Factors Associated With Operatively Confirmed Adnexal Torsion Among Pregnant Women - A Multicenter Cohort Study.

PURPOSE: The aim of this study was to investigate the association of clinical, laboratory, and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy. MATERIALS AND METHODS: A multicenter retrospective study of pregnant women who underwent urgent laparoscopy for suspected adnexal torsion during 2004-2019 in three tertiary medical centers. RESULTS: Adnexal torsion was found in 143/208 (68.8 %) cases. Women with adnexal torsion had lower parity and lower rates of previous cesarean section, but higher rates of fertility treatments and multiple gestations, and were more likely to report right lower abdominal pain, with shorter duration of symptoms (< 24 hrs) and vomiting but not nausea. Women with adnexal torsion were found to have higher rates of sonographic findings suggestive of ovarian edema, while normal-appearing ovaries on ultrasound were more common in women without torsion. A multivariate logistic regression analysis showed that complaints of right abdominal pain were positively associated with adnexal torsion (aOR [95 % CI] 5.03 (1.45-17.49), while previous cesarean delivery and ultrasound findings of normal-appearing ovaries were negatively associated with adnexal torsion (aOR of 0.17 (0.05-0.52) and 0.10 (0.02-0.43), respectively). CONCLUSION: Clinical characteristics and ultrasound findings may be incorporated into the emergency room workup of pregnant women with suspected adnexal torsion.

Single- versus multiple-dose methotrexate in cesarean scar pregnancies management: treatment and reproductive outcomes.

PURPOSE: We aim to assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single-dose methotrexate (MTX) versus multiple-dose MTX protocols. METHODS: A retrospective cohort study including two tertiary medical centers was conducted. All women diagnosed with CSPs between the years 2011 and 2019 that were initially managed with systemic MTX were included. Single-dose MTX practiced in one medical center was compared to multiple-dose MTX, practiced in the other medical center. RESULTS: The study cohort included 31 women in the single dose and 32 women in the multiple-dose MTX groups. Baseline characteristics did not differ between groups. The primary outcome occurred in 12 (38.7%) of the cases in the single-dose group and in 6 (18.8%) in the multiple-dose group (p = 0.083). The rate of conversion to surgical treatment was similar in both groups (4 vs. 5 in the single vs. multiple-dose groups, respectively, p = 0.758). There was no significant difference between the single- and the multiple-dose groups in the administration of blood products (16.1% vs. 3.1%, respectively, p = 0.104), total days of admission (18 ± 9.3 vs. 17 ± 12.8 days, respectively, p = 0.850), and readmission rate (32.3% vs. 21.9%, respectively, p = 0.353). Data regarding sequential pregnancies were available for 11 women in the single and 13 women in the multiple-dose MTX groups. There were no differences between the groups in rates of term deliveries, CSP recurrence, and abortions. CONCLUSION: Both single- and multiple-dose MTX treatment protocols offer high success rate with a relatively low complication rate in the treatment of CSP.

Pelvic inflammatory disease among users and non-users of an intrauterine device.

The correlation between pelvic inflammatory disease (PID) and a present intrauterine device (IUD) has been debated. We aimed to evaluate the differences between IUD users and non-users among women hospitalised with a diagnosis of PID. Our hypothesis was that the role of a present IUD among PID patients is minimal, if any. We performed a retrospective cohort study during 2010-2018 in a tertiary university hospital. Overall, 474 hospitalised patients were diagnosed with PID. Of these, 121 patients were IUD users. The patients without an IUD were younger and had lower gravidity and parity. Among the patients without an IUD, higher rates of prior history of PID and fever at presentation were noticed. In 23.9% (29/121) of women, the IUD was inserted less than four weeks prior to the PID diagnosis. The patients with an IUD insertion-associated PID, had lower rates of tubo-ovarian abscess (2 (6.9%) versus 24 (26.0%), OR [95% CI] 0.18 (0.04-0.84), p = .02) at presentation, as well as a shorter length of stay (LOS) (median 4 versus 5 days, p = .05). In a patient in whom the IUD was retained, hospitalisation period was shorter (median LOS 4 days versus 5 days, p = .007). PID inpatients who carry an IUD represent a specific subset of patients with a milder disease.Impact statementWhat is already known on this subject? The correlation between pelvic inflammatory disease (PID) and a present intrauterine device (IUD) is debateable.What the results of this study add? PID inpatients who carry an IUD represent a specific subset of patients with milder disease.What the implications are of these findings for clinical practice and/or further research? Our results show that in IUD users with PID, the practice of IUD removal as part of their PID treatment is of little benefit.

Outcome of methotrexate treatment for ectopic pregnancies among obese women.

OBJECTIVE: Single dose administration of methotrexate (MTX) is considered the first line of treatment in selected patients with an ectopic pregnancy (EP). However, data regarding MTX efficacy among obese patients is limited. We sought to investigate the efficacy of MTX single dose regimen among obese patients MATERIAL AND METHODS: A retrospective cohort study conducted at a gynecology department in a tertiary teaching hospital, between January 2010 and December 2018, including women diagnosed with an EP and treated by a single-dose regimen of MTX. We compared success rate and gestation characteristics between obese and non-obese women. RESULTS: Overall, 195 women were treated with single-dose intramuscular MTX for EP during the study period. Of those, 31 women (15.9%) were obese (BMI ≥ 30 kg/m2) and the rest 164 (84.1%) were of normal body weight. Median MTX dosage for the obese group was 95 milligrams (IQR 91-104) vs. 83 milligrams (IQR 78-87) for the non-obese group. Treatment success rate of the overall cohort was 66.6% (130/195) and treatment success rate of single-dose MTX was comparable between the obese and non-obese groups (64.5% vs. 67.0%, p = 0.78). Obese patients were older as compared to non-obese (median age 33 vs. 29, p = 0.03). In multivariate logistic regression analysis, percentage hCG change from day 1 to day 4 was the only factor associated with treatment success (aOR 1.02; 95%CI 1.01, 1.04, p < 0.001). CONCLUSION: Single-dose MTX treatment among obese patients diagnosed with ectopic pregnancy led to similar success rates as compared to non-obese patients.

Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications.

OBJECTIVE: The use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery. METHODS: We conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 236/7 weeks gestation and underwent uterine curettage after the fetus was delivered. RESULTS: Overall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4-4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01-5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01-10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1-3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001). CONCLUSION: Intraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.

The role of supracervical hysterectomy in reducing blood products requirement in the management of placenta accreta: a case-control study.

Objective: While surgical management is the treatment of choice for abnormally invasive placenta, the role of supracervical hysterectomy in this setting is not well established. We aimed to compare supracervical versus total cesarean hysterectomy as a surgical option for abnormally invasive placenta.Methods: We carried out an 8-year retrospective case-control study. Six cases of a patient treated by total hysterectomy were matched and compared to 30 controls treated by supracervical hysterectomy. Matching of cases with controls was based on coexisting placenta previa, a number of previous cesarean sections, and age, with five controls per case. Cases and controls were comparable in placental invasion topography. We compared the operative approach in all histologically identified cases of abnormally invasive placenta.Results: Overall, 36 women with histologically proven abnormally invasive placenta were identified. Composite blood products morbidity was higher among total hysterectomy patients (p = .02). Freshly frozen plasma utilization was greater among total hysterectomy patients (p = .01). Median operative time (142 ± 48 versus 136 ± 58 minutes) and hospitalization time (8.9 ± 3.1 versus 7.3 ± 1.5 days) were comparable between those who underwent supracervical versus total hysterectomy (p > .05). No case of maternal or neonatal death was encountered.Conclusion: The favorable maternal and perinatal outcomes observed in our study, suggest that supracervical hysterectomy should be considered as the first-line approach in cases of abnormally invasive placenta managed operatively.

Success rate of methotrexate treatment for recurrent vs. primary ectopic pregnancy: a case-control study.

The aim of this study was to compare the success rate of methotrexate (MTX) treatment in patients with recurrent ectopic pregnancy (REP) and primary EP (PEP). A retrospective cohort study. The study cohort comprised all patients diagnosed with an EP and treated by intention with single-dose regimen of intramuscular MTX in a tertiary medical centre during 2010-2018. Cases (REP) and controls (PEP) were compared.262 patients had PEP and 32 had a REP. Women with REP had significantly higher gravidity order and higher incidence of previous abortions (5 vs. 3, median, p < .001, 59.3% vs. 32.8%, p < .001, respectively). Women with REP had a higher proportion of a history of previous surgery in general, and specifically pelvic surgery (46.8% vs. 20.6%, p < .001, 24.4% vs. 7.2%, p < .001, respectively). Treatment success was lower in the REP group (40.6% vs. 66.4%, p = .006, Odds ratio 0.34, 95% confidence interval 0.16, 0.73). In a logistic regression analysis, the only factor found to be independently associated with treatment failure was REP (adjusted odds ratio 0.30, 95% confidence interval 0.12, 0.77, p = .01). Our study suggests that medical treatment success with a single-dose regimen of MTX is lower than expected among REP cases, suggesting that different treatment approach should be considered in this setting.Impact statementWhat is already known on this subject ? There is paucity of data regarding success rate of methotrexate treatment for a recurrent ectopic pregnancy (REP).What do the results of this study add? Medical treatment success with a single-dose regimen of MTX in patients with a REP is lower than expectedWhat are the implications of these findings for future clinical practice and/or further research? As medical treatment success with a single-dose regimen of MTX for women with a REP is lower than expected, different treatment approach should be considered. Further and prospective studies with a larger sample size are needed to confirm our findings.

Risk factors for recurrent Pelvic Inflammatory Disease.

OBJECTIVE: Pelvic inflammatory disease (PID) is a common infection which can result in severe long term morbidity, such as chronic pelvic pain and infertility. The morbidity increases in correlation to the number of PID events. Our study aim to assess the risk factors for recurrence of pelvic inflammatory disease. METHODS: A retrospective case control study was conducted using data for all women who were admitted to a tertiary medical center for a recurrent PID over a duration of 15 years. Women who had a recurrent PID were compared to women admitted for PID treatment without further recurrence. Forward stepwise multivariate logistic regression analysis was subsequently carried out. RESULTS: The study included 133 women of whom 33 had recurrent PID. Women in the recurrent PID group had a higher rate of previous pelvic surgery (12 (36 %) vs. 20 (20 %), adjusted odds ratio [OR] 2.2 (95 % confidence interval CI 1.06-5.4, p = 0.05) and more had intrauterine devices (IUD) still in place if they had been previously present (5 (71.4 %) vs. 9(25.7 %), OR 7.2, (95 % CI 1.18-43.9), p = 0.02). The majority were treated with a combination of Ampicillin and Gentamycin, fewer received Augmentin or a cephalosporin base regimen (28 (84.8 %) vs 56 (56.0 %), OR 4.4, (95 % CI 1.5-12.3, p = 0.02), (1 (3.0 %) vs 27 (27.0 %), OR 0.08, (95 % CI 0.01-0.64), (4 (12.2 %) vs 17 (17.0 %)) respectively. In addition, invasive treatment had been required in more patients who later had a recurrent PID (6 (18.1 %) vs. 4(4.0 %), OR 5.3 (95 % CI 1.1.4-20.2), p = 0.007). Antibiotic regimens and invasive treatment were independently associated with recurrent PID (OR 2.69; 95 % CI 1.13-6.41, OR 2.10; 95 % CI 1.19-3.71, respectively). CONCLUSION: Among women with PID, special awareness should be given to women with previous pelvic surgery, who required an additional interventional treatment and have an IUD inserted. Efforts should be made to achieve treatment success and optimal prevention to prevent recurrent PID.

Conservative management of Caesarean scar pregnancies with systemic multidose methotrexate: predictors of treatment failure and reproductive outcomes.

RESEARCH QUESTION: Caesarean scar pregnancy (CSP) is an increasing concern in modern obstetrics. Early diagnosis and management are of utmost importance. The optimal management approach for CSP is not well established, with various treatment modalities reported. The role of conservative management of CSP has been previously reported, with conflicting results. This study aimed to further evaluate its role and better delineate the subsequent reproductive outcomes. DESIGN: A retrospective cohort study including all patients diagnosed with a CSP and treated by intention of conservative management with systemic methotrexate (MTX). Maternal and gestation characteristics were compared between treatment success and failure groups. RESULTS: Thirty-six cases of CSP were encountered. Overall, 29/36 (80.6%) were treated by systemic injection of MTX while the other 19.4% had combined systemic and local (i.e. intra-sac) MTX treatment. Invasive intervention was needed in five (13.9%) cases (failure group). Among those successfully treated with MTX, the median time to resolution was 22 (interquartile range 13-37) days. Cases who were converted to surgical treatment had a higher number of previous Caesarean deliveries (median 4 versus 2, P = 0.002). In logistic regression modelling, the number of previous Caesarean deliveries was the only factor independently associated with conversion to surgical management (odds ratio 2.02, 95% confidence interval 1.03-3.94). The majority of future pregnancies ended at term pregnancy with only one preterm delivery due to severe intrauterine growth restriction. CONCLUSIONS: Systemic MTX therapy is a safe and effective strategy for the treatment of CSP, with favourable subsequent reproductive results and a low conversion rate to surgical management.

Risk factors for recurrent ectopic pregnancy following single-dose methotrexate treatment.

Objective: Our study aimed to investigate the predisposing factors for recurrence of an ectopic pregnancy (EP) following single-dose methotrexate (MTX) treatment for a primary EP. Methods: This was a retrospective cohort study performed in a tertiary care medical centre including all patients diagnosed with primary EP and treated with a single-dose regimen of intramuscular MTX. EPs with future recurrence were compared with first time only EPs, to identify risk factors for recurrent EP. Forward stepwise multivariate logistic regression analyses were subsequently carried out. Results: The study included 272 women. Of those, 22 (8.1%) had a recurrent EP. Women in the recurrent EP group had a higher rate of abortions (45.5% vs 32.7%; p = 0.02), previous pelvic surgery (45.5% vs 6.5%; p < 0.001) and both pelvic and uterine surgery (4.5% vs 1.6%; p < 0.001). Conception by assisted reproductive technology (ART) was more common among the non-recurrent EP group (23.0% vs 4.5%; p = 0.04). Success of single-dose MTX treatment was lower in the recurrent EP group compared with the non-recurrent EP group (36.4% vs 65.7%; p = 0.006). A history of pelvic surgery was independently associated with recurrent EP (adjusted odds ratio [OR] 17.6; 95% confidence interval [CI] 4.9, 63.2; p = 0.001). Treatment success of single-dose MTX was independently protective for recurrent EP (adjusted OR 0.25; 95% CI 0.08, 0.76; p = 0.02). Conclusions: Among women with an EP, attention should be paid to those with previous pelvic surgery. Efforts should be made to achieve medical treatment success to prevent recurrent EP.

The predictive role of CA-125 in the management of tubo-ovarian abscess. A retrospective study.

OBJECTIVE: Tubo-ovarian abscess (TOA) is a well-established sequel of acute pelvic inflammatory disease (PID). While as up to 25% of women will experience conservative treatment failure, the factors associated with treatment failure are not clearly-established, and the role of Cancer antigen 125 (CA-125) is under-studied. We aim to evaluate the role of CA-125 in the conservative management of TOA. STUDY DESIGN: A retrospective cohort study conducted at tertiary university-affiliated hospital during 2007-2018. Ninety one patients were diagnosed with a TOA and underwent a trial of conservative management with intravenous antibiotics. Patients who eventually underwent surgical intervention were compared with patients managed conservatively. RESULTS: Overall, 39/91 (42.8%) underwent an invasive intervention subsequent to failed antibiotic treatment. Patients who experienced conservative treatment failure had higher medians of inflammatory markers as CRP (15.7 vs. 10.8 mg/L, p = 0.02), WBC count (14.2 vs. 12.4 1,000/mm3, p = 0.04) and platelet count (374 vs. 295 109/L, p = 0.04) at admission. Higher levels of CA-125 at admission were found in those who required an invasive intervention (57 vs. 30 U\ml, p = 0.02) as well. The largest diameter of TOA at admission was higher in those who required an invasive intervention as compared to those who were successfully treated conservatively (75 mm vs. 57 mm, p = 0.01). CA-125 level was found to be the only independent factor associated with conservative treatment failure (OR; 95% confidence interval [CI], 1.27, 1.08-1.48, p = 0.03). CONCLUSION: Elevated CA-125 serum levels were found to be associated with failure of conservative parenteral antibiotic therapy for TOA. This finding should be better evaluated in a prospective manner.

Early prediction of the success of methotrexate treatment success by 24-hour pretreatment increment in HCG and day 1-4 change in HCG.

RESEARCH QUESTION: Several studies have tried to identify early markers of treatment outcome after methotrexate (MTX) treatment for ectopic pregnancy, including pretreatment and day 4 human chorionic gonadotrophin (HCG) concentrations and their corresponding changes, and the increment in HCG during the initial 24 h after treatment. There have, however, been conflicting results. This study aimed to re-evaluate the role of these markers in the earlier identification of treatment success in a large cohort of women. DESIGN: This was a retrospective cohort study including women diagnosed with an ectopic pregnancy and treated with a regimen of a single dose of MTX. A comparison of maternal and gestation characteristics was made between groups in whom treatment was successful or failed. RESULTS: A total of 292 women treated with single-dose intramuscular MTX for ectopic pregnancy were included in this study. In the overall cohort, the treatment success rate with a single dose of MTX was 62.7% (183/292). Only two independent determinants were significantly associated with treatment success: the initial 24-h percentage increase in HCG (adjusted odds ratio [OR] 1.82, 95% confidence interval [CI] 1.26-2.63; P < 0.001) and the percentage change in HCG from day 1 to day 4 (adjusted OR 1.12, 95% CI 1.04-1.21; P < 0.001). The optimal cut-off points for prediction of treatment success were an increment of less than 17% in the 24 h before treatment and a decrease of more than 22% between the day 1 and day 4 HCG concentrations. CONCLUSIONS: A small increase in HCG concentration 24 h before treatment with MTX, alongside a decline in HCG concentration from day 1 to day 4, may predict the success of medical treatment for an ectopic pregnancy.

[Single incision laparoscopic combined cholecystectomy, bilateral salpingo-oophorectomy and omentectomy].

Single Incision Laparoscopic Surgery (SILS) is gaining popularity as a modality in surgery which reduces the number and size of skin incisions. General surgeons and urologists were the first to implement this technique, however, recently gynecologists have also started performing SILS procedures. We present the case of a 70 year old female who underwent a combined SILS procedure which included cholecystectomy, bilateral oophorectomy and omentectomy. The procedure lasted 100 minutes and the patient was discharged home the day after the operation. No operative or post-operative complications were noted. In this case report we present the technical details and demonstrate the collaboration between different disciplines which enables performing this complex and demanding procedure.

Case-control study of complications associated with bipolar and monopolar hysteroscopic operations.

STUDY OBJECTIVE: To examine whether all hysteroscopic operations can be performed using bipolar technology and to compare the complication rates of hysteroscopic surgery performed using monopolar and bipolar technology. DESIGN: Case-control study (Canadian Task Force classification II-2). SETTING: Endoscopic gynecology unit at a tertiary-care university hospital. PATIENTS: Women aged 17 to 88 years (median, 43.9 years) who underwent operative hysteroscopy to treat uterine disease. INTERVENTIONS: Operative hysteroscopy using bipolar technology and normal saline solution as irrigation medium. The control group was composed of women who underwent the procedure using monopolar technology, with glycine as irrigation medium, before adoption of bipolar technology. MEASUREMENTS AND MAIN RESULTS: Data regarding short-term complications were prospectively obtained during surgery and at 2-week follow-up. More than 1800 procedures were investigated (1318 in the study group and 524 in the control group). The complication rate was 4.1% in the study group and 2.8% in the control group (p = .08). CONCLUSION: Both monopolar and bipolar hysteroscopic techniques are safe and feasible. The bipolar hysteroscopic system has eliminated the need to use hypotonic solutions as irrigation medium, with its life-threatening complications. When limiting normal saline solution to 2 L, no serious complications associated with irrigation medium are expected. Therefore, we believe that when available, the bipolar system should be preferred.

Pilonidal cyst involving the clitoris in an 8-year-old girl--a case report and literature review.

Pilonidal disease is common among adolescents and adults, mainly located in the sacral area. Pilonidal disease involving the clitoris is extremely rare and has not been described in premenarcheal girls. We present a case of a recurrent pilonidal periclitoral cyst in an 8-year-old girl which was surgically treated.

Endometrial carcinoma first presenting as paraneoplastic cerebellar degeneration.

BACKGROUND: Paraneoplastic degeneration (PCD) is an immune-mediated disorder affecting the cerebellum, characterized by subacute onset of cerebellar dysfunction progressing to severe disability, and is associated with an underlying malignancy. Ovarian carcinoma and breast carcinoma are commonly implicated. CASE: We report a rare case PCD in an elderly woman, later diagnosed with endometrial carcinoma. CONCLUSION: PCD is an unusual and rare manifestation of gynecological malignancies, including endometrial carcinoma, and a high degree of suspicion is required in these cases in order to make the correct diagnosis.

Expression of E-cadherin transcriptional regulators in ovarian carcinoma.

Unlike most epithelial cancers, E-cadherin expression is upregulated in ovarian carcinoma effusions compared with corresponding primary tumors. In the present study, we analyzed the anatomic site-specific expression of transcription factors that negatively regulate E-cadherin in ovarian carcinoma. Using reverse-transcription polymerase chain reaction, mRNA in situ hybridization, and Western blotting, we analyzed the expression and localization of the Snail, Slug, and SIP1 transcription factors and E-cadherin in 78 effusions, 41 primary carcinomas, and 15 solid metastases. Slug mRNA and protein expression was highest in metastases (p=0.042 and p<0.001, respectively). Snail mRNA was comparable at all anatomic sites, but higher protein expression was found in primary tumors and solid metastases compared with effusions (p<0.001). SIP1 mRNA expression was higher in effusions (p<0.001) compared to other sites. Confocal microscopy analysis of fresh and cultured cells from effusion specimens revealed cytoplasmic localization of the Snail protein in primary tumor cells, with a nuclear shift following culturing of these cells. In conclusion, E-cadherin and its negative regulators show site-dependent expression in ovarian carcinoma. In solid tumors, E-cadherin is negatively regulated by Snail and Slug. In effusions, SIP1 may be the main regulator of E-cadherin, but with a lesser level of suppression compared with primary tumors and solid metastases.