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Obstetrical & Gynecological Survey Jul 2023Multiple postpartum scenarios require uterine exploration or instrumentation. These may introduce bacteria into the uterus, increasing the risk of endometritis. Data on...
IMPORTANCE
Multiple postpartum scenarios require uterine exploration or instrumentation. These may introduce bacteria into the uterus, increasing the risk of endometritis. Data on the use of antibiotics in these scenarios is limited, resulting in few guidelines and divergent care.
OBJECTIVE
To describe postpartum scenarios requiring uterine exploration and/or instrumentation, review data on antibiotic prophylaxis, and delineate antibiotic recommendations for each scenario.
EVIDENCE ACQUISITION
Original articles were obtained from literature search in PubMed, MEDLINE, and OVID; pertinent articles were reviewed.
RESULTS
These recommendations are based on published evidence and professional society guidelines. Antibiotic prophylaxis following manual placenta removal should include 1-time combination of ampicillin 2 g intravenously (IV) or cefazolin 1 g IV, plus metronidazole 500 mg IV. Antibiotic prophylaxis before postpartum dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade should include 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. If the patient in any of the above scenarios has received group B prophylaxis, then only metronidazole is recommended. Further randomized clinical trials are needed to optimize these regimens.
CONCLUSIONS
Uterine exploration or instrumentation increases the risk of postpartum endometritis and requires antibiotic prophylaxis. For manual placenta removal, we recommend 1-time combination of ampicillin 2 g IV or cefazolin 1 g IV, plus metronidazole 500 mg IV. For dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade, we recommend 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. For patients who already received antibiotic prophylaxis for group B , we recommend 1-time dose of metronidazole 500 mg IV.
RELEVANCE
Providers can utilize our guidelines to prevent postpartum endometritis in these scenarios requiring postpartum uterine exploration and/or instrumentation.
Topics: Female; Humans; Pregnancy; Ampicillin; Anti-Bacterial Agents; Antibiotic Prophylaxis; Cefazolin; Endometritis; Metronidazole; Postpartum Period; Puerperal Infection
PubMed: 37480294
DOI: 10.1097/OGX.0000000000001167 -
Journal of Minimally Invasive Gynecology Dec 2023Suction curettage is preferred over sharp curettage in obstetric settings. We compare the quality of operative tissue sampling between sharp curettage and suction...
STUDY OBJECTIVE
Suction curettage is preferred over sharp curettage in obstetric settings. We compare the quality of operative tissue sampling between sharp curettage and suction curettage using electric vacuum aspiration for nonobstetric abnormal uterine bleeding in reproductive-aged women.
DESIGN
A retrospective cohort study.
SETTING
Community hospital in Long Island, New York.
PATIENTS
Women ages 21 to 45 years (n = 257) who underwent operative curettage procedure for nonobstetric abnormal uterine bleeding.
INTERVENTIONS
Independent ratings of specimens from suction curettage using electric vacuum aspiration and sharp curettage by 2 pathologists blinded to method of tissue collection.
MEASUREMENTS AND MAIN RESULTS
The primary outcome was percentage of organized tissue, indicative of a higher-quality pathology specimen. Specimens obtained by electric suction curettage (p <.001) had a significantly higher percentage of organized tissue (M = 66.28, SD = 20.33) than sharp curettage (M = 55.51, SD = 24.17). There were no differences between the curettage groups for operative time, blood loss, intraoperative complications, or pathology diagnosis.
CONCLUSION
Specimens obtained with suction curettage contained more organized tissue with similar pathologist satisfaction and confidence scores than sharp curettage. We suggest clinicians consider electric suction curettage in the diagnostic workup of abnormal uterine bleeding in reproductive-aged women. In addition, patient-centered benefits include no increase in operative time, blood loss, or complication rate compared with sharp curettage.
Topics: Pregnancy; Humans; Female; Adult; Vacuum Curettage; Retrospective Studies; Uterine Diseases; Curettage; Uterine Hemorrhage
PubMed: 37661082
DOI: 10.1016/j.jmig.2023.08.428 -
Ceska Gynekologie 2022Uterine perforation is a potential, not rare complication of all intrauterine procedures and may be associated with injury of surrounding organs and structures. The...
OBJECTIVE
Uterine perforation is a potential, not rare complication of all intrauterine procedures and may be associated with injury of surrounding organs and structures. The incidence, risk factors, possible prevention, dia-gnosis, management and impact on future reproduction is reviewed here.
METHODS
Systematic review of available sources on the topic was carried out using the PubMed database and textbooks of Czech authors.
CONCLUSION
Some risk factors that make access to the uterine cavity difficult may be prevented, however, others remain unpreventable. For patients in whom the perforation occurred during sondage, dilatation or insertion of blunt and cold instrument, without significant bleeding and who are hemodynamically stable, observation is recommended rather than immediate abdominal exploration. The exception are young women planning pregnancy in whom endoscopic suture is indicated. Abdominal exploration is required in patients who have been injured by electrosurgical or sharp device, laser, vacuum curette, who are hemodynamically unstable or show signs of severe bleeding or visceral injury.
Topics: Female; Humans; Pregnancy; Uterine Perforation; Uterus
PubMed: 36055792
DOI: 10.48095/cccg2022295 -
Comparison Between Different Approaches Applied in Pediatric Adenoidectomy: A Network Meta-Analysis.The Annals of Otology, Rhinology, and... Feb 2023Adenoidectomy is a surgical procedure most frequently performed by otolaryngologists. However, there are no universally accepted guidelines for the choice of the... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Adenoidectomy is a surgical procedure most frequently performed by otolaryngologists. However, there are no universally accepted guidelines for the choice of the surgical approach in specific circumstances. Therefore, a network meta-analysis (NMA) is needed to summarize existing studies and provide more evidence-based medical guidelines.
METHODS
A systematic search of the literature was conducted in the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE databases from inception to 31 July 2021. A network meta-analysis of operating time, intraoperative blood loss, postoperative pain score, and incidence of postoperative residual tissue was performed.
RESULTS
A total of 20 studies with 2329 patients were included. Four common surgical approaches, including powered vacuum shaver adenoidectomy (PVSA), plasma field ablation adenoidectomy (PFAA), curettage adenoidectomy (CUA), and suction diathermy adenoidectomy (SDA), were compared for operative time, intraoperative blood loss, postoperative pain score, and incidence of postoperative residual tissue. There were no significant differences between the surgical techniques for the 3 endpoints, operative time, intraoperative blood loss, and incidence of postoperative residual tissue. The data showed lower postoperative pain scores for PFAA than for CUA (MD = -3.45, 95% CI [-6.01, -0.95]). There were no significant differences in other surgical approaches for postoperative pain scores.
CONCLUSION
There were no significant differences between PVSA, PFAA, CUA, and SDA for operative time, intraoperative blood loss, and incidence of postoperative residual tissue. PFAA had advantages over CUA for postoperative pain scores.
Topics: Child; Humans; Adenoidectomy; Blood Loss, Surgical; Network Meta-Analysis; Pain, Postoperative; Postoperative Hemorrhage
PubMed: 35227080
DOI: 10.1177/00034894221081612 -
BMJ Case Reports Dec 2023Postpartum pyometra is rare; however, it may lead to sepsis. The main initial symptoms are fever, lower abdominal pain and foul-smelling lochia. The treatment includes...
Postpartum pyometra is rare; however, it may lead to sepsis. The main initial symptoms are fever, lower abdominal pain and foul-smelling lochia. The treatment includes antibiotic administration and surgical drainage. This is a report of postpartum pyometra following a caesarean section that was successfully treated with manual vacuum aspiration, a simple and minimally invasive option. Other treatment options include pyometra reduction using placenta forceps and the placement of an intrauterine drainage catheter.
Topics: Humans; Pregnancy; Female; Pyometra; Vacuum Curettage; Cesarean Section; Anti-Bacterial Agents; Postpartum Period
PubMed: 38050392
DOI: 10.1136/bcr-2023-258048 -
Obstetrical & Gynecological Survey Oct 2017Ectopic pregnancy is a leading source of morbidity and mortality in pregnancy, accounting for 1% to 2% of all pregnancies. Timely diagnosis and management of these... (Review)
Review
IMPORTANCE
Ectopic pregnancy is a leading source of morbidity and mortality in pregnancy, accounting for 1% to 2% of all pregnancies. Timely diagnosis and management of these abnormal gestations are vital to patient safety.
OBJECTIVE
The objective of this study was to describe recent evidence in the risk factors, diagnosis, and management of ectopic pregnancy.
EVIDENCE ACQUISITION
Comprehensive review of the published literature.
RESULTS
Recent literature describes newly identified risk factors for ectopic pregnancy, particularly those specific to assisted reproduction. Furthermore, evidence mounts for the utility of endometrial sampling for the diagnosis of pregnancy location, allowing a significant proportion of women to avoid methotrexate by diagnosing failing intrauterine pregnancies instead. Finally, recent, high-level evidence supports (in women with normal contralateral fallopian tubes) the equivalence of salpingectomy and salpingostomy regarding rates of subsequent intrauterine pregnancy and recurrent ectopic pregnancy.
CONCLUSIONS AND RELEVANCE
While serial serum human chorionic gonadotropin levels and transvaginal ultrasound are the mainstays of ectopic pregnancy diagnosis, recent publications revisit the utility of endometrial sampling in diagnosing pregnancy location, using manual vacuum aspiration instead of the criterion-standard dilation and curettage. Expectant management of ectopic pregnancies is the subject of ongoing research, and in the meantime, treatment remains medical or surgical (dependent on clinical parameters and patient preference); salpingostomy and salpingectomy provide equivalent subsequent pregnancy outcomes in women with contralateral fallopian tubes in place.
Topics: Abortifacient Agents, Nonsteroidal; Chorionic Gonadotropin; Female; Humans; Methotrexate; Pregnancy; Pregnancy, Ectopic; Reproductive Techniques, Assisted; Risk Factors; Salpingostomy; Ultrasonography, Prenatal
PubMed: 29059454
DOI: 10.1097/OGX.0000000000000492 -
The Cochrane Database of Systematic... Jul 2015The World Health Organization recommends that abortion can be provided at the lowest level of the healthcare system. Training mid-level providers, such as midwives,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The World Health Organization recommends that abortion can be provided at the lowest level of the healthcare system. Training mid-level providers, such as midwives, nurses and other non-physician providers, to conduct first trimester aspiration abortions and manage medical abortions has been proposed as a way to increase women's access to safe abortion procedures.
OBJECTIVES
To assess the safety and effectiveness of abortion procedures administered by mid-level providers compared to doctors.
SEARCH METHODS
We searched the CENTRAL Issue 7, MEDLINE and POPLINE databases for comparative studies of doctor and mid-level providers of abortion services. We searched for studies published in any language from January 1980 until 15 August 2014.
SELECTION CRITERIA
Randomised controlled trials (RCTs) (clustered or not clustered), prospective cohort studies or observational studies that compared the safety or effectiveness (or both) of any type of first trimester abortion procedure, administered by any type of mid-level provider or doctors, were eligible for inclusion in the review.
DATA COLLECTION AND ANALYSIS
Two independent review authors screened abstracts for eligibility and double-extracted data from the included studies using a pre-tested form. We meta-analysed primary outcome data using both fixed-effect and random-effects models to obtain pooled risk ratios (RR) with 95% confidence intervals (CIs). We carried out separate analyses by study design (RCT or cohort) and type of abortion procedure (medical versus surgical).
MAIN RESULTS
Eight studies involving 22,018 participants met our eligibility criteria. Five studies (n = 18,962) assessed the safety and effectiveness of surgical abortion procedures administered by mid-level providers compared to doctors. Three studies (n = 3056) assessed the safety and effectiveness of medical abortion procedures. The surgical abortion studies (one RCT and four cohort studies) were carried out in the United States, India, South Africa and Vietnam. The medical abortion studies (two RCTs and one cohort study) were carried out in India, Sweden and Nepal. The studies included women with gestational ages up to 14 weeks for surgical abortion and nine weeks for medical abortion.Risk of selection bias was considered to be low in the three RCTs, unclear in four observational studies and high in one observational study. Concealment bias was considered to be low in the three RCTs and high in all five observational studies. Although none of the eight studies performed blinding of the participants to the provider type, we considered the performance bias to be low as this is part of the intervention. Detection bias was considered to be high in all eight studies as none of the eight studies preformed blinding of the outcome assessment. Attrition bias was low in seven studies and high in one, with over 20% attrition. We considered six studies to have unclear risk of selective reporting bias as their protocols had not been published. The remaining two studies had published their protocols. Few other sources of bias were found.Based on an analysis of three cohort studies, the risk of surgical abortion failure was significantly higher when provided by mid-level providers than when procedures were administered by doctors (RR 2.25, 95% CI 1.38 to 3.68), however the quality of evidence for this outcome was deemed to be very low. For surgical abortion procedures, we found no significant differences in the risk of complications between mid-level providers and doctors (RR 0.99, 95% CI 0.17 to 5.70 from RCTs; RR 1.38, 95% CI 0.70 to 2.72 from observational studies). When we combined the data for failure and complications for surgical abortion we found no significant differences between mid-level providers and doctors in both the observational study analysis (RR 1.36, 95% CI 0.86 to 2.14) and the RCT analysis (RR 3.07, 95% CI 0.16 to 59.08). The quality of evidence of the outcome for RCT studies was considered to be low and for observational studies very low. For medical abortion procedures the risk of failure was not different for mid-level providers or doctors (RR 0.81, 95% CI 0.48 to 1.36 from RCTs; RR 1.09, 95% CI 0.63 to 1.88 from observational studies). The quality of evidence of this outcome for the RCT analysis was considered to be high, although the quality of evidence of the observational studies was considered to be very low. There were no complications reported in the three medical abortion studies.
AUTHORS' CONCLUSIONS
There was no statistically significant difference in the risk of failure for medical abortions performed by mid-level providers compared with doctors. Observational data indicate that there may be a higher risk of abortion failure for surgical abortion procedures administered by mid-level providers, but the number of studies is small and more robust data from controlled trials are needed. There were no statistically significant differences in the risk of complications for first trimester surgical abortions performed by mid-level providers compared with doctors.
Topics: Abortifacient Agents; Abortion, Legal; Abortion, Therapeutic; Allied Health Personnel; Clinical Competence; Cohort Studies; Female; Humans; Midwifery; Mifepristone; Misoprostol; Nurses; Nursing Assistants; Observational Studies as Topic; Physician Assistants; Physicians; Pregnancy; Pregnancy Trimester, First; Randomized Controlled Trials as Topic; Vacuum Curettage
PubMed: 26214844
DOI: 10.1002/14651858.CD011242.pub2 -
Social Science & Medicine (1982) Jan 2020Manual Vacuum Aspirators (MVA), Dilation and Curettage (D&C), and medical abortifacients (Misoprostol, Mifepristone and Divabo) are available in clinical settings that...
Manual Vacuum Aspirators (MVA), Dilation and Curettage (D&C), and medical abortifacients (Misoprostol, Mifepristone and Divabo) are available in clinical settings that offer abortion and post-abortion care in Uganda. While these technologies imply appropriate and safe abortion care, legal and policy ambiguities impact health outcomes. In this article, we draw on an ethnography of abortion care delivery practice conducted in one district in Eastern Uganda between August 2018 and March 2019, with data from interviews and observations, both of interactions and during quality of care improvement and training meetings. We illuminate how, in the context of a financialized healthcare system and legal restrictions, the meanings and use of medical technologies and abortion care vary across different health facility types. In public health facilities, health workers become state agents in the control of women's bodies. In private health facilities, they become transgressors, who use medical technologies to help women attain termination surreptitiously. Health workers offset risks associated with any involvement in termination, such that pecuniary interests dominate their motivation. Normalized and disciplinary power enact and reproduce unsafe and risky conditions, leading to poor abortion care outcomes. We illustrate the mechanisms of domination and tactics of resistance in abortion care, and expose conditions upon which unsafe and risky outcomes are contingent.
PubMed: 32058197
DOI: 10.1016/j.socscimed.2020.112813 -
Contraception Sep 2022To measure the difference in procedure time between manual vacuum aspiration (MVA) and electric vacuum aspiration (EVA) during abortion procedures between 10 0/7 and 13... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To measure the difference in procedure time between manual vacuum aspiration (MVA) and electric vacuum aspiration (EVA) during abortion procedures between 10 0/7 and 13 6/7 weeks gestation.
STUDY DESIGN
We conducted a 1:1 randomized trial of individuals undergoing an abortion procedure between 10 0/7 and 13 6/7 weeks to MVA or EVA. Procedure time was the primary outcome. We performed an intention-to-treat analysis. A total of 132 patients (66 per arm) were needed to identify a 2-minute difference in time with 90% power and an alpha of 0.05. Given the non-parametric distribution of procedure times, we used Mann-Whitney U test to assess for differences in median procedure times.
RESULTS
We randomized 146 participants; 74 to MVA and 72 to EVA. Median procedure times were similar between the 2 groups; EVA 2.4 minutes (range 0.9-6.9 min) and MVA 2.6 minutes (range 1.1-9.0 min, p = 0.12). When stratified by gestational age, EVA between 12 0/7 and 13 6/7 weeks had a shorter median procedure time compared to MVA (2.5 min, range 1.4-6.9 min vs. 3.5 min range 1.7-9.0), respectively (p = 0.005). One conversion occurred from MVA to EVA at 13 weeks.
CONCLUSION
We found no difference in procedure time between MVA and EVA between 10 0/7 and 13 6/7 weeks gestation. MVA does take 1 minute longer than EVA when performed between 12 0/7-13 6/7 weeks; however, this difference is not likely be clinically significant.
IMPLICATIONS
Procedure times are similar for manual and electric vacuum aspiration for uterine evacuation between 10 and 14 weeks and the rate of conversion is low.
Topics: Abortion, Induced; Abortion, Spontaneous; Female; Gestational Age; Humans; Pregnancy; Pregnancy Trimester, First; Vacuum Curettage
PubMed: 35417756
DOI: 10.1016/j.contraception.2022.03.025 -
Medicina (Kaunas, Lithuania) Sep 2019We describe a novel technique for percutaneous tumor debulking and cavity creation in patients with extensive lytic lesions of the vertebral body including posterior...
Mechanical Cavity Creation with Curettage and Vacuum Suction (Q-VAC) in Lytic Vertebral Body Lesions with Posterior Wall Dehiscence and Epidural Mass before Cement Augmentation.
We describe a novel technique for percutaneous tumor debulking and cavity creation in patients with extensive lytic lesions of the vertebral body including posterior wall dehiscence prior to vertebral augmentation (VA) procedures. The mechanical cavity is created with a combination of curettage and vacuum suction (Q-VAC). Balloon kyphoplasty and vertebral body stenting are used to treat neoplastic vertebral lesions and might reduce the rate of cement leakage, especially in presence of posterior wall dehiscence. However, these techniques could theoretically lead to increased intravertebral pressure during balloon inflation with possible mobilization of soft tissue tumor through the posterior wall, aggravation of spinal stenosis, and resultant complications. Creation of a void or cavity prior to balloon expansion and/or cement injection would potentially reduce these risks. : A curette is coaxially inserted in the vertebral body via transpedicular access trocars. The intravertebral neoplastic soft tissue is fragmented by multiple rotational and translational movements. Subsequently, vacuum aspiration is applied via one of two 10 G cannulas that had been introduced directly into the fragmented lesion, while saline is passively flushed via the contralateral cannula, with lavage of the fragmented solid and fluid-necrotic tumor parts. We applied the Q-VAC technique to 35 cases of thoracic and lumbar extreme osteolysis with epidural mass before vertebral body stenting (VBS) cement augmentation. We observed extravertebral cement leakage on postoperative CT in 34% of cases, but with no clinical consequences. No patients experienced periprocedural respiratory problems or new or worsening neurological deficit. The Q-VAC technique, combining mechanical curettage and vacuum suction, is a safe, inexpensive, and reliable method for percutaneous intravertebral tumor debulking and cavitation prior to VA. We propose the Q-VAC technique for cases with extensive neoplastic osteolysis, especially if cortical boundaries of the posterior wall are dehiscent and an epidural soft tissue mass is present.
Topics: Adult; Aged; Aged, 80 and over; Bone Cements; Curettage; Female; Humans; Lumbar Vertebrae; Magnetic Resonance Imaging; Male; Middle Aged; Minimally Invasive Surgical Procedures; Osteolysis; Positron Emission Tomography Computed Tomography; Postoperative Complications; Spinal Neoplasms; Suction; Surgery, Computer-Assisted; Thoracic Vertebrae
PubMed: 31554335
DOI: 10.3390/medicina55100633