Hysteroscopic Lysis of Complex Uterine Adhesions After Interventional Radiology-Guided Access.

OBJECTIVE: To demonstrate a novel surgical technique using hysteroscopic lysis of adhesions after interventional radiology (IR)-guided access in patients with severe intrauterine adhesions and challenging uterine access. DESIGN: This video illustrates the technique of the safe division of intrauterine adhesions after IR-guided access. SETTING: Conventional hysteroscopic adhesiolysis might be inadequate or risky in cases of severely narrowed or obstructed uterine flow tract, possibly resulting in incomplete adhesiolysis, false passages, or uterine perforation. This video presents 2 cases from a tertiary center involving a multidisciplinary team of a reproductive surgeon and an interventional radiologist. The first case involves a 38-year-old with severe Asherman syndrome, who experienced unsuccessful attempt to treat adhesions that was complicated by a false passage. The second case involves a 39-year-old with recurrent severe Asherman syndrome and a history of unsuccessful attempts at hysterosalpingogram and conventional hysteroscopic lysis of adhesions. INTERVENTIONS: In the IR suite, the patient was put in a lithotomy position on the fluoroscopy table. A vaginal speculum was inserted exposing the cervix. The procedure was performed using intravenous sedation and topical anesthetic spray applied to the cervix. Using fluoroscopy, a balloon cannula was inserted through the cervix, followed by contrast injection to assess uterine access. If there is no route, transvaginal ultrasound-guided needle cannulation of the main portion of the uterine cavity would be performed, approximating as closely as possible to the expected route of the cervical canal. A guidewire followed by a locked loop catheter was advanced through adhesions into the uterine cavity. The catheter was left protruding from the cervix to guide the hysteroscope. The patient was then transferred to the operating room for the hysteroscopic procedure. Under the guidance of the intrauterine catheter, the adhesions were carefully lysed using cold scissors. The endometrial cavity and tubal openings were inspected to ensure complete adhesiolysis and exclusion of any other copathologies. CONCLUSION: IR guidance can provide a safe and effective approach to hysteroscopic lysis of adhesions in patients with challenging intrauterine adhesions and difficult uterine access, such as patients with severe Asherman syndrome, intractable cervical stenosis, uterine wall agglutination, previous adhesiolysis failure, marked fixed retroverted retroflexed uteri, and previous false passage or uterine perforation.

Intrauterine device-related uterine perforation incidence and risk (APEX-IUD): a large multisite cohort study.

BACKGROUND: Reports of perforation risk related to intrauterine devices (IUDs) inserted immediately post partum and among non-post-partum individuals are scarce, and previous studies with only 12-month follow-ups underestimate the risk. Breastfeeding at IUD insertion and insertion within 36 weeks post partum have been associated with increased risk of uterine perforation. The aim of these analyses was to compare the incidence and risks of IUD-related uterine perforations by non-post-partum and post-partum intervals at IUD insertion, and among post-partum individuals, to assess the impact of breastfeeding on these outcomes. METHODS: We did a multisite cohort study in the USA, using electronic health records (EHR). Study sites were three health-care systems and a site that used data from a health-care information exchange. The study population included individuals who were aged 50 years or younger and had an IUD insertion between Jan 1, 2001, and April 30, 2018. Individuals were excluded if they had not been in the health-care system for at least 12 months before IUD insertion. The primary outcome for this analysis was any IUD-related uterine perforation diagnosis for the first IUD insertion in this time period. Both complete and partial IUD-related perforations were identified. Chart abstraction was done to validate EHR-based algorithms or confirm perforations. The crude rate and cumulative incidence of uterine perforation were evaluated by non-post-partum and post-partum intervals at IUD insertion in the full cohort, and by breastfeeding status in a subcohort of post-partum individuals. Cox models estimated crude and adjusted hazard ratios (aHRs). FINDINGS: Data from 326 658 individuals in the full cohort and 94 817 individuals in the post-partum subcohort were analysed. In the full cohort, we identified 1008 uterine perforations (51·2% complete), with the 5-year cumulative incidence being the lowest in the non-post-partum group (0·29%, 95% CI 0·26-0·34). The aHR for the post-partum interval relative to non-post partum ranged from 2·73 (95% CI 1·33-5·63; 0 to 3 days post partum) to 6·71 (4·80-9·38; 4 days to ≤6 weeks post partum). The post-partum subcohort of individuals with breastfeeding information had 673 uterine perforations (62% complete), with a 5-year cumulative incidence of 1·37% (95% CI 1·24-1·52) and an increased risk with breastfeeding (aHR 1·37, 95% CI 1·12-1·66). INTERPRETATION: Although the risk for uterine perforation with IUD insertion 4 days to 6 weeks or less post partum is nearly seven times that of insertion non-post partum, perforation remains an incredibly rare event for all clinical time points. Despite a slight increased risk of perforation with breastfeeding at IUD insertion, the benefits of breastfeeding and effective contraception generally outweigh risks and should have little clinical impact. Therefore, IUD insertion timing should be based on individual desire for IUD contraception and patient convenience to assure an IUD insertion can occur. Careful follow-up of individuals at higher risk of uterine perforation is warranted. FUNDING: Bayer AG.

Intestinal obstruction in pregnancy-a rare presentation of uterine perforation.

BACKGROUND: Intestinal obstruction is an uncommon non-obstetric condition during pregnancy which may cause maternal and fetal mortality. Clinicians are confronted with challenges in diagnosis and treatment of intestinal obstruction due to the overlapping symptoms, concerns over radiological evaluation, and surgical risks. CASE PRESENTATION: We reported a 39-year old, gravida 7, para 2, woman who suffered from acute intestinal obstruction at 34 weeks of gestation. Ultrasonography and abdominal computed tomography were applied for intestinal obstruction diagnose. Conservative treatment was initially attempted. But following ultrasound found the absence of fluid in the amniotic sac and the patient showed no improvement in clinical symptoms. An emergency caesarean section was then performed. Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon. After adhesion dialysis, uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found without active bleeding. The uterine rupture was then repaired. CONCLUSIONS: Although uncommon during pregnancy, clinical suspicion of bowel obstruction is necessary especially in women with a history of abdominal surgery. Surgical intervention is indicated when conservative therapy fails and when there are signs of abnormal fetal conditions and worsened symptoms.

Complete perforated bladder from intrauterine devices: A case series report from a nationwide monitoring system.

AIM: Complete perforation of the bladder caused by an intrauterine device (IUD) is rare. This study examined the characteristics of patients associated with IUD-related bladder perforation and evaluated the relationship between mislocated IUDs and their potential complications. METHODS: From October 2005 to December 2021, 13 reports regarding complete perforations to the bladder by IUDs were retrieved from the National Contraceptives Adverse Reaction Monitoring System of China. The clinical features of these cases were analyzed. RESULTS: The median patient age was 30 (range, 27-46) years. There were four cases (4/13, 30.8%) with IUDs placed during lactation, one case (1/13, 7.7%) with an IUD placed after medical abortion, and eight cases (8/13, 61.5%) placed after menstruation. Seven cases (7/13, 53.9%) were first-time IUD users. The median duration of IUD placement was 47 (range, 1-145) months. Unexpected pregnancy was reported in five cases (5/13, 38.5%). Six cases (6/13, 46.2%) reported bladder stones with varying degrees of abdominal pain or urinary tract infection. Removal methods included laparotomy (four cases), cystoscopy (four cases), laparoscopy (two cases), laparoscopy combined with cystoscopy (two cases), and laparotomy after cystoscopy (one case). All IUDs were successfully removed. CONCLUSIONS: Complete perforation to the bladder by IUDs is a rare adverse event. Regular follow-up is required after the placement of IUDs. The possibility of uterine perforation should be investigated if IUD users encounter persistent lower abdominal pain or urinary tract infection.

Association between menorrhagia and risk of intrauterine device-related uterine perforation and device expulsion: results from the Association of Uterine Perforation and Expulsion of Intrauterine Device study.

BACKGROUND: Intrauterine devices are effective instruments for contraception, and 1 levonorgestrel-releasing device is also indicated for the treatment of heavy menstrual bleeding (menorrhagia). OBJECTIVE: To compare the incidence of intrauterine device expulsion and uterine perforation in women with and without a diagnosis of menorrhagia within the first 12 months before device insertion STUDY DESIGN: This was a retrospective cohort study conducted in 3 integrated healthcare systems (Kaiser Permanente Northern California, Southern California, and Washington) and a healthcare information exchange (Regenstrief Institute) in the United States using electronic health records. Nonpostpartum women aged ≤50 years with intrauterine device (eg, levonorgestrel or copper) insertions from 2001 to 2018 and without a delivery in the previous 12 months were studied in this analysis. Recent menorrhagia diagnosis (ie, recorded ≤12 months before insertion) was ascertained from the International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes. The study outcomes, viz, device expulsion and device-related uterine perforation (complete or partial), were ascertained from electronic medical records and validated in the data sources. The cumulative incidence and crude incidence rates with 95% confidence intervals were estimated. Cox proportional hazards models estimated the crude and adjusted hazard ratios using propensity score overlap weighting (13-16 variables) and 95% confidence intervals. RESULTS: Among 228,834 nonpostpartum women, the mean age was 33.1 years, 44.4% of them were White, and 31,600 (13.8%) had a recent menorrhagia diagnosis. Most women had a levonorgestrel-releasing device (96.4% of those with and 78.2% of those without a menorrhagia diagnosis). Women with a menorrhagia diagnosis were likely to be older, obese, and have dysmenorrhea or fibroids. Women with a menorrhagia diagnosis had a higher intrauterine device-expulsion rate (40.01 vs 10.92 per 1000 person-years) than those without, especially evident in the first few months after insertion. Women with a menorrhagia diagnosis had a higher cumulative incidence (95% confidence interval) of expulsion (7.00% [6.70-7.32] at 1 year and 12.03% [11.52-12.55] at 5 years) vs those without (1.77% [1.70-1.84] at 1 year and 3.69% [3.56-3.83] at 5 years). The risk of expulsion was increased for women with a menorrhagia diagnosis vs for those without (adjusted hazard ratio, 2.84 [95% confidence interval, 2.66-3.03]). The perforation rate was low overall (<1/1000 person-years) but higher in women with a diagnosis of menorrhagia vs in those without (0.98 vs 0.63 per 1000 person-years). The cumulative incidence (95% confidence interval) of uterine perforation was slightly higher for women with a menorrhagia diagnosis (0.09% [0.06-0.14] at 1 year and 0.39% [0.29-0.53] at 5 years) than those without it (0.07% [0.06-0.08] at 1 year and 0.28% [0.24-0.33] at 5 years). The risk of perforation was slightly increased in women with a menorrhagia diagnosis vs in those without (adjusted hazard ratio, 1.53; 95% confidence interval, 1.10-2.13). CONCLUSION: The risk of expulsion is significantly higher in women with a recent diagnosis of menorrhagia. Patient education and counseling regarding the potential expulsion risk is recommended at insertion. The absolute risk of perforation for women with a recent diagnosis of menorrhagia is very low. The increased expulsion and perforation rates observed are likely because of causal factors of menorrhagia.

Association between intrauterine device type and risk of perforation and device expulsion: results from the Association of Perforation and Expulsion of Intrauterine Device study.

BACKGROUND: Intrauterine devices, including levonorgestrel-releasing and copper devices, are highly effective long-acting reversible contraceptives. The potential risks associated with intrauterine devices are low and include uterine perforation and device expulsion. OBJECTIVE: This study aimed to evaluate the risk of perforation and expulsion associated with levonorgestrel-releasing devices vs copper devices in clinical practice in the United States. STUDY DESIGN: The Association of Perforation and Expulsion of Intrauterine Device study was a retrospective cohort study of women aged ≤50 years with an intrauterine device insertion during 2001 to 2018 and information on intrauterine device type and patient and medical characteristics. Of note, 4 research sites with access to electronic health records contributed data for the study: 3 Kaiser Permanente-integrated healthcare systems (Northern California, Southern California, and Washington) and 1 healthcare system using data from a healthcare information exchange in Indiana (Regenstrief Institute). Perforation was classified as any extension of the device into or through the myometrium. Expulsion was classified as complete (not visible in the uterus or abdomen or patient reported) or partial (any portion in the cervix or malpositioned). We estimated the crude incidence rates and crude cumulative incidence by intrauterine device type. The risks of perforation and expulsion associated with levonorgestrel-releasing intrauterine devices vs copper intrauterine devices were estimated using Cox proportional-hazards regression with propensity score overlap weighting to adjust for confounders. RESULTS: Among 322,898 women included in this analysis, the incidence rates of perforation per 1000 person-years were 1.64 (95% confidence interval, 1.53-1.76) for levonorgestrel-releasing intrauterine devices and 1.27 (95% confidence interval, 1.08-1.48) for copper intrauterine devices; 1-year and 5-year crude cumulative incidence was 0.22% (95% confidence interval, 0.20-0.24) and 0.63% (95% confidence interval, 0.57-0.68) for levonorgestrel-releasing intrauterine devices and 0.16% (95% confidence interval, 0.13-0.20) and 0.55% (95% confidence interval, 0.44-0.68) for copper intrauterine devices, respectively. The incidence rates of expulsion per 1000 person-years were 13.95 (95% confidence interval, 13.63-14.28) for levonorgestrel-releasing intrauterine devices and 14.08 (95% confidence interval, 13.44-14.75) for copper intrauterine devices; 1-year and 5-year crude cumulative incidence was 2.30% (95% confidence interval, 2.24-2.36) and 4.52% (95% confidence interval, 4.40-4.65) for levonorgestrel-releasing intrauterine devices and 2.30% (95% confidence interval, 2.18-2.44) and 4.82 (95% confidence interval, 4.56-5.10) for copper intrauterine devices, respectively. Comparing levonorgestrel-releasing intrauterine devices with copper intrauterine devices, the adjusted hazard ratios were 1.49 (95% confidence intervals, 1.25-1.78) for perforation and 0.69 (95% confidence intervals, 0.65-0.73) for expulsion. CONCLUSION: After adjusting for potential confounders, levonorgestrel-releasing intrauterine devices were associated with an increased risk of uterine perforation and a decreased risk of expulsion relative to copper intrauterine devices. Given that the absolute numbers of these events are low in both groups, these differences may not be clinically meaningful.

Complications after interval postpartum intrauterine device insertion.

BACKGROUND: In the United States, up to 57% of women report resumption of sexual activity by the 6 week postpartum visit. Effective contraception should be addressed and provided at that time, to avoid unintended pregnancies and optimize interpregnancy intervals. Long-acting reversible contraceptives are the most effective forms of reversible contraception and are increasingly popular during the postpartum period. However, timing of postpartum intrauterine device (IUD) placement varies among providers and many delay insertion due to concerns for uterine perforation or expulsion of the IUD. OBJECTIVE: This study aimed to evaluate uterine perforation and expulsion rates with IUD insertion at 4-8 weeks postpartum vs 9-36 weeks postpartum. STUDY DESIGN: We performed a retrospective cohort study using the Kaiser Permanente Southern California electronic medical record from 2010 to 2016. We calculated the proportion of perforations and expulsions with IUD insertion at 4-8 weeks vs 9-36 weeks postpartum. Our primary outcome was the perforation rate. Secondarily, we evaluated the expulsion rate. For our minimum sample size calculation, to detect a difference of 0.5% in the perforation rate, with a baseline perforation rate of 0.5% for the 9-36 week postpartum IUD placement group, 80% power, and 5% alpha error rate, we would need at least 4221 participants per group, 8442 in total. RESULTS: A total of 24,959 patients met inclusion criteria (n=13,180 in the 4-8 week group, n=11,777 in the 9-36 week group). Of 430 patients with a confirmed complication, 157 uterine perforations and 273 IUD expulsions were identified. Perforation rates were significantly higher with placement at 4-8 weeks than at 9-36 weeks (0.78% vs 0.46%; P=.001). After adjusting for race and ethnicity, breastfeeding, IUD type, provider type, parity, most recent delivery, and body mass index, the odds of perforation remained higher with placement at 4-8 weeks than at 9-36 weeks (adjusted odds ratio, 1.92; 95% confidence interval, 1.28-2.89). Our Kaplan-Meier survival curve showed that the risk of uterine perforation remained elevated until approximately 22-23 weeks postpartum. Expulsion rates were similar between the 2 groups (1.02 vs 1.17; P=.52). CONCLUSION: Uterine perforation after interval postpartum IUD insertion is greater at 4-8 weeks than at 9-36 weeks, although perforation rates remain low at <1%. Expulsion rates did not differ between the groups. Because overall rates of uterine perforation are low, women can safely be offered IUDs at any interval beyond 4 weeks with minimal concern for perforation.

Intrapartum versus postpartum insertion of intrauterine device in women delivering by cesarean section.

BACKGROUND: The intrauterine device (IUD), being a reversible and effective contraception method, is the most widely used worldwide. This study aims to demonstrate the efficacy of IUD insertion during elective lower segment cesarean section (LSCS) versus its insertion six weeks postpartum. METHODS: A cohort study was conducted on 200 women planned for elective cesarean delivery and desired IUD as a contraceptive method. They were allocated into two groups; group I, in which IUD was inserted during LSCS, and group II, in which IUD was inserted six weeks or more after LSCS. Both groups were compared regarding failed insertion, post-insertion pain, and uterine perforation. They were followed for one year for the incidence of menorrhagia, vaginal infection, IUD displacement/expulsion, missed threads, or unintended pregnancy. RESULTS: Women in the second group showed a significantly higher incidence of failed insertion and uterine perforation than women in the first group. On the contrary, women in the first group showed a significantly higher incidence of missed threads than women in the second group. Regarding other consequences, there were no significant differences between both groups concerning menorrhagia, vaginal infection, IUD displacement/expulsion, or unintended pregnancy. CONCLUSION: IUD insertion during elective LSCS showed a significantly lower incidence of failed insertion and uterine perforation than its insertion six weeks postoperative.

Safety and efficacy of microwave endometrial ablation for patients with previous uterine surgery: a pilot study.

MEA (microwave endometrial ablation) is a treatment that can control hypermenorrhea. With the increase in the number of caesarean sections and myomectomies, an increasing number of patients with MEA have undergone previous incision of the uterine myometrium. Uterine perforation is major complication. Here we compared the incidence of complications and recurrence between groups with or without previous uterine surgery. 35 patients who underwent MEA were enrolled in the study. We assessed the thickness of uterine myometrium by MRI and transvaginal ultrasonography (TV-US). 12 patients (34%) had previous uterine surgery; Among 12 patients with previous uterine surgery, 6 (50%) showed thinning of the myometrium. No patient showed any complications. There was no difference in recurrence rate between two groups (1/12 = 8% and 2/23 = 8%, respectively). MEA can be performed safely and effectively even for patients with previous uterine surgery.IMPACT STATEMENTWhat is already known on this subject? MEA (microwave endometrial ablation) is a treatment that can control hypermenorrhea.A few serious complications have been reported, including uterine perforation and intestinal injury. There have been no collective reports on women with a history of uterine surgery, and the decision to perform MEA and the detailed procedures have not been clarified.What do the results of this study add? No patient who received MEA showed any complication regardless of previous uterine surgery. There was no difference in recurrence rate of hypermenorrhea between groups with and without previous uterine surgery. MEA could be performed safely and effectively in patients with previous uterine surgery preoperative imaging and intraoperative ultrasoundsWhat are the implications of these findings for clinical practice and/or further research? Curently, with the increase in the number of caesarean sections and myomectomies, the increasing number of patients with MEA have undergone previous incision of the uterine myometrium and this causes thinning of the myometrium. MEA can be safely performed without losing any therapeutic effect, even in patients with a history of uterine surgery, by using MRI and TV-US as preoperative evaluations.

Uterine perforation during intrauterine procedures and its management.

OBJECTIVE: Uterine perforation is a potential, not rare complication of all intrauterine procedures and may be associated with injury of surrounding organs and structures. The incidence, risk factors, possible prevention, dia-gnosis, management and impact on future reproduction is reviewed here. METHODS: Systematic review of available sources on the topic was carried out using the PubMed database and textbooks of Czech authors. CONCLUSION: Some risk factors that make access to the uterine cavity difficult may be prevented, however, others remain unpreventable. For patients in whom the perforation occurred during sondage, dilatation or insertion of blunt and cold instrument, without significant bleeding and who are hemodynamically stable, observation is recommended rather than immediate abdominal exploration. The exception are young women planning pregnancy in whom endoscopic suture is indicated. Abdominal exploration is required in patients who have been injured by electrosurgical or sharp device, laser, vacuum curette, who are hemodynamically unstable or show signs of severe bleeding or visceral injury.

Hysteroscopic dilation techniques in hysteroscopic adhesiolysis. / é•œä¸‹æ‰©å®«æ³•åœ¨å®«è ”é•œå®«è ”ç²˜è¿žåˆ†ç¦»æœ¯ä¸­çš„åº”ç”¨.

OBJECTIVES: Intrauterine adhesion (IUA) is mainly caused by intrauterine operations such as pregnancy-related curettage and hysteroscopic surgery, resulting in the trauma to the basal layer of the endometrium. Hysteroscopic adhesiolysis is a crucial step in the comprehensive treatment of IUA, and the most common complication is uterine perforation. More than half of all uterine perforations occur during the hysteroscopy or probe/dilator pass through the internal os. Furthermore, inappropriate surgical procedures may lead to endometrial injury, recurrence or even aggravation of adhesions, and complications such as cervix laceration and false passage formation. This study aims to explore the usage of the hysteroscopic dilatation techniques to dilate the internal os and lower uterine segment, which is via hysteroscopy entering the internal os laterally and swinging, or by directly opening the forceps or scissors and bluntly spreading dissection under direct hysteroscopic vision. By using the hysteroscopic dilatation techniques, we intend to improve the effectiveness and safety of cervical dilation in patients with IUA in the internal os and/or lower uterine segment. METHODS: A total of 282 patients with adhesions in the internal os or lower uterine segment underwent HA in the Third Xiangya Hospital of Central South University from January 2020 to June 2021 were included, ranging from 21 to 46 (33.0±4.8) years old in age and 5 to 12 in the American Fertility Society score. Among them, there were 2 cases of false passage formation caused by traditional dilatation in other hospitals. All patients underwent hysteroscopy with integrated hysteroscopy with 5Fr instrument channel and 4.9 mm outer sheath diameter. The internal orifice of cervix and the lower segment of uterine cavity were dilated under the microscope. After the hysteroscopy entered the uterine cavity, the separation of uterine cavity adhesion and the placement of uterine contraceptive ring or uterine stent into the uterine cavity were performed routinely. Age, surgical records, and surgical videos of all included cases were collected. The success rate of dilation and the incidence of surgical complications were assessed. RESULTS: In all cases, the hysteroscopys successfully entered into the uterine cavity by using the hysteroscopic dilatation techniques without failure and switching to cervical dilators. In the 2 cases of false passage due to previous cervical dilation, the uterine cavity was identified and found successfully under direct hysteroscopic vision. During the whole surgery, the vision was clear, and no complications (such as cervix laceration, false passage formation, uterine perforation or water intoxication) occurred. One to 3 months postoperative hysteroscopy revealed no significant fibrotic stenosis in the internal os and lower uterine segment. CONCLUSIONS: The hysteroscopic dilation techniques are a strategy for separation methods that is following structural hierarchy anatomy in the mode of "see and treat" for the adhesion in the internal os and uterine cavity under direct hysteroscopic vision. This method not only has ultrasound guidance, but also has the judgment of structural hierarchy anatomy under direct hysteroscopic vision, so there is less chance of anatomical level judgment error. This method makes full use of the hysteroscopic judgement of the experienced hysteroscopic surgeons, so that surgeons can timely find and avoid re-entering the old false passage caused by previous surgery. The adhesions in the internal os and lower uterine segment were separated by the hysteroscopic dilation techniques. In this way, the damage to the endometrium caused by forced insertion of the hysteroscopy can be avoided. Meticulous separation of adhesions and cervical dilation under direct hysteroscopic vision can effectively reduce the occurrence of surgical complications such as false passage formation, cervical laceration, and uterine perforation. The use of mini-hysteroscopy eliminates the need for preoperative cervical preparation, avoiding associated risks and side effects. Moreover, for patients with adhesions in the internal os and lower uterine segment, preoperative cervical preparation is not effective in cervical dilation, while the hysteroscopic dilation techniques are effective, with higher patient acceptance due to the absence of preoperative cervical preparation. For the skilled hysteroscopic surgeons, the hysteroscopic dilation technique is easy to operate and worthy of clinical application.

A phase III randomised trial of trans-abdominal ultrasound in improving application quality and dosimetry of intra-cavitary brachytherapy in locally advanced cervical cancer.

INTRODUCTION: Intra-cavitary brachytherapy (ICB) remains an integral part of radiotherapy treatment in cervical cancer. Two-dimensional X ray point-based planning remains common and blind insertion leads to uterine perforations and higher toxicity. We conducted a randomised controlled trial of using trans-abdominal ultrasound in performing ICB to reduce perforation and organ at risk doses. PATIENT AND METHODS: The present study is a phase III open label randomised controlled trial of ultrasound guided ICB conducted on invasive cervical cancer patients. Patients were randomised by a simple computer-generated randomization chart into Arm A (No Ultrasound guidance) and Arm B (ICB with ultrasound guidance). The uterine perforation rates, tandem length change rates, bladder doses, rectal dose and procedure times were compared. Fischer exact test was used to compare the arms and p value <0.05 considered significant. RESULTS: A total of 160 patients were randomised. With US assistance, the uterine perforation rate was 1.25% (n = 1). In the non-US assistance arm the perforation rate was 12.5% (n = 10) (p = 0.005). Mean time to complete the entire procedure was significantly shortened from 26 min to 19 min favouring the US arm (p = 0.001). Dosimetric assessment between the two groups showed significant decrease in dose received by the various organs at risk with US assistance. CONCLUSION: The present study confirms significant improvement in application quality as well as dosimetry with reduction in procedure time. Trans-Abdominal US should be routinely used for ICB procedures, particularly in resource limited settings.

Design of the Association of Uterine Perforation and Expulsion of Intrauterine Device study: a multisite retrospective cohort study.

BACKGROUND: Intrauterine devices are effective and safe, long-acting reversible contraceptives, but the risk of uterine perforation occurs with an estimated incidence of 1 to 2 per 1000 insertions. The European Active Surveillance Study for Intrauterine Devices, a European prospective observational study that enrolled 61,448 participants (2006-2012), found that women breastfeeding at the time of device insertion or with the device inserted at ≤36 weeks after delivery had a higher risk of uterine perforation. The Association of Uterine Perforation and Expulsion of Intrauterine Device (APEX-IUD) study was a Food and Drug Administration-mandated study designed to reflect current United States clinical practice. The aims of the APEX-IUD study were to evaluate the risk of intrauterine device-related uterine perforation and device expulsion among women who were breastfeeding or within 12 months after delivery at insertion. OBJECTIVE: We aimed to describe the APEX-IUD study design, methodology, and analytical plan and present population characteristics, size of risk factor groups, and duration of follow-up. STUDY DESIGN: APEX-IUD study was a retrospective cohort study conducted in 4 organizations with access to electronic health records: Kaiser Permanente Northern California, Kaiser Permanente Southern California, Kaiser Permanente Washington, and Regenstrief Institute in Indiana. Variables were identified through structured data (eg, diagnostic, procedural, medication codes) and unstructured data (eg, clinical notes) via natural language processing. Outcomes include uterine perforation and device expulsion; potential risk factors were breastfeeding at insertion, postpartum timing of insertion, device type, and menorrhagia diagnosis in the year before insertion. Covariates include demographic characteristics, clinical characteristics, and procedure-related variables, such as difficult insertion. The first potential date of inclusion for eligible women varies by research site (from January 1, 2001 to January 1, 2010). Follow-up begins at insertion and ends at first occurrence of an outcome of interest, a censoring event (device removal or reinsertion, pregnancy, hysterectomy, sterilization, device expiration, death, disenrollment, last clinical encounter), or end of the study period (June 30, 2018). Comparisons of levels of exposure variables were made using Cox regression models with confounding adjusted by propensity score weighting using overlap weights. RESULTS: The study population includes 326,658 women with at least 1 device insertion during the study period (Kaiser Permanente Northern California, 161,442; Kaiser Permanente Southern California, 123,214; Kaiser Permanente Washington, 20,526; Regenstrief Institute, 21,476). The median duration of continuous enrollment was 90 (site medians 74-177) months. The mean age was 32 years, and the population was racially and ethnically diverse across the 4 sites. The mean body mass index was 28.5 kg/m2, and of the women included in the study, 10.0% had menorrhagia ≤12 months before insertion, 5.3% had uterine fibroids, and 10% were recent smokers; furthermore, among these women, 79.4% had levonorgestrel-releasing devices, and 19.5% had copper devices. Across sites, 97,824 women had an intrauterine device insertion at ≤52 weeks after delivery, of which 94,817 women (97%) had breastfeeding status at insertion determined; in addition, 228,834 women had intrauterine device insertion at >52 weeks after delivery or no evidence of a delivery in their health record. CONCLUSION: Combining retrospective data from multiple sites allowed for a large and diverse study population. Collaboration with clinicians in the study design and validation of outcomes ensured that the APEX-IUD study results reflect current United States clinical practice. Results from this study will provide valuable information based on real-world evidence about risk factors for intrauterine devices perforation and expulsion for clinicians.

Ex-vivo forces associated with intrauterine device placement and perforation: a biomechanical evaluation of hysterectomy specimens.

BACKGROUND: This biomechanical analysis of hysterectomy specimens assesses the forces associated with intrauterine device placement. These include compressive forces required to cause uterine perforation with two commonly available commercial intrauterine device placement instruments and a metal uterine sound. METHODS: We obtained hysterectomy specimens at a single academic center. All specimens resulted from excision for benign conditions in premenopausal women by any operative method. Within one hour of excision, we stabilized uterine specimens in an apparatus specifically designed for this analysis. A single, experienced clinician performed all experimental maneuvers and measured forces with a Wagner FDIX-25 force gauge. The investigator applied traction on a tenaculum to approximate force used during an intrauterine device placement. The maximum compressive force to the uterine fundus was determined by using manufacturers' placement instruments for two commercially available products and a metal sound. RESULTS: Sixteen individuals provided hysterectomy specimens. No complete perforations occurred while using loaded intrauterine devices; in a single observation the LNG IUS entered the myometrium. The plastic intrauterine device placement rod bowed in all attempts and did not perforate the uterine serosa at the fundus. A metal uterine sound created a complete perforation in all specimens (p < .001). The lowest mean maximum force generated occurred with the levonorgestrel intrauterine system placement instrument 12.3 N (SD ± 3.8 N), followed by the copper T380A intrauterine device placement instrument 14.1 N (SD ± 4.0 N), and highest for the metal sound 17.9 N (SD ± 7.6 N) (p < 0.01). CONCLUSIONS: In this ex-vivo model, metal uterine sounds caused complete perforation and intrauterine device placement instruments did not. This study received Institutional Review Board (IRB0059096) approval.

Intrauterine devices migrated into the bladder: two case reports and literature review.

BACKGROUND: Intrauterine devices (IUD) are widely used all over the world. One of the most serious complications is uterine perforation, and it is very rare for the IUD to penetrate the bladder after perforation. Here we report two cases of IUD migration into the bladder, and review the literature to analyze the possible causes and solutions of such complications. CASE PRESENTATION: Case NO. 1 is a 37-year-old female who presented lower urinary tract symptoms for a year. Cystoscopy showed that a strip of metal penetrated into the bladder, and the surface was covered with stones. The patient underwent cystotomy and foreign body removal under general anesthesia. Case NO. 2 is a 46-year-old woman who previously inserted an IUD in 1998, but she had an unexpected pregnancy in 1999. Her doctor believed that "the IUD had spontaneously expulsed" and a new IUD was inserted after her pregnancy was terminated. Her CT scan showed an IUD on the left side of the bladder and another IUD in the uterus. Her foreign body was removed by cystotomy. CONCLUSION: Patients with IUD should be suggested to check the device regularly, and those who with a missed IUD have to rule out the possibility of IUD migration. For patients with IUD combined with lower urinary tract symptoms, it is necessary to be aware of whether IUD perforation affects the bladder.

Transvaginal strangulated bowel evisceration through uterine perforation due to unsafe abortion: a case report and literature review.

BACKGROUND: Induced abortion, whether therapeutic or elective, is a surgical procedure frequently practiced worldwide. It is a significant cause of maternal morbidity and mortality. When the procedure is performed in precarious conditions, by unqualified personnel, it leads to serious consequences, including uterine perforation and its associated lesions. Its management remains a medico-surgical emergency. CASE PRESENTATION: We present two cases of unsafe abortions performed by cervical dilatation and intrauterine curettage which resulted in uterine perforation and intestinal evisceration through the vagina leading to acute intestinal obstruction. Both patients underwent intensive resuscitation followed by an emergency laparotomy. The first case was a 26-year-old woman living in rural Cameroon. Following a procedure of termination of her pregnancy, the patient noted the presence of bowel at the vaginal introitus associated with signs of intestinal obstruction. She was transferred to a specialized center was after 4 days later of the onset of the evisceration. Considering the gangrened eviscerated terminal ileum, a right hemicolectomy with anastomosis was performed, as well as a suture of the uterine perforation. The second patient was an 18-year-old African living as a refugee in Cameroon. She was referred for abdominal pain in the context of intestinal obstruction with a viable jejunal loop extruding through the vagina. A simple jejunal resection was performed with end-to-end anastomosis and suture of the uterine perforation. In both cases, the postoperative course was uneventful. CONCLUSIONS: Uterine perforation is a serious complication of intrauterine gynecological procedures and instrumental abortion in particular. It can lead to evisceration of the intra-abdominal viscera through the uterine perforation. It is therefore a real surgical emergency with multiple and fatal consequences.

Rectal Perforation by an Intrauterine Device Leading to Fatal Intra-Abdominal Sepsis and Necrotizing Fasciitis.

BACKGROUND: Colorectal injury from an intrauterine device (IUD) is rare but may lead to major complications. CASE: A 55-year-old woman presented to a tertiary care hospital with 4 days of generalized weakness, confusion, dysuria, and lower back pain. She provided a vague history of an unsuccessful attempt to remove an IUD 30 years prior. A computed tomography scan demonstrated an IUD in the rectal lumen, with gluteal and pelvic gas and fluid collections. Emergency surgery found necrotizing fasciitis. Despite multiple debridements, sigmoidoscopic IUD removal, and long-term intravenous antibiotics, the patient died from sepsis and multiorgan failure. CONCLUSION: IUDs require proper monitoring and timely removal to prevent potential complications associated with organ perforation.

Dislocated intrauterine devices: clinical presentations, diagnosis and management.

OBJECTIVE: Intrauterine devices (IUDs) are globally one of the most popular methods of contraception. Uterine perforation is one of the most significant complications of IUD use and commonly occurs at the time of IUD insertion rather than presenting as delayed migration. This paper reports a series of 13 cases of displaced IUDs requiring retrieval by laparoscopy or laparotomy. All the IUDs were copper bearing and most perforations occurred immediately after IUD insertion. CASES: In two patients with sigmoid colon injury and IUD penetration of the appendix, laparoscopic management had failed and laparotomy was necessary owing to severe obliteration of the pelvic cavity. In one patient laparotomy was the preferred surgical approach owing to acute bowel perforation. In the remaining patients, the displaced devices were successfully removed by laparoscopy. CONCLUSION: Uterine perforation and IUD migration to the organs in the abdominopelvic cavity are serious complications of IUD insertion and can be successfully managed by laparoscopy, or by laparotomy in the presence of severe pelvic adhesions or unexpected complications.

Intrauterine device extraction through laparoscopic hysterotomy.

CASE REPORT: A 52-year-old woman with an intrauterine device placed more than 10 years before consulted our department after a failed attempt to its removal in the outpatient area. While performing the colposcopy a completely fibrosed cervical canal permitted no access to the uterine cavity. The IUD was confirmed to still be placed intrauterine by pelvix x-ray and an endovaginal sonography. Due the risk for future infections, a device extraction was recommended, although the patient categorically refused a hysteroscopic approach as an hysterectomy. After discussing all available options the patient agreed on a laparoscopic approach with uterine conservation. It was performed through a vertical hysterotomy with the electrocautery hook and the incision closed using intracorporeal vycril stitches. The patient was dismissed 48 h after surgery. A sonographic control was carried 6 months later revealing no evidence of scar complication. DISCUSSION: Hysteroscopy with or without sonographic intraoperative control to avoid uterine perforation, remains the recommended treatment in case of retained IUD. Difficult cases with a fibrotic cervix can be dilated with a scalpel under general anaesthesia before hysteroscopy to retrieve the coil. Laparoscopic approach is usually being used as a minimally invasive procedure for the extraction of IUD that are misplaced or migrate to the peritoneal cavity. In very seleted cases, laparoscopy can be a useful tool in case other approaches are ineffective or rejected by the patient.

Homelessness, housing instability, and abortion outcomes at an urban abortion clinic in the United States.

BACKGROUND: Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population. OBJECTIVE: This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship. STUDY DESIGN: Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of ≥20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries. RESULTS: Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications. CONCLUSION: Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.