Manually driven versus motor driven hysteroscopic tissue removal system for polypectomy: Long-term results.

OBJECTIVE: The aim of this follow-up study is to compare a manually driven hysteroscopic tissue removal system (ResectrTM 9 Fr) with a motor driven system (TruclearTM) in terms of long-term clinical outcomes such as abnormal uterine bleeding and polyp recurrence. STUDY DESIGN: This is a follow-up of a multicenter randomized controlled trial comparing a manually and motor driven hysteroscopic tissue removal system for polypectomy. This prospective cohort study was performed at Ghent University Hospital (Ghent, Belgium) and Catharina Hospital Eindhoven (Eindhoven, the Netherlands). The trial was registered at Clinicaltrials.gov (Trial ID = NCT05337605, April 2022). Seventy-five women with abnormal uterine bleeding who participated in the randomized controlled trial and had pathological confirmation of the diagnosis of an endometrial polyp, were contacted. Fifty-five women (70.67 %) were willing to participate in this follow-up study. The primary outcome was the recurrence and/or persistence of abnormal uterine bleeding and the time to the recurrence of abnormal uterine bleeding. Secondary outcomes were polyp recurrence and time to polyp recurrence, symptom relief, satisfaction score regarding symptom relief and general satisfaction score regarding the surgical procedure. RESULTS: In the manually driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 26 months (95 % CI 20 - 32). In the motor driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 29 months (95 % CI 23- 34). A log-rank test showed a non-significant difference between both groups (P =.77). There was no significant difference in polyp recurrence (P =.22) or symptom relief between the two groups (P =.67). Additionally, the groups did not differ in satisfaction scores regarding symptoms or polypectomy (P =.16 and P =.61, respectively). CONCLUSION: This long-term follow-up study showed no statistically significant difference in the recurrence and persistence of abnormal uterine bleeding between a manually and motor driven hysteroscopic tissue removal system for polypectomy.

The risk factors for premalignant and malignant endometrial polyps in premenopausal and postmenopausal women and trends over the past decade: A retrospective study in a single center, South Korea.

OBJECTIVES: To assess the prevalence and risk factors for premalignancy and malignancy in endometrial polyps and to evaluate trends over the past decade. STUDY DESIGN: This was a retrospective study of patients who underwent hysteroscopic polypectomy at Inha University Hospital, South Korea between January 2013 and June 2023. The demographic and clinical characteristics of the patients reviewed to identify risk factors for premalignancy and malignancy in endometrial polyps included the following: age, parity, body mass index, menopausal status, abnormal uterine bleeding symptoms, diabetes mellitus, hypertension, polycystic ovarian syndrome, use of menopausal hormonal therapy or oral contraceptives, tamoxifen treatment in patients with breast cancer, and the number of polyps. RESULTS: In total, 725 patients were enrolled, among whom 52 (7.2 %) had premalignant and malignant lesions. In logistic regression analysis, menopause (OR: 8.37, 95 % CI [3.33-21.04]), abnormal uterine bleeding (OR: 7.42, 95 % CI [2.13-25.86]), obesity (OR: 3.22, 95 % CI [1.53-6.77]), multiple polyps (OR: 2.86, 95 % CI [1.39-5.88]) and nulliparity (OR: 2.64, 95 % CI [1.13-6.19]) were significantly associated with premalignancy and malignancy in polyps. Annual trends during the study period showed an increase in the number of patients with three of the five risk factors (obesity, multiple polyps, and nulliparity) and an increase in the prevalence of premalignancy and malignancy in polyps. CONCLUSIONS: Menopause, abnormal uterine bleeding, obesity, multiple polyps, and nulliparity increase the risk of premalignancy and malignancy in endometrial polyps. The prevalence of premalignant and malignant polyps has been increasing over the past decade. The risk factors that have contributed to this trend were obesity, nulliparity, and multiple polyps.

Neonatal uterine bleeding: Risk factors and its association with endometriosis-related symptoms later in life.

OBJECTIVE: We examined the prevalence and risk factors in association with neonatal uterine bleeding (NUB) by retrospective search of contemporary and historical medical records and investigated the possible association between the history of NUB at birth and endometriosis-related symptoms later in life who are now young women. STUDY DESIGN: This was a retrospective case-controlled cohort study and prospective evaluation of web-based questionnaire survey on symptoms related to endometriosis among young women born with and without NUB. Multiple regression analysis was performed incorporating various confounding variables that may influence the occurrence of NUB or the reporting of endometriosis symptoms later in life. RESULTS: Among the 1093 female neonates born between 1996 and 2000, 105 of them had NUB, yielding with a prevalence of 9.6 %. Of the 807 female babies born between 2013 and 2017, 25 (3.1 %) had NUB. Multiple Logistic regression analysis indicated that younger age of the mother [odds ratio (OR) = 0.92, 95 % confidence interval (CI) = 0.85-1.00, P = 0.048] and longer gestational age of 39 weeks (OR = 3.04, 95 % CI = 1.43-6.45, P = 0.004) and of ≥ 40 weeks (OR = 4.54, 95 % CI = 2.20-9.39, P < 0.0001) of gestation were significantly associated with the occurrence of NUB. While the possibility of recall bias cannot be ruled out, newborn females who had a history of NUB appeared to complain of various endometriosis-related symptoms later in life during adulthood. CONCLUSIONS: We confirmed the validity of the reported prevalence and risk factors of NUB. NUB indeed occurs with a prevalence of 3-10% during the historical and contemporary period. Longer gestational age and younger maternal age may be considered as high-risk factors for the occurrence of NUB. The clinical relevance of our findings remains to be elucidated. Future prospective studies, preferably with larger sample sizes and the inclusion of NUB cases after discharge from the hospital, may further illuminate some unresolved issues. We also need to confirm the endometriosis-related symptoms in women with and without history of NUB via more definitive diagnosis such as imaging and histology.

Characteristics of Cervical Cancer Caused by the Human Papillomavirus 18 and Its Genetic Variations in Vietnamese Women.

BACKGROUND: The involvement of HPV18 in cervical cancer pathogenesis, as well as its high oncogenic potential and influence on the variation of cervical cancer distribution in different geographical regions, makes assessing the characteristics of cervical cancer and its variants the basis for considering potential carcinogenic HPV18 sequence variations and vaccine strategies. METHODS: A prospective study was conducted at Vietnam Central Obstetrics Hospital from January 1, 2019 to December 31, 2020. HPV18 infection was confirmed in cervical cancer patients using molecular diagnostics. Nucleotide sequences of the HPV18 E6, E7, and L1 genes were used to analyze genetic variations. The demographic, clinical, and laboratory data of the patients were collected and statistically analyzed. RESULTS: Among 48 patients with HPV18-infected cervical cancer, 79.2% were between the ages of 35-54; while only 20.8% were < 35 and > 54 years old. 100% of patients have been pregnant at some point in their lives, with ≥3 pregnancies accounting for 83.3%. Patients with cervical cancer caused by HPV18 infection were predominantly in stages 0 and I, with no patients in stages II, III, or IV. A single HPV18 infection generates much more cervical cancer cases than multiple HPV18 infections. Symptoms such as lower abdomen pain, unusual anginal discharge, and vaginal bleeding were observed in both stages 0 and I; however, vaginal bleeding after sex was only detected in women with stage I cervical cancer. Cervicitis, cervical ectropion, and ulcers are reported in cervical status stages 0 and I; however, warts and ulcers were only present in stage I. Magnetic resonance imaging produces far superior outcomes than ultrasound. All cytology and pathology tests confirmed L/HSIL, SCC, AC, and CIS. On the other hand, a single HPV18 infection was associated with a significantly higher risk of L/HSIL, SCC, AC, and CIS than multiple HPV18 infections. Nulceotide sequences of the E6, E7, and L1 genes revealed 20 mutations, including three (E6), five (E7), and twelve (L1) mutations. High-frequency mutations (95.8%-100% of HPV18 samples had mutations) occur at the following positions: C287G - P61P (E6 gene), G5503A - R25Q, C5701G - P91R, C6460G - P344R, C6625G - P399R, and C6842G - P471R (L1 gene). A phylogenetic tree based on the E6/E7/L1 gene sequence revealed that 100% belonged to A lineage, with 97.9% belonging AA (Asian Amerindian - A1) and 2.1% belonging to the E (European - A5). CONCLUSION: Patients with a single HPV18 infection have a higher risk of cervical cancer than those infected with HPV18 and other high-risk strains simultaneously. HPV18 single-infection, on the other hand, had considerably higher incidences of L/HSIL, SCC, AC, and CIS than HPV18 co-infection. The HPV18 strain that was found in Vietnam belonged to lineage A (A1 and A5), which contains several oncogene mutations.

Value and influencing factors of preoperative MRI evaluation for previous cesarean scar defect associated abnormal uterine bleeding in patients undergoing laparoscopic surgery. / æœ¯å‰ç£å ±æŒ¯è¯„ä»·è ¹è ”é•œæ‰‹æœ¯æ²»ç–—å‰–å®«äº§åˆ‡å£ç˜¢ç—•ç¼ºé™·ç›¸å ³å¼‚å¸¸å­å®«å‡ºè¡€çš„ä»·å€¼åŠå½±å“å› ç´ ï¼ˆè‹±æ–‡ï¼‰.

OBJECTIVES: As the cesarean section rate increases year by year, the treatment of previous cesarean scar defects (PCSD) poses a significant challenge. This study aims to evaluate the clinical value of preoperative magnetic resonance imaging (MRI) technology and analyze relevant influencing factors for patients with abnormal uterine bleeding (AUB) associated with cesarean scar defects who underwent laparoscopic surgery. METHODS: A retrospective cohort analysis was performed on women who underwent laparoscopic surgery for PCSD-related AUB at the Department of Gynecology, the Third Xiangya Hospital of Central South University from 2018 to 2022. A total of 57 patients who underwent laparoscopic surgery for the treatment of AUB associated with PCSD were divided into 2 groups based on their postoperative clinical cure status: The clinically-cured group (n=28, 49.1%) and the non-clinically-cured group (n=29, 50.9%). After a postoperative follow-up period of 3 months for all participants, logistic regression analysis was conducted to explore the correlation between the clinical cure rate of AUB associated with cesarean scar defects treated by laparoscopic surgery and various factors. These factors included patient age, clinical symptoms, obstetric history, history of cesarean section, basic clinical information, preoperative MRI parameters, and postoperative menstrual conditions. RESULTS: There were no significant differences in many aspects, including the patient's age at the time of previous cesarean section, number of pregnancy, time since the previous cesarean section, the uterus position assessed by preoperative T2 signal MRI, defect length, defect width, residual muscle layer thickness, adjacent uterine muscle layer thickness, and distance from the defect to the external cervical os between the 2 groups (all P>0.05). However, the time of onset of AUB symptoms (P=0.036, OR=1.019, 95% CI 1.002 to 1.038) and the depth of the defect on the preoperative MRI (P=0.010, OR=5.793, 95% CI 1.635 to 25.210) were identified as risk factors affecting the clinical cure rate. CONCLUSIONS: The time of onset of AUB symptoms and the depth of the defect on preoperative MRI are risk factors that influence the clinical cure rate of laparoscopic surgery for the treatment of AUB associated with PCSD, which could be helpful for evaluating the prognosis of disease.

Risk factors of heavy uterine bleeding in patients with endometriosis and adenomyosis treated with dienogest.

OBJECTIVE: Dienogest (DNG), a fourth-generation progestin, reduces pain associated with endometriosis and uterine adenomyosis; however, it is associated with irregular uterine bleeding that can cause anemia and poor quality of life. We investigated risk factors for heavy bleeding following DNG administration. MATERIALS AND METHODS: We retrospectively investigated patients who received DNG for risk factors of heavy uterine bleeding, including clinical diagnosis, use of pretreatment gonadotropin-releasing hormone agonist, smoking, cancer antigen 125, and blood hormone levels. We additionally assessed the uterine area in patients with uterine adenomyosis, the major axis of the uterine body, the major axis of myometrial thickness, the site of tumor development, and the site of myoma development in patients with uterine fibroids. RESULTS: Eighty Japanese patients were administered DNG. The median age was 41 (range: 24-51) years. The odds ratio (OR) for moderate-to-severe bleeding according to clinical diagnosis were 0.33 (P = 0.011) for endometrioma and 9.00 (P = 0.049) for uterine adenomyosis. Receiver operating characteristic curve analysis of the uterine area associated with uterine adenomyosis showed an area under the curve (AUC) of 0.909 between those with major and minor bleeding, with an optimal cut-off value of 7388.2 mm2. The uterine body major axis had an AUC of 0.946, with an optimal cut-off value of 78.3 mm. The major axis of myometrial thickness had an AUC of 0.855, with an optimal cut-off value of 46.8 mm. CONCLUSION: Patients with endometrioma treated with DNG were less likely to experience heavy uterine bleeding. Uterine bleeding in patients with uterine adenomyosis and adenomyosis associated with uterine fibroids should be closely monitored while administering DNG.

Comparing endometrial biopsy results with hysteroscopic pathology in women presenting with abnormal and postmenopausal uterine bleeding.

OBJECTIVE: To compare pathology results after office-based blind endometrial biopsy and pathology results from hysteroscopy in women presenting with abnormal uterine bleeding (AUB). METHODS: A retrospective cohort study of biologic women presenting with AUB at a tertiary care referral care center. Patients were included if they underwent evaluation with blind endometrial biopsy performed in the office followed by hysteroscopy within one year. Hysteroscopic findings and pathology were correlated with index endometrial biopsy findings. RESULTS: 689 patients met inclusion criteria. The mean age and BMI were 49 (±10) years and 31 (±8) kg/m2. The median duration of bleeding leading up to presentation was of 3.5 (1.5-9) months. Of the patients who had operative hysteroscopic pathology demonstrating endometrial polyp, 30.6 % (81) had a polyp detected on office endometrial biopsy. Of the patients who had hysteroscopic pathology demonstrating intracavitary fibroids, 0 % (0) were detected on endometrial biopsy. Of the patients who had hyperplasia without atypia on hysteroscopy, 28.6 % (4) were detected or suspected on endometrial biopsy. Of the patients who had hyperplasia with atypia on hysteroscopy, 5.9 % (1) were detected or suspected on endometrial biopsy. There were 12 cases of confirmed or suspected malignancy on hysteroscopy, of which 8.3 % (1) were detected on endometrial biopsy. CONCLUSION: Concordance between focal findings on office hysteroscopy and endometrial biopsy is low. Endometrial biopsy when malignancy is suspected has been shown to be of benefit, but in the setting of suspected benign focal pathology, blind assessment of the endometrial cavity for definitive diagnosis should be abandoned. In women with symptomatic uterine bleeding, hysteroscopic visualization is associated with increased sensitivity in identifying intrauterine pathology.

Risk of diabetes and cardiovascular diseases in women with vaginal bleeding before 20 gestational weeks: Danish population-based cohort study.

BACKGROUND: Women's reproductive health is associated with cardiovascular morbidity. However, an association of vaginal bleeding (VB) in pregnancy with diabetes and cardiovascular outcomes has scarcely been investigated. METHODS: We conducted a population-based cohort study in Denmark (1994-2018). Using nationwide registries, among 903 327 women we identified 1 901 725 pregnancies: 39 265 ended in childbirth and were affected by VB; 1 389 285 ended in childbirth and were unaffected by VB; 333 785 ended in a termination, and 139 390 ended in a miscarriage. The outcomes were diabetes types 1 and 2, hypertension, ischaemic heart disease including myocardial infarction, atrial fibrillation or flutter, heart failure and ischaemic and haemorrhagic stroke. We computed incidence rates and hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, calendar year of pregnancy end, morbidities and reproductive and socioeconomic factors, using inverse probability of treatment-weighted Cox proportional hazards regression. RESULTS: In analyses of VB-affected vs VB-unaffected pregnancies, aHRs were 1.15 (1.03-1.28) for diabetes type 1, 1.19 (1.13-1.26) for diabetes type 2, 1.19 (1.14-1.25) for hypertension, 1.26 (1.16-1.37) for ischaemic heart disease, 1.21 (1.03-1.42) for myocardial infarction, 1.32 (1.14-1.51) for atrial fibrillation or flutter and 1.23 (0.99-1.52) for heart failure. aHRs were 1.41 (1.26-1.57) and 1.46 (1.23-1.72) for ischaemic and haemorrhagic stroke, respectively. When contrasting VB-affected pregnancies with terminations, aHRs were up to 1.3-fold increased for diabetes and hypertension; however, when contrasting VB-affected pregnancies with miscarriages, estimates were below or close to the null value. CONCLUSIONS: Women's risks of diabetes and cardiovascular outcomes later in life were increased following VB-affected vs VB-unaffected pregnancy or termination, but not following VB-affected pregnancy vs miscarriage.

Manejo das irregularidades menstruais secundárias ao uso de contraceptivos ­ análise das recomendações atuais / Management of menstrual irregularities secondary to contraceptive use ­ analysis of current recommendations

As irregularidades menstruais representam uma série de desordens na quantida- de, duração, frequência ou regularidade do sangramento uterino. Entre suas cau- sas destaca-se o sangramento secundário ao uso de anticoncepcionais, uma razão frequente de descontinuidade dos contraceptivos, podendo aumentar as taxas de gestações não planejadas. Boa parte dos contraceptivos pode levar a mudanças no padrão de sangramento uterino, e a abordagem inicial do sangramentos irregula- res inclui a avaliação de outras possíveis causas, o reforço do uso correto da medi- cação, a tranquilização da paciente quanto à benignidade do quadro e à tendência a melhora com a continuidade do uso. Os anti-inflamatórios podem ser usados como estratégia inicial, e, não havendo resposta satisfatória, há alternativas espe- cíficas para cada método. Este trabalho visa identificar as recomendações atuais sobre o manejo do sangramento anormal decorrente de contraceptivos, por meio de revisão narrativa de estudos publicados sobre o tema nos últimos vinte anos.

Abnormal uterine bleeding represents a series of disorders in the amount, du- ration, frequency and or regularity of uterine bleeding. Among its causes, uterine bleeding secondary to the use of contraceptives stands out as a frequent reason for contraceptive discontinuity, which could lead to unplanned pregnancies. Most contraceptives can cause changes in the pattern of uterine bleeding, and the ini- tial approach of the abnormal bleeding includes assessing other possible cau- ses, reinforcing the correct use of medication, and reassuring the patient about the benignity of the condition and the tendency to improve with the continuity of the treatment. Anti-inflammatory drugs can be used as an initial strategy, and, if there is no satisfactory answer, there are specific alternatives for each contracep- tive method. This work aims to identify them current recommendations on the management of abnormal bleeding resulting from contraceptives use, through a narrative review of studies published on the subject in the last twenty years.

Ultrasound for diagnosis of postpartum retained products of conception-How accurate we are?

OBJECTIVE: Postpartum retained products of conception (RPOC) can cause short- and long-term complications. Diagnosis is based on ultrasound examination and treated with hysteroscopy. This study evaluated the size of RPOC that can be related to a positive pathology result for residua. MATERIALS AND METHODS: This retrospective cohort study included women who underwent hysteroscopy for postpartum RPOC diagnosed by ultrasound, 4/2014-4/2022. Demographics, intrapartum, sonographic, intraoperative, and post-operative data were retrieved. We generated a ROC curve and found 7 mm was the statistically sonographic value for positive pathology for RPOC. Data between women with sonographic RPOC ≤ 7 mm and > 7 mm were compared. Positive and negative predictive values were calculated for RPOC pathology proved which was measured by ultrasound. RESULTS: Among 212 patients who underwent hysteroscopy due to suspected RPOC on ultrasound, 20 (9.4%) women had residua ≤ 7 mm and 192 (90.6%) had residua > 7 mm. The most common complaint was vaginal bleeding in 128 cases (60.4%); more so in the residua > 7 mm group (62.5% vs. 40%, p = .05). Among women with residua ≤ 7 mm, the interval from delivery to hysteroscopy was longer (117.4 ± 74.7 days vs. 78.8 ± 68.8 days, respectively; p = .02). Positive pathology was more frequent when residua was > 7 mm. PPV for diagnosis of 7 mm RPOC during pathology examination was 75.3% and NPV 50%. CONCLUSIONS: Sonographic evaluation after RPOC showed that residua > 7 mm was statistically correlated with positive RPOC in pathology and PPV of 75% and NPV of 50%. Due to the high NPV and low complication rate of office hysteroscopy, clinicians should consider intervention when any RPOC are measured during sonographic examination to reduce known long-term complications.

Polycystic ovary syndrome and body image concerns during adolescence.

PURPOSE: This study aimed to compare body image concerns in adolescents with and without PCOS. DESIGN AND METHODS: This cross-sectional study included 1076 adolescents, including 344 with PCOS and 732 without PCOS. The participants were asked to complete a comprehensive questionnaire that included demographic and reproductive parameters and the body image concerns inventory (BICI) which comprised two factors (1-dissatisfaction and embarrassment about one's appearance and 2-social function due to appearance concerns). Linear regression analysis was conducted to evaluate the effect of hyperandrogenism and/or abnormal uterine bleeding (AUB) and/or obesity on BICI and its domains both before and after adjustment for potential confounders. RESULTS: The result showed that adolescents with PCOS had a worse total BICI score and its domains (p < 0.05). In multivariable-adjusted regression models, adolescents with PCOS were more likely to have a high body image concern (ß = 0.05, P < 0.001), while those with high household income were less likely to have body image concern (ß = -0.08, P = 0.004). Considering hyperandrogenism status, those with high household income were also less likely to have high body image concern (ß = -0.08, P = 0.004), and age of menarche (ß = -0.01, P = 0.013) were also inversely associated with total BICI score. Likewise, considering obese status, only high household income (ß = -0.08, P = 0.004) was inversely associated with total BICI score. Also, considering menstrual irregularity status, high household income (ß = -0.08, P = 0.005), and age of menarche (ß = -0.01, P = 0.01) were inversely associated with the total BICI score. CONCLUSION: Adolescents with PCOS had higher body image concerns. Apart from the being PCOS label, abnormal uterine bleeding was also a predictor of body image concern. PRACTICAL IMPLICATIONS: Clinicians should pay attention to the greater influence of the PCOS label on altered body image in adolescents.

Endometrial Angiogenesis of Abnormal Uterine Bleeding and Infertility in Patients with Uterine Fibroids-A Systematic Review.

Uterine fibroids are the most common benign tumors in women, with abnormal uterine bleeding (AUB) as the main reported symptom. Additionally, an association between fibroids and infertility has been established, especially if the fibroid protrudes in the uterine cavity. Hormonal therapy is associated with side-effects and as well as hysterectomy, which is incompatible with a desire to conceive. To improve treatment, it is essential to unravel the etiology of fibroid-related symptoms. We aim to evaluate endometrial angiogenesis in women with fibroids, with and without AUB, and the influence of pharmaceutical therapies in these patients. Furthermore, we explore the possible role of altered angiogenesis in patients with fibroids and infertility. We performed a systematic review according to PRISMA-guidelines (PROSPERO: CRD42020169061), and included 15 eligible studies. Endometrial expression of vascular endothelial growth factor (VEGF) and adrenomedullin was increased in patients with fibroids. This suggests aberrant angiogenesis, potentially involving disturbed vessel maturation, resulting in immature and fragile vessels. Treatment with gonadotropin-releasing hormone agonist, ulipristal acetate, and continuous oral contraception pills reduced several angiogenic parameters, including VEGF. If infertile and fertile patients with fibroids were compared, a significant decreased expression of the bone morphogenetic protein/Smad-protein pathway was found, possibly caused by the increased expression of transforming growth factor-beta. For future therapeutic development, these different angiogenic pathways could be of interest as possible targets to treat fibroid-related symptoms.

Muerte materna asociada a una malformación arteriovenosa uterina / Maternal death associated with uterine arteriovenous malformation

La malformación arteriovenosa uterina (MAVU), para algunos autores considerada como fístula arteriovenosa, representa entre el 1 y 2% de la hemorragia genital e intraperitoneal como resultado de la rotura vascular espontánea o provocada posterior a una intervención quirúrgica.Exponemos un caso de muerte materna ocurrida durante una caminata sobre una pendiente, presentando metrorragia y desvanecimiento con desenlace letal. La autopsia médico legal demostró un útero gestante con hemorragia del miometrio y múltiples coágulos hemáticos, diagnosticada anatomopatológicamente como MAVU.La muerte materna es un problema de salud pública multifactorial en los países subdesarrollados, la MAVU es una causa poco frecuente, sin embargo, algunos autores la consideran subdiagnosticada; han aumentado el reporte de casos en los últimos años y en los países en desarrollo puede ser letal. (AU)

Uterine arteriovenous malformation (UAMM) for some authors, considered an arteriovenous fistula, represents between 1% and 2% of genital and intraperitoneal hemorrhage as a result of spontaneous or provoked vascular rupture after a surgical intervention.We present a case of maternal death that occurred during a walk on a slope, presenting metrorrhagia and fainting with a fatal outcome. The medico-legal autopsy showed a pregnancy uterus with myometrial hemorrhage and multiple blood clots, diagnosed pathologically as a uterine arteriovenous malformation.Maternal death is a multifactorial public health problem in underdeveloped countries. Uterine arteriovenous malformation is a rare cause, however some authors consider it underdiagnosed; reported cases have increased in recent years and in developing countries it can be lethal. (AU)

Vaginal bleeding in a newborn as initial presentation of uterus didelphys.

Vaginal bleeding of the newborn is described as a normal phenomenon, occurring physiologically in a subset of baby girls as a response to decreased oestrogen levels in the postnatal period compared with in utero exposure. Here, we present the case of heavy vaginal bleeding prompting an evaluation via transabdominal ultrasound, which was ultimately diagnostic for uterus didelphys. We suggest that neonates with uterus didelphys are predisposed to heavy bleeding due to relatively larger amount of the endometrial tissue in two cavities. While diagnosis of Müllerian anomalies is typically made in adulthood, an earlier diagnosis facilitates timely medical and surgical intervention and prompts screening for concurrent and associated conditions. In summary, we recommend routine consideration of transabdominal ultrasound to investigate abnormal vaginal bleeding in the newborn.

Women with Anemia Refractory to Oral Iron Treatment Following Bariatric Surgery: a Short-Term Analysis.

INTRODUCTION: Iron deficiency and anemia are common after bariatric surgery. Women have a higher risk of developing such long-term complications. Though oral supplementation is indicated, intravenous iron therapy is required in some cases. METHODS: This retrospective study included patients who underwent bariatric surgery between 2012 and 2018. Postoperative anemia patients receiving parental iron therapy were assessed during the first 24 months. Their baseline characteristics, surgery type, and laboratory test results were analyzed. A follow-up analysis included a subgroup of women with and without gynecological disorders. Patients with vitamin B12 or folic acid deficiencies were excluded. RESULTS: Six hundred eleven (63.3%) met the inclusion criteria: 525 underwent gastric bypass, of which 79.6% were women. Overall, postoperative anemia was 28.9% (24.5% related to gastric bypass), especially among women (84%). Anemia refractory to oral iron therapy was observed in 12.9% of patients. All the patients requiring iron infusions (n = 54) were women, and half of them (51.8%) reported abnormal uterine bleeding. Postsurgical hemogram values were significantly lower in patients with abnormal uterine bleeding (despite the same number of infusions) than in those without gynecological disorders; 89.2% of these women had preoperative anemia. CONCLUSION: Anemia is frequent in bariatric surgery patients despite supplementation. Women undergoing gastric bypass with a history of gynecological disorders are prone to require more iron infusions. Consulting with the patient about a higher risk is important, and probably knowing the plan or including the opinion of an OBGYN to determine as a team the assessment, treatment, and prognosis.

Uterine Arteriovenous Malformation (AVM) - a Potentially Life-Threatening Cause of Post-Partum Vaginal Bleeding.

BACKGROUND Uterine arteriovenous malformation (AVM) is a rare but potentially life-threatening medical condition. It is a congenital or acquired structural abnormality that may result in potentially life-threatening bleeding. Due to the nonspecific symptoms, this condition may be mistaken for more benign causes of vaginal bleeding, thus potentially leading to adverse outcomes and delay in diagnosis and treatment. Most cases of uterine AVM are acquired, and the post-partum period is an especially vulnerable time. CASE REPORT This is a case of a 26-year-old woman who presented to the Emergency Department with post-partum vaginal bleeding. During her evaluation, a uterine AVM was suspected based on Doppler ultrasound and was confirmed with computed tomography angiography. The patient was admitted to the hospital and treated with catheter embolization with complete resolution of bleeding and return to normal activities shortly after discharge. CONCLUSIONS This report describes a hemodynamically stable patient who presented to the Emergency Department with post-partum vaginal bleeding caused by a large uterine AVM. Despite her benign initial presentation clinically, she had a potentially life-threatening condition that could have resulted in significant morbidity if the diagnosis had been missed or delayed. It is important to maintain a high index of suspicion for even benign-appearing vaginal bleeding in the Emergency Department and to obtain the appropriate diagnostic studies to rule out potentially dangerous causes, especially in the setting of recent pregnancy or gynecologic instrumentation.

Is Cervical Length a Useful Predictor of Antepartum Hemorrhage in Patients with Placenta Previa?

OBJECTIVE: Placenta previa complicates 0.3-0.5% of pregnancies and can cause sudden antepartum massive hemorrhage (APH). Previous studies have indicated that cervical length (CL) measured by transvaginal ultrasonography may be a predicting parameter for APH in patients with placenta previa; however, conflicting data exist. Thus, we investigated the association between CL and APH in patients with placenta previa. METHODS: In total, 129 singleton pregnant women with placenta previa, who delivered at our institution from January 2010 to December 2016, were included in this study. The shortest CL measured throughout gestation was used for analysis, and we defined CL less or more than 30 mm as short or normal CL, respectively. We performed univariate and multivariate analyses, and a receiver-operating characteristics (ROC) curve was plotted to determine the cut-off CL value to predict APH. RESULTS: APH occurred in 26 patients. The adjusted odds ratio for APH was 3.80 (95% CI, 1.36-10.65) in patients with short CL. ROC analysis was performed to determine a cut-off CL value of 35 mm to predict APH, with a sensitivity of 80.7% and a specificity of 60.2%. CONCLUSIONS: Our data indicated that CL measurements may be useful in determining patients at high risk of APH.

Does the presence of single compared to multiple endometrial polyps alter the risk of cancer in post-menopausal women?

OBJECTIVE: To evaluate the relative rates of malignancy in women with single and multiple polyps presenting to a UK Cancer Centre with postmenopausal bleeding (PMB). STUDY DESIGN: A retrospective review of patients treated at Royal Derby Hospital (RDH) for PMB who underwent outpatient hysteroscopy based on ultrasonographic suspicion of endometrial polyps between May 2014 to December 2019. The main outcome measure was the rates of precancerous and malignant histology for single or multiple polyps. The secondary outcomes assessed the influence of risk factors on the rates of malignancy within the single and multiple polyps groups. RESULTS: The study population was 851 women of which 533 were in the single polyp group and 318 in the multiple polyps group. The multiple polyps group (mean age 65.2 years) was older compared to the single polyp group (mean age 62.1 years), P = 0.0001. Elevated rates of cancer was driven most significantly by endometrioid cancer in the multiple polyps compared to single polyp group, with rates of 50/314 (16 %) and 28/512 (5.5 %) respectively, P=< 0.00001. For rarer histologies there was no significant difference between the proportion of serous, carcinosarcomas and clear cell cancers between those with single compared to multiple polyps (P > 0.05). Significantly more endometrial hyperplasia with atypia (AEH) was found in the multiple polyps compared to single polyp group, with rates of 18/314 (5.7 %) and 15/512 (2.9 %) respectively, P = 0.046. CONCLUSION: Our study found increased rates of endometrioid cancer and its precursor, AEH within the multiple polyps compared to the single polyps groups. Future risk predicting algorithms should consider incorporating single and multiple polyps as part of their risk model.

Subchorionic Hematoma Volume Measured by Virtual Organ Computer-Aided Analysis in the Prediction of First-Trimester Pregnancy Outcome.

ABSTRACT: This study aimed to assess the association of subchorionic hematoma (SCH) size measured by virtual organ computer-aided analysis (VOCAL) with the first-trimester pregnancy outcome. A total of 139 first-trimester pregnancies from 6 to 12 weeks of gestational age with SCH were included. The circumference, area, and volume of the SCH (Cs, As, and 3DVs) and gestational sac (Cg, Ag, and 3DVg) were automatically calculated by VOCAL. Interobserver agreement was assessed with the intraclass correlation coefficient and Bland-Altman plot. Odds ratios for the clinical and ultrasound characteristics of adverse pregnancy outcomes were estimated by univariate or multivariable logistic regression. There was high interobserver agreement in VOCAL measurements of the SCH and gestational sac (intraclass correlation coefficients, >0.900). By univariate regression analysis, women with adverse pregnancy outcomes were more likely to have vaginal bleeding, a larger As and 3DVs, and higher Cs/Cg, As/Ag, and 3DVs/3DVg ratios (all P < 0.05). In the multivariable regression analysis, a higher 3DVs/3DVg ratio of SCH (odds ratio, 1.034; 95% confidence interval [CI], 1.015-1.053; P = 0.000) and vaginal heavy bleeding had a significant positive relationship with the risk of adverse pregnancy outcomes (odds ratio, 7.846; 95% CI, 1.104-55.737; P = 0.039) remained associated with an increased risk of adverse pregnancy outcomes. With 11.87% as the cutoff, the receiver operating characteristic curve yielded a good predictive performance (area under the curve, 0.713) and high sensitivity (91.18%). The measurements of SCH by VOCAL provide high reliability for estimating the total hematoma burden in first-trimester pregnant patients. A greater volume proportion (3DVs/3DVg) of SCH worsens the pregnancy outcome, and a greater risk of adverse pregnancy outcome also associated with the severity of vaginal bleeding.