Comparison of Pipelle sampler with conventional dilatation and curettage (D&C) for Chinese endometrial biopsy.

The aim of this study is to investigate the accuracy and adequacy of the Pipelle endometrial sampler for endometrial biopsy as compared with those of conventional dilatation and curettage (D&C). A total of 245 patients subject to endometrial biopsy were included in this study. We have shown that the failure rates with D&C and Pipelle were 7.75% and 8.98%, respectively, without statistical difference. Additionally, the obtained specimen quality and accurate diagnosis of various diseases using the two methods had no significant statistical differences. Furthermore, patients experienced less pain when Pipelle sampler was used than D&C. Therefore, Pipelle sampler is effective in obtaining adequate endometrial tissue for histodiagnosis, and is applicable in most of the cases for Chinese endometrial biopsy.

Use of a hysteroscopic morcellator to resect miscarriage in a woman with recurrent Asherman's syndrome.

Uterine curettage may result in formation of intrauterine adhesions, which can predispose to recurrent miscarriage [1]. Herein is presented a video case report of a 24-year-old woman with recurrent miscarriages and recurrent intrauterine adhesions after treatment of non-progressive pregnancies. Targeted intrauterine pregnancy tissue removal using a hysteroscopic morcellator was performed to reduce the risk of adhesion recurrence. Successful removal of products of conception, without subsequent adhesion formation, and an ongoing viable pregnancy followed. Selective targeted removal of products of conception may offer some advantage to women with a predisposition to recurrent Asherman's syndrome.

Comparison of endometrial aspiration biopsy techniques: specimen adequacy.

OBJECTIVE: To compare adequacy of specimens obtained by 3 different endometrial aspiration biopsy techniques--corkscrew, modified dilatation and curettage (D&C) and a combination of both, with or without povidone-iodine cervical cleansing. STUDY DESIGN: A retrospective chart review of a single group practice using a single endometrial aspiration biopsy device for all 3 techniques. Each attending indicated their method of use with the device. For diagnostic purposes, specimen adequacy was categorized as "satisfactory," "suboptimal" and "insufficient." RESULTS: There were 66 corkscrew, 71 modified D&C and 55 biopsies performed using the combined technique. Mean age was 48; 62.5% were premenopausal and 89% had a normal-sized uterus. Postmenopausal patients were more likely than younger women to have suboptimal or insufficient samples, 27% vs. 11%, respectively. Using the combined technique was better (95%) than the corkscrew alone (77%) for satisfactory specimens. Diagnosis was possible in 90% of specimens. CONCLUSION: The combined technique appears to be better than using either technique alone. Povidone-iodine cervical cleansing is safe but may be unnecessary. Because of the large numbers of endometrial biopsies performed yearly, even a small difference in test characteristics can have significant clinical ramifications.

Use of an endotracheal tube for surgical abortion complicated by a leiomyomatous uterus: a case report.

BACKGROUND: Abnormal uterine anatomy, especially leiomyomas, can significantly impact the difficulty and potential morbidity of surgical uterine evacuation. To avoid hysterotomy and/or hysterectomy, limited evidence exists to guide surgical uterine evacuation when pregnancy tissue is inaccessible with routine instruments. CASE PRESENTATION: A 41-year-old G4P1021 African American woman at 14 4/7 weeks' gestation was referred for surgical-induced abortion in the setting of an enlarged leiomyomatous uterus. Two large opposing leiomyomas at the internal cervical os rendered pregnancy tissue inaccessible with routine gynecologic surgical instruments. With ultrasound guidance, an endotracheal tube was connected to routine electric suction and utilized to complete uterine evacuation. CONCLUSIONS: With distorted or markedly enlarged uterine anatomy rendering pregnancy tissue inaccessible with routine surgical instruments, the minimally invasive use of an endotracheal tube may aid completion of uterine evacuation for surgical uterine evacuation.

Using Three-Dimensional Printing to Fabricate a Tubing Connector for Dilation and Evacuation.

BACKGROUND: This is a proof-of-concept study to show that simple instrumentation problems encountered in surgery can be solved by fabricating devices using a three-dimensional printer. The device used in the study is a simple tubing connector fashioned to connect two segments of suction tubing used in a surgical procedure where no commercially available product for this use is available through our usual suppliers in New Zealand. MATERIALS AND METHODS: A cylindrical tubing connector was designed using three-dimensional printing design software. The tubing connector was fabricated using the Makerbot Replicator 2X three-dimensional printer. The connector was used in 15 second-trimester dilation and evacuation procedures. Data forms were completed by the primary operating surgeon. Descriptive statistics were used with the expectation that the device would function as intended in all cases. EXPERIENCE: The three-dimensional printed tubing connector functioned as intended in all 15 instances. CONCLUSION: Commercially available three-dimensional printing technology can be used to overcome simple instrumentation problems encountered during gynecologic surgical procedures.

Endometrial sampling devices for early diagnosis of endometrial lesions.

PURPOSE: Endometrial carcinoma is the most common gynecologic malignancy in both developed and some developing countries. Unlike cervical cancer, for which there is routine screening, only patients symptomatic for endometrial carcinoma typically seek medical help for its diagnosis and treatment. Dilatation and curettage (D&C) has been the standard procedure for evaluating suspicious endometrial lesions. The discomfort and injury caused by the D&C procedure, however, restrict its use as a screening method for early diagnosis of endometrial lesions. High-risk endometrial cancer patients would benefit from an effective and low-cost screening test. In recent years, several endometrial devices have been developed and proposed as screening tools. METHODS: We have reviewed and evaluated the literature relating to the endometrial sampling devices in clinical use or clinical trials, with the goal of comparing devices and identifying the most appropriate ones for screening for endometrial lesions. Eligible literature was identified from systematic PubMed searches, and the relevant data were extracted. Comments, letters, unpublished data, conference proceedings, and case reports were excluded from our search. Seventy-four articles on endometrial sampling devices were obtained for this review. RESULTS: The main screening devices for endometrial carcinoma are aspiration devices (such as the Vabra aspirator), Pipelle, Tao Brush, and SAP-1 device. Among these devices, the Tao Brush is the most promising endometrial sampler for screening for endometrial lesions. However, its sampling insufficiency, cost, and unsuccessful insertion rate (20 % in nulliparous and 8 % in parous women) are problematic. CONCLUSIONS: A more accurate and low-cost endometrial sampler, with improved specimen sufficiency and higher sensitivity for endometrial lesions, needs tobe developed and clinically verified.

Analysis of cervical resistance during continuous controllable balloon dilatation: controlled clinical and experimental study.

BACKGROUND: Hydraulic dilatation is a novel method of cervical dilatation that is based on continuous controllable dilatation (CCBD) by the pumping of fluid into the balloon extension of the system. The main advantage of this procedure is that it allows control of and insight into the process of cervical dilatation. METHODS: For the purposes of our research, we created a new and upgraded system for CCBD which consists of a programmed hydrostatic pump connected to a balloon extension. With regard to our aim to precisely measure and determine the location of the cervical resistance, we placed two pressure-measuring films, one on the top and one on the bottom of the balloon extension. This study included 42 patients in whom cervical resistance was measured before suction curettage. RESULTS: Cervical dilatation and measurement of cervical resistance were successful in all patients. The analysis of the pressure-measuring films showed that the points of highest resistance were located in the zone of the internal cervical os and that these values were much higher than those in the zone of the external cervical os (0.402 versus 0.264 MPa at the upper pressure-sensitive film; 0.387 versus 0.243 MPa at the lower pressure-sensitive film). This study also showed that an increase in cervical resistance in the zone of the internal cervical os was followed by an increase in cervical resistance in the zone of the external cervical os. CONCLUSIONS: During CCBD, the internal cervical os is the centre of cervical resistance, and the values do not decline with the number of miscarriages or the number of previous births. TRIAL REGISTRATION NUMBER: ISRCTN Registry identifier: ISRCTN30949871 . Date of registration: 13 May 2015.

Cervical Preparation Before Dilation and Evacuation Using Adjunctive Misoprostol or Mifepristone Compared With Overnight Osmotic Dilators Alone: A Randomized Controlled Trial.

OBJECTIVE: To evaluate operative time after adjunctive misoprostol or mifepristone compared with overnight osmotic dilators alone for cervical preparation before dilation and evacuation at 16-23 6/7 weeks of gestation. METHODS: This double-blind, three-arm, multicenter, randomized trial compared overnight osmotic dilators alone, dilators plus 400 micrograms buccal misoprostol 3 hours preoperatively, and dilators plus 200 mg oral mifepristone during dilator placement for dilation and evacuation. Our primary outcome was dilation and evacuation operative time within two cohorts: 16-18 6/7 weeks of gestation (N=150) and 19-23 6/7 weeks of gestation (N=150). Three hundred women were required for 80% power to detect a 2-minute difference in operative time. Secondary outcomes included initial cervical dilation, side effects, physician satisfaction by Likert scale, and complications. RESULTS: Between February 2013 and February 2014 we randomized 300 women evenly across treatment arms. Group demographics were similar. We found no difference in operative time in either gestational cohort (early cohort [minutes]: 5.11±3.0 dilators alone, 4.99±3.3 misoprostol, 4.33±2.0 mifepristone, P=.34; late cohort [minutes]: 7.50±3.7 dilators alone, 7.62±5.4 misoprostol, 6.74±3.2 mifepristone, P=.53). In the early cohort, initial dilation was greater with misoprostol than dilators alone (2.4 compared with 2.0 cm, P=.007). Patients given misoprostol had significantly more pain, fever, and chills. In the late cohort, dilation and evacuation procedures were less difficult after mifepristone (4.1%, 95% confidence interval [CI] 0.0-9.6) than misoprostol (18.8%, 95% CI 7.7-29.8) or dilators alone (18.8%, 95% CI 7.7-29.8; P=.04). We had inadequate power to infer differences in complications: dilators alone (10%, 95% CI 4.2-16.0) compared with misoprostol (2%, 95% CI 0-4.7) compared with mifepristone (2%, 95% CI 0-4.8). CONCLUSION: Despite no difference in operative time, adjunctive mifepristone facilitates later dilation and evacuation compared with osmotic dilators alone and is better tolerated than misoprostol. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01751087. LEVEL OF EVIDENCE: I.

Transcervical uterine cultures with a new endometrial suction curette: a comparison of three sampling methods in postpartum endometritis.

The potential for cervicovaginal contamination has precluded direct sampling of the endometrial cavity and has led to the development of multi-lumen protected catheter systems, among other techniques. The extent of this presumed contamination was examined using three different techniques in 55 postpartum women with the diagnosis of endometritis. Each woman had the endometrium sampled with an unprotected cotton-tipped swab, a double-lumen catheter with brush, and a flexible endometrial suction curette. A statistically larger number of bacterial species was recovered with the cotton swab (2.4) than with the double-lumen catheter (1.3) or the suction curette (1.7) (P less than .001). A difference was also noted between the double-lumen catheter and the suction curette (P = .006); however, this represented less than one-third of a single bacterial species. The larger number of bacterial species recovered by the unprotected methods was found to result not from cervicovaginal contamination, as suspected, but from a significant increase in the recovery of bacteria commonly regarded as potential pathogens, such as Bacteroides bivius, Streptococcus faecalis, Proteus mirabilis, and Bacteroides melaninogenicus.

A randomized trial of the sleeved cytobrush and the endocervical curette.

OBJECTIVE: To compare endocervical specimens obtained with the endocervical curette to those obtained with the sleeved cytobrush. METHODS: All nonpregnant women undergoing either cervical conization or hysterectomy were eligible for this randomized, split-sample trial. Both endocervical curette and cytobrush sampling were performed on all 62 participants before surgery, with randomization designating the order of the sampling procedures. A pathologist blinded to sampling order reviewed study specimens. The endocervical canals of the surgical specimens were evaluated against endocervical curette and brush samples. Odds ratios (ORs), relative risks (RRs), and risk differences were used to compare the sensitivity and specificity of each procedure in unmatched and matched analyses. RESULTS: There was a significantly higher rate of inadequate specimens in the endocervical curette group (22% versus 2% in the brush group; 95% confidence interval [CI] for the difference: 9%, 31%). Unmatched analysis showed the two tests to be comparable in terms of sensitivity and specificity. Whereas the specificities of both tests were high (100% for the endocervical curette, 88% for the brush; RR 1.13, 95% CI 1.00, 1.28), the sensitivities were poor (44% for the sleeved brush and 32% for the endocervical curette; RR 1.38, 95% CI 0.65, 2.94). Matched analysis showed the sleeved endocervical brush to be a more sensitive sampling method compared with the curette (OR 2.04, 95% CI 0.98, 4.22). Sparse data prevented a matched analysis on the specificity of the two tests. CONCLUSION: Endocervical sampling with the sleeved cytobrush achieves similar sensitivity and specificity to that of traditional endocervical curettage. Given the much greater rate of inadequate specimens when using the endocervical curette, the sleeved cytobrush is a reasonable alternative to this technique.

Prolonged retention of laminaria fragments: an unusual complication of laminaria usage.

A single laminaria japonica was placed the day before an abortion requested by a 32-year-old nulliparous woman. On the day of the procedure, the laminaria was found to be tightly wedged in the cervix, and attempts at removal resulted in pushing the laminaria into the uterine cavity. The abortion was completed, and 3 days later, after placement of additional osmotic dilators, the intrauterine laminaria was crushed and removed. Fifteen months later, a small fragment of laminaria passed spontaneously. Hysteroscopy was performed, and approximately 30 fragments of laminaria were removed.

Abnormal uterine bleeding.

Physicians who care for female patients cannot avoid the frequent complaint of abnormal uterine bleeding. Knowledge of the disorders that cause this problem can prevent serious consequences in many patients and improve the quality of life for many others. The availability of noninvasive and minimally invasive diagnostic studies and minimally invasive surgical treatment has revolutionized management of abnormal uterine bleeding. Similar to any other disorder, the extent to which a physician manages abnormal uterine bleeding depends on his or her own level of comfort. When limitations of either diagnostic or therapeutic capability are encountered, consultation and referral should be used to the best interest of patients.

A new method for diagnostic curettage.

A new device ('Abradul') for policlinical curettage was tested for reliability. The histology of the curettage obtained prior to hysterectomy was compared blindly to that of the surgical specimens in 61 patients. As a correlation of almost 100% was found, the results for this convenient and economical outpatient procedure are very promising. Routine screening for the patient at risk is now within reach.

First trimester abortion by vacuum aspiration: interphysician variability.

This study compares the performances of four physicians using two types of plastic cannulae (flexible and rigid) for 1100 vacuum aspiration procedures. The criteria for assessing physician performance by cannula type were: (a) frequency of cannula obstructions, (b) amount of retained tissue obtained by sharp curettage after vacuum aspiration, (c) estimated blood loss during the procedure and (d) time required to perform the procedure. Data for each physician were compared and yielded significantly different results. The length of time required to use the cannula differed significantly among physicians; two of them had significantly shorter cannula times with the flexible instrument. The others had the lowest distributions of blood loss and the most difference between cannula usage. Consistent grouping over several variables suggests that differences in these criteria are more likely to be attributable to subtle distinctions in operator technique than to variations in equipment.

A comparison of metal and plastic cannulae for performing vacuum.

A comparative study was conducted to evaluate the efficacy of a metal or flexible plastic 8 mm cannula for artificial abortion by vacuum aspiration for patients at six to 10 weeks' gestation. Complication rates, amounts of retained tissue (obtained with a curette check), frequencies of cannula obstructions and procedure times were used as criteria for determining the efficacy of the two types of cannulae. Two physicians participated in the study: one was responsible for the preliminary examination and performance of the abortion, and the other physician, who was kept unaware of the type of cannula used, was responsible for patient care after completions of the abortion to the time of the follow-up visit. Paracervical block anesthesia was used in all cases. Differences in complication rates (controlled for gestational age) between groups of subjects aborted with either the metal or flexible plastic cannula were not significantly different (p less than .05). For both patient groups shock was the most frequently reported immediate complication (2.7% in the metal cannula group, 4,7% in the flexible plastic cannula group), and leukorrhea was the most frequently reported complication at the time of follow-up (3.3% metal, 5.3% flexible plastic). Amounts of retained tissue and frequency of cannulae obstruction were similar for both groups. Procedure times were also similar for both groups (means of 5.7 minutes and 5.5 minutes, respectively, for procedures performed with the metal and flexible plastic cannulae).

Accuracy of endometrial biopsy with the Cornier pipelle for diagnosis of endometrial cancer and atypical hyperplasia.

OBJECTIVE: To establish the accuracy of endometrial biopsy with the Cornier pipelle in the diagnosis of endometrial cancer and atypical endometrial hyperplasia in our milieu. MATERIAL AND METHOD: We reviewed 1,535 anatomopathologic reports on endometrial biopsies taken from outpatients using the Cornier pipelle between 1997 and 2000, in pre- and postmenopausal patients with abnormal vaginal bleeding. In 168 patients (10.9%), curettage and/or hysterectomy was subsequently carried out. In these cases, the anatomopathologic reports were compared to determine sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratio (LR). RESULTS: Sensitivity was 84.2%, specificity was 99.1%, accuracy was 96.9%, PPV was 94.1%, NPV was 93.7% and LR was 93.5. In 249 cases (16.09%) the material was insufficient for study. CONCLUSION: We determined that endometrial biopsy taken with the Cornier pipelle is, as we practice it, an accurate method for diagnosis of endometrial cancer and its precursor, atypical hyperplasia.

Transcervical endometrial resection when hysterectomy is dangerous.

Severe blood loss from dysfunctional uterine bleeding may be refractory to medical therapy and hysterectomy the only option. In two young women with severe bleeding where medical measures were ineffective and hysterectomy was a hazardous option, we performed a transcervical endometrial resection. In both of them the bleeding stopped immediately and no further treatment was required for dysfunctional uterine bleeding. They have had amenorrhea now for over six months. Transcervical endometrial resection is an option when hysterectomy is hazardous and the bleeding is refractory to medical treatment.

[Fractionated suction curettage with the Vabra-duplex disposable set and the reciprotor-VAB-1 vacuum pump (author's transl)]. / Die fraktionierte Saugkürettage mit dem Vabra-Duplex-Einmalgerät und der Reciprotor-VAB-1-Vakuumpumpe.

Diagnostic suction curettage was carried out in 82 women with genital bleeding, in 32 cases without anaesthesia and in 50 cases under general anaesthesia. The accuracy of the findings was checked by conventional curettage or hysterectomy in 75 cases. Dilatation of the endocervix was unnecessary in 81 women. Exact fractionation of the material obtained from the cervix and the body of the uterus was always possible, whereby the separation was just as good as with conventional curettage. The obtained aspirate enabled a histological diagnosis to be made in 80 cases. It was possible to prepare a cytological smear in 2 cases. The tolerance of patients to vacuum curettage carried out without anaesthesia was reasonably good. With Vabra-Duplex disposable set the physician has a device at his disposal which is particularly suitable for women still wishing to have a child and for patients in whom anaesthesia constitutes a risk factor. It appears to be suited for performance as an ambulant procedure.

Outpatient diagnostic suction curettage: a personal series.

PIP: The experience of a gynecologist in the use of the Vabra aspirator for determining endometrial status in New Zealand women with menstrual disturbances is reported. Over a 3-1/2 year period, 201 patients were referred to their general practitioners because of abnormal vaginal bleeding. Of the 196 patients who consented to Vabra curettage the preliminary vaginal examination was not possible in 2 patients and it was not possible to pass the sound or aspirator beyond the internal os in 6 patients. Outpatient curettage was performed on the remaining 188 patients. The age range was 22-77 years. The most common indications were heavy, frequent or irregular periods or post-menopausal bleeding. Intermenstrual or post-coital bleeding were less common indications for determining endometrial status. Specimens suitable for a histological diagnosis were obtained from all but 9 women. 8 of these 9 women presented with post-menopausal bleeding. Most patients were able to resume normal activities immediately, and none needed to rest for longer than 5 minutes after the procedure. There were no known cases of syncope, perforation, hemorrhage, or infection. 154 patients rated their discomfort during the procedure as minimal or nil; 28 complained of moderate discomfort and 6 of severe discomfort. Patient discomfort was reported to be less as experience was gained by the operator. Bleeding after the procedure was limited to transient spotting in all but 2 cases.^ieng

The unripe cervix and its management for labour induction.

Cervical state plays an important part in the outcome of induced labour. The mechanism governing the process of ripening, which is part of the continuum ending in labour, is still not fully understood, but is thought to involve several hormonal interactions including oestrogens, progesterone, and prostaglandins. The prostaglandins have been found to produce the best results for inducing labour when the cervix is unripe and are most effective when administered locally and most convenient when placed in the vagina as a viscous gel, wax pessary or slow release pessary. They are of benefit for labour induction in cases previously delivered by lower segment caesarean section, breech presentation, and multiple pregnancies. Hyperstimulation and fetal distress may occur and this might be reduced with the use of the controlled release hydrogel pessary. Newer approaches using an antiprogestin or recombinant relaxin are being explored in the hope that further improvements in outcome can be obtained.