A survey of uterine perforation following dilatation and curettage or evacuation of retained products of conception

Study Of 11,914 women who underwent dilatation and curettage over a 7-year period (1995–2002) at Princess Badea Teaching Hospital in Irbid, North Jordan, 23 patients sustained a uterine perforation. In 22 cases, the operator was a trainee. Previous gynaecological surgery had been performed in only 2 of these 23 women.Conclusion Operator inexperience seemed to be the only risk factor in this very common operation.     

Role of transvaginal sonography in the diagnosis of retained products of conception

Introduction The aim of this study was to evaluate the criteria of endometrial thickness to detect retained products of conception following first trimester spontaneous abortion or elective pregnancy termination. Methods This was a retrospective study on 116 patients who underwent uterine re-evacuation with a diagnosis of retained products of conception based on clinical and sonographic findings. Pathologic reports of samples obtained during re-evacuation were reviewed for the presence of gestational tissue. Endometrial thickness determined by transvaginal sonography and certain clinical features (gestational age and interval between initial curettage and re-evacuation, which may affect presence or absence of gestational tissue, parity, indication for initial curettage) were noted. The sensitivity and specificity of sonographic measurement of endometrial thickness for detecting retained products of conception were assessed. Results Histopathologic reports confirmed the diagnosis of retained products of conception in 66 of 116 patients (56.9%). Percentage of nulliparity and the time elapsed between initial curettage and re-evacuation were significantly high in patients with retained products of conception. The sensitivity and specificity of endometrial thickness greater than 13 mm for detecting retained products of conception were 85 and 64%, respectively. Conclusion An endometrial thickness of 13 mm or more, detected by transvaginal sonography, has the best diagnostic efficiency for detection of retained products of conception following first trimester spontaneous abortion or elective pregnancy termination.     

Hysteroscopic Removal of Retained Products of Conception Implanted Over a Focal Area of Adenomyosis: A Case Report

Study Objective

To describe a technique for hysteroscopic removal of retained products of conception (RPOC) implanted over an area of adenomyosis.

Transvaginal ultrasound and sonohysterography for assessment of postpartum residual trophoblastic tissue

Objective

To compare the accuracy of transvaginal ultrasound and sonohysterography (SHG) in diagnosing residual trophoblastic tissue in postpartum women and to assess the adverse effects and complications of the SHG procedure.

Methods

A prospective study of patients with postpartum bleeding enrolled for clinical symptoms and signs of residual trophoblastic tissue. All women underwent transvaginal ultrasound and SHG. Uterine cavity curettage was performed in all women and the material collected was sent for pathologic examination.

Results

Among 84 patients, transvaginal ultrasound revealed residual trophoblastic tissue in 60 women, whereas SHG detected residual trophoblastic tissue in 48 and blood clots in 12. Pathologic examination confirmed trophoblastic tissue in 48 patients and blood clots in 12. Fifteen (17.9%) patients experienced adverse effects after SHG. Thirteen (15.5%) experienced postprocedural fever that resolved with antibiotics. Two women (2.4%) had severe complications of infection: 1 required surgery for peritonitis, which revealed salpingitis and a pelvic abscess; 1 experienced fever and mild abdominal pain that resolved with antibiotics after 10 days of hospitalization.

Conclusions

Although SHG showed greater accuracy than transvaginal ultrasound in detecting residual trophoblastic tissue, a high proportion of patients experienced adverse effects.     

Postpartum transcervical endometrial resection under laparoscopic control for retained degenerated products of conception

We describe a case of postpartum haemorrhage due to retained products of conception that failed to resolve after two attempts of evacuation of retained products of conception. A subsequent histology and MRI scan confirmed retained products of conception despite repeated attempts at treatment. We introduce transcervical endometrial resection as an efficient method of removing degenerated retained products of conception refractory to standard treatment.     

Efficacy of hyaluronic acid on the prevention of intrauterine adhesion and the improvement of fertility: A meta-analysis of randomized trials

Backgroundand purpose:Intrauterine adhesion (IUA) and re-adhesion were common problems in women of childbearing age. The aim of our research was to evaluate the efficacy of hyaluronic acid gel on preventing IUA and improving the fertility.MethodsA systematic search for randomized controlled trial (RCT) articles that tested the effectiveness of using hyaluronic acid gel during intrauterine surgery in prevention of IUA and improvement of fertility was performed in PubMed, Medline, Embase, the Cochrane Library and clinicaltrials.gov until December 2020. Data were extracted independently and analyzed using RevMan statistical software version 5.3.ResultsTwelve articles (11 studies) were deemed eligible for inclusion. There was a significantly reduced proportion of IUA after using hyaluronic acid gel during intrauterine operation (OR 0.39, 95% CI 0.29 to 0.52). It has significantly reduced the incidence of moderate-to-severe IUA after using hyaluronic acid gel, but no effect on the mild IUA. In addition, our analysis showed that the hyaluronic acid gel group was associated with a significant increased incidence of pregnancy (OR 1.64, 95% CI 1.08 to 2.50).ConclusionOur analysis confirmed that using hyaluronic acid gel during intrauterine operation seemed to be more helpful for patients with high risk of IUA. However, larger and well-designed studies would be desired in the future to confirm its efficacy and safety in protecting fertility.     

Chromosomal copy number analysis of products of conception by conventional karyotyping and next-generation sequencing

PurposeChromosomal abnormalities are a major cause of spontaneous abortion, and conventional G‐banded karyotyping (G‐banding) is mainly utilized for chromosomal analysis. Recently, next‐generation sequencing (NGS) has been introduced for chromosomal analysis. Here, we aimed to investigate the applicability and utility of NGS‐based chromosomal analysis of products of conception (POC) on chorionic villus samples from spontaneous abortion.MethodsThe results of chromosomal analysis of 7 chorionic villus samples from spontaneous abortion were compared between conventional G‐banding and NGS‐based chromosomal copy number analysis. Age dependency and frequency of each chromosomal aneuploidy were evaluated for 279 cases analyzed by NGS.ResultsExcluding two cases (culture failure and maternal cell contamination), the results were consistent between G‐banding and NGS. For cases analyzed by NGS, the rate of chromosomal abnormality increased in a maternal age‐dependent manner. The frequency of each chromosomal aneuploidy detected by NGS was almost the same as that previously reported. Finally, NGS analysis was possible for difficult cases by G‐banding analysis, such as culture failure, maternal cell contamination, long‐term storage cases, and low cell number.ConclusionsChromosome analysis using NGS not only obtains comparable results to conventional G‐banding, but also can analyze POC more accurately and efficiently.     

Intercoat (Oxiplex/AP Gel) for Preventing Intrauterine Adhesions After Operative Hysteroscopy for Suspected Retained Products of Conception: Double-Blind,Prospective, Randomized Pilot Study

Study ObjectiveTo evaluate the safety and effectiveness of Oxiplex/AP gel (Intercoat) in reducing intrauterine adhesion formation after hysteroscopic treatment because of retained products of conception (RPOC).DesignProspective double-blind, randomized, controlled pilot study (Canadian Task Force classification I).SettingTertiary medical center.PatientsAll women who underwent hysteroscopic treatment because of RPOC at our institution between September 2009 and June 2012 were invited to participate. After operative hysteroscopy, participants were randomized to either have their uterine cavity filled with Oxiplex/AP gel (study group, n = 26) or not (control group, n = 26).InterventionsDiagnostic office hysteroscopy to assess for adhesion formation was performed after 6 to 8 weeks. Findings were graded according to the American Fertility Society classification. Rates of subsequent pregnancy in the 2 groups were assessed.Measurements and Main ResultsIntraoperative complication rates were similar between the 2 groups. There were no postoperative complications after Oxiplex/AP gel application. Moderate to severe adhesions developed in 1 woman (4%) in the study group and 3 (14%) in the control group (p = .80). During follow-up of 20 months (range, 2–33 months), 7 women (27%) in the treatment group conceived, compared with 3 (14%) in the control group (p = .50).ConclusionIntrauterine application of Oxiplex/AP gel after hysteroscopic removal of RPOC is safe. In this small sample, the difference in the rate of intrauterine adhesions was not statistically significant. A larger study would enable further establishment of the safety and efficacy of use of this gel.     

Perinatal outcomes in singleton and twin ICSI pregnancies following hysteroscopic correction of partial intrauterine septa

Purpose

To investigate the perinatal outcomes of patients with clinical pregnancies from ICSI treatments who had previously undergone hysteroscopic surgery to correct partial intrauterine septa and compare them to outcomes of patients with no intrauterine anomalies.

Method

A retrospective observational analysis of 2024 ultrasound confirmed pregnancies from ICSI treatments performed between January 2005 and June 2012. The patients were grouped according to their intrauterine status, and sub-grouped according to the number of fetal hearts observed; singleton control (n = 1128), twin control (n = 566), singleton septum (n = 217) and twin septum (n = 113). The primary outcomes analyzed were miscarriage, preterm, very preterm, stillbirth, vanishing twin and live delivery rates, as well as low birth weight and very low birth weight rates.

Result(s)

The live birth rate (89,9 %) in the singleton control subgroup was non-significantly higher than the live birth rate (85,3 %) in the septum subgroup, with a RR of 1,05 (p = 0,0583, 95 % CI 0,9943–1,1182) for live birth. In contrast the live birth rate (91,3 %) in twin control subgroup was significantly higher than the live birth rate (84,1 %) in the septum subgroup, with a RR 1,09 (p = 0,0282, 95 % CI 0,9988–1,1819). Non-significantly, higher miscarriage and stillbirth rates were the main contributors to the reduced live birth rates. The singleton and twin septum subgroups also had higher rates of premature and very premature delivery and LBWs and vLBW, especially in the singleton septum subgroup.

Conclusion(s)

The hysteroscopic correction of intrauterine septa may not eliminate all risks for premature delivery.     

The nature of intrauterine adhesions following reproductive hysteroscopic surgery as determined by early and late follow-up hysteroscopy: clinical implications

Objective To evaluate the rate and characteristics of postoperative intrauterine adhesions (IUA) that might be formed following hysteroscopic reproductive surgery from both a gross and a histologic perspective as determined by early and late follow-up diagnostic hysteroscopy. Methods Retrospective analysis of 61 women wishing a pregnancy and suffering from a significant intrauterine pathology affecting their reproductive outcome were reviewed. All patients were treated hysteroscopically. Subsequently, they were randomly assigned to perform a follow-up diagnostic hysteroscopy at a variable intervals from their initial surgery. Multiple hysteroscopic-guided biopsies from IUA, when present, were obtained in several cases. Twenty patients were in the early group and had follow-up hysteroscopy performed 2–4 weeks after the initial operation. The late diagnostic group consisted of 41 patients with follow-up hysteroscopy at about 12 months (8–16 months). The two groups were similar to composition. Postoperatively, none of the early diagnostic group underwent hysterosalpingography (HSG) whereas all of the late group performed HSG 4 months following the initial surgery, which showed at least one-third of the cavity free of adhesions. When adhesions were present, no effort was made to lyse them. Results At follow-up hysteroscopy, 25% of both groups had no significant adhesions. Grade I adhesions (thin, filmy) occurred in 60% of the early hysteroscopy patients and in only 12% of the late group (P < 0.05). Grade II adhesions were present in 10% of the early group and in up to 41% in the late group (P < 0.05), whereas Grade III adhesions were present in only 5% of the early hysteroscopy group, but in 22% of the late one (P < 0.05). Correlation between hysteroscopic and histologic findings were good in most of cases in both groups. Follow-up to determine the subsequent reproductive outcome revealed similar conception rates in both groups. Conclusion The IUA that might be formed immediately following hysteroscopic reproductive surgery are histologically different from those appearing a longer time after the original operation. Routine early follow-up hysteroscopy can influence the prognosis resulting from the original surgery.     

高龄女性自然妊娠及辅助生殖技术子代的安全性

近年来,随着生育年龄的推迟,高龄妊娠不断增多,辅助生殖技术的需求不断增大,其子代安全性问题也越来越受到关注,相关研究亦逐渐增多。对于高龄妇女,如何降低子代出生缺陷、规避风险以达到优生目的的前提是了解高龄自然妊娠及辅助生殖技术可能造成的风险。文章将对高龄妇女自然妊娠与辅助生殖技术的子代安全性进行归纳总结。     

A comparison of psychological stress among women with and without reproductive failure

Objective

To determine whether women with recurrent implantation failure (RIF) after in vitro fertilization (IVF), similar to women with recurrent pregnancy loss, have significantly higher stress levels than women without reproductive failure, and to compare stress levels between women with RIF and women with recurrent pregnancy loss.

Methods

In a questionnaire-based study between September 2009 and January 2011, psychological stress was measured among patients attending recurrent pregnancy loss and RIF clinics at the Royal Hallamshire Hospital, Sheffield, UK. Participants completed the Fertility Problem Inventory (FPI), the Perceived Stress Scale (PSS), and the Positive and Negative Affect Schedule (PANAS) on their first visit to their respective clinic. Thirty fertile control women also completed the 3 validated questionnaires.

Results

Compared with the control group, women with RIF and recurrent pregnancy loss had significantly higher scores in the FPI (RIF, P < 0.001; recurrent pregnancy loss, P = 0.003) and the PANAS negative affect domain (RIF, P = 0.004; recurrent pregnancy loss, P = 0.001), and lower scores in the PANAS positive affect domain (RIF, P < 0.001; recurrent pregnancy loss, P < 0.001). Whereas the perceived stress score (PSS) of the recurrent pregnancy loss group was significantly higher than that of the control group (P = 0.006), the score of the RIF group was not, although the difference tended toward statistical significance (P = 0.058).

Conclusion

The study findings confirm the stressful nature of RIF and recurrent pregnancy loss.     

Evaluation of the efficacy of traditional Chinese medicine for the reproductive and pregnancy outcomes in women with endometriosis: A nationwide population-based study

ObjectivePatients with endometriosis may seek traditional Chinese medicine (TCM) to help them conceive. The present study aims to evaluate the effects of TCM on reproductive and pregnancy outcomes in patients with endometriosis.Materials and methodsThe patients with endometriosis taken from the National Health Insurance (NHI) research database between 2000 and 2012 were divided into two cohorts based on the use of TCM treatment. The two cohorts were matched by age and comorbidities and followed up until a new diagnosis of infertility, ectopic pregnancy, or miscarriage. Multivariable Cox proportional hazards models were used to evaluate the hazard ratio (HR) of reproductive and pregnancy outcomes.ResultsA total of 5244 patients with endometriosis were analyzed, including 1748 TCM users and 3496 matched control subjects. The proportion of infertility was higher in TCM users than in non-TCM users (adjusted hazard ratio [HR]: 1.34, 95% confidence interval [CI]: 1.13–1.60). However, there was no significant difference in the proportion of ectopic pregnancies between TCM users and non-TCM users (adjusted HR: 0.82, 95% CI: 0.60–1.13). There was no significant difference in the proportion of miscarriages between TCM users and non-TCM users (adjusted HR: 1.23, 95% CI: 0.95–1.61).ConclusionTCM treatment showed insignificant efficacy in decreasing the risk of ectopic pregnancy and miscarriage in patients with endometriosis.     

A preliminary study of the relationship between the long arm of the Y chromosome (Yqh+) and reproductive outcomes in IVF/ICSI-ET

Objective

To compare the reproductive outcomes of Yqh+-carrying and control couples undergoing IVF/ICSI treatments.

Study design

Retrospective analysis of 72 Yqh+ carriers and 986 Yqh+ non-carriers undergoing their first cycle of ART in a single centre between August 2005 and May 2011.

Results

Yqh+ carrying couples had significantly worse reproductive outcomes compared with control couples undergoing IVF treatment. There were a significantly higher cancellation rate (20.69% vs 7.9%; P < 0.05; OR, 3.03; CI, 1.18–7.79) and a significant lower fertilisation rate (50.05% vs 66.01%; P < 0.05; OR, 0.61; CI, 0.49–0.57), implantation rate (8.33% vs 20.87%; P < 0.05; OR, 0.35; CI, 0.14–0.87), good quality embryo ratio (44.70% vs 57.89%; P < 0.05; OR, 0.59; CI, 0.43–0.80) and clinical pregnancy rate (17.39% vs 39.59%; P < 0.05; OR, 0.32; CI, 0.11–0.96) in Yqh+ group compared with control group undergoing IVF treatment. Yqh+ carrying couples had similar reproductive outcomes compared with control couples undergoing ICSI treatment.

Conclusions

The Y chromosome polymorphic variant Yqh+ most likely plays a role in infertility. Yqh+ couples with poor reproductive outcomes in IVF treatment can be advised to undergo ICSI to improve their reproductive results in the next cycle.     

Cervical priming prior to dilatation and evacuation: A comparison of methods

Vaginal administration of prostaglandin analogues resulted in cervical changes that facilitated dilatation and evacuation in 80 patients in the late first trimester and the second trimester of pregnancy. When 0.5 mg and 1.0 mg of 15(S)-15-methyl-prostaglandin F_2α (15-ME-PGF_2α) was compared to 30 and 60 mg of 9-deoxo-16, 16-dimethyl-9 methylene prostaglandin E₂ (PGE₂ analogue), the PGE₂ analogue appeared to have more cervical ripening effect than did the 15-ME-PGF_2α. Overall, the 30 mg PGE₂ vaginal suppository seemed to offer the most optimal combination of effectiveness, sufficient cervical dilatation, and minimal side effects. With the prostaglandins, maximal cervical effect was observed at 4 to 5 hours; this rapid effectiveness allows administration of the prostaglandin to accommodate a 1-day stay for surgical evacuation. The preoperative cervical priming results with the prostaglandins were compared to those obtained with the use of laminaria tents. Although the number of patients who needed further dilatation at the time of operation was less with the laminaria, the incidence of complications and the time for adequate dilatation were higher in that group.     

A comparison of obstetrical outcomes and costs between misoprostol and dinoprostone for induction of labor

Objective: The objective of this study is to compare resource utilization (efficiency) and obstetrical/cost outcomes of single dose misoprostol versus dinoprostone for induction of labor (IOL) at term.

Methods: Retrospective cohort of induced deliveries 37–41 weeks gestation presenting with a Bishop score?≤4 using single-dose-50?mcg vaginal misoprostol or 10?mg-dinoprostone vaginal-inserts. Dinoprostone patients were compared (5:1) with misoprostol patients. The primary outcome variable was length of L&D stay (proxy for resource utilization). Baseline characteristics, clinical outcomes, and costs were compared.

Results: Three-hundred thirty-one patients were included, 276 received dinoprostone and 55 received misoprostol. The misoprostol group had statistically significant decreased time to active labor [median 8?h (1.6,24) versus 12(0.8,52)], time-to-delivery [median 11?h (4,31) versus 17(2.8,56)] and L&D stay [median 16?h (13,28) versus 24(18,30)]. Differences remained significant after adjustment for race, method of delivery, birth weight, gravidity/parity, gestational age, and BMI (adjusted p values?<0.001, <0.01, and?<?0.05, respectively). There were no statistical differences in Apgar scores, tachysystole rate, cesarean section rate, and composite maternal/neonatal morbidity. A policy of using misoprostol would result in annual cost savings of approximately $242 500 at our institution as compared with dinoprostone.

Conclusion: Single-dose misoprostol is more efficient in IOL at term with respect to L&D utilization and cost and its use is not associated with increased adverse obstetrical outcomes.