Hysteroscopic rollerball endometrial ablation as an alternative treatment for adenomyosis with menorrhagia and/or dysmenorrhea.

AIM: The aim of this study was to assess the long-term effectiveness and safety of hysteroscopic rollerball endometrial ablation as a surgical management of adenomyosis with menorrhagia and/or dysmenorrhea. We compared the results of patients who underwent pretreatment with gonadotropin-releasing hormone (GnRH) agonist with the results of those who did not. METHODS: A retrospective study included 190 adenomyotic patients who suffered from menorrhagia and/or dysmenorrhea and underwent hysteroscopic rollerball endometrial ablation. Main outcome measures were rates of successful operation, complications, improvement of abnormal uterine bleeding and pelvic pain after the surgery. RESULTS: The majority of the patients (142, 74.7%) underwent hysteroscopic rollerball endometrial ablation during the early proliferative phase of the menstrual cycle. The rest were operated on after GnRH agonist pretreatment for 6-8 weeks. Ablations were successfully performed on all patients in a day surgery setting. The average operation time was 36.3 ± 7.1 min. The mean glycine deficit was 583.4 ± 247.3 mL. The ablation in the no-pretreatment group took a significantly longer time and had more glycine absorption compared to the GnRH agonist pretreatment group (P < 0.0001). Mean postoperative follow-up duration was five years (range 1-10 years). A total of 187 patients (98.4%) who had undergone hysteroscopic endometrial ablation reported decreased bleeding: amenorrhea in 58 (30.5%), hypomenorrhea in 78 (41.1%), and eumenorrhea in 51 (26.8%) patients. Three patients (1.6%) underwent hysterectomy due to symptoms recurrence. A total of 165 (86.8%) patients with dysmenorrhea reported either reduced or no dysmenorrhea. There was no significant difference in the efficacy of hysteroscopic rollerball endometrial ablation between patients who underwent pretreatment with GnRH agonists and those who did not. No major complications related to the procedure were reported. CONCLUSIONS: Hysteroscopic rollerball endometrial ablation as a surgical management of menorrhagia and dysmenorrhea that develops in patients with adenomyosis is an effective and safe procedure. It can reduce the need for the unnecessary major surgery of hysterectomy.

Prevalence of subclinical vitamin K deficiency in Thai newborns: relationship to maternal phylloquinone intakes and delivery risk.

BACKGROUND: Vitamin K deficiency bleeding (VKDB) in infants is a rare but serious worldwide problem, particularly in Southeast Asia. Apart from exclusive breast feeding, little is known of the maternofetal risk factors that predispose infants to VKDB. OBJECTIVES: To assess (a) the relationships between functional vitamin K insufficiency in a large cohort of Thai mothers to that of their newborn infants and (b) the importance of delivery risk factors and maternal intakes of vitamin K as determinants of neonatal vitamin K status. METHODS: Vitamin K status was assessed by measuring undercarboxylated prothrombin (protein induced by vitamin K absence/antagonist-II (PIVKA-II)) in 683 mothers and in the cord blood of their babies by sensitive immunoassay. Dietary phylloquinone (vitamin K(1); K(1)) intakes were assessed in 106 of these mothers by food frequency questionnaire. RESULTS: Babies were categorised as 'normal' (n=590) or 'high risk' (n=93) according to birth weight and delivery type. PIVKA-II was detectable (>0.15 arbitrary units (AU)/ml) in 85 mothers (12.4%) and 109 babies (16.0%) with median levels of 0.78 and 1.04 AU/ml in mothers and babies, respectively. 'High-risk' babies had a higher median detectable PIVKA-II concentration than 'normal-risk' babies (3.1 vs 1.0 AU/ml, p=0.02) and a higher prevalence of clinically relevant (>5.0 AU/ml) concentrations (p=0.006). Mothers with K(1) intakes below the US recommended 'adequate intake' for pregnancy (<90 microg/day) had a higher prevalence of detectable PIVKA-II (18.8%) than those with adequate intakes (3.3%) (p=0.01). CONCLUSIONS: Functional, clinically relevant, vitamin K insufficiency was more common in 'high-risk' than 'normal-risk' newborns. Vitamin K insufficiency in mothers was linked to lower dietary K(1) intakes during pregnancy.

Effectiveness of recombinant activated factor VII (rFVII a) for controlling intractable postpartum bleeding: report of two cases and literature review.

BACKGROUND: Recombinant activated factor VII is used for the treatment in patients with inherited or acquired hemophilia with inhibitors and congenital factor VII deficiencies. OBJECTIVE: Using recombinant activated factor VII in primary postpartum hemorrhage. MATERIAL AND METHOD: Two cases of women who had postpartum hemorrhage and were treated with recombinant activated factor VII after all conventional treatment failed. RESULTS: The intractable hemorrhage stopped after treatment with recombinant activated factor VII CONCLUSION: The present report showed that massive postpartum hemorrhage that failed to all procedures was controlled successfully by recombinant activated factor VII.

A randomized comparison of vaginal misoprostol and dinoprostone for cervical priming in nulliparous women before operative hysteroscopy.

OBJECTIVE: To compare the efficacy and side effects of vaginal misoprostol with dinoprostone for cervical priming before operative hysteroscopy and to assess the cervicouterine complications related to cervical dilatation and hysteroscopic surgery. DESIGN: A prospective randomized study. SETTING: Tertiary university hospital. PATIENT(S): Three hundred ten nulliparous women with definite intrauterine lesions. INTERVENTION(S): Hysteroscopic surgery of intrauterine lesions. MAIN OUTCOME MEASURE(S): Cervical response, outcome, complications of hysteroscopic surgery, and side effects of both drugs. RESULT(S): Among the 310 patients recruited, 152 were randomized to the vaginal misoprostol group and 158 to the dinoprostone group. Mean cervical dilatation, cervical dilatation rate, and mean time for cervical dilatation to Hegar 9 were significantly different between the misoprostol group (7.4 +/- 0.8 mm, 70.4%, and 39.5 +/- 18.8 seconds, respectively) and the dinoprostone group (7.0 +/- 0.9 mm, 80.4%, and 43.6 +/- 17.1 seconds, respectively). Cervical tearing during hysteroscopic surgery occurred in 3 patients (2.0%) in the misoprostol group and in 12 patients (7.6%) in the dinoprostone group. There were more side effects in the misoprostol group. The significant difference of side effects between the two groups were abdominal pain, vaginal bleeding, and feeling feverish, which occurred in 36.2%, 29.6%, and 7.2% in the misoprostol group compared to 21.5%, 16.5%, and 1.3%, respectively, in the dinoprostone group. CONCLUSION(S): Vaginal misoprostol is more effective than dinoprostone for cervical priming in nulliparous women before hysteroscopic surgery. Although more side effects occurred in the misoprostol-treated patients, they were mild. We suggest using vagina misoprostol for cervical priming instead of dinoprostone.

A comparison of the efficacy of sublingual and oral misoprostol 400 microgram in the management of early pregnancy failure: a randomized controlled trial.

OBJECTIVE: To compare repeated doses of sublingual with oral misoprostol in the medical management of early pregnancy failure. MATERIAL AND METHOD: One hundred and thirty eight women with a period of gestation less than 20 week calculated by her last menstrual period and less than 12 weeks by size were sequentially allocated to two groups to receive either 400 microg of misoprostol orally or sublingually every 4 hours until termination of pregnancy was completed. RESULTS: There is no difference in the mean induction to abortion interval. Fever and chill were more common in sublingual group compared with oral group. The other adverse effects were similar and included nausea, vomiting, diarrhea, abdominal pain, and headache. CONCLUSION: Sublingual misoprostol is as effective as oral route. Most adverse effects are similar in both groups except fever was more common in sublingual group.

A randomised controlled trial of 6 and 12 hourly administration of vaginal misoprostol for second trimester pregnancy termination.

OBJECTIVE: To compare the effectiveness of vaginal misoprostol administered 6 or 12 hourly for second trimester pregnancy termination. DESIGN: A randomised controlled trial. SETTING: University teaching hospital. SAMPLE: Two hundred and seventy-nine pregnant women at gestations between 14 and 26 weeks undergoing pregnancy termination. METHODS: Women were randomised to receive 600-microg misoprostol tablets vaginally either every 6 hours or every 12 hours until abortion occurred. MAIN OUTCOME MEASURES: Induction-abortion interval, success rate within 24 and 48 hours and adverse effects. RESULTS: There was no significant difference in the median induction to abortion interval 6 hours (16 hours) and 12 hours (16 hours; P= 0.80). The total dose of misoprostol was higher in the 6-hour group (1800 vs 1200 microg). The cumulative abortion rates within 24 hours were 74% and 67% and within 48 hours 94% and 92%, in the 6- and 12-hour groups, respectively. Fever was more common in the 6-hour group (53%) versus the 12-hour group (31%; P < 0.001). The incidence of nausea, vomiting, diarrhoea, severe bleeding and abdominal pain were similar. CONCLUSIONS: Misoprostol (600 microg) administered at 12-hour intervals was associated with fewer adverse effects and was as effective as a 6-hour interval.

Hysteroscopic polypectomy in 240 premenopausal and postmenopausal women.

OBJECTIVE: To ascertain the therapeutic efficacy and safety of hysteroscopic polypectomy in 240 premenopausal and postmenopausal patients. DESIGN: Retrospective study. SETTING: Tertiary university hospital. PATIENT(S): Two hundred forty patients with intrauterine endometrial polyps, who mostly suffered from abnormal uterine bleeding and infertility. INTERVENTION(S): Hysteroscopic polypectomy using various instruments including microscissors, grasping forceps, or electrosurgery either with a monopolar probe or a resectoscope. MAIN OUTCOME MEASURE(S): Operating time, amount of glycine absorption, complications, resumption of normal menstruation, cumulative pregnancy rate, and recurrent rate of polyps after hysteroscopic surgery. RESULT(S): Resectoscopic polypectomy needed more operating time, had more glycine absorption and complications, but less recurrence than other hysteroscopic techniques. The resectoscope had a 0% recurrence rate and that grasping forceps had a 15% recurrence rate. A total of 21 (8.7%) complications occurred, but no major complications were noted. After long-term follow-up of 9 years and 2 months, those with abnormal uterine bleeding resumed normal menstruation in 93.1% and those with infertility had a cumulative pregnancy rate of 42.3%. There was no statistical difference in reproductive outcome between patients having polyps < or = 2.5 cm and >2.5 cm. CONCLUSION(S): We found hysteroscopic polypectomy to be effective, safe, minimally invasive procedure with low rate and mild complications. Restoration of reproductive ability did not depend on the size of the removed lesion. Resectoscopic surgery is more preferable to prevent recurrence of polyps.

Comparison of oral and vaginal misoprostol for induction of labor at term: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of oral with vaginal misoprostol for induction of labor at term. METHODS: One hundred and fifty-three pregnant women at term with indications for induction of labor and Bishop score < or = 6 were randomly assigned to receive misoprostol either 100 microg orally or 50 microg vaginally every 6 h for 48 h. Repeated doses were given until Bishop score > or = 8 was achieved or spontaneous rupture of membranes occurred. Those who were not in labor after 48 h had labor induced with amniotomy and oxytocin. The main outcome measure was induction to delivery time. RESULTS: The median induction to vaginal delivery time in the oral group (14.3 h) was not significantly different from that of the vaginal group (15.8 h). The median number of doses was also not significantly different in the oral group compared with the vaginal group. There was a significant higher incidence of uterine tachysystole in the vaginal group compared to the oral group (17.1% vs 5.3%, P = 0.032). There was no hyperstimulation in either group. There were no significant differences between the groups with respect to oxytocin augmentation, cesarean section rate, analgesic requirement, and neonatal outcomes. CONCLUSION: Oral administration of 100 microg misoprostol has similar efficacy to intravaginal administration of 50 microg misoprostol for labor induction with less frequent abnormal uterine contractility. 100 microg of misoprostol orally can be used as an alternative to the vaginal route for labor induction.

Slow fetal heart rate may predict pregnancy outcome in first-trimester threatened abortion.

Two hundred forty pregnant women presented with first-trimester threatened abortion were examined by transvaginal ultrasound. Women with a slow fetal heart rate of less than 120 beats per minute may eventually be at increased risk for pregnancy loss.

Vaginal misoprostol for cervical priming before dilatation and curettage in postmenopausal women: a randomized controlled trial.

AIM: To investigate the efficacy of vaginal misoprostol for cervical priming before dilatation and curettage in postmenopausal women. METHODS: Forty-four postmenopausal women with indication for dilatation and curettage were randomly assigned to receive either 400 micro g of misoprostol or placebo vaginally 6 h before dilatation and curettage. The main outcome measures were the number of women who required cervical dilatation, cervical width, time taken to dilate to Hegar 6 and other complications. RESULTS: The mean cervical diameter (4.59 millimeters in the misoprostol group vs 4.41 millimeters in the placebo group) was comparable between the two groups. A similar number of women in the misoprostol group and in the placebo group required cervical dilatation (12 vs 16, P = 0.35). The operative times for both groups were similar. The incidence of side-effects was comparable in both groups. There were two uterine perforations in the misoprostol group (2 vs 0). CONCLUSION: There was no significant benefit from applying 400 micro g vaginal misoprostol 6 h prior to dilatation and curettage in postmenopausal women.

Postterm with favorable cervix: is induction necessary?

OBJECTIVE: To study the cesarean rate between expectant management and immediate induction in the otherwise uncomplicated postterm pregnancy with favorable cervix. STUDY DESIGN: A total of 249 women with uncomplicated pregnancies at 41 weeks plus 3 days (290 days) with favorable cervix (Bishop score > or =6) were randomized to either expectant management (n=125) or immediate induction of labor (n=124). The women in the induction group were sent to labor ward for induction by artificial rupture of membranes (ARM) and/or oxytocin infusion. The women with expectant management had nonstress test (NST) and amniotic fluid index (AFI) performed once a week and twice a week after 43 weeks of gestation until spontaneous labor. RESULTS: The cesarean rate was not different between expectant management and immediate induction (21.6% versus 26.6%; P=0.36). Ninety-five percent of the expectant group delivered within 1 week after enrollment, and all of them delivered within 9 days after randomization. Maternal and fetal complications in both groups were not different. There was also no difference in the mean birth weight (P=0.24) and the frequency of macrosomia (birth weight > or = 4000 g) between the two groups (P=0.23). CONCLUSION: Cesarean section rate between expectant management and immediate induction in the otherwise uncomplicated postterm pregnancy with favorable cervix was not different. Due to the very low adverse perinatal outcome, both expectant management and immediate induction are acceptable.

A randomized trial of oral and vaginal misoprostol to manage delivery in cases of fetal death.

OBJECTIVE: To compare the effectiveness and side effects of oral and vaginal misoprostol for the termination of second and third trimester pregnancy with intrauterine fetal death. METHODS: Eighty pregnant women at 16-41 weeks' gestation with intrauterine fetal death were randomized in two groups to receive either 400 micro g of misoprostol orally every 4 hours (n = 40) or 200 micro g of misoprostol vaginally every 12 hours (n = 40) until the termination of pregnancy was completed. The adverse effects, progress, and outcomes of delivery were assessed. RESULTS: The groups were similar in age, weight, height, gestational age, parity, and modified Bishop scores before intervention. The mean induction-to-delivery time in the oral group (13.95 [standard deviation (SD) = 5.63] hours) was significantly shorter than the time in the vaginal group (18.87 [SD = 10.38] hours, P =.001). The number of deliveries within 24 hours after the initial drug administration in the oral group (92.5%) was significantly higher than the number in the vaginal group (67.5%, P <.001), and all delivered within 48 hours after the initial drug administration. However, the gastrointestinal side effects in the oral group was significantly higher than in the vaginal group (P =.005). CONCLUSION: Misoprostol (400 micro g given orally every 4 hours) was more effective than misoprostol (200 micro g given vaginally every 12 hours) for the termination of second and third trimester pregnancy with intrauterine fetal death, but with more gastrointestinal side effects.