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European Journal of Obstetrics,... Mar 2021To evaluate the feasibility, safety, and effectiveness of Focused Ultrasound Ablation Surgery (FUAS) combined with ultrasound-guided suction curettage in the management...
OBJECTIVE
To evaluate the feasibility, safety, and effectiveness of Focused Ultrasound Ablation Surgery (FUAS) combined with ultrasound-guided suction curettage in the management of Cesarean Scar Pregnancy (CSP).
STUDY DESIGN
We retrospectively analyzed 52 patients with CSP from April, 2017, to December, 2019. All the patients received one session of FUAS, and suction curettage under ultrasound guidance was performed 1-3 days after FUAS. The intraoperative blood loss in suction curettage, duration of vaginal bleeding after curettage, reproductive outcomes, and adverse effects were recorded and analyzed.
RESULTS
All the 52 patients completed one session of FUAS combined with suction curettage without serious adverse effects. The mean intraoperative blood loss was 32.81 ± 53.83 mL. 47 (90.38 %) patients had a successful suction curettage with a blood loss of less than 80 mL. 5 (9.62 %) patients had an active bleeding of ≥80 mL; however, the bleeding was stopped effectively by Foley's urinary catheter and no evident bleeding presented when the catheter was removed 24 h later. The mean duration of vaginal bleeding was 7.88 ± 4.24 days. 48 (92.30 %) patients recovered with little vaginal bleeding after curettage. 4 (7.69 %) type III CSP patients experienced late-onset severe bleeding and required UAE or surgery. During 6-36 months of the follow-up period, 12 patients expressed reproductive plan, in which 4 patients delivered by cesarean section, 3 patients had an ongoing pregnancy and 1 patient had an abortion in the early pregnancy.
CONCLUSIONS
FUAS combined with ultrasound-guided suction curettage is a safe and effective treatment strategy in the management of CSP type I and CSP type II and is particularly advantageous for CSP patients with reproductive requirements. However, further studies are warranted to determine the meticulous inclusion criteria for patients with type III CSP.
Topics: Cesarean Section; Cicatrix; Female; Humans; Pregnancy; Retrospective Studies; Treatment Outcome; Ultrasonography, Interventional; Uterine Artery Embolization; Vacuum Curettage
PubMed: 33444810
DOI: 10.1016/j.ejogrb.2020.12.031 -
Journal of Obstetrics and Gynaecology... Jun 2022Manual uterine aspiration (MUA) is a currently underused management option for early pregnancy loss (EPL) in the emergency department (ED). This study addresses the...
OBJECTIVES
Manual uterine aspiration (MUA) is a currently underused management option for early pregnancy loss (EPL) in the emergency department (ED). This study addresses the safety and efficiency of MUA in the ED.
METHODS
We performed a single-site retrospective observational chart review of pregnant women presenting to the ED with vaginal bleeding and ED pathology submissions for products of conception (POC) between 2012 and 2016. Patients were excluded for gestational age >14 weeks, no evidence of pregnancy loss, uterine cavity anomaly, hemodynamic instability, or hemoglobin <80 g/L. We compared the frequencies of complications (need for blood transfusion, repeat ED visit, failed initial management, admission to hospital) and ED utilization time between 4 management options: expectant, misoprostol, MUA, and electric vacuum aspiration (EVA) outside the ED, as well as time to procedure between MUA and EVA.
RESULTS
A total of 162 patients were included with 123 (76%) having a pathology report positive for POC. The mean patient and gestational ages were 30 ± 7 years and 66 ± 17 days, respectively. One hundred nine patients were managed expectantly, 9 were given misoprostol, 23 underwent MUA, and 21 underwent EVA. Composite complication rates were 40%, 33%, 9%, and 10% (P = 0.001), and mean ED times were 5.4, 4.9, 7.3, and 6.0 hours (P = 0.01), for expectant, misoprostol, MUA, and EVA, respectively. The mean time to procedure was 5.1 hours for MUA and 23.1 hours for EVA (p=0.002).
CONCLUSIONS
Integrating MUA in the ED has the potential to reduce health care resource utilization while improving patient care.
Topics: Abortion, Spontaneous; Adult; Emergency Service, Hospital; Female; Humans; Misoprostol; Pregnancy; Pregnancy Trimester, First; Retrospective Studies; Vacuum Curettage; Young Adult
PubMed: 35248776
DOI: 10.1016/j.jogc.2022.02.009 -
Hormone Molecular Biology and Clinical... Mar 2020Intramyometrial ectopic pregnancy (IMEP) is a rare form of ectopic pregnancy. It is defined as a conceptus implanted within the myometrium and is completely surrounded...
Intramyometrial ectopic pregnancy (IMEP) is a rare form of ectopic pregnancy. It is defined as a conceptus implanted within the myometrium and is completely surrounded by myometrium with clear separation from both the uterine cavity and tubes. IMEP possesses not only diagnostic but also therapeutic challenge. The majority of reported cases were managed by hysterectomy. Early management of unruptured IMEP using methotrexate may help to preserve fertility. We, for the first time, report a case of ruptured IMEP managed successfully using suction and curettage followed by Bakri balloon tamponade and avoiding hysterectomy. Post-procedure, the patient received two doses of intramuscular methotrexate 50 mg/m2 due to plateauing serial beta human chorionic gonadotropin (β-hCG) levels and subsequently achieved undetectable level 10 weeks post-methotrexate. She also had complete resolution of the ectopic intramyometrial mass.
Topics: Abortifacient Agents, Nonsteroidal; Adult; Chorionic Gonadotropin, beta Subunit, Human; Female; Humans; Methotrexate; Myometrium; Organ Sparing Treatments; Pregnancy; Pregnancy, Ectopic; Rupture, Spontaneous; Uterine Balloon Tamponade; Uterine Hemorrhage; Uterine Rupture; Vacuum Curettage
PubMed: 32167930
DOI: 10.1515/hmbci-2020-0001 -
Global Health, Science and Practice Aug 2019Unsafe abortion contributes to maternal mortality worldwide and disproportionately affects the most disadvantaged women and girls; thus, improving the treatment of...
BACKGROUND
Unsafe abortion contributes to maternal mortality worldwide and disproportionately affects the most disadvantaged women and girls; thus, improving the treatment of complications of abortion is essential. Shifting PAC treatment from sharp dilation and curettage (D&C) to the use of aspiration techniques, notably manual vacuum aspiration (MVA), and medical treatment with misoprostol improves health outcomes. Equally critical is ensuring that women have access to voluntary contraception after an abortion to prevent future unintended pregnancies. In humanitarian settings, access to voluntary family planning to disrupt the cycle of unsafe abortion is even more critical because access to quality services cannot be guaranteed due to security risks, migration, and devastation of infrastructure. Save the Children applied a multipronged postabortion care (PAC) approach in the Democratic Republic of the Congo (DRC), Somalia, and Yemen that focused on capacity building; assurance of supplies and infrastructure; community collaboration and mobilization; and monitoring and evaluation.
METHODS
Program-level data were extracted for each of the 3 countries from the inception of their program through 2017. The sources of information included monthly service delivery reports that tracked key PAC indicators as well as qualitative data from evaluations of community mobilization activities.
RESULTS
The number of PAC clients increased in all countries. In the DRC in 2012, 19% of PAC clients requiring treatment received D&C; in 2017 the percentage was reduced to 3%. In 2013, 25% of all PAC clients in Yemen were treated with D&C; this percentage was reduced to 3% in 2017. The proportion of women choosing contraception after an abortion increased. In 2012, only 42% of all PAC clients in the DRC chose a contraceptive method; by 2017, the proportion had increased to 70%. Somalia had substantial increases in PAC demand, with the percentage of all PAC clients electing contraception increasing from 64% in 2012 to 82% in 2017. In Yemen, where the health system has been constrained due to severe conflict, the percentage of PAC clients choosing voluntary contraception rose from 17% in 2013 to 38% in 2017. Uptake and demand for PAC was mobilized through targeted community outreach in each context.
CONCLUSION
These data demonstrate that providers can effectively shift away from D&C as treatment for PAC and that contraceptive uptake by PAC clients can increase substantially, even in settings where the use of contraception after abortion is often stigmatized.
Topics: Abortifacient Agents, Nonsteroidal; Abortion, Induced; Aftercare; Capacity Building; Community Participation; Democratic Republic of the Congo; Dilatation and Curettage; Emergencies; Equipment and Supplies; Family Planning Services; Female; Health Services Accessibility; Humans; Misoprostol; Pregnancy; Quality Improvement; Quality of Health Care; Relief Work; Somalia; Vacuum Curettage; Yemen
PubMed: 31455621
DOI: 10.9745/GHSP-D-18-00400 -
International Journal of Hyperthermia :... 2022To investigate the clinical efficacy and safety of high intensity focused ultrasound (HIFU) combined with ultrasound-guided suction curettage in patients with type...
Analysis of the type of cesarean scar pregnancy impacted on the effectiveness and safety of high intensity focused ultrasound combined with ultrasound-guided suction curettage treatment.
OBJECTIVE
To investigate the clinical efficacy and safety of high intensity focused ultrasound (HIFU) combined with ultrasound-guided suction curettage in patients with type I/II/III cesarean scar pregnancy (CSP).
METHODS
A total of 153 patients with CSP were enrolled and classified according to the type of CSP. All of them were treated by HIFU combined with ultrasound-guided suction curettage. When active uterine bleeding was observed after curettage, a Foley balloon was used for hemostasis by compression. Baseline characteristics, technical parameters of HIFU, intraoperative blood loss in suction curettage, the time for serum β-HCG to return to normal levels, reproductive outcomes, and adverse effects were recorded and analyzed.
RESULTS
152 patients completed one session of HIFU combined with suction curettage except one patient transferred to surgery. Total energy used for ablation and the time for serum β-HCG return to normal level in type II and III were significantly higher than type I ( < .05). The treatment time and sonication time of HIFU in type III were significantly longer than type I ( < .05). Vaginal bleeding after curettage and the rate of using Foley catheter balloon in type III was larger than type I and II.
CONCLUSIONS
HIFU combined with ultrasound-guided suction curettage is a safe and effective treatment option for patients with type I/II/III CSP and desire for fertility. Patients with type III CSP were more dependent on Foley catheter balloon compression therapy than the other two types after HIFU combined with curettage.
Topics: Pregnancy; Female; Humans; Vacuum Curettage; Cicatrix; Cesarean Section; Pregnancy, Ectopic; Ultrasonography, Interventional
PubMed: 36414236
DOI: 10.1080/02656736.2022.2107715 -
Reproductive Health Nov 2020The quality of obstetric care has been identified as a contributing factor in Indonesia's persistently high level of maternal mortality, and the country's restrictive...
BACKGROUND
The quality of obstetric care has been identified as a contributing factor in Indonesia's persistently high level of maternal mortality, and the country's restrictive abortion laws merit special attention to the quality of post-abortion care (PAC). Due to unique health policies and guidelines, in Indonesia, uterine evacuation for PAC is typically administered only by Ob/Gyns practicing in hospitals.
METHODS
Using data from a survey of 657 hospitals and emergency obstetric-registered public health centers in Java, Indonesia's most populous island, we applied a signal functions analysis to measure the health system's capacity to offer PAC. We then used this framework to simulate the potential impact of the following hypothetical reforms on PAC capacity: allowing first-trimester uterine evacuation for PAC to take place at the primary care level, and allowing provision by clinicians other than Ob/Gyns. Finally, we calculated the proportion of PAC patients treated using four different uterine evacuation procedures.
RESULTS
Forty-six percent of hospitals in Java have the full set of services needed to provide PAC, and PAC capacity is concentrated at the highest-level referral hospitals: 86% of referral hospitals have the full set of services, staffing, and equipment compared to 53% of maternity hospitals and 34% of local hospitals. No health centers are adequately staffed or authorized to offer basic PAC services under Indonesia's current guidelines. PAC capacity at all levels of the health system increases substantially in hypothetical scenarios under which authorization to perform first-trimester uterine evacuation for PAC is expanded to midwives and general physicians practicing in health centers. In 2018, 88% percent of PAC patients were treated using dilation and curettage (D&C).
CONCLUSIONS
Offering first-trimester uterine evacuation for PAC in PONEDs and allowing clinicians other than Ob/Gyns to perform this procedure would greatly improve the capacity of Java's health system to serve PAC patients. Increasing the use of vacuum aspiration and misoprostol for PAC-related uterine evacuation would lower the burden of treatment for patients and facilitate the task-shifting efforts needed to expand access to this life-saving service.
Topics: Abortion, Induced; Aftercare; Female; Health Personnel; Health Services Accessibility; Humans; Indonesia; Misoprostol; Oxytocics; Postoperative Complications; Pregnancy; Pregnancy Trimester, First; Quality of Health Care; Vacuum Curettage
PubMed: 33239059
DOI: 10.1186/s12978-020-01033-3 -
BMC Pregnancy and Childbirth Feb 2024Cesarean scar pregnancy (CSP) is a long-term complication of cesarean section characterized by the localization of a subsequent gestational sac within the scar area or...
BACKGROUND
Cesarean scar pregnancy (CSP) is a long-term complication of cesarean section characterized by the localization of a subsequent gestational sac within the scar area or niche developed as a result of a previous cesarean section. Its incidence has increased substantially because of the high global cesarean section rate in recent decades. Several surgical and drug treatments exist for this condition; however, there is currently no optimal treatment. This study compared the effectiveness of direct hysteroscopic removal of the gestational tissue and hysteroscopy combined with vacuum suction for the treatment of CSP.
METHODS
From 2017 to 2023, 521 patients were diagnosed with CSP at our hospital. Of these patients, 45 underwent hysteroscopy. Among them, 28 underwent direct hysteroscopic removal (hysteroscopic removal group) and 17 underwent hysteroscopy combined with vacuum suction (hysteroscopic suction group). The clinical characteristics and outcomes of the hysteroscopic removal group and hysteroscopic suction group were analyzed.
RESULTS
Among the 45 patients, the amount of bleeding and hospitalization cost were significantly higher in the hysteroscopic removal group than in the hysteroscopic suction group (33.8 mL vs. 9.9 mL, P < 0.001; and 8744.0 yuan vs. 5473.8 yuan, P < 0.001; respectively). The operation time and duration of hospitalization were significantly longer in the hysteroscopic removal group than in the hysteroscopic suction group (61.4 min vs. 28.2 min, P < 0.001; and 3.8 days vs. 2.4 days, P = 0.026; respectively). Three patients in the hysteroscopic removal group had uterine perforation and received laparoscopic repair during operation. No complications occurred in the hysteroscopic suction group. One patient in the hysteroscopic removal group received ultrasound-guided suction curettage due to postoperative moderate vaginal bleeding, and one patient in the hysteroscopic suction group received ultrasound-guided suction curettage due to postoperative gestational residue and elevated serum beta-human chorionic gonadotropin levels. Reproductive function was preserved in all patients.
CONCLUSIONS
Hysteroscopy is an effective method for treating CSP. Compared with direct hysteroscopic removal, hysteroscopy combined with vacuum suction is more suitable for CSP. However, multicenter prospective studies with large sample sizes are required for verification of these findings.
Topics: Pregnancy; Humans; Female; Hysteroscopy; Cesarean Section; Cicatrix; Retrospective Studies; Prospective Studies; Pregnancy, Ectopic; Postoperative Hemorrhage; Treatment Outcome
PubMed: 38383385
DOI: 10.1186/s12884-024-06344-y -
International Journal of Hyperthermia :... 2022To explore a new high-intensity focused ultrasound (HIFU) sonication strategy for cesarean scar pregnancy (CSP) and to compare the clinical effectiveness and safety of...
High intensity focused ultrasound combined with ultrasound-guided suction curettage treatment for cesarean scar pregnancy: a comparison of different HIFU sonication strategies.
OBJECTIVE
To explore a new high-intensity focused ultrasound (HIFU) sonication strategy for cesarean scar pregnancy (CSP) and to compare the clinical effectiveness and safety of this new HIFU sonication strategy with the conventional HIFU sonication strategy followed by ultrasound-guided dilation and curettage (USg-D&C) for CSP.
MATERIALS AND METHODS
91 patients with CSP treated by HIFU and USg-D&C in People's Hospital of Deyang City between January 2017 and December 2019 were retrospectively reviewed in this study. Based on the HIFU sonication strategy, patients were divided to two groups: 44 patients were exposed to 'C-shape' sonication layer by layer around the implantation location of the pregnancy sac (control group), while the other 47 patients were exposed to 'I-shape' sonication layer by layer only on the deep part which close to the bladder of the implantation location of the pregnancy sac (experimental group). The differences in clinical efficacy between the two groups were analyzed. Baseline characteristics, technical parameters of HIFU treatment and USg-D&C data were recorded. Adverse events were also recorded.
RESULTS
No statistically significant difference was observed between the two groups in baseline characteristics including age, body mass index (BMI), menopause time, largest diameter of gestational sac, pretreatment serum β-hCG, thickness of gestational sac, embedding myometrium, previous cesarean sections and interval from last cesarean section (CS). The average treatment intensity in the experimental group was significantly lower than that in the control group ( < .05). The median sonication time, total energy used for HIFU ablation, and energy efficiency factor (EEF) in the experimental group were significantly lower than the control group ( < .05). No statistically significant difference was observed between the two groups in treatment power and treatment time ( > .05). Sciatic/buttock pain and postoperative lower abdominal pain in the control group were significantly stronger than that in the experimental group ( < .05). There were no statistically significant differences in post-HIFU vaginal bleeding and discharging, urinary tract irritation, the operation time of USg-D&C, the amount of vaginal bleeding during USg-D&C, and the time for serum β-hCG back to a normal level between the two groups ( > .05).
CONCLUSIONS
The 'I-shape' strategy of HIFU treatment for CSP was effective and safe, with shorter sonication time, less energy input and lower incidence of sonication-related pain occurred in postoperative lower abdominal and sciatic nerve/buttock.
Topics: Cesarean Section; Cicatrix; Extracorporeal Shockwave Therapy; Female; Humans; Pregnancy; Pregnancy, Ectopic; Retrospective Studies; Sonication; Treatment Outcome; Ultrasonography, Interventional; Vacuum Curettage
PubMed: 35196957
DOI: 10.1080/02656736.2022.2044078 -
Obstetrics and Gynecology Jan 2020To estimate the efficacy and safety of mifepristone antagonization with high-dose oral progesterone. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To estimate the efficacy and safety of mifepristone antagonization with high-dose oral progesterone.
METHODS
We planned to enroll 40 patients in a double-blind, placebo-controlled, randomized trial. We enrolled patients at 44-63 days of gestation with ultrasound-confirmed gestational cardiac activity who were planning surgical abortion. Participants ingested mifepristone 200 mg and initiated oral progesterone 400 mg or placebo 24 hours later twice daily for 3 days, then once daily until their planned surgical abortion 14-16 days after enrollment. Follow-up visits were scheduled 3±1, 7±1, and 15±1 days after mifepristone intake with ultrasonography and blood testing for human chorionic gonadotropin and progesterone. Participants exited from the study when they had their surgical abortion or earlier for gestational cardiac activity absence, gestational sac expulsion, or medically indicated suction aspiration. We assessed the primary outcome of continued gestational cardiac activity at approximately 2 weeks (15±1 day), side effects after drug ingestion, and safety outcomes including hemorrhage and emergent treatment.
RESULTS
We enrolled participants from February to July 2019 and stopped enrollment after 12 patients for safety concerns. Mean gestational age was 52.5 days. Two (one per group) voluntarily discontinued 3 days after mifepristone ingestion for subjective symptoms (nausea and vomiting, bleeding). Among the remaining 10 patients (five per group), gestational cardiac activity continued for 2 weeks in four in the progesterone group and two in the placebo group. One patient in the placebo group had no gestational cardiac activity 3 days after mifepristone use. Severe hemorrhage requiring ambulance transport to hospital occurred in three patients; one received progesterone (complete expulsion, no aspiration) and two received placebo (aspiration for both, one required transfusion). We halted enrollment after the third hemorrhage. No other significant side effects were reported.
CONCLUSION
We could not estimate the efficacy of progesterone for mifepristone antagonization due to safety concerns when mifepristone is administered without subsequent prostaglandin analogue treatment. Patients in early pregnancy who use only mifepristone may be at high risk of significant hemorrhage.
CLINICAL TRIAL REGISTRATION
ClinicalTrials.gov, NCT03774745.
Topics: Abortifacient Agents, Steroidal; Abortion, Induced; Administration, Oral; Adult; California; Chorionic Gonadotropin; Double-Blind Method; Female; Gestational Age; Humans; Mifepristone; Pregnancy; Progesterone; Uterine Hemorrhage; Vacuum Curettage; Young Adult
PubMed: 31809439
DOI: 10.1097/AOG.0000000000003620 -
Revista Colombiana de Obstetricia Y... Mar 2022Objectives: To characterize a cohort of women with voluntary interruption of pregnancy (VIP) and to describe intraoperative complications according to the technique...
Objectives: To characterize a cohort of women with voluntary interruption of pregnancy (VIP) and to describe intraoperative complications according to the technique used. Materials and Methods: Descriptive study in a historical cohort of women undergoing VIP in two healthcare institutions in Medellín, Colombia, in 2019. Women with pelvic infection and STIs were excluded. Consecutive sampling was used. Sociodemographic, sexual and reproductive health, clinical characteristics of the pregnancy, legal cause of the VIP, characteristics of the care process and complications of the VIP techniques up to post-procedural day 7 were the measured variables. A descriptive analysis was carried out. Results: Overall, 1,520 women were identified as eligible during the study period. Of them, 46 were intervened in other institutions, leaving 1,474 candidates to enter the study. Of them, 30 were excluded because of pelvic or sexually transmitted infections. Ultimately, 1,444 pregnant women were included in the analysis. Risk to the mother’s health was the most frequent legal cause in 94.3% of cases. Ninety-nine percent of women received pre-procedural counseling, and 78.4% agreed to use some form of contraception after VIP. Manual vacuum aspiration (MVA) was used in 95.6% of women and dilation and curettage (D&C) in 4.4%. Complications up to postoperative day 7 occurred in 17.56%, and there were no complications in the MVA group; 80% of women attended the follow-up visit on post-VIP day 7. Conclusions: MVA is a safe procedure which was not associated with complications within the first seven post-VIP days in the studied patients. Prospective studies to assess the safety and cost of the different VIP options are required.
PubMed: 35503301
DOI: 10.18597/rcog.3760