The Bakri balloon for the management of postpartum hemorrhage in cases with placenta previa

Objective

To evaluate the success rate of the Bakri balloon in the event of uncontrollable hemorrhage due to placenta previa.

Study design

We evaluated 25 patients who were treated with the Bakri balloon who had severe postpartum hemorrhage with placenta previa and failed medical treatment with uterotonic agents.

Results

The Bakri balloon was inserted abdominally during cesarean section in 24 of 25 cases. In only one case was it inserted vaginally. The Bakri tamponade was effective in 22 cases (88%). There were three cases with failure: two patients needed an additional procedure (hypogastric artery ligation and B-Lynch suture) and one patient needed hysterectomy.

Conclusions

The Bakri balloon is the least invasive, rapid method in the management of bleeding due to placenta previa with minimal complications.     

Inversión uterina puerperal: experiencia en nuestro centro

Objective

To assess the incidence, outcomes, and risk of recurrence of puerperal uterine inversion in our hospital.

Material and methods

A retrospective study was carried out in 22 cases of puerperal uterine inversion from January 1993 to December 2013 in our hospital. We analyzed different risk factors.

Results

The mean age of the patients was 28 years (18-41). Nineteen (86%) were nulliparous. Four (18%) had undergone previous uterine surgery. Delivery was through cesarean section in 6 patients (27%) and through the vaginal route in 16 (73%). The mean birthweight was 3111 grams (2130-3950). Retained placenta occurred in 8 patients (36.4%) and uterine atony in 3 (13.6%). Uterine inversion was acute in all patients. Complications and management consisted of severe hemorrhage in 7 patients, 20 cases (91%) were resolved by the Johnson procedure, and 22 hysterectomies (9%) were performed. There were no deaths and no recurrences.

Conclusions

In our study, important risk factors were nulliparity and placenta accreta. Early diagnosis and treatment are of the utmost importance. Surgery should be the last option.     

Robotic-assisted laparoscopic surgery in uterine pathology

Objective

The feasibility and safety of robotic surgery have been demonstrated by numerous comparative studies. The aim of our study was to compare several parameters related to robotic surgical procedures in uterine pathology, and to analyse clinico-biological parameters that may influence the post-operative evolution of the patients.

Study design

Retrospective analysis of 100 patients with uterine pathology who had undergone robotic-assisted laparoscopic surgery at the Santa Chiara Hospital, Pisa, Italy, between 2008 and 2010.

Results

Duration of surgery, docking, hysterectomy, uterine suture, blood loss, and days of hospitalisation significantly improved in parallel with the increasing experience of the surgical team. Paradoxically, the length of myomectomy increased in the same time interval, probably due to operating on more complex clinical cases with this procedure as the surgical team's experience grew. None of the robotic surgeries was converted to laparotomy. No intra- or post-operative complications were noted.

Conclusion

Since robotic-assisted laparoscopic surgery is becoming the preferred surgical technique for uterine pathology treatment, more clinical studies and development of protocols are essential to increase the quality of surgical treatment.     

Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage

Objectives

The aims of this study are to determine the incidence and aetiology of major obstetric haemorrhage (MOH) in our population, to examine the success rates of medical and surgical interventions and to identify risk factors for peripartum hysterectomy and end organ dysfunction (EOD).

Study design

This prospective study from 2004 to 2007 was carried out in three Dublin maternity hospitals. Women were identified as having MOH if they received ≥5 units of red cell concentrate (RCC) acutely. Risk factors for hysterectomy or end organ dysfunction were calculated using logistic regression.

Results

One hundred and seventeen cases of MOH in 93,291 deliveries were identified (1.25/1000). The predominant cause was uterine atony. Haemostasis was achieved with medical therapy alone in 15% of cases. The hydrostatic balloon and the B-Lynch suture arrested bleeding in 75% and 40% of cases utilised respectively. Hysterectomy was required to arrest bleeding in 24% of women and 16% of women developed end organ dysfunction (11 had both). There was one maternal death. Independent risk factors for hysterectomy included the number of previous caesarean sections (OR 3.28, 95% CI 1.95-5.5), placenta praevia (OR 13.5, 95% CI 7.7-184), placenta accreta (OR 37.7, 95% CI 7.7-184), uterine rupture (OR 7.25, 95% CI 1.25-42) and the number of units of RCC transfused (OR 1.31, 95% CI 1.13-1.5). Independent risk factors for end organ dysfunction (EOD) were placenta accreta (OR 5, 95% CI 1.5-16.5), uterine rupture (OR 13.86, 95% CI 2.32-82), the number of RCC transfused (OR 1.31, 95% CI 1.13-1.5) and the minimum haematocrit recorded (OR 5.53, 95% CI 1.7-18).

Conclusions

MOH is complicated by hysterectomy in 24% and end organ dysfunction in 16% of cases. The risk of peripartum hysterectomy is increased with the number of previous caesarean sections, the aetiology of the bleed, namely placenta praevia/accreta or uterine rupture and the volume of blood transfused. Critically, failure to maintain optimal haematocrit during the acute event was associated with end organ dysfunction.     

Emergency peripartum hysterectomy: a comparison of cesarean and postpartum hysterectomy

Objectives

The purpose of this study was to evaluate the incidence, risk factors, indications, outcomes, and complications of emergency hysterectomy performed after cesarean deliveries (cesarean hysterectomy) and vaginal deliveries (postpartum hysterectomy).

Study design

We conducted a retrospective cohort study from 1990 to 2002 of patients who had peripartum hysterectomies at a single tertiary hospital. Comparisons were made between cesarean and postpartum hysterectomies.

Results

There were 55 cases of emergency peripartum hysterectomy (38 cesarean hysterectomies, and 17 postpartum hysterectomies), for a rate of 0.8 per 1000 deliveries. Overall, the most common indication for hysterectomy was uterine atony (56.4%), followed by placenta accreta (20.0%). Average estimated blood loss was 3325.6±1839.2 mL, average operating time was 157.1±75.4 minutes, average time from delivery to completing the hysterectomy was 333.8±275.7 minutes, and the average length of hospitalization was 11.0±7.9 days. The cesarean delivery rate at Grady Memorial Hospital during the study period was 14.2%. There were no statistically significant differences between variables examined when comparisons were made by cesarean vs postpartum hysterectomy.

Conclusion

Uterine atony is the leading indication for emergency hysterectomy performed following cesarean and vaginal deliveries.     

B-Lynch suture — An experience

Objectives

To study the effectiveness of B-Lynch suture to control postpartum hemorrhage. To know the effect of this extreme degree of compression (produced by B- Lynch suture) on uterine anatomy three months after delivery.

Method

B-Lynch suture (Classical / modified form) was applied in 75 cases. A No. 2 chromic catgut suture was used on a big size round body needle. During the placement of suture, patient was placed in frog-leg position to assess the compression effect of B-Lynch suture. In 62 cases (82.66%) B-Lynch suture was the only intervention. In 8 cases (10.66%) uterine arteries (O’Leary method) were also ligated and in Ave cases (6.66%) cervico-isthmic apposition suture was also applied in addition to B-Lynch suture.

Result

Failure rate was 2.67%. Hysterectomy was required in two cases

Conclusion

B-Lynch suture technique is a simple, effective, safe, life saving and fertility preserving method to control atonic postpartum hemorrhage.     

The B-Lynch technique for the management of intraoperative uterine atony

This paper reports the experience of 150 B-Lynch suture applications for the management of uterine atony during caesarean section that did not respond to conventional therapeutical measures. Technique was considered effective if the need for hysterectomy was avoided. High-risk antenatal obstetrical conditions included: pre-eclampsia (12%), oligohydramnios (8%), polyhydramnios (4.7%). A total of 36% were primigravid, 66% had been in active labour, 4.7% received misoprostol and 26.7% used oxytocin for labour augmentation. Suture was successful in 95.3%, with only five cases requiring hysterectomy combined with uterine artery ligation and two uterine artery ligations alone to control bleeding and uterine atony ('floppiness'). Although 26.7% of cases required transfusions, no maternal deaths were reported, and overall women were discharged after a median 4-day hospital stay without further complications upon follow-up. The B-Lynch technique was an effective intraoperative measure to control uterine atony. Despite the encouraging results, long term assessment on a larger sample is needed in our clinical scenario.     

Use of second-line therapies for management of massive primary postpartum hemorrhage

Objective

To determine rates of use and success of second-line therapies for massive primary postpartum hemorrhage (PPH).

Methods

A retrospective cohort study was conducted among 91 women who gave birth at Kwong Wah Hospital, Hong Kong, between January 1, 2006, and December 31, 2011. Inclusion criteria were gestational age of at least 24 weeks and massive PPH (defined as blood loss ≥ 1500 mL within 24 hours after birth). Second-line therapies assessed were uterine compression sutures, uterine artery embolization, and balloon tamponade after failure of uterine massage and uterotonic agents to stop bleeding.

Results

The rate of massive PPH was 2.65 per 1000 births. Second-line therapies were used among 42 women with PPH, equivalent to a rate of 1.23 per 1000 births. Only 21.4% of the women who received second-line therapies required rescue hysterectomy. A rising trend was observed for the use of second-line therapies, whereas the incidence of rescue hysterectomy and estimated blood loss were found to concomitantly decrease.

Conclusion

Increasing use of second-line therapies among women with massive PPH was associated with a decreasing trend for rescue hysterectomy. Obstetricians should, therefore, consider all available interventions to stop PPH, including early use of second-line options.     

Colposacropexia por laparoscopia en el tratamiento del prolapso genital

Objectives

To analyze the results of laparoscopic colposacropexy and to achieve a long-lasting support system without recurrences.

Material and methods

From March 2001 to March 2007, we performed laparoscopic colposacropexy in 42 patients. The mean age was 56 years (42-70 years).Patients with prior hysterectomy showed complex vaginal vault prolapse while those without hysterectomy showed prolapse affecting more than one compartment. The 28 women with pelvic uterine prolapse underwent hysterectomy (supracervical hysterectomy in 15 and total hysterectomy in 13). The transperitoneal Burch procedure was carried out in eight patients with stress urinary incontinence.

Results

The mean length of follow-up was 3.5 years (range: 1-6). Surgery was successful in 39 patients (92.8%). Anterior compartment recurrence was observed in one patient and severe lumbar pain associated with postoperative spondylodiscitis in another patient. A third patient required posterior trachelectomy. The mean operating time was 180 min (range: 120-240). The mean length of hospital stay was 2.5 days (range: 2-3).

Conclusions

Laparoscopic colposacropexy is a safe and constantly evolving procedure with longterm durability. This procedure provides similar results to laparotomy but produces fewer vaginal complications.     

The role of loop electrosurgical excisional procedure in the management of adenocarcinoma in situ of the uterine cervix

Objectives

To evaluate the occurrence of residual or recurrent disease after loop electrosurgical excisional procedure (LEEP) for adenocarcinoma in situ (AIS) of the uterine cervix.

Study design

Records of 78 patients with a histological diagnosis of AIS of uterine cervix on LEEP who were treated and followed at our center between 1992 and 2008 were, retrospectively, reviewed.

Results

Of 78 patients who underwent LEEP, 47 had negative and 31 had positive resection margins. Of the 47 patients with negative margins, 30 underwent subsequent hysterectomy and residual AIS, including 1 invasive adenocarcinoma, was present in 17% (5/30) of patients. The remaining 17 had no additional procedures. Of the 31 patients with positive margins, 29 patients underwent subsequent hysterectomy and residual AIS, including 4 invasive adenocarcinomas, was present in 48% (14/29) of patients. The remaining two had no additional procedures. After a mean follow-up time of 28 months (range, 1–74 months), no recurrences were observed among the 19 patients who did not undergo hysterectomy.

Conclusions

The incidence of residual disease in patients with negative margins after LEEP for AIS of the uterine cervix is low but not negligible. Therefore, conservative management in these patients seems to be feasible but careful surveillance is required. However, positive resection margin carries a higher risk for residual AIS or occult invasive adenocarcinoma, warranting additional LEEP or hysterectomy in these patients.     

Reproductive performance after conservative surgical treatment of postpartum hemorrhage

Objective

To evaluate the impact of bilateral internal iliac artery ligation (BIL), bilateral uterine artery ligation (BUAL), step-wise uterine devascularization (SWUD), and B-Lynch on infertility, ovarian reserve, and pregnancy outcome.

Methods

The study included 168 infertile or pregnant patients—recruited at outpatient clinics in Egypt—who had previously undergone uterine-sparing surgery (BIL [group I], n = 59; SWUD [group II], n = 65); BUAL [group III], n = 2; and B-Lynch [group IV], n = 42). One-way analysis of variance was used to compare the prevalence of infertility, the status of ovarian reserve, and the prevalence and type of relevant maternal and/or fetal obstetric complications between the groups.

Results

Groups II and IV had the highest prevalences of infertility. The ovarian reserve was significantly lower in group II. Unexplained infertility was the predominant cause of infertility in group I, anovulation and premature ovarian failure in group II, and endometriosis and intrauterine adhesions in group IV. The frequency of obstetric complications, particularly placenta previa and preterm labor, was high in group IV.

Conclusion

Of the 4 procedures, BIL had the least deleterious effect on reproductive performance; SWUD increased the risk of premature ovarian failure, and B-Lynch increased the risks of endometriosis, intrauterine adhesions, placenta previa, and preterm labor.     

La histerectomía laparoscópica: un abordaje posible. Estudio retrospectivo de las histerectomías laparoscópicas realizadas en un hospital público

Objective

To assess the outcomes of laparoscopic hysterectomy in a public hospital.

Material and methods

We performed a retrospective study of laparoscopic hysterectomies carried out between January 2005 and December 2007. The parameters evaluated were indication, type of hysterectomy, uterine weight, length of hospital stay, and complications.

Results

In the period analyzed, we performed 284 hysterectomies, of which 103 (36.36%) were laparoscopic. The morbidity rate was 9.7% and complications were related to the learning curve. The mean length of hospital stay was 2.56 days.

Conclusions

Laparoscopic hysterectomy is a safe procedure that requires a learning curve of 30-40 procedures. Due to its advantages, this option should be offered in all gynecology services.     

Caesarean scar pregnancy: comparative efficacy and safety of treatment by uterine artery chemoembolization and systemic methotrexate injection

Objectives

The aim of this study was to investigate the efficacy and safety of uterine artery embolization (UAE) combined with intra-arterial methotrexate (MTX) infusion for the treatment of caesarean scar pregnancy (CSP), compared with systemic MTX injection combined with uterine curettage.

Study design

A retrospective cohort study. An analysis of CSP patients was performed using records from the Department of Obstetrics and Gynecology in Renji Hospital for the period between January 1, 2000 and December 30, 2010. Twenty-two patients received UAE combined with intra-arterial MTX infusion and in this group 16 patients received uterine curettage after UAE, whereas 25 patients received intramuscular MTX injection and subsequent uterine curettage. The clinical information on these patients and clinical outcomes were reviewed.

Results

All patients in the UAE group were treated successfully and 2 patients in the non-UAE group had to undergo hysterectomy or uterine repair. No patients in the UAE group had recurrent vaginal bleeding of more than 100 ml/day after treatment, while 8 patients in the non-UAE group did, and this difference was significant. The blood loss during uterine curettage in the UAE group was much less than in non-UAE group. The serum β-hCG level in the UAE group recovered more quickly than in the non-UAE group, and hospital stay was significantly shorter in the UAE group.

Conclusions

UAE combined with intraarterial MTX infusion turned out to be an effective and safe treatment for CSP.     

Uso de misoprostol en el tratamiento de abortos diferidos del primer trimestre

Objective

To evaluate the results of our experience with sublingual misoprostol as an alternative treatment for early missed abortions.

Material and methods

A retrospective study was carried out at the Consorcio Sanitario Anoia between March 2010 and December 2012 in 252 patients diagnosed with missed first-trimester abortions, who were treated with sublingual misoprostol, with prior consent.

Results

The effectiveness of misoprostol therapy was 84.77% (206 cases). In 143 cases (58.85%) the result was achieved with the first dose and in 63 cases (25.92%) with the second. In 37 cases (15.23%), misoprostol therapy (with a single dose in 8 cases and following the protocol with a double dose in 29 cases) was ineffective and uterine curettage was required.Overall patient satisfaction with medical treatment scored an average of 7.5 points among the 235 patients who were treated following the protocol.

Conclusion

Medical treatment is less aggressive than surgery, with success rates approaching 90%. Minor side effects are manageable with additional medication. Overall patient satisfaction was high and the costs were lower than for surgical treatment.     

The wait time creep: Changes in the surgical wait time for women with uterine cancer in Ontario,Canada, during 2000–2009

Objective

Uterine cancer is a major cancer of women, with outcomes potentially worsening with delayed diagnosis or hysterectomy, the main treatment. Yet cancer surgery wait times are not reported by cancer site. This study sought to examine changes in wait times for uterine cancer surgery between 2000 and 2009 and to identify predictors of longer surgery wait times.

Methods

Population-based retrospective analysis of a cohort of uterine cancer patients diagnosed between April 2000 and March 2009. Using linked administrative data, all cases in which a patient had hysterectomy following diagnosis were identified. Wait time was defined as days from diagnosis of uterine cancer (day 0) to hysterectomy. Regression analysis was used to examine the relationship between covariates and wait time.

Results

Wait times increased steadily between 2000 and 2006 from a median of 34 to 54 days, followed by a plateau until 2009—during which patients waited a median of between 53 and 55 days for surgery after diagnosis. Overall, 55% of patients had a wait time longer than 6 weeks after diagnosis. Predictors of a wait time greater than 6 weeks included older age, region, lower income, later year of diagnosis, surgery by a gynaecologic oncologist, non-sarcoma histology group and having surgery in a teaching hospital.

Conclusion

Over half of uterine cancer patients waited longer than the recommended 6 weeks for surgery. Future reporting of cancer wait times by each disease site regularly would help to identify progress to reduce wait times and opportunities for improvement.     

Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis

Objective

To identify the frequency and assess risk factors for unexpected discovery of peritoneal endometriotic implants in patients who underwent myomectomy or hysterectomy for symptomatic uterine leiomyomas.

Study design

We retrospectively collected medical records of 829 patients with symptomatic leiomyomas in The University of Tokyo Hospital. All the patients underwent abdominal or laparoscopic surgeries between January 2001 and December 2010 and the presence or absence of endometriosis during surgery was analyzed. Possible determinant to predict coexistent endometriosis was statistically investigated.

Results

In total, 105 leiomyoma cases (12.7% in 829 patients) were diagnosed with endometriosis. Patients with small dominant leiomyomas were significantly complicated by peritoneal endometriotic implants (small leiomyomas were classified as <8 cm). The patients with both diagnoses were more likely to be infertile and at age 39 years or younger than those with leiomyoma alone.

Conclusions

Women undergoing myomectomy or hysterectomy with both endometriosis and leiomyomas have several different clinical features compared with women with only leiomyomas. The size of largest leiomyoma may provide an important clue for coexistent endometriosis. Women with substantial infertility despite a smaller leiomyomas burden may be more likely to have a surgical indication for concomitant endometriosis.     

The effect of treatment preference and treatment allocation on patients’ health-related quality of life in the randomized EMMY trial

Objectives

To determine the effect of preference and treatment allocation on health-related quality of life (HRQOL) in patients in the randomized EMMY trial of hysterectomy versus uterine artery embolization (UAE) for symptomatic uterine fibroids.

Study design

We invited 349 patients eligible for trial participation, of which 177 agreed to participate (the ‘randomized group’). Within the randomized group, patients were allocated to.UAE (n = 88) or hysterectomy (n = 89). The remaining 172 patients refused randomization and received the treatment of their preference (varying from hysterectomy to no treatment at all), of which 103 patients agreed to fill in questionnaires (the ‘preference group’). Patients’ treatment preferences and HRQOL were assessed at baseline and the patients were prospectively followed to evaluate HRQOL at 12 months after treatment.

Results

At baseline, most patients in the randomized group preferred UAE: 115/177 (65%). In the preference group most patients preferred hysterectomy: 100/172 (58%). At 12 months there was no effect of having had the preferred treatment on HRQOL, neither in the randomized nor in the preference group. The randomized group improved significantly in both mental and physical health, compared to baseline. In the preference group, only mental health improved compared to baseline, while physical health did not improve significantly.

Conclusions

In a randomized trial comparing UAE and hysterectomy for symptomatic fibroids, the pre-randomization preference for a specific treatment did not affect HRQOL.Trial participants improved better on physical HRQOL than women who refused to participate.     

Embolización de las arterias uterinas en el tratamiento del mioma uterino sintomático. Resultados en 90 pacientes a los 2 años

Objective

To evaluate the mid-term outcomes and patient satisfaction following UAE in women with symptomatic leiomyomata, as well as to assess safety treatment.

Material and methods

Prospective study of 90 patients from Sabadell Hospital between December 2002 and October 2006.Data were collected using a questionnaire and was later introduced in a specific database. Statistical analysis of data was carried out using SPSS 15.0.All patients went on a 2-year follow-up after UAE, including clinical, laboratory and diagnostic imaging examinations.Symptoms were scored as successful, improvement, unchanged or worsened. Adverse events were noted following the Society of Interventional Radiology's classification. Patients were also asked about their satisfaction.The need of an eventual hysterectomy or the persistence of symptoms was considered to be a treatment failure.

Results

The improvement of symptoms occurred in 90,7% of all the embolized women. We had to perform a second embolization in 4 cases, and a hysterectomy in 6 cases.6 months later, null vascularisation or hypovascularisation of the myoma was observed in 92.8% of women. Over two years, the average volume reduction of the dominant myoma was 76.3%.The rate of major complications was 12.7%. Patient satisfaction for the procedure was 90.2%.

Conclusions

Uterine artery embolization is an effective treatment for women with symptomatic uterine leiomyomata, being well accepted by the patients in the mid-term follow-up.