M. Levie

Paracervical Block Efficacy in Office Hysteroscopic Sterilization: A Randomized Controlled Trial

OBJECTIVE: To estimate the efficacy of paracervical block compared with saline for pain relief during office hysteroscopic sterilization. METHODS: This study was a randomized, placebo-controlled study of women desiring hysteroscopic sterilization. A paracervical block of 1% lidocaine or normal saline was administered before office hysteroscopic sterilization. Patients and investigators were blinded to assignments. A pre hoc power analysis determined that 40 women would be required per arm to detect a difference of 0.9 cm on a visual analog scale. Pain was recorded on a visual analog scale at multiple procedure time points. Individualized standardized pain scores were constructed by weighted reporting of objective and subjective sensation. RESULTS: A total of 103 consecutive women were eligible, and 80 women were randomized, with 40 per group. Thirty-seven (93%) in each group had successful placement. The lidocaine group showed significantly lower pain scores for tenaculum placement (mean±standard deviation: 0.97±1.28 compared with 3.00±2.41, P<.001) traversing the external cervical os (1.46±1.71 compared with 3.77±2.68, P<.001) and internal os (1.79±2.11 compared with 4.10±2.77, P<.001). There was no significant observed difference with device placement in tubal ostium (3.15±2.69 compared with 3.74±2.73, P=.33). Multivariable linear regression analysis demonstrated a relationship of pain to procedural time (P=.047) and to group assignment (P<.01). CONCLUSION: Paracervical block with 1% lidocaine provides effective pain relief for cervical manipulations during office hysteroscopic sterilization, but does not reduce the pain associated with upper uterine/tubal manipulation when placing the devices. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00811187. LEVEL OF EVIDENCE: I

Analysis of pain and satisfaction with office-based hysteroscopic sterilization

OBJECTIVE To assess pain and patient satisfaction with office-based hysteroscopic sterilization. DESIGN This prospective, observational study was designed to assess patient pain perception and satisfaction with office-based hysteroscopic sterilization using the Essure device (Conceptus, Mountain View, CA). SETTING Faculty practice office at an inner-city urban medical center. PATIENT(S) Women seeking hysteroscopic sterilization. INTERVENTION(S) Office hysteroscopic sterilization under local anesthesia. MAIN OUTCOME MEASURE(S) Pain assessed at the time of the procedure by a 0-10 visual scale and satisfaction by a 1-5 scale. RESULT(S) From June 2003 to June 2006, 209 patients were recruited. The mean scores for average procedural pain, most procedural pain, and average menstrual pain were 2.6+/-2.1, 3.3+/-2.5, and 3.6+/-2.6, respectively. Standardized pain scores revealed that 149 subjects (70%) experienced average pain that was less than or equal to the pain experienced with their menses. Mean satisfaction rating for the procedure was 4.7+/-0.71. CONCLUSION(S) Office-based hysteroscopic sterilization performed with local anesthesia alone is well tolerated, and patients are satisfied with this method for permanent sterilization.

The myomatous erythrocytosis syndrome: A review

Objective To review the literature regarding the association of erythrocytosis and uterine myomas, because of the lack of anemia in many women with menorrhagia and fibroids. Data Sources We searched the MEDLINE English-language data base and reference lists to find articles referring to the myomatous erythrocytosis syndrome. Methods of Study Selection All case reports of the myomatous erythrocytosis syndrome were included in this review. Data Extraction and Synthesis Symptoms, laboratory studies, histopathologic findings, and possible etiologies for each of 31 cases were extracted. The symptoms described were most commonly related to the presence of a myomatous uterus with occasional manifestations of erythrocytosis. A routine complete blood count was used to diagnose erythrocytosis in all cases. Evaluation of the bone marrow, blood volume, erythrocyte life span, and erythropoietin activity have all been used to help confirm the diagnosis. The histopathologic findings were similar to those commonly seen in myomas. Possible factors in the etiology of this syndrome include: vascular shunts within the myoma, large uterine size, myoma site, change in red cell life span, alteration in erythropoietin production by the kidney, and autonomous secretion of erythropoietin or an erythropoietin-like substrate by the myomatous uterus. Conclusion Elevated levels of erythropoietin accompany the myomatous erythrocytosis syndrome. All myomas may alter erythropoietin production, causing varying degrees of erythrocytosis, which could explain the lack of anticipated anemia despite the presence of menorrhagia. Use of the currently available, highly sensitive radioimmunoassay for erythropoietin should help in our understanding of the role uterine myomas play in erythropoiesis.

Efficacy of a novel educational curriculum using a simulation laboratory on resident performance of hysteroscopic sterilization.

OBJECTIVE To assess whether a novel educational curriculum using a simulation teaching laboratory improves resident knowledge, comfort with, and surgical performance of hysteroscopic sterilization. DESIGN An educational prospective, pretest/posttest study. SETTING The Montefiore Institute of Minimally Invasive Surgery Laboratory. PATIENT(S)/SUBJECT(S): Thirty-four OB/GYN residents in an academic medical center. INTERVENTION(S) Hysteroscopic sterilization simulation laboratory and a brief didactic lecture. MAIN OUTCOME MEASURE(S) Differences in scores on validated skill assessment tools: Task specific checklist, Global Rating Scale (GRS), pass fail assessment, and a multiple-choice examination to evaluate knowledge and attitude. RESULT(S) In the entire cohort improvements were observed on all evaluation tools after the simulation laboratory, with 31% points (SD+/-11.5, 95% confidence interval [CI] 27.3-35.3) higher score on the written evaluation; 63% points (SD+/-15.7, 95% CI 57.8-68.8) higher score on the task specific checklist; and 54% points (SD+/-13.6, 95% CI 48.8-58.3) higher score on the GRS. Higher PGY status was correlated with better pretest performance, but was not statistically significant in posttest scores. Residents reported an improvement in comfort performing the procedure after the laboratory. CONCLUSION(S) Simulation laboratory teaching significantly improved resident knowledge, comfort level, and technical skill performance of hysteroscopic sterilization.

Group a streptococcus causing necrotizing fasciitis and toxic shock syndrome after medical termination of pregnancy

BACKGROUND: Group A Streptococcus is an aerobic gram-positive bacteria known to cause cutaneous infections. Invasive infections can lead to toxic shock syndrome with multiorgan failure and mortality rates of 25–48%. CASE: A healthy, young woman developed necrotizing fasciitis, myonecrosis, and toxic shock syndrome after an elective medical termination of pregnancy. This patient had confirmed group A Streptococcus on blood cultures and underwent surgical debridement. After aggressive surgical treatment, below–the-knee amputation, and antibiotic therapy, the patient survived. CONCLUSION: This case demonstrates the need for prompt recognition and treatment of necrotizing fasciitis/toxic shock syndrome.

Review of Vasopressin Use in Gynecologic Surgery

Vasopressin has been used in gynecologic surgery since the 1950s. Since its initial introduction, multiple applications of vasopressin have been explored. The expansion of vasopressin usage in gynecologic surgery is being fueled in part by the increase in minimally invasive surgical techniques, in which alternative methods of temporary hemostasis are in high demand. Nevertheless, much criticism has been directed toward use of vasopressin because of reports of serious complications including cardiac arrest. These concerns have caused several countries to restrict or prohibit the use of this valuable drug. This review explores the mechanisms of vasopressin, the current literature on vasopressin use in gynecologic surgery, and evaluates the reported complications associated with vasopressin use.

Cervical intraepithelial neoplasia: an overview of diagnosis and management.

The incidence of cervical cancer has decreased markedly in developed countries because of the early detection and treatment of cervical intraepithelial neoplasia (CIN). Cervical cancer has dropped from the second most common malignancy in the UK and the United States to the sixth (1). More than fifty million Papanicolaou (Pap) smears are performed annually in the United States and about 5% are abnormal (2). Screening cytology allows for the detection of preinvasive disease. An abnormal screen should prompt further evaluation by colposcopy with directed biopsies, endocervical curettage (ECC), and cone biopsy where appropriate. Once a diagnosis of CIN has been established, several treatment options are available. Recent studies show that the treatment of CIN has reduced the risk of invasive cervical cancer by 95% for at least 8 years and probably longer (3). While we continue to make great strides in decreasing cervical cancer, The American Cancer Society still estimates that 12,900 women in the United States will be diagnosed with cervical cancer and 4400 women will die as a result of their disease this year (4). The criteria for histological grading of CIN, its natural history and epidemiology, and the diagnosis of CIN as well as the management options and appropriate followup will be discussed.

Factors Predicting the Success Rate of a Single Dose of Systemic Methotrexate for the Treatment of Ectopic Pregnancy.

Withdrawn

Abstract 3730: Feasibility of office hysteroscopy for evaluation of women with postmenopausal bleeding and association with improved pathological diagnosis

Objectives: Endometrial sampling is critical in the evaluation of women for cancers of the uterine corpus. Hysteroscopy in the operating room is associated with monetary and time expense to the patient and health care system. The purpose of this study was to compare histopathological diagnoses of endometrial biopsies obtained by office hysteroscopy (OH) versus endometrial pipelle (EP). Methods: After IRB approval, records of all women with ICD-9 diagnosis (627.1) for postmenopausal bleeding who had OH attempted in the last 5 years at a single medical institution were evaluated. Demographic data collected included age, BMI, medical comorbidities, and histopathologic diagnosis. “Inadequate tissue” for pathologic evaluation was defined as stated in the pathology report or absence of endometrial tissue on biopsy specimen. Statistical analysis was performed using chi-square and Fisher9s exact testing with SPSS software. Results: 85 OHs were attempted and 50 had prior attempted EPs. 98% of OHs and 94% of EPs were successfully performed. However, adequate pathology was obtained in 93% of OHs verses 38% of EPs (p Conclusions: OH is a feasible procedure that may enhance clinicians’ ability to diagnose benign, pre-malignant and malignant causes of post-menopausal bleeding. Further research is needed to understand the association of cost and quality of life with OH versus hysteroscopy in the operating room. Citation Format: Jacquelyn M. Shaw, Sukrant Mehta, Scott Chudnoff, Mark Levie, Mark H. Einstein, Gary L. Goldberg, Nicole S. Nevadunsky. Feasibility of office hysteroscopy for evaluation of women with postmenopausal bleeding and association with improved pathological diagnosis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3730. doi:10.1158/1538-7445.AM2015-3730