Self-inflicted cesarean section with maternal and fetal survival.

An unusual case of self-inflicted cesarean section with maternal and child survival is presented. No similar event was found in an Internet literature search. Because of a lack of medical assistance and a history of fetal death in utero, a 40-year-old multiparous woman unable to deliver herself alone vaginally sliced her abdomen and uterus and delivered her child. She was transferred to a hospital where she underwent repair of the incisions and had to remain hospitalized. Mother and child survived the event. Unusual and extraordinary measures to preserve their offspring sometimes moves women to extreme decisions endangering their own lives. Social, educational, and health measures should be instituted all over the world, particularly in rural areas of developing countries, to avoid such extreme events.

Resectoscopic treatment of complete longitudinal vaginal septum.

Every gynecologist can easily recognize vaginal abnormalities and the subsequent disturbances of sexual function, such as dyspareunia and apareunia, arising from them. In the case of congenital vaginal septum, it is extremely important to completely assess the abnormality before planning for surgical treatment. Because normal vaginal development is subsequent to the canalization and fusion of the two Müllerian ducts once vacuolization has occurred, but not their union, a duplication of different degree will be the consequence. If the defect is complete, a didelphys uterus with a double vagina will result. The aim of our report is to describe the endoscopic technique used to treat three cases of complete longitudinal vaginal septum and to highlight the main differences between our technique and the standard surgical procedure.

Endometriosis: current concepts and therapy.

Endometriosis is the growth of endometrial tissue in ectopic locations. The clinical picture is extremely pleiomorphic, which can make the diagnosis difficult. Despite 70 years of theories and experimentation, the cause is not clear, and it is likely that more than one mechanism is at work in most patients. Both medical and surgical treatments are available. In each case, the woman and her physician should formulate a comprehensive treatment plan that addresses the primary complaint as well as the patient's reproductive desires.

Tissue response to the STOP microcoil transcervical permanent contraceptive device: results from a prehysterectomy study.

OBJECTIVE: The present study examines the safety, effectiveness, and local tissue response for a new transcervical fallopian tube permanent contraceptive device, the STOP device (Conceptus, Inc., San Carlos, CA). DESIGN: Nonrandomized prospective evaluation of tubal occlusion and histologic response. SETTING: Inpatient, university and university-affiliated medical centers in the United States and Mexico. PATIENT(S): Premenopausal and perimenopausal women with benign indications for hysterectomy who were able to defer their hysterectomy for 1 to 13 weeks. INTERVENTION(S): A transcervically placed microcoil (STOP device) was inserted into the fallopian tubes of women who were scheduled for hysterectomy, and the device was worn for 1 to 12 weeks. At hysterectomy, hysterosalpingography was done to determine tubal occlusion; subsequently, the tubes containing the STOP devices were processed, sectioned, and evaluated to determine the histologic response. MAIN OUTCOME MEASURE(S): Ability to place a device and evaluate tubal occlusion and tissue response. RESULT(S): Devices were placed in 33 women, representing 57 tubes; the women wore the devices from 1 day to 30 weeks. Histology on 27 women (47 tubes) showed an acute inflammatory and fibrotic response in the short term that, over time, became a chronic inflammatory response with extensive fibrosis. CONCLUSION(S): The localized tissue response and notable absence of any normal tubal architecture in the segment of the fallopian tube containing the STOP device supports the postulated mechanisms of action of the device. Prehysterectomy study findings suggest the usefulness of the STOP device for pregnancy prevention, this is being evaluated in long-term safety and effectiveness studies.

Role of vaginal sonography and hysterosonography in the endoscopic treatment of uterine myomas.

OBJECTIVE: To summarize the advantages and disadvantages of the various imaging techniques used to evaluate uterine leiomyomas preoperatively and to propose a classification system for intramural and subserosal leiomyomas that may better serve the endoscopist in surgical treatment. DESIGN: A MEDLINE search of the available literature was performed. CONCLUSION(S): Selective use of the various imaging techniques is required based on the clinical situation. Classification systems that describe the degree of myometrial involvement are needed for appropriate case selection and counseling by the endoscopist.

Office hysteroscopy.

Office hysteroscopy has developed into an easy, safe, quick, and effective method of intrauterine evaluation that provides immediate results, offers the capacity of direct targeted biopsies of suspicious focal lesions, and offers the direct treatment of some intrauterine conditions. It has been facilitated by the availability of small-caliber endoscopes. Because of its simplicity and ease, the procedure is applicable as a screening method for patients with abnormal uterine bleeding or questionable hysterograms and for patients with suspected intrauterine pathology. Office hysteroscopy can be undertaken in a short period of time with minimal morbidity and inconvenience to the patient. It is important, nonetheless, to select the patients appropriately and time the examination strictly to the early follicular phase, once menstruation has ceased. When suction aspiration plastic cannulas are used for endometrial sampling, the combined procedure, hysteroscopy-suction sampling, offers an excellent method in the evaluation of patients with abnormal uterine bleeding. Transvaginal sonography with or without fluid enhancement complements the uterine evaluation, rather than replacing hysteroscopy, by outlining intramural uterine lesions such as myomas, adenomyosis, and other adnexal pathology not susceptible to hysteroscopic evaluation. Although some patients may not require analgesia or anesthesia for office hysteroscopy, the majority will benefit from a paracervical block or topical anesthesia, particularly if a suction endometrial aspiration will follow hysteroscopy or if any hysteroscopic intervention is performed, including a targeted biopsy. The success office hysteroscopy depends on the appropriate selection of the patient, the absence of contraindications, adequate instrumentation, and meticulous technique.

Endometrial carcinoma after endometrial ablation: high-risk factors predicting its occurrence.

Our purpose was to review reported cases of endometrial carcinoma after endometrial ablation and to evaluate high-risk factors predicting its occurrence. We present guidelines for the treatment of abnormal uterine bleeding unresponsive to medical therapy in this high-risk group of patients. Eight detailed reports on endometrial carcinoma after endometrial ablation were reviewed. The indications, methods of treatment, follow-up, and associated high-risk factors for endometrial carcinoma were analyzed. A focused list of high-risk factors for endometrial carcinoma was developed on the basis of the data collected. Guidelines were established to enable surgeons to minimize the risks of subsequent uterine cancer in women with abnormal uterine bleeding that is unresponsive to medical therapy (ie, candidates for ablation). Women who had endometrial carcinoma develop after ablation had predictive high-risk factors for subsequent neoplasia, and all eventually underwent a hysterectomy. Women with abnormal uterine bleeding and high-risk factors for endometrial carcinoma who did not respond to medical treatment may safely undergo endometrial ablation but must have a preablation biopsy indicating normal endometrium. Persistent hyperplasia unresponsive to hormonal therapy should influence the selection of a hysterectomy. Careful screening of patients before undergoing endometrial destructive procedures is prescient because minimally invasive, nonhysteroscopic ablative techniques are now emerging.

Emergency endometrial ablation for life-threatening uterine bleeding as a result of a coagulopathy.

The clinician has few medical and surgical options for managing life-threatening uterine hemorrhage. Hormone therapy often fails to arrest the bleeding. Hysterectomy under these emergency circumstances is also not optimal. Emergency endometrial ablation was successful in stopping exsanguinating uterine hemorrhage in three women and may be an important alternative in management of this disorder.

Complications of fluid overload from resectoscopic surgery.

Excess absorption of liquid distending media is one of the most frequent complications of operative hysteroscopy. Although most women recover uneventfully, we are seeing cases of permanent morbidity or death resulting from this complication.

[Conservative laparoscopic treatment of bilateral ectopic pregnancy. 2 case reports and review of the literature]. / Tratamiento laparoscópico conservador del embarazo ectópico bilateral. Informe de dos casos y revisión de la literatura.

Ectopic pregnancy is a frequent clinic entity, with an incidence from 4.5 to 16.8 for 1000 pregnancies. The frequency of ectopic pregnancy has been triplicated in the last years, mainly owed to increase of sexual transmitted diseases, increase in salpinges' surgery and in assisted reproductive medicine. The ectopic pregnancy is also the most frequency cause of maternal death during the first trimester of pregnancy. The frequency of bilateral tubal ectopic pregnancy is extremely rare, it is reported from 1:125 to 1:1580 of all ectopic pregnancies. The first case of bilateral tubal ectopic pregnancy was reported n 1918 by Bledsoe. In Mexico, Molina described the first case in 1993, with conservative laparoscopic treatment. Two clinic cases are presented of bilateral ectopic pregnancy, treated conservatively by laparoscopy. The first one with background of sterility because of anovulation, receiving treatment with menotropins for ovarian hyperstimulation, the other one. In the second case, was a spontaneous pregnancy, in a patient with a history of several pelvic surgeries. In this case a bilateral salpingostomy was realized. In both cases was demonstrated chorionic villi by histopathology. These cases are a model of nature to evaluate the real utility of several diagnostic and therapeutic methods which are available nowadays for the treatment of ectopic pregnancy.

Assessment of the safety of intrauterine instillation of heated saline for endometrial ablation.

OBJECTIVE: To evaluate the safety of pressure, temperature-controlled, continuously circulating hot saline (EnAbl system, InnerDyne Medical, Sunnyvale, CA) for endometrial ablation using the in vivo human uterus. DESIGN: Clinical safety study. SETTING: An academic research environment. PATIENTS: Eleven women undergoing abdominal hysterectomy because of abnormal uterine bleeding. INTERVENTION: Before uterine removal, endometrial cavities were exposed to 15 minutes of recirculatory normal saline heated to 70-85 degrees C. MAIN OUTCOME MEASURE(S): The uteri were analyzed for extent of thermal damage using standard histopathological techniques and tissue viability histochemical staining. Intrauterine pressures and serosal and subserosal temperatures were continuously monitored by computer. RESULT(S): In each treated specimen, histochemical staining demonstrated a depth of necrosis that extended through the entire endometrium and approximately 1-2 mm into the myometrium. The control specimen showed no thermal or mechanical damage. There were no observed negative effects or related complications with this system. CONCLUSION(S): The computer-controlled system employing continuously circulating hot saline is an effective method to destroy the endometrium. In four cases with clearly patent tubes, no spill was observed. In all 11 patients, serosal and subserosal temperatures were within safe levels (mean temperature, 37 degrees C).

[Endometrial ablation by liquid heat using the EnAbl system in patients after abdominal hysterectomy. Study of safety]. / Ablación endometrial por medio de calor líquido usando el sistema EnAbl, en pacientes sometidas a histerectomía abdominal. Estudio de seguridad.

Security and efficacy of an EnABL, were evaluated; this system had been designed for endometrial ablation by liquid heat in uterine cavity. Eleven patients were included, from the Outpatient Department (INP), programmed for different causes that objectives of this study for abdominal hysterectomy due to abnormal uterine bleeding. The study was approved by Ethical and Scientific Committees. Each patient had preoperative studies, endometrial biopsy, PAP, and ultrasound, in series. The patients with uterus larger than 14 cm, possible cancer; younger than 18 year, or with active bleeding at the time of hysterectomy, were excluded. Each patient received a schema of standard endometrial suppression. The system was applied previously to TAH; 2271 measurements of temperature at one minute intervals were done during liquid heat application. Surgical pieces were sent to histology to analyze the thermic damage through macroscopic aspect, HE tinction and an immunohistochemical cellular viability of NADH test. The thermal damage by macroscopic appearance was 4.33 +/- 1.03 mm, with HE of 4.15 +/- 0.75 mm and with the tinction of NADH of 4.25 mm +/- 0.79. The maximal damage by macroscopic appearance was 4.33 +/- 1.03 mm, with HE of 4.15 +/- 0.75 mm, and with NADH it was 4.25 mm +/- 0.79. The maximal damage was by macroscopic appearance was 6.0 mm and the minimal one was 2.0 mm. In evaluation by H/E, maximal was 5.1 mm and the minimal one was 2.3 mm. In NADH tinction maximal was 4.25 and minimal 2.4 mm. Horizontal analysis showed eight patients with major thermal damage at 4 mm; and two patients with lesser damage at 4 mm. Sub-serous temperatures measured with thermopairs, were done 1504 times, in total. Average was 36.28 degrees C, ranging 35 to 37 degrees C. Maximal temperature was 45 degrees C, 1-2 mm, bellow from serous surface of uterus, and the last one was 28 degrees C. The serous temperatures measured by infrared radiation were done 767 times with an average temperature of 34.6 degrees C. Average was 34-35 C, with standard deviation of 1-2 degrees C. Maximal temperature was 40 degrees C and minimal 29 degrees C. There were no adverse effects. This study shows that EnAbl system is an efficacious method.

Response of the primate secretory endometrium to subchronic hypercortisolemia.

OBJECTIVE: To assess the impact of subchronic and moderate hypercortisolism on the secretory endometrium of the cynomolgus monkey. METHODS: Osmotic pumps containing hydrocortisone phosphate (HP) were implanted subcutaneously in each monkey on the first day of the menstrual cycle; each monkey also received pumps containing saline in another cycle. Blood was obtained three times per week and urine was collected daily for hormone analyses. Endometriectomy was performed 13 +/- 1 days after the serum estradiol (E2) peak in each study cycle. RESULTS: Infusion of HP elevated serum cortisol levels by an average of 70%. Mean serum progesterone (P) levels were decreased by 50% during the secretory phase of HP-treatment cycles by comparison with self-control cycles (P < .01); as a result, the mean endometrial glycogen concentration was reduced by 30% (P < .05) and the activity of 17 beta-hydroxysteroid dehydrogenase was decreased by 70% (P < .05). Serum E2 levels were not consistently elevated by HP treatment, but cytosolic estrogen receptor levels of the endometrium were decreased by 50% (P < .01), indicating increased estrogenic stimulation. Histologic development of the secretory endometrium was retarded, but the length of the secretory phase was not affected by the treatment. CONCLUSION: A moderate elevation of serum cortisol levels over one menstrual cycle consistently produced a reduction in serum P and a hypoprogestogenic-hyperestrogenic response of the secretory endometrium in the cynomolgus monkey.

Strategies for ovulation induction and oocyte retrieval in the lowland gorilla.

PURPOSE: Ovulation induction and oocyte retrieval were performed in a lowland gorilla in an attempt to propagate and potentially cryopreserve embryos from an infertile animal and to advance techniques to help preserve this endangered species. RESULTS: Following 34 days of leuprolide acetate suppression, human menopausal gonadotropins were administered for 14-days in a 32-year-old wild-born lowland gorilla. Ten oocytes were retrieved by transrectal ultrasound-guided aspiration. Other approaches to oocyte recovery were not feasible in this case. A serum estradiol concentration of 4700 pg/ml at the time of human chorionic gonadotropin administration did not induce ovarian hyperstimulation. Mature oocytes were recovered from follicles measuring 14 to 24 mm in diameter, with a corresponding average serum estradiol concentration of approximately 300 pg/ml for each mature follicle. Cryopreservation of a gorilla embryo was effected from cryopreserved gorilla spermatozoa. CONCLUSIONS: Parameters for monitoring ovulation induction in the gorilla appear to be similar to those for humans. The results indicate that the use of a gonadotropin releasing hormone agonist and higher doses of gonadotropins than previously used in gorillas appear to improve oocyte recovery.

Hysteroscopic treatment of partial and complete uterine septum.

OBJECTIVE: To review the experience with hysteroscopic treatment of uterine septa, particularly those involving the cervix. METHODS: One hundred twenty-four patients with septate uterus were treated hysteroscopically. Seven of these women had a uterine septum involving the uterus and cervix. All patients but nine who were infertile had demonstrated repetitive pregnancy losses with nothing to explain the reproductive failure but the uterine septation. The preoperative reproductive performance included 299 pregnancies, of which 258 were spontaneous abortions (86.6%) and 28 preterm pregnancies (9.6%) that resulted in viable infants. RESULTS: Following treatment, 101 patients achieved pregnancy (81.4%). There were 84 term pregnancies (83.1%) and 7 preterm viable pregnancies (6.9%). There were 12 spontaneous abortions, all in the first trimester (11.8%); 23 patients had not become pregnant as yet (18.5%). Of the seven patients with complete uterine septum, including the cervix, six had delivered an infant at term, one by cesarean section at 41 weeks because of breech presentation, and the other five by vaginal delivery at 38, 37 1/2, 39, 40 and 39 weeks. CONCLUSION: Hysteroscopic treatment of the septate uterus can be extended to practically all types of uterine septa, including those involving the cervix.

Eight years' experience performing procedures with flexible hysteroscopes.

Flexible hysteroscopy is a valuable technique with a wide range of applications in gynecology and infertility. Its design, characteristics, and applications make it an important addition to the instruments available to gynecologic surgeons.

Tubal cannulation.

While uterotubal chromopertubations were performed early in the 1970s with the introduction of hysteroscopy, cornual cannulation was extended and adapted to fluoroscopy. The disadvantages of fluoroscopy include the difficulty in ruling out tubal spasm, inability to evaluate distal tubal disease, and other pelvic abnormalities. Tubal cannulation has emerged as an excellent alternative to treat patients with cornual obstruction. Only those patients in whom cannulation fails should be subjected to microsurgical reconstruction. While cannulation with coaxial catheters began under fluoroscopy, the use of the hysteroscope simplifies the technique. With laparoscopy the hysteroscopic approach enables tubal cannulation and evaluation of the entire pelvis. Treatment of additional problems affecting the fallopian tubes, particularly adhesions and endometriosis, is possible. Laparoscopy helps in monitoring the procedure and visual assessment of tubal patency. The ability to observe the uterotubal junctions directly by hysteroscopy provides an excellent approach for tubal cannulation. There are two techniques to cannulate the fallopian tubes, either with coaxial catheters or catheters with distal balloons, but the result obtained with these two techniques is similar. The simplicity of coaxial catheters makes this approach more appealing, and with the hysteroscope one can avoid exposure to radiation. The results obtained with tubal cannulation are encouraging and this procedure should be offered as the initial method to attempt treatment of tubal cornual obstruction. Often it can represent an excellent alternative to microsurgical tubal anastomosis, avoiding a laparotomy and extended disability.

Rollerball endometrial ablation.

Attempts at endometrial destruction to treat abnormal uterine bleeding unresponsive to medical therapy in women at risk to hysterectomy are not new. However, a practical and effective method was not introduced until the early 1980s, when the Nd:YAG laser was used through the hysteroscope for endometrial photocoagulation. Soon after, electrosurgery proved to be a good alternative for endometrial ablation, either by resection, coagulation, or both. Because of its relative simplicity, effectiveness, and low complication rate, the rollerball endometrial ablation has been attractive to physicians and patients alike as a good alternative to endometrial laser ablation. The overall results, particularly in properly selected patients who have been hormonally suppressed to thin the endometrium and permit good tissue penetration of the electrosurgical energy, have been most satisfactory.