J Hebert

The Effect of the 39-Week Initiative on Intrauterine Demise: One Hospital's Experience [254].

INTRODUCTION: Published studies have shown mixed results regarding the risks of intrauterine fetal demise after implementation of guidelines for reduction of nonmedically indicated deliveries before 39 weeks of gestation. Our objective was to describe the variation in rates of intrauterine fetal demise in a high-risk patient population after implementation of guidelines eliminating nonmedically indicated deliveries before 39 weeks of gestation. METHOD: This was a retrospective chart review of patients with intrauterine fetal demise delivering at or beyond 20 weeks of gestation or birth weight 350 g or more when the gestational age was unknown between March 4, 2012, and July 31, 2014, at Hurley Medical Center in Flint, Michigan. RESULTS: A total of 6,561 deliveries were performed during the study period. Group 1: 2,846 deliveries before implementation of the guidelines with 16 cases of intrauterine fetal demise. Group 2: 3,715 deliveries after the guidelines with 29 cases of intrauterine fetal demise. Despite a small sample size, the most concerning observation is that the rate of intrauterine fetal demise between 37 and 39 weeks of gestation increased from 0.35 to 1.35 per 1,000 births after implementation of the guidelines. CONCLUSION: In our institute, the rate of stillbirth has increased since implementation of and strict adherence to guidelines for the elimination of elective induction of labor or cesarean delivery before 39 weeks of gestation were instituted. This is a disturbing trend that needs further evaluation, especially in medical centers caring for a high-risk pool of patients for whom all medical indications are not covered by the lists of approved indications.

Pediatric Foley Catheter Placement After Operative Hysteroscopy Does Not Cause Ascending Infection

STUDY OBJECTIVE To determine the incidence of postoperative ascending infection without antibiotics with the use of a pediatric Foley catheter (PFC) after operative hysteroscopy for intrauterine pathology. DESIGN Retrospective case series (Canadian Task Force classification III). SETTING University-affiliated outpatient medical center. PATIENTS Patients who underwent operative hysteroscopy for uterine septum, arcuate uterine anomaly, or multiple submucosal myomas between 1992 and 2015. INTERVENTIONS In all patients, a PFC was placed in the endometrial cavity at the conclusion of operative hysteroscopy and left in place for 7 days to reduce intrauterine adhesion formation. MEASUREMENTS AND MAIN RESULTS A total of 1010 patients who underwent operative hysteroscopy for uterine septum (n = 479), arcuate uterine anomaly (n = 483), or multiple submucosal myomas (n = 48) were studied. All patients presented with infertility, recurrent pregnancy loss, or excessive uterine bleeding (in patients with submucous myomas). In all patients, a PFC was placed at the conclusion of the procedure and left in place for 7 days. An 8Fr PFC was used after hysteroscopic division of uterine septum or arcuate uterine anomaly, and a 10Fr PFC was used after hysteroscopic myomectomy. Patients with a history of pelvic inflammatory disease were excluded. Following PFC placement, patients were prescribed estrogen for 6 weeks and progestogen for the last 10 days of the estrogen course. No prophylactic antibiotic therapy was provided. All patients were discharged to home on the same day. Postoperative pain was well controlled with oral pain medication in 98.5% of the patients. There were no reported postoperative infections, and all patients had an uneventful recovery. CONCLUSION In 1010 consecutive operative hysteroscopies followed by temporary (7-day) PFC placement, no clinically significant uterine infection was observed.

Safety and Efficacy of Two Techniques of Temporary Ovarian Suspension to the Anterior Abdominal Wall after Operative Laparoscopy

Background This retrospective study compares the safety and efficacy of temporary ovarian suspension (TOS) to the anterior abdominal wall using absorbable versus non-absorbable suture after operative laparoscopy to elevate the ovaries away from the ovarian fossa to reduce postoperative adhesion development. Methods Patients (n=152) underwent TOS to the anterior abdominal wall at the conclusion of surgery between 1998 and 2017. One hundred forty-two patients underwent operative laparoscopy for advanced stages of endometriosis (93.4%) and 10 patients for other indications (6.6%). In 78 patients the ovaries were suspended to the fascia using absorbable 3-0 plain catgut sutures (Group 1). In 74 earlier patients non-absorbable 3-0 mono-lamentous nylon was used to suspend the ovaries to the anterior abdominal (Group 2). Results In both groups there was no reported incidence of any major intra-operative complications such as bleeding, or late complications such as infection, hematoma or bowel herniation through the suture loop and its sequalae (bowel obstruction or strangulation). In all patients in both groups the ovaries were present in its anatomical location on transvaginal ultrasound scan, one week after surgery following absorption or removal of the TOS suture. There was no significant difference in clinical pregnancy (34.3% vs 44.2%) and delivery (31.3% vs 36.5%) rates in patients who conceived with non-IVF methods between Group 1 and Group 2 respectively. Conclusions TOS to the anterior abdominal wall, using absorbable or non-absorbable sutures, in an attempt to reduce postoperative adhesion development between the ovary and ovarian fossa, is simple, safe, easy to learn, and has potential effectiveness.

Placental Location and Reproductive Outcome in Patients With Uterine Septum or Arcuate Uterus [19G]

INTRODUCTION: The aim of this study is to determine placental location in pregnancy that ended in a live birth in patients with known uterine septum or arcuate uterine anomaly. METHODS: This retrospective study included sixty-seven patients who had a live birth and a diagnosis of uterine septum or arcuate uterine anomaly based on trans-vaginal 3D ultrasound scan (TV 3D US) with or without saline infusion sonohysterogram (SIH) between 2005 and 2015. Thirty patients (44.8%) presented with secondary infertility, 6 patients (9%) presented with recurrent pregnancy loss (RPL), 3 patients (4.5%) presented with history of miscarriage, and 28 (41.8%) presented with secondary infertility and miscarriage or RPL. RESULTS: Mean age was 32.4±4.3 years. Mean gestational age was 37.1±3.9 weeks. Placental location was not on the septum in 57 patients (85.1%); placental location was anterior in 29 patients (43.3%), posterior in 25 patients (37.3%), and lateral in 3 patients (4.5%). Eight patients (11.9%) had partial fundal location (fundal anterior in 6 patients [75%], and fundal posterior in 2 patients [25%]). Placental location was fundal in 2 patients (3%). In one of these patients the septum was found to be very vascular during hysteroscopy; the patient experienced vaginal bleeding through the pregnancy and delivered at 28 weeks. CONCLUSION: Our data support the long held theory that placental location in relation to uterine septum or arcuate uterine anomaly influence reproductive outcomes. Also, our data may explain the variable reproductive outcome of patients with such anomalies in the literature.

Reproductive Outcome in Patients With Uterine Septum or Arcuate Uterus and a Previous Live Birth [28E]

INTRODUCTION: Patients with known uterine septum or arcuate uterine anomaly who had a successful live birth with placental location not on the septum and subsequently present with reproductive failure pose a difficult management decision. The aim of this study is to compare pregnancy outcomes in patients who had hysteroscopic correction of the uterine anomaly to those who did not in such group of patients. METHODS: This retrospective study included 67 patients who had a live birth and a diagnosis of uterine septum (complete [2.4%], incomplete [61.9%]), or arcuate uterine anomaly (35.7%), between 2005 and 2015. Subsequently 30 patients (44.8%) presented with secondary infertility, 6 patients (9%) presented with recurrent pregnancy loss (RPL), 3 patients (4.5%) presented with history of miscarriage, and 28 (41.8%) presented with secondary infertility and miscarriage or RPL. Forty-eight patients (71.6%) underwent hysteroscopic correction and 19 patients (28.4%) elected not to have surgery. RESULTS: Mean age was 32.4+4.3 years. Mean gestational age was 37.1+3.9 weeks. Of the 48 patients who underwent hysteroscopic correction, 34 conceived (70.8%). Of those, 31 delivered/ongoing (64.6%), and 3 miscarried (8.8%). Of the 19 patients who elected not to have surgery, 1 patient conceived (5.3%), and her pregnancy is ongoing (P<.001). CONCLUSION: Hysteroscopic correction of uterine septum or arcuate uterine anomaly significantly improves reproductive outcomes in patients who present with reproductive failure even after a previous successful live birth.

Should Prophylactic Anticoagulation Be Considered with Large Uterine Leiomyoma? A Case Series and Literature Review

Introduction. Uterine leiomyomas, also called uterine fibroids or myomas, are the most common pelvic tumors in women. They are very rarely the cause of acute complications. However, when complications occur they cause significant morbidity and mortality. Thromboembolic disease has been described as a rare complication of uterine leiomyomas. DVT is a serious illness, sometimes causing death due to acute PE. Cases. We report a case series of 3 patients with thromboembolic disease associated with uterine leiomyoma at Hurley Medical Center, Flint, Michigan, during 2015 and conduct a literature review on the topic. A literature search was conducted using Medline, PubMed, and PMC databases from 1966 to 2015. Conclusion. The uterine leiomyoma is a very rare cause of PE and only few cases have been reported. DVT secondary to uterine leiomyoma should be considered in a female presenting with abdominal mass and pelvic pressure, if there is no clear common cause for her symptoms. Thromboembolic disease secondary to large uterine leiomyoma should be treated with acute stabilization and then hysterectomy. Prophylactic anticoagulation would be beneficial for lowering the risk of VTE in patients with large uterine leiomyoma.

Successful Management of Infertile Patient with Trans-Fundal Uterine Membrane

Background: This case report describes an infertile patient with a rare endometrial cavity pathology diagnosed on hysteroscopy. Case: The patient was a 39-year-old female with primary infertility of 9 years’ duration. A diagnosis of a possible T-shaped uterus on a previous hysterosalpingogram was not confirmed on diagnostic hysteroscopy 5 years earlier at a different infertility center, where she had undergone a cycle of in-vitro fertilization with embryo transfer (IVF-ET) but was unable to conceive. At the time of diagnostic hysteroscopy at the current, unit the patient was found to have a T-shaped cavity and a trans-fundal uterine membrane obscuring an arcuate fundus. Hysteroscopic division of this thin membrane was performed successfully, followed by hysteroscopic division of the uterine septum and hysteroscopic metroplasty of her T-shaped uterus. Results: Subsequently, the patient conceived with IVF-ET but had an early miscarriage. A second IVF-ET cycle resulted in resulted in delivery of a healthy male infant at term. Conclusions: This report described a case of an infertile patient with a trans-fundal membrane in association with a uterine anomaly. The discovery of such a membrane and the uterine anomaly described above, and their hysteroscopic surgical correction, may have contributed to the successful reproductive outcome for this patient. ( J GYNECOL SURG 29:88)