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Case Reports in Women's Health Dec 2023Gestational trophoblastic disease (GTD) is an abnormal pregnancy caused by the placenta, which can potentially metastasise. Suction evacuation is recommended for...
Gestational trophoblastic disease (GTD) is an abnormal pregnancy caused by the placenta, which can potentially metastasise. Suction evacuation is recommended for diagnosis and treatment, and dilatation and evacuation (D&E) is usually performed under intravenous anaesthesia due to the short operation time and minimal blood loss. We refer to the guidelines produced by the Japan Society of Obstetrics and Gynaecology (JSOG), and acknowledge that practices vary globally. However, to the best of our knowledge, there is no evidence on perioperative management and arrangements in D&E required for managing giant hydatidiform moles, such as preventing massive haemorrhage, respiratory dysfunction with a pathogenesis like ovarian hyperstimulation syndrome (OHSS), or intensive care needs. This case report describes perioperative considerations for managing a giant hydatidiform mole using D&E in a uterus enlarged to the third-trimester pregnancy size. A 28-year-old multiparous woman was clinically diagnosed with a hydatidiform mole after a spontaneous miscarriage due to abnormal genital bleeding, systemic oedema, and abdominal distention. Ultrasound and computed tomography showed a ballooning uterus with a third-trimester pregnancy size, a robust intrauterine mass, and ascites. Serum hCG levels were extremely high (>3,000,000 mIU/mL), confirming the clinical diagnosis of a hydatidiform mole. Emergency D&E was safely performed under multidisciplinary perioperative management, with careful preparation and support. This is a rare experience-based case report and valuable documentation detailing multidisciplinary perioperative management under general anaesthesia. To the best of our knowledge, this is the first report describing the considerations, details, and innovations required in the perioperative management of giant hydatidiform moles using D&E.
PubMed: 37954516
DOI: 10.1016/j.crwh.2023.e00556 -
PloS One 2023Management of uterine evacuation is essential for increasing safe abortion care. Monitoring through surveillance systems tracks changes in clinical practice and provides...
BACKGROUND
Management of uterine evacuation is essential for increasing safe abortion care. Monitoring through surveillance systems tracks changes in clinical practice and provides information to improve equity in abortion care quality.
OBJECTIVE
This study aimed to evaluate the frequency of manual vacuum aspiration (MVA) and medical abortion (MA), and identify the factors associated with each uterine evacuation method after surveillance network installation at a Brazilian hospital.
METHODS
This cross-sectional study included women admitted for abortion or miscarriage to the University of Campinas Women's Hospital, Brazil, between July 2017 and November 2020. The dependent variables were the use of MVA and MA with misoprostol. The independent variables were the patients' clinical and sociodemographic data. The Cochran-Armitage, chi-square, and Mann-Whitney U tests, as well as multiple logistic regression analysis, were used to compare uterine evacuation methods.
RESULTS
We enrolled 474 women in the study, 91.35% of whom underwent uterine evacuation via uterine curettage (78.75%), MVA (9.46%), or MA (11.54%). MVA use increased during the study period (Z = 9.85, p < 0.001). Admission in 2020 (odds ratio [OR] 64.22; 95% confidence interval [CI] 3.79-1086.69) and lower gestational age (OR 0.837; 95% CI 0.724-0.967) were independently associated with MVA, whereas the only factor independently associated with MA was a higher education level (OR 2.66; 95% CI 1.30-5.46).
CONCLUSION
MVA use increased following the installation of a surveillance network for good clinical practice. Being part of a network that encourages the use of evidence-based methods provides an opportunity for healthcare facilities to increase access to safe abortions.
Topics: Pregnancy; Humans; Female; Musa; Aftercare; Cross-Sectional Studies; Abortion, Induced; Vacuum Curettage; Hospitals, University; Abortion, Spontaneous
PubMed: 38100497
DOI: 10.1371/journal.pone.0296009 -
BMC Women's Health Oct 2023Placental polyps are rare complications of delivery or abortion. They are thought to complicate less than 0.25% of all pregnancies, although the actual incidence is...
BACKGROUND
Placental polyps are rare complications of delivery or abortion. They are thought to complicate less than 0.25% of all pregnancies, although the actual incidence is unknown. While they typically occur within four weeks of delivery or abortion, they can have a variable presentation, which can lead to a delay in care.
CASE PRESENTATION
A 35-year-old G4P2012 patient presented at 9 weeks gestation for a medication abortion. Post-abortion ultrasound after one week confirmed the abortion was complete and her bleeding ceased. The patient then presented two months later with the new onset of worrisome bleeding. She was found on ultrasound to have a new hypervascular polypoidal mass in the endometrial cavity. She then underwent an in-office dilation and curettage with an electric vacuum aspirator, which was curative. A follow up ultrasound three months later demonstrated no recurrence.
CONCLUSIONS
Placental polyps are a rare complication following pregnancy and should be included in the differential when a patient presents with bleeding and a new mass in the endometrial cavity on ultrasound following a delivery or abortion, even when frankly retained products of conception had been ruled out at time of abortion.
Topics: Pregnancy; Female; Humans; Adult; Placenta; Abortion, Spontaneous; Uterus; Abortion, Induced; Polyps; Puerperal Disorders
PubMed: 37817177
DOI: 10.1186/s12905-023-02672-x -
Acta Obstetricia Et Gynecologica... Jun 2024Cesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination is often recommended in the early first trimester....
Surgical evacuation combined with Shirodkar cervical suture and selective uterine artery embolization: A fertility preserving treatment for 10-15 weeks' live cesarean scar ectopic pregnancies.
INTRODUCTION
Cesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination is often recommended in the early first trimester. Management of more advanced cases is challenging due to higher risks of major intraoperative hemorrhage. Hysterectomy is currently the intervention of choice for advanced cases. This study aimed to investigate if advanced live CSEPs could be managed effectively conservatively using suction curettage and interventional radiology.
MATERIAL AND METHODS
A retrospective single-center cohort study was performed. A total of 371 women diagnosed with CSEP were identified between January 2008 and January 2023. A total of 6% (22/371) women had an advanced live CSEP with crown-rump length (CRL) of ≥40 mm (≥10 weeks' gestation). Of these, 77% (17/22) opted for surgical intervention, whilst the remaining five continued their pregnancies. A preoperative ultrasound was performed in each patient. All women underwent suction curettage under ultrasound guidance and insertion of Shirodkar cervical suture as a primary hemostatic measure combined with uterine artery embolization (UAE) if required. The primary outcome was rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss, UAE, intensive care unit admission, reintervention, hysterectomy, hospitalization duration and rate of retained products of conception. Descriptive statistics were used to describe these variables.
RESULTS
Median CRL of the 17 patients included was 54.1 mm (range: 40.0-85.7) and median gestational age based on CRL was 12 + 3 weeks (range: 10 + 6-15 + 0). On preoperative ultrasound scan placental lacunae were recorded in 76% (13/17) of patients and color Doppler score was ≥3 in 67% (10/15) of patients. At surgery, Shirodkar cervical suture was used in all cases. It was successful in achieving hemostasis by tamponade in 76% (13/17) of patients. In the remaining 24% (4/17) patients tamponade failed to achieve complete hemostasis and UAE was performed to stop persistent arterial bleeding into the uterine cavity. Median intraoperative blood loss was 800 mL (range: 250-2500) and 41% (7/17) women lost >1000 mL. 35% (6/17) needed blood transfusion. No women required hysterectomy.
CONCLUSIONS
Surgical evacuation with Shirodkar cervical suture and selective UAE is an effective treatment for advanced live CSEPs.
Topics: Humans; Female; Uterine Artery Embolization; Pregnancy; Adult; Retrospective Studies; Pregnancy, Ectopic; Cesarean Section; Cicatrix; Fertility Preservation; Vacuum Curettage; Pregnancy Trimester, First; Suture Techniques; Blood Loss, Surgical
PubMed: 38366724
DOI: 10.1111/aogs.14803 -
BMC Pregnancy and Childbirth Feb 2024Intrauterine adhesion (IUA) can arise as a potential complication following uterine surgery, as the surgical procedure may damage the endometrial stratum basalis. The... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Intrauterine adhesion (IUA) can arise as a potential complication following uterine surgery, as the surgical procedure may damage the endometrial stratum basalis. The objective of this study was to assess and compare the occurrence of IUA in women who underwent ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA) for managing first-trimester miscarriage.
METHODS
This was a prospective, single-centre, randomised controlled trial conducted at a university-affiliated tertiary hospital. Chinese women aged 18 years and above who had a delayed or incomplete miscarriage of ≤ 12 weeks of gestation were recruited in the Department of Obstetrics and Gynaecology at the Prince of Wales. Recruited participants received either USG-MVA or EVA for the management of their miscarriage and were invited for a hysteroscopic assessment to evaluate the incidence of IUA between 6 and 20 weeks after the surgery. Patients were contacted by phone at 6 months to assess their menstrual and reproductive outcomes.
RESULTS
303 patients underwent USG-MVA or EVA, of whom 152 were randomised to 'USG-MVA' and 151 patients to the 'EVA' group. Out of the USG-MVA group, 126 patients returned and completed the hysteroscopic assessment, while in the EVA group, 125 patients did the same. The incidence of intrauterine adhesion (IUA) was 19.0% (24/126) in the USG-MVA group and 32.0% (40/125) in the EVA group, showing a significant difference (p < 0.02) between the two groups. No significant difference in the menstrual outcomes at 6 months postoperatively between the two groups but more patients had miscarriages in the EVA group with IUA.
CONCLUSIONS
IUAs are a possible complication of USG-MVA. However, USG-MVA is associated with a lower incidence of IUA postoperatively at 6-20 weeks. USG-MVA is a feasible, effective, and safe alternative surgical treatment with less IUA for the management of first-trimester miscarriage.
TRIAL REGISTRATION
The study was registered with the Centre for Clinical Research and Biostatics- Clinical Trials Registry (CCRBCTR), which is a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) (Unique Trial Number: ChiCTR1900023198 with the first trial registration date on 16/05/2019).
Topics: Pregnancy; Female; Humans; Abortion, Spontaneous; Vacuum Curettage; Prospective Studies; Pregnancy Trimester, First; Uterine Diseases; Tissue Adhesions; Ultrasonography, Interventional
PubMed: 38355420
DOI: 10.1186/s12884-024-06328-y