Homelessness, housing instability, and abortion outcomes at an urban abortion clinic in the United States.

BACKGROUND: Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population. OBJECTIVE: This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship. STUDY DESIGN: Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of ≥20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries. RESULTS: Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications. CONCLUSION: Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.

Management of intra-abdominally translocated contraceptive devices, is surgery the only way to treat this problem?

This study was a multi-centre retrospective review of patients with uterine perforation caused by intrauterine contraceptive devices (IUDs). A total of 15 patients were registered, in a seven year period. Among them, five were asymptomatic and the rest were symptomatic. Asymptomatic patients were managed conservatively, except in one case in which the patient requested surgery because she also wanted a tubal ligation. Symptomatic patients all underwent surgery. All the surgeries were elective and all the surgical procedures were initiated laparoscopically. There were seven complications in the surgically managed group: conversion to laparotomy (n = 3), bowel injury (n = 2), bladder injury (n = 1), and wound infection (n = 1). Mild and severe adhesions (81.8%), and abscess (18.1%) formation related to translocated IUD (TIUD) were observed during surgery. All the patients were uneventful at 1 to 5 years of follow-up. A TIUD, by causing adhesions, complicates future laparoscopic surgery and increases the likelihood of conversion to laparotomy. While surgery is indicated to prevent TIUD-induced adhesive complications, it may also be the cause of both adhesions and complications, resulting in a vicious cycle. Some asymptomatic women, especially elderly patients with comorbidities, may not need or may be better managed without treatment. Impact statement In this study we try to find an answer for the question of "Should removal of a translocated intrauterine contraceptive device (TIUD) routinely be performed even if patients are asymptomatic?" From only the theoretical point of view there were some reports supporting conservative management in asymptomatic patients. The other studies addressing this issue were case reports including few patients with a short-term follow-up. The novelties of the present study include multi-centre design, detailed clinical and surgical information about the patients and the long period of follow-up. Most clinicians have limited experiences in managing TIUD because perforation is a rare event. So it can be difficult to know exactly what the surgeon will encounter intraoperatively. We undertook this study with the aim of providing a perspective about patients with TIUD for those faced with this situation. This is a descriptive study reporting 15 cases of TIUDs and management. Asymptomatic patients were managed conservatively, and symptomatic patients were operated. There are important implications resulting from this study that in asymptomatic patients leaving the IUD in place may be a reasonable option, mostly as the risk of surgical intervention is quite high with a high rate of complications with surgical management.

Uterine perforation following a fractional curettage successfully treated with the modified polysaccharide 4DryField® PH: a case report.

BACKGROUND: Uterine perforation is the most common complication of curettage and may result in bleeding. Therefore, urgent control of bleeding from the uterine wall perforation is necessary to avoid an emergency hysterectomy or blood transfusion, to prevent peritoneal adhesion formation, possible chronic pelvic pain, and infertility. In the present case, an active bleeding secondary to a perforation of the uterus during curettage, for diagnosis of endometrial carcinoma, was instantaneously and successfully treated with only the application of a novel modified polysaccharide powder. This is, to the best of our knowledge, the first time that the agent 4DryField® has been used for this purpose. CASE PRESENTATION: A 71-year-old German woman with serometra and endometrial hyperplasia suffered a perforation of the anterior wall of the uterus during the hysteroscopic resection of submucosal polyps and a fractional curettage. Subsequently, an immediate laparoscopy showed an active bleeding from the wound, which was promptly stopped with only the application of the hemostatic and anti-adhesion polysaccharide powder, 4DryField®. There were no postoperative complications. Nine weeks later, a laparoscopic hysterectomy with bilateral salpingoophorectomy for endometrial carcinoma (histology: stage IA, pT1a, cN0, L0 V0 M0/G2) was performed. The former injured area looked slightly prominent, was completely healed, and showed a shiny serosa. All her pelvic organs were free of adhesions, and there was one 0.5-mm calcified granuloma in the Douglas pouch. CONCLUSIONS: The efficient hemostasis combined with the adhesion prevention effect of 4DryField®, allowed a fast control of the uterine wall bleeding, saved operation time, avoided the risks of other procedures for bleeding control and contributed to the normal healing of the uterine wall without any adhesion formation.

Uterine arteriovenous fistula after perforation during the placement of an intrauterine device - Minimally invasive treatment using uterine artery embolization.

Uterine arteriovenous fistula (AVF) is a rare, but potentially life-threatening condition. Acquired fistulae may occur as a result of trauma or instrumentation, endometrial carcinoma, gestational trophoblastic disease, and intrauterine devices (IUDs). Herein the authors present the case of a 33-year-old woman with a uterine AVF developing after uterine perforation during the placement of a levonorgestrel IUD. The fistula was diagnosed using color Doppler ultrasonography and angiography and the treatment was conducted by minimally invasive approach using uterine artery embolization.

Facility-based treatment for medical complications resulting from unsafe pregnancy termination in the developing world, 2012: a review of evidence from 26 countries.

UNLABELLED: With changing conditions affecting receipt of postabortion care, an updated estimate of the incidence of treatment for complications from unsafe pregnancy termination is needed to inform policies and programmes. National estimates of facility-based treatment for complications in 26 countries form the basis for estimating treatment rates in the developing world. An estimated seven million women were treated in the developing world for complications from unsafe pregnancy termination in 2012, a rate of 6.9 per 1000 women aged 15-44 years. Regionally, rates ranged from 5.3 in Latin America and the Caribbean to 8.2 in Asia. Results inform policies to improve women's health. TWEETABLE ABSTRACT: An estimated 7 million women were treated in the developing world for complications of unsafe TOP in 2012.

Complications of Hysteroscopic and Uterine Resectoscopic Surgery.

Adverse events associated with hysteroscopic procedures are generally rare, but, with increasing operative complexity, it is now apparent that they are experienced more often. There exists a spectrum of complications that relate to generic components of procedures, such as patient positioning, anesthesia, and analgesia, to a number that are specific to intraluminal endoscopic surgery that largely comprise perforation and injuries to surrounding structures and blood vessels. Whereas a number of endoscopic procedures require the use of distending media, the response of premenopausal women to excessive absorption of nonionic fluids used for hysteroscopy is somewhat unique, and deserves special attention on the part the surgeon. There is also an increasing awareness of uncommon but problematic sequelae related to the use of monopolar radiofrequency uterine resectoscopes that involve thermal injury to the vulva and vagina. Furthermore, the uterus that has previously undergone hysteroscopic surgery may behave in unusual ways, at least in premenopausal women who experience menstruation or who become pregnant. Fortunately, better understanding of the mechanisms involved in these adverse events, as well as the use or development of a number of innovative devices, have collectively provided the opportunity to perform hysteroscopic and resectoscopic surgery in a manner that minimizes risk to the patient.

[COMPLICATIONS OF DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY--REVIEW].

Hysteroscopy is a diagnostic or surgical mini-Invasive gynecologic operating procedure. The complications of this standard procedure are relatively rare. According to retrospective studies they are 0.95-13.6%. They occur more often by an operative rather than a diagnostic hysteroscopy. These complications could be divided into two groups of an approximately equal occurrence--due to a dilation and passing through the cervix uteri (cervical laceration, creative a false cervix uteri, perforation, bleeding, impossibility to pass through the inner orifice of the cervical canal, insufficiency of the cervix uteri) and due to the operative technique itself (uterine perforation, fluid overload, thermal or mechanical trauma of the inner urinaiy and gastrointestinal tract, infection, rupture of the uterus during a subsequent pregnancy). The most occurring complication is namely the uterine perforation--1-9%, the most severe could indeed be the fluid overload--0.01-11%. The gynecologist performing the hysteroscopy should be well grounded in the typical complications. Unveiling and performing a quick intervention of the latter could prevent unwanted consequences for the patient and the legal issues that could follow occur.

Cervical perforation by the strings of a levonorgestrel releasing-intrauterine system: a case report.

A very rare case of perforation of the uterine cervix by the strings of a levonorgestrel releasing-intrauterine system (LNG-IUS) in a 47-year-old woman is presented. The method to retrieve the strings back into the cervical canal, leaving the LNG-IUS in situ, is described. We suggest that the threads of an intrauterine contraceptive occasionally may penetrate tissue like setons do, when used for treatment of fistulae.

Uterine perforation as a complication of surgical abortion causing small bowel obstruction: a review.

OBJECTIVE: Small bowel obstruction after unrecognized or conservatively treated uterine perforation is extremely rare. It is a surgical emergency and the delay in diagnosis and treatment has deleterious consequences for the mother. The purpose of this study is to critically review the available literature and ascertain the level of evidence for the mechanisms, diagnosis and management of small bowel obstruction after uterine perforation due to surgical abortion. METHODS: Systematic literature search was conducted in Pubmed (1946 to 2012) and Pubmedcentral (1900 to 2012) including all available English and French language fulltext articles. Three evaluators reviewed and selected all available case reports and case series. Search terms included small bowel obstruction, bowel obstruction, bowel incarceration, bowel entrapment, vaginal evisceration, uterine perforation, uterine rupture, and abortion. The exclusion criteria were (1) complex injuries where small bowel incarceration was present but with bleeding and/or bowel perforation as the leading symptomatology; (2) articles only numbering the patients without details on the topic. Analyses of incidence, risk factors, mechanisms of the disease, time of clinical presentation, diagnostic modalities, treatment, and maternal outcome were included. RESULTS: Of the 73 articles screened 30 cases of small bowel obstruction were included in the review forming incidence, risk factors, and mechanisms of the disease, diagnosis, therapy, and maternal outcome. CONCLUSIONS: A systematic review defined four mechanisms of small bowel obstruction after transvaginal instrumental uterine perforation with significant variations in clinical presentation and time of presentation. Duration of symptoms depend on the mechanism of small bowel obstruction. Vaginal evisceration is surgical emergency and treatment is mandatory without diagnostic workup. Survival rate during last century is 93 %. Multicentric trials and publication of all such cases are needed to determine algorithms for diagnosis and management of small bowel obstruction caused by instrumental uterine perforation.

Complications of surgical abortion.

Surgical abortion is one of the most common procedures performed in reproductive-aged women and when performed by a skilled provider in the appropriate setting, it is one of the safest surgeries. Though the risk of complications is low, it increases exponentially with gestational age. Factors increasing risk of morbidity may be demographic, such as increasing patient age; medical, such as prior cesarean delivery; and procedural, such as inadequate dilation. This chapter will provide information on how to recognize factors that increase risk, steps to minimize risk, and to identify and manage complications promptly.

Computed tomography features of spontaneously perforated pyometra: a case report.

Spontaneous perforation of pyometra is an extremely rare emergent gynecologic disease. We report a 73-year-old woman with a spontaneously perforated pyometra presenting with acute abdomen in the emergency department. A dedicated computed tomography examination of the abdominal and pelvic regions revealed the diagnosis. The patient recovered well after surgical intervention and antibiotic treatment.

[Analysis on the complications of hysteroscopic surgeries].

OBJECTIVE: To investigate the causations, management and prevention methods on the complications of hysteroscopic procedures. METHODS: Retrospective analysis of 36 cases with hysteroscopic complication, focusing on their characteristics and clinical management as well as prevention methods during the ten years from 1993 to 2004. RESULTS: Among 36 cases, 11 cases with uterine perforation and incomplete perforation, which happened during the complicated procedures, were treated by both laparoscopy and laparotomy. Five cases with heavy bleeding were encountered because of the deeply injury to the uterine wall and Foley catheter was inserted into uterine cavity and it stopped the bleeding successfully except in one case done by hysterectomy. Three cases with fluid overload syndrome were cured by using diuretic agent and saline infusion. There is no serious consequence in one case with air embolism due to prompt diagnosis and treatment. Four cases with postablation-sterilization syndrome were treated effectively by performing hysterectomy plus single or bilateral salpingectomy, dilating cervical canal as well as resecting adhesions. Twelve cases with adhesion inside uterine cavity followed hysteroscopy were also treated by dilating cervical canal, underwent adhesionlysis and hysterectomy. CONCLUSIONS: The potential factors causing complications of hysteroscopy include complicated procedures inside uterine cavity, higher pressure of irrigation, deep injury of endometrium as well as incomplete removal of endometrium during hysteroscopic operations. It is the necessary measures to reduce the complications by performing laparoscopy or B ultrasound monitoring simultaneously, standardizing the procedure and strengthening postoperation management.

Perforación uterina y de colon por T de cobre / Uterine and colon perforation caused by a copper T

Se reporta el caso de una paciente de 36 años, con perforación uterina y del colon sigmoides con una Tcu colocada 14 años atrás, y que evolucionó en forma asintomática. El manejo requirió de histerectomía abdominal, con reparación de colon sigmoides y colostomía transversa temporal con evolución final satisfactoria. La perforación uterina por dispositivos intrauterinos (DIU), constituye una complicación poco frecuente, y puede acompañarse de perforación de otras víceras en el 15 por ciento, de los casos principalmente del intestino. Descriptores: DIU, perforación uterina, complicaciones

Laparoscopic oxidized cellulose (Surgicel) application for small uterine perforations.

OBJECTIVES: To test the efficacy and safety of laparoscopic oxidized cellulose application at the uterine perforation site. METHODS: In a prospective study over a 3.5-year period a total of 30 women undergoing combined surgical termination of pregnancy and laparoscopic sterilization who had a small uterine perforation were recruited. Oxidized cellulose (Surgicel) was inserted and attached to the perforation site with a laparoscope. The end point was sealing of the perforation and complete hemostasis. Laparotomy was performed if hemostasis was not achieved. RESULTS: The mean age, parity and gestation were 31.4 years, 3.8 and 9.3 weeks. The perforations occurred in the fundal region (60%), anterior wall (16.7%), posterior wall (13.3%), upper lateral wall (3.3%) and lower lateral wall (6.7%). Mean size of perforations, respectively according to site were 4.3 mm, 3.2 mm, 3.4 mm, 3 mm and 3.5 mm in the five groups. Laparoscopic oxidized cellulose application was successful in all women with fundal, anterior, posterior and upper lateral uterine wall perforations. In two women with perforations on the lower lateral wall, due to excessive blood loss, oxidized cellulose fell off; laparotomy was performed and hemostasis was achieved with sutures. All 28 laparoscopically-treated women were discharged on the next day in good condition with no complications. CONCLUSIONS: Laparoscopic oxidized cellulose application appears to be a safe and effective treatment for small uterine perforations that are bleeding moderately.

[Complications of operative hysteroscopy]. / Complications de l'hystéroscopie opératoire.

OBJECTIVES: Assess the prevalence and severity of the various complications of operative hysteroscopy, the context in which they occur and the treatments proposed. METHOD: A single-center observational study from 1/1/90 to 1/1/99 including 2,116 surgical hysteroscopies (resection of a fibroma (782) or polyp (422), section of a septate uterus (199), synechia uteri (90) and endometrectomy (623)). RESULTS: There were 74 complications (3.5%). The most frequent was uterine perforation (34 cases (1.61%)). There were 13 cases of haemorrhage (0.61%), 16 cases of post-surgical fever (0.76%) and 11 metabolic complications (0.47%). Synechia uteri was the surgical intervention with the greatest risk of complications. CONCLUSIONS: The complications of surgical hysteroscopy are rare and relatively benign. Uterine perforation appears to predominate. In our study, the risk of complication was enhanced in the case of synechia uteri.