Enhanced myometrial vascularity: case presentation and review.

OBJECTIVE: To describe the etiology of arteriovenous malformations (AVM) and enhanced myometrial vascularity (EMV), and review updates in management for patients with retained products of conception (RPOC) associated with EMV through a case presentation. DESIGN: A 6-minute narrated video discusses the recent distinction between EMV and AVM. The etiology, symptoms, imaging findings/interpretation, and management based on symptoms are reviewed in detail. As this represents a single case report, it does not meet the definition of research according to the regulations at 45 CFR 46.102(l); therefore, institutional review board approval was not required. SETTING: Tertiary referral center. PATIENT(S): Eight weeks after suction dilation and curettage (D&C) for an incomplete abortion, a 28-year-old gravida 1, para 0 patient presented to an outside facility with RPOC, menorrhagia, and an acute decrease in hemoglobin. After uterine AVM was diagnosed, she was transferred to our facility for further care. INTERVENTION(S): After transfer to our center, ultrasound demonstrated RPOC, with prominent internal vasculature containing peak systolic velocity >20 cm/s. A diagnosis of EMV was made. Magnetic resonance imaging confirmed a prominent serpentine vessel at the endometrium and RPOC within the uterine cavity (Fig. 1). Due to her anemia, she underwent uterine artery embolization (UAE) followed by suction D&C (Fig. 2). Hysteroscopy was performed before and after suction D&C and after curettage, a large vascular bundle was appreciated at the surface of the endometrium. MAIN OUTCOME MEASURE(S): None. RESULT(S): The patient presented to the clinic 2 weeks postoperatively with the resolution of abnormal uterine bleeding symptoms and a negative ß-human chorionic gonadotropin test. CONCLUSION(S): Management of patients with EMV is dependent on the extent of their symptoms. If significant bleeding is present, surgical management is required. Previous reports suggested that patients with EMV and RPOC should undergo UAE before D&C, but more recent studies suggest that D&C may be initiated without UAE, as EMV associated with RPOC may be a normal transient placentation phenomenon and have less risk of hemorrhage than previously suspected. However, in patients with significant preoperative bleeding and/or anemia, we propose that UAE should still be considered. Each patient requires individualized management based on symptoms, signs, imaging, and plans for future fertility. The ideal management of patients with RPOC and EMV remains to be determined.

Acute pelvic pain following miscarriage heterotopic pregnancy must be excluded: case report.

BACKGROUND: Heterotopic pregnancies are increasing in prevalence and this case highlights the importance of excluding the diagnosis in patients with pelvic pain following miscarriage. A known pre-existing intrauterine pregnancy can be falsely reassuring and delay the diagnosis of a potentially life-threatening concurrent ectopic pregnancy. CASE PRESENTATION: In this report, we describe a case of spontaneous heterotopic pregnancy in a woman who had initially presented with pelvic pain and vaginal bleeding, and was diagnosed on pelvic ultrasound with a missed miscarriage; a non-viable intrauterine pregnancy. She re-presented 7 days later with worsening pelvic pain and bleeding, and a repeat pelvic ultrasound identified a ruptured tubal ectopic pregnancy in addition to an incomplete miscarriage of the previously identified intrauterine pregnancy. She underwent an emergency laparoscopy where a ruptured tubal ectopic pregnancy was confirmed. CONCLUSION: Being a time critical diagnosis with the potential for an adverse outcome, it is important that the emergency physician considers heterotopic pregnancy as a differential diagnosis in patients presenting with pelvic pain following a recent miscarriage. The same principle should apply to pelvic pain in the context of a known viable intrauterine pregnancy or recent termination of pregnancy. A combination of clinical assessment, beta human chorionic gonadotropin levels, point of care ultrasound and formal transvaginal ultrasound must be utilized together in these situations to explicitly exclude heterotopic pregnancy.

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.

Trends in misoprostol use and abortion complications: A cross-sectional study from nine referral hospitals in Nigeria.

OBJECTIVE: The study aimed to assess the use of misoprostol and complications associated with abortions in referral hospitals in Nigeria, a country with restrictive abortion laws. METHODS: A cross-sectional study at nine referral hospitals in South-west Nigeria. Nine years' data were retrieved from medical records, including 699 induced abortions. Independent variable was the method of abortion; dependent variables were complications, need for treatment and mortality. Statistical significance was tested with Chi-square, Fishers' exact and chi-square for trend tests (p<0.05). RESULTS: There were 699 induced abortions amongst 2,463 abortions found in records. Nearly 70% were surgical abortions, but misoprostol use significantly increased over the study period in a linear trend (Χ2 trend: 30.96, P <0.001). Patients who used misoprostol were significantly less likely to have infectious morbidity, genital tract injuries or medical complications. There was no difference in incomplete abortion in the groups. Patients were more likely to have in-patient care with surgical abortions (p<0.001), to need prolonged antibiotic regimens (p = 0.003), need further surgeries or additional specialist care (p = 0.009). CONCLUSION: Misoprostol abortion has significantly increased over time, and was associated with less morbidity and need for further treatment, in this study. It appears to be the safer option.

Clinical and imaging predictors of management in retained products of conception.

OBJECTIVES: To determine if clinical and ultrasound (US) imaging features help predict management in clinically suspected retained products of conception (RPOC). METHODS: 334 patients sonographically evaluated for RPOC were included in this IRB-approved retrospective study. Of the 334 patients, 176 had sonographic diagnosis of RPOC and comprised the final study group. Patients were managed expectantly, medically, or surgically in accordance with clinical judgment of treating physicians. Pelvic sonograms were retrospectively reviewed for endometrial stripe thickness and vascularity was graded on a 0-3 scale based on appearance relative to myometrium (Grade 0: no vascularity, Grade 1: minimal vascularity, Grade 2: moderate vascularity, Grade 3: marked vascularity). Clinical and imaging predictors of management were evaluated in univariate and multivariate analysis. RESULTS: Mean patient age was 29.6 years and mean gestational age was 17.4 weeks. Most (74.4%) women presented with vaginal bleeding. 83 patients (47.2%) were treated conservatively with expectant management, 42 (23.8%) were treated medically, and 51 (29.0%) required surgical intervention. Mean endometrial stripe thickness was 21.3 mm. 47 women (26.7%) had vascularity score of 0; 50 (28.4%) had score 1; 52 (29.6%) had score 2; and 27 (15.3%) had score 3. In univariate analysis, serum hemoglobin (Hb) (p < 0.0001), endometrial stripe thickness on US (p < 0.005), presenting symptoms (p = 0.03), and US vascularity score (p < 0.005) were statistically significant predictors of final management. In multivariate logistic regression, serum Hb (OR 0.69, 95% CI 0.55-0.86, p < 0.0009), endometrial stripe thickness (OR 1.08, 95% CI 1.04-1.12, p < 0.0001), and US vascularity score (OR 1.77, 95% CI 1.16-2.70, p < 0.01) were statistically significant predictors of need for surgery. CONCLUSIONS: Serum Hb, endometrial stripe thickness, and US vascularity score were significant predictors of clinical management, particularly the need for surgical intervention, in women with clinically suspected RPOC.

Are women with complications of an incomplete abortion more likely to be HIV infected than women without complications?

BACKGROUND: There is limited published evidence about the status of HIV among women who have had abortions or suffered from abortion complications. Understanding this connection is critical for building the evidence base and for guiding strategies to manage the sexual and reproductive health needs of women living with HIV. The purpose of this study is to determine whether women who suffered incomplete abortion complications are more likely to be HIV infected than those without complications. We hypothesized that women with incomplete abortion complications have higher rates of HIV infection than women who attended clinic for other obstetric reasons. METHODS: The analysis used a secondary dataset from a published case-control study that enrolled 1) 70 women at discharge after receiving in-patient care for complications resulting from induced abortion, and 2) 69 women (the comparison group) who visited the same hospital during the same time period for other obstetric needs. The primary outcome was seeking care for complications of incomplete abortion versus seeking care for other obstetric needs (dichotomous). The primary exposure variable was self-reported HIV status which was categorized into three groups: HIV positive, HIV negative, and HIV unknown. Unadjusted and adjusted associations between being in the abortion complications group, HIV status and other selected population characteristics were estimated using univariate and multivariate logistic regression. RESULTS: Of 139 women enrolled in this study. Seventy (50.4 %) women had abortion complications and 69 (49.6 %) did not. Of the total study population, 18 (12.9 %) were HIV positive, 50 (36.0 %) were HIV negative, and the HIV status of 71 women (51.1 %) was unknown. Compared to women who were HIV negative, women who were HIV positive had similar odds of being in the abortion complications group in both univariate and multivariate analyses (ρ =0.62 and ρ = 0.76). However, compared to HIV-negative women, those women who did not know their HIV status had greater odds of being in the abortion complications group (OR = 3.8, 95 % CI, 1.88, 8.20) in univariate analysis. After adjusting for potential confounding variables, the odds of being in the abortion complications group remained greater among women who did not know their HIV status compared to HIV-negative women (adjusted OR = 2.8, 95 % CI, 1.20, 6.54). CONCLUSIONS: This study points to the need for targeted interventions aimed at strengthening the delivery and coverage of HIV-testing programs for pregnant women and post-abortion care. In addition, more research is needed to better understand the relationships between unsafe abortion, abortion complications and unknown HIV status.

Effects of leonurine hydrochloride on medically induced incomplete abortion in early pregnancy rats.

OBJECTIVES: To determine the effect of leonurine hydrochloride (LH) on abnormal bleeding induced by medical abortion. STUDY DESIGN: Rats had incomplete abortions induced in early pregnancy using mifepristone in combination with misoprostol. After abortion, rats were treated with LH for 7 days, and the duration and volume of uterine bleeding were observed. Approximately 30min after the last treatment, the animals were killed and the uterine shape was observed. The sinistro-uteri were suspended in organ baths to record the contraction curves, including the frequency and tension for 10min; the dextro-uteri were fixed with formaldehyde for pathologic evaluation. In addition, blood samples were collected from the femoral artery for the measurement of estradiol (E2) and progesterone (P) levels by radioimmunoassay. RESULTS: In in vivo experiments, compared with the model group, LH treatment markedly reduced the volume of bleeding and intrauterine residual, and significantly shortened the duration of bleeding. From the contraction curve, LH notably reinforced the frequency and tension of uterine contractions. LH remarkably elevated the serum estradiol level in rats, but had no obvious effect on progesterone level. CONCLUSIONS: LH has an inhibitory effect on bleeding caused by incomplete abortion; the mechanism may be related to up-regulation of the E2 level, leading to an increase in uterine contractions and evacuation of intrauterine residuum.

Partial foetal retention following aglepristone treatment in a bitch.

This short communication describes the case of partial foetal retention in an 18-month-old female French bulldog following induction of abortion owing to an undesired mating. Abortion was induced with aglepristone administered in two consecutive protocols of a dual injection 1 day apart. After failure of the first treatment to achieve abortion, 15 days later, a second treatment was administered. Delivering of aborted foetus occurred 2 days after the last administration. Five weeks after the abortion, the female showed a weak haemorrhagic vaginal discharge. On ultrasound examination, the presence of uterine wall distension as well as a puppy skull inside the uterus was observed. This clinical case makes clear that although aglepristone is a very reliable drug, follow-up of the female during treatment and in the immediate post-partum is necessary to ensure a good outcome.

Best predictors of grayscale ultrasound combined with color Doppler in the diagnosis of retained products of conception.

OBJECTIVES: To determine the best predictors of the presence of retained products of conception (RPOC) on grayscale and color Doppler transvaginal sonographic examination. METHODS: This was a retrospective study of 91 consecutive patients who underwent transvaginal sonography (TVS) with color Doppler to evaluate for the presence of RPOC. The images of TVS studies were reviewed by two radiologists in consensus blinded to the final outcome. Data on a number of variables including endometrial measurable mass and focal increased color vascularity were collected as predictors of RPOC. The patients' ages ranged from 17 to 48 years (mean, 31.8 ± 6.8) and gestational age from 5 to 24 weeks (mean, 9.2 ± 3.8). Thirty-six were confirmed as RPOC by dilatation and curettage (D&C) and pathology. Fifty-five were considered negative, 9 based on D&C results and 46 on clinical grounds. RESULTS: Sensitivity, specificity, negative- and positive-predictive and accuracy values were 81% (CI: 68%-94%), 71% (CI: 59%-83%), 85% (CI: 74%-95%), 64% (CI: 50%-78%), and 75% (CI: 66%-84%) to detect RPOC when a mass was present. The corresponding numbers for the presence of focal color vascularity were 94% (CI: 87%-100%) (p = 0.07), 67% (CI: 55%-80%) (p > 0.05), 95% (CI: 88%-100%) (p = 0.1), 65% (CI: 52%-78%) (p > 0.05), and 78% (CI: 70%-87%) (p > 0.05). Of the patients with confirmed RPOC on pathology, five had focal increased vascularity and no massand none had a mass without focal increased vascularity. CONCLUSION: An area of focal increased vascularity with or without a mass is the best predictor of the presence of RPOC.

Management of retained products of conception with marked vascularity.

Cases of retained products of conception (RPOC) with marked vascularity present a clinical challenge because simple dilation and curettage (D&C) can lead to life-threatening hemorrhage. We describe here two cases of hypervascular RPOC that were successfully managed with two different approaches. Case 1: A 26-year-old woman with history of 3 D&Cs was transported to the emergency room for heavy vaginal bleeding 45 days after a spontaneous abortion. Diagnosis of RPOC with aneurysm-like structure was considered and uterine artery embolization was performed. Four days after the uterine artery embolization, reduction of the vascularity of RPOC was confirmed on color Doppler ultrasonography and D&C was successfully carried out. Case 2: A 37-year-old woman with history of one cesarean section became pregnant after the regular menses. She underwent D&C for missed abortion at 8 weeks' gestation. Seven days after the D&C, sonographically heterogenous mass emerged in the vicinity of the previous cesarean scar. Thereafter, the mass gradually grew larger and diagnosis of hypervascular placental polyp was considered. As the amount of vaginal bleeding was small, expectant management was instituted. Sixty-one days after the first D&C, reduction of the vascularity of RPOC was confirmed on color Doppler ultrasonography and D&C was successfully completed.

Role of clinical and ultrasound findings in the diagnosis of retained products of conception.

OBJECTIVE: To assess the role of clinical and ultrasound findings as predictors of retained products of conception (RPOC) in women with a suspicion of incomplete miscarriage. METHODS: This was a retrospective study of 91 patients admitted for suspected RPOC after spontaneous first-trimester miscarriage who were evacuated surgically, and for whom histopathological reports were available. All the women underwent transvaginal sonography after their miscarriage. The decision to evacuate the uterus was based on vaginal bleeding, lower abdominal pain and/or sonographic findings of hyperechoic material or endometrial thickness more than 8 mm. Maternal age, gestational age, clinical signs and symptoms and sonographic findings were recorded. Clinical and sonographic findings were compared with the histopathological reports and the sensitivity and specificity of vaginal bleeding, abdominal pain and sonographic appearance of the endometrium for detecting the products of conception were assessed. RESULTS: Histopathological analysis confirmed the presence of chorionic villi in 55 women (60%) and decidua in 36 (40%). Vaginal bleeding was more frequent in women with RPOC (P < 0.001), whilst lower abdominal pain was a more frequent symptom in those with decidua (P = 0.019). The ultrasound finding of hyperechoic material had a sensitivity of 78%, specificity of 100% and positive and negative predictive values of 100% and 75%, respectively, in predicting RPOC. Vaginal bleeding as a predictor of RPOC had a sensitivity of 93%, specificity of 50%, and positive and negative predictive values of 74% and 82%, respectively. The combination of hyperechoic material and/or vaginal bleeding increased the sensitivity to 98% and negative predictive value to 95%. There was no significant difference in endometrial thickness between the two groups. CONCLUSION: The ultrasound finding of hyperechoic material is the best predictor for diagnosing RPOC. In the absence of hyperechoic material and vaginal bleeding, RPOC are extremely unlikely.

A probable secondary infertility due to osseous metaplasia of the endometrium.

OBJECTIVE: Osseous metaplasia is a rare pathological entity that affects the uterus and usually appears following abortion, chronic endometritis, metabolic disorders or following LEEP excision of the cervix. CASE: Herein, we present the occurrence of osseous metaplasia in a 27-year-old patient with a history of an abortion 2 years ago and suffering infertility. CONCLUSION: We suggest that the infertility in this patient may be caused by calcification and ossification of fetal tissue retained in the uterus after abortion.

The value of measuring endometrial thickness and volume on transvaginal ultrasound scan for the diagnosis of incomplete miscarriage.

OBJECTIVE: To identify ultrasound measurements that are the best predictors of the presence of retained products of conception (RPOC) within the uterine cavity in women with clinical diagnosis of incomplete miscarriage. METHODS: This was a prospective observational study, set in a dedicated early pregnancy assessment unit in a London teaching hospital. Endometrial thickness and the volume of suspected retained products of conception were measured by transvaginal ultrasound scan preoperatively. Indications for surgical intervention were heavy vaginal bleeding or continuous bleeding lasting > 7 days. The main outcome measure was histological evidence of chorionic villi in surgical specimens. RESULTS: Among the patients, 109 (85%) had evidence of chorionic villi on histology, whilst decidua was only found in the remaining 19 (15%). There was no identifiable cut-off for endometrial thickness or volume that could be used to differentiate between retained products of conception and decidua. CONCLUSION: Measurements of endometrial thickness or volume on ultrasound scan are not good tests for diagnosing an incomplete miscarriage.

Routine histopathologic analysis of product of conception following first-trimester spontaneous miscarriages.

AIM: To evaluate the histopathologic findings relating to tissue samples collected at surgical uterine evacuation in first-trimester spontaneous miscarriages. METHODS: In this retrospective study, histopathologic diagnosis of the tissue samples obtained via surgical uterine evacuation in patients who were admitted to the Early Pregnancy Clinic in a 12-month period with the diagnosis of incomplete miscarriage (n = 970), missed miscarriage (n = 406) and anembryonic miscarriage (n = 230) in the first trimester was recorded and compared with the presurgery diagnosis. RESULTS: Uterine evacuation was performed in cases of incomplete miscarriage (n = 970, 60.4%), missed miscarriage (n = 406, 25.2%) and anembryonic miscarriage (n = 230, 14.3%). Histopathologic examination revealed the product of conception in 1119 patients (69.7%), while partial hydatidiform mole was diagnosed in 33 patients (2.1%). Complete hydatidiform mole was detected in only seven cases (0.43%). Exaggerated placental site and placental site trophoblastic nodule was detected in two cases (0.12%). Decidual tissue without chorionic villi was reported in 272 patients (16.9%), raising the suspicion of presence of other pathology. CONCLUSIONS: By routine histopathologic assessment of products of first-trimester spontaneous miscarriages, important pathologies such as molar pregnancy and placental trophoblastic disease can be diagnosed. Histopathological assessment has great value in the identification of an ectopic pregnancy or infection when compared with clinical and laboratory findings.

The role of ultrasound imaging in diagnosing and investigating early pregnancy failure.

The advent of high-resolution transvaginal ultrasound (TVS) has revolutionized our understanding of the pathophysiology and the management of early pregnancy failure. Knowledge of the ultrasound appearances of normal early pregnancy development and a good understanding of its pitfalls are essential for the diagnosis and management of early pregnancy failure. Ultrasound imaging has rapidly replaced all other techniques used to study normal human development in the first trimester, and ultrasound features of the early gestational sac have corroborated anatomical studies showing that the first structures to appear are the celomic cavity and the secondary yolk sac. No single ultrasound measurement of the different anatomical features in the first trimester has been shown to have a high predictive value for determining early pregnancy outcome. Similarly, Doppler studies have failed to demonstrate abnormal blood flow indices in the first-trimester uteroplacental circulation of pregnancies that subsequently end in miscarriage. Ultrasound parameters combined with maternal serum hormone levels, maternal age, smoking habits, obstetric history and the occurrence of vaginal bleeding have all been combined in multivariate analyses, with mixed results. Combined ultrasound and in-vitro experiments have demonstrated that the maternal circulation inside the placenta starts at the periphery at around 9 weeks of gestation and that this is associated with a physiological oxidative stress which could be the trigger for the formation of the placental membranes. Abnormal development of these membranes can result in subchorionic hemorrhage and threatened miscarriage with subsequent long-term consequences such as preterm rupture of the membranes and preterm labor, irrespective of the finding of a hematoma on ultrasound. In both euploid and aneuploid missed miscarriages there is clear ultrasound evidence for excessive entry of maternal blood at a very early stage inside the developing placenta resulting in oxidative stress and subsequent degeneration of villous tissue. The finding of blood flow in the intervillous space in cases of first-trimester miscarriage using color Doppler also appears to be useful in the prediction of success of expectant management. Miscarriages with blood flow within the intervillous space are up to four times more likely to complete with expectant management. TVS is considered the gold standard in the diagnosis and management of incomplete miscarriage. Expectant management of miscarriage, using ultrasound parameters to determine eligibility, could significantly reduce the number of unnecessary evacuations of the retained products of conception, depending on the criteria used.

MR imaging of maternal diseases of the abdomen and pelvis during pregnancy and the immediate postpartum period.

Magnetic resonance (MR) imaging provides multiplanar large field-of-view images of the body with excellent soft-tissue contrast and without ionizing radiation. As a result, MR imaging is increasingly being used to image the maternal abdomen and pelvis during and immediately after pregnancy. Results of rapid T1- and T2-weighted imaging are often diagnostic, and blood vessels, ductal structures, and the urinary tract can frequently be visualized without intravenous administration of contrast material. Until more conclusive safety data become available, MR imaging should be reserved for cases in which results of ultrasonography are inconclusive and patient care depends on further imaging. In the setting of acute abdomen during pregnancy, MR imaging allows identification of areas of inflammation, abscess formation, hemorrhage, and bowel obstruction. MR imaging also helps determine the organ of origin, extent, and composition of maternal neoplasms and is useful in evaluation of müllerian duct anomalies and abnormalities of placental formation, position, and implantation. Many postpartum complications such as retained products of conception and uterine dehiscence may be diagnosed with MR imaging when results of other modalities are indeterminate.

Novel treatment of a patient with secondary infertility due to retained fetal bone.

OBJECTIVE: To describe a simple and previously unreported treatment for retained fetal bone fragments as a cause of secondary infertility. SETTING: Fertility center at a Canadian teaching hospital. DESIGN: Case report. PATIENT(S): A 36-year-old woman with a 15-year history of secondary infertility. INTERVENTION(S): A second dilation and curettage (D+C) performed under abdominal ultrasound guidance was performed where the curette could be directed for the removal of echogenic endometrial foci. MAIN OUTCOME MEASURE(S): Resolution of long-term infertility. RESULT(S): Spontaneous pregnancy 4 months after ultrasound-guided D+C and subsequent term delivery. CONCLUSION(S): If an echogenic area is discovered in the endometrium, it is now standard to look at the uterine cavity by hysteroscopy. However, if the hysteroscopy is normal, we suggest that a D+C with intraoperative abdominal ultrasound assistance be done to ensure that all the abnormal tissue is removed.

Histological analysis of the products of conception following first trimester abortion at Jordan University Hospital.

OBJECTIVE: To evaluate the value of histopathological examination of products of conception in first trimester abortion. SETTINGS: University hospital. DESIGN: Retrospective record review over 2 years, from January 1999 to January 2001. PATIENTS: A total number of 293 patients with the diagnosis of first trimester abortion were admitted and their abnormal pregnancy evacuated. RESULTS: The highest type of abortion among the studied group was incomplete abortion, 140 patients (48%), and surgical evacuation was the most common method of termination, 202 patients (69%). The histopathology reports confirmed the pregnancy in all patients and revealed partial mole in 51 patients (17%), undiagnosed abnormality in 8 patients (2.7%), suggesting the possible cause for recurrent pregnancy loss in 4 patients (1.4%). CONCLUSION: Histopathological assessment for the products of conception proved to be an important tool in detecting molar pregnancy and hydropic changes that necessitate special follow-up protocol and unmasking ectopic pregnancies for further management.

Is pathology examination useful after early surgical abortion?

OBJECTIVE: To study if the pathologist's examination of surgical abortion tissue offers more information than immediate fresh tissue examination by the surgeon. Immediate examination of the fresh tissue aspirate after surgical abortion helps reduce the risk of failed abortion and other complications. Regulations in some states also require a pathologist to analyze abortion specimens at added cost to providers. We conducted this study to evaluate the incremental clinical benefit of pathology examination after surgical abortion at less than 6 weeks' gestation. METHODS: As part of a prospective case series of women who had early surgical abortions at the Planned Parenthood League of Massachusetts during a 32-month period, we collected data on clinical outcomes and the results of postoperative tissue examinations. Using outcomes verified by in-person follow-up as the "gold standard," we calculated the validity of the tissue examinations by the surgeons and the outside pathologists. RESULTS: A total of 676 women had documented outcomes and complete tissue examination data. The sensitivity (ability of the examiner to detect an outcome other than complete abortion) was 57% (95% confidence interval [CI] 35, 76) for the surgeons' tissue inspections and 22% (95% CI 8, 44) for the pathologists' examinations. The predictive value of a positive (abnormal) tissue screen was 14% (95% CI 8, 24) and 7% (95% CI 3, 17) for the surgeons and pathologists, respectively. CONCLUSION: Routine pathology examination of the tissue aspirate after early surgical abortion confers no incremental clinical benefit. Although the surgeons' tissue inspections predicted abnormal outcomes poorly, the pathologists did no better. Our results challenge the rationale for state regulations requiring pathologic analysis of all surgical abortion specimens.