Spontaneous haemoperitoneum in pregnancy and endometriosis: a case series.

OBJECTIVE: To report pregnancy outcomes of SHiP (spontaneous haemoperitoneum in pregnancy) and the association with endometriosis. DESIGN: Retrospective case note review. SETTING: Dutch referral hospitals for endometriosis. SAMPLE: Eleven women presenting with 15 events of SHiP. METHODS: In collaboration with the Dutch Working Group on Endometriosis, unpublished cases of SHiP that occurred in the Netherlands between 2010 and 2015 were retrieved. MAIN OUTCOME MEASURES: Maternal and perinatal mortality and morbidity. RESULTS: SHiP occurred predominantly in the second and third trimester of pregnancy. The earliest and major presenting symptom was an acute onset of abdominal pain, often combined with low haemoglobin levels or signs of fetal distress. Imaging was a diagnostic tool when free peritoneal fluid could be observed. For surgical treatment of the bleeding site, a midline laparotomy was mostly needed, the median estimated amount of blood loss was 2000 mL. No fetomaternal or perinatal mortality was reported, despite a high rate of preterm births (54.5%). In all women, endometriosis was diagnosed at a certain moment in time and therefore was probably involved in the pathogenesis of SHiP. Four women showed recurrence of SHiP. In one of these cases the second event of SHiP occurred in a subsequent pregnancy. CONCLUSION: Pregnancy outcomes of SHiP are improving when compared with previous reports, with absent fetomaternal and perinatal mortality in this recent series. Growing knowledge and adequate multidisciplinary intervention may have contributed to these favourable results. Increasing awareness of this serious complication of pregnancy is advocated, especially in women diagnosed with endometriosis. TWEETABLE ABSTRACT: Growing awareness of SHiP is advocated, especially in women diagnosed with endometriosis.

An appraisal of the role of laparoscopy: past, present, and future.

OBJECTIVE: To review the role of laparoscopy in the management of chronic pelvic pain (CPP). METHOD: A literature search was conducted to obtain a clear perspective on the role of laparoscopy for CPP. RESULTS: Laparoscopy has been widely used as a diagnostic tool in CPP, but often falls short in defining the type and activity of ectopic endometrial-like tissue. Because pelvic endometriosis includes a wide range of lesions, histological confirmation varies greatly. The evaluation of peritoneal endometriosis at laparoscopy can be misleading. In one study 43% of the patients with minimal or mild endometriosis were found at second-look laparoscopy to be free of lesions. Finally, laparoscopy is not without major complications and the risk of undiagnosed bowel injury is likely to be underestimated. CONCLUSION: The diagnosis of endometriosis can no longer be limited to the visual inspection of the pelvis but requires a wider range of investigations to assess the reproductive system and the role of endometriotic lesions and adhesions in CPP.

An appraisal of the role of laparoscopy: past, present, and future.

OBJECTIVE: To review the role of laparoscopy in the management of chronic pelvic pain (CPP). METHOD: A literature search was conducted to obtain a clear perspective on the role of laparoscopy for CPP. RESULTS: Laparoscopy has been widely used as a diagnostic tool in CPP, but often falls short in defining the type and activity of ectopic endometrial-like tissue. Because pelvic endometriosis includes a wide range of lesions, histological confirmation varies greatly. The evaluation of peritoneal endometriosis at laparoscopy can be misleading. In one study 43% of the patients with minimal or mild endometriosis were found at second-look laparoscopy to be free of lesions. Finally, laparoscopy is not without major complications and the risk of undiagnosed bowel injury is likely to be underestimated. CONCLUSION: The diagnosis of endometriosis can no longer be limited to the visual inspection of the pelvis but requires a wider range of investigations to assess the reproductive system and the role of endometriotic lesions and adhesions in CPP.

Endometriosis. Current issues in diagnosis and medical management.

OBJECTIVE: To explore the hypothesis that endometriosis is a disease not just because it exists but because it is functionally active. STUDY DESIGN: Qualitative research analyzing the morphologic appearances of endometriosis and the clinical effect of medical therapies. RESULTS: Analysis of the appearances of symptomatic endometriosis demonstrates that the ectopic endometriumlike tissue mimics eutopic endometrium but with loss of polarization. Ectopic implants resembling superficial endometrium are hemorrhagic and associated with adhesion and pseudocyst or endometrioma formation. Ectopic implants resembling basal or junction zone endometrium are associated with nodular adenomyotic lesions in the posterior fornix and pelvic supportive structures. They are characterized by smooth muscle hyperplasia and T-lymphocyte aggregates. CONCLUSION: Medical therapy has been shown to be very efficient in reducing pelvic pain as soon as amenorrhea is created and maintained. Regression, but not elimination, of the implant is obtained by medical therapy. Clinical data support the hypothesis that the efficacy of medical therapy is largely achieved by preventing cyclic bleeding in the implants.

Endometriosis--a disease because it is characterized by bleeding.

The hypothesis is advanced that endometriosis, an ovarian steroid hormone-dependent process, is physiologic unless recurrent bleeding in the ectopic implants causes progressive disease and symptoms. Diagnosis should take into account the detection of chronic bleeding, and efficient medical treatment can be achieved by amenorrhea without the induction of hypoestrogenism.

Underwater Nd:YAG laser coagulation of blood vessels in a rat model.

Endoscopic coagulation of placental and umbilical cord vessels has been suggested as a treatment for selected cases of twin-twin transfusion syndrome and of acardiac twin. The feasibility, safety and hemostatic effect of neodymium:yttrium-aluminium-garnet (Nd:YAG) laser in an underwater environment were experimentally studied in an in vivo model, mimicking the in utero situation and fetoplacental vessels. In 10 male Wistar rats, immersed in normal saline at 38 degrees C, femoral vessels, carotid artery, abdominal aorta and vena cava were coagulated under endoscopic control. A 100-Watt Nd:YAG laser was used in continuous mode with a 600-micron fiber. Outcome measurements were vascular diameter, total energy (joules) used to obtain visual coagulation and subsequent vascular obliteration. Overall failure rate was 32% and perforation of the vessel occurred in 7.7% of cases.

Reconstruction of the ovary containing large endometriomas by an extraovarian endosurgical technique.

OBJECTIVE: To describe and evaluate the surgical treatment of large ovarian endometriomas by an extraovarian endosurgical technique. DESIGN: Prospective case series study. SETTING: University center and tertiary referral center for endoscopic surgery. PATIENTS: Patients with large ovarian endometriomas. INTERVENTION: A two-step endosurgical procedure: the first step is a combined diagnostic and operative procedure confirming the diagnosis and preparing the involution of the pseudocyst and the second step includes adhesiolysis and superficial coagulation of the inverted cortex. MAIN OUTCOME MEASURES: Operative findings and recurrence of endometriomas in the operated ovaries. RESULTS: Sixteen patients presenting with 20 large typical ovarian endometriomas were operated using the two-step endosurgical technique. Both steps were performed on 18 endometriomas. One patient with bilateral endometriomas refused the second endoscopic procedure. The long-term follow-up showed no recurrence in the 18 ovaries that were treated by the two-step endoscopic technique. CONCLUSIONS: The two-step extraovarian endosurgical technique can be applied in large typical endometriomas to reconstruct the ovary without excision and is followed by a low recurrence rate.

Peritoneal healing after fibrin glue application: a comparative study in a rat model.

The influence of fibrin glue on adhesion formation and peritoneal healing is evaluated in a prospective, randomized, controlled study. In all, 20 Wistar rats underwent microsurgical suturing of two silicone sheets, one covered with a fibrin glue barrier, to the anterior peritoneum. Each animal thus served as its own control. After 10 days, adhesions and peritoneal healing were evaluated by a blinded observer through a second-look laparotomy. Adhesions were scored using a modification of the classification of Diamond. Tissue around the silicone sheet was examined histologically and by scanning electron microscopy to evaluate the inflammatory reaction and peritoneal healing (ingrowth of blood vessels and quality of peritoneal cells). Adhesion scores for treated and control sides were (mean +/- SD) 2.89 +/- 4.68 and 6.79 +/- 9.09 (P = 0.181) respectively, and the percentage of the sheet covered by peritoneum was 26.25 +/- 31.50 and 29.21 +/- 40.21 (P = 0.226) respectively. Using the paired Wilcoxon rank test, the P values for the ingrowth of blood vessels and peritoneal healing evaluated by histology and scanning electron microscopy were 0.842, 0.692 and 0.695 respectively. We conclude that although the mean adhesion score was reduced by > 50% by fibrin glue, there is no statistically significant difference concerning adhesion formation or peritoneal healing with the use of fibrin glue.

Clinical value and cumulative pregnancy rates following rigid salpingoscopy during laparoscopy for infertility.

This study was designed to evaluate the routine use of rigid salpingoscopy during diagnostic laparoscopy for infertility, and to relate the morphologic image of the endosalpinx with pregnancy outcome. A total of 158 consecutive patients (232 Fallopian tubes) undergoing a diagnostic laparoscopy for infertility were studied. Salpingoscopy was performed at the time of diagnostic laparoscopy for infertility. The intraluminal image was classified using a simplified classification (class I-V). The relationship between this classification and the cumulative pregnancy rates was calculated using life table analysis. Patients with a normal salpingoscopy (class I and II) had a 71% cumulative pregnancy rate. In the intermediate group (class III) the cumulative pregnancy rate was 34%. No intrauterine pregnancies were observed in the group with severe intratubal pathology (class IV and V). Of the 107 slapingoscopies of patients with endometriosis 105 (98%) were class I or II. However, among patients with pelvic adhesions, only 42% were normal. Nine out of 50 abnormal salpingoscopies were found when no tubal factor was suspected during laparoscopy, without any pelvic adhesions. These results suggest that salpingoscopy is an important tool for detecting mucosal abnormalities, and for eventually referring patients for assisted reproductive technology. Salpingoscopy is usually normal in patients with endometriosis, but in patients with non-endometriotic pelvic adhesions it is not.

Intrauterine endoscopic creation of urinary tract obstruction in the fetal lamb: a model for fetal surgery.

OBJECTIVE: Our purpose was to evaluate the feasibility of intrauterine endoscopic fetal surgery in a fetal lamb model by creating a urinary tract obstruction. STUDY DESIGN: Lower urinary tract obstruction was created by ligation of the urethra and urachus in 21 fetal lambs, eight at 95 to 105 days' gestation (term 145 days) and 13 at 70 to 75 days. The endoscopic approach consisted of a 0-degree 5 mm telescope, three 5 mm cannulas, uterine distention by amnioinfusion, and adapted instrumentation. Intrauterine fetal monitoring included temperature and pulse oximetry registration. RESULTS: In 20 cases the urachus could be identified and ligated inside the umbilical cord. The urethra was ligated in the anterior abdominal wall (n = 7) or obstructed at the level of the penis (n = 13). Mean fetal heart rate was 147 +/- 35 beats/min, and fetal temperature at the end of intervention was 38.14 degrees +/- 2.1 degrees C. The overall postoperative survival rate was 76%. CONCLUSION: Urinary tract obstruction can be created endoscopically in the fetal lamb. This operation can serve as a model for endoscopic fetal surgery.