Caesarean scar pregnancy: is there a light in the end of the tunnel?

PURPOSE: To summarize and present a single tertiary center's 25 years of experience managing patients with caesarean scar pregnancies and their long-term reproductive and obstetric outcomes. METHODS: A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians' decisions, patient counseling, and parental requests. RESULTS: Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%). CONCLUSION: CSP treatment focusing on reducing morbidity and preserving fertility has encouraging long-term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

[THE FALL AND RISE OF PROGESTERONE PREPARATIONS IN THE PREVENTION OF PRETERM LABOR].

INTRODUCTION: Preterm labor involves about 7.4% of live births in Israel and constitutes over 85% of morbidity and mortality in newborns. Risk factors for preterm labor include a history of preterm delivery shortening of the uterine cervix, cervical procedures, uterine malformations, polyhydramnios, intrauterine growth restriction, preeclampsia, multiple gestations, and more. Progesterone is an essential hormone in the process of fertilization and is involved in the menstrual cycle, implantation and preservation of pregnancy. Due to its various functions in the prevention of preterm labor, the use of progesterone as a preventive treatment has been extensively studied since the second half of the last century and tested in various forms of administration, mainly intramuscular injection and vaginal root. For years, women with a history of preterm labor were treated with intramuscular progesterone once a week between 16 to 36 weeks' gestation or until birth. Recently, vaginal progesterone treatment was initiated in women with cervical length > 25 mm measured by ultrasound between 18-24 weeks gestation. Studies have shown that progesterone treatment reduces the incidence of preterm labor given in the proper indication. This update overview examines progesterone treatment for the prevention of preterm labor.

Analgesic Efficacy of Intrauterine Lidocaine Flushing in Hysterosalpingo-foam Sonography: A Double-blind Randomized Controlled Trial.

STUDY OBJECTIVE: To evaluate the efficacy of flushing the uterine cavity with lidocaine before hysterosalpingo-foam sonography (HyFoSy) to reduce procedure-related pain. DESIGN: A double-blind randomized controlled trial was conducted at the Department of Obstetrics and Gynecology, Shamir Medical Center, Israel between June 2020 and September 2020 involving 80 women undergoing a HyFoSy procedure. SETTING: University-affiliated medical center. PATIENTS: A total of 40 women were assigned randomly to the lidocaine group and 40 to the saline (placebo) group using a predetermined randomization code. Intrauterine instillation before the procedure consisting of either lidocaine 2% or normal saline alone was conducted, respectively. INTERVENTIONS: The primary outcome measure was the visual analog scale (VAS) pain score during the phase of intrauterine foam instillation reported by the women after the procedure. The VAS consisted of a 10-cm line ranging from 0 to 10 (anchored by 0 = no pain and 10 = very severe pain). On the basis of the VAS scores, the pain level ratings were classified as mild (rated 1-3), moderate (4-6), or severe (7-10). MEASUREMENTS AND MAIN RESULTS: The patient characteristics and obstetric data were found to be similar in both groups. Comparison of the VAS pain scores experienced during the procedure showed that women in the lidocaine flushing group rated the procedure less painful than the women in the saline group (3.0 ± 1.3 vs 6.3 ± 1.5, respectively; p = .001). The incidence of severe pain was significantly lower in the lidocaine group than the saline group (2.5% and 45.0%, respectively, p = .001). CONCLUSION: Lidocaine flushing of the uterine cavity before HyFoSy significantly decreased the pain known to be caused by this procedure and had the advantage of no side effects. It is easily applied, relatively inexpensive, and may affect compliance with this procedure.

Analgesic efficacy of virtual reality for acute pain in amniocentesis: A randomized controlled trial.

BACKGROUND: To evaluate the efficacy of virtual reality (VR) as a distraction technique in the management of acute pain and anxiety during amniocentesis. STUDY DESIGN: A randomized controlled trial was conducted between September 2020 and October 2020 involving 60 women undergoing mid-trimester amniocentesis. Thirty women were assigned randomly to the VR intervention (immersive video content as a distraction method) group and 30 to the standard care group using a predetermined randomization code. The primary outcome measure was the visual analog scale (VAS) pain score, along with the women's ratings of their extent of anxiety experienced during the procedure. The VAS consisted of a 10 cm line ranging from 0 to 10 (anchored by 0 = no pain and 10=very severe pain). Anxiety was assessed on Spielberger's state-trait anxiety inventory (STAI) questionnaire. RESULTS: The patients' characteristics and obstetric data were similar in both groups. The ratings on the VAS indicated that the VR intervention was associated with significantly less pain than the ratings in the standard of care group; namely, 2.5 ± 1.5 vs. 3.8 ± 1.7, respectively (95 % CI 0.44-2.13; p = 0.003). There were no significant differences in maternal anxiety levels before and after amniocentesis. CONCLUSION: The VR intervention as a distractive technique emerged as effective in reducing pain during amniocentesis. It is easy to use, relatively inexpensive, has the advantage of no serious side effects, and may decrease the fear of pain that can affect patients' experiences and compliance with this procedure.