[Uterine rupture during medical termination of pregnancy or intrauterine death: A risk management study]. / Rupture utérine sur interruption médicale de grossesse ou mort fœtale in utero : une étude de gestion du risque.

OBJECTIVE: To describe and analyze a series of uterine ruptures (UR) that occurred in the context of medical termination of pregnancy (MTP) or intrauterine death (IUD) from a risk management perspective. METHODS: French retrospective descriptive observational study of all cases of UR occurring during induction for IUD or MTP, reported between 2011 and 2021 by Gynerisq. Cases were recorded on a basis of voluntary reports using targeted questionnaires. RESULTS: Between November 27, 2011, and August 22, 2021, 12 cases of UR occurring during an induction for IUD or MTP were recorded. 50 % of the patients had never given birth by cesarean section. The term of delivery varied from 17+3 days to 41+2 days. The clinical signs found were pain (n=6), ascending fetal presentation (n=5) and bleeding (n=4). All patients were managed by laparotomy, 5 were transfused. One vascular ligation and one hysterectomy were required. CONCLUSION: Knowledge of surgical history is involved in the prevention of UR. The signs of detection are pain, ascending presentation and bleeding. The speed of management and good teamwork allow a reduction of maternal complications. The findings of the morbidity and mortality reviews show that prevention and mitigation barriers can be established.

Utero-placental apoplexy during induction of therapeutic abortion in a 18-week pregnancy.

Utero-Placental Apoplexy, or Couvelaire Uterus, is a third-trimester major obstetrical complication, occurring especially during labor. It consists of placental abruption followed by an acute intradecidual hemorrhage produced by the rupture of the uterus-placental spiral arterioles leading to a retroplacental hematoma. This hemorrhage infiltrates the uterine wall up to intra- and retro-peritoneal areas. We provide a case report, on which no previous literature is available, of a utero-placental apoplexy during induction of therapeutic abortion.

Disseminated Intravascular Coagulation and Hemorrhage After Dilation and Evacuation Abortion for Fetal Death.

OBJECTIVE: To examine the association between fetal death and risk of hemorrhage and disseminated intravascular coagulation (DIC) among women undergoing dilation and evacuation (D&E) procedures. METHODS: We conducted a retrospective cohort study of all D&Es at one academic abortion clinic in San Francisco between 2009 and 2013. We abstracted data on fetal death status, demographic characteristics, and complications including hemorrhage and DIC. We examined the risk of hemorrhage and DIC among women with fetal death compared with those without. We conducted unadjusted and adjusted analyses for the outcomes of hemorrhage, DIC, and any complication. RESULTS: Among 92 cases of D&E for fetal death and 4,428 cases of D&E for other reasons, hemorrhage occurred in 10% and 7%, respectively (P=.28), and DIC occurred in 2.0% and 0.2% of the fetal death and nonfetal death cohorts (P<.001). In adjusted analysis, fetal death was associated with 2.9 times higher odds of hemorrhage (95% CI 1.4-6.0). In an unadjusted analysis, fetal death was associated with 12.3 times higher odds of DIC (95% CI 2.6-58.6) and 3.0 times higher odds of any complication (95% CI 1.6-5.9). CONCLUSION: Women undergoing D&E for fetal death are far more likely to experience DIC and hemorrhage than are women without fetal death, yet the absolute risk is low (2%). Although D&E providers should be prepared for DIC and hemorrhage, we do not recommend any specific preoperative preparation because the vast majority of D&E abortions for fetal death are uncomplicated.

First-trimester abortion complicated with placenta accreta: A systematic review.

Placenta accreta is a potentially life-threatening condition that may complicate a first-trimester abortion in rare occasions, and it can be difficult to recognize. We reviewed the literature in PubMed-indexed English journals through August 2018 for first-trimester postabortal placenta accreta, after which 19 articles and 23 case reports were included. The risk factors for the development of abnormal placentation are previous cesarean section (87%), previous history of uterine curettage (43.5%), and previous history of surgical evacuation of a retained placenta (4.3%). Ten patients (43.5%) had an advanced age (≧35 years). Most patients clinically presented with vaginal bleeding, ranging from intermittent or irregular bleeding, persistent bleeding, and profuse or massive bleeding. The onset of symptoms might be during the intra- or immediate postoperative period. Some patients had delayed symptoms 1 week to 2 years postoperatively. Conservative management may be attempted as the primary rescue, including uterine artery embolization (UAE), transcatheter arterial chemoembolization (TACE) with dactinomycin, and laparoscopic hysterotomy with placental tissue removal. However, most reports in the literature suggested either abdominal or laparoscopic hysterectomy as the definitive treatment for first-trimester postabortal placenta accreta. High index of clinical suspicion with anticipation of placenta accreta in early pregnancy is highly essential for timely diagnosis, providing the physician better opportunities to promptly manage this emergent condition and improve outcomes.

Spontaneous Resolution of an Acquired Uterine Arteriovenous Malformation in an Elderly Primigravida.

BACKGROUND Uterine arteriovenous malformation (AVM) is an uncommon lesion characterized by an abnormal connection between arterial and venous circulation that can be congenital or acquired. Acquired uterine AVMs are generally traumatic and follow delivery, abortion, curettage, or uterine surgery. CASE REPORT A 45-year-old female who was gravida 1 para 0 presented to our hospital with severe vaginal bleeding. Two weeks before, the patient underwent therapeutic abortion. At admission, a transvaginal ultrasound showed an unclear intrauterine lesion that spread out to the myometrium. Color Doppler evaluation demonstrated an elevated color score. Beta human chorionic gonadotropin (beta-hCG) levels were measured at admission and daily repeated, with a progressive decrease of values up to a negative level. A pelvic magnetic resonance imaging described an area of tubular and tortuous structures involving the myometrium. A computed tomography angiography confirmed the presence of a lesion infiltrating the endometrium and myometrium containing arteriovenous structures with a highly enhanced effect. Despite these findings, the patient was clinically stable. A diagnosis of uterine AVM was made and, after accurate counselling with the patient, she was discharged and underwent "watch and wait" management. After 35 days, the patient had a follow-up ultrasound that showed a complete resolution of the uterine lesion. CONCLUSIONS AVM should be considered in the presence of heavy and sudden vaginal bleeding in a patient with risk factors for acquired AVM. A color Doppler ultrasound scan should be performed as the first approach and an expectant management should be taken into account especially with a patient of childbearing age and hemodynamic instability.

Sepsis after uterine artery embolization-assisted termination of pregnancy with complete placenta previa: A case report.

Uterine artery embolization (UAE)-assisted induction of labor is an alternative method of managing pregnant women with complete placenta previa (CPP). Sepsis secondary to UAE, although rare, is a serious complication. We herein present a case of severe sepsis following UAE-assisted termination of a pregnancy at 27 gestational weeks in a woman with CPP. The woman developed a high-grade fever and elevated inflammatory indices following UAE. She did not recover until the infected tissue was removed by emergency cesarean section. This case suggests that the increasing use of UAE for termination of pregnancy in women with CPP requires awareness regarding the possibility of serious sepsis associated with this procedure.

Contraceptive Provision after Medication and Surgical Abortion.

OBJECTIVE: This study sought to compare contraception provided to patients after medication and surgical abortion. STUDY DESIGN: Women who underwent first trimester induced abortion at a university-based urban clinic between May 2009 and May 2014 were identified. Medical records were reviewed to determine the method of contraception provided by the clinic to patients after medication and surgical abortion. Postabortal contraception was defined as any contraception administered or prescribed from our health system within 4 weeks of surgical abortion or mifepristone administration. RESULTS: We reviewed 824 women who were 9 weeks gestational age or less and able to choose between medication and surgical termination of pregnancy. Overall, 587 (71.1%) had a surgical abortion and 237 (28.9%) had a medication abortion. Women who had surgical abortions were more likely to initiate long-acting reversible contraception (41.9% vs. 23.2%; p < .0001) and more likely to be provided with any type of contraception overall (83% vs. 64.6%; p < .0001). The overall follow-up rate after medication abortion was 71.7%. CONCLUSIONS: Women who had surgical abortions had a greater odds of receiving long-acting reversible contraception than those who had medication abortions. Surgical abortion patients were also more likely to be provided contraception overall. Further prospective research is needed to determine the reasons for this difference and to ensure that all patients obtain the contraception that they desire.

Predictive factors for the methotrexate treatment outcome in ectopic pregnancy: A comparative study of 400 cases.

OBJECTIVE: We sought to evaluate the global success rate of intramuscular methotrexate for the treatment of ectopic pregnancy, identify factors predictive of treatment success or failure, and study methotrexate tolerability in a large patient cohort. STUDY DESIGN: For this single-center retrospective observational study, we retrieved the records of all women who had a clinically or echographically confirmed ectopic pregnancy with a Fernandez score <13 and who were treated according to a 1mg/kg intramuscular single-dose methotrexate protocol. Medical treatment failure was defined by an obligation to proceed to laparoscopy. Needing a second injection was not considered to be medical treatment failure. RESULTS: Between February 2008 and November 2013 (69 months), 400 women received methotrexate for ectopic pregnancy. The medical treatment protocol was effective for 314 patients, i.e., an overall success rate of 78.5%. A single methotrexate dose was sufficient for 63.5% of the women and a second dose was successful for 73.2% of the remaining women. The medical treatment success rate fell as initial hCG levels climbed. The main factors associated with methotrexate failure included day (D) 0, D4 and D7 hCG levels, pretherapeutic blood progesterone, hematosalpinx at D0 and pain at D7. Early favorable kinetics of hCG levels was predictive of success. Methotrexate treatment was successful in 90% of women who had D0 hCG <1000IU/l. Methotrexate tolerability was good, with only 9% of the women reporting non-severe adverse effects. The fertility rate with delivery after medical treatment for ectopic pregnancy was 80.7%. CONCLUSION: In this study, we showed that an initial hCG value <1000IU/l and favorable early HCG kinetics were predictive factors for the successful medical treatment of ectopic pregnancy by methotrexate, and hematosalpinx and pretherapeutic blood progesterone >5ng/ml at diagnosis were predictive of its failure. We also confirmed good tolerability for single-dose methotrexate protocols.

[Five cases of interstitial heterotopic pregnancy after IVF-ET treated by laparoscopic surgery].

To evaluate the efficency and safety of laparoscopic surgery in the treatment of interstitial heterotopic pregnancy (IHP) after IVF-ET, five patients with interstitial heterotopic pregnancy after IVF-ET treated by laparoscopy in our hospital from Jan. 2012 to Jan. 2015 were retrospectively analyzed. All operations were finished laparoscopically without any major complications and they successfully delivered. The results suggest that laparosccpic surgery is feasible and safe for IHP to maintain the trauterine pregnancy, and it can diagnose and treat IHP at early stage, which cause mininmal injuries and less disturbance to trauterine pregnancy and ensure rapid recovery.

Safety of Outpatient Surgical Abortion for Obese Patients in the First and Second Trimesters.

OBJECTIVE: To evaluate the relationship between obesity and surgical abortion complications in the outpatient setting. METHODS: We conducted a retrospective cohort study of 4,968 women undergoing surgical abortion at a large outpatient clinic network from September 2012 to July 2014. We used log-binomial regression to evaluate body mass index (BMI) as an independent risk factor for first- and second-trimester abortion complications. Body mass index was analyzed as both a continuous and categorical predictor. We assessed complications including need for uterine reaspiration (including same-day reaspiration), uterine perforation, cervical laceration, infection, emergency department visit or hospitalization, and excessive blood loss defined as estimated blood loss greater than or equal to 100 mL. RESULTS: The majority (77%) of procedures was performed in the first trimester. Forty-seven percent of women were normal weight or underweight, 28% were overweight, and 25% were obese, including 4% with BMI greater than or equal to 40. The overall complication rate was 1.7%; the most common complications were need for uterine reaspiration (1.0%) and excessive blood loss (0.6%). Obesity was not associated with increased risk of surgical complications, including when adjusting for age, gestational age, and history of prior cesarean delivery. CONCLUSION: In a high-volume outpatient abortion clinic with experienced health care providers, abortion is very safe. Obesity does not appear to be an independent predictor for abortion complications and should not be used in isolation to refer women to hospital-based facilities for abortion care in the first or second trimester.

A new tubal classification system for fertility prognosis after laparoscopic salpingostomy for tubal pregnancy.

OBJECTIVE: To assess the objectivity and accuracy of a new system that predicts the pregnancy outcomes in patients with tubal pregnancy after laparoscopic salpingostomy. STUDY DESIGN: 480 tubal pregnancy patients were retrospectively stratified as mild, moderate, or severe group according to the new tubal classification system in which pelvic adhesions, tubal morphology, structure, and patency were included. The follow-up was performed for 24 months to determine spontaneous pregnancy outcomes. RESULTS: The tubal classification was significantly associated with intrauterine pregnancy rates (mild 70.9% vs. moderate 66.0% vs. severe 41.8%, P=0.001) and recurrent ectopic pregnancy rates (mild 2.8% vs. moderate 4.2% vs. severe 10.9%, P=0.047). The 24-month cumulative rate of intrauterine pregnancy was 73.5% in the mild group, 68.5% in the moderate group, and 45.8% in the severe group (P=0.002). The 24-month cumulative repeat ectopic pregnancy rate was 6.6% in the mild group, 9.1% in the moderate group, and 15% in the severe group (P=0.154). In Cox multivariate regression analysis, a lack of a history of infertility [hazard ratio (HR)=0.633, P=0.001] and tubal scoring (mild HR=2.408, P=0.008; moderate HR=2.147, P=0.010) were significantly associated with a higher rate of spontaneous intrauterine pregnancy. Having a history of infertility (HR=0.351, P=0.037) and no prior abdominopelvic surgery (HR=2.907, P=0.014) were significantly associated with a lower ectopic pregnancy rate. CONCLUSION: The new tubal classification system significantly correlated with spontaneous pregnancy outcomes in patients with tubal pregnancy following laparoscopic salpingostomy.

Doctors or mid-level providers for abortion.

BACKGROUND: The World Health Organization recommends that abortion can be provided at the lowest level of the healthcare system. Training mid-level providers, such as midwives, nurses and other non-physician providers, to conduct first trimester aspiration abortions and manage medical abortions has been proposed as a way to increase women's access to safe abortion procedures. OBJECTIVES: To assess the safety and effectiveness of abortion procedures administered by mid-level providers compared to doctors. SEARCH METHODS: We searched the CENTRAL Issue 7, MEDLINE and POPLINE databases for comparative studies of doctor and mid-level providers of abortion services. We searched for studies published in any language from January 1980 until 15 August 2014. SELECTION CRITERIA: Randomised controlled trials (RCTs) (clustered or not clustered), prospective cohort studies or observational studies that compared the safety or effectiveness (or both) of any type of first trimester abortion procedure, administered by any type of mid-level provider or doctors, were eligible for inclusion in the review. DATA COLLECTION AND ANALYSIS: Two independent review authors screened abstracts for eligibility and double-extracted data from the included studies using a pre-tested form. We meta-analysed primary outcome data using both fixed-effect and random-effects models to obtain pooled risk ratios (RR) with 95% confidence intervals (CIs). We carried out separate analyses by study design (RCT or cohort) and type of abortion procedure (medical versus surgical). MAIN RESULTS: Eight studies involving 22,018 participants met our eligibility criteria. Five studies (n = 18,962) assessed the safety and effectiveness of surgical abortion procedures administered by mid-level providers compared to doctors. Three studies (n = 3056) assessed the safety and effectiveness of medical abortion procedures. The surgical abortion studies (one RCT and four cohort studies) were carried out in the United States, India, South Africa and Vietnam. The medical abortion studies (two RCTs and one cohort study) were carried out in India, Sweden and Nepal. The studies included women with gestational ages up to 14 weeks for surgical abortion and nine weeks for medical abortion.Risk of selection bias was considered to be low in the three RCTs, unclear in four observational studies and high in one observational study. Concealment bias was considered to be low in the three RCTs and high in all five observational studies. Although none of the eight studies performed blinding of the participants to the provider type, we considered the performance bias to be low as this is part of the intervention. Detection bias was considered to be high in all eight studies as none of the eight studies preformed blinding of the outcome assessment. Attrition bias was low in seven studies and high in one, with over 20% attrition. We considered six studies to have unclear risk of selective reporting bias as their protocols had not been published. The remaining two studies had published their protocols. Few other sources of bias were found.Based on an analysis of three cohort studies, the risk of surgical abortion failure was significantly higher when provided by mid-level providers than when procedures were administered by doctors (RR 2.25, 95% CI 1.38 to 3.68), however the quality of evidence for this outcome was deemed to be very low. For surgical abortion procedures, we found no significant differences in the risk of complications between mid-level providers and doctors (RR 0.99, 95% CI 0.17 to 5.70 from RCTs; RR 1.38, 95% CI 0.70 to 2.72 from observational studies). When we combined the data for failure and complications for surgical abortion we found no significant differences between mid-level providers and doctors in both the observational study analysis (RR 1.36, 95% CI 0.86 to 2.14) and the RCT analysis (RR 3.07, 95% CI 0.16 to 59.08). The quality of evidence of the outcome for RCT studies was considered to be low and for observational studies very low. For medical abortion procedures the risk of failure was not different for mid-level providers or doctors (RR 0.81, 95% CI 0.48 to 1.36 from RCTs; RR 1.09, 95% CI 0.63 to 1.88 from observational studies). The quality of evidence of this outcome for the RCT analysis was considered to be high, although the quality of evidence of the observational studies was considered to be very low. There were no complications reported in the three medical abortion studies. AUTHORS' CONCLUSIONS: There was no statistically significant difference in the risk of failure for medical abortions performed by mid-level providers compared with doctors. Observational data indicate that there may be a higher risk of abortion failure for surgical abortion procedures administered by mid-level providers, but the number of studies is small and more robust data from controlled trials are needed. There were no statistically significant differences in the risk of complications for first trimester surgical abortions performed by mid-level providers compared with doctors.

Expecting the Unexpected: Perspectives on Stillbirth and Late Termination of Pregnancy for Fetal Anomalies.

Expectant mothers and their spouses spend months preparing to eagerly welcome their much-anticipated baby into their family. Stillbirth or a diagnosis of life-limiting fetal anomalies comes as a devastating turn of events for affected women and their families. From the time of diagnosis to intervention (i.e., induction of labor for stillbirth or late termination of pregnancy for fetal anomalies), affected women often feel vulnerable and abandoned, with many experiencing long-term psychological and emotional effects. Knowledge of obstetric management, ethical and medical challenges, and psychological aspects have evolved in recent years. Familiarity with this emerging knowledge better prepares the obstetric anesthesiologist to deliver effective and empathic care. Encounters with women experiencing stillbirth and life-limiting fetal anomalies prompted this review of current evidence regarding parturient' perspectives on their care as they set out on the road to recovery.

Vulvar myiasis following suction and evacuation for incomplete abortion.

Myiasis is caused by fly larva capable of penetrating healthy or necrotic tissue, usually in tropical and subtropical countries. The involvement of an exposed area is common; however it may very rarely involve the genital region. We present a rare case of vulvar myiasis which occurred after suction and evacuation performed for incomplete abortion.

Septic abortion with placenta accreta in pregnancy after endometrial ablation.

BACKGROUND: Pregnancy after endometrial ablation is a rare event, occurring in approximately 0.7% of cases. When it occurs, serious complications may be anticipated for both mother and fetus, including abnormal placentation. Termination of pregnancy in these cases is a challenging issue, made more so by the lack of availability of these services. CASE: We report a case of pregnancy after endometrial ablation complicated by placenta accreta. Initiation of a second-trimester termination procedure with lethal fetal injection resulted in subsequent septic abortion necessitating abdominal hysterectomy. CONCLUSION: Pregnancy after endometrial ablation is a rare and potentially morbid event. Patients should be counseled about the necessity of contraception at the time of endometrial ablation. Termination should be approached with caution and requires the availability of skilled providers.

Infantile hemangioma-like vascular lesion in a 26-year-old woman after abortion.

A 26-year-old woman (G2P1A1) presented with a 5-week history of multiple red marks on her body after a therapeutic abortion. A physical examination found 15 palpable red marks on her head, neck, chest, arms and legs. Proliferating endothelial cells, which expressed CD31, CD34, von Willebrand factor, but not Glut-1 and merosin, were observed in the lesional area by histopathological analyses. Histocompatibility antigen typing of 2 lesions was identical to a sample from peripheral blood. Accelerated regression was observed in 2 lesions treated by intralesional injection of betamethasone, while spontaneous regression was observed within 9 months in the remaining lesions without any treatment. Rapid growth, spontaneous regression and histological analyses in this case support the diagnosis of 'infantile hemangioma-like vascular lesion'.

Analysis of the efficacy of three treatment options for cesarean scar pregnancy management.

AIM: To assess three different methods in treating patients with cesarean scar pregnancy (CSP). METHODS: We evaluated pre-, intra- and postoperative conditions of 124 CSP patients in one of the three treatment groups, of which 37 patients underwent uterine curettage by hysteroscopy under ultrasound monitoring (group 1), 28 patients were treated with methotrexate followed by hysteroscopy (group 2) and 59 cases underwent uterine arterial embolization followed by hysteroscopy (group 3). The treatment options were determined based on the patients' conditions. RESULTS: Among all three groups, group 3 (uterine arterial embolization followed by hysteroscopy) had the least intraoperative blood loss and the highest success rate with curettage, but the highest hospitalization cost. Group 1 (only hysteroscopy) had the shortest length of hospitalization and the lowest cost, but the highest intraoperative blood loss and slowest recovery. Group 2 (methotrexate followed by hysteroscopy) had the longest period of hospitalization, and other indexes had fallen in between the other two groups. CONCLUSION: Among the three methods, uterine arterial embolization followed by hysteroscopy is the safest and most efficient method without considering the cost of hospitalization. Patients with a low level of ß-hCG may consider choosing hysteroscopy under ultrasound monitoring or methotrexate followed by hysteroscopy. The advantage is low cost of hospitalization; however, patients may be under relatively higher surgical risks and lower first time surgical success rate, especially for patients treated by hysteroscopy under ultrasound monitoring.

Uterine preservation surgery for placental polyp.

AIM: To examine clinical and surgical performances of cases with placental polyps in which uterine preservation surgery was conducted. METHODS: During the period September 2002 to April 2009, we examined eight cases (hysteroscopic resection, six cases; laparotomy, one case; dilatation and curettage, one case) diagnosed with placental polyp that had been treated with polyp extraction surgery. Imaging evaluation was done using magnetic resonance imaging and 2-D ultrasound. RESULTS: Three of the eight cases (37.5%) had been first-time pregnancies. Most of our cases experienced minimal surgical manipulation after medical abortion. Among them, six cases (75%) were mid-term medical abortions, one case (12.5%) received no treatment after spontaneous abortion, and one case (12.5%) had postsurgical abortion (dilatation and curettage). All cases showed variable amount of blood flow in the internal mass and myometrium by color Doppler ultrasound. Magnetic resonance imaging angiography showed contrast effects in the intrauterine cavity and myometrium in selected cases. The average duration from diagnosis to surgery was 32 days (range, 11-105). Color Doppler revealed a reduction in blood flow in five cases during the waiting period until surgery with an average blood loss of 10 g (range, 0-20) during surgery. CONCLUSION: Use of color Doppler ultrasound may be useful in diagnosing placental polyp. Although hysteroscopic resection of placental polyp is effective in patients hoping for uterine preservation, delaying timing of surgery may reduce blood loss during operative procedure.