A. Debby

Role of Sonography in the Diagnosis of Retained Products of Conception

Objective. To present our experience with clinical and sonographic diagnosis of retained products of conception and to evaluate its correlation with histopathologic findings. Methods. This was a retrospective study on 156 patients admitted for retained products of conception. Women were referred because of 1 or more of the following: abdominal pain, bleeding, and fever. The status of the cervix was evaluated by bimanual examination. The diagnosis of retained products of conception was made when a sonographic finding of hyperechoic or hypoechoic material was seen in any part of the uterine cavity or the presence of a thickened endometrial stripe greater than 8 mm and an irregular interface between the endometrium and myometrium was found. One hundred twenty‐one women (77.6%) were admitted after dilation and curettage for abortion, and 35 (22.4%) were admitted after spontaneous labor. Results. Histopathologic reports confirmed the diagnosis of retained products of conception in 86 (71%) of 121 women in the postabortion group and in 17 (48.5%) of 35 women in the postpartum group. The overall false‐positive rate for sonographic diagnosis was 34%. For women after abortion and after delivery, the false‐positive rates were 28.9% and 51.5%, respectively. Conclusions. Reliance on common signs and symptoms to diagnose retained products of conception as well as the use of sonography is associated with an unacceptably high false‐positive rate, mainly after delivery. A more conservative approach to the treatment of retained products of conception is suggested.

Favorable outcome following emergency second trimester cerclage

Background: To evaluate the outcome of midtrimester emergency cerclage with or without bulging of membranes. Methods A retrospective cohort study of 99 women who underwent emergency second trimester cerclage (16–27 gestational weeks). In 75 women the cervix was dilated and effaced but without bulging of membranes (group 1), and in 24 women the dilation and effacement of the cervix were accompanied by bulging of membranes into the vagina in an hourglass formation (group 2). McDonald technique was applied in all patients. Results Prolongation of pregnancy was significantly longer in group 1 compared to group 2 (14.3 ± 6.5 vs 9.3 ± 4.8 weeks, p = 0.007). The mean gestational age at delivery was significantly higher in group 1 compared to group 2 (34.6 ± 4.6 vs 29.5 ± 3.2 weeks, p = 0.001). The incidence of chorioamnionitis was higher in group 2 compared to group 1 but statistically insignificant (25% vs 15%, p = 0.2). The overall neonatal survival was 83% (82 out of 99 neonates), without statistical difference between the two groups (86% in group 1 and 71% in group 2, p = 0.2). Conclusions Favorable neonatal outcome may be accomplished in patients with cervical incompetence in the second trimester of pregnancy following cervical emergency suturing even performed when the membranes are bulging through the cervix into the vagina.

Laparoscopic Surgery for Extrauterine Pregnancy in Hemodynamically Unstable Patients

STUDY OBJECTIVE To assess the feasibility and safety of laparoscopic surgery in treatment of ectopic pregnancy in hemodynamically unstable women. DESIGN Three-year observational study (Canadian Task Force classification II-2). SETTING Tertiary university hospital. PATIENTS One hundred one women with ectopic pregnancy who underwent laparoscopic surgery, 18 with substantial intraabdominal bleeding and with clinical signs and symptoms of hemodynamic instability. INTERVENTION Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS Compared with stable patients, hemodynamically unstable women had significantly more free blood in the abdomen (1244 +/- 590 vs 173 +/- 301 ml, p <0.0001), had significantly lower hemoglobin levels (7.8 +/- 1.4 vs 11.9 +/-1.4 g%, p <0.0001), and required significantly more frequent blood transfusions (83% vs 3.6%, p <0.0001). Similarly, their hemodynamic values such as pulse rate and blood pressures were worse. Among these women, 15 (83%) had a tubal pregnancy, 2 had an interstitial pregnancy, and 1 had a tubal abortion. Those with tubal pregnancy who were hemodynamically unstable underwent salpingectomy. Only one required conversion to laparotomy. No major intraoperative or postoperative complications occurred, and all women made a full and uneventful recovery. CONCLUSION Improved anesthesia and cardiovascular monitoring, together with advanced laparoscopic surgical skills and experience, justifies operative laparoscopy for surgical treatment of ectopic pregnancy even in women with hemodynamic instability.

The role of tamoxifen in the treatment of symptomatic uterine leiomyomata — a pilot study

OBJECTIVES To determine the efficacy of tamoxifen in patients with leiomyomata complaining of abdominal pains and vaginal bleeding. STUDY DESIGN Prospective, randomized, double blind study. A total of 10 patients received for 6 months 20 mg tamoxifen daily, and 10 women received placebo. All patients underwent serial pelvic and ultrasound exams and endometrial sampling was performed prior to initiation of treatment. After 5 years, the patients were interviewed again. RESULTS Uterine size was not affected by the use of tamoxifen. Patients reported a blood loss decrease of 40--50% at the end of the study (P=0.0001). In the control group a slight increase in blood loss was reported. Hemoglobin levels remained unchanged in both groups. In the study group patients reported after 4 months of treatment a substantial decrease in the intensity of pain (P=0.018). Seven patients in the study group and one patient in the control group developed ovarian cysts. CONCLUSIONS Treatment with tamoxifen added only marginal benefit while causing unacceptable side effects. Tamoxifen does not seem to be a useful adjunct in the treatment of symptomatic uterine leiomyomata and its use for this indication should be discouraged.

The optimal cutoff serum level of human chorionic gonadotropin for efficacy of methotrexate treatment in women with extrauterine pregnancy

To evaluate the efficacy of methotrexate treatment for extrauterine pregnancy and define criteria for prediction of success.

Fertility outcome following combined methotrexate treatment of unruptured extrauterine pregnancy

Objective To assess the effectiveness of systemic treatment with methotrexate in combination with local injection for unruptured tubal pregnancy, and to evaluate reproductive function following treatment.

The Minilaparoscope as a Tool for Localization and Preparation for Cannula Insertion in Patients with Multiple Previous Abdominal Incisions or Umbilical Hernia

STUDY OBJECTIVE To access a method that attempts to reduce the risk of bowel and blood vessel trauma in entry-risk patients during laparoscopy. DESIGN Three-year observational study (Canadian Task Force classification II-2). SETTING Tertiary university hospital. PATIENTS Thirty-one women defined as entry-risk due to previous multiple abdominal surgeries or repair of umbilical hernia. INTERVENTION Laparoscopy performed with a 2 mm minilaparoscope inserted at Palmers point, a midclavicular position under the lower left rib. MEASUREMENTS AND MAIN RESULTS In most cases the minilaparoscope was used to inspect the anterior abdominal wall for adhesions. When a location free from adhesions was seen or created by adhesiolysis, the 5- or 10-mm cannula was inserted, followed by the laparoscope. Periumbilical adhesions were more common after previous longitudinal incisions. There were no complications. CONCLUSIONS Minilaparoscopy is safe and effective for identifying and preparing a proper cannula insertion point. This may be useful for avoiding bowel or other cannula-related trauma in women at high risk for such a complication.

Sonographic characteristics of the uterine cavity following first‐trimester uterine evacuation

To characterize the sonographic appearance of the uterine cavity after first‐trimester uterine evacuation and to follow the evolution of these findings in an attempt to reduce the number of unnecessary surgical interventions following evacuation.

Methotrexate versus hyperosomolar glucose in the treatment of extrauterine pregnancy

Abstract The aim of this prospective, randomized, double blind study was to compare the efficacy of methotrexate and hyperosmolar glucose injected directly into the extra-uterine gestational sac under laparoscopic vision. The study included twenty women with ectopic pregnancy. Inclusion criteria were intact tubal pregnancy, not exceeding 4 cm in diameter, rising or plateauing βhCG levels, and no evidence of intra-abdominal bleeding. The patients were treated by laparoscopically guided injection of 3 mL fluid into the area containing the tubal pregnancy. The fluid contained either 25 mg methotrexate (n=9) or 50% glucose (n=9). Daily decrease in βhCG levels was faster in patients treated by methotrexate (median 8.7%) than in those treated by hyperosmolar glucose (median 4.8%), p=0.17. The study was discontinued due to a higher failure rate in the group treated by hyperosmolar glucose. In conclusion, local injection of methotrexate is superior to hyperosmolar glucose. It can be used as an alternative to salpingostomy or salpingotomy whenever laparoscopy is performed for the diagnosis and treatment of extra-uterine pregnancy.

Postoperative analgesia with tramadol and indomethacin for diagnostic curettage and early termination of pregnancy

BACKGROUND The postoperative analgesic effects of rectal indomethacin and tramadol were compared in patients undergoing elective termination of first trimester pregnancy and diagnostic dilatation and curettage. METHODS Eighty-one American Society of Anesthesiologists class I and II women undergoing first trimester termination of pregnancy or diagnostic dilation and curettage were randomly allocated to receive rectal suppositories of either tramadol 100 mg (n=41) or indomethacin 100 mg (n=40) 90 min before induction of anesthesia. Pain scores and side effects were evaluated until discharge. Intraoperative anesthetic and postoperative analgesic consumption was also recorded. Intravenous metamizole 1 g was employed for postoperative rescue analgesia. RESULTS When compared to the indomethacin group, the tramadol group required less intraoperative propofol [136 mg ±28 vs. 160 mg ±35 (P=0.001)], less rescue analgesia [2.4% vs. 22% (P=0.005)] and lower visual analogue pain scores [2.4 ±8 vs. 23 ±22 (P=0.005)]. The incidence of postoperative nausea and vomiting was similar in both groups. CONCLUSION When compared to indomethacin 100 mg, preoperative administration of tramadol 100 mg provides superior postoperative analgesia with minimal adverse effects.