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Medicine Jul 2022Interstitial pregnancy (IP) is a rare but extremely life-threatening form of ectopic pregnancy. The traditional surgical treatment for this anomaly is the resection of...
RATIONALE
Interstitial pregnancy (IP) is a rare but extremely life-threatening form of ectopic pregnancy. The traditional surgical treatment for this anomaly is the resection of uterine cornua or fallopian tubes, which often damages their structural integrity, thereby compromising the reproductive potential for women who wish to preserve fertility.
PATIENT CONCERNS
A 33-year-old female was admitted to our hospital with suspected ectopic pregnancy, following a 4-weeks history of positive pregnancy tests after uterine evacuation. The patient was hemodynamically stable on arrival. Ultrasound revealed an empty uterus with an eccentric gestational sac located at the fundus and surrounded by a thin myometrium, indicative of a suspected interstitial pregnancy.
DIAGNOSIS AND INTERVENTION
After failed attempt at medical management with a single dose of intramuscular methotrexate, the patient was arranged for hysteroscopy-assisted laparoscopy. In surgery, the uterine cavity appeared empty, and a 2 × 2 cm bulge with increased vascularity at the right uterine courna was identified upon examination. The gestational sac was aspirated through the vagina from the right ostium of the uterine tube using a suction curette pointing at the right ostium. Sutures were not needed afterward, and the myometrial anatomy was left undisrupted. The diagnosis of IP was confirmed by the postoperative histological report.
OUTCOMES
Perioperative blood loss was approximately 10 ml and the operative time was 40 minutes. The patient had an uneventful postoperative recovery and was discharged after 3 days. Subsequent follow-ups showed a significant reduction in the patient serum beta hCG to 48IU/L within 5 days postoperation, and a negative result after 7 days.
LESSONS
This novel surgical technique is an alternative minimally-invasive approach for selected early diagnosed and hemodynamically stable IP patients. The technique represents a safe, quick, and simple approach combining the benefits of laparoscopy, such as allowing for immediate conversion of cornuectomy when uterus ruptures, and the benefits of suction curettage, such as shorter operative time and minimal blood loss. We believe patients with interstitial pregnancy who still have fertility wishes would benefit from this surgical technique to a larger extent in the future.
Topics: Adult; Female; Humans; Hysteroscopy; Laparoscopy; Pregnancy; Pregnancy, Interstitial; Uterus; Vacuum Curettage
PubMed: 35777020
DOI: 10.1097/MD.0000000000029730 -
Contraception Nov 2022We assessed the safety and effectiveness of direct-to-patient telehealth provision of medication abortion in Australia.
Effectiveness and safety of a direct-to-patient telehealth service providing medication abortion targeted at rural and remote populations: Cross-sectional findings from Marie Stopes Australia.
OBJECTIVES
We assessed the safety and effectiveness of direct-to-patient telehealth provision of medication abortion in Australia.
STUDY DESIGN
We included all medication abortions (January 2017-December 2018) from Marie Stopes Australia's patient management and adverse event reporting systems. We defined effectiveness as whether the patient had a continuing pregnancy, incomplete abortion, and/or subsequent vacuum aspiration or procedural abortion and safety as whether the patient experienced any adverse event.
RESULTS
Direct-to-patient telehealth was more effective than in-clinic provision (97.2% vs 95.4%). The proportion of adverse events did not differ between groups.
CONCLUSIONS
This direct-to-patient telehealth service is safe and effective.
Topics: Abortion, Induced; Australia; Cross-Sectional Studies; Female; Humans; Pregnancy; Telemedicine; Vacuum Curettage
PubMed: 35753405
DOI: 10.1016/j.contraception.2022.06.010 -
Annals of Medicine and Surgery (2012) May 2022The management of a large uterine fibroid concurrent with gestational trophoblastic disease (GTD) in a nullipara is complicated, challenging yet should focus on...
INTRODUCTION
The management of a large uterine fibroid concurrent with gestational trophoblastic disease (GTD) in a nullipara is complicated, challenging yet should focus on conserving fertility. We would like to share our experience.
CASE DESCRIPTION
A 28-year-old G1P0A0 of 10-11 weeks' gestation presented with a profuse vaginal bleeding with a history of passing swollen, grape-like tissues from the vagina. Since 7 months prior, a large uterine fibroid >10 cm had been diagnosed on ultrasound. Patient was diagnosed with GTD with β-human chorionic gonadotropin (hCG) levels exceeding 1,000,000 mIU/mL. No pulmonary metastases were detected. She underwent a vacuum curettage for her complete hydatidiform mole.Six days later, she underwent an elective myomectomy. Her nulliparity precluded hysterectomy. Post-discharge, her β-hCG levels plateaued and were consistently high over 3 consecutive measurements. A diagnosis of gestational trophoblastic neoplasia (GTN) was established. Patient is currently undergoing a methotrexate-folinic acid rescue chemotherapy regimen due to her having a low risk, stage 1 GTN.
DISCUSSION
Uterine fibroid may reach exceptional sizes. There is so far no link between GTD and uterine fibroids but their concurrent presence is extremely rare. The definitive management for a large fibroid is hysterectomy but considering the patient's nulliparity, a myomectomy was appropriate. GTD's definitive management is vacuum curettage.Periodical β-hCG measurement should follow discharge. Plateauing β-hCG levels indicated GTN and due to her low-risk GTN, she required a single-agent methotrexate chemotherapy. Most patients with low-risk GTN make a complete recovery.
CONCLUSION
Fertility after myomectomy and GTN generally has an excellent prognosis.
PubMed: 35638016
DOI: 10.1016/j.amsu.2022.103659 -
Patient Safety in Surgery May 2022In Japan, dilatation & curettage (D&C) has been performed under general anesthesia as a surgery for an early pregnancy miscarriage for a long time. In 2016, manual...
Safety and efficacy of manual vacuum aspiration under local anesthesia compared to general anesthesia in the surgical management of miscarriage: a retrospective cohort study.
BACKGROUND
In Japan, dilatation & curettage (D&C) has been performed under general anesthesia as a surgery for an early pregnancy miscarriage for a long time. In 2016, manual vacuum aspiration (MVA) under general anesthesia was introduced at our hospital and has been used as a surgical treatment for first-trimester pregnancy miscarriage, with its utility to date being reported here. In July 2018, our hospital introduced the MVA procedure under local anesthesia. In this study, we evaluated the efficacy and safety of MVA under general and local anesthesia in first-trimester pregnancy miscarriage surgery in Japanese women.
METHODS
In this retrospective observational cohort study, we enrolled 322 pregnant women at less than 12 weeks of gestation, who underwent MVA surgery under local anesthesia (n = 166) or conventional general anesthesia (n = 156). The duration of surgery, blood loss volume, quantity of anesthesia, presence or absence of retained products of conception, and clinical complications were evaluated. In addition, the intraoperative pain and treatment satisfaction were assessed using the visual analog scale (VAS).
RESULTS
The duration of surgery was significantly shorter in the local anesthesia group. No significant differences were observed between both groups in terms of the blood loss volume and incidence of retained products of conception. In addition, no serious complications were observed in either group. No significant differences were noted between the two groups in the VAS scores for pain and treatment satisfaction.
CONCLUSIONS
In this retrospective study, the use of MVA under local anesthesia for early pregnancy miscarriage surgery was found to be equally safe and effective when performed under conventional general anesthesia. This technique allowed the achievement of appropriate pain control with excellent patient satisfaction.
PubMed: 35614492
DOI: 10.1186/s13037-022-00328-7 -
The International Journal of... Jun 2022The culture failure rate of conventional karyotyping in products of conception evacuated from early pregnancy loss by traditional electrical vacuum aspiration and/or...
OBJECTIVE
The culture failure rate of conventional karyotyping in products of conception evacuated from early pregnancy loss by traditional electrical vacuum aspiration and/or dilation & curettage remains high. We aim to determine whether obtaining products of conception from early pregnancy loss via another evacuation approach, ultrasound-guided manual vacuum aspiration, could decrease the culture failure rate of karyotyping.
METHODS
For patients with early pregnancy loss, ultrasound-guided manual vacuum aspiration (Case group) and traditional electrical vacuum aspiration and/or dilation & curettage (Control group) were applied as surgical methods for pregnancy loss management respectively. The evacuated products of conception were subjected to cytogenetic karyotyping analysis. The primary outcome was the culture failure rate of karyotyping. Secondary outcomes included the chromosomal abnormality spectrum, maternal cell contamination, and complications from the manual vacuum aspiration procedure.
RESULTS
For the case group, 132 products of conception were genetically analyzed by conventional karyotyping. The culture failure rate was significantly lower than that of the control cohort (2.3% vs 7.4%, p = 0.027). 65.2% of cases were abnormal within the detection scope of karyotyping. The euploid female to male ratio was 0.82 (18:22), suggesting a lower likelihood of maternal cell contamination. The efficacy in achieving complete evacuation was 99.6%. There were no significant complications from the procedure.
CONCLUSION
Ultrasound-guided manual vacuum aspiration approach significantly decreased the culture failure rate of karyotyping and decreased maternal cell contamination tendency, enabling a high and accurate cytogenetic diagnosis. It is especially crucial when the cytogenetic analysis is required in the early pregnancy loss clinics.
Topics: Abortion, Spontaneous; Cohort Studies; Cytogenetic Analysis; Female; Humans; Male; Pregnancy; Ultrasonography, Interventional; Vacuum Curettage
PubMed: 35580747
DOI: 10.1016/j.biocel.2022.106226 -
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 -
Zhonghua Fu Chan Ke Za Zhi Apr 2022To investigate the clinical effect of focused ultrasound ablation surgery (FUAS) combined with suction curettage for mass-type cesarean scar pregnancy (CSP) and to...
To investigate the clinical effect of focused ultrasound ablation surgery (FUAS) combined with suction curettage for mass-type cesarean scar pregnancy (CSP) and to analyze the influencing factors of vaginal bleeding and readmission. From January 2014 to December 2020, 88 patients with mass-type CSP were treated by FUAS combined with suction curettage in the Third Xiangya Hospital of Central South University. The clinical results and the influencing factors of bleeding and readmission for mass-type CSP were analyzed. All the patients underwent one time FUAS treatment successfully. Immediately after FUAS treatment, color Doppler ultrasound showed obvious necrosis and no perfusion area in all lesions, and the blood flow in the mass-type CSP tissue significantly decreased. The median volume of blood loss in the procedure was 20 ml (range: 5-950 ml). Thirteen patients (15%, 13/88) had vaginal bleeding≥200 ml, and 15 patients (17%, 15/88) were hospitalized again. The average time for menstruation recovery was (28±8) days (range: 18-66 days). The average time needed for serum human chorionic gonadotropin-beta subunit to return to normal levels was (22±6) days (range: 7-59 days). The risk of large vaginal bleeding of patients were related to the blood supply of the mass (=5.280, 95%: 1.335-20.858, =0.018) and the largest diameter of the mass (=1.060, 95%: 1.010-1.120, =0.030). The risk of readmission were related to the largest diameter of the mass (=1.055, 95%: 1.005-1.108, =0.030) and the depth of the uterus cavity (=1.583, 95%: 1.015-2.471, =0.043). No serious complications such as intestinal and nerve injury occurred during and after FUAS treatment. FUAS combined with suction curettage is safe and effective in treating patients with mass-type CSP through this preliminary study. The volume of vaginal bleeding are associated with the blood supply of the mass and the largest diameter of the mass, the risk of readmission are related to the largest diameter of the mass and the depth of the uterus cavity.
Topics: Cesarean Section; Cicatrix; Female; High-Intensity Focused Ultrasound Ablation; Humans; Pregnancy; Pregnancy, Ectopic; Uterine Hemorrhage; Vacuum Curettage
PubMed: 35484656
DOI: 10.3760/cma.j.cn112141-20210902-00483 -
Contraception Sep 2022To evaluate whether administration of intranasal fentanyl reduces reported pain during first-trimester uterine aspiration. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To evaluate whether administration of intranasal fentanyl reduces reported pain during first-trimester uterine aspiration.
STUDY DESIGN
We conducted a multicenter, randomized, double-blind, placebo-controlled trial of patients with pregnancies less than or equal to 14 weeks gestation seeking uterine aspiration for induced abortion, early pregnancy loss, or failed medication abortion. We randomized participants 1:1 to either intranasal fentanyl 100 mcg or intranasal placebo. All participants received ibuprofen and a standardized paracervical block. The primary outcome was pain indicated at the time of uterine aspiration on a 100 mm visual analog scale (VAS). We designed the study to detect a 15 mm difference in mean pain scores, which required 53 people in each arm for a total of 106 participants. Secondary outcomes included postprocedure pain and patient satisfaction with pain control.
RESULTS
From March 2017 through June 2018, we screened 355 people for eligibility and enrolled 107 participants. Those who received intranasal fentanyl reported similar uterine aspiration pain to participants who received placebo (58.4 ± 28.0 fentanyl vs 58.6 ± 24.5 placebo, p = 0.97). Participants who received intranasal fentanyl also reported similar postprocedure pain scores compared to participants who received placebo (19.1 ± 19.4 fentanyl vs 17.2 ± 19 placebo, p = 0.63), and were equally satisfied with procedure pain control (66.8 ± 31.2 fentanyl vs 63.3 ± 29.2 placebo, p = 0.57).
CONCLUSION
Intranasal fentanyl did not decrease reported pain with first-trimester uterine aspiration, nor did it decrease postprocedure pain compared to placebo. As an adjunct to ibuprofen and paracervical block, intranasal fentanyl did not improve patient satisfaction with pain control.
IMPLICATIONS
Intranasal fentanyl does not reduce reported pain with first-trimester uterine aspiration, however abortion-seeking patients are amenable to receiving intranasal medications for pain management.
Topics: Abortion, Induced; Double-Blind Method; Female; Fentanyl; Humans; Ibuprofen; Pelvic Pain; Pregnancy; Pregnancy Trimester, First
PubMed: 35472333
DOI: 10.1016/j.contraception.2022.04.008 -
The Pan African Medical Journal 2022single-dose of sublingual misoprostol 400mcg with the participant followed-up at the gynecology clinic one week after with an ultrasound scan for the completeness of the... (Randomized Controlled Trial)
Randomized Controlled Trial
INTRODUCTION
single-dose of sublingual misoprostol 400mcg with the participant followed-up at the gynecology clinic one week after with an ultrasound scan for the completeness of the uterine evacuation. Objective: to compare the effectiveness of single-dose sublingual misoprostol to manual vacuum aspiration in the treatment of incomplete spontaneous abortion in Enugu, Nigeria.
METHODS
the primary outcome measure was the incidence of complete uterine evacuation (complete abortion) after one week of treatment while the secondary outcome measures included incidence, types, and tolerability of treatment side effects as well as participants' satisfaction with the treatment received.
RESULTS
two hundred and three participants who met the study criteria and completed the study were randomised into the intervention group (n=102) received single-dose sublingual misoprostol 400mcg and the control group (n= 101) received manual vacuum aspiration. Incidence of complete abortion was 86.3% for the misoprostol group and 100.0% for the control group, RR = 0.86, (CI 95%: 0.80 - 0.93), p <0.001. The most common side effect was abdominal pain with an incidence of 27.5% versus 48.55 for the misoprostol and control groups respectively (p = 0.002). Most participants in each group (81.1% versus 77.6% for the misoprostol and control groups respectively) considered the side effects as tolerable. The mean visual analogue scale score for maternal satisfaction was higher in the misoprostol group (86.7 ± 14.11) than the control group (81.36 ± 11.10), p < 0.001.
CONCLUSION
the treatment of incomplete spontaneous abortion with single-dose sublingual misoprostol 400mcg produced a high rate of complete abortion among women in Enugu, Nigeria. Despite having a lower complete abortion rate, maternal satisfaction was higher when compared with women that had manual vacuum aspiration of the uterus. Trial registration: trial registration number - PACTR202009857889210, date of registration - September 23, 2020. Retrospectively registered.
Topics: Abortifacient Agents, Nonsteroidal; Abortion, Incomplete; Abortion, Induced; Abortion, Spontaneous; Female; Humans; Misoprostol; Nigeria; Pregnancy; Vacuum Curettage
PubMed: 35432695
DOI: 10.11604/pamj.2022.41.90.29364 -
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