RESUMEN
BACKGROUND: Misoprostol is a well-studied medical treatment for early pregnancy loss (EPL), with success rates ranging between 70 and 90%. However, treatment failure is associated with major patient discomfort, including the need for surgical intervention to evacuate the uterus. It was previously reported that medical treatment was especially successful among women who conceived after in vitro fertilization (IVF). We aimed to study if there is a difference in rates of medical treatment failures for EPL between pregnancies conceived by IVF and spontaneous pregnancies. METHODS: In this retrospective cohort study, we included all women who underwent medical treatment for EPL at our institute between 07/2015 and 12/2020. Treatment outcome was compared between IVF and spontaneous pregnancies. Treatment failure was defined as a need for surgical intervention, namely, dilation & curettage (D&C) and/or hysteroscopy, due to retained products of conception, which was defined as a gestational sac or endometrial thickness greater than 15 mm in a TVS scan. RESULTS: Overall, 775 patients were included, of which 195 (169/775 = 25.1%) ultimately required surgical intervention. There was no difference between the study groups in the rate of treatment failure. However, among IVF pregnancies, the rate of emergency D&C was lower (3.6% vs. 9.8%, p = 0.001), compared to spontaneous group. CONCLUSION: In cases of medical treatment for EPL, IVF pregnancies had no differences in rates of treatment failure compared to spontaneous pregnancies. That being said, IVF pregnancies have lower chances to undergo emergency D&C, compared to spontaneous pregnancies.
Asunto(s)
Aborto Espontáneo , Misoprostol , Embarazo , Humanos , Femenino , Estudios Retrospectivos , Fertilización In Vitro , Fertilización , Resultado del EmbarazoRESUMEN
RESEARCH QUESTION: What is the global variability in misoprostol treatment for the management of early pregnancy loss (EPL)? DESIGN: An international web-based survey of fertility specialists and obstetrics and gynaecology clinicians was conducted between August and November 2020. The survey consisted of 16 questions addressing several aspects of misoprostol treatment for EPL. RESULTS: Overall, 309 clinicians from 80 countries participated in the survey, of whom 67.3% were fertility specialists. Nearly one-half (47.9%) of the respondents let the patient choose the first line of treatment (expectant management, misoprostol treatment or surgical aspiration) according to her own preference. The 248 respondents who administer misoprostol in their daily practice were asked further questions; 59.7% of them advise patients to take the medication at home. The most common dose and route of administration is 800 µg administered vaginally. Only 28.6% of participants use mifepristone pretreatment. Variation in the timing of the first follow-up visit after misoprostol administration was wide, ranging from 24 h to 1 week in most clinics. In case of incomplete expulsion, only 42.3% of the respondents routinely administer a second dose. The timing of the final visit and the definition of successful treatment also differed greatly among respondents. CONCLUSIONS: There is large variability in the use of misoprostol for the management of EPL. High-quality research is necessary to examine several aspects of the treatment. Particularly, the timing and effectiveness of a second dose administration and the criteria to decide on treatment failure or success deserve more research in the future.
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Aborto Espontáneo/tratamiento farmacológico , Misoprostol/administración & dosificación , Oxitócicos/administración & dosificación , Medicina Reproductiva/estadística & datos numéricos , Femenino , Humanos , Internacionalidad , Embarazo , Encuestas y CuestionariosRESUMEN
RESEARCH QUESTION: Does long-term reproductive outcome after early pregnancy loss (EPL) differ between women who are treated with misoprostol and surgical aspiration. DESIGN: A historic cohort study of all women who were diagnosed with early pregnancy loss (≤12 weeks), in a single medical centre, between September 2016 and August 2017, was conducted. The women were treated with either misoprostol or surgical aspiration according to their own preferences. Women who were lost to follow-up or did not attempt to conceive again were excluded. The primary outcome measure was the cumulative pregnancy rate within 12 months from intervention. RESULTS: Baseline characteristics were comparable between women who received misoprostol (nâ¯=â¯163) and women who underwent surgical aspiration (nâ¯=â¯122). Women who received misoprostol had a higher rate of interventions for retained products of conception (11.0% versus 3.3%, respectively; Pâ¯=â¯0.015). The misoprostol and the surgical aspiration groups did not differ in rate of repeated miscarriages (17.8% versus 21.3%, respectively; Pâ¯=â¯0.45), or pregnancy rate within 6 months (58.3% versus 50.0%, respectively; Pâ¯=â¯0.16), 12 months (78.5% versus 78.7%, respectively; Pâ¯=â¯0.97) and 24 months (92.0% versus 91.8%, respectively; Pâ¯=â¯0.94). Live birth rate within 24 months was comparable (62.0% versus 58.2%, respectively; Pâ¯=â¯0.52), as well as gestational age at birth (38.5 versus 38.6 weeks, respectively; Pâ¯=â¯0.81) and birthweight (3295 versus 3161 g, respectively; Pâ¯=â¯0.07). CONCLUSIONS: Long-term reproductive outcomes are comparable in women with EPL who are treated with either misoprostol or surgical aspiration. Our findings may help counselling patients facing EPL who have concerns about their future reproduction.
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Abortivos no Esteroideos/uso terapéutico , Aborto Espontáneo/terapia , Misoprostol/uso terapéutico , Paracentesis , Reproducción/fisiología , Aborto Espontáneo/tratamiento farmacológico , Aborto Espontáneo/cirugía , Adulto , Femenino , Humanos , Embarazo , Resultado del Embarazo , Primer Trimestre del Embarazo , Resultado del TratamientoRESUMEN
OBJECTIVE: To compare patient characteristics, imaging results, surgical management and prognosis of borderline ovarian tumors (BOT) between pre and postmenopausal patients. MATERIALS AND METHODS: A retrospective cohort of all cases of histologically verified BOT between 1990-2018, comparing presentation, imaging, surgical procedures and recurrence. Patients were included in the postmenopausal group if they reported 12 months of amenorrhea with or without menopausal symptoms. RESULTS: During this 28 year study period, 66 operations were performed in which BOT was confirmed. Postmenopausal patients were 37-89 years old and premenopausal patients 18-50 years old, with an average age of 63.9 ± 13.4 and 36.2 ± 8.4 years, respectively (p < 0.001). The majority of patients in both groups were diagnosed due to abdominal pain, followed by incidental diagnosis on routine ultrasound. Imaging and CA-125 levels upon presentation were similar. Almost sixty percent of postmenopausal and 26.3% of premenopausal patients underwent laparotomy (p = 0.01), while those who underwent laparoscopy were 35.7% and 60.5%, respectively (p = 0.03). Most postmenopausal patients underwent bilateral salpingo-oophorectomy (BSO), whereas premenopausal surgeries involved cystectomy. Nearly all study patients were diagnosed in stage one. Malignant transformation occurred in 7.1% of postmenopausal patients. No malignant transformation was found in premenopausal patients. CONCLUSION: BOT's present similarly in pre and postmenopausal patients. Postmenopausal patients undergo more extensive surgery, and are diagnosed in early stage disease. Despite a tendency for a more conservative approach in premenopausal patients, prognosis is similar in both groups.
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Neoplasias Ováricas/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Persona de Mediana Edad , Neoplasias Ováricas/patología , Posmenopausia , Premenopausia , Pronóstico , Estudios RetrospectivosRESUMEN
RESEARCH QUESTION: Does extending the follow-up after misoprostol treatment for early pregnancy loss increase the success rate? DESIGN: Patients who had experienced early pregnancy loss (<12 weeks) and were treated with misoprostol in a single university-affiliated medical centre were prospectively followed before and after the implementation of a new treatment protocol extending the follow-up from 1 to 2 weeks. All patients received misoprostol 800 µg vaginally on day 1 and a second dose, when needed, on day 4 or 8. Patients underwent surgical aspiration after 1 week in the early follow-up group (nâ¯=â¯84) or 2 weeks in the delayed follow-up group (nâ¯=â¯85) if complete expulsion was not achieved (defined as endometrial thickness ≤15 mm and absence of gestational sac on transvaginal sonography). The primary outcome was treatment success, defined as no need for surgical aspiration. RESULTS: Women in the delayed follow-up group had a higher rate of successful treatment compared with women in the early follow-up group (88.2% versus 76.2%, respectively; Pâ¯=â¯0.040), and a lower rate of second dose administration (32.9% versus 51.2%, respectively; Pâ¯=â¯0.016). The incidence of non-expulsion of the gestational sac was also lower in the delayed follow-up group (1.2% versus 10.7%; Pâ¯=â¯0.009). Treatment acceptability did not differ between the study groups. CONCLUSION: In women with early pregnancy loss treated with misoprostol, extending the follow-up protocol from 1 to 2 weeks resulted in an increase in treatment success.
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Aborto Espontáneo/tratamiento farmacológico , Cuidados Posteriores/métodos , Pérdida del Embrión/tratamiento farmacológico , Misoprostol/uso terapéutico , Tiempo de Tratamiento , Aborto Incompleto/diagnóstico , Aborto Incompleto/terapia , Aborto Espontáneo/terapia , Adulto , Intervención Médica Temprana/métodos , Pérdida del Embrión/terapia , Femenino , Edad Gestacional , Humanos , Embarazo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Isolated fallopian tube torsion (IFTT) is a rare gynecological entity and its diagnosis is challenging. OBJECTIVES: To compare clinical characteristics, sonographic findings, surgical management, and outcomes of women with surgically verified IFTT compared to those diagnosed with adnexal torsion. METHODS: A retrospective case-control study in a university hospital was conducted. Thirty-four women with surgically verified IFTT between March 1991 and June 2017 were compared to 333 women diagnosed with adnexal torsion within the same time period. RESULTS: Both groups presented primarily with abdominal pain, which lasted longer prior to admission among the IFTT group (46.8 ± 39.0 vs. 30.0 ± 39.4 hours, P < 0.001). Higher rates of abdominal tenderness with or without peritoneal signs were found in the adnexal torsion group (90.3% vs. 70.6%, P < 0.001). Sonographic findings were similar; however, an increased rate of hydrosalpinx was found among the IFTT group (5.9% vs. 0.0%, P = 0.008). Suspected adnexal torsion was the main surgical indication in only 61.8% of IFTT cases compared with 79.0% in the adnexal torsion group (P = 0.02). Salpingectomy with or without cystectomy was more commonly performed in the IFTT group (35.3% vs. 1.5%, P < 0.001). The leading pathological findings among the IFTT group were hydrosalpinx and paraovarian cysts. CONCLUSIONS: The clinical signs and symptoms of IFTT and adnexal torsion are similar. Although sonographic imaging demonstrating a paraovarian cyst or hydrosalpinx may be helpful in diagnosing IFTT, it is rarely done preoperatively.
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Enfermedades de los Anexos/diagnóstico por imagen , Anexos Uterinos/diagnóstico por imagen , Anexos Uterinos/cirugía , Enfermedades de los Anexos/cirugía , Adulto , Estudios de Casos y Controles , Enfermedades de las Trompas Uterinas/diagnóstico por imagen , Enfermedades de las Trompas Uterinas/cirugía , Trompas Uterinas/diagnóstico por imagen , Trompas Uterinas/cirugía , Femenino , Humanos , Estudios Retrospectivos , Anomalía Torsional , Ultrasonografía/métodosRESUMEN
BACKGROUND: When a woman with an endometrioma presents with acute abdominal pain, it is unclear whether ovarian torsion should be suspected. OBJECTIVES: To compare patient characteristics, imaging results, and surgical management of endometriomas in elective versus emergent surgeries. METHODS: This retrospective cohort study included women treated at our institution during the period 1990-2015 who presented with histologically verified endometrioma and who underwent either planned surgery or emergent surgery due to suspected adnexal torsion. RESULTS: Of 225 surgeries performed, 174 were elective and 51 emergent. Patients in the emergent group were significantly younger (33.9 ± 11.1 vs. 39.01 ± 10.9 years, P = 0.004). Abdominal pain was the main complaint of all the emergent surgery patients and the leading complaint in 21% of the elective surgery patients (P < 0.001), with right-sided predominance in both groups. Sonographic parameters were similar in both groups. Bilateral ovarian cysts were noted in 11.7% and 11.0% of emergent and elective patients, respectively (P = 0.87). Laboratory evaluation was notable for a higher white blood cell count and CA125 levels among emergent patients. All patients in the emergent group and 93% of patients in the elective group were managed laparoscopically. No cases of torsion were noted. The rate of intra-pelvic adhesions was similar in both groups (56.8% vs. 66.6%, P = 0.19). CONCLUSIONS: Endometrioma may present with acute abdominal pain. However, adnexal torsion in these patients is rare. These cases can be managed using a minimally invasive approach, assuming an optimal surgical setting.
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Enfermedades de los Anexos/complicaciones , Enfermedades de los Anexos/diagnóstico por imagen , Endometriosis/complicaciones , Endometriosis/cirugía , Anomalía Torsional/complicaciones , Anomalía Torsional/diagnóstico por imagen , Dolor Abdominal/etiología , Dolor Abdominal/cirugía , Dolor Agudo/etiología , Dolor Agudo/cirugía , Enfermedades de los Anexos/cirugía , Adulto , Estudios de Cohortes , Procedimientos Quirúrgicos Electivos/métodos , Endometriosis/diagnóstico por imagen , Femenino , Humanos , Estudios Retrospectivos , Anomalía Torsional/cirugía , Resultado del Tratamiento , Ultrasonografía/métodosRESUMEN
STUDY OBJECTIVE: To compare the operative results of midurethral sling (MUS) surgeries for stress urinary incontinence (SUI) performed by residents under the guidance of an attending specialist in urogynecology and those performed by attendings. DESIGN: Retrospective chart review (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: A retrospective analysis of all MUS surgeries performed at a single public tertiary medical center between January 2009 and December 2013 was carried out. A total of 257 patients underwent transobturator tape (TOT) placement during the study period, including 136 (52.9%) placed by an attending specialist in urogynecology (group A) and 121 (47.1%) placed by a resident, under the guidance of an attending (group B). MEASUREMENTS: The efficacy of treatment was evaluated in terms of early postoperative course, reoperation, and symptom improvement, as based on the Pelvic Floor Distress Inventory short form (PFDI-20) questionnaire. The primary outcome was patient-reported symptoms of SUI, as assessed with the PFDI-20 questionnaire, as well as absence of surgical retreatment for SUI. RESULTS: Immediate postoperative complications were comparable in the 2 groups, as were subjective failure and self-reported SUI. The primary outcome-moderate and severe symptoms of SUI-were reported by 23.7% of the patients in group A and 23.6% of those in group B (p = .91). At a mean follow-up of 40 months in both groups, symptoms, as assessed using the urinary scale and prolapse scale of the PFDI-20, were also similar in the 2 groups. The rate of reoperation with repeated sling for SUI was 5% in both groups. CONCLUSION: The operative results of TOT surgery for SUI performed by residents under the guidance of an attending specialist in urogynecology did not differ significantly from those performed by the attendings themselves.
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Internado y Residencia , Cabestrillo Suburetral , Incontinencia Urinaria de Esfuerzo/cirugía , Procedimientos Quirúrgicos Urológicos/métodos , Adulto , Anciano , Femenino , Humanos , Modelos Logísticos , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
AIM: To compare clinical variables, sonographic findings and pregnancy outcomes following the hysteroscopic removal of retained products of conception (RPOC) after delivery and abortion. METHODS: This is a retrospective cohort of operative hysteroscopies performed between 2011 and 2015 for suspected RPOC, during which trophoblastic tissue was obtained. Patient demographics, clinical presentation, sonographic evaluation, subsequent infertility and pregnancy outcomes were compared between post-delivery (n = 85) and post-abortion (n = 93) cases. RESULTS: The main presenting symptom in both study groups was vaginal bleeding. On sonographic evaluation, maximal endometrial thickness was significantly higher in the post-delivery group, while irregularity and increased flow were more common in the post-abortion group. There was a similar rate of deliveries following hysteroscopy in both groups with 40% in the post-delivery group and 39.7% in the post-abortion group. Deliveries in the post-delivery group were characterized by a higher rate of abnormal placentation - 30.5% - including low lying placenta and placenta accreta. A significant rate of vaginal deliveries in both groups entailed manual removal of the placenta or exploration of the uterine cavity (23.5 and 10.5%, p = 0.20). CONCLUSION: Pregnancies following RPOC after delivery entail a higher rate of abnormal placentation.
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Aborto Inducido/efectos adversos , Parto Obstétrico/efectos adversos , Histeroscopía/métodos , Retención de la Placenta/cirugía , Resultado del Embarazo/epidemiología , Adulto , Estudios de Cohortes , Parto Obstétrico/métodos , Femenino , Humanos , Histeroscopía/efectos adversos , Retención de la Placenta/diagnóstico , Embarazo , Complicaciones del Embarazo/epidemiología , Complicaciones del Embarazo/etiología , Estudios Retrospectivos , Trofoblastos , UltrasonografíaRESUMEN
BACKGROUND: Laparoscopic salpingectomy is strongly related to successful in vitro fertilization (IVF) treatments. OBJECTIVES: To compare the ovarian reserve, including anti-mullerian hormone (AMH) levels, in patients who underwent salpingectomy before IVF to IVF patients who had not been salpingectomized. METHODS: In this retrospective study, medical records of women who were treated by the IVF unit at our institute were reviewed. We retrieved demographic data, surgical details, and data regarding the ovarian reserve. Details of 35 patients who were treated by IVF after salpingectomy were compared to 70 IVF patients with no history of salpingectomy treatment. Nine women underwent IVF treatment before and after having salpingectomy, and their details were included in both groups. RESULTS: The levels of AMH, follicular stimulating hormone (FSH), estradiol, and progesterone were not significantly different in the groups. The antral follicular count (AFC), number of oocytes retrieved, amount of gonadotropin administered for ovarian stimulation, and number of embryos transferred (ET) were also not significantly different. CONCLUSIONS: Salpingectomy does not seem to affect ovarian reserve in IVF patients.
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Hormona Antimülleriana/sangre , Fertilización In Vitro/estadística & datos numéricos , Laparoscopía/estadística & datos numéricos , Reserva Ovárica/fisiología , Salpingectomía/estadística & datos numéricos , Adulto , Femenino , Fertilización In Vitro/métodos , Humanos , Laparoscopía/efectos adversos , Inducción de la Ovulación/métodos , Inducción de la Ovulación/estadística & datos numéricos , Estudios Retrospectivos , Salpingectomía/efectos adversosRESUMEN
BACKGROUND: Different clinical and sonographic parameters have been suggested to identify patients with retained products of conception. In suspected cases, the main treatment is hysteroscopic removal. OBJECTIVES: To compare clinical, sonographic, and intraoperative findings in cases of hysteroscopy for retained products of conception, according to histology. METHODS: The results of operative hysteroscopies that were conducted between 2011 and 2016 for suspected retained products of conception were evaluated. Material was obtained and evaluated histologically. The positive histology group (n=178) included cases with confirmed trophoblastic material. The negative histology group (n=26) included cases with non-trophoblastic material. RESULTS: Patient demographics were similar in the groups, and both underwent operative hysteroscopy an average of 7 to 8 weeks after delivery/abortion. A history of vaginal delivery was more common among the positive histology group. The main presenting symptom in all study patients was vaginal bleeding, and the majority of cases were diagnosed at their routine postpartum/abortion follow-up visit. Sonographic parameters were similar in the groups. Intraoperatively, the performing surgeon was significantly more likely to identify true trophoblastic tissue as such than to correctly identify non-trophoblastic tissue (P < 0.001). CONCLUSIONS: Suspected retained trophoblastic material cannot be accurately differentiated from non-trophoblastic material according to clinical, sonographic, and intraprocedural criteria. Thus, hysteroscopy seems warranted in suspected cases.
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Histeroscopía/métodos , Retención de la Placenta/diagnóstico por imagen , Trofoblastos/patología , Ultrasonografía/métodos , Aborto Inducido/efectos adversos , Aborto Espontáneo , Adulto , Estudios de Cohortes , Parto Obstétrico/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Retención de la Placenta/cirugía , Embarazo , Estudios Retrospectivos , Adulto JovenRESUMEN
STUDY QUESTION: Does repeat administration of misoprostol for early pregnancy loss increase the treatment success rate? SUMMARY ANSWER: Repeat administration of misoprostol does not increase the treatment success rate, and is associated with more analgesics use. WHAT IS KNOWN ALREADY: Misoprostol reduces the need for surgical evacuation and shortens the time to complete expulsion in patients with early pregnancy loss. However, the impact of repeat doses of misoprostol is not clear. STUDY DESIGN, SIZE, DURATION: A randomized clinical trial was conducted in a single tertiary hospital, recruiting women with early pregnancy loss (<12 weeks), seeking medical treatment, between August 2015 and June 2016. A sample size of 160 patients was sufficient to detect a 30% decrease in treatment success. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants received 800 µg of misoprostol vaginally on Day 1, and were then randomly assigned into two groups: Patients in the single-dose group were evaluated on Day 8. Patients in the repeat-dose group were evaluated on Day 4, when they were given a repeat dose if required, and scheduled for re-evaluation on Day 8. If complete expulsion was not achieved on Day 8 (endometrial thickness >15 mm or the presence of gestational sac on transvaginal sonography), participants underwent surgical evacuation. The primary outcome was treatment success, defined as no need for surgical intervention up to Day 8. MAIN RESULTS AND THE ROLE OF CHANCE: Final analysis included 87 participants in the single-dose group and 84 participants in the repeat-dose group, out of whom 41 (48.8%) received a second dose. Treatment succeeded in 67 (77%) patients in the single-dose group and 64 (76%) patients in the repeat-dose group (RR 0.98; 95% CI 0.83-1.16; P = 0.89). Patients in the repeat-dose group reported more use of over the counter analgesics (82.1% versus 69.0%, P = 0.04). LIMITATIONS, REASONS FOR CAUTION: The study was not blinded and our definition of complete expulsion may be debated. Follow-up time was not equal in all participants, since some had a complete expulsion on Day 4 and some underwent emergent D&C before Day 8. This, however, should not affect the primary outcome. WIDER IMPLICATIONS OF THE FINDINGS: Our results suggest that a single-dose protocol is superior to a repeat-dose protocol due to a comparable success rate and more favorable outcomes regarding the need for analgesic drugs. STUDY FUNDING/COMPETING INTEREST(S): We did not receive funding for this study and we declare no conflict of interest. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT02515604). TRIAL REGISTRATION DATE: 2 August 2015. DATE OF FIRST PATIENT'S ENROLMENT: 19 August 2015.
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Aborto Incompleto/tratamiento farmacológico , Aborto Espontáneo/fisiopatología , Pérdida del Embrión/fisiopatología , Misoprostol/administración & dosificación , Oxitócicos/administración & dosificación , Dolor Abdominal/tratamiento farmacológico , Dolor Abdominal/etiología , Aborto Incompleto/diagnóstico por imagen , Aborto Incompleto/etiología , Aborto Incompleto/cirugía , Centros Médicos Académicos , Adulto , Analgésicos/administración & dosificación , Analgésicos/uso terapéutico , Terapia Combinada/efectos adversos , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Humanos , Análisis de Intención de Tratar , Israel , Perdida de Seguimiento , Misoprostol/efectos adversos , Misoprostol/uso terapéutico , Oxitócicos/efectos adversos , Oxitócicos/uso terapéutico , Pacientes Desistentes del Tratamiento , Embarazo , Centros de Atención Terciaria , Ultrasonografía , Legrado por Aspiración/efectos adversosRESUMEN
BACKGROUND: Epithelial ovarian cancer is assumed to derive from the fallopian tube. Salpingectomy has been previously demonstrated to reduce the risk of ovarian cancer, and may be used as a means of sterilization. OBJECTIVE: We aimed to compare short-term ovarian reserve and operative complications in cases of salpingectomy and tubal ligation during cesarean section. STUDY DESIGN: Study patients who underwent elective cesarean section at our institution and requested sterilization were randomized to bilateral salpingectomy or tubal ligation. Prior to surgery, blood samples were obtained for antimüllerian hormone. Surgical course was noted, including overall time, complications, and postoperative hemoglobin. Repeat antimüllerian hormone samples were obtained from patients 6-8 weeks following surgery. RESULTS: In all, 46 patients were recruited for participation, of whom 33 completed a follow-up visit, and for whom repeat antimüllerian hormone levels were available. Patients in the salpingectomy group were slightly older (37.0 ± 3.9 vs 34.3 ± 4.1 years, P = .02). No differences were noted in patient parity, body mass index, or gestational age between the groups. Pregnancy and postdelivery antimüllerian hormone levels were not significantly different between the groups, with an average increase of 0.58 ± 0.98 vs 0.39 ± 0.41 ng/mL in the salpingectomy and tubal ligation groups, respectively (P = .45). Surgeries including salpingectomy were longer by an average 13 minutes (66.0 ± 20.5 vs 52.3 ± 15.8 minutes, P = .01). No difference was demonstrated between the groups regarding surgical complications and postoperative hemoglobin decrease. CONCLUSION: Sterilization by salpingectomy appears to be as safe as tubal ligation regarding operative complications and subsequent ovarian reserve. As salpingectomy offers the advantage of cancer risk reduction, it may be offered in the settings of elective preplanned surgeries.
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Cesárea , Reserva Ovárica , Salpingectomía , Esterilización Tubaria , Adulto , Hormona Antimülleriana/sangre , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , EmbarazoRESUMEN
INTRODUCTION AND HYPOTHESIS: The aim of the mediolateral episiotomy incision is to increase the diameter of the soft tissue of the vaginal outlet to facilitate birth and to prevent vaginal tears. Episiotomy angles that are too narrow and close to the midline increase the risk of obstetric anal sphincter injuries. In order to determine the optimal angle of the episiotomy, we assessed the changes in the angles of episiotomy lines marked during the first stage of labor and measured at the time of crowning of the head. METHODS: Incision lines for mediolateral episiotomy were marked on the perineal skin at angles of 30°, 45°, and 60° from the midline during the first stage of labor in women with a singleton pregnancy. The angles of the marked lines were measured at crowning of the head. Mediolateral episiotomy was performed only for obstetric indications. RESULTS: The study included 102 women with a singleton pregnancy. Of these women, 50 were primiparous and 52 were multiparous. All angles marked during the first stage of labor increased significantly (by more than 30°) at crowning of the head. Similar changes were observed in primiparous and multiparous women. CONCLUSIONS: The angle of the mediolateral episiotomy line was significantly greater at crowning of the head than when marked during the first stage of labor. To achieve the desired episiotomy angle, it is important to take into consideration the changes in mediolateral episiotomy angles that occur during labor.
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Episiotomía/métodos , Trabajo de Parto/fisiología , Complicaciones del Trabajo de Parto/prevención & control , Herida Quirúrgica , Adulto , Episiotomía/efectos adversos , Femenino , Feto , Cabeza , Humanos , Perineo/cirugía , Embarazo , Coloración y Etiquetado , Vagina/lesiones , Vagina/cirugíaRESUMEN
STUDY OBJECTIVE: The standard treatment of endometrial cancer (EC) and complex atypical hyperplasia (CAH) is hysterectomy with or without adnexectomy. In the last decade several centers have attempted to perform hysteroscopic resection of malignant and premalignant polyps as an alternative to hysterectomy. In the present study we evaluated the safety of this procedure in regard to residual uterine pathology. DESIGN: Retrospective chart review (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Women (n = 1766) who underwent hysteroscopic polypectomy during the years 1998 to 2016. INTERVENTIONS: Patients with CAH and endometrioid type EC in the removed polyps who underwent hysterectomy were included in the study. Patients with nonendometrioid pathology were excluded. The operative and pathologic reports of the hysteroscopy and hysterectomy procedures were revised. MEASUREMENTS AND MAIN RESULTS: Forty-three women (2.4%) were diagnosed with premalignant and malignant polyps: 21 with EC and 22 with CAH. Thirty-four women (79.0%) underwent hysterectomy and were included in the study group. The median age was 62 years (range, 35-83). Most women (79.4%) presented with postmenopausal bleeding or menorrhagia. In 13 patients (38.2%) more than 1 polyp was removed. The median size of the polyps was 2 cm (range, 1-4). In 27 women there were no other visible endometrial findings during the hysteroscopy except for the removed polyp. However, in 24 women (88.9%) residual CAH or EC was present in the hysterectomy specimen, mostly (55.6%) as multifocal lesions. CONCLUSION: Our results indicate that hysteroscopic evaluation of the uterine cavity and polyp resection are not enough for the eradication of premalignant and malignant endometrial lesions. This alternative should be reserved for well-selected cases such as for fertility preservation and for patient with surgical risk factors that after the hysteroscopic polypectomy will receive further medical treatment.
Asunto(s)
Neoplasias Endometriales/cirugía , Histeroscopía/efectos adversos , Histeroscopía/métodos , Pólipos/cirugía , Lesiones Precancerosas/cirugía , Neoplasias Uterinas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Endometriales/patología , Endometrio/patología , Endometrio/cirugía , Femenino , Humanos , Histerectomía/efectos adversos , Histerectomía/métodos , Menorragia/cirugía , Persona de Mediana Edad , Pólipos/patología , Lesiones Precancerosas/patología , Embarazo , Complicaciones Neoplásicas del Embarazo/patología , Complicaciones Neoplásicas del Embarazo/cirugía , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Enfermedades Uterinas/cirugía , Hemorragia Uterina/cirugía , Neoplasias Uterinas/patologíaRESUMEN
STUDY OBJECTIVE: To compare the effectiveness of and patient satisfaction with different routes of misoprostol administration for short-term cervical priming before operative hysteroscopy. DESIGN: Randomized blinded trial (Canadian Task Force classification I). SETTING: University hospital. PATIENTS: One hundred and twenty patients undergoing operative hysteroscopy. INTERVENTIONS: Patients were randomly assigned to receive 400 µg of misoprostol administered orally (n = 40), vaginally (n = 40), or sublingually (n = 40) for cervical priming at 1.5 to 4 hours before undergoing operative hysteroscopy. MEASUREMENTS AND MAIN RESULTS: The primary outcome was preoperative cervical dilatation. Secondary outcomes included cervical consistency, ease of dilation and time of dilation, patient discomfort, and side effects. No differences were noted among the 3 groups in terms of patient age, parity, previous vaginal delivery, menopausal status, and time interval from preparation to procedure. Patients in the 3 groups reported similar discomfort and side effects. Initial mean cervical dilatation was 6.1 ± 2.0 mm in the oral group, 6.4 ± 2.1 in the vaginal group, and 6.4 ± 1.8 mm in the sublingual group (p = .75). Cervical consistency and ease of dilation were similar among the groups. The mean time of dilation was 37.2 ± 30.6 seconds in the oral group, 31.7 ± 29.0 seconds in the vaginal group, and 31.5 ± 21.7 seconds in the sublingual group (p = .59). Additional subanalyses according to menopausal status and parity did not demonstrate any differences among the groups. CONCLUSION: Same-day cervical priming for operative hysteroscopy is achieved equally with all routes of misoprostol administration, with similar patient satisfaction and side effects.
Asunto(s)
Cuello del Útero/efectos de los fármacos , Histeroscopía , Misoprostol/administración & dosificación , Oxitócicos/administración & dosificación , Administración Intravaginal , Administración Sublingual , Adulto , Femenino , Hospitales Universitarios , Humanos , Persona de Mediana Edad , Paridad , Satisfacción del PacienteRESUMEN
AIM: To compare patient characteristics, imaging and surgical management of mature cystic teratomas (MCTs) according to surgery type - elective versus emergent. METHODS: The study included surgeries performed between 1990 and 2016, during which histologically verified ovarian MCT material was obtained. The elective management group included surgeries performed at a pre-set date or incidental finding of MCT as part of a different surgery. Emergent surgeries were considered as such if performed as a result of suspected adnexal torsion. RESULTS: One hundred ninety two operations in which MCT was confirmed by histology were included: 136 elective, 56 emergent. The majority (88.5%) of study patients were of reproductive age. Patients in the emergent surgery group were significantly younger (27.5 ± 10.2 vs 36 ± 13.8 years, P < 0.001). Sensitivity for dermoid diagnosis was significantly increased among elective surgery patients (65.2% vs. 47.1%, P = 0.02). Laparoscopy was the preferred surgical mode in both study groups. Adnexal torsion was confirmed in 67.8% of emergent surgeries. Conservative surgery, including cystectomy with or without detorsion, was more commonly performed in emergent surgeries (91% vs. 72.7%, P = 0.006). Bilateral salpingo-oophorectomy with or without total abdominal hysterectomy was more commonly performed in elective surgery patients (22% vs. 3.5%, P = 0.001). Patient parity, mass size and white blood cell count were independently associated with adnexal torsion. CONCLUSIONS: Adnexal torsion is common among symptomatic patients with MCT and is related to mass size, patient age, past parity and white blood cell count. Most patients with MCT are of reproductive age and thus are treated with a minimally invasive approach.
Asunto(s)
Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Procedimientos Quirúrgicos Ginecológicos/estadística & datos numéricos , Neoplasias Ováricas/cirugía , Teratoma/cirugía , Enfermedades de los Anexos/complicaciones , Enfermedades de los Anexos/cirugía , Adulto , Tratamiento Conservador/estadística & datos numéricos , Quiste Dermoide/complicaciones , Quiste Dermoide/diagnóstico , Quiste Dermoide/cirugía , Femenino , Humanos , Histerectomía/estadística & datos numéricos , Laparoscopía/estadística & datos numéricos , Persona de Mediana Edad , Neoplasias Ováricas/complicaciones , Neoplasias Ováricas/diagnóstico , Salpingostomía/estadística & datos numéricos , Teratoma/complicaciones , Teratoma/diagnóstico , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: To compare effectiveness and patient satisfaction of different routes of misoprostol for short-term (same day) cervical priming in first trimester surgical abortions. METHODS: In a blind randomized trial, patients undergoing surgical abortion at a gestational age of 6 + 0-14 + 6 were administered oral, vaginal, or sub-lingual 400 mcg misoprostol, 1.5 to 4 h prior to procedure. Surgeons blinded to patient allocation evaluated cervical priming. The primary outcome was initial cervical dilatation. Secondary outcomes were cervical consistency, ease of dilation, patient discomfort, and side effects. RESULTS: From July 2015 through May 2016, 120 patients were randomized as follows: 40 to oral, 40 to vaginal, and 40 to sublingual misoprostol administration. No differences were noted in patient age, gestational age, curettage indication (termination/delayed miscarriage), past vaginal delivery, and administration to procedure interval. Initial cervical dilatation was similar between the groups, as were cervical consistency and ease of dilation. Patients noted the greatest discomfort and side effects with sublingual administration. The followings were found to be independently associated with cervical dilatation in a linear regression analysis: sublingual administration, gestational age, missed abortion, and previous vaginal delivery. Side effects and administration to procedure interval were found non-significant. CONCLUSION: The same day cervical priming for first trimester surgical abortion is similarly achieved with all routes of misoprostol administration. In cases of termination of pregnancy with no prior vaginal delivery, sublingual administration may be considered, but entails a higher rate of side effects and patient discomfort.
Asunto(s)
Abortivos no Esteroideos/administración & dosificación , Aborto Inducido/métodos , Primer Periodo del Trabajo de Parto/efectos de los fármacos , Misoprostol/administración & dosificación , Abortivos no Esteroideos/efectos adversos , Abortivos no Esteroideos/uso terapéutico , Administración Intravaginal , Administración Oral , Administración Sublingual , Adulto , Femenino , Humanos , Modelos Lineales , Misoprostol/efectos adversos , Misoprostol/uso terapéutico , Satisfacción del Paciente , Embarazo , Primer Trimestre del EmbarazoRESUMEN
BACKGROUND: Several studies have addressed the issue of undetected uterine pathology in women undergoing hysterectomy for pelvic organ prolapse (POP). However, these studies differ largely with respect to the incidence of malignancy found, study population, and preoperative evaluation. OBJECTIVES: To assess the risk of unexpected pre-malignant and malignant uterine pathological findings after vaginal hysterectomy for POP repair, in a single medical center in Israel. METHODS: A retrospective study was performed of all patients who underwent vaginal hysterectomy due to symptomatic POP between January 1990 and April 2015 in a single tertiary medical center. Selected clinical and pathological data were retrieved from the computerized medical records. All specimens were routinely sent for histopathological assessment. All women were managed according to a uniform protocol that required the presence of a preoperative normal Pap smear, and included preoperative transvaginal sonography and endometrial biopsy when indicated. Patients in whom premalignant or malignant lesions were found preoperatively were not included in the study. RESULTS: The study comprised 667 patients. The overall rate of malignant or significant premalignant pathologies (6 cases) was 0.89%, including one (0.14%) case of endometrial carcinoma. All premalignant and malignant pathologies were found only in post-menopausal patients. The rate of significant endometrial pathological lesions found in asymptomatic post-menopausal women was only 0.35%. CONCLUSIONS: The rate of preoperatively undetected abnormal histopathological findings in patients who undergo vaginal hysterectomy due to POP is very low, and therefore more extensive preoperative evaluation is not warranted in them.
Asunto(s)
Neoplasias Endometriales , Histerectomía Vaginal/métodos , Lesiones Precancerosas , Neoplasias del Cuello Uterino , Útero/patología , Adulto , Anciano , Enfermedades Asintomáticas/epidemiología , Registros Electrónicos de Salud/estadística & datos numéricos , Neoplasias Endometriales/epidemiología , Neoplasias Endometriales/patología , Femenino , Humanos , Cuidados Intraoperatorios/métodos , Israel/epidemiología , Persona de Mediana Edad , Prolapso de Órgano Pélvico/diagnóstico , Prolapso de Órgano Pélvico/cirugía , Posmenopausia , Lesiones Precancerosas/epidemiología , Lesiones Precancerosas/patología , Cuidados Preoperatorios/métodos , Estudios Retrospectivos , Manejo de Especímenes/métodos , Manejo de Especímenes/estadística & datos numéricos , Neoplasias del Cuello Uterino/epidemiología , Neoplasias del Cuello Uterino/patologíaRESUMEN
PURPOSE: To compare clinical characteristics of adnexal torsion in premenarchal patients as compared to postmenarchal ones. METHODS: A retrospective 22-year cohort of all cases of surgically verified adnexal torsion in premenarchal and postmenarchal patients (excluding postmenopausal and pregnant patients). Data collected included symptoms, signs and imaging at presentation, surgical mode, and procedure and histology. RESULTS: 16 cases of adnexal torsion among premenarchal patients were compared to 302 cases among postmenarchal ones. Clinical presentation was similar, notable only for more nausea and vomiting among the premenarchal group. Ovarian cysts were more commonly demonstrated among postmenarchal patients (82.4 and 30.8%, p < 0.001), as opposed to a normal adnexal appearance on ultrasound, which was more common in premenarchal patients (69.3 vs. 17.2%, p < 0.001). Absent Doppler flow, when preformed, did not differ statistically between the groups. Laparoscopic detorsion only was more commonly performed in premenarchal patients (56.2 vs. 19.8%, p = 0.001), with a trend for detorsion and cystectomy/fenestration, which were more common in postmenarchal surgeries (25 vs. 50.6%, p = 0.06). Histology was similar among both groups, with no cases of malignancy in premenarchal patients. CONCLUSION: Adnexal torsion in premenarchal patients is rare, presents similarly to older patients, but involves a normal adnexa in 69% of cases, therefore requiring a high index of suspicion in any premenarchal patient with acute onset abdominal pain.