Emergency and prophylactic uterine artery embolization in gynecology and obstetrics - a retrospective analysis.

BACKGROUND: This study aimed to evaluate the safety and efficacy of emergency and prophylactic uterine artery embolization (UAE) in our clinical practice, including technical success, clinical success, and associated complications. PATIENTS AND METHODS: In this retrospective study, we analyzed 64 women who underwent emergency (n =18) and prophylactic (n = 46) UAE. Indications for emergency UAE included postpartum hemorrhage or severe hemorrhage during pregnancy termination, while prophylactic UAE was performed prior to surgical removal of retained products of conception (RPOC), delivery with abnormal placental implantation, or pregnancy termination (cervical pregnancy or fetal anomalies accompanied by abnormal placental implantation). Technical success of UAE was defined as complete exclusion of the vascular lesion and contrast stasis on the final angiogram, while clinical success was defined as cessation of bleeding after UAE Termination without a hysterectomy. RESULTS: The overall clinical success of UAE in our study was 97% (62/64). All embolization procedures were technically and clinically successful in the prophylactic group without life-threatening hemorrhages or hysterectomies (100% success rate, 46/46). However, while 100% technical success was similarly attained in the emergency group, bleeding was successfully controlled in 89% of cases (16/18). In two patients with significant blood loss (over 2000 mL), embolization failed to achieve hemostasis, resulting in persistent bleeding and subsequent hysterectomy. CONCLUSIONS: UAE is a safe and effective procedure for managing primary postpartum hemorrhage or severe hemorrhage during pregnancy termination and for decreasing the risk of severe hemorrhage during surgical removal of RPOC, delivery with abnormal placental implantation, or pregnancy.

Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization: the PASTIME protocol.

BACKGROUND: Multidisciplinary care of placenta accreta spectrum cases improves pregnancy outcomes, but the specific components of such a multidisciplinary collaboration varies between institutions. As experience with placenta accreta spectrum increases, it is crucial to assess new surgical techniques and protocols to help improve maternal outcomes and to advocate for hospital resources. OBJECTIVE: This study aimed to assess a novel multidisciplinary protocol for the treatment of placenta accreta spectrum that comprises cesarean delivery, multivessel uterine embolization, and hysterectomy in a single procedure within a hybrid operative suite. STUDY DESIGN: This was a matched prepost study of placenta accreta spectrum cases managed before (2010-2017) and after implementation of the Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol (2018-2021) at a tertiary medical center. Historical cases were managed with internal iliac artery balloon placement in selected cases with the decision to inflate the balloons intraoperatively at the discretion of the primary surgeon. Intraoperative Embolization cases were compared with historical cases in a 1:2 ratio matched on the basis of placenta accreta spectrum severity and surgical urgency. The primary outcome was a requirement for transfusion with packed red blood cells. Secondary outcomes included estimated surgical blood loss, operative and postoperative complications, procedural time, length of stay, and neonatal outcomes. RESULTS: A total of 15 Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization cases and 30 matched historical cases were included in the analysis. There were no demographic differences noted between the groups. A median (interquartile range) of 0 units (0-2 units) of packed red blood cells were transfused in the Intraoperative Embolization group compared with 2 units (0-4.5 units) in the historical group (P=.045); 5 of 15 (33.3%) Intraoperative Embolization cases required blood transfusions compared with 19 of 30 (63.3%) cases in the historical group (P=.11). The estimated blood loss was significantly less in the Intraoperative Embolization group with a median (interquartile range) of 750 mL (450-1050 mL) compared with 1750 mL (1050-2500 mL) in the historical group (P=.003). There were no cases requiring massive transfusion (≥10 red blood cell units in 24 hours) in the Intraoperative Embolization group compared with 5 of 30 (16.7%) cases in the historical group (P=.15). There were no intraoperative deaths from hemorrhagic shock using the Intraoperative Embolization protocol, whereas this occurred in 2 of the historical cases. The mean duration of the interventional radiology procedure was longer in the Intraoperative Embolization group (67.8 vs 34.1 minutes; P=.002). Intensive care unit admission and postpartum length of stay were similar, and surgical and postoperative complications were not significantly different between the groups. The gestational age and neonatal birthweights were similar; however, the neonatal length of stay was longer in the Intraoperative Embolization group (median duration, 32 days vs 15 days; P=.02) with a trend toward low Apgar scores. Incidence of arterial umbilical cord blood pH <7.2 and respiratory distress syndrome and intubation rates were not statistically different between the groups. CONCLUSION: A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization is associated with a decrease in blood transfusion requirements and estimated blood loss with no increase in operative complications. The Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol provides a definitive surgical method that warrants consideration by other centers specializing in placenta accreta spectrum treatment.

Options for Prevention and Management of Menstrual Bleeding in Adolescent Patients Undergoing Cancer Treatment: ACOG Committee Opinion, Number 817.

ABSTRACT: Obstetrician-gynecologists frequently are consulted either before the initiation of cancer treatment to request menstrual suppression or during an episode of severe heavy bleeding to stop bleeding emergently. Adolescents presenting emergently with severe uterine bleeding usually require only medical management; surgical management rarely is required. Surgical management should be considered for patients who are not clinically stable, or for those whose conditions are not suitable for medical management or have failed to respond appropriately to medical management. When used continuously, combined hormonal contraceptives are effective for producing amenorrhea, although complete amenorrhea cannot be guaranteed. The risk of venous thromboembolism in patients with cancer is compounded by multiple factors, including presence of metastatic or fast-growing, biologically aggressive cancers; hematologic cancers; treatment-related factors such as surgery or central venous catheters; and the number and type of comorbid conditions. Although as a group, patients undergoing cancer treatment are at elevated risk of venous thromboembolism compared with the general population, this risk may be extremely elevated for certain patients and existing guidance on risk stratification should be consulted. The decision to use estrogen in patients with cancer should be tailored to the individual patient after collaborative consideration of the risk-benefit ratio with the patient and the health care team; the patient should be closely monitored for known adverse effects such as liver toxicity and venous thromboembolism.

A randomized controlled trial of methylergonovine prophylaxis after dilation and evacuation abortion.

OBJECTIVE: To evaluate the efficacy of intramuscular methylergonovine maleate as prophylaxis against excessive bleeding when given after dilation and evacuation (D&E) at 20-24 weeks. STUDY DESIGN: We performed a randomized, double-blinded, placebo-controlled trial in patients without excessive bleeding requiring intervention after D&E completion. We administered study treatment within one minute of the end of the procedure. We primarily compared outcomes using a composite of indicators of excessive post-procedure blood loss (post-procedure measured blood loss exceeding 125 mL, uterine massage or compression for at least two minutes, administration of additional uterotonic medication, intrauterine balloon tamponade, uterine re-aspiration, blood transfusion, uterine artery embolization, hospital admission for bleeding, or major surgery). Secondary outcomes included individual indicator occurrences, satisfaction, and side effects. RESULTS: From March 3, 2015 to March 31, 2017, we randomized 284 participants (n = 140 methylergonovine, n = 144 placebo), five before we registered the trial with clinicaltrials.gov. Baseline characteristics were similar between groups. The composite outcome occurred in 78 (56%) methylergonovine and 75 (52%) placebo participants (p = 0.5). Methylergonovine recipients required more intrauterine balloon use (n = 20 [14%]) versus placebo (n = 10 [7%]), p = 0.04. We also observed a non-significant trend towards more uterotonic administration (n = 56 [40%] versus n = 43 [30%], p = 0.07) and hospital admissions for bleeding (n = 4 [3%] versus n = 0, p = 0.06) in the methylergonovine group compared to placebo. CONCLUSION: We observed no improvement in the composite outcome for excessive bleeding with prophylactic post-procedure methylergonovine. In addition, individual excessive bleeding outcomes occurred more frequently in the methylergonovine group, potentially indicating harm with its prophylactic use after D&E. IMPLICATIONS: When administered prophylactically immediately after dilation and evacuation abortion at 20-24 weeks, methylergonovine increases uterine bleeding. Given the lack of data for effectiveness as a prophylactic agent and our findings indicating harm, we do not recommend its use for post-operative prophylaxis.

Optimal timing of the loop electrosurgical excision procedure according to different phases of the menstrual cycle.

OBJECTIVE: To determine whether treatment of cervical precancerous lesions in the follicular phase or luteal phase of the menstrual cycle affects perioperative and postoperative blood loss during the LEEP. METHODS: In this randomized trial, 73 patients were assigned to either the follicular phase group (n = 37) or the luteal phase group (n = 36). Ultimately, the conditions of 36 patients in the follicular phase group and 34 patients in the luteal phase group were analyzed. The primary outcome measure was median early postoperative blood loss. Secondary outcomes were median intraoperative bleeding, the rate of late postoperative bleeding, and persistent vaginal bleeding. RESULTS: Baseline demographic data were similar in the two groups. Median intraoperative blood loss was significantly lower in the follicular phase group than in the luteal phase group (32.7 [20.1-78.3] vs. 44.6 [30.4-104.2] mL, respectively; P < 0.001). Median early postoperative blood loss was also lower in the follicular phase group than in the luteal phase group (209.2 [67.7-468.6] vs. 289.0 [120.3-552.8] mL, respectively; P = 0.01). Moreover, the rate of late postoperative bleeding was higher in the luteal phase group than in the follicular phase group (20.6% vs. 2.8%, respectively; P = 0.02). CONCLUSION: Performing LEEP during the follicular phase of the menstrual cycle significantly reduces median intraoperative blood loss, early postoperative blood loss, and the rate of late postoperative blood loss.

Abnormal uterine bleeding in users of rivaroxaban and apixaban.

Up to two-thirds of menstruating women experience abnormal uterine bleeding (AUB) when treated with oral anticoagulants. However, the true prevalence of AUB for specific agents remains uncertain, as many of these episodes, while interfering significantly with quality of life and overall health, are not captured by definitions of major bleeding (MB) or clinically relevant nonmajor bleeding (CRNMB) used in clinical trials. A 2017 systematic review determined that women taking rivaroxaban, but not edoxaban or apixaban, had a twofold higher risk of AUB than women taking warfarin. Since then, new data have become available from extension trials, cancer-associated venous thromboembolism trials, pediatric trials, and a few observational studies specifically examining AUB as an outcome. Reported rates of uterine CRNMB were low (around 1%) and similar for rivaroxaban and apixaban in all these studies, and no episodes of uterine bleeding meeting MB criteria were reported. Rates of AUB not meeting MB or CRNMB criteria were much higher, affecting up to 50% of women on rivaroxaban. Only 1 such study included women on apixaban, and no AUB was reported. In pediatric trials, 19% of girls experienced menorrhagia when treated with rivaroxaban. In conclusion, rates of uterine MB and CRNMB were low in all studies, but rates of other types of AUB not meeting these criteria ranged from 15.8% to 50%. We conclude that AUB is underreported due to the limitations of MB/CRNMB criteria despite its substantial impact on quality of life. We urge future investigators to include broader definitions of AUB to better capture the impact of this outcome in menstruating women treated with oral anticoagulants.

Intraoperative tranexamic acid to decrease blood loss during myomectomy: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Myomectomy is associated with a significant risk of hemorrhage. Tranexamic acid is a synthetic lysine derivative with antifibrinolytic activity used in other surgical disciplines to reduce blood loss during surgery. However, its utility in gynecologic surgery is not well understood. OBJECTIVE: This study aimed to determine the effect of early administration of intravenous tranexamic acid on perioperative bleeding and blood transfusion requirements in women undergoing myomectomy. STUDY DESIGN: This study was a double-blinded, randomized, placebo-controlled trial conducted in an academic teaching hospital. Women with symptomatic fibroids thought to be at risk for large intraoperative blood loss who met the following criteria were included in the study: (1) at least 1 fibroid ≥10 cm, (2) any intramural or broad ligament fibroid ≥6 cm, and/or (3) at least 5 total fibroids based on preoperative imaging. Patients were randomized to receive a single intravenous bolus injection of tranexamic acid 15 mg/kg (intervention group) versus an intravenous bolus injection of saline of equivalent volume (placebo group) 20 minutes before the initial surgical incision. Perioperative bleeding was defined by measuring intraoperative estimated blood loss, change between pre- and postoperative hemoglobin, and frequency of blood transfusions. Estimated blood loss was calculated by combining the blood volume collected within the suction canister and the weight of used sponges. The 2 groups were compared for age; body mass index; perioperative hemoglobin and hematocrit; perioperative blood loss; duration of surgery; blood transfusion requirements; and the number, total weight, and volume of myomas removed. RESULTS: A total of 60 patients (30 per arm) were enrolled into the study between March 1, 2015, and January 29, 2018. Age, body mass index, baseline hemoglobin and/or hematocrit, number and total weight of myomas removed, and size of myomas did not differ between arms. Of 60 patients, 32 (53%) had laparoscopic myomectomy, 24 (40%) had robotic myomectomy, and 4 (7%) had laparotomy. Median estimated blood loss was 200 mL for the tranexamic acid group and 240 mL for the placebo group (P=.88). There was no difference in median duration of surgery (165 vs 164 minutes; P=.64) or change in perioperative hemoglobin (1.00 vs 1.1 g/dL; P=.64). Patients in the tranexamic acid group did not require blood transfusions; however, 4 patients (13.3%) in the placebo group (P=.11) required blood transfusions. CONCLUSION: Intravenous administration of tranexamic acid in patients undergoing laparoscopic or robotic myomectomies was not associated with decreased blood loss.

Application of cook balloon during aorta replacement in a pregnant Marfan-syndrome patient: a case report.

BACKGROUND: Aortic dissection is a rare and emergent condition. Aortic dissection during pregnancy is not much known but it is quite lethal to both mother and infant. Earlier reports published show that clinicians conducted hysterectomies during cesarean section to avoid anticoagulant-induced uterine bleeding during the following aortic surgery. CASE PRESENTATION: A woman (38, gravida 1, para 0) in the 37th gestational week suffered an acute, severe, sharp pain in the chest and back. She was diagnosed with Standford type A aortic dissection and suspected with Marfan syndrome. An emergency cesarean section was performed immediately to deliver the baby. Since the patient was on anticoagulants during aortic replacement, so Cook balloon was inserted into the uterus to prevent postpartum hemorrhage. This helped to maintain the uterus intact. Family genetic testing showed that the patient was a carrier of FBN1 mutation which was inherited from the patient's mother, and the newborn also carried the mutation. Hence the patient was concluded to be positive for Marfan syndrome. CONCLUSION: It is important that clinicians should pay attention to the possibility of aortic dissection in a pregnant woman with chest, abdominal or back pain. In this case study, we employed Cook balloon during cesarean section to avoid anticoagulant-induced uterine bleeding during the following aortic surgery.

Effects of combined GnRH receptor antagonist linzagolix and hormonal add-back therapy on vaginal bleeding-delayed add-back onset does not improve bleeding pattern.

Linzagolix is a novel, oral GnRH receptor antagonist developed for the treatment of endometriosis and uterine fibroids. We assessed high-dose linzagolix safety and bleeding pattern effects in healthy women using combined versus delayed hormonal add-back therapy (ABT). This was a single-center, open-label, parallel-group study in 32 premenopausal women, who were randomized to daily linzagolix (200 mg)/ABT for 10 weeks ("Combined-ABT") or linzagolix (200 mg) for 4 weeks followed by linzagolix (200 mg)/ABT for 6 weeks ("Delayed-ABT"). Main outcome measures included bleeding records, trough estradiol (E2) concentrations and adverse events. Linzagolix alone promptly reduced bleeding, leading to amenorrhea in all women by week 5. When combined ABT was started (week 5), spotting (≤ 0.80 days/week/subject) and bleeding (≤ 0.53 days/week/subject) occurred; bleeding was markedly more frequent than after ABT start in the "Combined-ABT" group. In the "Combined-ABT" group, spotting (≤ 0.69 days/week/subject) and occasional bleeding (≤ 0.25 days/week/subject) occurred during the first half of treatment with a tendency to further decrease during the second half. Linzagolix alone rapidly reduced E2 reaching median week 4 levels of 4.1 pg/mL. Median E2 after combined linzagolix/ABT ranged between 35 and 42 pg/mL for the "Delayed-ABT" group (weeks 5-10) and between 24 and 32 pg/mL for the "Combined-ABT" group (weeks 1-10). Linzagolix was well tolerated. Most frequently reported adverse events were headache (32/156) and hot flushes (19/156). Hot flushes exclusively occurred in the "Delayed-ABT" group. In this study, treatment start with a combined linzagolix/ABT regimen resulted in better bleeding control, no hot flushes, and lower median E2 levels than a "Delayed-ABT" regimen. These results may help defining the linzagolix/ABT regimen to be adopted when treating sex-hormone-dependent diseases. Clinical Trial Registration Number-EudraCT Number: 2017-003822-34.

Intercepting Endometrial Cancer: Opportunities to Expand Access Using New Technology.

Although endometrial cancer is often diagnosed at an early curable stage, the incidence and mortality from endometrial cancer is rising and minority women are particularly at risk. We hypothesize that delays in clinical presentation contribute to racial disparities in endometrial cancer mortality and treatment-related morbidity. Improved methods for endometrial cancer risk assessment and distinguishing abnormal uterine bleeding and postmenopausal bleeding from physiologic variation are needed. Accordingly, we propose a multipronged strategy that combines innovative patient education with novel early detection strategies to reduce health impacts of endometrial cancer and its precursors, especially among Black women. Futuristic approaches using gamification, smartphone apps, artificial intelligence, and health promotion outside of the physical clinic hold promise in preventing endometrial cancer and reducing morbidity and mortality related to the disease, but they also raise a number of questions that will need to be addressed by future research.

Motherwort injection in preventing post-abortion hemorrhage after induced abortion: A multi-center, prospective, randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of motherwort injection (MI, Yi mu cao) in preventing post-abortion hemorrhage and promoting uterine retraction after induced abortion surgery. METHODS: In this multi-center randomized controlled trial undertaken between September 2014 and August 2016, 408 child-bearing age women who underwent induced abortion surgery and randomly assigned to two groups: MI group who received intramuscular MI treatment (n = 207) and no-treatment group (n = 201). The volume of vaginal bleeding and its duration were used as primary end points; and uterine size and dimension were measured as secondary end points. Blood coagulation indices, routine blood and adverse events were recorded to evaluate the safety. RESULTS: The efficacy analysis was based on 366 patients. No significant difference were found in baseline characteristics between the two groups (P > 0.05). The amount of vaginal bleeding and duration of bleeding were significantly reduced in MI group compared with on-treatment group in Full Analysis Set (FAS) and Per Protocol Set (PPS) populations (P < 0.001). The volume and perimeter of the uterine dimensions in MI group were smaller than no-treatment group (P < 0.001). No significant abnormal vital signs were observed. Only 1 case of mild, transient erythema was found in MI group. CONCLUSIONS: MI could reduce post-abortion hemorrhage and improve uterine retraction in women undergoing surgical induced abortion, without serious adverse events. It was a safe and effective treatment in preventing post-abortion hemorrhage after induced abortion.

[Effectiveness of progesterone in pregnancy complications]. / Effect van progesteron bij zwangerschapscomplicaties.

This commentary reflects on the effectiveness of progesterone in early pregnancy complications. Several studies have investigated the role of progesterone in women with bleeding in early pregnancy and in women with recurrent miscarriages. These publications suggests that first trimester use of progesterone is not effective to prevent miscarriages when there is blood loss in the first trimester, and that it is also not effective to prevent new miscarriages in women with recurrent miscarriages in their history. However, subgroup analysis tells us it might be effective to prevent new miscarriages in women with blood loss in the first trimester and three earlier miscarriages. Expert groups in the Netherlands are currently considering recommendations on the prescription of progesterone for women with early pregnancy complications.

Can the combination of internal iliac temporary occlusion and uterine artery embolization reduce bleeding and the need for intraoperative blood transfusion in cases of invasive placentation?

OBJECTIVES: Women with invasive placentation (IP) are at high risk of life-threatening hemorrhage. In the last two decades, less invasive surgical approaches combined with endovascular procedures have proven to be safe. Most case series describe the use of temporary balloon occlusion and embolization, either combined or not. Concerning hemorrhage rates, each separate interventional approach performs better than surgery alone does, yet it is not clear whether the combination of multiple interventional techniques can be beneficial and promote a lower incidence of intrapartum bleeding. We aim to evaluate whether combining temporary balloon occlusion of the internal iliac artery and uterine artery embolization promotes better hemorrhage control than do other individual interventional approaches reported in the scientific literature in the context of cesarean birth followed by hysterectomy in patients with IP. METHODS: This is a retrospective analysis of patients with confirmed IP who underwent temporary balloon occlusion and embolization of the internal iliac arteries followed by puerperal hysterectomy. We compared patient results to data extracted from a recent systematic review and meta-analysis of the current literature that focused on interventional procedures in patients with IP. RESULTS: A total of 35 patients underwent the procedure during the study period in our institution. The mean volume of packed red blood cells and the estimated blood loss were 487.9 mL and 1193 mL, respectively. Four patients experienced complications that were attributed to the endovascular procedure. CONCLUSION: The combination of temporary balloon occlusion and uterine artery embolization does not seem to promote better hemorrhage control than each procedure performed individually does.

Patient-reported outcome measures in benign gynecologic surgery: updates and selected tools.

PURPOSE OF REVIEW: Use of patient-reported outcome measures in clinical practice and research is becoming more prevalent and reflects initiatives to center the patient in healthcare delivery and outcomes assessment. The purpose of this review is to provide a summary description of selected, validated tools used to assess outcomes related to several benign gynecologic conditions: abnormal uterine bleeding, fibroids and endometriosis. RECENT FINDINGS: Given the availability of several validated instruments to assess patient outcomes in benign gynecology, there is still significant heterogeneity in tools used in trials. SUMMARY: Patient outcomes assessment should be an integral part of clinical practice and research in order to treat the whole patient and address any health-related impacts on quality of life. More attention is needed to increase standardization of tools used in research to facilitate assessment of comparative efficacy between treatments.

Etonogestrel Subdermal Implant-Associated Regression of Endometrial Intraepithelial Neoplasia.

BACKGROUND: Endometrial intraepithelial neoplasia is a precursor lesion to endometrial adenocarcinoma. Total hysterectomy is the preferred management, but systemic or locally acting progestin therapies are acceptable alternatives. The use of the etonogestrel subdermal implant for treatment of endometrial intraepithelial neoplasia has not been studied. CASE: A 36-year-old woman, G2P2002, with obesity presented with abnormal uterine bleeding. Her endometrial specimen demonstrated endometrial intraepithelial neoplasia. She declined both hysterectomy and conventional medical management. The etonogestrel implant was offered as an alternative to no treatment. After etonogestrel implant insertion, serial biopsies showed regression of endometrial intraepithelial neoplasia. Sixteen months after implant insertion, biopsy showed inactive and atrophic endometrium. CONCLUSION: The etonogestrel subdermal implant should be considered for further study for the treatment of endometrial intraepithelial neoplasia in women who decline surgical management.

Effects of Prophylactic Oxytocin on Bleeding Outcomes in Women Undergoing Dilation and Evacuation: A Randomized Controlled Trial.

OBJECTIVE: To estimate whether routine use of intravenous oxytocin decreases the frequency of interventions to control excess blood loss during dilation and evacuation (D&E). METHODS: In this multisite, randomized, double-blind, placebo-controlled trial, women undergoing D&E at 18-24 weeks of gestation received 30 units of oxytocin in 500 mL of intravenous fluid or 500 mL of intravenous fluid alone initiated on speculum placement. The primary outcome was the frequency of interventions to control excess bleeding. A sample size of 75 patients per group was needed to detect a 15% decrease in intervention from 20% to 5% with 80% power and two-sided alpha 0.05. Secondary outcomes included measured blood loss, complications, procedure duration, postoperative pain, and patient satisfaction. RESULTS: From November 2014 to February 2018, we screened 337 women and randomized 160 to receive prophylactic oxytocin (n=82) or placebo (n=78). Demographic characteristics were similar between groups. The frequency of interventions for bleeding, our primary outcome, was 7.3% in the oxytocin group vs 16.7% in the placebo group, difference of 9.4% (95% CI -21.0% to 1.9%). Interventions primarily included uterine massage and uterotonic administration. Among our secondary outcomes, median measured blood loss was lower in the oxytocin group at 152 (interquartile range 98-235) mL vs 317 (interquartile range 168-464) mL (95% CI 71.6-181.5). Frequency of hemorrhage, defined as blood loss of 500 mL or more and 1,000 mL or more, was lower in the oxytocin group at 3.7% vs 21.8%, difference of 18% (95% CI -29 to -6.9%) and 1.2% vs 10.3%, difference of 9.0% (95% CI -17 to -0.7%), respectively. Procedures were shorter in the oxytocin group at a median of 11.0 (interquartile range 8.0-14.0) vs 13.5 (interquartile range 10.0-19.0) minutes in the placebo group (95% CI 1.0-4.0). We found no differences in the frequency of nonhemorrhage complications, pain scores, or satisfaction scores between groups. CONCLUSION: Prophylactic use of oxytocin during D&E at 18-24 weeks of gestation did not decrease the frequency of interventions to control bleeding. However, oxytocin did decrease blood loss and frequency of hemorrhage. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT02083809.

Transient Occlusion of Uterine Arteries in Procedures with High Risk of Uterine Bleeding.

INTRODUCTION: Uterine-conservative surgery via laparoscopy is a challengeable and high risk because of heavy intra-operative bleeding events in reproductive women with highly vascular uterine benign disease. There are three reported cases of women with highly vascular uterine benign diseases and high risk of intra-operative heavy bleeding, but were treated successfully to control intra-operative heavy bleeding risk by transient occlusion of the uterine artery (TOUA) through laparoscopy and resulted in safe conservation of the uterus. CASE PRESENTATION: The cases of women with high risk of heavy bleeding during therapeutic procedure included cesarean scar pregnancy, hydatid form mole on cesarean scar, and cervical pregnancy. All these women had the strong desire to presere their fertility and uterus. In all the three cases, we used the method of TOUA and performed therapeutic surgeries successfully, with less bleeding and safe conservation of the uterus through laparoscopy. CONCLUSION: Laparoscopic TOUA could be a therapeutic option to manage heavy intra-operative bleeding during conservative uterine surgeries associated with the risk of heavy bleeding.

Tissue-selective estrogen complex for women who experience breast discomfort or vaginal bleeding when on hormone therapy.

OBJECTIVE: The objective of this study was to evaluate the effects of switching from hormone therapy to tissue-selective estrogen complex (TSEC) in women who experience vaginal bleeding or breast discomfort. METHODS: This retrospective cohort study included 82 postmenopausal women who received TSEC after switching from another hormone therapy due to adverse events. Changes in symptoms and imaging after switching to TSEC were evaluated. RESULTS: The mean age was 56.9 years. The women were switched to TSEC due to vaginal bleeding in 56.1% and breast discomfort in 47.6% (multiple choices were allowed). After the switch, almost all women (97.6%) experienced an improvement in adverse events. However, 27% of the women had worsening of vasomotor symptoms, which was more common when hormone therapy was changed from 2 mg of estradiol (41.7%) compared with 1 mg of estradiol (16.7%), 0.625 mg of conjugated estrogen (30%), or tibolone (12.5%). Images of breast lesions and fibroids before the switch were assessed, showing no change in most women. CONCLUSIONS: This study suggests that TSEC is a good option for women who have breast discomfort or persistent bleeding during other hormone therapy when taking into account the differences in estrogen dose.

Can the combination of internal iliac temporary occlusion and uterine artery embolization reduce bleeding and the need for intraoperative blood transfusion in cases of invasive placentation?

OBJECTIVES: Women with invasive placentation (IP) are at high risk of life-threatening hemorrhage. In the last two decades, less invasive surgical approaches combined with endovascular procedures have proven to be safe. Most case series describe the use of temporary balloon occlusion and embolization, either combined or not. Concerning hemorrhage rates, each separate interventional approach performs better than surgery alone does, yet it is not clear whether the combination of multiple interventional techniques can be beneficial and promote a lower incidence of intrapartum bleeding. We aim to evaluate whether combining temporary balloon occlusion of the internal iliac artery and uterine artery embolization promotes better hemorrhage control than do other individual interventional approaches reported in the scientific literature in the context of cesarean birth followed by hysterectomy in patients with IP. METHODS: This is a retrospective analysis of patients with confirmed IP who underwent temporary balloon occlusion and embolization of the internal iliac arteries followed by puerperal hysterectomy. We compared patient results to data extracted from a recent systematic review and meta-analysis of the current literature that focused on interventional procedures in patients with IP. RESULTS: A total of 35 patients underwent the procedure during the study period in our institution. The mean volume of packed red blood cells and the estimated blood loss were 487.9 mL and 1193 mL, respectively. Four patients experienced complications that were attributed to the endovascular procedure. CONCLUSION: The combination of temporary balloon occlusion and uterine artery embolization does not seem to promote better hemorrhage control than each procedure performed individually does.

Ulipristal acetate for pre-operative management of uterine fibroids: Modeling outcomes and costs.

OBJECTIVES: The aim of this study was to evaluate the pharmacoeconomic profile in Italy of preoperative treatment with ulipristal acetate at the dose of 5 mg/day for 13 weeks in comparison with placebo prior to surgical management of symptomatic uterine fibroids. STUDY DESIGN: The pharmacoeconomic analysis was based on the calculation of incremental cost-effectiveness ratio (ICER). Effectiveness data were derived from the randomized-controlled trial PEARL-1, whilst costs data were retrieved from the published literature. A Markov model was employed to simulate the pattern of costs and two univariate sensitivity analyses tested the robustness of the results. RESULTS: In comparison with placebo, ulipristal acetate 5 mg for presurgical therapy was estimated to be associated with an incremental cost of €351 per patient. Costs per patient were €3836 for ulipristal acetate vs €3485 for placebo. The incremental effectiveness was 0.01931 QALYs per patient (around 7 quality-adjusted days per patient). Hence, the cost effectiveness ratio was calculated to be €18,177 per QALY gained. CONCLUSIONS: Preoperative use of ulipristal acetate 5 mg in patients with uterine fibroids has a favourable pharmacoeconomic profile.