Vaginoscopy to investigate vaginal bleeding and discharge in prepubertal girls.

STUDY OBJECTIVE: To investigate the aetiology of vaginal bleeding and discharge in prepubescent girls, and the utility of vaginoscopy for making a diagnosis. DESIGN: Retrospective observational study over 14 years. SETTING: Two major tertiary referral paediatric hospitals in Sydney, Australia. PARTICIPANTS: All prepubescent girls (n = 104) who presented with vaginal bleeding and/or discharge and subsequently underwent a vaginoscopy. A total of 120 procedures were performed. MAIN OUTCOME MEASURES: Surgical findings at vaginoscopy; number needed to investigate (NNI) to establish a diagnosis and to exclude malignancy. RESULTS: There were 52/120 (43.3%) vaginoscopies which provided a positive diagnosis, including 36/86 (41.8%) performed for bleeding and 16/34 (47.0%) for vaginal discharge. In the vaginal bleeding group, the causes found were a foreign body in 11/86 (12.7%), vulvovaginitis in 6/86 (6.9%), benign Mullerian papilloma in 5/86 (5.8%), trauma in 4/86 (4.6%), and malignant tumours in 2/86 (2.3%). To establish a diagnosis in girls presenting with vaginal bleeding, the NNI was 2.4; to detect a malignancy the NNI was 43.0. In girls presenting with vaginal discharge, vulvovaginitis was noted intraoperatively in 7/34 (20.6%) and a foreign body was found in 7/34 (20.6%). No malignant tumours were identified in the vaginal discharge group. To establish a diagnosis in girls presenting with vaginal discharge, the NNI was 2.1. CONCLUSIONS: Vaginoscopy is an important diagnostic tool in the setting of vaginal bleeding in prepubescent girls, allowing the ability to confirm a diagnosis, and importantly, to exclude malignancy.

Updates in emergency medicine: Ectopic pregnancy.

INTRODUCTION: Ectopic pregnancy is a serious condition that can have significant morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy. CONCLUSIONS: Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.

Uncommon Histopathological Subtypes and Variants of Cervical Carcinoma Diagnosed at a Tertiary Care Centre: A Case Series.

Introduction Cervical cancer ranks among the top gynaecological cancers worldwide. It is linked to lower socioeconomic status and high human papillomavirus (HPV) prevalence. This is a series of six cervical carcinoma cases analysed from 2021 to 2023 at our tertiary care centre to identify rare subtypes of cervical carcinoma. We document rare subtypes, which include glassy cell carcinoma, small cell neuroendocrine carcinoma, papillary squamous-transitional variant, basaloid squamous cell carcinoma and serous carcinoma of the uterine cervix. Immunohistochemistry (IHC) was helpful in confirmation of the subtypes and in diagnosing HPV-associated cases. Materials and methods This case series comprises six cases, including rare subtypes and variants of cervical carcinoma histopathologically diagnosed by the Department of Pathology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India, between 2021 and 2023. The demographic profile and patient details were obtained from the hospital information system and archival case files after obtaining informed consent from the patients. The H&E and relevant IHC slides along with histopathology reports of the included cases were analysed and studied. Results This series includes six cases of rare subtypes of cervical carcinoma, comprising glassy cell carcinoma, small cell neuroendocrine carcinoma, papillary squamous-transitional variant, basaloid squamous cell carcinoma (SCC), and serous carcinoma. Each subtype displays distinct clinicopathological features, emphasizing the need for specific diagnostic and treatment approaches, which are crucial in improving patient survival. Conclusion Six rare subtypes and variants of cervical carcinoma have been discussed in this case series, after correlating with histopathology reports and clinical and radiological findings. Understanding the histopathological characteristics of these rarer subtypes is essential for accurate diagnosis and timely intervention. This series highlights the importance of comprehensive screening strategies, early diagnosis and awareness of rarer subtypes and variants of cervical carcinoma among healthcare professionals. These factors can tailor therapeutic options and improve patient outcomes.

Association between the regular use of vaginal dilators and/or sexual activity and vaginal morbidity in locally advanced cervical cancer survivors - An EMBRACE-I study report.

PURPOSE: To provide risk estimations for vaginal morbidity with regard to vaginal dilation (summarizing the use of dilators and/or sexual activity) in locally advanced cervical cancer patients (LACC) treated with definitive radiochemotherapy and image-guided adaptive brachytherapy (IGABT) within the prospective, multi-institutional EMBRACE-I study. MATERIAL/METHODS: Physician-assessed vaginal morbidity (CTCAEv3.0), use of vaginal dilators and patient-reported sexual activity (EORTC-CX24) were prospectively assessed at baseline and during regular follow-up. Frequency analysis for vaginal dilation was performed in a sub-cohort of patients with ≥3 follow-ups. Regular dilation was defined if reported in ≥50% of follow-ups, no/infrequent dilation if reported in <50%. Actuarial estimates were calculated with Kaplan-Meier method; comparisons evaluated with the log-rank test. Univariate and multivariable Cox proportional hazard regression were used to evaluate risk factors for vaginal stenosis G≥2. RESULTS: The EMBRACE-I study included a total of 1416 patients (2008-2015); 882 were evaluated in the present report with a median follow-up of 60 months. Of those, 565 (64%) reported regular dilation. This was associated with a significantly lower 5-year risk of vaginal stenosis G≥2 compared to no/infrequent dilation (23% vs. 37%, p≤0.001). This univariate finding was confirmed by multivariable analysis, after adjusting for other risk factors (HR=0.630, p=0.001). Regular vaginal dilation was also associated with a significantly higher risk for vaginal dryness G≥1 (72% vs. 67%, p=0.028) and bleeding G≥1 (61% vs. 34%, p≤0.001). CONCLUSION: Vaginal stenosis represents irreversible fibrotic changes that can cause pain during gynecological examination and dyspareunia in LACC survivors. Regular vaginal dilation (defined as the use of dilators and/or sexual activity) is associated with a significantly lower risk for G≥2 vaginal stenosis, suggesting a potential improvement of vaginal patency. It is also associated with a significantly higher risk for mild G≥1 dryness and bleeding (no higher risk for G≥2), which both can be clinically managed.

Uterine Arteriovenous Malformations.

Uterine arteriovenous malformations (AVMs) are an abnormal presence of shunts between myometrial arteries and veins within the myometrium that usually occurs after a traumatic event on the uterus and it is often diagnosed after a miscarriage. In this case report, we propone the case of a woman, gravida 3 para 2, admitted at the emergency department presenting deep vaginal bleeding and suspicion of incomplete miscarriage at 11 weeks of pregnancy. The suspect of AVM was made with noninvasive procedure; transvaginal ultrasound examination with the advantage of color Doppler showed a myometrial hypervascular lesion of the posterior wall. Pulsed Doppler permitted the waveform analysis of uterine arteries and three-dimensional sonography with color Doppler and reconstructions clearly showed dilated ad tortuous blood vessels within the contest of the myometrium. Magnetic resonance angiography showed multiple tubular structures with tortuous appearance that confirmed the suspicion of AVM. Uterine artery embolization was performed of the right uterine artery. One month after uterine embolization, the ultrasound control confirmed the complete resolution of the AVM.

Uterine Artery Pseudoaneurysm after Total Abdominal Hysterectomy Managed by Ultrasound-guided Percutaneous Glue Injection.

Uterine artery pseudoaneurysm (UAP) following abdominal hysterectomy is an uncommon complication. However, it can cause life-threatening bleeding, necessitating early diagnosis and intervention. Imaging is vital in its prompt diagnosis and aids in planning interventions. Here, we describe a case of recurrent massive per-vaginal bleeding from a left UAP developed following total abdominal hysterectomy and bilateral salpingo-oophorectomy. Bleeding was successfully managed with percutaneous ultrasound-guided glue (N-butyl cyanoacrylate) injection into the aneurysmal sac. The patient is doing well without any recurrent bleeding.

Management challenges of a cervical carcinosarcoma in a premenopausal woman in northern Tanzania: A rare case report and review of current literature.

INTRODUCTION AND IMPORTANCE: Cervical carcinosarcomas (CCS) are uncommon aggressive gynecological malignancies that typically occur in postmenopausal females. Data on CCS, incidence, clinical presentation, magnitude and management strategies remain scarce especially in Sub-Saharan countries like Tanzania. In this report, we report the rarity of this particular condition in premenopausal woman, the literature surrounding similar reports, and the many challenges that arise in the management of CCS. CASE PRESENTATION: We present a redudancy case of a 35-year-old female from Northern Tanzania who presented with vaginal bleeding, foul smelling discharge, and severe abdominal pain intermittently for a year. The Speculum exam revealed a fungating mass on the cervix, and CT confirmed the irregular mass centered in the uterine cervix expanding in the fornices infiltrating the uterine neck. A cervical biopsy revealed carcinosarcoma of the cervix stage IIA. Due to the patient's instability, she was admitted and started on chemotherapy and later on recommended for radiation without surgical intervention. CLINICAL DISCUSSION: In this case report, we discuss the condition's rarity and multiple barriers we encountered during management of this complicated patient with CCS. Choosing an optimal treatment approach was challenging due to the lack of guidelines and available literature as well as the patient's instability. CONCLUSION: his case is notable due to the rarity of this cervical neoplasm especially in premenopausal women and the challenging management of the condition due to a notable lack of treatment recommendations.

The Effect of Inhaled Oxygen on Postpartum Hemorrhage: A Systematic Review and Meta-Analysis.

Background: Postpartum Hemorrhage (PPH) is a significant problem that can increase the risk of maternal mortality. Previous studies investigated the effect of Inhaled Oxygen (IO) on PPH. They found some conflicting results. Thus, the current systematic review and meta-analysis aimed to determine the effect of IO on PPH. Materials and Methods: Randomized trials were searched according to the PRISMA framework until the end of November 2022 in Web of Science, PubMed, Scopus, and Cochrane Library databases. Statistical analyses were performed in the STATA v. 14 software. I2 statistic was applied to assess heterogeneity between studies. The random effect model, sample size, and mean and standard deviation of each group were applied to report the pooled effect size. Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to evaluate the risk of bias in the included studies. Finally, five articles were included in the meta-analysis. Two and three studies reported the mean of bleeding after vaginal delivery during one- and two-hours oxygen therapy, respectively. Results: Results showed that IO significantly reduced bleeding by 38.91 mL in the intervention group compared to routine care (WMD: -38.91, 95%CI: -60.18 to -17.64) after vaginal delivery. In addition, IO during one (WMD: -38.42, 95%CI: -71.62 to -5.22) and two (WMD: -41.93, 95%CI: -60.15 to - 23.71) hours significantly decreased bleeding in the intervention. Conclusion: According to the present study, IO can significantly reduce PPH in the intervention group compared to routine care. However, more rigorously randomized clinical trials are required to decide better about this issue.

Uterine Arteriovenous Malformation With Raised Serum Beta-Human Chorionic Gonadotropin (ß-hCG) Levels: A Diagnostic and Therapeutic Dilemma.

Uterine arteriovenous malformations (AVM) are rare and usually present in women of reproductive age. Clinical presentation may overlap with early pregnancy, retained products of conception (RPOC), or gestational trophoblastic disease (GTD) if it occurs in a pregnant patient or the immediate postpartum period and becomes challenging to manage. Here, we present two cases of uterine AVM that presented with vaginal bleeding after miscarriages. In these cases, the presentation was vaginal bleeding with raised serum beta-human chorionic gonadotropin (ß-hCG) levels. The uterine AVM was diagnosed with ultrasound and contrast-enhanced CT and subsequently managed with uterine artery embolization. Although rare, uterine AVM should be kept in the differentials in a premenopausal patient with abnormal vaginal bleeding and positive serum ß-hCG levels. It should be differentiated from other common causes of vaginal bleeding with raised serum ß-hCG levels, such as early pregnancy, GTD, and RPOC, as early diagnosis and proper treatment are crucial for favorable outcomes.

Consensus Statements for Assessment and Management of Threatened Miscarriage in the First Trimester in Pakistan: A Three-Step Modified Delphi Approach.

BACKGROUND AND OBJECTIVE: It aimed to develop an expert consensus regarding the risk assessment, diagnosis, and threatened miscarriage management during the first trimester in Pakistan. METHODS: A three-step modified Delphi method was applied to develop the consensus. Eleven specialized obstetricians and gynecologists participated in its development. If 75% or higher agreement level was attained on each assertion, it was declared as a consensus. RESULTS: Age of 35 or above, previous history of two or more previous miscarriages, and direct strong trauma were considered to be threatened miscarriage risk factors. Infection was discussed and specified to include specific infectious diseases, like malaria, and COVID-19 as a risk factor. The experts agreed from the first time on considering endocrinological disorders, thrombophilia, and lifestyle variables as threatened miscarriage risk factors. They proposed adding a statement concerning acquired thrombophilia which was accepted unanimously. Finally, experts agreed on the importance of educating pregnant women about factors whose risk can be modified by modifying their behavior. As for diagnosis statements, it was agreed to be trifold: physical examination, imaging, and laboratory testing. Physical examination included abdominal and pelvic exams but focused more on vaginal examination with speculum to identify bleeding severity and etiology. The statements regarding the imaging approaches to diagnose threatened miscarriage in the first trimester achieved a consensus in most statements. TVS was recommended to check on uterine structural abnormalities, fetus viability focusing on heartbeat and crown-to-rump length, gestation sac size and emptiness, subchorionic hematoma, and ectopic pregnancy. Each was defined on how to identify and diagnose in separate statements. Statements about laboratory tests indicated the need for human chorionic gonadotropin hormone assessment whether serial or once is dependent on the ultrasound. Recommended hematologic investigations include complete blood count for anemia, Rh factor for potential bleeding risk and in special cases, thrombophilia assessment is undertaken. The first and foremost management aspect was follow-up while most management statements were controversial, and some were altogether removed with only some reaching agreement after discussion. CONCLUSION: These consensus statements aggregated the best available evidence and experts' opinion-supported statements to improve patient education, risk assessment, diagnosis, and evaluation as well as management of threatened miscarriage during the first trimester in Pakistan.

Minimally Invasive Endovascular Management of Uterine Arteriovenous Malformations: A Single Center Experience and Case Series.

Uterine arteriovenous malformations (UAVMs) are rare and abnormal entanglements of uterine arteries and veins that are potentially fatal, requiring blood transfusions in about a third of cases. Although the optimal management of the condition is not well established in the literature, surgical hysterectomy is believed to be the only definitive treatment for arteriovenous malformations. We present three cases of UAVMs treated by a minimally invasive endovascular approach. Chief complaints were heavy menstrual bleeding and sudden onset heavy bleeding. The diagnosis was confirmed by computed tomography imaging and angiography of the pelvic vessels. Uterine artery embolization (UAE) was performed in all patients. The follow-up period was uneventful. In our experience, the UAE provides satisfactory results in terms of success rates, complications, and short hospital stays.

A comparison of the clinical features of molar pregnancy in adolescents and adults.

Objective: To compare the age-specific clinical features of molar pregnancy and to describe the risk factors associated with this situation. Method: This retrospective case-control study was conducted at the Department of Obstetrics and Gynecology. Tepecik Education and Research Hospital, Izmir, Turkey. The participants included both adolescents (≤ 19 years) and adults with histologically confirmed hydatidiform moles in our institution between January 2015 and January 2022. The interventions and main outcome measures of this study involved evaluating the clinical and ultrasonographic features, as well as the risk factors, associated with molar pregnancies in adolescents. Results: This study of 137 patients with molar pregnancy found that adults had a higher incidence of partial molar pregnancy (20 patients versus seven patients) and lower beta-hCG levels than adolescents (176.890.71 mIU/ml versus 253.734.47 mIU/ml). Adolescents had a higher likelihood of hyperthyroidism (25.4% versus 9.2%). bleeding on admission (4.2% versus 1.51%),. longer hospital stays (5.44 ± 2.73 days versus 3.59 ± 3.08 days). Higher rates of uterine enlargement and postoperative bleeding (15.5% versus 1.5%). Adolescents also required more analgesia (97% versus 89.4%). Conclusions: Adolescents with Gestational trophoblastic diseases (GTD) may present with more severe symptoms compared to adults, which can lead to delayed diagnosis and treatment. Further research is needed to better understand the underlying mechanisms and risk factors for GTDs in this population. Increased awareness and education can help improve recognition and management of GTDs in adolescents and improve their overall health outcomes.

Kaposiform Lymphangiomatosis as a Cause of Vaginal Bleeding & Discharge: A Case Report.

BACKGROUND: Prepubertal vaginal bleeding is a common presentation for pediatric adolescent gynecologists with a broad differential diagnosis that historically may not have included complex lymphatic anomalies. However, given recent consensus criteria and imaging capabilities, this may be a condition that pediatric adolescent gynecologists see more frequently in the future. CASE: We present a case of a 5-year-old pre-pubertal girl whose only presenting symptoms of a rare complex lymphatic anomaly was copious vaginal bleeding. After three vaginoscopies, two hysteroscopies, two pelvic MRIs, and a percutaneous ultrasound guided core needle biopsy, this patient was eventually diagnosed with Kaposiform lymphangiomatosis at age 9 years-old, and she is now being treated medically with sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, with improvement in her symptoms. SUMMARY AND CONCLUSION: Complex lymphatic anomalies should be considered after initial and secondary workups for pre-pubertal vaginal bleeding or copious vaginal discharge are negative. Furthermore, this case illustrates the value of pelvic MRI in the setting of unknown cause of vaginal bleeding when typical workup is negative.

A Case of Well-Differentiated Endometrial Adenocarcinoma in a Postmenopausal Woman.

Endometrial adenocarcinoma is a prevalent malignancy among postmenopausal women, often presenting with symptoms such as abnormal vaginal bleeding and pelvic pain. We present a case of a 60-year-old postmenopausal female who exhibited abnormal vaginal bleeding for three months, accompanied by pelvic pain and unintentional weight loss. Clinical evaluation, including physical examination, imaging studies, and histopathological examination, led to the diagnosis of well-differentiated endometrial adenocarcinoma. The patient underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy, and histopathological analysis confirmed invasive tumor involvement in the lower uterine segment and cervix. The final pathological tumor, node, and metastasis (TNM) staging was reported as pT1b No Mx, FIGO (International Federation of Gynecology and Obstetrics) stage II. This case underscores the importance of considering endometrial adenocarcinoma in the differential diagnosis of postmenopausal bleeding and highlights the significance of timely diagnosis and multidisciplinary management for optimizing patient outcomes.

Case report: A rare case of malacoplakia resembling a malignant tumor of the cervix: a case report and review of the literature.

Malacoplakia is a rare chronic granulomatous disease that mostly affects the gastrointestinal tract and urinary tract of immunocompromised patients; malacoplakia rarely effects the female reproductive tract. Here, we report a 56-year-old patient who underwent thymectomy for thymoma and myasthenia gravis prior to developing cervical and vaginal malacoplakia. The patient presented with recurrent vaginal bleeding. We discovered that there were alterations in the cervical cauliflower pattern during colposcopy, which is suggestive of cervical cancer. Pathological examination of the lesion tissue showed that a large number of macrophages aggregated, and M-G bodies with concentric circles and refractive properties were observed between cells. Immunostaining for CD68 and CD163 was positive, and special staining for D-PAS and PAS was positive. The discovery of Escherichia coli in bacterial culture can aid in the diagnosis of malacoplakia. Following surgery, we performed vaginal lavage with antibiotics in addition to resection of local cervical and vaginal lesions. This study provides a fresh perspective on the management of genital malacoplakia.

Risk factors for intensive care unit admission after cesarean hysterectomy for placenta accreta spectrum.

OBJECTIVE: Placenta accreta spectrum (PAS) is a complex disorder of uterine wall disruption with significant morbidity and mortality, particularly at time of delivery. Both physician and physical hospital resource allocation/utilization remains a challenge in PAS cases including intensive care unit (ICU) beds. The primary objective of the present study was to identify preoperative risk factors for ICU admission and create an ICU admission prediction model for patient counseling and resource utilization decision making in an evidence-based manner. METHODS: This was a case-control study of 145 patients at our PAS referral center undergoing cesarean hysterectomy for PAS. Final confirmation by histopathology was required for inclusion. Patient disposition after surgery (ICU vs post-anesthesia care unit) was our primary outcome and pre-/intra-/postoperative variables were obtained via electronic medical records with an emphasis on the predictive capabilities of the preoperative variables. Uni- and multivariate analysis was performed to identify independent predictive factors for ICU admission. RESULTS: In this large cohort of 145 patients who underwent cesarean hysterectomy for PAS, with histopathologic confirmation, 63 (43%) were admitted to the ICU following delivery. These patients were more likely to be delivered at an earlier gestational age (34 vs 35 weeks, P < 0.001), have had >2 episodes of vaginal bleeding and emergent delivery compared to patients admitted to patients with routine recovery care (44% vs 18.3%, P = 0.009). Uni- and multivariate logistic regression showed an area under the curve of 0.73 (95% CI: [0.63, 0.81], P < 0.001) for prediction of ICU admission with these three variables. Patients with all three predictors had 100% ICU admission rate. CONCLUSION: Resource prediction, utilization and allocation remains a challenge in PAS management. By identifying patients with preoperative risk factors for ICU admission, not only can patients be counseled but this resource can be requested preoperatively for staffing and utilization purposes.

Isolated Vaginal Bleeding Before the Onset of Puberty.

Isolated vaginal bleeding before the onset of puberty is a rare presentation of isosexual precocity. In most cases, isolated vaginal bleeding without an abnormal genital examination is self-limited with resolution usually within 1 to 3 episodes. Watchful waiting is appropriate in most patients who do not have persistent bleeding, other signs of puberty, or signs/symptoms of an underlying etiology. Workup for patients with concerning features may include puberty hormone levels and/or transabdominal and transperineal ultrasound.

Association between Antenatal Vaginal Bleeding and Adverse Perinatal Outcomes in Placenta Accreta Spectrum.

Background and Objectives: Placenta accreta spectrum (PAS) disorders are placental conditions associated with significant maternal morbidity and mortality. While antenatal vaginal bleeding in the setting of PAS is common, the implications of this on overall outcomes remain unknown. Our primary objective was to identify the implications of antenatal vaginal bleeding in the setting of suspected PAS on both maternal and fetal outcomes. Materials and Methods: We performed a case-control study of patients referred to our PAS center of excellence delivered by cesarean hysterectomy from 2012 to 2022. Subsequently, antenatal vaginal bleeding episodes were quantified, and components of maternal morbidity were assessed. A maternal composite of surgical morbidity was utilized, comprised of blood loss ≥ 2 L, transfusion ≥ 4 units of blood, intensive care unit (ICU) admission, and post-operative length of stay ≥ 4 days. Results: During the time period, 135 cases of confirmed PAS were managed by cesarean hysterectomy. A total of 61/135 (45.2%) had at least one episode of bleeding antenatally, and 36 (59%) of these had two or more bleeding episodes. Increasing episodes of antenatal vaginal bleeding were associated with emergent delivery (p < 0.01), delivery at an earlier gestational age (35 vs. 34 vs. 33 weeks, p < 0.01), and increased composite maternal morbidity (76, 84, and 94%, p = 0.03). Conclusions: Antenatal vaginal bleeding in the setting of PAS is associated with increased emergent deliveries, earlier gestational ages, and maternal composite morbidity. This important antenatal event may aid in not only counseling patients but also in the coordination of multidisciplinary teams caring for these complex patients.

Uterine arteriovenous malformation: a case of challenges in diagnosis and management of a patient with a history of misdiagnosed hemorrhage.

Introduction: Uterine arteriovenous malformations (AVMs) are a rare cause of obstetrical hemorrhage. It can be congenital due to a defect during embryogenesis or acquired. Uterine AVMs can cause life threatening postpartum hemorrhage, and is most frequently misdiagnosed. This case highlights the diagnostic challenges posed by uterine arteriovenous malformation, a rare vascular anomaly that poses significant challenges in diagnosis and management. Case presentation: This case report details the clinical presentation, diagnostic challenges, and treatment approach for a 39-year-old woman. In the absence of a medical history indicative of pre-existing ailments, the individual in question has undergone two emergency cesarean sections as documented in her surgical history, in addition to two previous dilation and curettage D&C operations. The patient presented with heavy vaginal bleeding 6 months after a cesarean section. The patient's clinical presentation, imaging findings, and intraoperative observations collectively substantiate the diagnosis of uterine AVMs. Discussion: Women who have had uterine instrumentatio surgery, such as a cesarean section or dilatation and curettage (D&C) are more likely to develop acquired uterine AVMs. The absence of uterine artery embolism options compelled the use of alternative diagnostic methods, including contrast MRI, which successfully detected abnormal vascular lesions. The choice for hysterectomy was influenced by the patient's completion of childbearing and the presence of large vessels in proximity to critical regions. Conclusion: This case emphasizes the significance of adapting treatment plans based on local resource constraints and the need for ongoing efforts to enhance diagnostic capabilities in undeserved regions.

The Association of High-Molecular-Weight Hyaluronic Acid (HMWHA), Alpha Lipoic Acid (ALA), Magnesium, Vitamin B6, and Vitamin D Improves Subchorionic Hematoma Resorption in Women with Threatened Miscarriage: A Pilot Clinical Study.

Background-We evaluated whether the oral intake of high-molecular-weight hyaluronic acid (HMWHA) in association with alpha lipoic acid (ALA), magnesium, vitamin B6, and vitamin D can improve the resorption of subchorionic hematoma in cases of threatened miscarriage. Methods-In this study, we enrolled 56 pregnant women with threatened miscarriage (i.e., subchorionic hematomas, pelvic pain/uterine contractions, and/or vaginal bleeding) between the 6th and the 13th week of gestation. They were treated with vaginal progesterone (200 mg/twice a day) (control group; n = 25) or vaginal progesterone plus oral 200 mg HMWHA, 100 mg ALA, 450 mg magnesium, 2.6 mg vitamin B6, and 50 mcg vitamin D (treatment group; n = 31; DAV®-HA, LoLi Pharma srl, Rome, Italy). An ultrasound scan was performed at the first visit (T0) and after 7 days (T1) and 14 days (T2) until hematoma resorption. Results-At the ultrasound scan, the treatment group showed faster resorption of the subchorionic hematoma compared with the control group, both at T1 (control group 140 (112-180), treated group 84 (40-112), p < 0.0031), and T2 (control group: 72 (48-112), treated group: 0 (0-0), p < 0.0001). Moreover, subjective symptoms, such as vaginal bleeding, abdominal pain, and uterine contractions, showed a faster decrease in the treatment group than in the control group. Conclusions-The association may more rapidly improve the resolution of threatened miscarriage and related symptoms compared to the standard local protocol.