Ayman Al-Talib

Pathophysiology and possible iatrogenic cause of leiomyomatosis peritonealis disseminata.

We present a case of leiomyomatosis peritonealis disseminata (LPD) after myoma morcellation and review the literature using the keywords leiomyomatosis peritonealis disseminata and disseminated peritoneal leiomyomatosis. The search was conducted in Medline, EMBASE, and Cochrane Database of systematic reviews. We encountered 132 cases of LPD in the English literature; 113 in the reproductive age group, 7 in postmenopausal women, 6 in males, and another in a horse. The possible causes could be divided into hormonal, subperitoneal mesenchymal stem cells, metaplasia, genetic, or iatrogenic after morcellation of myoma during laparoscopic surgery. Our case and 4 others reported in the literature support the contribution of the iatrogenic theory. It appears that LPD could be due to metaplasia of mesenchymal cells of the peritoneum and, in susceptible women, leaving fragments of myoma in the abdominal cavity might contribute to the development of LPD. Accordingly, one should avoid leaving fragments of the uterus or myoma tissue in the abdominal cavity after morcellation.

Effects of excision of ovarian endometrioma on the antral follicle count and collected oocytes for in vitro fertilization

We compared the response of operated and nonoperated ovaries to gonadotropin stimulation in 38 women who had had excision of ovarian endometrioma. The antral follicle count, numbers of dominant follicles, and number of oocytes collected in the operated ovaries were significantly lower than in the nonoperated ovaries suggesting reduced ovarian reserve after excision of ovarian endometrioma.

Predisposing Factors and Treatment Outcome of Different Stages of Intrauterine Adhesions

OBJECTIVE To evaluate the predisposing factors and treatment outcomes of different stages of intrauterine adhesions. METHODS We examined the medical records of women with Asherman syndrome seen during the period of January 2000 to December 2007 at two McGill University teaching hospitals in Montreal. Data retrieved included patients age, menstrual pattern, fertility, factors related to intrauterine adhesions, and rates of amenorrhea and pregnancy at 12-month follow-up. The diagnosis was established by hysteroscopic examination. After confirmation of the diagnosis, the intrauterine adhesions were removed using a standard technique with a loop electrode and glycine 1.5% as distension medium. In cases with severe intrauterine adhesions, abdominal ultrasound was used to ensure that the uterine cavity was not breached. At the completion of each procedure a number 16 Foley catheter with 5 mL of normal saline in the bulb was placed in the uterine cavity and removed five days later. In addition, vaginal estradiol 17 beta was administered three times daily for four weeks with oral progesterone administered in the fourth week of estradiol treatment. RESULTS Of 65 patients, we identified 24 with stage I intrauterine adhesions (36.9%), 30 with stage II (46.2%), and 11 with stage III (16.9%). The main reasons for referral were infertility (stage I 75%, stage II 73.3%, stage III 27.3%), and amenorrhea (stage I 25%, stage II 23.3%, stage III 72.7%). The main predisposing factor was dilatation and curettage. Of 40 patients with intrauterine adhesions related to early pregnancy curettage, 18 patients (45%) had stage I adhesions, 17 (42.5%) had stage II, and five (12.5%) had stage III. This contrasted with 10 patients who had peripartum curettage, in whom six (60%) developed stage III adhesions (P = 0.004). The rate of amenorrhea was 32.3% before adhesiolysis and 9.2% after. Among 43 women who wished to conceive, the pregnancy rate was 51.2% and the live birth rate 32.6%. CONCLUSION The main reasons for referral of women with intrauterine adhesions are infertility and amenorrhea. Postpartum curettage leads to severe adhesions. The rates of pregnancy and term pregnancy among this selected group of women were similar regardless of the severity of adhesions.

Clinical presentation and treatment outcome of molar pregnancy: Ten years experience at a Tertiary Care Hospital in Dammam, Saudi Arabia.

Objectives: To study the clinical presentation and treatment outcome of molar pregnancy at a Tertiary Care Hospital in Dammam, Saudi Arabia. Materials and Methods: Reviewed medical records of all molar pregnancy cases among all the deliveries at a tertiary care hospital in Dammam from 2005 to 2014, after approval by institutional ethical review committee. Data abstracted included patient′s age, parity, presenting symptoms, gestational age at diagnosis, uterine size, ultrasonographic findings, BhCG level at the time of diagnosis and at follow-up after evacuation, and blood loss during evacuation. Data was entered and analyzed using Excel; frequency distribution for categorical variables and descriptive statistics for continuous variables were computed. Results: Of a total of 25,000 deliveries in ten years, 22 cases of complete molar pregnancy were encountered: 0.9 cases of molar pregnancy per 1000 pregnancies. Majority of patients (63.7%) were older than 35 years, and were nulliparous (45.5%). The commonest symptom was vaginal bleeding (86.4%) followed by hyperemesis gravidarum (41.0%); Hyperthyroidism was seen in 1 patient (4.5%). Ovarian enlargement by theca-lutin cyst was seen in 3 patients (13.6%). The majority of patients (63.6%) had normal BhCG within 9 weeks (63 days) after suction curettage. The majority of the cases followed a benign course. Conclusion: Aged older than 35 years seems a risk factor and vaginal bleeding is the commonest presenting symptom. Early booking of pregnant women to antenatal care clinics and routine first trimester ultrasound made diagnosis easier and earlier before complications appear.

Contents Vol. 69, 2010

M.A. Belfort, Provo, Utah J. Bornstein, Nahariya H.L. Brown, Durham, N.C. C. Chapron, Paris J. de Haan, Maastricht G.A. Dekker, Adelaide J.A. Deprest, Leuven K. Hecher, Hamburg S. Kahhale, São Paulo H. Kliman, New Haven, Conn. T.F. Kruger, Tygerberg J.A. Kuller, Raleigh, N.C. M.J. Kupferminc, Tel Aviv H. Minkoff , Brooklyn, N.Y. J. Moodley, Congella J.M. Mwenda, Nairobi H. Odendaal, Tygerberg J.T. Repke, Hershey, Pa. Founded 1895 as ‘Monatsschrift für Geburtshilfe und Gynäkologie’, continued 1946–1969 as ‘Gynaecologia’ and 1970–1977 as ‘Gynecologic Investigation’

Morbidity with total laparoscopic and laparoscopically assisted vaginal hysterectomy

We evaluated the operative and postoperative morbidity among 103 women who underwent total laparoscopic hysterectomy and 107 others who underwent laparoscopically assisted vaginal hysterectomy. Blood loss was significantly greater in the assisted vaginal hysterectomy group (178.0 ± 12.1 ml) than in the total hysterectomy group (130.2 ± 10.7 ml) (p < 0.001). Despite higher uterine weight in the total hysterectomy group, the operative time of both techniques was similar. The complications of both hysterectomies were also comparable. The results from our study suggest that the complication rates of laparoscopically assisted vaginal hysterectomy and total hysterectomy are similar. However, laparoscopically assisted vaginal hysterectomy is associated with increased blood loss.