Best practices in surgical abortion

Surgical abortion in the first trimester comprises the majority of voluntary pregnancy interruptions performed in the United States. The majority of these procedures are done in outpatient settings with the patient under local anesthesia. Appropriate volume of and deep injection of local anesthetic can reduce pain associated with the procedure. Waiting between administration of the paracervical block and initiating the procedure does not affect pain. Intravenous administration of sedation and analgesia improves patient satisfaction but does not significantly affect pain ratings. Antibiotic prophylaxis is warranted. Vasopressin is useful for prevention of hematometra and hemorrhage. Less evidence supports the routine use of ergots. Preoperative cervical priming reduces the risk of cervical injury and uterine perforation. Attention to operative technique can reduce the risk of incomplete abortion. Routine postoperative care at 2 or 3 weeks is timed to identify complications and to reinforce pregnancy and sexually transmitted disease prevention.     

The clinical use of karyotyping spontaneous abortions

OBJECTIVE: The objective of this study was to assess the clinical use of routinely karyotyping spontaneous abortion material. STUDY DESIGN: We retrospectively reviewed the records of the Pittsburgh Cytogenetics Laboratory from January 1, 1998, to December 31, 2001, for all tissues from spontaneous losses at 20 weeks' gestation or less for which complete medical records were available. RESULTS: There were 517 submitted samples of which 28 (5.4%) failed to grow in culture. Overall, 55.8% of samples were abnormal; 52.3% of normal results were male. In samples from pregnancies at 13 weeks or less the rate of abnormality was 69.1%. When analyzed by maternal age, the rate of abnormality for first-trimester losses was 57.2% in women younger than 35 years, and 82.3% in those 35 years or older. There was no difference in the rate of abnormality when comparing first loss with two or more losses, first pregnancy with two or more pregnancies, or the presence or absence of at least one live birth. CONCLUSION: Chromosome abnormalities are the cause for pregnancy loss in 50% to 80% of cases, depending on maternal age and gestational age at time of the loss. Karyotyping of spontaneous losses in the first trimester beginning with the patient's second loss provides clinically important etiologic information and decreases the number of evaluations necessary for recurrent pregnancy loss.     

Dynamics of endometrial thickness over time: a reappraisal to standardize ultrasonographic measurements in an infertility program

OBJECTIVE: To assess changes in endometrial thickness during different phases of spontaneous uterine contractions in the menstrual cycle. DESIGN: Prospective, longitudinal study. SETTING: Infertility clinic. PATIENT(S): Sixty-eight infertile patients seen for basic assessment between January 30 and July 1, 2002. MAIN OUTCOME MEASURE(S): Endometrial thickness on two-dimensional transvaginal ultrasonography. RESULT(S): Changes in endometrial thickness were seen on transvaginal ultrasonongraphy in 52 of 68 (76.47%) patients during spontaneous uterine contractions throughout the follicular phase of menstrual cycle. Changes involved the myometrium and subendometrium. Changes in thickness ranged from 1.3 mm to 2.8 mm, regardless of the day of study. CONCLUSION(S): Multiple measurements must be made to calculate a mean endometrial thickness that takes into account alterations due to contractions.     

Violence does not influence early pregnancy loss

OBJECTIVE: To examine the relationship between physical violence, controlling behavior, and spontaneous abortion (SAB). DESIGN: Nested case-control study. SETTING: Emergency department of a university hospital. PATIENT(S): One thousand one hundred ninety-nine pregnant women. MAIN OUTCOME MEASUREMENT(S): Physical violence and controlling behavior. RESULT(S): Cases experienced a SAB (n = 392) and controls maintained their pregnancy through 22 weeks (n = 807). Fifteen percent of women reported violence during the pregnancy, and 49% had reported one or more past episodes of violence. We found no relationship between any measure of physical violence (past, current, or by perpetrator) and the risk of SAB. CONCLUSION(S): Although physical violence was very prevalent in the study population, exposure to violence did not influence the risk of SAB.     

口服卵清蛋白和滋养细胞膜抗原诱导小鼠妊娠免疫耐受效果的观察

目的　观察口服卵清蛋白 (OVA)和滋养细胞膜抗原 (TMA)诱导小鼠妊娠免疫耐受效果 ,探讨原因不明复发性自然流产的口服免疫疗法。方法　建立自然流产小鼠模型CBA/J×DBA/ 2 ,分不同剂量观察经口服途径给妊娠CBA/J小鼠OVA和TMA1、TMA2 3种抗原后胚胎丢失率的变化。实验分为 4组 :(1 )口服抗原 (即OVA、TMA1和TMA2 )免疫组 :分为低剂量单次 (即OVA 2 0 μg× 1次 ,TMA1和TMA2均为 50 0 μg× 1次 )、低剂量 5次 (即OVA 2 0 μg× 5次、2 0 0 μg× 5次、2mg× 5次 ,TMA1和TMA2均为 50 0 μg× 5次、1mg× 5次、2mg× 5次 )和高剂量单次 (即OVA 2 0mg× 1次 ,TMA1和TMA2均为 8mg× 1次 ) ;(2 )另设 3个对照组 ,即未免疫组 (未予任何处理 )、主动免疫组 (腹腔注射雄性BALB/c小鼠脾细胞 )和空白对照组 (口服生理盐水 )。结果　 4组小鼠的胚胎丢失率分别为 :未免疫组 2 9% ,主动免疫组 8% ,空白对照组 2 8% ;口服抗原免疫组中 ,口服OVA 2 0 μg× 1次、2 0 μg× 5次、2 0 0 μg× 5次、2mg× 5次、2 0mg× 1次者分别为 2 6 %、6 %、1 0 %、4 %和 1 0 % ,口服TMA1及TMA2 50 0 μg× 1次、50 0 μg× 5次、1mg× 5次、2mg× 5次、8mg× 1次者分别为 2 2 %及 2 6 %、2 3 %及 4 %、2 7%及1 1 %、2 7%及 3 %、2 4 %     

Decreased progesterone receptor expression in the intermediate trophoblastic cells of spontaneous abortions

OBJECTIVE: To determine whether there are differences in the expression of progesterone receptor (PR) in intermediate trophoblastic cells of pregnancies ending in either spontaneous abortion (SAB) or elective abortion. DESIGN: Immunohistochemical identification of PR in intermediate trophoblastic cells. SETTING: Academic medical center. PATIENT(S): Subjects were 86 patients who either underwent first trimester SAB or elective abortion. INTERVENTION(S): All SAB and elective abortion specimens were serially sectioned and immunohistochemically stained for PR and for melanoma cell adhesion molecule. Melanoma cell adhesion molecule immunohistochemical staining was used as a sensitive and specific marker to identify intermediate trophoblastic cells on the adjacent tissue section. MAIN OUTCOME MEASURE(S): The PR staining of intermediate trophoblastic cells by semiquantitative immunostaining score. RESULT(S): The PR expression in intermediate trophoblastic cells was significantly greater in elective abortion specimens than in SAB specimens. When controlling for estimated gestational age, the difference in PR expression was even greater. CONCLUSION(S): The quantity of PR in intermediate trophoblastic cells is significantly less in SAB when compared to elective abortion pregnancies. Although it is unknown whether this is a primary or secondary event, this information may be an important finding in attempting to characterize both the molecular etiology of implantation and the molecular pathophysiology of SAB.     

Coagulation factor XII activity, but not an associated common genetic polymorphism (46C/T),is linked to recurrent miscarriage

OBJECTIVE: To investigate whether a factor XII genetic polymorphism is associated with first-trimester embryonal loss. DESIGN: Prospective case-control study. SETTING; Nagoya City University Hospital. PATIENT(S): Eighty-three patients with a history of two or more unexplained first-trimester recurrent miscarriages and 67 controls with no obstetric complications or history of miscarriage. MAIN OUTCOME MEASURE(S): Plasma factor XII activity, a genetic polymorphism (46 C-->T) of factor XII, lupus anticoagulant, and beta(2)glycoprotein I dependent anticardiolipin antibodies. RESULT(S): Ten of the 83 patients and 1 of the 67 controls had decreased factor XII activity; the difference in frequency was statistically significant. Wild-type (CC), heterozygote (CT), and homozygote (TT) allele patterns were observed in 8, 36, and 39 patients, respectively, compared with 11, 20, and 36 of the patients and controls, respectively. The mean (+/- SD) corresponding factor XII activity was 154.8 +/- 44.8%, 112.7 +/- 30.2%, and 66.2 +/- 29.2% in patients and 164.6 +/- 26.7%, 114.3 +/- 28.1%, and 70.4 +/- 18.1% in controls. The two groups did not differ in the frequency of the T allele or categories of factor XII activity. CONCLUSION(S): Factor XII activity overall, but not the 46C/T common genetic polymorphism, is associated with recurrent miscarriage.     

Management of missed abortion in a patient with congenital cervical atresia

OBJECTIVE: To describe a patient with congenital cervical atresia who became pregnant through IVF and thawed transmyometrial ET and then experienced a missed abortion. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A patient with congenital cervical atresia who underwent reconstructive surgery at 23 years of age and underwent IVF twice at 28 and 30 years of age. INTERVENTION(S): Abortion management. MAIN OUTCOME MEASURE(S): Medical follow-up of IVF-ET, resultant pregnancy, and abortion. RESULT(S): After the second cycle of IVF with frozen-thawed transmyometrial ET, the patient became pregnant but then experienced a missed abortion. Serum beta-hCG levels decreased, the two gestational sacs disappeared, and genital bleeding without signs of infection occurred 14 weeks after diagnosis of the abortion. The abortion was managed conservatively. CONCLUSION(S): When assisted reproductive techniques are used in patients with congenital cervical atresia, the risks (including those relating to the management of an abortion) should be explained in detail to the couple and sufficient informed consent should be obtained before starting IVF-ET procedures.     

Nasopharyngectomy for recurrent nasopharyngeal carcinoma: a review of 31 patients and prognostic factors

OBJECTIVES/HYPOTHESIS: Nasopharyngectomy is a well-established treatment option for recurrent nasopharyngeal carcinoma. Over a period of 4 years and 3 months, in a total of 43 patients, 45 nasopharyngectomies were performed. Thirty-one patients with follow-up ranging from 12 to 58 months were studied. Twenty-two patients (58%) survived; of these, 18 patients (82%) remained disease free. All patients who developed repeat recurrence or died (n = 12) had a high recurrent T-stage tumor, skull base involvement, multiple recurrences, positive surgical margins, or concurrent neck node metastasis. These factors are poor prognostic parameters and might mitigate the indications for aggressive salvage surgery. However, low recurrent T-stage tumor without neck metastasis carries a good prognosis. Modern minimally invasive surgery carries minimal morbidity.STUDY DESIGN A retrospective study was made to determine prognostic indicators in patients treated with salvage surgery for recurrent nasopharyngeal carcinoma. METHODS: Medical records were analyzed for all patients who had received nasopharyngectomy for recurrent nasopharyngeal carcinoma from March 1997 to June 2001. They were followed up from March 1997 to January 2002. Recurrent T stage, nodal metastasis, surgical approach, surgical margins, and pathological nodal status, together with surgical mortality, morbidity, and the delivery of postoperative irradiation, were compared with survival. RESULTS: In all, 43 patients underwent 45 nasopharyngectomies over a period of 4 years and 3 months. Patients with less than 1 year of follow-up were excluded. Four patients with residual disease, who represent a more favorable group, and five patients with planned debulking, nasopharyngectomy, and postoperative stereotactic irradiation were also excluded. The study group comprised 25 men and 6 women (ratio of 4:1) with age ranging from 26 to 69 years (mean age, 49.5 y). In 28 patients (90.3%), the recurrence of nasopharyngeal carcinoma was their first recurrence; in 3 patients (9.7%), the recurrences were second recurrences. Twenty-two patients (71%) survived, achieving a mean survival of 28.5 months. Nine patients died with a mean interval of 7.8 months (range, 1-14 mo). Of the nine patients who died, six (67%) had T3 or T4 tumor, four (44.4%) had concurrent recurrent neck disease, and five (55.5%) had positive surgical margins. Two patients died of perioperative meningitis. Fifteen (83.3%) of the 18 disease-free survivors had a low recurrent T-stage tumor. Mean intervals for development of repeat recurrence or distant metastasis were 16 and 7.9 months, respectively. CONCLUSIONS: High recurrent T stage, skull base involvement, repeated recurrence before surgery, nodal metastasis, and positive surgical margins carry a poor prognosis. This is particularly evident with high T stage and concurrent nodal metastasis. However, patients with low T stage have a survival advantage and benefit most from surgical treatment.