Clinical presentation, investigation, underlying causes, and subsequent pregnancy outcomes among different phenotypes of second trimester miscarriage.

AIM: To evaluate the causes of miscarriage and subsequent pregnancy outcomes among different phenotypes of second trimester miscarriage. METHODS: Retrospective analysis of 170 consecutive second trimester miscarriages between 14 + 0 and 23 + 6 weeks recorded in the Clinical Data Analysis and Reporting System from 2012 to 2021. Cases were excluded if miscarriages occurred before 14 + 0 weeks of gestation, data were incomplete, or passage of the fetus happened before the clinical assessment. Cases were classified with a stepwise approach into three phenotypic groups including silent miscarriages (ST-SM), rupture of membranes (ST-ROM), and inevitable miscarriages (ST-IM) depending on the fetal heart pulsation and leakage of liquor at presentation. Clinical investigation of the underlying causes and the outcome of the subsequent pregnancy was then reviewed. RESULTS: There were 97 cases of ST-SM, 21 cases of ST-ROM, and 52 cases of ST-IM. Placental histology and karyotype examination were more likely to yield significant results in the cases of ST-ROM and ST-SM (p < 0.05). The phenotypic examination identified different underlying causes including fetal anomaly, suspected cervical insufficiency, diabetes mellitus, and unknown causes (p < 0.001). Sixty-four cases achieved a subsequent pregnancy. Although women with history of ST-ROM and ST-IM received more cervical length monitoring and cervical cerclage than those with ST-SM (66.7% vs. 44.4% vs. 7.5%, p = 0.0002; and 16.7% vs. 22.2% vs. 2.5%, p = 0.031, respectively), the risk of recurrent second trimester miscarriage was higher in ST-ROM and ST-IM than in ST-SM (16.7% vs. 0%, p = 0.018). CONCLUSION: The classification can differentiate different second trimester miscarriage phenotypes, which offers essential information to guide investigation panels of the underlying cause of miscarriages, and the prognosis and management of subsequent pregnancy. Future researches focused on second trimester miscarriage should report their findings according to different phenotypes.

Ultrasonography in the diagnosis of vulvar abscess.

This case image demonstrates the usefulness of vulvar ultrasound in the diagnosis of vulvar abscess.

Efficacy and safety of ultrasound-guided high-intensity focused ultrasound for uterine fibroids: a preliminary experience.

The objective of this prospective cohort study was to evaluate the therapeutic efficacy and safety of ultrasound-guided high-intensity focussed ultrasound (HIFU) in the treatment of uterine fibroids. Twenty premenopausal women with symptomatic fibroids underwent ultrasound-guided HIFU therapy. Twenty-two fibroids with a median baseline volume of 127.0 cm3 (range 18.5-481.2 cm3) were treated. The percentages fibroid volume reduction were 46.9 (range -8.8-73.1) at 1-month, 57.4 (-51.5-95.2) at 3-month, 60.1 (-18.9-97.8) at 6-month and 75.9 (-33.7-99.3) at 12-month, after treatment. The modified Uterine Fibroid Symptom and Quality of Life (UFS-QOL) scores were reduced by 40.7% (0-59.3%) at 3-month, 45.5% (0-70.4%) at 6-month and 44.9% (0-71.4%) at 12-month after treatment. Three patients required subsequent surgical interventions. No significant complications were encountered. Ultrasound-guided HIFU appears to be effective and safe for the treatment of symptomatic uterine fibroids in selected patients. Impact statement What is already known on this subject? Ultrasound-guided high-intensity focussed ultrasound (HIFU) is a relatively new uterine-sparing treatment for fibroids. Most clinical reports are from China, which suggest that this treatment is a safe and effective modality. However, in many other countries, HIFU treatment for fibroids, especially using ultrasound as image guidance, is still considered novel with limited clinical experience. What do the results of this study add? This preliminary report adds to our limited local experience on HIFU and provides reassurance on our continual utilisation of this treatment modality for fibroids. With the increasing demand of uterine-sparing alternatives, experiences shared among different countries are important to make this treatment modality generalisable and universally acceptable. What are the implications of these findings for clinical practice and/or further research?Ultrasound-guided HIFU (USgHIFU) can potential be offered as an alternative treatment modality for women with fibroids.

Patients on Long-Term Warfarin Undergo Gynecological Surgeries: A 10-Year Review of Perioperative Anticoagulation.

OBJECTIVE: The aim of this study was to review our experience with patients having gynaecological surgeries while on long-term anticoagulation and to postulate a better guide for their perioperative management. MATERIAL AND METHODS: A retrospective review of all women on long-term warfarin who underwent gynaecological surgeries from January 2003 to December 2012. Data from medical records including operation reports and inpatient and outpatient charts were reviewed and analyzed. RESULTS: Sixty-seven cases from 58 patients were identified. Twenty and 38 patients underwent major and minor gynaecological surgeries, respectively. The incidence of postoperative bleeding was higher after major surgery (4 cases, 20%) than after minor surgery (1 case, 2.1%; P = 0.025). All bleeding complications occurred between postoperative day 3 and day 10. Three patients, who had resumption of warfarin at a lower dose and slowly stepped up, had no bleeding complications. None of our patients developed venous thromboembolic complications. There was one mortality due to septic shock. CONCLUSION: Patients on long-term anticoagulation have a trend of increased bleeding complications after major gynaecological surgeries than in minor gynaecological surgeries. We suggest that delaying resumption of warfarin at a lower dose may have a role in reducing the risk of postoperative bleeding without increasing the risk of venous thromboembolism.

A Randomized Controlled Trial Comparing Trainee-Directed Virtual Reality Simulation Training and Box Trainer on the Acquisition of Laparoscopic Suturing Skills.

OBJECTIVE: To compare the proficiency of novices in acquiring laparoscopic suturing skills following training in a virtual reality simulator or box trainer compared to no training. METHODS: This was a RCT in a university-affiliated teaching hospital recruiting participants who had no laparoscopic suturing experience to have suturing skill training in the virtual reality simulator, box trainer, or no training as control. Trainees were allowed to terminate training when they perceived competence in the procedure. Suturing skills were tested in the box trainer and scored using a modified Global Operative Assessment of Laparoscopic Skills questionnaire by their own self-evaluation and two experienced gynaecological laparoscopists. RESULTS: Of the 36 participants recruited, 27 (75%) had no laparoscopic experience. Participants with no laparoscopic experience took longer to complete training than those with experience (median 90 minutes [interquartile range (IQR) 80-115] vs. 55 min [IQR 40-65], respectively; P = 0.044). There were no differences in successful completion of the task (7/12 [58.3%], 10/12 [83.3%], 7/12 [58.3%]; P = 0.325), median suturing time in seconds (628 [IQR 460-835], 611 [IQR 434-691], 609 [IQR 540-837]; P = 0.702), mean subjective (mean ± SD 9.8 ± 1.8, 10.4 ± 2.8, 9.3 ± 2.4; P = 0.710), and objective (7.2 ± 1.8, 8.2 ± 2.1, 7.6 ± 1.7; P = 0.426) modified Global Operative Assessment of Laparoscopic Skills score in the simulator, pelvic trainer, and control groups, respectively. The intraclass correlation coefficient of the two reviewers was 0.422 (95% CI 0.159-0.717). CONCLUSION: Trainees were unable to accurately assess themselves as to skill level in laparoscopic suturing. A longer training time is required for novices to master laparoscopic suturing using a simulator or box trainer.

Ovarian Reserve After Ultrasound-Guided High-Intensity Focused Ultrasound for Uterine Fibroids: Preliminary Experience.

OBJECTIVE: To determine the effect on ovarian reserve of ultrasound-guided high-intensity focused ultrasound (HIFU) in the treatment of uterine fibroids. METHODS: We performed a mid-study analysis of markers of ovarian reserve using data from a prospective cohort study evaluating the safety of ultrasound-guided HIFU for uterine fibroids. Blood samples obtained from 12 women with uterine fibroids less than one week before treatment were used for measurement of serum anti-Mullerian hormone (AMH), and this testing was repeated in the first, third, sixth, and 12th month after ultrasound-guided HIFU treatment. RESULTS: Fourteen fibroids from 12 patients were treated using ultrasound-guided HIFU. The median baseline fibroid volume was 101.2 cm(3) (range 18.5 to 349.2 cm(3)). The median treatment time was 140.5 minutes (46 to 192 minutes), and median sonication time was 1449 seconds (range 541 to 2445 seconds). The median energy delivered was 575 521.5 joules (range 216 400 to 898 273 joules). The median AMH levels (ng/mL) before treatment and at one, three, six, and 12 months after treatment were 0.3 (range 0.01 to 1.94), 0.47 (0.01 to 1.43), 0.205 (0.01 to 1.81), 0.26 (0 to 2.37), and 0.06 (0.02 to 1.04), respectively. There was no significant difference between the AMH levels before and at any time after treatment. No patient became amenorrheic or reported symptoms suggestive of menopause after treatment. CONCLUSION: Our preliminary experience suggests that ovarian reserve does not seem to be affected by ultrasound-guided HIFU in the treatment of uterine fibroids.

Successful Treatment of a Pararenal Pregnancy Using High-Dose Methotrexate Regimen: A Case Report.

Background: Upper abdominal pregnancy is rare. Most patients present with hemoperitoneum, requiring emergency laparotomy. Case: A 32-year-old woman presented with acute abdominal pain and an elevated beta-human chorionic gonadotropin (ß-hCG) level. Ultrasound, computerized tomography (CT) scans, and laparoscopy failed to locate the source of elevated hCG. Subsequent positron emission tomography (PET)-CT demonstrated a cystic mass in the left pararenal region with no increased uptake. Repeated ultrasound scan revealed a live fetus implanted laterally to the abdominal aorta. After failing to respond to methotrexate at the usual dosage, a regimen used in gestational trophoblastic neoplasia was given. The pregnancy underwent miscarriage afterwards, and the hCG level gradually returned to normal. Conclusion: The site of an ectopic pregnancy should be sought thoroughly to avoid missing an abdominal pregnancy and hence disastrous hemoperitoneum. While medical therapy with high-dose methotrexate is not a standard treatment, it can be considered after failing the traditional therapy, provided that there is adequate treatment monitoring and expertise in handling the side effects of the medication.

Local Methotrexate Injection as the First-line Treatment for Cesarean Scar Pregnancy: Review of the Literature.

The objective of this study was to determine the outcome of using ultrasound-guided local methotrexate injection as the first-line treatment of cesarean scar pregnancy (CSP). A literature review was performed on all eligible reports using this modality as the first-line treatment of CSP. Relevant publications were obtained from the PubMed electronic database from inception to December 2014. Ninety-six cases from 95 women reported in 17 articles were reviewed. The success rate was 73.9% after a single local methotrexate injection. An accumulated success rate of 88.5% could be achieved after additional local or intramuscular methotrexate administration. Eleven cases (11.5%) failed methotrexate treatment and required surgical interventions. Except for women with serum human chorionic gonadotropin levels higher than 100 000 IU/L, ultrasound-guided local methotrexate injection could be considered as a first-line treatment modality for CSP.

Two-dimensional versus three-dimensional laparoscopy: evaluation of physicians' performance and preference using a pelvic trainer.

STUDY OBJECTIVE: To compare the proficiency and preference of physicians in performing standard tasks in a box trainer using 2-dimensional (2D) versus 3-dimensional (3D) laparoscopy. DESIGN: Prospective randomized controlled trial. DESIGN CLASSIFICATION: Prospective, randomized controlled trial (Canadian Task Force classification I). SETTING: Tertiary care teaching hospital. PARTICIPANTS: Thirty physicians from the Department of Obstetrics and Gynecology. INTERVENTION: Participants were randomly assigned to perform a set of 3 to 4 tasks in a pelvic trainer using 2D laparoscopy first and then 3D laparoscopy, and vice versa. MAIN RESULTS AND MEASUREMENTS: The time taken to complete the tasks and side effects experienced were noted. Participants were asked to complete a modified Global Operative Assessment of Laparoscopic Skills (GOALS) form at the end of their tasks to evaluate their experiences and to assess their own proficiency with both visual modalities. RESULTS: The time taken for peg transfer, duct cannulation, and suturing was significantly faster using 3D laparoscopy compared with 2D laparoscopy. There were no significant differences in the time taken for pattern cutting with both visual modalities. Participants experienced more dizziness using 3D laparoscopy (6.9% vs 37.9%; p = .004). The GOALS self-evaluation score was significantly higher for 3D compared with 2D laparoscopy. After the study, 11 of 29 (37.9%) participants preferred 2D, 16 of 29 (55.2%) preferred 3D, and 1 of 29 (8.3%) had no preference. CONCLUSION: Although 3D laparoscopy scored higher on self-evaluation and was preferred by more participants, it only gave better objective performance in the completion of some selected tasks by participants with intermediate skill levels and was associated with more dizziness. Further studies are needed to determine the value of 3D laparoscopy, especially when used in the clinical setting.

Sonographic characteristics of the uterus in asymptomatic women after second-trimester medical termination of pregnancy.

OBJECTIVES: The purpose of this study was to evaluate the sonographic characteristics of the uterus after apparently uncomplicated second-trimester medical termination of pregnancy and to follow the evolution of these findings until the return of menstruation. METHODS: Twenty-three women who requested termination of pregnancy at gestational ages between 14 and 20 weeks were recruited. Uterine characteristics were measured by 2- and 3-dimensional transvaginal with or without transabdominal sonography. The uterine anteroposterior diameter, length, and width, endometrial thickness, presence of an endometrial mass, intrauterine vascularity, and endometrial volume were measured within 24 hours, 1, 2, 4, 6, and 8 weeks after termination, and during the postmenstrual phase. RESULTS: The mean uterine anteroposterior diameter, uterine length, uterine width, endometrial thickness, and endometrial volume ± SD deceased gradually from 66.1 ± 9.7 to 40.9 ± 5.3 mm, 131.4 ± 14.7 to 81.3 ± 13.8 mm, 84.6 ± 10.3 to 54.2 ± 7.6 mm, 25.6 ± 8.1 to 4.5 ± 2.6 mm, and 39.4 ± 22.6 to 2.5 ± 2.1 mL, respectively, from within 24 hours after termination to the postmenstrual phase. Endometrial masses were identified in 8 women (34.8%) within 4 weeks after termination, which could persist for up to 8 weeks. However, all endometrial masses resolved after menstruation. Minimal and moderate endometrial vascularity was detectable in up to 21.7% after termination; none was detectable in any women after menstruation. CONCLUSIONS: This study provides information on the normal sonographic parameters of the uterus after second-trimester medical termination of pregnancy, which has been lacking in the literature. Also, our findings suggest that all endometrial masses regress with time; therefore, asymptomatic women with an incidental finding of an endometrial mass can be followed without the need for an immediate intervention.

Clinical Significance of Pyometra.

OBJECTIVE: To review the clinical profiles and management outcomes of patients with pyometra. STUDY DESIGN: A retrospective review of all women admitted with a confirmed diagnosis of pyometra over an 8-year period (January 2003 to December 2010). The medical records, including operation notes, histological and microbiological results, were reviewed. RESULTS: A total of 57 patients accounting for 76 admissions were identified. The mean patient age was 82.0 ± 11.3 years. The most common presenting symptom was postmenopausal bleeding (59.2%), followed by vaginal discharge (40.8%), fever (6.6%), and abdominal pain (5.3%). Drainage of pyometra was either by uterine Foley catheter insertion (48 patients [84.2%]) or repeated endometrial aspiration (2 patients [3.5%]). Antibiotics were prescribed to 49 patients (86.0%). Diagnostic hysteroscopy with mechanical cervical dilation was performed in 6 patients (10.5%). Gynecological malignancy was identified in only 1 patient, while colorectal cancer was identified in 2 patients. No patient had spontaneous uterine perforation or sepsis. Sixteen patients had recurrent pyometra within a mean follow-up period of 5.1 ± 5.8 months (range, 0.5-23 months). CONCLUSION: Pyometra usually presents with postmenopausal bleeding and can be treated with drainage and antibiotics treatment. In contrast to previous reports, our study indicates that spontaneous uterine perforation and gynecological malignancies are not commonly associated with pyometra.

Caesarean scar pregnancy: a 10-year experience.

AIMS: To review the management and outcome of all women with caesarean scar pregnancy (CSP) at a single centre. METHODS: A retrospective review of women diagnosed with CSP between January 2004 and December 2013 was performed. Women were identified from the admission and Early Pregnancy Assessment Clinic records. RESULTS: Twenty-two cases of CSP were identified during the study period. The median gestational age at diagnosis was 6.7 weeks (range 4.7-11.8 weeks). All diagnoses were made by ultrasound, the most common finding of which was a heterogeneous mass at the site of the caesarean scar (100%). The median duration for human chorionic gonadotropin to return to undetectable level was 10 weeks (range 2-20 weeks), although the duration for sonographic resolution of the CSP can take much longer. The success rate of intralesional methotrexate was 80% in our series. CONCLUSION: There is no consensus regarding the method of choice for managing CSP. Medical management using intralesional methotrexate appears to be an acceptable treatment in clinically stable women.

Recurrence of carcinoma of appendix presenting as vulvar swelling: a case report.

BACKGROUND: Adenocarcinoma of the vulva is rare and can develop as metastatic recurrence originating from the appendix. Vulvar swelling can be one of the presenting symptoms and should not be presumed to be lymphedema unless possible malignant metastasis has been excluded. CASE: We report a case of vulvar swelling arising after hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aotic lymphadenectomy, and appendectomy for presumed ovarian malignancy. Pathology revealed stage IV carcinoma of the appendix. The patient presented with vulvar swelling 12 months after the operation. An erythematous vulva with multiple hard nodular growths was found on examination. Biopsy confirmed recurrence of adenocarcinoma of the appendix. CONCLUSION: Recurrent carcinoma of the appendix can metastasize to the vulva and may present as vulvar swelling.

Contexte : L'adénocarcinome de la vulve est rare et peut prendre la forme d'une récurrence métastatique trouvant son origine dans l'appendice. La tuméfaction vulvaire peut être l'un des premiers symptômes à se manifester; on doit donc éviter de présumer qu'il s'agit d'un lymphoedème, à moins que la présence possible de métastases malignes ait été écartée. Cas : Le cas qui nous occupe porte sur une tuméfaction vulvaire qui est apparue à la suite d'une hystérectomie, d'une salpingo-ovariectomie bilatérale, d'une lymphadénectomie pelvienne et para-aortique, et d'une appendicectomie pratiquées en raison d'une malignité ovarienne présumée. La pathologie a révélé la présence d'un carcinome de l'appendice de stade IV. La patiente présentait une tuméfaction vulvaire, douze mois après l'intervention chirurgicale. L'examen a révélé une vulve érythémateuse présentant de multiples excroissances nodulaires dures. La biopsie a confirmé la présence d'une récurrence de l'adénocarcinome de l'appendice. Conclusion : La récurrence d'un carcinome de l'appendice peut entraîner la formation de métastases au niveau de la vulve et pourrait se manifester sous la forme d'une tuméfaction vulvaire.

Time to revisit the human chorionic gonadotropin discriminatory level in the management of pregnancy of unknown location.

OBJECTIVES: The purpose of this study was to review the management and outcomes of all patients with pregnancy of unknown location who had serum human chorionic gonadotropin (hCG) levels greater than 1000 mIU/mL in our institution and to determine the likelihood of a subsequent normal intrauterine pregnancy at different hCG discriminatory levels. METHODS: A retrospective review was performed on all women admitted with the diagnosis of pregnancy of unknown location and an hCG level greater than 1000 mIU/mL over a 5-year period (July 2007 to June 2012). Patients were identified from a computerized hCG result database. The medical records, including sonographic findings, hCG levels, and outcomes, were reviewed. RESULTS: A total of 113 patients were identified. There were 23 viable intrauterine pregnancies (20.4%) and 22 visualized ectopic pregnancies (19.5%). The highest hCG level associated with a subsequent normal intrauterine pregnancy was 9083 mIU/mL in a patient with triplet pregnancy. Possible factors associated with nonvisualization of a normal intrauterine pregnancy included uterine fibroids, adenomyosis, endometrial polyps, and obesity. The negative laparoscopy rate was 48.8%. CONCLUSIONS: Viable intrauterine pregnancy is possible in patients with pregnancy of unknown location and hCG levels above the generally accepted discriminatory zone, strict adherence to which can potentially disrupt a normal pregnancy. We support the need for judicious use of the hCG discriminatory level in hemodynamically stable patients with pregnancy of unknown location, and the decision to intervene should not be based solely on a single hCG level.

Hysterectomy for abnormal cervical smear when local excision is not possible.

OBJECTIVE: To review the outcomes of those women who underwent hysterectomy because of an abnormal cervical smear where local excision was considered technically not possible. MATERIALS AND METHODS: A retrospective chart review was performed for all women who had hysterectomy at a university-affiliated hospital, carried out during the period between January 2000 and June 2012, because of cervical neoplasia. RESULTS: Fifty-six women were identified. The mean (standard deviation [SD]) age of the women at the time of hysterectomy was 61.4 (8.2) years. Two women (3.6%) had cervical carcinoma, and adjuvant treatment was required in both cases. Being postmenopausal and older than 50 years and having a history of previous local excisional procedure were associated with a higher risk of high-grade cervical intraepithelial neoplasia found during hysterectomy (p > .005). During a mean (SD) follow-up of 42.3 (30.8) months after hysterectomy, 35.7% of women had persistent cytologic abnormality after hysterectomy, with 19.6% having subsequent histologically proven vaginal intraepithelial neoplasia (VAIN). Women's age, route of hysterectomy, previous local excision, degree of cytologic abnormality before hysterectomy, presence of VAIN before hysterectomy, and final histology of the hysterectomy specimen could not predict subsequent VAIN after hysterectomy. CONCLUSIONS: Hysterectomy seems to be an appropriate option in management, but further surgery or adjuvant therapy may be needed. Women should also be aware of the possibilities of persistent cytologic abnormalities including VAIN, but unfortunately, no predictive factor for its occurrence can be identified.

Mullerian cyst of the uterus misdiagnosed as ovarian cyst on pelvic sonography.

Mullerian cyst of the uterus, also known as endosalpingiosis, is rare and often can be misdiagnosed as adnexal cyst on pelvic sonography. A 47-year-old woman was referred for an incidental finding of a right adnexal mass on pelvic sonography, suspected to be an ovarian cyst. During laparoscopy, a pedunculated cystic mass arising from the right anterior uterine wall was seen. The mass was resected laparoscopically and histologic examination showed a benign Mullerian cyst of the uterus. Diagnosis of Mullerian cyst of the uterus can be challenging. However, with increased awareness, preoperative diagnosis of this condition should be possible sonographically.