vNOTES hysterectomy using the lateral window technique in case of a ventrofixed uterus following previous cesarean sections: A video article.

vNOTES uses the vagina as the surgical channel for endoscopy and achieves improved cosmesis compared to conventional laparoscopy as there are no abdominal incisions. Ventrofixation of the uterus to the abdominal wall following previous cesarean sections further adds to the surgeon's concern of bladder injury. In such cases, a modification of the technique is proposed: introducing the vNOTES port first, before the opening of the vesico-uterine peritoneal folds, thus carried out under endoscopic view. Medial anterior vesico-uterine adhesions are identified and circumscribed by creating a lateral window in the broad ligament on both sides. This allows the cutting of adhesions under endoscopic view to minimize the risk of bladder injuries. The aim of this technical note is to present this modification of the surgical technique for vNOTES hysterectomy in case of ventrofixed uterus.

[Endometrial osseous metaplasia: A case report]. / Métaplasie osseuse de l'endomètre : à propos d'un cas.

Endometrial osseous metaplasia (EOM) is a rare condition characterised by the presence of bone in the uterine cavity. Some patients with this condition present with secondary infertility due to the presence of a foreign body in the endometrium. We report a case of a 39-year-old woman who presented with secondary infertility due to EOM. EOM is a rare cause of infertility that can be easily managed by hysteroscopic removal of the bony fragments.

Prophylactic attempt at manual rotation in brow presentation at full dilatation.

We report our management of brow presentation at full dilatation by a prophylactic attempt at manual rotation or immediate cesarean delivery, depending on practitioner training. During the study period, 49 women with brow presentation were collected for an overall 30 452 deliveries (1/621) and 22 (44.9%) of them were diagnosed at full dilatation. For the latter, an attempt at manual rotation was performed in 13 cases (59.1%) with no particular maternal or neonatal complications reported and vaginal delivery occurred in 10 (76.9%). Maternal and neonatal outcomes were similar between women with immediate cesarean section or prophylactic manual rotation, except for a shorter duration of hospitalization in the group with attempted manual rotation (p < 0.01). Prophylactic attempted manual rotation in brow presentation diagnosed at full dilatation may be associated with a high rate of vaginal delivery with no specific maternal or neonatal complications.

Long-term psychological impact of severe postpartum hemorrhage.

OBJECTIVE: To estimate the long-term psychological impact of severe postpartum hemorrhage in women whose uterus was preserved. DESIGN: Retrospective study. SETTING: University-affiliated tertiary referral center. POPULATION: All consecutive women who underwent embolization for postpartum hemorrhage between 1994 and 2007 and whose uterus was preserved were included. METHODS: Data were retrieved from medical files and semi-structured telephone interviews. In semi-structured interviews, women were asked about their perceptions and memories of the experience. MAIN OUTCOME MEASURES: Perceptions and memories of the postpartum hemorrhage during and after delivery. RESULTS: Follow-up was successful for 68 of the 91 (74.7%) women included. Of the 46 (67.6%) who reported negative memories of the delivery and postpartum period, the main memory for 24 was a fear of dying (35.3%). Of the 28 (41.2%) who reported continued repercussions, 16 (23.5%) thought about this delivery and its complications at least once a month, five (7.3%) reported persistent fear of dying, four (5.9%) reported sexual problems, and three (4.4%) women considered that the event was, at least in part, responsible for their subsequent divorce. Of the 15 women who had a subsequent full-term pregnancy, nine (60%) reported intense anxiety throughout the pregnancy, and one (6.7%) developed depression requiring antidepressant treatment during pregnancy. CONCLUSIONS: Severe postpartum hemorrhage may have a long-term psychological impact on women despite uterine preservation.

Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage.

OBJECTIVES: To estimate what factors are associated with a failed pelvic arterial embolization for postpartum hemorrhage and to attempt to estimate efficacy of pelvic arterial embolization in rare conditions. METHODS: This was a retrospective cohort study including all consecutive women who underwent pelvic arterial embolization trial for postpartum hemorrhage between 1994 and 2007 at a tertiary care center. Pelvic arterial embolization failure was defined as the requirement for subsequent surgical procedure to control postpartum hemorrhage. RESULTS: Pelvic arterial embolization was attempted in 0.3% of deliveries by the same radiologist in 87% of cases. Failures occurred in 11 of 100 cases (11%) and in 4 of 17 cases (24%) of placenta accreta or percreta. The major complication rate after pelvic arterial embolization was low (3%). Fifty patients (50%) were transferred from nine other institutions. Pelvic arterial embolization was performed in 11 cases (11%) after a failed conservative surgical procedure and in eight cases (8%) for secondary postpartum hemorrhage, with success rates of 91% and 88%, respectively. Pelvic arterial embolization demonstrated a patency throughout one ligated pedicle in 9 of the 11 cases of failed conservative surgical procedure (82%). Twin pregnancy, chorioamnionitis, operative vaginal delivery, hospital-to-hospital transfer, nature of embolizing agent and arteries embolized, failed surgical procedure, secondary postpartum hemorrhage, cause of postpartum hemorrhage, and more than one pelvic arterial embolization were not found to be significantly associated with failed pelvic arterial embolization. CONCLUSION: The only factors significantly associated with failed pelvic arterial embolization were a higher rate of estimated blood loss (more than 1,500 mL) and more than 5 transfused red blood cell units. Attempted pelvic arterial embolization after a failed vessel ligation procedure and for a secondary postpartum hemorrhage is a good option with high success rates.

Fertility after B-Lynch suture and stepwise uterine devascularization.

OBJECTIVE: To report the obstetric outcome in a patient who had previously undergone a stepwise uterine devascularization followed by a B-Lynch suture for severe postpartum hemorrhage (PPH). DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 29-year-old woman whose first pregnancy was complicated by severe PPH due to uterine atony. INTERVENTION(S): Stepwise uterine devascularization followed by a B-Lynch suture because of persistent PPH. MAIN OUTCOME MEASURE(S): Preservation of reproductive capacity. RESULT(S): Two years later, the patient conceived spontaneously and delivered a healthy infant by caesarean section after an uneventful pregnancy. During the operation, the uterus showed no marks of the former B-Lynch suture. CONCLUSION(S): This is the first reported case of obstetric outcome after stepwise uterine devascularization and B-Lynch suture. Further case series with mid- and long-term follow-up are required to determine whether the B-Lynch suture has an impact on the patient's subsequent fertility and pregnancies and to establish its place in the PPH surgical management algorithm.

Successful expectant management for a cornual heterotopic pregnancy.

OBJECTIVE: To report the obstetric outcome after expectant management for a right cornual heterotopic pregnancy. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 33-year-old salpingectomized woman with an 8-year history of primary infertility who conceived after in utero transfer of two embryos obtained by in vitro fertilization. INTERVENTION(S): Expectant management and close ultrasonographic and clinical monitoring. MAIN OUTCOME MEASURE(S): Obstetric outcome. RESULT(S): The intrauterine pregnancy proceeded unremarkably. A caesarean section was performed for dystocia and allowed the delivery of a healthy 4170 g male infant. The examination of the uterus showed a prerupture of the right uterine horn. CONCLUSION(S): Expectant management for cornual heterotopic pregnancy could be considered a successful option in a symptom-free patient where the ectopic embryo has a limited craniocaudal length with no cardiac activity. Our case also suggests that elective cesarean section could be the optimal mode of delivery for rare cases of successful management for cornual heterotopic pregnancy, regardless of the therapeutic option chosen for the cornual pregnancy, due to the theoretical increase risk of uterine rupture during labor.

B-Lynch suture for massive persistent postpartum hemorrhage following stepwise uterine devascularization.

OBJECTIVE: To estimate the effectiveness and safety of the B-Lynch suture for severe persistent postpartum hemorrhage (PPH) following vessel ligation before considering hysterectomy and its impact on menstruation and uterine cavity. DESIGN: Cohort study. SETTING: University-affiliated tertiary referral center. Population. Fifteen consecutive women who underwent B-Lynch suture for persistent PPH despite vessel ligation. METHODS: Data were retrieved from medical files and telephone interviews. MAIN OUTCOME MEASURE(S): Hysterectomy, infection, hysteroscopy, future menstruations. RESULTS: In 13 of the 15 cases (86.7%), PPH occurred after cesarean deliveries. B-Lynch sutures controlled the hemorrhage and resulted in an avoidance of immediate hysterectomy in 12 of 15 cases (80%). The postpartum period was uneventful for 14 of 15 women (93.3%). In one case hysterectomy was required due to pyometra in an ischemic uterus. In the remaining 11 women where the uterus was preserved, ambulatory hysteroscopy was normal. No women reported any differences in menses or pain compared to that they experienced before pregnancy, or any clinical symptoms of early menopause. One woman reported a subsequent pregnancy with normal conception delay, whereas the ten remaining women had no desired pregnancy due to, in each case, the fear of PPH recurrence. CONCLUSIONS: B-Lynch technique appears to be an effective procedure with a relatively low morbidity to control persistent severe PPH following a failure of vessel ligation before considering hysterectomy.

Is painful rectovaginal endometriosis an intermediate stage of rectal endometriosis?

OBJECTIVE: To compare the history of pain complaints of women presenting rectovaginal and rectal endometriosis to show that rectovaginal locations may progress to a rectal involvement of the disease. DESIGN: Retrospective comparative study. SETTING: Department of Gynecology and Obstetrics, University Hospital Rouen, France. PATIENT(S): Thirty-two patients with rectovaginal endometriosis and 16 patients with rectal involvement. INTERVENTION(S): Standardized questionnaires recording the clinical history of painful deep endometriosis up to diagnosis. MAIN OUTCOME MEASURE(S): Length of time from onset of pain to diagnosis, types of pain, disability related to the pain, and number of physicians consulted before the diagnosis was made. RESULT(S): Women with rectal endometriosis had an earlier onset of dysmenorrhoea. The age of dysmenorrhoea and the length of time between the onset of the first pain to the first time that the endometriosis was suspected were significantly increased in women with rectal endometriosis. Pain during defecation was more frequent in patients with rectal endometriosis. Women consulted an average of three physicians before the endometriosis diagnosis was suggested. A nongynecologist physician made the diagnosis of rectovaginal and rectal endometriosis in respectively 26% and 31% of cases. CONCLUSION(S): Rectal endometriosis is associated with an earlier onset and a longer history of painful symptoms until the diagnosis was made when compared with rectovaginal endometriosis locations. These observations support the hypothesis that rectovaginal location may be an intermediate stage of rectal endometriosis.

Endorectal ultrasound accuracy in the diagnosis of rectal endometriosis infiltration depth.

OBJECTIVE: To evaluate the accuracy of endorectal ultrasound examination to ascertain the deepest rectal layer involved in rectal endometriosis. DESIGN: Retrospective study. SETTING: Department of obstetrics and gynecology at a university hospital in France. PATIENT(S): Women presenting with rectal endometriosis who had undergone rectal resection during a 22-month period. INTERVENTION(S): Endorectal ultrasonography. MAIN OUTCOME MEASURE(S): The predicted rectal infiltration depth by using endorectal examination was compared with histological findings. The level of agreement was evaluated by using the coefficients of concordance kappa and weighted kappa. RESULT(S): Sixteen women were included in the study. Rectal resection was segmental in 14 cases and was limited in 2 cases. The agreement between 2 examinations was considered good in 9 cases (56%). Endorectal ultrasound overestimated the depth of infiltration in 5 cases and underestimated it in 2 cases. The coefficients of concordance kappa (95% confidence interval) and weighted kappa (95% confidence interval) were, respectively, 0.17 (0-0.34) and 0.22 (0.04-0.4), corresponding to poor concordance between the endorectal ultrasonography and histological examination. CONCLUSION(S): Accuracy in the prediction of rectal-layer involvement in endorectal ultrasonography appears to be limited. This information should not be considered sufficient when selecting the type of rectal-resection procedure.