Endometrial thickness following early miscarriage in IVF patients - is there a preferred management approach?

BACKGROUND: Endometrial thickness (ET) has previously been shown to positively correlate with implantation and clinical pregnancy rates. Pregnancies achieved using in-vitro fertilization (IVF) technique are prone to higher rates of early miscarriage. The aim of this study was to compare the effects of expectant management, medical treatment (Misoprostol) and dilation and curettage (D&C) for early miscarriage following IVF cycles on the subsequent cycle outcomes - endometrial thickness and reproductive outcomes. METHODS: A retrospective cohort study of women who underwent embryo transfer, conceived and had first trimester miscarriage with at least one subsequent embryo transfer. ET measurements during fresh or frozen-thawed IVF cycles were assessed for each patient. Comparisons of ET differences between the miscarriage and the subsequent cycles, as well as reproductive outcomes, were performed according to the initial miscarriage management approach. RESULTS: A total of 223 women were included in the study. Seventy-eight women were managed conservatively, 61 were treated with Misoprostol and 84 women underwent D&C. Management by D&C, compared to conservative management and Misoprostol treatment was associated with higher prevalence of a significant (> 2 mm) ET decrease (29.8%% vs. 14.1and 6.6%, respectively; p < .001) and was the only approach associated with a significant increase in the rates of ET under 7 and 8 mm in the following cycle (p = 0.006 and 0.035; respectively). Clinical pregnancy rates were significantly lower following D&C compared with conservative management and Misoprostol (16.7% vs. 38.5 and 27.9%, respectively; p = 0.008) as well as implantation rate (11.1% vs. 30.5.% and 17.7, respectively; p < 0.001). CONCLUSION: Our data suggest that D&C management of a miscarriage is associated with decreased ET and higher rates of thin endometrium in the subsequent IVF cycle, compared with conservative management and Misoprostol treatment. In addition, implantation and pregnancy rates were significantly lower after D&C.

Plummer-Vinson syndrome: A decade's experience of 132 cases from a single center.

BACKGROUND AND AIM: Plummer-Vinson syndrome (PVS) comprises triad of iron deficiency anemia, dysphagia, and post-cricoid esophageal web. PVS is rare nowadays due to improved nutritional status. However, we encountered patients with PVS regularly at our center. Data regarding PVS are limited; hence, we aimed to study the clinical features, treatment outcomes, and development of complications in patients with PVS. METHODS: The study was conducted over a 10-year period (January 2008 to January 2018) in a medical college setting. All adults with dysphagia, anemia, and post-cricoid web or those with iron deficiency anemia and post-cricoids web were included in the study. Patients were treated with iron supplementation and Savary-Gilliard bougie dilation of the web. Patients were followed-up for the recurrence of dysphagia and development of complications. RESULTS: Overall, 153 patients exhibited esophageal web, of which 132 (86.27%) patients had concomitant PVS and 21 (13.7%) patients did not. The mean age was 43.50 years (range 16-76) and 113 (85.6%) were women. Single session of Savary-Gilliard bougie dilation was successful in 90.7% of patients in relieving dysphagia and 9.3% developed recurrence, requiring repeated dilations. Four patients had concomitant squamous cell carcinoma of esophagus along with PVS and two developed upper gastrointestinal malignancy during follow-up. CONCLUSION: Plummer-Vinson syndrome is predominantly seen in middle aged women and present with symptoms of iron deficiency anemia and early grade dysphagia. Single session of Savary-Gilliard bougie dilation was successful in majority of patients in relieving dysphagia. Overall risk of developing upper gastrointestinal malignancy was 4.5%.

A study on the timing of uterine artery embolization followed by pregnancy excision for cesarean scar pregnancy: a prospective study in China.

BACKGROUND: Cesarean scar pregnancy (CSP) remains a sporadic and special form of ectopic pregnancy in which the fertilized ovum is implanted on a previous cesarean scar within 12 weeks. This study aims to evaluate the optimal time interval between uterine artery embolization (UAE) and curettage modalities in order to provide the best clinical outcomes. METHODS: From January 2018 to December 2020, we recruited 61 patients with CSP. They were randomly divided into two groups depending on whether the time interval between UAE and dilatation and curettage (D&C) requires additional hospitalization: 31 patients received prophylactic UAE followed by D&C on the same day (0-12 h; group A) and 30 patients need hospitalization (12-72 h; group B). The clinical characteristics, diagnostic data, and outcomes of the two groups were compared and analyzed. RESULTS: A total of 59 (96.72%) cases had responded well to the first treatment. One patient in each arm undergone retreatment, but none of the 61 patients needed additional hysterectomy. There was no considerable relationship between the two groups with respect to the intraoperative hemorrhage during D&C, serum index (containing ß-hCG, hemoglobin, CRP, and D-dimer) on the first day after D&C, side effects (containing fever and abdominal pain), renal, hepatic, and coagulation function, time of CSP residual mass disappearance, and hospitalization cost. The time of serum ß-hCG resolution after surgery was 41.22 ± 14.97 days in group A and 66.67 ± 36.64 days in group B (P = 0.027), and group A treatment resulted in a shorten hospital stay as compared with group B (4.81 ± 2.74 days vs. 6.80 ± 2.14 days, P <  0.001). However, the average hourly serum ß-hCG decrease rate within 24 h and the leukocytes on the first day after D&C in group B were superior than in group A (P <  0.050). CONCLUSION: For patients with CSP, UAE followed by D&C on the same day (0-12 h) appears to have more advantages in hospitalization and recovery time, while the long time interval (12-72 h) may have a lower risk of inflammation and a more rapid decrease in serum ß-hCG level within 24 h after D&C surgery. The treatment of CSP should be individualized based on the conditions of patients.

An updated guide to the diagnosis and management of cesarean scar pregnancies.

PURPOSE OF REVIEW: To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required. SUMMARY: Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.

Interventions for non-tubal ectopic pregnancy.

BACKGROUND: Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua uteri, the ovary, the cervix, and the abdomen. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP). OBJECTIVES: To evaluate the clinical effectiveness and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy in terms of fertility outcomes and complications. SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) search portal and nine other databases to 12 December 2019. We handsearched reference lists of articles retrieved and contacted experts in the field to obtain additional data. SELECTION CRITERIA: We included randomized controlled trials (RCTs) published in all languages that examined the effects and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy. DATA COLLECTION AND ANALYSIS: We used Cochrane standard methodological procedures. Primary outcomes were treatment success and complications. MAIN RESULTS: We included five RCTs with 303 women, all reporting Caesarean scar pregnancy. Two compared uterine arterial embolization (UAE) or uterine arterial chemoembolization (UACE) plus methotrexate (MTX) versus systemic MTX and subsequent dilation and suction curettage; one compared UACE plus MTX versus ultrasonography-guided local MTX injection; and two compared suction curettage under hysteroscopy versus suction curettage under ultrasonography after UAE/UACE. The quality of evidence ranged from moderate to very low. The main limitations were imprecision (small sample sizes and very wide confidence intervals (CI) for most analyses), multiple comparisons with a small number of trials, and insufficient data available to assess heterogeneity. UAE/UACE versus systemic MTX prior to suction curettage Two studies reported this comparison. One compared UAE with systemic MTX and one compared UACE plus MTX versus systemic MTX, in both cases followed by a suction curettage. We are uncertain whether UAE/UACE improved success rates after initial treatment (UAE: risk ratio (RR) 1.00, 95% CI 0.90 to 1.12; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.87, 95% CI 0.54 to 1.38; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced rates of complications (UAE: RR 0.47, 95% CI 0.13 to 1.75; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.62, 95% CI 0.26 to 1.48; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced adverse effects (UAE: RR 1.58, 95% CI 0.41 to 6.11; 1 RCT, 72 women; low-quality evidence; UACE: RR 1.16, 95% CI 0.32 to 4.24; 1 RCT, 28 women; low-quality evidence), and it was not obvious that the types of events had similar values to participants (e.g. fever versus vomiting). Blood loss was lower in UAE/UACE groups than systemic MTX groups (UAE: mean difference (MD) -378.70 mL, 95% CI -401.43 to -355.97; 1 RCT, 72 women; moderate-quality evidence; UACE: MD -879.00 mL, 95% CI -1135.23 to -622.77; 1 RCT, 28 women; moderate-quality evidence). Data were not available on time to normalize ß-human chorionic gonadotropin (ß-hCG). UACE plus MTX versus ultrasonography-guided local MTX injection We are uncertain whether UACE improved success rates after initial treatment (RR 0.95, 95% CI 0.56 to 1.60; 1 RCT, 45 women; very low-quality evidence). Adverse effects: the study reported the same number of failed treatments in each arm (RR 0.88, 95% CI 0.40 to 1.92; 1 RCT, 45 women). We are uncertain whether UACE shortened the time to normalize ß-hCG (MD 1.50 days, 95% CI -3.16 to 6.16; 1 RCT, 45 women; very low-quality evidence). Data were not available for complications. Suction curettage under hysteroscopy versus under ultrasonography after UAE/UACE. Two studies reported this comparison. One compared suction curettage under hysteroscopy versus under ultrasonography after UAE, and one compared these interventions after UACE. We are uncertain whether suction curettage under hysteroscopy improved success rates after initial treatment (UAE: RR 0.91, 95% CI 0.81 to 1.03; 1 RCT, 66 women; very low-quality evidence; UACE: RR 1.02, 95% CI 0.96 to 1.09; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced rates of complications (UAE: RR 4.00, 95% CI 0.47 to 33.91; 1 RCT, 66 women; very low-quality evidence; UACE: RR 0.18, 95% CI 0.01 to 3.72; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced adverse effects (UAE: RR 3.09, 95% CI 0.12 to 78.70; 1 RCT, 66 women; very low-quality evidence; UACE: not estimable; 1 RCT, 92 women; very low-quality evidence). We are uncertain whether suction curettage under hysteroscopy shortened the time to normalize ß-hCG (UAE: MD 4.03 days, 95% CI -1.79 to 9.85; 1 RCT, 66 women; very low-quality evidence; UACE: MD 0.84 days, 95% CI -1.90 to 3.58; 1 RCT, 92 women; low-quality evidence). Non-tubal ectopic pregnancy other than CSP No studies reported on non-tubal ectopic pregnancies in locations other than on a caesarean scar. AUTHORS' CONCLUSIONS: For Caesarean scar pregnancies (CSP) it is uncertain whether there is a difference in success rates, complications, or adverse events between UAE/UACE and administration of systemic MTX before suction curettage (low-quality evidence). Blood loss was lower if suction curettage is conducted after UAE/UACE than after administration of systemic MTX (moderate-quality evidence). It is uncertain whether there is a difference in treatment success rates, complications, adverse effects or time to normalize ß-hCG between suction curettage under hysteroscopy and under ultrasonography (very low-quality evidence). There are no studies of non-tubal ectopic pregnancy other than CSP and RCTs for these types of pregnancy are unlikely.

Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications.

OBJECTIVE: The use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery. METHODS: We conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 236/7 weeks gestation and underwent uterine curettage after the fetus was delivered. RESULTS: Overall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4-4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01-5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01-10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1-3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001). CONCLUSION: Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.

Local intra-gestational sac methotrexate injection followed by dilation and curettage in treating cesarean scar pregnancy.

PURPOSE: To assess the safety and efficacy of local intra-gestational sac methotrexate injection followed by dilation and curettage (D&C) in treating cesarean scar pregnancies (CSP). METHOD: Medical records of CSP patients treated with local intra-gestational sac methotrexate injection followed by dilation and curettage were analyzed at the Maternal and Child Hospital of Guangxi Zhuang Autonomous Region, China. RESULTS: Thirty-one patients were included in this study. The mean gestational age, sac diameter and thickness of the uterine scar were 49.6 ± 7.7 days, 1.8 ± 0.6 cm and 0.30 ± 0.15 cm, respectively. The median pretreatment serum ß-human chorionic gonadotropin (ß-HCG) level was 40,887 mIU/mL, with the 25th and 75th percentiles at 19,852 and 74,552, respectively. The median blood loss during D&C was 20 mL with the 25th and 75th percentiles at 10 mL and 50 mL. Following D&C, a Foley's balloon catheter compression was implanted in 26 (83.9%) patients due to active uterine bleeding. All patients had a ß-HCG regression time of ≤ 4 weeks after D&C. While 30 patients (96.8%) had a uterine recovery time of ≤ 4 weeks, and 29 patients (93.5%) had resumption of menstruation of less than 6 weeks. Three patients (9.7%) had complications. One of them suffered from massive vaginal bleeding and underwent s blood transfusion. There were no other complications, such as pelvic infection and uterine rupture during the procedures. And no patient was converted to surgical resection or uterine artery embolization. Overall, 30 patients (96.8%) were treated successfully. CONCLUSION: Local intra-gestational sac methotrexate injection followed by D&C with the aid of a Foley's balloon catheter compression appears to be a safe and effective treatment for CSP. Further randomized controlled trials are suggested to confirm these findings.

Non-pharmacological anxiety reduction with immersive virtual reality for first-trimester dilation and curettage: a pilot study.

OBJECTIVES: Most women experience moderate to severe pain during first-trimester surgical termination of pregnancy despite the application of various analgesic techniques. Studies have shown that virtual reality (VR) is effective in reducing anxiety among a range of women in differing circumstances. Our study objectives were to assess the feasibility of using VR during first-trimester dilation and curettage under local anaesthesia and understand the effect of VR on procedure-related anxiety during first-trimester dilation and curettage. METHODS: A pilot feasibility study was conducted in a convenience sample of 30 women (15 in the intervention group and 15 in the control group). Anxiety scores were recorded before, during and after the procedure. In-depth interviews were conducted after the procedure. RESULTS: Participants reported that VR was either very effective (53%) or somewhat effective (40%) in relieving anxiety during and after the procedure. Eleven participants used the VR device for the entire procedure and four participants removed it during the procedure. The anxiety scores before the procedure were not significantly different between the groups. The intervention group had a median five point post-procedure decrease in anxiety score rated on a visual analogue scale, which was significantly different from that of the control group. Overall, participants had a positive experience but there were some technological frustrations. CONCLUSION: Women undergoing dilation and curettage in the first trimester were able to use a VR device during the procedure. VR-induced distraction and relaxation helped to reduce anxiety in some participants both during and after the procedure.

Different Surgical Approaches to 313 Cesarean Scar Pregnancies.

STUDY OBJECTIVE: To evaluate the efficacy of different surgical treatments for cesarean scar pregnancy (CSP). DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Affiliated university hospitals. PATIENTS: Women (n = 313) with CSP. INTERVENTIONS: Dilation and curettage under ultrasound guidance (DCUS, n = 124), dilation and curettage with hysteroscopic guidance (DCH, n = 103), vaginal excision (n = 55), laparotomy (n = 12), and laparoscopy (n = 19). MEASUREMENTS AND MAIN RESULTS: Undetectable serum human chorionic gonadotropin (hCG) levels and thickness of the uterine scar were measured before and after surgery. Success rates of the 5 surgical treatments of CSP (DCUS, DCH, vaginal excision, laparotomy, and laparoscopy) ranged between 89% and 100%. Postoperative treatment was not needed in the vaginal and laparotomy groups, and vaginal treatment was associated with shorter operative time than laparotomy and laparoscopy and shorter time to undetectable hCG levels than DCUS and DCH. Serum hCG levels on day 3 after surgery were significantly lower than baseline levels in all groups of patients, but there was no significant difference between levels on days 3 and 5 postoperatively. Median scar thickness after surgery in the vaginal surgery, laparotomy, and laparoscopy groups was thicker than that in the DCUS and DCH groups. CONCLUSION: In certain circumstances, CSP can be treated simply by DCH or DCUS. However, time to undetectable hCG levels is prolonged compared with more invasive techniques.

Cost-effectiveness analysis of biopsy strategies for endometrial cancer diagnosis in women with postmenopausal bleeding: Pipelle sampling curette versus dilatation & curettage.

BACKGROUND: Endometrial sampling is widely used for accurate diagnosis of endometrial cancer (EC), which is the most common gynecologic cancer in US women. The objective of this study was to explore the cost-effectiveness of two endometrial sampling procedures for diagnosing EC: (1) Pipelle endometrial sampling (Pipelle), and (2) dilatation & curettage (D&C), while accounting for sampling procedure failure rates and diagnostic accuracy in women with postmenopausal bleeding (PMB). METHOD: The decision analytic model was built to compare the cost-effectiveness of Pipelle and D&C strategies in a hypothetical cohort of PMB women. The analysis was performed from the perspective of a public healthcare payer (Medicare, US). We used 2017 Medicare reimbursement data for cost estimation. The effectiveness of these two diagnostic strategies was measured by analyzing the remaining life expectancy after EC diagnosis and subsequent treatment. RESULTS: The base case analysis suggested that Pipelle was not only equally effective (32.11 vs. 32.11 years of life), but also less costly ($1897.80 vs. $2999.11) based on Medicare reimbursement when compared to D&C. In one-way sensitivity analyses and Monte Carlo probabilistic sensitivity analysis, the Pipelle remained the more cost-effective sampling strategy even after accounting for sampling failure rate associated with each sampling strategy. CONCLUSION: The Pipelle is the more cost-effective sampling strategy compared to D&C for EC diagnosis in women with PMB. From the cost-effectiveness perspective, the higher sampling failure rate of Pipelle should not be regarded as a limitation in its clinical application.

Diagnosis and management of patients with enhanced myometrial vascularity associated with retained products of conception.

OBJECTIVES: To assess the complication rate, including estimated amount of blood loss, in patients undergoing dilation and curettage (D&C) for the treatment of retained products of conception with markedly enhanced myometrial vascularity mimicking arteriovenous malformation. METHODS: This was a retrospective medical-records review study of patients with retained products of conception with enhanced myometrial vascularity presenting to our ultrasound unit between August 2015 and August 2017. Color/power Doppler imaging was used subjectively to identify the degree and extent of vascularity. All patients underwent D&C, and their operative reports and medical records were reviewed to see if ultrasound guidance was used, to ascertain estimated blood loss and to identify complications during or after the procedure. RESULTS: The study group included 31 patients, of whom seven had retained products of conception after a vaginal delivery and 24 had retained products of conception after a first-trimester termination or miscarriage. The largest dimension of the region of enhanced myometrial vascularity ranged from 10 mm to 53 mm, with 14/31 having a width of ≥ 20 mm. Fifteen patients underwent a standard D&C procedure, 13 an ultrasound-guided procedure and three hysteroscopy. Estimated operative blood loss varied from negligible to a maximum of 400 mL. There were no intraoperative complications, although one patient was treated for presumed endometritis. CONCLUSIONS: An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as 'acquired arteriovenous malformation', with some recommending management with uterine-artery embolization. Our study demonstrates that the enhanced myometrial vascularity is associated with retained products of conception, and surgical removal by D&C, possibly with the aid of ultrasound guidance or hysteroscopy, is a safe treatment option. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Misoprostol treatment vs expectant management in women with early non-viable pregnancy and vaginal bleeding: a pragmatic randomized controlled trial.

OBJECTIVE: To compare vaginal misoprostol treatment with expectant management in early non-viable pregnancy with vaginal bleeding with regard to complete evacuation of the uterine cavity within 10 days after randomization. METHODS: This was a parallel randomized controlled, open-label trial conducted in Skåne University Hospital, Sweden. Patients with anembryonic pregnancy or early fetal demise (crown-rump length ≤ 33 mm) and vaginal bleeding were randomly allocated to either expectant management or treatment with a single dose of 800 µg misoprostol administered vaginally. Patients were evaluated clinically and by ultrasound until complete evacuation of the uterus was achieved (no gestational sac in the uterine cavity and maximum anteroposterior diameter of the intracavitary contents < 15 mm as measured by transvaginal ultrasound on midsagittal view). Follow-up visits were planned at 10, 17, 24 and 31 days. Dilatation and evacuation (D&E) was recommended if miscarriage was not complete within 31 days, but was performed earlier at patient's request, or if there was excessive bleeding as judged clinically. Analysis was by intention to treat. The main outcome measure was number of patients with complete miscarriage without D&E ≤ 10 days. RESULTS: Ninety-four patients were randomized to misoprostol treatment and 95 to expectant management. After exclusion of three patients and withdrawal of consent by two patients in the expectant management group, 90 women were included in this group. Miscarriage was complete ≤ 10 days in 62/94 (66%) of the patients in the misoprostol group and in 39/90 (43%) of those in the group managed expectantly (risk difference (RD) = 23%; 95% CI, 8-37%). At 31 days, the corresponding figures were 81/94 (86%) and 55/90 (61%) (RD = 25%; 95% CI, 12-38%). Two patients from each group underwent emergency D&E because of excessive bleeding and one of these in each group received blood transfusion. The number of patients undergoing D&E at their own request was higher in the expectantly managed group, 15/90 (17%) vs 3/94 (3%) in the misoprostol group (RD = 14%; 95% CI, 4-23%), as was the number of patients making out-of-protocol visits, 50/90 (56%) vs 27/94 (29%) (RD = 27%; 95% CI, 12-40%). Compared with the expectant management group, more patients in the misoprostol group experienced pain (71/77 (92%) vs 91/91 (100%); RD = 8%; 95% CI, 1-17%) and used painkillers (59/77 (77%) vs 85/91 (93%); RD = 17%; 95% CI, 5-29%). No major side effect was reported in any group. CONCLUSIONS: In women with early non-viable pregnancy and vaginal bleeding, misoprostol treatment is more effective than is expectant management for complete evacuation of the uterus. Both methods are safe but misoprostol treatment is associated with more pain than is expectant management. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Tumor Grade Correlation Between Preoperative Biopsy and Final Surgical Specimen in Endometrial Cancer: The Use of Different Diagnostic Methods and Analysis of Associated Factors.

OBJECTIVE: This study aimed to identify the correlation between histology tumor grade of the preoperative biopsy using dilatation and curettage (D&C), Pipelle, or hysteroscopy and final surgical specimen in women with endometrioid endometrial cancer. MATERIALS AND METHODS: Patients on whom a preoperative biopsy was performed between 2009 and 2016 were reviewed and cases with apparent early-stage endometrioid endometrial cancer were included in the study. The accuracy of preoperative biopsy performed before hysterectomy using D&C, Pipelle, or hysteroscopy was compared. RESULTS: A total of 332 patients were included. The diagnostic method was D&C in 43 cases (13%), Pipelle in 102 (31%), and hysteroscopy in 187 (56%). The preoperative diagnosis included G1 tumors in 177 cases (53.3%), G2 in 103 (31%), and G3 in 52 (15.6%). The surgical specimen confirmed endometrioid endometrial tumor in 309 patients (93%).The accuracy rates of preoperative biopsy and surgical specimen were 74.69%, 73.19%, and 89.75% for G1, G2, and G3, respectively. Hysteroscopy showed better κ index (κ = 0.551) than did D&C (κ = 0.392) and Pipelle (κ = 0.430). Tumor diameter greater than 30 mm was the only factor independently associated with absence of correlation between preoperative and postoperative tumor grade (odds ratio [95% confidence interval], 1.959 [1.096-3.504], P = 0.023). CONCLUSIONS: Preoperative biopsy, regardless of the method, has its limitations in predicting the tumor grade compared with final surgical specimen in women with endometrioid endometrial cancer at an apparent early stage. Concordance between the biopsy and hysterectomy specimen is less likely to happen in the case of preoperative G1 or G2 tumors, as well as in big tumors. Although hysteroscopy was associated with the highest tumor grade agreement, no differences in correlation between the 3 methods (D&C, Pipelle, and hysteroscopy) were found.

Cytological assessment of endometrial washings obtained with Karman cannula using a liquid-based preparation method for the detection of endometrial pathologies.

OBJECTIVE: The aim of this study was to evaluate the diagnostic efficacy and utility of liquid-based cytology in ThinPrep (Cytyc Corporation, Boxborough, MA) for endometrial lesions in patients presenting with abnormal uterine bleeding. MATERIALS AND METHODS: Two hundred and thirteen women scheduled for dilatation and curettage because of abnormal uterine bleeding were enrolled in the study. After providing informed consent, all the women proceeded sequentially to endometrial cytology and then dilatation and curettage. RESULTS: In the premenopausal group, cytological failure was 4.8%, histopathological failure was 2.4%; cytologic insufficiency in the postmenopausal group was 2.1%, and histopathologic insufficiency was 19.6%. When cytologic and histopathological sufficiency rates were compared in all cases, cytologic insufficiency was 4.2% and histopathologic insufficiency was 6.1%. This difference was statistically significant (p < 0.039). The diagnostic accuracy, sensitivity, specificity, PPV, and NPV of the liquid-based endometrial cytology for premenopausal patients were 96.79, 58.33, 97.92, 70, and 96.58%, respectively. In the postmenopausal cases, the accuracy of diagnosis of endometrial cytology was 97.30%, sensitivity 100%, specificity 96.67%, PPV 87.50%, and NPV 100%. When cytologic and histopathologically inadequate cases were excluded, no cytologic and histopathological abnormal findings were found in endometrial thickness cutoff ≤ 5 mm for all patients. CONCLUSION: The use of liquid-based cytology with TVS may contribute to increasing the diagnostic accuracy of the test and reduce unnecessary D&C for women. When TVS is used as a triage indicator, regardless of menopausal status in ≤ 5 mm endometrial thickness cases, endometrial cytology is an absolutely reliable method for detecting cancer.

Is Routine Curettage a Useful Tool to Evaluate Persistent Tumor in Patients Who Underwent Primary Chemoradiation for Locally Advanced and/or Lymph Node Positive Cervical Cancer?

OBJECTIVE: Response evaluation after primary chemoradiation (RCTX) in patients with cervical cancer remains difficult. Routine hysterectomy after primary RCTX is associated with considerable surgical morbidity without impact on survival. The purpose of the present study was to evaluate value of routine curettage after RCTX to detect persistent tumor. METHODS: Between 2006 and 2012, patients (n = 217) with cervical cancer in International Federation of Gynecology and Obstetrics stages IB1 N1 (14%), IB2 (9%), IIA (5%), IIB (46%), IIIA (4%), IIIB (15%), IVA (6%), and IVB (1%), respectively, underwent primary RCTX. After RCTX, curettage was recommended to all patients to evaluate response. RESULTS: In 136 (63%) of patients with cervical cancer, 1 or 2 consecutive curettages were performed at least 6 weeks after primary RCTX without any complications. In 21 (15%) patients, at least 1 curettage was positive for cervical cancer. In 7 patients, secondary hysterectomy was performed after 1 positive finding and persistent tumor was found in all of them. In the remaining 14 patients, there were 2 positive curettages in 5, 1 undetermined result followed by 1 positive in 3, and 1 positive followed by 1 negative in 6 patients, respectively. In the latter group, no tumor was detected in the uterus, whereas in all other patients with 2 curettages except one, residual carcinoma was detected. Five (24%) of 21 patients with positive histology are free of disease during follow-up. Decision for or against secondary hysterectomy was correct due to histological finding of curettage in 99%. CONCLUSIONS: Routine curettage is a useful tool to guide decision for secondary hysterectomy with high accuracy after primary RCTX and avoids overtreatment.

Liquid-based endometrial cytology associated with curettage in the investigation of endometrial carcinoma in a population of 1987 women.

PURPOSE: The aim of this study was to investigate the diagnostic accuracy of liquid-based endometrial cytology, in comparison with histology. METHODS: 1987 patients scheduled for hysteroscopy were enrolled in this study. All patients proceeded sequentially through endometrial cytology, hysteroscopy and then dilatation and curettage (D&C). Cytology sampling was performed by brushing the uterus cavity using SAP-1 and the sample was prepared to liquid-based smear using SurePath technology. The slides were stained by Papanicolaou method. All cytological diagnosis was correlated with the D&C histological diagnosis. RESULTS: Cyto-histological correlations were possible in 1672 (89.3%) patients: in 254 (12.8%) patients the D&C was inadequate, in 75 (3.8%) patients the cytology was inadequate, and in 14 (0.7%) patients both were inadequate. In postmenopausal women, 758 of 790 cytologies (96.0%) were adequate, while 586 of 790 histologies (74.2%) were adequate. SAP-1 provided more sufficient materials for cytology than D&C for histology (P < 0.001). Taking atypical hyperplasia or worse as a positive result, the diagnostic accuracy of liquid-based endometrial cytology was 86.1%, sensitivity was estimated at 70.3%, specificity at 88.5%, positive predictive value at 48.0% and negative predictive value at 95.2%. Taking endometrial carcinoma as a positive result, the diagnostic accuracy of liquid-based endometrial cytology was 94.4%; sensitivity was estimated at 53.2%, specificity at 98.6%, positive predictive value at 79.8% and negative predictive value at 95.3%. CONCLUSIONS: Liquid-based endometrial cytology can be considered a useful method for detecting of endometrial pathology as a first-line approach.

Comparison of Tissue Yield Using Frictional Fabric Brush Versus Sharp Curettage For Endocervical Curettage.

OBJECTIVE: The aim of the study was to evaluate and compare the diagnostic yield of conventional endocervical curettage (ECC) with fabric-based ECC in a consistent physician group. MATERIALS AND METHODS: This is a retrospective case-control study of patients who underwent ECC both before and after introduction of a fabric-based ECC device. Histologic examination of curettings was categorized as satisfactory, limited, or inadequate. The Kruskall-Wallis test was used to compare proportions of gross descriptions and final diagnoses between groups. RESULTS: Between January 2010 and July 2011, 9234 ECCs were performed using conventional ECC technique. From September 2011 to October 2013, 774 ECCs were performed with the fabric-based ECC. Using the conventional ECC technique, 7809 (84.6%) of specimens were satisfactory, 1037 (11.2%) were limited, and 388 (4.2%) were inadequate and repeat biopsy was recommended. With fabric ECC, 705 (91.1%) of specimens were satisfactory, 64 (8.3%) were limited, and 5 (0.6%) were inadequate, and repeat biopsy was recommended. There were significantly fewer inadequate specimens with the fabric-based ECC (4.2% vs 0.6%, p < .001). CONCLUSIONS: Fabric-based ECC may significantly decrease inadequate and limited ECC specimens.

Case Report of an Ectopic Molar Pregnancy in the Presence of an Intrauterine Device.

BACKGROUND: Ectopic molar pregnancy is a rare phenomenon and has not been reported in the presence of an intrauterine device (IUD). Clinical diagnosis of molar pregnancy is challenging and requires careful follow-up. CASE: A 25-year-old woman (gravida 2, para 0) with a copper IUD in place presented with a positive pregnancy test. Diagnosis of the complete hydatidiform mole was pathologically confirmed after surgery following clinical and sonographic investigations that identified a left-sided ectopic pregnancy. CONCLUSION: Gestational trophoblastic disease (GTD) presenting as an ectopic pregnancy is a very rare occurrence. This patient recovered without event through a combined management and follow-up for ectopic pregnancy and gestational trophoblastic disease. Appropriate identification and management of this clinical problem is essential in order to prevent initial complications as well as subsequent malignant sequelae.

Hysteroscopic Curettage Using the Lin Snare and Y Adaptor: A Review of 300 Cases.

STUDY: To present a de novo technique of endometrial sampling - hysteroscopic curettage. OBJECTIVE: Aim to describe this new procedure and study its effectiveness and accuracy. DESIGN: Prospective study (Canadian Task Force Classification II-2). SETTING: University-affiliated public hospital. PATIENTS: Two hundred and ninety-three consecutive patients who attended outpatient gynaecological endoscopic centre. INTERVENTION: A total of 300 hysteroscopic curettage was carried out using flexible hysteroscope and Lin snare system. MAIN RESULTS: The procedure failure rate is 2.67%. Out of 292 successful hysteroscopic curettages, hysteroscopy alone has a sensitivity of 99% and negative predictive value of 97.7%. The accuracy was further improved to near perfection with curettage histology. The negative predictive value is 99%. CONCLUSION: Hysteroscopic curettage is easy to perform, highly effective and accurate. It offers an excellent outpatient alternative for patients who require endometrial sampling and/or an evaluation of abnormal uterine bleeding.

Management of Cesarean Scar Pregnancy Using Ultrasound-Guided Dilation and Curettage.

STUDY OBJECTIVE: To evaluate the potential risk factors associated with failed ultrasound-guided dilation and curettage (D&C) treatment of cesarean scar pregnancy (CSP). DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: Fifty-one patients diagnosed with CSP and treated with ultrasound-guided D&C at Shanghai General Hospital of Shanghai Jiao Tong University. INTERVENTION: Lesion resection using ultrasound-guided D&C. MEASUREMENTS AND MAIN RESULTS: Clinical characteristics, vaginal bleeding, abdominal pain, the size of the gestational sac, cardiac motion, blood flow around the gestational sac, cesarean scar thickness, and serum ß-human chorionic gonadotropin (ß-hCG) levels were compared between the successful operation group and the failed operation group. Cesarean scar thickness was the main risk factor that determined the success of ultrasound-guided D&C. The success rates were 50% and 97.67% for those with cesarean scars <3 mm thick and those with scars >3 mm thick, respectively (p = .001). The success rate was also associated with the abundance of blood flow surrounding the capsule and size of the gestational sac (p < .005). Surgical success was not affected by abnormal vaginal bleeding, abdominal pain, cardiac motion, or serum ß-hCG levels. CONCLUSION: Ultrasound-guided D&C is the first choice for treating CSP if the cesarean scar is >3 mm thick, blood flow is not abundant, and the maximum diameter of the gestational sac is <30 mm. A transabdominal procedure is preferred for patients with high-risk factors.