Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation.

OBJECTIVE: To demonstrate the unique use of Endoloop during laparoscopic removal of an exophytic interstitial ectopic pregnancy to ensure hemostasis, provide counter traction against a uterine manipulator, and reduce the likelihood of entry into the endometrium. DESIGN: Case report with intraoperative surgical footage. SETTING: Tertiary care referral center operating room. PATIENT(S): Single patient case report. INTERVENTION(S): A single patient with an ectopic pregnancy suspected using ultrasound and confirmed during surgery. MAIN OUTCOME MEASURE(S): Laparoscopic removal of the interstitial ectopic pregnancy via a wedge resection cornuectomy without endometrial involvement using a monopolar hook, Endoloop, and a William's cystoscopic needle for the injection of vasopressin. RESULT(S): The patient was a 32-year-old G7P1051 with a history of a left tubal ectopic pregnancy status post a laparoscopic left salpingectomy, 1 full-term vaginal delivery, 2 elective terminations, 2 early pregnancy losses, smoking (1 pack per day), and marijuana use (6 blunts per day). She initially presented in November 2020 with intermittent but worsening left lower quadrant abdominal pain and was found to have a left adnexal mass, raising concern for an ectopic pregnancy in the setting of a ß-human chorionic gonadotropin (ß-hCG) level of 6,411 mIU/mL, and no intrauterine pregnancy identified using transvaginal ultrasound. She was counseled on medical vs. surgical management and she elected to receive an injection of methotrexate in the emergency department (ED) before discharge with a scheduled follow-up visit at the clinic for standard ß-hCG trends. The patient did not attend her scheduled day 4 and 7 visits for ß-hCG levels or her 2-week appointment for ultrasound; so, she was called over the phone and asked to come to the ED as soon as possible for evaluation. Approximately 3 weeks after the injection of methotrexate, the patient was still experiencing intermittent left lower quadrant abdominal pain. A repeat ultrasound in the ED showed no intrauterine gestational sac, an endometrial thickness of 0.6 cm, a normal right ovary, a normal left ovary with a corpus luteum cyst, a small amount of free fluid in the cul-de-sac, and a left adnexal extraovarian complex cystic structure measuring 2.9 × 2.4 cm with a fetal pole. The fetal pole corresponded with a gestation period of 6 weeks and 3 days, based on a crown-rump length of 0.59 cm, and lacked cardiac activity. The ß-hCG level at this time was 1,124 mIU/mL, and the patient strongly desired surgical management for her ongoing abdominal pain and unresolved ectopic pregnancy. The patient's vital signs and complete blood count were within normal limits. The patient desired future fertility. A repeat transvaginal ultrasound before surgery showed the extraovarian nature of the ectopic pregnancy but could not specify whether it was intrauterine or intra-abdominal in the left adnexa; so, the decision was made to proceed with a diagnostic laparoscopy. After laparoscopic entry through Palmer's point using the Veress needle and then insertion of a 5-mm trocar under direct visualization, the left exophytic interstitial ectopic pregnancy was discovered, as depicted in the video. Given the patient's desire for future fertility, a wedge resection cornuectomy without the involvement of the endometrium was the ideal surgical approach. Subsequent trocar placement consisted of a 10-mm trocar in the umbilicus and a 5-mm trocar in the left lower quadrant. The Endoloop was initially inserted into the umbilical 10-mm trocar to allow for placement around the interstitial ectopic pregnancy to achieve hemostasis and act as a tourniquet. The Endoloop suture was passed into the abdomen and then pulled laterally using an atraumatic grasper through the left lower quadrant trocar to provide counter traction against a uterine manipulator that was deviating the uterus to the patient's right side. This created an excellent plane for dissection along the myometrial base of the interstitial pregnancy to prevent the removal of excess uterine tissue and decrease the likelihood of entry into the endometrial cavity. Injection of 4 units vasopressin (20u in 50 mL of normal saline) using a William's cystoscopy catheter through the umbilical port further ensured hemostasis along the base of the ectopic pregnancy during removal using a monopolar hook. The cystoscopy catheter was chosen for its length and flexible body to maximize maneuverability. Electrocautery was used as needed for hemostasis. After the removal of the ectopic pregnancy using the monopolar hook, the myometrium and serosa were reapproximated in a running 2-layered fashion using a V-Loc suture. The ectopic pregnancy was removed from the abdomen in a specimen retrieval bag through the 10-mm umbilical port. The 10-mm port was closed using a standard fascial closure device and then the skin of all the port sites was reapproximated using 4-0 Monocryl suture. Two important factors that favored this surgical technique over hysterectomy or standard cornuectomy included the patient's strong desire for future fertility and the exophytic nature of the interstitial pregnancy. Nevertheless, as the pregnancy increases in distance from the cornua, so does the likelihood that the pregnancy will be a normal intrauterine pregnancy, which greatly impacts counseling and management if the pregnancy is desired. Postoperative care was routine and the recommendation was made to wait at least 3 months to attempt another pregnancy and to undergo saline-infused sonography for the evaluation of the endometrial cavity; however, the patient never followed up. CONCLUSION(S): This video demonstrates the unique use of Endoloop and vasopressin through a William's cystoscopy injection needle during the laparoscopic removal of an exophytic interstitial ectopic pregnancy. The Endoloop helped to ensure hemostasis, provide counter traction against the uterine manipulator, and optimize visualization to reduce the likelihood of endometrial involvement in a patient who desired future fertility.

Enhanced myometrial vascularity: case presentation and review.

OBJECTIVE: To describe the etiology of arteriovenous malformations (AVM) and enhanced myometrial vascularity (EMV), and review updates in management for patients with retained products of conception (RPOC) associated with EMV through a case presentation. DESIGN: A 6-minute narrated video discusses the recent distinction between EMV and AVM. The etiology, symptoms, imaging findings/interpretation, and management based on symptoms are reviewed in detail. As this represents a single case report, it does not meet the definition of research according to the regulations at 45 CFR 46.102(l); therefore, institutional review board approval was not required. SETTING: Tertiary referral center. PATIENT(S): Eight weeks after suction dilation and curettage (D&C) for an incomplete abortion, a 28-year-old gravida 1, para 0 patient presented to an outside facility with RPOC, menorrhagia, and an acute decrease in hemoglobin. After uterine AVM was diagnosed, she was transferred to our facility for further care. INTERVENTION(S): After transfer to our center, ultrasound demonstrated RPOC, with prominent internal vasculature containing peak systolic velocity >20 cm/s. A diagnosis of EMV was made. Magnetic resonance imaging confirmed a prominent serpentine vessel at the endometrium and RPOC within the uterine cavity (Fig. 1). Due to her anemia, she underwent uterine artery embolization (UAE) followed by suction D&C (Fig. 2). Hysteroscopy was performed before and after suction D&C and after curettage, a large vascular bundle was appreciated at the surface of the endometrium. MAIN OUTCOME MEASURE(S): None. RESULT(S): The patient presented to the clinic 2 weeks postoperatively with the resolution of abnormal uterine bleeding symptoms and a negative ß-human chorionic gonadotropin test. CONCLUSION(S): Management of patients with EMV is dependent on the extent of their symptoms. If significant bleeding is present, surgical management is required. Previous reports suggested that patients with EMV and RPOC should undergo UAE before D&C, but more recent studies suggest that D&C may be initiated without UAE, as EMV associated with RPOC may be a normal transient placentation phenomenon and have less risk of hemorrhage than previously suspected. However, in patients with significant preoperative bleeding and/or anemia, we propose that UAE should still be considered. Each patient requires individualized management based on symptoms, signs, imaging, and plans for future fertility. The ideal management of patients with RPOC and EMV remains to be determined.

Hysteroscopic incision of the incomplete uterine septum using 5-French scissors with marking strategies: a modified hysteroscopic technique.

OBJECTIVE: To demonstrate an easier surgical strategy by using the marking technique for hysteroscopic incision of the uterine septum using 5-French cold scissors. DESIGN: A step-by-step surgical video demonstration. SETTING: Gynecologic department of the affiliated hospital. PATIENT(S): A 33-year-old woman presented with a 4-year history of primary infertility. She previously had undergone transcervical resection of (uterine) septum owing to the presence of a complete uterine septum and double cervices. Postoperative 3-dimensional ultrasound revealed a 1.2-cm residual uterine septum, and the outline of the uterine fundus was flat. A second surgery for resection of the residual septum was recommended before in vitro fertilization and embryo transfer. We used the Campo hysteroscope (4.4-mm outer sheath) and 5-French scissors with our modified marking strategy to incise the incomplete uterine septum. INTERVENTION(S): There were several critical strategies for this approach. After fully exposing 2 fallopian tube ostia, a 3-5-mm mark was made on each side of the uterine fundus where the septum ended, and the marks were parallel to the fallopian tubal ostia. The septum then was incised along the line between the two previously marked points that served as the endpoints. Care was taken to avoid incising myometrial blood vessels during incision, and the 5-French bipolar electrode was used for coagulation when necessary. At the end of the surgery, the distension pressure was gradually decreased to 80 mm Hg to confirm hemostasis of the wound before withdrawing the hysteroscope. MAIN OUTCOME MEASURE(S): Description of a modified hysteroscopic technique. RESULT(S): The overall operation time was 10 minutes, and the estimated blood loss was 5 mL. The residual septum was resected successfully while maintaining optimal hysteroscopic visualization. There were no short-term complications, such as uterine perforation or fluid overload. Hysteroscopic evaluation performed 3 months after surgery revealed that the uterine cavity was nearly normal, with no intrauterine adhesion appreciated. There are several advantages to this innovative and practical hysteroscopic surgical approach. Marking the lateral limits of the uterine septum means that a shorter reference line is obtained to incise the septum effectively rather than using the bilateral ostia as reference points. At the same time, marking the bilateral endpoint of the uterine septum incision at the beginning of the surgery might be helpful when bilateral tubal ostia are invisible because of quick absorption of the distension media, which causes insufficient distention pressure at the end of the surgery. Use of the narrow 5-French scissors allowed for instrumentation without prior cervical dilation. Moreover, with this "see and treat" strategy, a clear visualization of the surgical field was maintained without inserting and withdrawing the hysteroscope. The endometrium sustained minimal damage because of the "cold scissors" technique. CONCLUSION(S): Our hysteroscopic marking strategy allows the surgeon's intraoperative judgment to be efficient and safe during incision of the uterine septum and ensures that the incision is adequate. It is an improved and valid surgical strategy for hysteroscopic incision of the uterine septum.

Obstetrical outcome in the third trimester after hysteroscopic adhesiolysis.

BACKGROUND: Intrauterine adhesion (IUA) is caused by adhesion of the uterine cavity due to the damage of endometrium. Hysteroscopic adhesiolysis (HA) is the main treatment. The objective of the study was to investigate the obstetrical outcome in the third trimester of women who previously underwent HA. METHODS: We performed a retrospective cohort study in the university-affiliated hospital. A total of 146 women with a history of HA who had given birth in their third trimester from May 2012 to May 2019 were enrolled (study group), while 292 women with a negative history of HA were matched for maternal age, gravidity, parity, and delivery year. The parameters of obstetrics and infants were investigated to evaluate the change in the third trimester of women with a history of HA. RESULTS: There was no significant difference between study and control groups in gestational weeks, nor in fetal gender distribution, birth weight, Apgar score, fetal distress, and neonatal intensive care unit (NICU) admissions after delivery (P>0.05). In addition, when compared with the control group, women with a history of HA were at a higher risk of placental risks (P<0.05), such as placenta previa (11.6% versus 3.1%), abnormally invasive placenta (AIP) (33.56% versus 2.7%), and retained placenta (42.5% versus 8.6%). This resulted in a significantly higher postpartum hemorrhage (PPH) rate in the study group as compared with that in the control group (8.9% versus 1.0%, P<0.05). Such cases were more likely to be found in patients with severe IUA compared with those who were assessed as mild and moderate. CONCLUSIONS: The history of HA might be an important risk factor inducing placental problems and PPH in the third trimester. More attention should be paid to the labor of pregnant women with a history of HA.

Transverse, vertical, and anterior-posterior changes between tooth-anchored versus Dresden bone-anchored rapid maxillary expansion 6 months post-expansion: A CBCT randomized controlled clinical trial.

OBJECTIVE: The main aim of this randomized clinical trial was to determine 3 dimensional skeletal and dental changes six months after the use of bone-anchored versus tooth-anchored rapid maxillary expanders in adolescents. The secondary aim was to determine the symmetrical or asymmetrical expansion pattern between both appliances. MATERIALS AND METHODS: Fifty adolescents with skeletally constricted maxilla (mean age 13-14 years) were randomly assigned into: Dresden B-RME, Hyrax T-RME, or untreated control groups. CBCT scans were taken at initial and expander removal (6 months). Three-dimensional references and treatment landmarks were identified. Orthogonal distances were calculated from those landmarks. The main outcome was to compare skeletal and dental changes in each group and the secondary outcome was to verify if these changes were symmetric or not. Data was analysed using descriptive statistics and repeated measure MANCOVA and MANOVA. RESULTS: Both treatment groups showed significant skeletal and dental expansion compared to controls. T-RME group had greater mean inter-molar crown expansion (5.66mm) than the B-RME group (4.17mm). Both T-RME and B-RME groups showed significant skeletal maxillary expansion compared to controls (mean 1.27mm and 1.31mm respectively, both p<0.01), although no significant difference was found between both appliances. B-RME group showed a lower ratio of dental to skeletal expansion than T-RME group. T-RME showed a symmetrical expansion pattern, whereas the B-RME showed an asymmetrical pattern relative to mid-sagittal plane. The extent of molar crown expansion was 1.84mm greater on the TAD-side compared to the Implant-side. T-RME group showed significant anterior movement of the maxillary first premolar and molar (1.5mm, p<0.05), and vertical dental extrusion (1.8mm). No significant dental vertical or anterior-posterior changes were noted in the B-RME group. CONCLUSIONS: T-RME and B-RME produced similar amounts of skeletal expansion. B-RME group produced a lower component of dental expansion. Due to the Dresden B-RME configuration, asymmetrical expansion was noted.

Biochemically engineered stromal cell-derived factor 1-alpha analog increases perfusion in the ischemic hind limb.

BACKGROUND: Despite promising therapeutic innovation over the last decade, peripheral arterial disease remains a prevalent morbidity, as many patients are still challenged with peripheral ischemia. We hypothesized that delivery of engineered stromal cell-derived factor 1-alpha (ESA) in an ischemic hind limb will yield significant improvement in perfusion. METHODS: Male rats underwent right femoral artery ligation, and animals were randomized to receive a 100 µL injection of saline (n = 9) or 6 µg/kg dosage of equal volume of ESA (n = 12) into the ipsilateral quadriceps muscle. Both groups of animals were also given an intraperitoneal injection of 40 µg/kg of granulocyte macrophage colony-stimulating factor (GMCSF). Perfusion was quantified using a laser Doppler imaging device preoperatively, and on postoperative days 0, 7, and 14. Immunohistochemistry was performed to quantify angiogenesis on day 14, and an mRNA profile was evaluated for angiogenic and inflammatory markers. RESULTS: Compared with the saline/GMCSF group at day 14, the ESA/GMCSF-injected animals had greater reperfusion ratios (Saline/GMCSF, 0.600 ± 0.140 vs ESA/GMCSF, 0.900 ± 0.181; group effect P = .006; time effect P < .0001; group×time effect P < .0001), elevated capillary density (10×; Saline/GMCSF, 6.40 ± 2.01 vs ESA/GMCSF, 18.55 ± 5.30; P < .01), and increased mRNA levels of vascular endothelial growth factor-A (Saline/GMCSF [n = 6], 0.298 ± 0.205 vs ESA/GMCSF [n = 8], 0.456 ± 0.139; P = .03). CONCLUSIONS: Delivery of ESA significantly improves perfusion in a rat model of peripheral arterial disease via improved neovasculogenesis, a finding which may prove beneficial in the treatment strategy for this debilitating disease.