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The Cochrane Database of Systematic... Jul 2020Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua uteri, the ovary, the cervix, and the abdomen. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP).
OBJECTIVES
To evaluate the clinical effectiveness and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy in terms of fertility outcomes and complications.
SEARCH METHODS
We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) search portal and nine other databases to 12 December 2019. We handsearched reference lists of articles retrieved and contacted experts in the field to obtain additional data.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) published in all languages that examined the effects and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy.
DATA COLLECTION AND ANALYSIS
We used Cochrane standard methodological procedures. Primary outcomes were treatment success and complications.
MAIN RESULTS
We included five RCTs with 303 women, all reporting Caesarean scar pregnancy. Two compared uterine arterial embolization (UAE) or uterine arterial chemoembolization (UACE) plus methotrexate (MTX) versus systemic MTX and subsequent dilation and suction curettage; one compared UACE plus MTX versus ultrasonography-guided local MTX injection; and two compared suction curettage under hysteroscopy versus suction curettage under ultrasonography after UAE/UACE. The quality of evidence ranged from moderate to very low. The main limitations were imprecision (small sample sizes and very wide confidence intervals (CI) for most analyses), multiple comparisons with a small number of trials, and insufficient data available to assess heterogeneity. UAE/UACE versus systemic MTX prior to suction curettage Two studies reported this comparison. One compared UAE with systemic MTX and one compared UACE plus MTX versus systemic MTX, in both cases followed by a suction curettage. We are uncertain whether UAE/UACE improved success rates after initial treatment (UAE: risk ratio (RR) 1.00, 95% CI 0.90 to 1.12; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.87, 95% CI 0.54 to 1.38; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced rates of complications (UAE: RR 0.47, 95% CI 0.13 to 1.75; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.62, 95% CI 0.26 to 1.48; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced adverse effects (UAE: RR 1.58, 95% CI 0.41 to 6.11; 1 RCT, 72 women; low-quality evidence; UACE: RR 1.16, 95% CI 0.32 to 4.24; 1 RCT, 28 women; low-quality evidence), and it was not obvious that the types of events had similar values to participants (e.g. fever versus vomiting). Blood loss was lower in UAE/UACE groups than systemic MTX groups (UAE: mean difference (MD) -378.70 mL, 95% CI -401.43 to -355.97; 1 RCT, 72 women; moderate-quality evidence; UACE: MD -879.00 mL, 95% CI -1135.23 to -622.77; 1 RCT, 28 women; moderate-quality evidence). Data were not available on time to normalize β-human chorionic gonadotropin (β-hCG). UACE plus MTX versus ultrasonography-guided local MTX injection We are uncertain whether UACE improved success rates after initial treatment (RR 0.95, 95% CI 0.56 to 1.60; 1 RCT, 45 women; very low-quality evidence). Adverse effects: the study reported the same number of failed treatments in each arm (RR 0.88, 95% CI 0.40 to 1.92; 1 RCT, 45 women). We are uncertain whether UACE shortened the time to normalize β-hCG (MD 1.50 days, 95% CI -3.16 to 6.16; 1 RCT, 45 women; very low-quality evidence). Data were not available for complications. Suction curettage under hysteroscopy versus under ultrasonography after UAE/UACE. Two studies reported this comparison. One compared suction curettage under hysteroscopy versus under ultrasonography after UAE, and one compared these interventions after UACE. We are uncertain whether suction curettage under hysteroscopy improved success rates after initial treatment (UAE: RR 0.91, 95% CI 0.81 to 1.03; 1 RCT, 66 women; very low-quality evidence; UACE: RR 1.02, 95% CI 0.96 to 1.09; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced rates of complications (UAE: RR 4.00, 95% CI 0.47 to 33.91; 1 RCT, 66 women; very low-quality evidence; UACE: RR 0.18, 95% CI 0.01 to 3.72; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced adverse effects (UAE: RR 3.09, 95% CI 0.12 to 78.70; 1 RCT, 66 women; very low-quality evidence; UACE: not estimable; 1 RCT, 92 women; very low-quality evidence). We are uncertain whether suction curettage under hysteroscopy shortened the time to normalize β-hCG (UAE: MD 4.03 days, 95% CI -1.79 to 9.85; 1 RCT, 66 women; very low-quality evidence; UACE: MD 0.84 days, 95% CI -1.90 to 3.58; 1 RCT, 92 women; low-quality evidence). Non-tubal ectopic pregnancy other than CSP No studies reported on non-tubal ectopic pregnancies in locations other than on a caesarean scar.
AUTHORS' CONCLUSIONS
For Caesarean scar pregnancies (CSP) it is uncertain whether there is a difference in success rates, complications, or adverse events between UAE/UACE and administration of systemic MTX before suction curettage (low-quality evidence). Blood loss was lower if suction curettage is conducted after UAE/UACE than after administration of systemic MTX (moderate-quality evidence). It is uncertain whether there is a difference in treatment success rates, complications, adverse effects or time to normalize β-hCG between suction curettage under hysteroscopy and under ultrasonography (very low-quality evidence). There are no studies of non-tubal ectopic pregnancy other than CSP and RCTs for these types of pregnancy are unlikely.
Topics: Abortifacient Agents, Nonsteroidal; Bias; Cesarean Section; Chemoembolization, Therapeutic; Cicatrix; Confidence Intervals; Dilatation and Curettage; Female; Humans; Hysteroscopy; Methotrexate; Pregnancy; Pregnancy, Ectopic; Randomized Controlled Trials as Topic; Sample Size; Ultrasonography, Interventional; Uterine Artery; Uterine Artery Embolization; Vacuum Curettage
PubMed: 32609376
DOI: 10.1002/14651858.CD011174.pub2 -
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 -
Taiwanese Journal of Obstetrics &... May 2020The aim of this study was to retrospectively evaluate the feasibility and safety of high-intensity focused ultrasound (HIFU) treatment as the preoperative management of...
OBJECTIVE
The aim of this study was to retrospectively evaluate the feasibility and safety of high-intensity focused ultrasound (HIFU) treatment as the preoperative management of cesarean scar pregnancy (CSP).
MATERIALS AND METHODS
225 patients with definite Type I CSP were treated with suction curettage under hysteroscopic guidance. Among them, 103 patients chose HIFU treatment before hysteroscopy (assign to the HIFU group), and the other 122 patients without any pretreatment before hysteroscopy to the control group. The successful rate, volume of intraoperative blood loss, time for serum β-human chorionic gonadotropin (β-hCG) level returned to normal, gestational sac disappeared, normal menstrual recovery, and adverse effects were collected and analyzed to compare the two approaches.
RESULTS
The successful rate (98.06%) in the HIFU group was higher than that (91.80%) in the contrast group. The median ablation time was 39 min and the median HIFU sonication time was 106.6 s. The median volume of intraoperative blood loss in the HIFU group was lower than that in the contrast group (P < 0.001), and the median time of gestational sac disappeared in the HIFU group was shorter than that in the contrast group. There were no statistically significant differences in the time of serum β-hCG returned to normal and days of menstrual recovery between the 2 groups.
CONCLUSION
Based on our results, it appears that HIFU ablation is a safe and effective modality as pre-treatment before hysteroscopy in the management of CSP.
Topics: Adult; Blood Loss, Surgical; Cesarean Section; Cicatrix; Feasibility Studies; Female; High-Intensity Focused Ultrasound Ablation; Humans; Hysteroscopy; Postoperative Complications; Pregnancy; Pregnancy, Ectopic; Preoperative Care; Retrospective Studies; Treatment Outcome; Vacuum Curettage
PubMed: 32416885
DOI: 10.1016/j.tjog.2020.03.009 -
Medicine Apr 2020The implantation of a gestational sac within the scar of a previous caesarean delivery is defined as caesarean scar pregnancy (CSP), which is classified into two types:...
INTRODUCTION
The implantation of a gestational sac within the scar of a previous caesarean delivery is defined as caesarean scar pregnancy (CSP), which is classified into two types: CSP I and CSP II. CSP II is life threatening, and no clear consensus for CSP II management exists.
PATIENT CONCERNS
A 31-year-old woman, gravida 1, para 1, with a previous caesarean delivery due to macrosomia, presented with an estimated 45 days of amenorrhea. The patient presented to the emergency department with vaginal bleeding for 1 day and no abdominal pain.
DIAGNOSES
An ultrasound examination was performed demonstrating a viable fetus that was embedded in the caesarean scar area and was bulging through the wall of the uterus into the bladder without contact with the uterine cavity or cervical canal. A diagnosis of type II caesarean scar pregnancy was made.
INTERVENTIONS
Local lauromacrogol was used to reduce the gestational sac blood supply. Suction curettage was performed under the guidance of abdominal ultrasound 24 h later, and the amount of bleeding was 20 mL. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (β-hCG).
OUTCOMES
Patient was followed up with β-hCG weekly levels which became <10 mIU/mL after 4 weeks of treatment.
CONCLUSION
Ultrasound-guided local lauromacrogol injection combined with suction curettage may be a safer and novel therapeutic method.
Topics: Adult; Cesarean Section; Cicatrix; Female; Humans; Polidocanol; Pregnancy; Pregnancy Complications; Ultrasonography; Vacuum Curettage
PubMed: 32332613
DOI: 10.1097/MD.0000000000019743 -
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 -
Obstetrics and Gynecology Jan 2020To estimate the incidence of gestational trophoblastic neoplasia following complete and partial molar pregnancy after reaching normal human chorionic gonadotropin (hCG)... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To estimate the incidence of gestational trophoblastic neoplasia following complete and partial molar pregnancy after reaching normal human chorionic gonadotropin (hCG) levels to guide evidence-based follow-up recommendations.
DATA SOURCES
MEDLINE, EMBASE, Web of Science, POPLINE, Cochrane, and ClinicalTrials.gov were searched from inception to November 2018, using the intersection of "gestational trophoblastic disease," "molar pregnancy," and "human chorionic gonadotropin" themes.
METHODS OF STUDY SELECTION
Search results were screened to identify cohort studies of molar pregnancy reporting gestational trophoblastic neoplasia development, with at least 6 months of intended normal hCG follow-up.
TABULATION, INTEGRATION, AND RESULTS
Two reviewers independently identified articles for inclusion. Data were extracted using a standardized form. For meta-analysis, cumulative incidence of gestational trophoblastic neoplasia, with CIs by the Agresti-Coull method, and pooled risk ratios (RRs) comparing complete and partial mole were calculated. Among the 19 eligible studies that reported adequate data for inclusion in the primary meta-analysis, we found low incidence of gestational trophoblastic neoplasia after normal hCG level following both complete mole (64/18,357, 0.35%, 95% CI 0.27-0.45%), and partial mole (5/14,864, 0.03%, 95% CI 0.01-0.08%). There was a significantly higher risk of gestational trophoblastic neoplasia after complete compared with partial molar pregnancy (RR 4.72, 95% CI 1.81-12.3, P=.002). Among gestational trophoblastic neoplasia cases after normal hCG level following complete mole, 89.6% occurred when the time from evacuation to normalization was 56 days or longer, and 60.7% were diagnosed beyond the commonly recommended 6-month surveillance interval. Sensitivity analyses, including those limiting to studies at low risk of bias, did not significantly affect results. We found an overall incidence of gestational trophoblastic neoplasia of 15.7% for complete mole (1,354/8,611, 95% CI 15.0-16.5%) and 3.95% for partial mole (221/5,593, 95% CI 3.47-4.50%).
CONCLUSION
Gestational trophoblastic neoplasia development after normal hCG level following molar pregnancy is rare. Recommendations for frequency and duration of hCG follow-up can be minimized to lessen burden on patients and informed by the type of molar pregnancy and time interval from uterine evacuation to hCG normalization.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42019116414.
Topics: Chorionic Gonadotropin; Female; Gestational Trophoblastic Disease; Humans; Hydatidiform Mole; Incidence; Pregnancy; Risk Factors; Uterine Neoplasms; Vacuum Curettage
PubMed: 31809433
DOI: 10.1097/AOG.0000000000003566 -
PloS One 2019Little evidence exists on women's experiences of care during abortion care, partly due to limitations in existing measures. Moreover, globally, the development and rapid... (Comparative Study)
Comparative Study
Little evidence exists on women's experiences of care during abortion care, partly due to limitations in existing measures. Moreover, globally, the development and rapid growth in the availability of medication abortions (MA) has radically changed the options for safe abortions for women. It is therefore important to understand how women's experiences of care may differ across medication and manual vacuum aspiration (MVA) abortions. This study uses a validated person-centered abortion care scale (categorized as low, medium, and high levels, with high levels representing the greatest level of person-centered care) to assess women's experiences of care undergoing medication abortions vs. MVA. This paper reports on a cross-sectional study of 353 women undergoing abortions at one of six family planning clinics in Nairobi County, Kenya in 2018. Comparing abortion types, we found that the MVA sample was more likely to report "high" levels of person-centered abortion care compared to the MA sample (36.3% vs. 23.0%, p = 0.005). No differences were detected with respect to Respectful and Supportive Care; however, the MVA sample was significantly more likely to report "high" levels of Communication and Autonomy compared to the MA sample (23.6% vs. 11.2%, p<0.0001). In multivariable ordered logistic regression, we found that the MVA sample had a 92% greater likelihood of reporting higher person-centered abortion care scores compared to MA clients (aOR1.92, CI: 1.17-3.17). Being employed and reporting higher self-rated health were associated with higher person-centered abortion care scores, while reporting higher levels of stigma were associated with lower person-centered abortion care scores. Our findings suggest that more efforts are needed to improve the domain of Communication and Autonomy, particularly for MA clients.
Topics: Abortion, Induced; Adult; Ambulatory Care Facilities; Attitude; Female; Humans; Kenya; Patient Satisfaction; Patients; Vacuum Curettage
PubMed: 31765417
DOI: 10.1371/journal.pone.0225333 -
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 -
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 -
Taiwanese Journal of Obstetrics &... Sep 2019Suction curettage is recommended for molar evacuation rather than sharp curettage because of its safety. However, the superiority of suction curettage with respect to... (Observational Study)
Observational Study
OBJECTIVE
Suction curettage is recommended for molar evacuation rather than sharp curettage because of its safety. However, the superiority of suction curettage with respect to the incidence of gestational trophoblastic neoplasia (GTN) has not been reported. This study aimed to compare the efficacy and safety of two evacuation procedures, vacuum aspiration and forceps/blunt curettage, for complete hydatidiform moles (CHMs) to determine the differences between them.
MATERIALS AND METHODS
Patients with androgenetic CHM determined by multiplex short tandem repeat polymorphism analysis were included in this observational cohort study. Patients underwent evacuation with forceps and blunt curettage (forceps group) before March 2013 and with vacuum aspiration (vacuum group) thereafter. GTN was diagnosed based on the International Federation of Gynecology and Obstetrics 2000 criteria. The incidence of GTN and other clinical parameters were compared.
RESULTS
Ninety-two patients were diagnosed with androgenetic CHM. The number of patients in the forceps and vacuum groups was 41 and 51, respectively. The incidence of GTN was 12.2% (5/41) and 13.7% (7/51) in the forceps and vacuum groups, respectively, which was not significantly different (P = 1, Fisher's exact test). No major adverse events, such as uterine perforation and blood transfusion, were noted in either group. The median surgery time was shorter in the vacuum group (16 min) than in the forceps group (25 min) (P = 0.05, Mann-Whitney U test).
CONCLUSION
There were no differences in the incidence of GTN between the forceps and vacuum groups for androgenetic CHM. However, vacuum aspiration could have the advantage of a shorter surgery period. The use of vacuum aspiration for molar pregnancy seems to be safer. Therefore, we recommend suction curettage for the first evacuation of hydatidiform moles.
Topics: Adult; Cohort Studies; Curettage; Female; Gestational Trophoblastic Disease; Humans; Hydatidiform Mole; Incidence; Postoperative Complications; Pregnancy; Surgical Instruments; Treatment Outcome; Uterine Neoplasms; Vacuum Curettage
PubMed: 31542087
DOI: 10.1016/j.tjog.2019.07.012