Postpartum monitoring of retained placenta.Two cases of abnormally adherent placenta.

To save fertility, hysterectomy may be avoided with abnormal placental adherence by leaving the placenta in situ. Several reports support this strategy, but no reports are available on optimal follow-up strategies. We present two women with conservative treatment of placenta accreta and describe the prospective monitoring of the clinical course, placental regression, and recovery of the uterine anatomy using serial sonography, hysteroscopy and magnetic resonance imaging. There was no postpartum hemorrhage. Menstrual cyclicity resumed within 18 weeks. The human chorionic gonadotropin serum levels normalized within 10 weeks, whereas regression of placenta tissue was slow and continued up to nine months after delivery. In both cases placental remnants persisted; in one woman they were removed and uterine anatomy restored. She had a subsequent uneventful pregnancy afterwards. The presented systematic follow-up provides tools to monitor and treat other women in similar ways.

Mifepristone followed by misoprostol compared with placebo followed by misoprostol as medical treatment for early pregnancy loss (the Triple M trial): A double-blind placebo-controlled randomised trial.

BACKGROUND: Worldwide, millions of women seek treatment for early pregnancy loss (EPL) annually. Medical management with misoprostol is widely used, but only effective 60% of the time. Pre-treatment with mifepristone prior to misoprostol might improve the success rate of medical management. METHODS: This was a multi-centre, double-blind, placebo-controlled randomised trial in 17 Dutch hospitals. Women with a non-viable pregnancy between 6 and 14 weeks of gestation were eligible for inclusion after at least one week of expectant management. Participants were randomised (1:1) between oral mifepristone 600 mg or an oral placebo tablet. Participants took 400 µg misoprostol orally, repeated after four hours on day two and, if necessary, day three. Primary outcome was expulsion of gestational sac and endometrial thickness <15 mm after 6-8 weeks. Analyses were done according to intention-to-treat principles. This trial is registered with ClinicalTrials.gov, NCT03212352. FINDINGS: Between June 28th 2018 and January 8th 2020, 175 women were randomised to mifepristone and 176 to placebo, including 344 in the intention-to-treat analysis. In the mifepristone group 136 (79•1%) of 172 participants reached complete evacuation compared to 101 (58•7%) of 172 participants in the placebo group (p<0•0001, RR 1•35, 95% CI 1•16-1•56). Incidence of serious adverse events was significantly lower in the mifepristone group with 24 (14%) patients affected versus 55 (32%) in the placebo group (p = 0•0005) (Table 3). INTERPRETATION: Pre-treatment with mifepristone prior to misoprostol was more effective than misoprostol alone in managing EPL. FUNDING: Healthcare Insurers Innovation Foundation, Radboud University Medical Centre, Canisius Wilhelmina Hospital.

Histopathological characteristics of BRCA1- and BRCA2-associated intraperitoneal cancer: a clinic-based study.

The aim of the research was to assess possible histopathological differences between BRCA1- and BRCA2-associated malignant intraperitoneal (ovarian/fallopian tube/peritoneal) tumors and their sporadic counterparts. Dutch families harboring pathogenic BRCA1 or BRCA2 mutations were selected. Included were patients who had had malignant primary ovarian, fallopian tube or peritoneal tumors. Histopathological data was compared with data obtained from the Dutch cancer registry between 1989 and 1993 (reference group). A total of 63 with primary intraperitoneal malignant tumors were identified in 41 families. Non-epithelial malignant tumors were not observed in the study group versus 6% (n = 404) in the reference group (n = 6789, P = 0.04). These tumors were excluded from further analysis, as were ovarian adenocarcinomas not otherwise specified, since these were detected in 22% of the study group, and in 19% of the reference group (P = 0.76). Serous carcinomas were detected in 94% (47/50) of the women in the study group in contrast to 62% (3145/5088) of the reference group (P < 0.01). In the study group, mucinous and endometrioid ovarian adenocarcinomas and serous ovarian borderline tumors each comprised 2.0% of the tumors. Clear cell ovarian carcinomas were not detected. In contrast, these percentages were 16% (P < 0.01), 10% (P = 0.07), 7% (P = 0.16) and 5% (P = 0.12), respectively, in the reference group. In the study group, 6.0% of the carcinomas arose in the fallopian tube versus 1.9% in the reference group (P = 0.03). Four percent of the study group developed primary serous peritoneal carcinomas, versus six percent in the reference group (P = 0.57). Serous carcinoma is the predominant type of intraperitoneal malignancy occurring in women harboring BRCA1 or BRCA2 mutations. Non-epithelial cancer does not seem to be part of the tumor spectrum of BRCA mutation carriers. This suggests, therefore, that serous tumors may be the only subtype related to a BRCA1 or BRCA2 mutation. Furthermore, fallopian tube carcinoma occurred more often in BRCA mutation carriers than in the reference population.

Sentinel lymph node detection in early stage uterine cervix carcinoma: a systematic review.

OBJECTIVE: The aim of this study was to systematically review the diagnostic performance of Sentinel Node (SN) detection for assessing the nodal status in early stage cervical carcinoma, and to determine which technique (using blue dye, Technetium-99m colloid (99mTc), or the combined method) had the highest success rate in terms of detection rate and sensitivity. METHODS: A comprehensive computer literature search of English language studies in human subjects on Sentinel Node procedures was performed in MEDLINE and EMBASE databases up to July 2006. For each article two reviewers independently performed a methodological qualitative analysis and data extraction using a standard form. Pooled values of the SN detection rate and pooled sensitivity values of the SN procedure are presented with a 95% confidence interval (95% CI) for the three different SN detection techniques. RESULTS: We identified 98 articles, and 23 met the inclusion criteria, comprising a total of 842 patients. Ultimately, 12 studies used the combined technique with a sensitivity of 92% (95% CI: 84-98%). Five studies used 99mTc-colloid, with a pooled sensitivity of 92% (95% CI: 79-98%; p=0.71 vs. combined technique), and four used blue dye with a pooled sensitivity of 81% (67-92%, p=0.17 vs. combined technique). The SN detection rate was highest for the combined technique: 97% (95% CI: 95-98%), vs. 84% for blue dye (95% CI: 79-89%; p<0.0001), and 88% (95% CI: 82-92%, p=0.0018) for 99mTc colloid. CONCLUSION: SN biopsy has the highest SN detection rate when 99mTc is used in combination with blue dye (97%), and a sensitivity of 92%. Hence, according to the present evidence in literature the combination of 99mTc and a blue dye for SN biopsy in patients with early stage cervical cancer is a reliable method to detect lymph node metastases in early stage cervical cancer.