Dilatation and Curettage after Uterine Artery Embolization versus Methotrexate Injection for the Treatment of Cesarean Scar Pregnancy: A Single-Center Experience.

Background and Objectives: Cesarean scar pregnancy (CSP) represents a type of ectopic pregnancy in which the embryo implants inside the scar of a previous cesarean section. This condition can lead to maternal morbidity and mortality. The best therapeutic approach in terms of clinical effectiveness and patient safety for CSP has not been described yet, although different therapeutic strategies are currently available. The purpose of the present study was to analyze the success rate of two different treatments in a single institution. Materials and Methods: A retrospective study was performed among patients diagnosed with CSP at the Gynecology and Obstetrics Department of the "Cannizzaro" Hospital in Catania (University of Enna-Italy) from January 2016 to December 2022. The diagnosis was made by 2D/3D transvaginal ultrasound, following Timor-Tritsch criteria. Two treatment strategies were performed: local and systemic methotrexate (MTX) injection and uterine artery embolization (UAE) with subsequent dilatation and curettage (D&C). All treated women underwent subsequent clinical and sonographic follow-up. Complete recovery was defined as the reduction of ß-HCG values until it was undetectable and the disappearance of the mass in the uterine scar on ultrasound. Results: Nineteen patients were included; nine were in the MTX group and ten were in the UAE + D&C group. No significant differences were found between the two groups in terms of clinical parameters. Treatment was successful in 4 of 10 (44%) patients in the MTX group and 10 of 10 (100%) in the UAE + D&C group (p = 0.01); the length of hospital stay was significantly shorter in the latter group (p < 0.0001). Conclusions: In our experience, administration of MTX is not recommended as the primary treatment or pre-treatment. Dilatation and curettage after uterine artery embolization are better than methotrexate injection for the treatment of cesarean scar pregnancy in a single-institution series in terms of complete recovery and length of hospital stay.

Does repetitive dilatation and curettage or hysteroscopic biopsy in patients treated with progestins for endometrial hyperplasia or carcinoma affect subsequent fetomaternal outcomes? A population-based study using the National Health Insurance Research Database of Taiwan.

OBJECTIVE: To investigate the impact of repeated dilatation and curettage or hysteroscopic biopsy on fetomaternal outcomes in patients receiving progestin treatment for endometrial hyperplasia or early-stage carcinoma. METHOD: This was a population-based study using the Taiwan National Health Insurance Research Database between 2009 and 2017 of women who gave birth and had a history of endometrial hyperplasia and early-stage carcinoma treated with progestins. Logistic regression analysis was used to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) reflecting the association between repeated procedures and fetomaternal outcomes. RESULTS: A total of 6956 women with 8690 deliveries were identified. Compared with those who had two or fewer procedures, women who received more than two procedures had a significantly higher risk for cervical insufficiency (aOR, 5.09 [95 CI, 2.31-11.24]). Furthermore, women who had more than two procedures were prone to have adverse neonatal outcomes, including Apgar score < 7 at 1 min (aOR, 1.97 [95% CI, 1.13-3.43]) and 5 min (aOR, 3.11 [95% CI, 1.33-7.23]) and preterm delivery <32 weeks (aOR, 2.86 [95% CI, 1.50-5.45]). CONCLUSION: Undergoing more than two procedures was associated with subsequent maternal cervical insufficiency, preterm delivery <32 weeks, and low neonatal Apgar score. Health care providers should be aware of the potential risks and balance the benefits and harms of repeated procedures.

D&C has the best concordance between preoperative and postoperative grades among morbidly obese endometrial cancer patients.

AIM: Endometrial cancer is diagnosed by obtaining uterine biopsies by pipelle, dilatation and curettage (D&C), or hysteroscopy. In 15%-25% of the cases, the preoperative and postoperative grades do not match. This discrepancy may carry significant clinical and prognostic consequences. We aimed to assess how body mass index (BMI) affects preoperative and postoperative grade mismatches and whether biopsy methods mitigate this effect. METHODS: We conducted a retrospective review of patients with endometrial cancer who underwent surgery at our center between 2014 and 2022. We stratified patients into six classes of BMI based on the WHO classification. Preoperative and postoperative grades were compared for concordance with regards to patient BMI and sampling method. RESULTS: A total of 158 patients were included, diagnosed by pipelle (n = 99), hysteroscopy (n = 15), or D&C (n = 44). For all methods, every unit increase in BMI increased the odds of having a gap between histology grades by 5.2%. In the pipelle group, the odds of a larger gap between the histology grades was 62% higher than that of women in the other groups. Among the D&C group, the odds of having a bigger difference between histology grades were 91.8% lower compared to the other groups. Patients with BMI over 30 had nearly 50% discrepancy when diagnosed with pipelle or hysteroscopy, but less than 10% with D&C. CONCLUSIONS: Increasing BMI is associated with decreasing concordance between preoperative and postoperative grades in endometrial cancer, especially when it exceeds 30. This effect is much less pronounced, however, when the diagnostic method is D&C.

Perforated Stress Ulcer of the Duodenum: a Case of an Unexpected Diagnosis in a COVID-19 Patient Following Dilatation and Curettage Procedure.

Background: Stress ulcers in the upper gastrointestinal tract can arise from pathologies related to erosive or inflammatory insults in critically ill patients. The relationship between stressful bodily events and the ischemia and perforation of stress ulcers is poorly understood. Objective: We present a case of perforated stress ulcer following an abortion that was treated by dilatation and curettage (D&C) and complicated by a coronavirus disease 2019 (COVID-19) infection. Case presentation: A 40-year-old lady presented to the emergency room complaining of diffuse abdominal pain, she was recently diagnosed with an incomplete abortion and managed via a D&C procedure in an external hospital. A computed tomography (CT) scan was done at our center for the abdomen and pelvis, showing extensive pneumoperitoneum, which brought the radiologist's attention to suspect a small bowel perforation presumably accompanying a uterine perforation secondary to the D&C. There were no obvious signs of pelvic small bowel perforation in the initial CT images. The perforated duodenal stress ulcer was diagnosed the next day by a new CT scan following oral contrast ingestion and managed surgically by repair and omental patch, and no other bowel perforations were found upon surgical exploration. After the surgery, the patient was diagnosed with COVID-19, and her clinical status deteriorated gradually during the following week, and she passed away from a cardiac arrest. Conclusion: It is unclear whether septic abortion or COVID-19 has resulted in stress ulcer perforation in our patient. This case report highlights the importance of raising early suspicion in the diagnosis of stress ulcer perforation in critically ill patients to reduce the risk of morbidity and mortality.

MRI-based scoring model to predict massive hemorrhage during dilatation and curettage in patients with cesarean scar pregnancy.

OBJECTIVE: To construct a scoring model based on MRI signs to predict massive hemorrhage during dilatation and curettage in cesarean scar pregnancy (CSP) patients. MATERIALS AND METHODS: The MRIs of CSP patients admitted to a tertiary referral hospital between February 2020 and July 2022 were retrospectively reviewed. The included patients were randomly assigned to the training and validation cohorts. The univariate and multivariate logistic regression analyses were adopted to identify the independent risk factors for massive hemorrhage (the amount of bleeding ≥ 200 ml) during the dilatation and curettage. A scoring model predicting intraoperative massive hemorrhage was established where each positive independent risk factor was assigned 1 point, and the predictive power of this model was evaluated both in the training and validation cohorts via the receiver operating characteristic curve. RESULTS: A total of 187 CSP patients were enrolled, who were divided into the training cohort (31 in 131 patients had massive hemorrhage) and validation cohort (10 in 56 patients had massive hemorrhage). The independent risk factors for intraoperative massive hemorrhage included cesarean section diverticulum area (OR = 6.957, 95% CI 1.993-21.887; P = 0.001), uterine scar thickness (OR = 5.113, 95% CI 2.086-23.829; P = 0.025) and gestational sac diameter (OR = 3.853, 95% CI 1.103-13.530; P = 0.025). A scoring model with a total point of 3 was developed and the CSP patients were divided into low-risk (Total points < 2) and high-risk groups (Total points ≥ 2) for intraoperative massive hemorrhage accordingly. This model possessed high prediction performance both in the training cohort (area under the curve [AUC] = 0.896, 95% CI 0.830-0.942) and validation cohort (AUC = 0.915, 95% CI 0.785-1.000). CONCLUSION: We first constructed a MRI-based scoring model for predicting intraoperative massive hemorrhage in CSP patients, which could help the decision-making of the patients' therapy strategies. Low-risk patients can be cured by D&C alone to reduce the financial burden, while high-risk patients require more adequate preoperative preparation or consideration of changing surgical approaches to reduce bleeding risk.

Hysteroscopic biopsy compared with endometrial curettage to assess the preoperative rate of atypical hyperplasia underestimating endometrial carcinoma.

PURPOSE: To evaluate the rate of atypical hyperplasia (AH) underestimating endometrial cancer (EC) comparing endometrial biopsy (EB) accomplished by hysteroscopic biopsy with dilatation and curettage (D&C). Second, to compare the two techniques to foresee EC grading. METHODS: This trial was based on the findings of two Gynecological Departments within the same Public Utility, sharing pathological service and database but routinely performing EB under hysteroscopic visualization (group A) or hysteroscopy followed by D&C (group B). We retrieved the clinical data of patients showing EC on hysterectomy throughout a 10-year period. The accuracy of hysteroscopic-view diagnosis and EB pathology were compared, having the pathologic findings of hysterectomy as reference. RESULTS: A total of 161 patients met the inclusion criteria. Among these, 109 and 52 were included in groups A and B, respectively. In group A, 32.1% of patients underwent EB in an out-patient setting. To foresee EC, hysteroscopic view showed a sensitivity of 82.5% and 70.2% in groups A and B, respectively (P = 0.019). An underestimation of EC diagnosed as AH on EB was found in 20 patients (12.4%). Among these, 18 (16.5%) and 2 (3.8%) were included in groups A and B, respectively (P = 0.022). In group A, a fault diagnosis of AH resulted higher when EB was performed as out-patient setting (P = 0.006). EB allowed the grading of EC in 73.3% and 90.3% of patients in groups A and B, respectively. The agreement was 73.7% and 85.1%, leading to moderate (κ = 0.56) and good (κ = 0.77) "κ" coefficient of concordance for groups A and B, respectively. CONCLUSIONS: EB performed by D&C lowers the rate of AH underestimating concurrent EC and improves the grading agreement when compared with hysteroscopic sampling.

Management of Early Pregnancy Loss.

This JAMA Insights Clinical Update discusses the management of early pregnancy loss, including expectant, medical, and surgical management regimens.

Clinical efficacy and re-pregnancy outcomes of patients with previous cesarean scar pregnancy treated with either high-intensity focused ultrasound or uterine artery embolization before ultrasound-guided dilatation and curettage: a retrospective cohort study.

BACKGROUND: Cesarean scar pregnancy (CSP) treated with either high-intensity focused ultrasound ablation (HIFU-a) or uterine artery embolization (UAE) combined with ultrasound-guided dilation and curettage (USg-D&C) was effective. However, there is insufficient comparative research evidence on clinical efficacy and subsequent pregnancy outcomes after previous CSP treatment. This study aims to investigate the efficacy, safety, and subsequent pregnancy outcomes of HIFU-a compared to UAE before USg-D&C for the treatment of CSP. METHODS: Between January 2016 and July 2020, a total of 272 patients received the pretreatment with HIFU-a or UAE(HIFU-a group: n = 118; UAE group: n = 154). The clinical characteristics, treatment success rate, postoperative pregnancy rate and outcome of the two groups were compared and analyzed. RESULTS: The demographic characteristics of the two groups were similar. After pretreatment, the adverse events rate of HIFU-a group was lower than that of UAE group (10.40% (16/154) vs. 40.70% (48/118), P = 0.00). All patients received the USg-D&C. The HIFU-a group was of less intraoperative blood loss (10.00 (5.00-20.00) vs. 12.50 (5.00-30.00) ml, P = 0.03). There was no statistically significant difference between the two groups in success rates. However, the HIFU-a group was of a shorter duration of postoperative vaginal bleeding (12.00 (9.00-13.00) vs. 14.00 (12.00-15.00) days, P = 0.00). There was no significant difference between the two groups in terms of subsequent pregnancy rates (P = 0.317). However, the recurrent CSP (rCSP) rate in the HIFU-a group was lower than that in the UAE group (7.70% (6/78) vs. 19.70%(13/66), P = 0.03). CONCLUSIONS: CSP treated with either HIFU-a or UAE combined with USg-D&C was safe and effective. Although no significant difference was found in the subsequent pregnancy outcomes of the two groups, the rCSP was more common in the UAE group. So, we recommend HIFU-a combined with USg-D&C treatment modality.

Obstetric outcomes after medroxyprogesterone acetate treatment for early stage endometrial cancer or atypical endometrial hyperplasia: a single hospital-based study.

BACKGROUND: To investigate perinatal outcomes in pregnancy after high-dose medroxyprogesterone acetate (MPA) therapy for early stage endometrial cancer (EC) and atypical endometrial hyperplasia (AEH) and to determine whether pregnancy after MPA therapy is at a higher risk of placenta accreta. METHODS: Data of 51 pregnancies in 46 women who received MPA therapy for EC or AEH and delivered after 22 weeks of gestation at Keio University Hospital were reviewed. A retrospective matched case-control study was performed to determine the risk of placenta accreta in pregnancy after MPA therapy compared with singleton pregnancies without any history of maternal malignancy treatments. RESULTS: The incidence of placenta accreta was higher in the MPA group than in the control group (15.7 vs. 0%, p = 0.0058). However, no differences in other perinatal outcomes were observed between groups. While gestational weeks at delivery in the MPA group were later than those in the control group (p = 0.0058), no difference in the incidence of preterm delivery was recorded between groups. In the MPA therapy group, the number of patients who underwent ≥ 6 dilation and curettage (D&C) was higher in the placenta accreta group than in the non-placenta accreta group (50.0 vs. 14.0%, p = 0.018). Patients with ≥ 6 D&Cs demonstrated a 6.0-fold increased risk of placenta accreta (p = 0.043, 95% CI 1.05-34.1) than those receiving ≤ 3 D&Cs. CONCLUSION: Pregnancy after MPA therapy is associated with a high risk of placenta accreta. In cases in which the frequency of D&C is high, placenta accreta should be considered.

Radiomics nomogram in aiding preoperatively dilatation and curettage in differentiating type II and type I endometrial cancer.

AIM: To established a radiomics nomogram for improving the dilatation and curettage (D&C) result in differentiating type II from type I endometrial cancer (EC) preoperatively. MATERIAL AND METHODS: EC patients (n=875) were enrolled retrospectively and divided randomly into a training cohort (n=437) and a test cohort (n=438), according to the ratio of 1:1. Radiomics signatures were extracted and selected from apparent diffusion coefficient (ADC) maps. A multivariate logistic regression analysis was used to identify the independent clinical risk factors. An ADC based-radiomics nomogram was built by integrating the selected radiomics signatures and the independent clinical risk factors. Decision curve analysis (DCA) was conducted to determine the clinical usefulness of the radiomics nomogram. The net reclassification index (NRI) and total integrated discrimination index (IDI) were calculated to compare the discrimination performances between the radiomics nomogram and the D&C result. RESULTS: Receiver operating characteristic (ROC) curves showed that the clinical risk factors, the D&C, and the ADC based-radiomics nomogram yielded areas under the ROC curves (AUCs) of 0.70 (95% CI: 0.64-0.76), 0.85 (95% CI: 0.80-0.89), and 0.93 (95% CI: 0.90-0.96) in the training cohort and 0.64 (95% CI: 0.57-0.71), 0.82 (95% CI: 0.77-0.87) and 0.91 (95% CI: 0.87-0.95) in the test cohort, respectively. The DCA, NRI, and IDI demonstrated the clinically usefulness of the ADC based-radiomics nomogram. CONCLUSION: The ADC-based radiomics nomogram could be used to improve the D&C result in differentiating type II from type I EC preoperatively.

Preoperative sampling in endometrial cancer: evaluation of the histopathological agreement with definitive surgical specimen

Purpose The main goal of this study is to assess the diagnostic agreement between preoperative biopsy and definitive histology of the surgical specimen to determine which sampling method is most suitable for diagnosis of early-stage endometrial cancer. Methods We performed a retrospective multicentric study to assess the correlation between three endometrial sampling methods (hysteroscopy, pipelle and D&C) in patients who had undergone preoperative endometrial biopsy and received primary surgical treatment for endometrial cancer. The primary objective was the agreement rate between hysteroscopy (HSC), endometrial biopsy (pipelle) and dilatation and curettage (D&C). Results A total of 1833 women who underwent preoperative sampling at 15 centers were included: 1042 biopsies were performed by HSC, 703 by pipelle and 88 by D&C. All three methods presented a moderate diagnostic concordance (κ = 0.40–0.61) with the definitive specimen’s histology: HSC (κ = 0.47), pipelle sampling (κ = 0.48) and D&C (κ = 0.48). Likewise, a subgroup analysis was performed by histological subtype comparing HSC and endometrial biopsy, showing that neither is superior as a diagnostic method. Conclusions According to this study, the use of pipelle sampling could become an adequate diagnostic method in endometrial cancer due to its similar agreement to HSC, ease of use and affordability (AU)

Preoperative sampling in endometrial cancer: evaluation of the histopathological agreement with definitive surgical specimen.

PURPOSE: The main goal of this study is to assess the diagnostic agreement between preoperative biopsy and definitive histology of the surgical specimen to determine which sampling method is most suitable for diagnosis of early-stage endometrial cancer. METHODS: We performed a retrospective multicentric study to assess the correlation between three endometrial sampling methods (hysteroscopy, pipelle and D&C) in patients who had undergone preoperative endometrial biopsy and received primary surgical treatment for endometrial cancer. The primary objective was the agreement rate between hysteroscopy (HSC), endometrial biopsy (pipelle) and dilatation and curettage (D&C). RESULTS: A total of 1833 women who underwent preoperative sampling at 15 centers were included: 1042 biopsies were performed by HSC, 703 by pipelle and 88 by D&C. All three methods presented a moderate diagnostic concordance (κ = 0.40-0.61) with the definitive specimen's histology: HSC (κ = 0.47), pipelle sampling (κ = 0.48) and D&C (κ = 0.48). Likewise, a subgroup analysis was performed by histological subtype comparing HSC and endometrial biopsy, showing that neither is superior as a diagnostic method. CONCLUSIONS: According to this study, the use of pipelle sampling could become an adequate diagnostic method in endometrial cancer due to its similar agreement to HSC, ease of use and affordability.

Comparison of Depression and Anxiety Scores in Multi/Nulliparous Women who have Undergone Dilatation and Curettage.

AIM: To demonstrate the duration of negative psychological effects of elective curettage on both nulliparous and multiparous women and to determine the association between parity and post-abortion depression and anxiety. MATERIALS AND METHODS: A total of 168 women who applied to our reproductive health clinic for elective abortion were included in this prospective study. 84 nulliparous and 84 multiparous women were asked to fill out Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI-II) forms by a psychiatrist at their pre-abortion consultation and at 3 months follow-up. A thorough anamnesis with demographic data of each patient was recorded at initial consultation. RESULTS: Depression and anxiety measurements in both groups significantly decreased at the end of the 3 months follow-up. The mean depression value in nullipara group decreased from 24.2 ± 5.8 to 9.4 ± 3.3 and anxiety from 23.5 ± 3.7 to 8.8 ± 2.5. In the multipara group, the mean depression score decreased from 15.7 ± 4.0 to 7.3 ± 2.3, and anxiety from 15.9 ± 4.0 to 7.9 ± 2.3. A significant decrease in both depression and anxiety scores could be observed in both groups. CONCLUSION: Although the severity of depression and anxiety varies between multiparous and nulliparous individuals, this study showed that both depression and anxiety scores return to normal values by the end a 3 months follow-up period.

Management of Acquired Uterine Arteriovenous Malformations Associated with Retained Products of Conception.

PURPOSE: To evaluate the efficacy and safety of different treatments for acquired uterine arteriovenous malformations associated with retained products of conception (UAVM-RPOC) and to investigate the role of uterine artery embolization (UAE) in acquired UAVM-RPOC. MATERIALS AND METHODS: This was a retrospective study of consecutive patients who were diagnosed with uterine arteriovenous malformation by ultrasound after recently terminated pregnancy. Forty-eight patients were included in this study and were divided into 2 groups (major and minor bleeding groups) according to vaginal bleeding. The treatments were analyzed between groups. Technical and clinical success rates of UAE were analyzed. RESULTS: Of the 48 patients, 11 patients were in the massive bleeding group and 37 were in the minor bleeding group. Five patients were referred for UAE in each group and UAE was a priority for patients with unstable hemodynamics (chi-square value = 5.524, P =.022). Conservative management, dilation and curettage (D&C), operative hysteroscopy, and UAE were performed in 16 (33%), 18 (38%), 7 (15%), and 13 (27%) patients, respectively. Two patients with ectopic pregnancies suffered uncontrollable bleeding during D&C and required emergent UAE. Three patients underwent UAE before surgery to prevent hemorrhage. The technical and clinical success rates of UAE were 100%. No complications or recurrences occurred. CONCLUSIONS: UAE is a safe and effective treatment for UAVM-RPOC and a priority for patients with unstable hemodynamics. Conservative management, D&C, and hysteroscopy are safe and effective for patients with UAVM-RPOC with stable hemodynamics. However, UAVM-RPOC following ectopic pregnancy may have high risks of massive hemorrhage during procedures.

Comparison of D&C and hysteroscopy after UAE in the treatment of cesarean scar pregnancy: A case-control study.

ABSTRACT: Cesarean scar pregnancy (CSP) stands for the severe complication secondary to cesarean section, and its incidence shows an increasing trend recently. However, no consensus has been reached about the CSP treatment. This study aims to explore the necessity of hysteroscopy (H/S) after preventive uterine artery embolization (UAE).A case-control report. The childbearing CSP patients with a cesarean section history were evaluated by ultrasonography, with a gestational age of less than 10 weeks. Thirty-four patients receiving dilation and curettage (D&C) after UAE were enrolled into the D&C group, whereas 46 undergoing H/S and curettage after UAE were enrolled into the H/S group.Differences in success rate and decrease in the ß-hCG level in serum on the second day of surgery were not significantly different between D&C and H/S groups (P > .05). Also, differences in side effect rate (except for the anesthesia-related side effects), intraoperative blood loss amount, postoperative bleeding time, and total length of hospital stay were not significant between 2 groups (P > .05). Compared with D&C group, H/S group had decreased postoperative length of hospital stay (P < .05), increased hospitalization cost (P < .05), and significantly elevated time of CSP mass disappearance (P < .05). In addition, 8 (18.19%) patients in H/S group developed anesthesia-related side effects.This study reveals no obvious difference between UAE + D&C and UAE + H/S in terms of the clinical efficacy and safety, except for the time of CSP mass disappearance and anesthesia-related side effects. The hospitalization cost is more expensive for UAE + H/S, but the postoperative length of stay is shorter for UAE + H/S. UAE + H/S is associated with the risk of anesthesia-associated side effects.