Dilatation and Curettage after Uterine Artery Embolization versus Methotrexate Injection for the Treatment of Cesarean Scar Pregnancy: A Single-Center Experience.

Background and Objectives: Cesarean scar pregnancy (CSP) represents a type of ectopic pregnancy in which the embryo implants inside the scar of a previous cesarean section. This condition can lead to maternal morbidity and mortality. The best therapeutic approach in terms of clinical effectiveness and patient safety for CSP has not been described yet, although different therapeutic strategies are currently available. The purpose of the present study was to analyze the success rate of two different treatments in a single institution. Materials and Methods: A retrospective study was performed among patients diagnosed with CSP at the Gynecology and Obstetrics Department of the "Cannizzaro" Hospital in Catania (University of Enna-Italy) from January 2016 to December 2022. The diagnosis was made by 2D/3D transvaginal ultrasound, following Timor-Tritsch criteria. Two treatment strategies were performed: local and systemic methotrexate (MTX) injection and uterine artery embolization (UAE) with subsequent dilatation and curettage (D&C). All treated women underwent subsequent clinical and sonographic follow-up. Complete recovery was defined as the reduction of ß-HCG values until it was undetectable and the disappearance of the mass in the uterine scar on ultrasound. Results: Nineteen patients were included; nine were in the MTX group and ten were in the UAE + D&C group. No significant differences were found between the two groups in terms of clinical parameters. Treatment was successful in 4 of 10 (44%) patients in the MTX group and 10 of 10 (100%) in the UAE + D&C group (p = 0.01); the length of hospital stay was significantly shorter in the latter group (p < 0.0001). Conclusions: In our experience, administration of MTX is not recommended as the primary treatment or pre-treatment. Dilatation and curettage after uterine artery embolization are better than methotrexate injection for the treatment of cesarean scar pregnancy in a single-institution series in terms of complete recovery and length of hospital stay.

Management of Acquired Uterine Arteriovenous Malformations Associated with Retained Products of Conception.

PURPOSE: To evaluate the efficacy and safety of different treatments for acquired uterine arteriovenous malformations associated with retained products of conception (UAVM-RPOC) and to investigate the role of uterine artery embolization (UAE) in acquired UAVM-RPOC. MATERIALS AND METHODS: This was a retrospective study of consecutive patients who were diagnosed with uterine arteriovenous malformation by ultrasound after recently terminated pregnancy. Forty-eight patients were included in this study and were divided into 2 groups (major and minor bleeding groups) according to vaginal bleeding. The treatments were analyzed between groups. Technical and clinical success rates of UAE were analyzed. RESULTS: Of the 48 patients, 11 patients were in the massive bleeding group and 37 were in the minor bleeding group. Five patients were referred for UAE in each group and UAE was a priority for patients with unstable hemodynamics (chi-square value = 5.524, P =.022). Conservative management, dilation and curettage (D&C), operative hysteroscopy, and UAE were performed in 16 (33%), 18 (38%), 7 (15%), and 13 (27%) patients, respectively. Two patients with ectopic pregnancies suffered uncontrollable bleeding during D&C and required emergent UAE. Three patients underwent UAE before surgery to prevent hemorrhage. The technical and clinical success rates of UAE were 100%. No complications or recurrences occurred. CONCLUSIONS: UAE is a safe and effective treatment for UAVM-RPOC and a priority for patients with unstable hemodynamics. Conservative management, D&C, and hysteroscopy are safe and effective for patients with UAVM-RPOC with stable hemodynamics. However, UAVM-RPOC following ectopic pregnancy may have high risks of massive hemorrhage during procedures.

Reproductive performance of women with and without intrauterine adhesions following recurrent dilatation and curettage for miscarriage: long-term follow-up of a randomized controlled trial.

STUDY QUESTION: Are the long-term reproductive outcomes following recurrent dilatation and curettage (D&C) for miscarriage in women with identified and treated intrauterine adhesions (IUAs) comparable to women without IUAs. SUMMARY ANSWER: Reproductive outcomes in women with identified and treated IUAs following recurrent D&C for miscarriage are impaired compared to women without IUAs; fewer ongoing pregnancies and live births are achieved with a prolonged time to a live birth. WHAT IS KNOWN ALREADY: The Prevention of Adhesions Post Abortion (PAPA) study showed that application of auto-crosslinked hyaluronic acid (ACP) gel, an absorbable barrier in women undergoing recurrent D&C for miscarriage resulted in a lower rate of IUAs, 13% versus 31% (relative risk 0.43, 95% CI 0.22 to 0.83), lower mean adhesion score and significant less moderate to severe IUAs. It is unclear what the impact is of IUAs on long-term reproductive performance. STUDY DESIGN, SIZE, DURATION: This was a follow-up of the PAPA study, a multicenter randomized controlled trial evaluating the application of ACP gel in women undergoing recurrent D&C for miscarriage. All included women received a diagnostic hysteroscopy 8-12 weeks after randomization to evaluate the uterine cavity and for adhesiolysis if IUAs were present. Here, we present the reproductive outcomes in women with identified and treated IUAs versus women without IUAs, 46 months after randomization. PARTICIPANTS/MATERIALS, SETTING, METHODS: Between December 2011 and July 2015, 152 women with a first-trimester miscarriage with at least one previous D&C, were randomized for D&C alone or D&C with immediate intrauterine application of ACP gel. Participants were approached at least 30 months after randomization to evaluate reproductive performance, obstetric and neonatal outcomes and cycle characteristics. Additionally, the medical files of all participants were reviewed. Main outcome was ongoing pregnancy. Outcomes of subsequent pregnancies, time to conception and time to live birth were also recorded. MAIN RESULTS AND THE ROLE OF CHANCE: In women pursuing a pregnancy, 14/24 (58%) ongoing pregnancies were recorded in women with identified and treated IUAs versus 80/89 (90%) ongoing pregnancies in women without IUAs odds ratio (OR) 0.18 (95% CI 0.06 to 0.50, P-value <0.001). Documented live birth was also lower in women with IUAs; 13/24 (54%) with versus 75/89 (84%) without IUAs, OR 0.22 (95% CI: 0.08 to-0.59, P-value 0.004). The median time to conception was 7 months in women with identified and treated IUAs versus 5 months in women without IUAs (hazard ratio (HR) 0.84 (95% CI 0.54 to 1.33)) and time to conception leading to a live birth 15 months versus 5.0 months (HR 0.54 (95% CI: 0.30 to 0.97)). In women with identified and treated IUAs, premature deliveries were recorded in 3/16 (19%) versus 4/88 (5%) in women without IUAs, P-value 0.01. Complications were recorded in respectively 12/16 (75%) versus 26/88 (30%), P-value 0.001. No differences were recorded in mean birth weight between the groups. LIMITATIONS, REASONS FOR CAUTION: In the original PAPA study, randomization was applied for ACP gel application. Comparing women with and without IUAs is not in line with the randomization and therefore confounding of the results cannot be excluded. IUAs, if visible during routine hysteroscopy after randomization were removed as part of the study protocol; the influence of IUAs on reproductive outcome may therefore be underestimated. Women undergoing a recurrent D&C for miscarriage were included, a specific group likely to generate clinically significant adhesions. The findings should therefore not be generalized to all women undergoing D&C for miscarriage. WIDER IMPLICATIONS OF THE FINDINGS: As IUAs have an impact on reproductive performance, even after hysteroscopic adhesiolysis, primary prevention is essential. Expectative and medical management should therefore be considered as serious alternatives for D&C in women with a miscarriage. In case D&C is necessary, application of ACP gel should be considered. STUDY FUNDING/COMPETING INTEREST(S): The original PAPA study (NTR 3120) was an investigator initiated study that was funded by the Foundation for scientific investigation in Obstetrics and Gynaecology of the Saint Lucas Andreas Hospital (currently renamed OLVG Oost), SWOGA. The syringes containing ACP gel were received from Anika Therapeutics, the manufacturer of Hyalobarrier® Gel Endo. The current follow-up study was also an investigator-initiated study without funding. The funder and sponsor had no role in the design of this follow-up study, data collection, data analysis, data interpretation, trial design, patient recruitment, writing of the report or any aspect pertinent to the study. ABH, RAL, JAFH and JWRT have no conflict to declare. HAMB reports being a member of safety board research Womed. TRIAL REGISTRATION NUMBER: Netherlands Trial Register NTR 3120.

Association Between First-Trimester Bleeding and Retained Placenta Requiring Dilatation and Curettage.

OBJECTIVE: Early subchorionic hemorrhage may lead to a disruption in the placental-uterine matrix, which may result in an adherence of the placenta to the endometrium. We evaluated the effect of a first-trimester bleed on the need for a post-vaginal delivery dilatation and curettage (D&C) for removal of retained placenta. METHODS: We conducted a case-control study at a tertiary care centre between 2012 and 2016. Patients identified through medical records as having required a post-vaginal delivery D&C for retained placenta were considered cases and were matched 1:5 with patients delivering vaginally within 1 week who did not require a D&C. History of first-trimester bleeding and subchorionic hemorrhage were identified through chart review. Conditional logistic regression analyses estimated the effect of a first-trimester bleed on the requirement for D&C for retained placenta. Models were adjusted for maternal age and previous uterine surgery. RESULTS: There were 68 cases of retained placenta requiring D&C, for an estimated 3 in 1000 deliveries. Patients requiring D&C were slightly older than controls but were otherwise comparable with respect to baseline demographic characteristics. In adjusted analyses, patients who required a postpartum D&C were more likely than controls to have had a first-trimester bleed at 11.8% and 0.6%, respectively (OR 25.3; 95% CI 4.7-135.4, P < 0.001). Postpartum D&C for retained placenta was associated with postpartum hemorrhage, need for blood transfusion, and manual removal of placenta. CONCLUSION: First-trimester bleeding should be considered a high-risk determinant for post-vaginal delivery D&C for retained placenta and for severe postpartum hemorrhage.

Identifying the risk factors and incidence of Asherman Syndrome in women with post-abortion uterine curettage.

AIM: To evaluate the risk factors and incidence of Asherman Syndrome in women with post-abortion uterine evacuation and curettage. METHODS: A total of 2546 patients who had surgical abortion (uterine evacuation and curettage) before the 20th gestational week with indications of missed abortion, anembryonic pregnancy, incomplete abortion, and elective curettage in a tertiary antenatal care center were recruited. The patients were called and surveyed for their symptoms; including infertility, oligo-amenorrhea and recurrent pregnancy loss, preterm birth and intrauterine growth retardation and abnormal placentation as criteria of Asherman Syndrome. Diagnostic (office) hysteroscopy was performed for 177 who had one of those complaints. RESULTS: The incidence of Asherman Syndrome was 1.6% (n = 43/2546). History of ≥3 abortions was the main factor that increased the risk of Asherman Syndrome for by 4.6 times. Use of vacuum aspiration or sharp curettage, premedication for cervical priming, and having a pregnancy >10th gestational weeks were not risk factors for Asherman Syndrome. CONCLUSION: When the diagnosis was based on presence of symptoms who underwent uterine instrumentation, the incidence of Asherman Syndrome was found to be 1.6%. Repeated abortions were the main risk factor for Asherman Syndrome and avoiding from repeated uterine instrumentations may have a role in prevention.

Interventions for non-tubal ectopic pregnancy.

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

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

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

Hysteroscopic Diagnosis of Omentum Incarceration Subsequent to an Iatrogenic Uterine Perforation.

STUDY OBJECTIVE: To present and discuss the hysteroscopic aspects of incarcerated omentum through uterine perforation caused by previous dilation and curettage (D&C) for an incomplete first-trimester abortion. DESIGN: A case report. SETTING: Constantine University Hospital, Constantine, Algeria. PATIENT: A 40-year-old, gravida 3, para 2 patient, with a history of an incomplete first-trimester spontaneous abortion treated 6 months before by D&C requiring medical assistance because of moderate, chronic pelvic pain. No other clinical or biological alteration was found. The ultrasound showed intracavitary hyperechogenic formation infiltrating the myometrium posteriorly. INTERVENTIONS: Hysteroscopy revealed a fatlike lesion arousing suspicion of a residual trophoblast; the differential diagnosis included intramyometrial fat metaplasia as well [1]. A mechanical cold loop resection was initiated. Instrumental manipulation of the mass released yellow drops, probably of lipid nature, subsequently leading to the discovery of a uterine perforation giving passage to the omentum. Histologic examination confirmed fat tissue. There was immediate resolution of symptoms. Laparoscopic repair was subsequently performed and consisted of suturing the defect. There were no further complications. MEASUREMENTS AND MAIN RESULTS: Few cases of omentum incarceration in a perforated uterus diagnosed during laparotomy or by magnetic resonance imaging have previously been reported [2-4]. To our knowledge, this is the first case revealed through hysteroscopy. CONCLUSION: In women with a history of intracavitary interventions such as D&C, omentum incarceration should be considered when hysteroscopy demonstrates a fatlike formation and yellow droplets released by pressing or mobilizing the formation. Surgeons should be cautious, never using electrosurgery on formations whose origin arouses suspicion.

New Crosslinked Hyaluronan Gel for the Prevention of Intrauterine Adhesions after Dilation and Curettage in Patients with Delayed Miscarriage: A Prospective, Multicenter, Randomized, Controlled Trial.

STUDY OBJECTIVES: To evaluate the efficacy of a new crosslinked hyaluronan (NCH) gel in reducing the formation of intrauterine adhesions (IUAs) after dilation and curettage (D&C). DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTINGS: Six hospitals for maternal and child healthcare in China. PATIENTS: A total of 300 patients were randomized to undergo D&C for delayed miscarriage without previous history of D&C. Twenty-six patients (9%) were lost to follow-up and were excluded from the analysis. INTERVENTIONS: Women were randomly assigned to D&C alone (control group; n = 150) or D&C plus NCH gel application (NCH gel group; n = 150) with 1:1 allocation. MEASUREMENTS AND MAIN RESULTS: All patients were evaluated using the American Fertility Society classification of IUAs during follow-up diagnostic hysteroscopy, scheduled at 3 months after D&C procedure. The primary endpoint was the number of women with IUAs at 3 months, and the secondary endpoints were adhesion scores and severity of IUAs. Postoperative efficacy data were available for 274 women (137 in each group). Intrauterine adhesion formations were observed in 13 of the 137 women (9.5%) in the NCH gel group and in 33 of the 137 women (24.1%) in the control group (p = .0012; relative risk [RR], 0.3939; 95% confidence interval [CI], 0.2107-0.7153), a difference of 14.6% (95% CI, 5.92%-23.28%) between the 2 groups. The extent of intrauterine cavity involved, type of adhesion and menstrual pattern, and cumulative adhesion scores were significantly lower in the NCH gel group compared with the control group (p = .0007, .008, .0012, and .0006, respectively). The proportion of women with moderate to severe IUAs was significantly lower in the NCH gel group than that in the control group (1 of 137 [0.7%] vs 16 of 137 [11.7%]; p = .0002; RR, 0.0625; 95% CI, 0.0084-0.4648), a difference of 11.95% (95% CI, 5.39%-16.51%) between the 2 groups. CONCLUSIONS: The current study demonstrates that IUAs are frequently formed after D&C for delayed miscarriage in women without a previous history of D&C procedures, and the application of NCH gel significantly reduces IUA formation.

Asherman's Syndrome: it may not be all our fault.

Asherman's Syndrome (AS) is an acquired condition defined by the presence of intrauterine adhesions (IUA) that cause symptoms such as menstrual abnormalities, pelvic pain, infertility, recurrent miscarriage, abnormal placentation and attendant psychological distress. Classically, AS is considered an iatrogenic disease triggered by trauma to the pregnant uterus. Different factors can cause the destruction of the endometrium, thus affecting the endometrial stem cell niche and creating IUAs. Curettage of the pregnant uterus appears to be the most common source of this destruction. Nevertheless, some AS cases have been associated with congenital uterine abnormalities and infections, and there are some idiopathic cases without any prior surgical procedures, suggesting a putative constitutional predisposition to IUA. Factors reported to cause AS share an underlying inflammatory mechanism leading to defective endometrial healing and vascularization. Interestingly, distinct genetic profiles have been observed in the endometrium of AS patients. These data suggest that AS might not just be an iatrogenic complication, but also the result of a genetic predisposition. Elucidating the possible physiopathological processes that contribute to AS will help to identify patients at risk for this condition, providing an opportunity for prevention.

Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome.

STUDY QUESTION: What are the live birth rate and risks of obstetric complications following the surgical management of intrauterine adhesions (IUA) such as Asherman syndrome (AS)? SUMMARY ANSWER: The live birth rate is 63.7%, and obstetric complications including placentation issues, prematurity and postpartum hysterectomy require that pregnancies in women after treatment for IUA should be considered moderate to high risk. WHAT IS KNOWN ALREADY: Studies reviewing short-term surgical, menstrual and fertility outcomes following hysteroscopic management are reassuring, with success correlated to the severity of IUA. There are limited data reporting live birth, neonatal and maternal complications. STUDY DESIGN, SIZE, DURATION: This retrospective study included all women treated for IUA by hysteroscopic synechiolysis under fluoroscopic guidance in two tertiary University-affiliated hospitals. All women reported at least one pre-treatment symptom including menstrual dysfunction, subfertility or pelvic pain and intended to become pregnant post-treatment. Survival curve analysis was performed for time to pregnancy, and obstetric data were collated from a National Obstetric Database for delivery and neonatal outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 154 women were included in the study. Surgical intervention involved hysteroscopic synechiolysis under fluoroscopic guidance until cavity restoration was confirmed. Questionnaires regarding fertility and its outcomes were sent to all women undergoing surgery, with analysis of menstrual, fertility rates and outcomes of those pregnancies including risks and complications to the woman and the offspring. MAIN RESULTS AND THE ROLE OF CHANCE: Women were followed up for a minimum of 1 year (range: 1-14 years) from index surgery. The chance of pregnancy was 98/124 (79.0% CI: 63.6, 83.1%) in women wishing to conceive and the chance of a live birth was 79/124 (63.7% CI: 51.3, 70.7%). The chance of a miscarriage was 29/124 (23.4% CI: 18.8, 37.1%). There were 93 live births in 79 women following surgery, with detailed obstetric data available for 85 of these births. They were complicated by abnormal placentation in 15/85 (17.6% CI: 13.0, 30.2%), postpartum hysterectomy in 4/85 (4.7% CI: -0.4, 7.0%), and prematurity in 25/85 (29.4% CI: 17.0, 35.3%) women. LIMITATIONS, REASONS FOR CAUTION: The retrospective nature of the study and extended follow-up time may cause selection and recall bias, however, pregnancy and its outcomes-particularly in women with problems of subfertility-are frequently key milestones, with birthdates readily recalled. Menstrual outcomes are more likely to be subject to recall bias. WIDER IMPLICATIONS OF THE FINDINGS: Our surgical data are similar to the published literature with reassuring short-term outcomes for menstruation and cavity reconstruction following surgery for IUA. Long-term outcomes including pregnancy rates were higher than published data, however, the obstetric and neonatal complication rates were increased, indicating a continuation of risk beyond infertility and into pregnancy. An altered biochemical or vascular environment is a possible explanation for impaired implantation resulting in poorer reproductive obstetric and neonatal outcomes. The relative rarity of IUA-particularly severe disease-makes prospective data collection difficult. Our data suggest that women with IUA should be treated as moderate-high risk obstetric patients in subsequent pregnancy and counselled appropriately. STUDY FUNDING/COMPETING INTEREST(S): No funding and no competing interests.

Caesarean scar pregnancy in the UK: a national cohort study.

OBJECTIVE: To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition. DESIGN: A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS). SETTING: 86 participating Early Pregnancy Units. POPULATION: All women diagnosed in the participating units with CSP between November 2013 and January 2015. METHODS: Cohort study of women identified through the UKEPSS monthly mailing system. MAIN OUTCOME MEASURES: Incidence, clinical outcomes and complications. RESULTS: 102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management. CONCLUSIONS: Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up. TWEETABLE ABSTRACT: Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.

Hypervascular retained product of conception: Characteristic magnetic resonance imaging and possible relationship to placental polyp and pseudoaneurysm.

The cases of two patients who developed myometrial vascularization following dilatation and curettage are described. In case 1, pathological diagnosis was possible with the resected specimens. This patient had hypervascular retained products of conception (RPOC). In case 2, the natural course of this pathological condition was observed, confirming a process of regression during repeated withdrawal bleeding. The three principal magnetic resonance imaging (MRI) findings in these cases were: (i) presence of a remnant; (ii) breaking of the junctional zone in contact with the remnant; and (iii) vascularization/flow voids infiltrating into the myometrium from the broken junctional zone. These three MRI findings differed in degree and varied in combination in each case of RPOC. Uterine artery pseudoaneurysms have been reported as intrauterine vascularization after abortion or delivery with subsequent spontaneous regression. These reports may include cases of hypervascular RPOC.

Interpregnancy interval and subsequent pregnancy outcomes after dilation and evacuation.

We conducted this study to compare outcomes for pregnancies conceived ≤6 months after dilation and evacuation (D&E) with those conceived >6 months after D&E. This retrospective cohort study included women who underwent D&E (14-26 weeks) and were readmitted with a subsequent pregnancy. The primary outcome was the rate of preterm birth (<37 weeks). We identified 737 D&Es with 214 subsequent pregnancies. Outcomes were available for 85.5% of these pregnancies. Preterm birth <37 weeks occurred in 9.4% (3/32) of patients with an interpregnancy interval ≤6 months and 20.7% (12/58) of patients with an interpregnancy interval >6 months (p = .17). No differences in preterm birth <34 weeks, postpartum haemorrhage, placentation abnormalities, intrauterine growth restriction, cervical insufficiency or mode of delivery were noted. Adverse pregnancy outcomes were not higher in the group of women who conceived ≤6 months after D&E compared to those who waited longer than 6 months. IMPACT STATEMENT What is already known on this subject: A small number of studies have noted an increased risk of adverse pregnancy outcomes with an interpregnancy interval of 6 months or fewer after a spontaneous or an induced abortion. What the results of this study add: We present the first study exploring pregnancy outcomes after dilation and evacuation for termination of pregnancy at 14 weeks or greater. Our results do not support an increased rate of adverse events with an interpregnancy interval of 6 months or fewer following dilation and evacuation. What the implications are of these findings for clinical practice and/or further research: Because of limitations in sample size, our results should be interpreted in the context of other studies.

Cesarean Scar Pregnancies: A Systematic Review of Treatment Options.

The objective of this systematic review was to assess the efficacy and safety of treatment options of cesarean scar pregnancies (CSPs). We searched MEDLINE, Embase, and the Cochrane Library from inception to June 2016 as well as reference lists. We included English publications reporting treatment outcomes of at least 10 cases of CSPs. Two authors screened for eligibility, extracted data, and assessed the quality of the included studies. Treatment was considered successful if no subsequent intervention was required after the index treatment. Of the 1257 citations identified, 63 studies were eligible. The overall success rate of systemic methotrexate (MTX) and/or local injection of MTX or potassium chloride was 62%. Dilation and curettage (D&C) was associated with a 28% risk of hemorrhage that dropped to 4% when combined with uterine artery embolization (UAE). Hysteroscopic resection of CSP was unsuccessful in 12% of cases, and inadequate human chorionic gonadotropin decay was the primary indication for additional intervention. Laparoscopic, vaginal, and open excision and repair of the defect were associated with a high success rate (≥96%) and a low risk of hemorrhage (≤4%). Expectant management resulted in a 57% live birth rate, but 63% of women required hysterectomy because of placental implantation abnormalities or second trimester uterine rupture. Most studies were of low methodologic quality, and given the heterogeneity between the studies and groups, statistical comparison of treatment options was deemed inappropriate. In conclusion, the decision to allow the progression of CSPs exposes women to a high risk of life-threatening hemorrhage and hysterectomy. Medical treatment options alone are often insufficient. D&C is a reasonable option in well-selected women or when combined with UAE. The potential benefits of excision and repair of scar defect on further pregnancy outcomes need to be further assessed.

Role of dilatation and curettage performed for spontaneous or induced abortion in the etiology of endometrial thinning.

AIM: The aim of this study was to clarify the role of dilatation and curettage (D&C) performed for spontaneous or induced abortion in the etiology of endometrial thinning. METHODS: This was a retrospective and cross-sectional study of 310 infertile patients from January 2013 through December 2015. Endometrial thickness observed 5-7 days after ovulation in a natural menstrual cycle was correlated with the number of D&C noted in each patient's history. RESULTS: Study 1 was an investigation of patients without D&C (group A: n = 232) and patients with D&C performed for spontaneous abortion (group B: n = 46). Study 2 was an investigation of patients in group A and patients with D&C performed for induced abortion (group C: n = 32). A significant negative correlation (P < 0.01) between endometrial thickness and number of D&C was observed in both studies. The mean endometrial thickness of the patients in group A was 10.9 ± 2.1 mm. The mean endometrial thickness of the patients in group B with one and ≥two D&C was 7.9 ± 2.3 and 6.9 ± 2.9 mm, respectively. The mean endometrial thickness of the patients in group C with one and ≥two D&C was 9.1 ± 2.3 and 7.8 ± 2.0 mm, respectively. There was a tendency toward gradual endometrial thinning following repeated procedures and the number of previous D&C was significantly associated with endometrial thinning (P < 0.001) in both studies. CONCLUSION: D&C performed for spontaneous or induced abortion may play a causal role in endometrial thinning.

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.

Comparison between Lornoxicam and Paracetamol for Pain Management after Dilation and Curettage for Abortion.

BACKGROUND: Management of postoperative pain has become a growing concern, even for minor gynecological procedures. Proper postoperative pain management has been shown to lead to earlier mobilization, shortened hospital stay, and increased patient satisfaction. The optimal means of reducing the pain of pregnancy termination has not yet been determined. OBJECTIVES: To compare the efficiency in pain management of two drugs, lornoxicam and paracetamol, given intravenously postoperatively to women who underwent abortion with dilation and curettage. METHODS: The cohort comprised 80 women scheduled for dilation and curettage for pregnancy termination at 6-12 gestational weeks. The anesthesiologist gave 1000 mg paracetamol or 20 mg lornoxicam soon after starting the procedure, according to a randomization table. The medical staff and the patients were blinded to the drug that was administered. Pain levels were evaluated by a 10 cm visual analogue scale (VAS) at 15, 30, 60, 90, and 120 minutes following arrival at the postoperative care unit. RESULTS: Mean levels of pain decreased from 60 minutes postoperative until the end of recording, reaching minimum levels at 120 minutes: 0.8 ± 0.19 and 1.5 ± 0.28, for lornoxicam and paracetamol, respectively. The differences between the groups were statistically significant (P < 0.05 from 60 minutes after the procedure until the time of discharge. CONCLUSIONS: Compared to women who received paracetamol, women who received lornoxicam after dilation and curettage for termination of pregnancy reported lower levels of pain, from 30 minutes postoperative until the time of discharge following the procedure.