Minimally invasive surgical treatment of Robert's uterus with missed miscarriage: case report.

Robert's uterus was firstly reported in 1970, it's a rare Müllerian duct anomaly with 2 intra-uterine cavities divided by asymmetrical septum. One of the cavities is completely obstructed to cervix by septum and menstruation fluid retents in this blind cavity, periodical pelvic pain during menstruation can lead attendance to hospital. We report a gravida of Robert's uterus with missed abortion in the blind cavity, who had mild dysmenorrhoea since adolescent age, diagnosed and treated by minimally invasive surgical methods. To our knowledge, it's a previously unreported case which gynaecologists terminated pregnancy in blind cavity of Robert's uterus without resecting the septum while dysmenorrhoea relieved entirely and postoperative volume of menstruation stayed the same as preoperative.

Hystero-embryoscopy: evaluation and evacuation of spontaneous missed abortions.

OBJECTIVE: To demonstrate the steps for hystero-embryoscopic evaluation of a 7-week spontaneous missed abortion and evacuation of the products of conception. Illustrate the surgical technique and highlight its advantages in improving the evaluation of spontaneous missed abortions. DESIGN: Video case presentation and demonstration of surgical technique. SETTING: Tertiary referral center. PATIENT(S): The patient provided consent for the video and its publication. INTERVENTION(S): Following vaginoscopy, the cervix was approached without prior blind cervical dilation. Navigation from the endocervix to the endometrial cavity was performed using a 2.9-mm diameter hysteroscope. The endometrial cavity was thoroughly inspected revealing an intact gestational sac and submucosal fibroids. An operative grasper was introduced, the chorion and amnion were penetrated, and embryoscopy was performed. In-flow was reduced for external morphological inspection of the embryo, which was then grasped and retrieved. The procedure was continued by introducing of a 26-french bipolar resectoscope, after which the products of conception were excised without electricity and sent for histologic and genetic analyses. MAIN OUTCOME MEASURE(S): This procedure allowed for proper embryonic evaluation and hysteroscopic evacuation of products of conception was successfully performed. RESULT(S): Cytogenic analysis of this case revealed a female embryo with trisomy 15. No maternal and fetal cell admixture was noted in the analysis, allowing a precise diagnosis. CONCLUSION(S): Hystero-embryoscopy is a valuable diagnostic and therapeutic procedure for cases of missed abortion. It may reveal embryonic morphological abnormalities, expand the diagnostic spectrum in the evaluation of pregnancy loss, and avoid potential complications from blind curettage.

Intravaginal misoprostol versus uterine curettage for missed abortion: A cost-effectiveness analysis.

PURPOSE: To evaluate the cost-effectiveness of a strategy based on direct-acting uterine curettage (UC) versus a pre-direct-acting misoprostol (1600 mg) in patients with missed abortion (MA), from the perspective of a National Health System. METHODS: An open prospective cohort study was carried out at Reina Sofía University Hospital (Córdoba, Spain) from January 1, 2019 to December 31, 2019 in 180 patients diagnosed with MA. The patients chose medical treatment with intravaginal misoprostol (800 µg/4 h) or UC after receiving complete and detailed information. The effectiveness, clinical characteristics of the patients, costs of treating and managing the disease, and satisfaction with the procedures were recorded. RESULTS: One hundred and forty-five patients (80.6%) chose misoprostol versus 35 patients (19.4%) who chose UC. The effectiveness of misoprostol has been 42% evaluated at 48 h; UC success rate has been 100%. The incidence of side effects is significantly higher in patients treated with misoprostol (p < 0.05); as well as the number of care received by the patient (p < 0.05). Satisfaction is higher in patients treated with UC (p < 0.05). However, the cost is almost 5-folds higher in patients treated with UC (p < 0.05). CONCLUSION: UC has a higher success rate, greater satisfaction, and a lower incidence of side effects, although significantly increases the cost compared to misoprostol in MA.

Efficacy of mifepristone and misoprostol for medical treatment of missed miscarriage in clinical practice-A cohort study.

INTRODUCTION: It has been estimated that one out of every four women experience first-trimester miscarriage. Missed miscarriage is a common form of early miscarriage where the products of conception are not expelled from the uterus. It is diagnosed by ultrasound. The primary objective of this study was to evaluate the success rate of a combination treatment with mifepristone and misoprostol for missed miscarriage in clinical practice. The secondary objective was to identify significant factors influencing the rate of success. MATERIAL AND METHODS: A cohort of 941 consecutive women with an ICD-10 diagnosis of missed miscarriage who received treatment with 800 µg vaginal misoprostol and 2 repeat doses of 400 µg oral misoprostol after mifepristone pretreatment between 1 January 2012 and 31 December 2014 was analyzed. Women with a uterine size smaller than 12 weeks who were planned for medical treatment were included in the study. The exclusion criteria were primary surgical management or planned follow up outside the Stockholm County Council area. RESULTS: The success rate of medical treatment, defined as no need for surgical treatment, was 85.5% (805/941) in women with a uterine size of less than 12 weeks. However, for women with uterine size below 9 weeks the success rate was 88.9% (586/659). Indeed, uterine size of 9 gestational weeks or larger at time of treatment was identified as the only significant risk factor for surgical intervention. CONCLUSIONS: The medical regimen for missed miscarriage offered in this study appears to be safe and with high rates of success. Conclusions about which women to exclude from medical treatment could not be made. Medical treatment may therefore benefit all women with missed miscarriage who wish to avoid primary surgery.

Comparison of the diagnostic value of histopathological examinations of miscarriage products after pharmacological induction of miscarriage and curettage.

OBJECTIVES: For early miscarriage (pregnancy loss ≤ 12 weeks of gestation), two types of therapeutic treatment are offered (pharmacotherapy and curettage of the uterine cavity) depending on the presence and severity of clinical symptoms as well as patient choice. Our study aimed to assess the diagnostic value of the results of histopathological examinations of miscarriage products in relation to the administered treatments. MATERIAL AND METHODS: 850 medical records from patients diagnosed with missed miscarriage or empty gestational sac were analyzed retrospectively. Patients underwent surgical treatment or pharmacotherapy. Inefficacy of pharmacotherapy resulted in subsequent curettage. The results of histopathology were evaluated for their diagnostic value and classified: subgroup 1 - high value specimen (the studied specimen included fetal tissues, and villi), and subgroup 2 - no-diagnosis (the studied specimen included maternal tissues, autolyzed tissues, blood clots). Data were compared with chi-squared test. Differences was considered significant at p < 0.05. RESULTS: 1128 histopathological test results were analyzed; 569 (50.4%) were obtained during pharmacotherapy and 559 (49.6%) after curettage; out of the latter 497 after the initial pharmacotherapy and 62 after surgery. In the pharmacotherapy group, high value specimens comprised 231 cases (40.59%) while no diagnosis was obtained in 338 cases (59.4%). Considering specimens obtained in the course curettage, high value specimens were found in 364 cases (65.1%) while results that did not allow a diagnosis to be made were found in 195 cases (34.9%). CONCLUSIONS: Tissue specimens of high diagnostic value are obtained significantly more often during surgical treatment of miscarriage than during pharmacotherapy.

Laparoscopic Evacuation of an Early Pregnancy.

STUDY OBJECTIVE: Minimally invasive surgical procedures have shown significant improvement over the last 20 years. Today, nearly half of the surgeries, including oncology, are performed with minimally invasive methods. In obstetrics and gynecology surgery practice, laparoscopy can now be used in almost all operations. In this video, we performed a laparoscopic evacuation of a 12-week missed abortion case like a cesarean section at the time of bilateral salpingectomy. DESIGN: A case report (Canadian Task Force classification III). SETTING: A tertiary referral center in Bursa, Turkey. PATIENT: A 38-year-old patient. INTERVENTION: Laparoscopic evacuation of the pregnancy product (like a cesarean section) and bilateral salpingectomy. The local institutional review board approved the video. MEASUREMENTS AND MAIN RESULTS: Gravida: 4, parity: 3. The patient was in the 12th week of her gestation when we diagnosed a missed abortion. In situs of the operation, there was a 12-week pregnancy filling the pouch of Douglas. We clipped the uterine arteries bilaterally and retracted the bladder flap to create a safe surgical incision in the low anterior segment of the uterus. We used the monopolar cautery to incise the uterus from superior to inferior similar to the low vertical classic uterine incision in the cesarean section. The abortus material was removed with the laparoscopic endobag, and bilateral salpingectomy was performed. CONCLUSION: Developments in minimally invasive surgery are progressing day by day. As advances in laparoscopic and robotic surgery progress, complicated surgical procedures would be done efficiently.

Retained products of conception: What is the risk for recurrence on subsequent pregnancies?

OBJECTIVE: To investigate whether women who were surgically treated for retained products of conception (RPOC) by either suction curettage or hysteroscopy are at risk for recurrent RPOC on their subsequent pregnancies. STUDY DESIGN: Retrospective analysis of 442 women surgically treated for RPOC following delivery or abortion by suction curettage (N = 63, 14.3%) or hysteroscopy (N = 379, 85.7%). Information on subsequent pregnancies and their outcomes was available for 161 (36.4%) women. RESULTS: One or more live births were reported for 150 (93.2%) of the women for whom information on subsequent pregnancies was available. The overall rate of spontaneous abortions was 31/161 (19.3%). Recurrent RPOC were diagnosed in 25 (15.5%) cases, while third stage of labor placental problems (including retained placenta or cotyledons and placenta accreta) were found in 44 (27.3%) cases. Recurrent RPOC was associated with treatment by suction curettage compared with hysteroscopy for the initial RPOC on multivariate logistic regression analysis (Odds Ratio [OR] = 3.6, 95% Confidence Interval [CI]1.3-10.5, p = 0.01) and with the initial RPOC occurring after delivery compared with after abortion (OR = 8.4, 95%CI 1.8-39.5, p = 0.006). CONCLUSION: Women treated for RPOC are at risk for recurrent RPOC and for third stage of labor placental problems on their subsequent pregnancies, especially those who had been managed by suction curettage in comparison with operative hysteroscopy. Clinical and ultrasound follow-up in the early and late postpartum period should be considered in women with a history of RPOC.

Manual Vacuum Aspiration (MVA) - A safe option for evacuation of first trimester miscarriage in cardiac patients.

This case series was done at Armed Forces Institute of Cardiology, National Institute of Heart Disease, Rawalpindi, to observe safety and efficacy of manual vacuum aspiration and frequency of complications in cardiac patients with missed abortion. All cardiac patients presenting in first trimester with diagnosed early foetal demise (missed miscarriage) or incomplete miscarriage were included. Manual vacuum aspiration was done as an outpatient procedure. Cardiac and procedure related complications including arrhythmias, thromboembolism, heart failure and ischaemia were noted. A total of 34 patients were enrolled. Mean age and parity was 25.9±2.25 years and 1.18±1.02. Mitral valve was the dominant valve involved in 20(58.8%) followed by double valve replacement in 5(14.7%), dilated cardiomyopathy 4(11.76%), aortic valve involvement in 3(8.8%) and supra ventricular tachycardia in 2(5.9%) patients. Complete evacuation was achieved in 100% patients and there were no major cardiac or gynaecological complications except arrhythmia in 1(2.9%) patient. MVA seems to be a safe and cost effective intervention compared to other modalities of miscarriage management even in high risk cardiac patients.

Utility of ßhCG monitoring in the follow-up of medical management of miscarriage.

OBJECTIVE: To evaluate the percentage change in total ßeta-unit human chorionic gonadotropin (ßhCG) levels (%ΔßhCG) in the prediction of treatment outcomes following intravaginal misoprostol for missed miscarriage before 13 weeks. METHODS: A secondary analysis of a randomised controlled study of medical management of miscarriage was performed. Total ßhCG levels were collected before misoprostol (baseline) and after a planned seven day interval (follow-up), when a transvaginal ultrasound (TVUS) reported a gestational sac as present or not. If no sac at TVUS, surgery was indicated on clinical criteria. %ΔßhCG ((baseline ßhCG - follow-up ßhCG)/baseline ßhCG × 100) was evaluated in the prediction of a sac at TVUS and surgery on clinical criteria. RESULTS: %ΔßhCG was calculated for cases with ßhCG levels within two days of misoprostol and TVUS; calculation interval determined case number. The median %ΔßhCG for 24 cases with a persistent sac (6-9 day interval) was significantly lower than for 145 with no sac (58.75% (interquartile range (IQR): 37.59-76.69; maximum 86.54) vs 97.65% (IQR: 95.44-98.43); P < 0.0001). The median %ΔßhCG for eight cases needing surgery on clinical criteria (5-9 day interval) was significantly lower than for 140 cases with no sac not needing surgery (79.68% (IQR: 64.63-91.15; maximum 94.06) vs 97.68% (IQR: 95.61-98.50); P < 0.0001). The area under the receiver-operator curve was 0.975 for prediction of a persistent sac and 0.944 for prediction of surgery on clinical criteria, respectively. %ΔßhCG > 87% predicted no sac at TVUS. %ΔßhCG > 94.5% predicted no surgery on clinical criteria. CONCLUSION: %ΔßhCG calculation over one week reliably predicted treatment outcomes after medical management of missed miscarriage.

Lower complication rates with office-based D&C under ultrasound guidance for missed abortion.

BACKGROUND: Missed abortion (MA) can be managed expectantly, medically or surgically. Surgical management has been performed safely in the office setting by suction dilation and curettage (D&C). Prior studies suggest that intraoperative ultrasound guidance (USG) may reduce complications for first-trimester therapeutic abortion. The aim of this study was to evaluate the safety of office D&C for MA using real-time USG. METHODS: This retrospective cohort study included 255 patients who underwent office D&C under USG for first trimester MA at a single university-affiliated fertility clinic during January 2011-December 2013. Transabdominal USG was utilized during the procedure and was immediately followed by a transvaginal ultrasound examination to confirm full evacuation. Intra- and postoperative complication rates were compared to previously published data. RESULTS: There were no intraoperative complications, including excessive blood loss or uterine perforation. Two of the 255 patients (0.87%) were diagnosed with RPOCs requiring uterine re-evacuation. This rate of RPOCs was superior to rates previously reported for D&Cs without USG (2.6-4.9%, P=0.046). There were no other post procedure complications identified. CONCLUSIONS: We observed very low complications rate in Office-based D&C under USG, lower than those reported in the literature with unguided D&C.

Bleeding in the retroperitoneal space under the broad ligament as a result of uterine perforation after dilatation and curettage: Report of a case.

Uterine perforation, a complication of dilation and curettage, is typically recognized immediately after the procedure by clinical symptoms of peritoneal irritation resulting from intraperitoneal bleeding. Our patient complained of having an uncomfortable feeling, slight dizziness, palpitation in the sitting position and abdominal discomfort but did not show signs of peritoneal irritation 24 h after dilation and curettage. However, she suddenly complained of abdominal pain. Tenderness and rebound tenderness were detected at the lower abdominal wall. Ultrasonography and magnetic resonance imaging suggested uterine perforation. When the abdominal cavity was opened, a hematoma under the broad ligament of the uterus, laceration of the side wall of the uterine cervix and a small amount of bloody ascites and small clots in the abdominal cavity were observed. The uterine cervical wall was sutured. Physicians should postpone discharge and observe the clinical course carefully when a patient complains of inexplicable discomfort after dilation and curettage.

Sublingual misoprostol plus laminaria for cervical preparation before surgical management of late first trimester missed abortions, a randomized controlled trial.

OBJECTIVE: Comparing the efficacy of low-dose sublingual misoprostol plus laminaria to medium-dose sublingual misoprostol alone for cervical dilation before surgical management of late first trimester missed abortions. METHODS: Randomized, controlled trial evaluated 70 women with missed abortion, admitted for surgical termination of pregnancy. The patients were randomly assigned to receive 200 µg sublingual misoprostol with cervical laminaria (intervention group) or 400 µg sublingual misoprostol without laminaria (control group), four hours before surgical process. The study is registered at www.irct.ir (IRCT2014070711020N4). RESULTS: More patients in the intervention group achieved the desired cervical dilation (≥Hegar7) before surgical process than the control group (91.4% versus 17.1%, p < 0.001). Patients in the intervention group experienced less pain during the waiting period (mean Visual Analog Scale scores: 30.8 ± 3.7 versus 43.7 ± 5.9, p < 0.001), and had higher satisfaction level (highly satisfied: 97.1% versus 77.1%, p = 0.02). Four patients in the intervention group and none in the control group had spontaneous expulsion of pregnancy products (p = 0.11). CONCLUSIONS: Compared to medium-dose sublingual misoprostol alone, using a combination of cervical laminaria plus low-dose sublingual misoprostol before surgical process is associated with significantly more effective and rapid cervical dilation, lower requirement for mechanical dilation, lower abdominal pain and discomfort during the waiting period and higher patients' satisfaction.

Sublingual misoprostol for management of empty sac or missed miscarriage: The first two years' experience at a metropolitan Australian hospital.

BACKGROUND: Misoprostol management of miscarriage is only now becoming widely used in Australia. AIMS: To review the efficacy, safety and the popularity of outpatient sublingual misoprostol in empty sac/missed miscarriage management over its first two years of availability in a metropolitan Australian hospital. MATERIALS AND METHODS: A retrospective cohort review was undertaken of women choosing sublingual misoprostol 600 µg (three tablets) × three doses for miscarriage management. Principal outcomes assessed were miscarriage resolution without the need for curettage and complications. Additionally, the relative popularity of misoprostol versus surgery by place of birth and over time, and the return of pregnancy tissue for histology were analysed. RESULTS: Between 1 December 2012 and 30 November 2014, 279 women chose sublingual misoprostol for nonurgent miscarriage management, while 420 chose surgery (40 and 60%, respectively). Of the misoprostol cohort, 269 had complete data; 239 of 269 (88.8%) had resolution without curettage, nine (3.3%) had acute curettage, 21 (7.8%) had nonacute curettage, 30 (11.15%) had unplanned emergency department presentation, 11 (4.1%) had unplanned admission, three (1.1%) had blood transfusion and one (0.4%) had an infection requiring admission. Misoprostol was as popular with Australian-born as overseas-born women; 53.5% of patients returned histopathology specimens; one (0.7%) demonstrated partial hydatidiform mole. CONCLUSIONS: Outpatient management of missed/empty gestational sac miscarriage using sublingual misoprostol is associated with a high rate of avoiding curettage and the low rate of complication. It is equally popular with Australian-born and overseas-born women. Just over 50% returned pregnancy tissue for analysis.

[Transcervical Embryoscopy after Missed Abortion in Monoamniotic Twins with Discordant Exencephaly]. / Transzervikale Embryoskopie nach verhaltenem Abort in monoamnioten Zwillingen mit diskordanter Exenzephalie.

INTRODUCTION: Monoamniotic twins are considered a cause of high-risk pregnancies. Thereby, discordant malformations do occur rarely. A discordant exencephaly has been described in only a few cases. Transcervical embryoscopy can be performed in cases of monoamniotic twins with missed abortion directly before the abort-curettage. CASE REPORT: The case of a 35-year-old G1/P0 women in the 12(th) week of pregnancy is described. She had a monoamniotic twin pregnancy with discordant exencephaly and missed abortion diagnosed at 11+2 weeks. A transcervical embryoscopy was performed immediately before the abort-curettage and identified the discordant exencephaly and an additional umbilical cord knot of the 2 foetuses as a probable cause for the abortion. DISCUSSION: The transcervical embryoscopy lead in our case report to the diagnosis of a umbilical cord knot in a monoamniotic twin pregnancy with missed abortion. We also identified a discordant exencephaly by embryoscopy. With blunt access to the amniotic cavity, the transcervical embryoscopy applies only a minor additional risk to the abort-curettage. However, it should only be performed when the patient explicitly asks for enhanced diagnostics. CONCLUSION: Transcervical embryoscopy can be performed as an additional diagnostic tool in cases of monoamniotic twins with missed abortion. However, a detailed risk-benefit analysis should be done upfront in consultation with the patient.

Prevalence and risk factors of inadequate cervical dilation following laminaria insertion in second-trimester abortion--case control study.

OBJECTIVE: The objective was to explore the prevalence of and risk factors for inadequate cervical dilation following insertion of a single set of laminaria in women scheduled for dilation & evacuation (D&E) at 14-24 weeks' gestation. STUDY DESIGN: We retrospectively reviewed all cases of women who underwent pregnancy termination by D&E at 14-24 weeks' gestation between January 2003 and December 2013. All cases in which the surgical procedure was cancelled due to failure to achieve adequate cervical dilation after a single set of laminaria inadequate cervical dilation were included. The control group was women who underwent D&E following adequate cervical dilation after a single set of laminaria, and were matched according to gestational week in a ratio of 1:3. RESULTS: The overall dilation failure rate was 3.2%, with 4.0% among the induced-abortion patients and 1.5% among the patients with fetal demise (p=.002). Patients who had inadequate cervical dilation had lower rates of gravidity (p=.002) and previous spontaneous vaginal delivery (p<.001), along with higher rates of primigravidity, nulliparity (p<.001), previous cesarean section/s (p=.041), previous abdominal surgeries (p=.001) and previous cervical procedures (p=.003), compared to controls. A multivariable logistic regression analysis revealed two risk factors for inadequate cervical dilation following laminaria insertion, namely, previous cesarean section (p=.002) and previous cervical procedure (p<.001), whereas increased gravidity was found to protect against inadequate cervical dilation (p=.002). CONCLUSIONS: Previous cesarean section/s, cervical procedures and primigravidity were found to be risk factors for failure to achieve adequate cervical dilation after a single set of laminaria. Women who are scheduled for D&E, and in whom one of these risk factors exists, might benefit from additional interventions to achieve better cervical preparation.