores, postoperative hospital stay, and hospitalization expenses, will be evaluated. The primary outcome is the operating time for total hysterectomy under LESS, and the other outcomes are secondary outcomes.DiscussionIt is expected that the efficacy of the two techniques in LESS, the chopstick technique vs. the cross technique, will be compared and accumulate safety data on the new techniques will be accumulated.Trial registrationChiCTR2000040843, registered on June 16,2020Protocol version:Version 2.0; Date: 2020.05.10

Features of uterine cavity in women with extragenital disorders and abnormal uterine bleedings

Objectives: to determine the features of the uterine cavity in women with extragenital disorders and abnormal uterine bleedings (AUB) using modern diagnostic methods.Materials and methods. The study involved 100 women with AUB and concomitant extragenital disorders, who constituted the main group. The control group consisted of 50 somatically healthy women. Women underwent ultrasound with Doppler mapping, and MRI if indicated to assess the condition of the pelvic organs. Due to the presence of AUB the patients of the main group underwent hysteroscopy and/or separate diagnostic curettage with further morphological assessment of the material obtained.Results. Ultrasound showed that the uterine size in women of the control group corresponded to physiological norms, and the thickness and structure corresponded to the M-echo phase of the menstrual cycle. The main group was additionally divided into subgroups depending on the detected pathological changes in the uterine cavity: endometrial polyp (glandular polyp, adenofibromatous polyp), submucous leiomatous node, endometrial polyp and submucous leiomatous node, endometrial hyperplasia, endometrial hyperplasia in combination with submucous leiomatous node. During the Doppler study the blood flow in the uterine, basal and spiral arteries was analyzed depending on the echographic assessment of the state of the uterine cavity in the main group in comparison with the data of the control group. The patients of the main group were found to have a significant increase in the level of the pulsation index in all the studied vessels in comparison with the corresponding values in the control group (Kruskal–Wallis test, Mann–Whitney test, p &lt; 0.001).Conclusions. The most common disorder of the uterine cavity in women with extragenital diseases and AUB, detected by ultrasound scanning, were polyps of the uterine cavity and endometrial hyperplasia. A feature of blood flow in pathological processes in the uterine cavity was an increase in the pulsation index in the uterine, basal and spiral arteries in women of the main group compared to the control group.

Impact of Uterine Size on Outcomes of Total Laparoscopic Hysterectomy for Uterine Leiomyomas

Background: Given that total laparoscopic hysterectomy (TLH) is less invasive than open surgery, its popularity has increased in Japan. The aim of the present study was to determine the most appropriate uterine size for the safe completion of TLH for the treatment of uterine leiomyomas. Methods: This retrospective study included 505 patients who underwent TLH for uterine leiomyomas. Patients were divided into three groups according to the weight of the excised uterus (&lt;500 g, n = 347; 500–1000 g, n = 125; &gt;1000 g, n = 33). TLH procedures were performed by a resident physician under the supervision of an attending physician. Clinical outcomes including blood loss and duration of surgery were collected from patients’ electronic medical records and compared according to uterine size. Magnetic resonance imaging (MRI) was performed prior to TLH for detection, localization, and measurement of the myoma. Results: Mean operation times were shortest (&lt;500 g: 163 min; 500–1000 g: 190 min; &gt;1000 g: 209 min) and the mean volume of blood lost was lowest (&lt;500 g: 116 mL; 500–1000 g: 208 mL; &gt;1000 g: 402 mL) in patients with a uterus weighing less than 500 g. There were no significant differences in operation time or bleeding between those with a uterine weight of 500–1000 g or &gt;1000 g. MRI revealed that myomas tended to be restricted within the sacral promontory in patients with uterine weights &lt;500 g, whereas those in the other two groups tended to extend beyond this region. Conclusions: TLH outcomes are best when the uterine weight is &lt;500 g. The use of MRI prior to TLH may provide insights into uterine size and/or mass and thus allow for improved surgical planning.

Factors associated with prolonged uterine ischemia time and impact on biomarker expression for patients undergoing surgical management of endometrial cancer (537)

<b>Objectives:</b> The College of American Pathologists recommends < 60 min of ischemia time (IT) for breast cancer specimens to preserve biomarker expression. Our institution implemented a quality improvement initiative in 2019 to limit IT for the uterus to < 60 min for patients undergoing surgery for endometrial cancer (EC) in order to optimize immunohistochemistry (IHC) detection of HER2, ER, PR, and Mismatch Repair (MMR) proteins. We sought to determine patient and surgical factors that influence IT and analyze the association between prolonged IT (≥ 60 min) and biomarker expression in EC specimens. <b>Methods:</b> This is a retrospective review of patients who had a hysterectomy for EC in a comprehensive cancer center from June 2019 to February 2021. Clinical, surgical, and pathologic data were abstracted from medical records. IT was defined as the time between uterine vessel ligation to tissue fixation in formalin. We compared demographic and clinical-pathologic features for patients whose uterine specimens had IT of < 60 min to those with prolonged IT (≥ 60 min). IHC results for HER2, ER, PR, and MMR proteins were also compared between the two groups. Categorical data were compared using Chisquare or Fisher's exact test. Table 1 <b>Results:</b> Two hundred ninety-nine patients underwent hysterectomy for EC with documented IT during the study period. Most patients had endometrioid histology preoperatively (68%), had FIGO stage IA (64%), and underwent minimally invasive surgery (97%). The average length of surgery was 144 min and the average IT was 41 min. Prolonged IT occurred in 37 (12.4%) cases. Demographic factors associated with prolonged IT included age < 50 (p=0.047) and African American race (p<0.001). Uterine weight (p<0.001), need for minilaparotomy (p<0.001), additional procedures performed (p=0.006), and length of surgery (p<0.001) were associated with prolonged IT (Table 1). Day of the week, time of day, trainee involvement, and surgeon were not associated with ischemia time. IHC for HER2, ER, and PR was performed on 10%, 11%, and 10% of specimens, respectively, whereas IHC for MMR proteins was performed in 98% of cases. Though not statistically significant, there was a trend noted toward negative ER expression on IHC in specimens with prolonged IT (p=0.056). There was no association between IT and expression of HER2 (p=0.508), PR (p=0.25), and MMR proteins (p=0.143-1). <b>Conclusions:</b> Approximately 12% of EC specimens had ischemia time > 60 min. Patient factors (age < 50, race) and surgical factors (need for mini-laparotomy, additional procedures, and length of surgery) were associated with prolonged ischemia time. We suspect this is primarily due to uterine size and surgical complexity, which are not modifiable. The potential impact of IT on IHC detection of HER2, ER, PR, and MMR merits further investigation.

Anemia-Associated Platelets and Plasma Prothrombin Time Increase in Patients with Adenomyosis.

Patients with adenomyosis are hypercoagulable and often accompanied by anemia, but the specific changes in anemia-related coagulation parameters are still unclear. This study investigated the changes in and influencing factors of coagulation parameters related to anemia in patients with adenomyosis (AM). The coagulation parameters, including platelet count (PC), plasma prothrombin time (PT), activated partial prothrombin time (APTT), thrombin time (TT) and fibrinogen (FB), and hemoglobin (Hb), were measured in patients with adenomyosis (229 cases in AM group), uterine leiomyoma (265 cases in LM group), and undergoing tubal anastomosis (142 cases in the control group). The age of the control group was younger than that of the AM group and the LM group. Compared with the AM and LM groups, the uterus size of the control group was smaller; the AM group was larger than the LM group. The Hb concentration of the AM group was lower than that of the LM and control groups. Compared with the LM and control groups, PC increased and TT shortened in the AM group. APTT in the AM group was shorter than in the control group, and PT was longer than in the LM group. After adjustment using multiple logistic regression analysis, adenomyosis was correlated with Hb concentration (or = 0.971, 95% CI 0.954–0.988, p < 0.001), PC (or = 1.006, 95% CI 1.002–1.011, p = 0.004), PT (or = 3.878, 95% CI 2.347–6.409, p < 0.001), age (or = 1.062, 95% CI 1.013–1.114, p = 0.013), and uterine size (or = 1.103, 95% CI 1.011–1.203, p = 0.028). Correlation analysis showed that PC (r = −0.309) and PT (r = −0.252) were negatively correlated with anemia. The increase in Hb-related PC and PT in patients with adenomyosis indicates that the timely and early detection of coagulation parameters is needed for patients with severe anemia, older age, and larger uterine volume.

The Uterus as an Influencing Factor for Late Embryo/Early Fetal Loss—A Clinical Update

Simple SummaryPregnancy loss following a positive pregnancy diagnosis in the absence of infectious disease of the reproductive system is a main factor limiting reproductive efficiency in high producing dairy cows. We describe here some circumstances such as the age of the dam, retained placenta and uterine size in which the uterus may be associated with pregnancy loss.Here we revise circumstances of non-infectious causes in which the uterus may be associated with pregnancy loss during the late embryo/early fetal period (following a positive pregnancy diagnosis in lactating dairy cows). As the uterine size increases with parity and pregnant heifers with no detrimental effects of a previous parturition, a primigravid uterus is proposed as a reference for identifying risk factors that negatively influence pregnancy in lactating cows. Cows suffering placenta retention or with a large uterus at insemination were selected as topics for this revision. Retained placenta, that occurs around parturition, has a long-lasting influence on subsequent pregnancy loss. Although retained placenta is a particularly predisposing factor for uterine infection, farm conditions along with cow factors of non-infectious cause and their interactions have been identified as main factors favoring this disorder. A large uterus (cervix and uterine horns lying outside the pelvic cavity) with no detectable abnormalities has been associated with low fertility and with a greater incidence of pregnancy loss. A large reproductive tract may well derive from an inadequate uterine involution. Therefore, peripartum management and strategies to reduce the incidence of uterine disorders should reduce their associated financial losses in the herds.

Conservative surgical repair in cervical atresia associated with partial or complete absence of the vagina

To describe the surgical technique of laparoscopically assisted uterovaginal/vestibular anastomosis in patients with cervical atresia associated with partial or complete absence of the vagina. Surgical video article. Local institutional review board approval and written permission from the patients were obtained. Tertiary referral center. The surgical video presents surgical correction in 3 different patients with cervical agenesis. The first patient, aged 14 years, had a normoconformed uterus and total absence of the vagina. The second patient, aged 12 years, demonstrated a left unicornuate uterus and partial absence of the vagina. The third patient, aged 13 years, displayed a right unicornuate uterus and total absence of the vagina. Laparoscopic time and perineal time. During laparoscopy, the entire abdominopelvic cavity was assessed to evaluate the uterine morphology and size to exclude anomalies such as hematometra. The adnexa and adhesions were evaluated and any endometrial flare-ups were treated appropriately. A laparoscopic ultrasound probe was used to evaluate the size and location of the endometrial cavity. In cases with total absence of vaginas, an H-shaped incision in the hymenal dimple allowed a larger area of available tissue for the anastomosis. A tunnel was then created by blunt finger dissection between the bladder and rectum. Simultaneously, the uterus was pushed caudally by an assistant while the operator grasped it from below using an internal probe. A circular myometrial incision at the uterine caudal body allowed to reach the endometrial cavity and open it. The edges of the uterine cavity were then anastomized with the edges of the hymenal incision. In cases with partial absence of vaginas, the creation of the tunnel between the vagina and rectum was not necessary and the open uterus was anastomosed with the margins of the vaginal dome, engraved on the guide of a metal dilator. All patients received broad-spectrum antibiotics (i.e., cephalosporins of the last available generation) on the day before surgery and on the day of surgery. Intraoperative anatomic and ultrasound data, neovaginal length, and recovery of menstrual function 180 days after surgery. The surgical procedure was successful in all cases. No major complications were recorded, and in particular, no bladder or rectal injuries occurred. No stenosis of the neocervix was recorded. The main hospital stay of the patients was 3.5 ± 1.5 days. In each case, the neovagina developed gradually over time after surgery because of the upward traction action exerted by the uterus through its natural ligament apparatus (cardinal ligaments and ovarian vessels). This fact eliminated the requirement for the use of a mold after surgery. At the 15-week follow-up, vaginoscopy was performed, with mucus observed at the site of uterovaginal anastomosis in all cases. None of the patients developed infection after surgery because of the avoidance of molds or pessaries and the natural mucus production. Six months after surgery, the length of the neovagina was >4 cm in all 3 cases. Laparoscopic-assisted uterovaginal/vestibular anastomosis may be considered the treatment of choice for patients with cervical atresia associated with partial or complete absence of the vagina.

Long-term treatment of dienogest with symptomatic adenomyosis: retrospective analysis of efficacy and safety in clinical practice

ABSTRACT Objective: To evaluate the efficacy and safety of dienogest (DNG) in women with symptomatic adenomyosis.Methods: Women with symptomatic adenomyosis were included in this retrospective observation study. Group 1 (maximum uterine dimension ≥ 100.0 mm) began DNG after 4 months of GnRH-a administration, Group 2 (maximum uterine dimension < 100.0 mm) received DNG with no prior GnRH-a treatment. All women were assessed for their pain symptoms, uterine size, adverse effects and laboratory hematology at baseline and every 6 months during the treatment.Results: 123 women were enrolled in this study, in Group 1 (71 women) with severe uterine enlargement, the median VAS score was 80 mm prior to GnRH-a administration and 10, 10, 10, 20, and 20 mm, respectively, after 0, 6,12,18, and 24 months of DNG treatment. The mean uterine volume decreased from 262.9 ml to 104.7 ml after GnRH-a therapy, and slowly increased from 104.7 ml to 139.5 ml after 24 month-treatment of DNG. Another 52 women with mild uterine enlargement received DNG without prior GnRH-a administration, median VAS score was 70 mm at baseline and decreased to 20, 20, 10, and 10 mm at 6,12,18, and 24 months. The mean uterine volume slightly decreased from 157.9 ml to 153.3 ml after 24 months of DNG treatment (p > 0.05). All laboratory parameters were in the normal range.Conclusions: DNG is effective and well tolerated as a long-term treatment for symptomatic adenomyosis, and it can be used as maintenance therapy after discontinuation of GnRH-a administration.

Personal experience of Non Descent Vaginal Hysterectomy (NDVH) in a District Hospital - A Study of 60 cases.

Objective(S): To share our experience and explore the safety &amp; feasibility of NDVH in 60 cases. Methods: This prospective observational study was conducted from Jan 2016 to Dec 2017 in Obstetrics and Gynaecology Department of Sylhet shaheed Shamsuddin Ahmed Hospital, Sylhet. Sixty patients requiring hysterectomy for benign nonprolapsed gynaecological disorders were the target population. Prerequisite for non-descend vaginal hysterectomy were uterine size not exceeding 20 weeks, adequate vaginal access with uterine mobility. Main outcome measures were i) Procedures of removal of large uterus ii) Time taken to complete the operation iii) Blood loss during operation iv) Postoperative hospital stay. v) Postoperative complications. Results: Vaginal hysterectomy was completed successfully in 100% cases. All patients were multiparous and in 41-45 years age group (37%). Commonest indication was AUB (37%), Second indication was fibroid uterus (35%) and next indication was adenomyosis (13%). In most of the case uterus was 10-12 weeks size (37%), in 28% cases uterine size was less than 8 weeks, 14-16 weeks size in 27% cases and uterus was more than 16 weeks size in 8% cases. Morcellation techniques like bisection, myomectomy, wedge resection and debulking were done to remove bigger sized uterus. Mean operating time was 45 minutes. Mean blood loss was 60ml. Average hospital stay was 3 day. Complications were minimum which included UTI and febrile morbidity. At 12 weeks postoperative follow up 72% patient had no adverse complain though 18% cases was drop out. Conclusions: Vaginal hysterectomy is safe feasible, scarless and patient friendly approach for benign gynaecological disorders other than prolapsed uterus. In this era of minimally invasive surgery, non-descend vaginal hysterectomy is to be considered as a safe option.

First report on clinical aspects, blood profiles, bacterial isolation, antimicrobial susceptibility, and histopathology in canine pyometra in Thailand.

Background and Aim:Canine pyometra, either the closed (closed pyometra [CP]) or open (open pyometra [OP]) cervix type, is a frequent uterine disease in intact old age bitches. Therefore, early diagnosis and appropriate medical and surgical treatments are crucial to avoid the life-threatening condition in these bitches. This study aimed to investigate clinical alterations, blood parameters, causative bacteria, antimicrobial susceptibility, and uterine histopathology obtained during aseptic surgical treatment on bitches with pyometra.Materials and Methods:Sixty bitches of various breeds and ages with presumptive pyometra diagnoses were included in the study. The diagnoses were based on history, clinical examination, blood parameters, radiography, and ultrasonography. All pyometra bitches were ovariohysterectomized as an emergency surgical treatment. In addition, uterine content and tissues were submitted for bacterial isolation, antimicrobial susceptibility, and uterine histopathological analysis.Results:Except for abdominal CP distention, no specific clinical signs were linked to the pyometra type. The mean values of total white blood cell count (WBC) and plasma protein were predominantly raised in pyometra bitches regarding hematological parameters. Leukocytosis was found in both types; however, the WBC in CP was markedly higher than in OP. The mean value of blood urea nitrogen increased in the CP group. Klebsiella pneumoniae and Escherichia coli were the most frequent causative bacteria isolated in CP and OP, respectively. All isolated bacteria were 100% susceptible to imipenem, meropenem, and carbapenem. Marbofloxacin was the second most effective drug against isolated bacteria from both groups. Uncomplicated cystic endometrial hyperplasia (CEH) was not presented in the CP group. CEH and chronic endometritis (type IV), the most severe uterine histopathological changes, were discovered in the CP and OP.Conclusion:The CP and OP groups presented leukocytosis, increased plasma protein, and CEH and chronic endometritis. Depression, abdominal distention, and enlarged uterine size were the major characteristics of the CP group. Furthermore, abdominal distension is presented in other abnormalities in clinical practices, providing a differential diagnosis. Drugs in the carbapenem group were the most effective against isolated bacteria; however, they are not routinely used due to bacterial resistance concerns. Thus, marbofloxacin was recommended as an alternative medical treatment because it is convenient to manage by both oral and injection routes.

Measurement of Uterus Sizes Of Multiparous Women using Ultrasound

Human uterus is a pear-shaped fibromuscular organ. The measurements of a typical uterus are 7.6x4. 5x3cm. The uterus grows slowly during fetal life until the end of the first trimester when it grows at a higher rate due to increased maternal oestrogen production. As a result of this continuation of the maternal oestrogen the uterus shrinks immediately after delivery. Objective: To evaluate uterus size in multiparous women using ultrasound. Methods: It was a cross-sectional study carried out at private sector hospital of Gujrat over 4 months period from December 2021 to March 2022. The sample size was 41 calculated via a convenient sampling approach from previously published studies. Multiparous women following ultrasound examination during the study period were included after receiving informed consent. The patients’ demographic statistics were collected on a specially designed data collecting sheet. The data was analyzed using the SSPS V20 program. Results: The average length was 7.9±1.15, width was 4.3±0.77, and thickness 3.5±0.66. There was no significant correlation between uterine size (length, width, thickness) and many parities because the value in the "Sig. (2-tailed)" is 0.607, 0.640, and 0.983 respectively which is more than 0.05.Conclusion: The current study found no correlation between the number of parities and the length, width, and thickness diameters of the uterus.

Frequency Of Uterine Anomalies Associated with Persistent Miscarriages in Pregnancy on Ultrasound

Miscarriages is when an embryo/foetus expires before the tenth week of gestation. It occurs most commonly early during pregnancy. Women who had a miscarriage looked to be more likely to die before the age of 70 than those who had any other pregnancy outcomes. Objective: To determine the frequency of uterine abnormalities related with persistent miscarriages in pregnancy on ultrasound. Methods: It was a cross-sectional study conducted over a period of 4 months from February 2022 to May 2022. A sample size of 70 patients was collected using purposive sampling technique. Data was collected from Memorial Christian Hospital Sialkot. Patients with multiple miscarriages due to uterine abnormalities were included in the current study. Patients with less than two miscarriages, self-induced miscarriages and miscarriages due to foetal anomalies were excluded. Data was analysed using SPSS version 20.0. Results: The study showed that the mean age of affected women experiencing miscarriage is 28.72. The highest rate of miscarriage was found in 38 (54.3%) of females and least in 4 (5.7%). The common cause of miscarriage was fibroids. Out of 70 females, 34 (48.6%) had fibroids, 14 (20%) had cervical incompetence, 9 (12.9%) had uterine adhesions, 6 (8.6%) had abnormal uterine size, 4 (5.7%) had uterine polyp and remaining 3 (4.3%) had congenital anomalies. Conclusion: The study concluded that miscarriages and uterine factors are closely linked. Uterine fibroids have shown the highest percentage of patients that had undergone miscarriage.