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Frontiers in Endocrinology 2021Cesarean scar pregnancy affects 6% of all ectopic pregnancies in women with prior cesarean section, and there is currently no consensus on the optimal treatment. Options... (Comparative Study)
Comparative Study Randomized Controlled Trial
A Comparison of Ultrasound Guided Curettage With and Without Uterine Artery Embolization on Controlling Intraoperative Blood Loss for a Cesarean Scar Pregnancy Treatment: Study Protocol for a Randomized Clinical Trial.
INTRODUCTION
Cesarean scar pregnancy affects 6% of all ectopic pregnancies in women with prior cesarean section, and there is currently no consensus on the optimal treatment. Options of surgical treatment have a risk of intraoperative blood loss; therefore, uterine artery embolization (UAE) has been considered as an option of reducing intraoperative blood loss. However, UAE may be overused in clinical practice, especially in China. We present this protocol for a randomized clinical trial investigating the necessity of performing UAE for cesarean scar pregnancy, in combination with surgical suction curettage, taking into account the different subtypes of cesarean scar pregnancy. We recently developed a risk-scoring system (QRS) to estimate intraoperative blood loss, with 93.8% sensitivity and 6.3% false negative. Through this randomized clinical trial, we will retrospectively validate the QRS score on predicting intraoperative blood loss.
METHODS AND ANALYSIS
We propose undertaking a randomized clinical trial sequentially recruiting 200 patients. All the patients will randomly receive ultrasound guided curettage with or without UAE. Data on the subtypes of cesarean scar pregnancy (Types 1 and II and III) detected by ultrasound will be collected before operation. The score on estimating intraoperative blood loss assessed by our recently developed quantitative risk-scoring system (QRS) will be collected before the operation. We will primarily compare the duration of the operation, intraoperative blood loss, and complications between the two groups. We will also retrospectively analyze the association of subtypes of cesarean scar pregnancy and the options of treatment and validate the QRS score. Outcomes of subsequent pregnancy within the 2-year follow-up will be secondary outcomes.
TRIAL REGISTRATION NUMBER
[website], identifier ChiCTR2100041654.
Topics: Blood Loss, Surgical; Cesarean Section; China; Cicatrix; Curettage; False Negative Reactions; Female; Humans; Pregnancy; Pregnancy Outcome; Pregnancy, Ectopic; Randomized Controlled Trials as Topic; Retrospective Studies; Risk; Risk Assessment; Sensitivity and Specificity; Ultrasonography; Ultrasonography, Interventional; Uterine Artery Embolization; Vacuum Curettage
PubMed: 34194390
DOI: 10.3389/fendo.2021.651273 -
Nigerian Journal of Clinical Practice May 2020Manual vacuum aspiration is a safe and effective technology for the treatment of incomplete miscarriage but it is not widely available and affordable in rural areas... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Manual vacuum aspiration is a safe and effective technology for the treatment of incomplete miscarriage but it is not widely available and affordable in rural areas particularly in low-resource countries. Misoprostol is an alternative to manual vacuum aspiration for the treatment of incomplete miscarriage.
AIM
To compare the effectiveness, client acceptability and satisfaction, and cost-effectiveness of misoprostol with manual vacuum aspiration for the treatment of the first-trimester incomplete miscarriage.
SUBJECTS AND METHODS
This study was conducted between February 1, 2018 and August 31, 2018 at Alex Ekwueme Federal University Teaching Hospital Abakaliki, Nigeria. 100 participants were randomized to treatment with either manual vacuum aspiration or 600 μg oral misoprostol. The main outcome measures assessed at 1-week follow-up were complete uterine evacuation, client acceptability and satisfaction, and cost-effectiveness. Data were analyzed using SPSS version 25. Sociodemographic characteristics, treatment outcomes and other variables were summarized by descriptive statistics. Chi-square test was used for comparison between groups as regard categorical data while Student's't' test was used for comparison between groups for continuous data. P value of <0.05 was regarded as statistically significant.
RESULTS
There was a higher failure rate in the misoprostol arm when compared with MVA. Although this difference in complete uterine evacuation rate did not reach statistical significance (81.3% versus 95.7%, RR = 4.3, 95% CI 0.98-18.9, P value = 0.05), more participants in the misoprostol arm would choose the method again when compared with women in the MVA group (47 versus 30, X = 16.95, P < 0.001). The mean client satisfaction score was significantly higher among women in the misoprostol arm compared to MVA group (13.2 (2.1) versus 7.3 (4.6), P < 0.001). The mean cost of primary treatment was higher in the MVA group compared with misoprostol arm ($67.8 (8.9) versus 14.4 (4.0), P < 0.001). There was no significant difference in the mean cost of repeat uterine evacuation in both study arms (MVA, $64.9 (6.3) versus misoprostol, $65.76 (6.6), P = 0.86).
CONCLUSION
Although medical treatment was associated with a higher failure rate, there was no statistically significant difference in the effectiveness of both treatment methods. However, medical treatment was associated with higher client acceptance and satisfaction and was more cost-effective than surgical treatment.
Topics: Abortifacient Agents, Nonsteroidal; Abortion, Incomplete; Administration, Oral; Adult; Female; Humans; Misoprostol; Nigeria; Patient Satisfaction; Pregnancy; Pregnancy Trimester, First; Treatment Outcome; Vacuum Curettage
PubMed: 32367870
DOI: 10.4103/njcp.njcp_379_19 -
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 -
Medical Archives (Sarajevo, Bosnia and... Apr 2020The association of acute intermitetn porphyria (AIP) with pregnancy and as a cause of spontaneous abortion is rare.
INTRODUCTION
The association of acute intermitetn porphyria (AIP) with pregnancy and as a cause of spontaneous abortion is rare.
AIM
To show a case of AIP known before pregnancy in a patient who had a spontaneous abortion.
CASE REPORT
A gynecologist examined 26-year-old patient in the 8th week of gestation, due to initial spontaneous abortion, abdominal pain, constipation, muscle weakness, vomiting and dark colour of urine. Her therapy was dydrogesterone. In consultation with an anesthesiologist, a short intravenous anesthesia, vacuum aspiration, and curettage were performed.During hospitalization, the patient ceased to take harmful drugs and she was given haemarginate, glucose and symptomatic drugs, and she recovered completely.
CONCLUSION
Treatment of threatened spontaneous abortion in AIP remains the subject of dilemma and controversy, and future research is needed.
Topics: Abortion, Spontaneous; Adult; Aminolevulinic Acid; Contraceptives, Oral, Hormonal; Disease Progression; Dydrogesterone; Female; Humans; Porphobilinogen; Porphyria, Acute Intermittent; Pregnancy; Progestins; Vacuum Curettage
PubMed: 32577061
DOI: 10.5455/medarh.2020.74.153-155 -
American Journal of Obstetrics and... Mar 2024Traditionally, curettage has been the most widely performed surgical intervention for removing retained products of conception. However, hysteroscopic removal is...
Reproductive and obstetrical outcomes after treatment of retained products of conception: hysteroscopic removal vs ultrasound-guided electric vacuum aspiration, a prospective follow-up study.
BACKGROUND
Traditionally, curettage has been the most widely performed surgical intervention for removing retained products of conception. However, hysteroscopic removal is increasingly performed as an alternative because of the potentially lower risk of intrauterine adhesions and higher rates of complete removal. Until recently, studies comparing curettage with hysteroscopic removal regarding reproductive and obstetrical outcomes were limited, and data conflicting.
OBJECTIVE
This study aimed to assess reproductive and obstetrical outcomes in women wishing to conceive after removal of retained products of conception by hysteroscopy or ultrasound-guided electric vacuum aspiration.
STUDY DESIGN
This was a prospective long-term follow-up study, conducted in 3 teaching hospitals and 1 university hospital. Patients were included from April 2015 until June 2022 for follow-up, either in a randomized controlled, nonblinded trial on the risk of intrauterine adhesions after removal of retained products of conception, or in a cohort alongside the randomized trial. Women with an ultrasonographic image suggestive of retained products of conception ranging from 1 to 4 cm were eligible. Surgical procedures in the randomized controlled trial were hysteroscopic morcellation or ultrasound-guided electric vacuum aspiration. In the cohort study, hysteroscopic treatment included hysteroscopic morcellation or cold loop resection compared with ultrasound-guided electric vacuum aspiration.
RESULTS
A total of 261 out of 305 patients (85.6%) were available for follow-up after removal of retained products of conception, resulting in a cohort of 171 women after hysteroscopic removal and 90 women after removal by ultrasound-guided vacuum aspiration. Respectively, 92 of 171 women (53.8%) in the hysteroscopic removal group and 56 of 90 (62.2%) in the electric vacuum aspiration group wished to conceive (P=.192). Subsequent pregnancy rates were 88 of 91 (96.7%) after hysteroscopic removal and 52 of 56 (92.9%) after electric vacuum aspiration (P=.428). The live birth rates were 61 of 80 (76.3%) and 37 of 48 (77.1%) after hysteroscopic removal and electric vacuum aspiration, respectively (P=.914), with 8 of 88 pregnancies (9.1%) in the hysteroscopic removal group and 4 of 52 (7.7%) in the electric vacuum aspiration group still ongoing at follow-up (P=1.00). The median time to conception was 8.2 weeks (interquartile range, 5.0-17.2) in the hysteroscopic removal group and 6.9 weeks (interquartile range, 5.0-12.1) in the electric vacuum aspiration group (P=.262). The overall placental complication rate was 13 of 80 (16.3%) in the hysteroscopic removal group and 11 of 48 (22.9%) in the electric vacuum aspiration group (P=.350).
CONCLUSION
Hysteroscopic removal and ultrasound-guided electric vacuum aspiration of retained products of conception seem to have no significantly different effects on subsequent live birth rate, pregnancy rate, time to conception, or pregnancy complications. Reproductive and obstetrical outcomes after removal of retained products of conception are reassuring, albeit with a high risk of placental complications.
PubMed: 38521232
DOI: 10.1016/j.ajog.2024.03.017 -
Journal of Obstetrics and Gynaecology... May 2022Manual vacuum aspiration is a safe surgical option for the management of early pregnancy loss. To provide rapid, patient-centred access to MVA, an Outpatient Program for...
OBJECTIVE
Manual vacuum aspiration is a safe surgical option for the management of early pregnancy loss. To provide rapid, patient-centred access to MVA, an Outpatient Program for Early pregnancy Loss ("OPEL") was established at our institution. Objectives were to (1) assess complete uterine evacuation rates; (2) assess complication rates, and (3) assess patient satisfaction with the program.
METHODS
With REB approval, a retrospective study was performed. Patient records from the first 18 months of OPEL (November 2015 to April 2017) were reviewed. Anonymous patient satisfaction questionnaires were completed immediately post-procedure.
RESULTS
A total of 162 patients received treatment. Missed abortions accounted for 94 cases (58%). Median delay from referral to clinic appointment was 4.0 (interquartile range [IQR] 2.0-6.0) days. Average length of stay was 3.0 (IQR 2.5-3.0) hours. Efficacy of the procedure was 95.1%. Complication rate (immediate and delayed) was 14.2% and included intraoperative hemorrhage (3.1%; 5/162), Asherman's syndrome (1.9%; 3/162), retained products of conception requiring further treatment (4.9%; 8/162), and postoperative infection requiring antibiotic therapy (1.9%; 3/162). A total of 151 post-procedure satisfaction surveys were completed (93%); 100% agreed/strongly agreed that the nursing staff and physicians provided professional and compassionate care; 99.3% were satisfied with their care overall. Qualitative feedback was positive.
CONCLUSION
Pregnant patients experiencing early pregnancy loss benefit from safe, timely, accessible, patient-centred care in the outpatient OPEL program. Similar models should be adopted nationally to ensure women experiencing this common pregnancy complication receive safe and compassionate care.
Topics: Abortion, Induced; Abortion, Spontaneous; Canada; Female; Humans; Outpatients; Pregnancy; Pregnancy Trimester, First; Retrospective Studies
PubMed: 34973436
DOI: 10.1016/j.jogc.2021.11.018 -
Archives of Gynecology and Obstetrics Dec 2020This study aims at assessing the effectiveness of various treatment protocols with the help of some parameters in caesarean scar pregnancies. (Comparative Study)
Comparative Study
OBJECTIVE
This study aims at assessing the effectiveness of various treatment protocols with the help of some parameters in caesarean scar pregnancies.
METHODS
A total of 26 patients were assessed in the study. The patients were divided into 4 groups. Group 1 consisted of those who had a wedge resection (n = 7), group 2 those who had a suction curettage (n = 10), group 3 those who had a systemic methotrexate (MTX) (n = 5) and group 4 those who had a systemic + local MTX (n = 4). The ßHcg half-lives, haemoglobin levels at the time of admittance and discharge, and hospital stays of the groups were compared.
RESULTS
The difference between group 1 and group 4 was found significant (p = 0.002) with respect to days of hospital stay. There was no statistically significant difference between the groups with respect to ßHcg half-lives and haemoglobin values.
CONCLUSION
The results of our study showed that there were no significant differences between treatment outcomes when appropriate protocols were employed. Therefore, the important point in CSPs is to assess correctly the type of CSP, the myometrial thickness and the patient's hemodynamic condition and select the most appropriate protocol accordingly rather than trying to establish a single standard treatment protocol.
Topics: Abortifacient Agents, Nonsteroidal; Adult; Cesarean Section; Cicatrix; Clinical Protocols; Female; Humans; Length of Stay; Methotrexate; Pregnancy; Pregnancy, Ectopic; Retrospective Studies; Treatment Outcome; Vacuum Curettage
PubMed: 32974746
DOI: 10.1007/s00404-020-05800-2 -
Ceska Gynekologie 2021To describe the case of ectopic pregnancy in the scar after caesarean section and its successful treatment using the technique of sonographically controlled vacuum...
OBJECTIVE
To describe the case of ectopic pregnancy in the scar after caesarean section and its successful treatment using the technique of sonographically controlled vacuum aspiration.
CASE REPORT
The case of a 35-year-old patient with a history of two caesarean sections referred by a district gynecologist in the 6th week of pregnancy with suspected pathological localization of pregnancy in a scar after a previous caesarean section. The procedure for the diagnosis and treatment of ectopic pregnancy in the scar after previous caesarean sections has been successfully resolved using sonographically controlled vaginal vacuum aspiration.
CONCLUSION
Caesarean scar pregnancy occurs as a complication of previous caesarean section or other uterine instrumental performances. The use of the sonographically controlled vacuum aspiration technique appears to be a successful method of treating pregnancy in a scar after a caesarean section.
Topics: Adult; Cesarean Section; Cicatrix; Female; Humans; Pregnancy; Pregnancy, Ectopic; Ultrasonography, Interventional; Vacuum Curettage
PubMed: 34167311
DOI: 10.48095/cccg2021184 -
Revista Colombiana de Obstetricia Y... Sep 2019To describe the safety of medical and surgical treatments used in women seeking voluntary pregnancy termination.
OBJECTIVE
To describe the safety of medical and surgical treatments used in women seeking voluntary pregnancy termination.
METHODS
Historical cohort of all pregnant women with up to 26 weeks of gestation who received treatment for voluntary pregnancy termination in a referral institution in Medellín, Colombia, between January 2013 and December 2014.Sampling was consecutive. Measured variables included sociodemographic and obstetric variables, undesired effects, and complications of the voluntary pregnancy termination treatment. A descriptive analysis was carried out.
RESULTS
Overall, 87 women were included. The mean age at the time of termination was 24 years (inter-quartile range [IQR] = 12), 69.0% were single, and 73,4% were unemployed. The main reason for termination was the risk to the mother's health in 61,0% of cases, followed by a history of sexual violence in 26.4% and fetal malformations in 12.6%; a total of 70 women (80,4%) had less than 18 weeks of gestation and were treated with misoprostol plus manual vacuum aspiration; 17 (19,6%) had between 18 and 26 weeks of gestation and were treated with misoprostol followed by dilation and curettage. The first group (gestational age <18 weeks) experienced undesired effects such as pain and vomiting; in the second group (> or equal to 18 weeks), 41.0% of the women experienced hemorrhage.
CONCLUSIONS
The risk to the mother's health was the main reason for the termination of pregnancy. Termination before 18 weeks was found to be safe, while termination between 18 and 26 weeks using misoprostol and curettage was associated with a high frequency of hemorrhage.
Topics: Abortifacient Agents, Nonsteroidal; Abortion, Induced; Adolescent; Adult; Cohort Studies; Colombia; Dilatation and Curettage; Female; Gestational Age; Humans; Misoprostol; Pregnancy; Pregnancy Trimester, Second; Vacuum Curettage; Young Adult
PubMed: 31738487
DOI: 10.18597/rcog.3267 -
BMC Women's Health Oct 2021Retained products of conception (POC) following uterine evacuation can lead to adverse sequelae, including hemorrhage, endometritis, intrauterine adhesions, and...
BACKGROUND
Retained products of conception (POC) following uterine evacuation can lead to adverse sequelae, including hemorrhage, endometritis, intrauterine adhesions, and reoperation. Use of procedural transvaginal sonography (TVUS) in the operating room has been proposed to help decrease retained POC.
METHODS
A retrospective review of all first trimester uterine evacuation procedures from 1/2015 to 2/2017 was performed, noting use of transabdominal ultrasonography, retained products of conception, and complications. A practice change was implemented in May 2018, in which routine intra-procedural TVUS use was initiated. A second retrospective chart review was conducted to assess for post-implementation incidence of retained POC, re-operation, and associated complications.
RESULTS
Prior to intra-procedural TVUS implementation, 130 eligible procedures were performed during the specified timeframe, with 9/130 (6.9%) incidence of retained products of conception. TAUS was performed in 59/130 (45.4%) of procedures, and 4/9 (44.4%) of those with retained products. There were eight re-operative procedures in seven patients, and two patients were treated with misoprostol. Complications included hemorrhage, Asherman's syndrome and endometritis. Following implementation, 95 first trimester procedures were performed with transvaginal sonography, with 0 (0%) cases of retained POC (p = 0.01), no incidences of re-operation (p = 0.02), and one case of Asherman's syndrome. TVUS findings led to additional focused suction curettage in 20/95 (21.0%) of procedures. The endometrium was measured on procedure completion in 64 procedures, with a mean thickness of 5.5 mm (1-12 mm).
CONCLUSION
Implementation of routine TVUS during uterine evacuation may reduce the incidence of retained POC and associated reoperation rates. Further multi-center trials are needed to confirm this finding.
Topics: Female; Humans; Pregnancy; Pregnancy Trimester, First; Quality Improvement; Retrospective Studies; Ultrasonography; Vacuum Curettage
PubMed: 34602062
DOI: 10.1186/s12905-021-01488-x