Search

Aim To compare patient characteristics, imaging and surgical management of mature cystic teratomas (MCTs) according to surgery type - elective versus emergent. Methods The study included surgeries performed between 1990 and 2016, during which histologically verified ovarian MCT material was obtained. The elective management group included surgeries performed at a pre-set date or incidental finding of MCT as part of a different surgery. Emergent surgeries were considered as such if performed as a result of suspected adnexal torsion. Results One hundred ninety two operations in which MCT was confirmed by histology were included: 136 elective, 56 emergent. The majority (88.5%) of study patients were of reproductive age. Patients in the emergent surgery group were significantly younger (27.5 ± 10.2 vs 36 ± 13.8 years, P < 0.001). Sensitivity for dermoid diagnosis was significantly increased among elective surgery patients (65.2% vs. 47.1%, P = 0.02). Laparoscopy was the preferred surgical mode in both study groups. Adnexal torsion was confirmed in 67.8% of emergent surgeries. Conservative surgery, including cystectomy with or without detorsion, was more commonly performed in emergent surgeries (91% vs. 72.7%, P = 0.006). Bilateral salpingo-oophorectomy with or without total abdominal hysterectomy was more commonly performed in elective surgery patients (22% vs. 3.5%, P = 0.001). Patient parity, mass size and white blood cell count were independently associated with adnexal torsion. Conclusions Adnexal torsion is common among symptomatic patients with MCT and is related to mass size, patient age, past parity and white blood cell count. Most patients with MCT are of reproductive age and thus are treated with a minimally invasive approach. [ABSTRACT FROM AUTHOR]

Objective To compare the efficacy and tolerability of vaginal misoprostol and laminaria for cervical preparation before second-trimester surgical abortion. Study design We performed a prospective, randomized trial comparing midnight administration of misoprostol 600 mcg vaginally to midnight placement of laminaria, before surgical abortions among women at 13–20 weeks of gestation. The primary outcome was preoperative cervical dilation. Secondary outcomes were the need for further dilation, procedure duration and difficulty, immediate complications and side effects. Results Eighty-four women were randomized, with a median gestational age of 16.5 weeks. The mean time interval between misoprostol and laminaria placement and dilatation and evacuation initiation was 11.0±2.9 and 11.2±2.0 h, respectively (p=.17). Cervical dilation was not greater in the laminaria group as compared to the misoprostol group (12.8 vs. 12.4 mm, respectively; p=.32). No difference was demonstrated regarding the need for additional dilation or the difficulty of the procedure. Procedures performed after laminaria insertion were 1 min longer (median 11 vs. 10 min, p=.04). Participants found laminaria placement more uncomfortable than vaginal misoprostol placement. Other than pain, additional side effects occurred only in the misoprostol group, primarily nausea and vomiting. One participant in the misoprostol group experienced fetal expulsion during the night before the intended procedure. Conclusion Either vaginal misoprostol or laminaria provides adequate dilation for second-trimester surgical abortion. Laminaria causes more pain at insertion and misoprostol causes more side effects. Implications statement We found that cervical preparation in an inpatient setting for approximately 11 h with misoprostol 600 mcg vaginally is comparable to 11 h of laminaria. However, given the potential for spontaneous expulsion and more side effects with misoprostol, laminaria is likely a better general option in such a setting. [ABSTRACT FROM AUTHOR]

We report on management and subsequent fertility outcome of interstitial pregnancy in a retrospective cohort study (Canadian Task Force classification II-3) at a university affiliated teaching hospital. Of 706 women with extrauterine pregnancy, 14 consecutive women with interstitial pregnancy were treated by methotrexate, laparotomy or laparoscopy between 1997 and 2007. The first four women, with significant hemoperitoneum, were treated by laparotomy. Of the next 10 women, four were selected for medical treatment with methotrexate. Only one case was treated successfully. The other six women had laparoscopic treatment. Of nine laparoscopies, one was converted to laparotomy due to excessive blood loss during the procedure. Of nine women desiring a child, three were infertile, whereas six conceived with an intrauterine pregnancy. A change from diagnosis later in pregnancy and laparotomy to more conservative treatment, mainly by laparoscopy, suggests a possibly better subsequent pregnancy rate. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the efficacy of methotrexate treatment for extrauterine pregnancy and define criteria for prediction of success. Methods: Of 829 patients with an ectopic pregnancy admitted to E. Wolfson Medical Center, Holon, Israel, from January 1997 through December 2009, 238 had asymptomatic tubal pregnancies and increasing serum β-human chorionic gonadotropin (βhCG) levels. These patients were treated with a single intramuscular injection of 50mg of methotrexate (MTX) per square meter of body surface. Success was defined as undetectable βhCG levels without the need for a surgical intervention. Results: The groups of patients successfully treated (n=167 [70%]) and unsuccessfully treated (n=71 [30%]) were compared. They were similar regarding age and gravidity. The initial serum βhCG level was significantly higher in the latter group than in the former (3798mIU/mL vs. 1601mIU/mL, P <0.01). The success rate was 88% when initial βhCG levels were less than 1000mIU/mL, 71% when they were between 1000 and 2000mIU/mL, and only 59% when they were between 2000 and 3000 mIU/mL. Conclusion: Methotrexate treatment is a safe and effective alternative to surgery. However, patients with initial βhCG levels higher than 2000mIU/mL should only be offered the surgical approach. [Copyright &y& Elsevier]

The article compares a “no touch” approach to diagnostic hysteroscopy without anesthesia with traditional diagnostic hysteroscopy after intracervical injection of mepivacaine hydrochloride 3 percent. Less pain was reported by patients under the altered approach to diagnostic hysteroscopy. The complete elimination of any type of premedication, analgesia or anesthesia has been permitted by the technique. The use of vaginoscopy over the traditional method is supported by the findings.

OBJECTIVE: To assess the feasibility and outcome of laparoscopic surgery for the management of extremely large ovarian cysts. METHODS: From July 2000 to December 2003, 21 patients with extremely large ovarian cysts were managed laparoscopically. The masses were cystic or complex, reached the umbilicus or higher, and were not associated with ascites or enlarged pelvic or para-aortic lymph nodes on computed tomography scan. Serum CA 125 levels were within the normal range or mildly elevated (« 130 mIU/mL). The mean and median ages of the patients were 45 ± 20 and 46 years, respectively (range 17–89 years). Seven women were postmenopausal and the rest were premenopausal. The patients underwent cystectomy or adnexectomy depending on each patient's age and obstetric history. RESULTS: Two laparoscopies were converted to laparotomy, one because of ovarian malignancy and the second because of technical difficulties related to morbid obesity and severe intra-abdominal adhesions. The postoperative recovery was uneventful in all women. CONCLUSION: With proper patient selection, the size of an ovarian cyst is not necessarily a contraindication for laparoscopic surgery. [ABSTRACT FROM AUTHOR]

Endometrial destruction is an accepted conservative surgical approach for women with dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. The possibility exists that endometrial carcinoma may develop even years after such procedure.We report on a case of endometrial carcinoma, which was diagnosed 3 years after hysteroscopic resection of the endometrium for dysfunctional uterine bleeding in a patient with no risk factors.Endometrial carcinoma after hysteroscopic endometrial ablation is still a possibility even when strict selection criteria are applied. [ABSTRACT FROM AUTHOR]

BACKGROUND: Endometrial destruction is an accepted conservative surgical approach for women with dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. The possibility exists that endometrial carcinoma may develop even years after such procedure. CASE: We report on a case of endometrial carcinoma, which was diagnosed 3 years after hysteroscopic resection of the endometrium for dysfunctional uterine bleeding in a patient with no risk factors. CONCLUSION: Endometrial carcinoma after hysteroscopic endometrial ablation is still a possibility even when strict selection criteria are applied. [ABSTRACT FROM AUTHOR]

Background: Misoprostol is a well-studied medical treatment for early pregnancy loss (EPL), with success rates ranging between 70 and 90%. However, treatment failure is associated with major patient discomfort, including the need for surgical intervention to evacuate the uterus. It was previously reported that medical treatment was especially successful among women who conceived after in vitro fertilization (IVF). We aimed to study if there is a difference in rates of medical treatment failures for EPL between pregnancies conceived by IVF and spontaneous pregnancies. Methods: In this retrospective cohort study, we included all women who underwent medical treatment for EPL at our institute between 07/2015 and 12/2020. Treatment outcome was compared between IVF and spontaneous pregnancies. Treatment failure was defined as a need for surgical intervention, namely, dilation & curettage (D&C) and/or hysteroscopy, due to retained products of conception, which was defined as a gestational sac or endometrial thickness greater than 15 mm in a TVS scan. Results: Overall, 775 patients were included, of which 195 (169/775 = 25.1%) ultimately required surgical intervention. There was no difference between the study groups in the rate of treatment failure. However, among IVF pregnancies, the rate of emergency D&C was lower (3.6% vs. 9.8%, p = 0.001), compared to spontaneous group. Conclusion: In cases of medical treatment for EPL, IVF pregnancies had no differences in rates of treatment failure compared to spontaneous pregnancies. That being said, IVF pregnancies have lower chances to undergo emergency D&C, compared to spontaneous pregnancies. [ABSTRACT FROM AUTHOR]

Objective: To study whether the interval between gestational age calculated using the last menstrual period (GA-LMP) and gestational age calculated via ultrasound (GA-US) is correlated with the success rate of medical treatment in cases of miscarriages. Methods: This was a retrospective cohort study conducted in a gynecology unit in a tertiary medical center. Women who underwent medical treatment with Misoprostol for miscarriage at the Edith Wolfson Medical Center between 07/2015 and 12/2020 were included. Incomplete or septic miscarriages, multiple pregnancies, patients with irregular periods, and cases of missing data were excluded. Failure of medical treatment was defined as the need for surgical intervention due to a retained gestational sac, severe bleeding or retained products of conception. The cohort study was divided into two groups: patients with successful treatment and patients for whom surgical intervention was eventually needed. We performed both a univariate and multivariate analysis in order to identify whether a correlation between GA-LMP and GA-US interval is indeed a factor in the success rate of a medical abortion. Results: Overall, 778 patients were included in the study. From this cohort 582 (74.9%) had undergone a successful medical treatment, while 196 (25.1%) required surgical intervention due to the failure of medical treatment, as defined above. The GA-LMP to GA-US interval (in weeks) was 2.6 ± 1.4 in the success group, while the GA in the failure group was 3.1 ± 1.6 (p < 0.001). After performing a multivariant regression analysis, we were able to show that the GA-LMP to GA-US interval was found to be independently correlated with an increase in the treatment failure rate (aOR = 1.24, CI 95% (1.01–1.51), p = 0.03). Conclusions: In cases of miscarriage, longer GA-LMP to GA-US interval has been shown to be an independently correlated factor to lower success rate of the medical treatment option. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to compare the efficacy of labor induction by Foley catheter balloon (FCB) insertion to intravaginal dinoprostone tablet placement in women with an unfavorable cervix.Materials and Methods: A prospective randomized controlled trial was conducted. Women were assigned to insertion of a FCB or placement of a vaginal dinoprostone tablets and their outcome were compared.Results: The study comprised 300 women. The time to active labor was significantly shorter in the FCB compared with the dinoprostone group, but required more oxytocin administration. A lower rate of cesarean section was found only in nulliparous women in the FCB group. The neonatal outcome was favorable and similar in both groups.Conclusion: Both methods had similar results regarding achieving vaginal delivery within 24 h and cesarean section rate. For nulliparous women, the FCB induction method had the advantage of a shorter time to active labor and a lower rate of cesarean section. [ABSTRACT FROM AUTHOR]

Graphical abstract Highlights • In healthy women, ENaC is localized in the apical membrane of the uterine epithelia. • A patient with pseudohypoaldosteronism could not conceive despite repeated IVF treatments. • In her endometrial Pipelle biopsy samples, ENaC could hardly be detected on the apical membrane. • These findings support the hypothesis that ENaC expression in the endometrium is crucial for implantation. Abstract Pseudohypoaldosteronism type 1 (PHA) is a syndrome of unresponsiveness to aldosterone. The severe form of this disease results from mutations in the genes that encode for the epithelial sodium channel subunits, SCNN1A, SCNN1B, and SCNN1G. A PHA patient under our care failed to conceive after many years and IVF trials. Our earlier studies had shown that ENaC is expressed in the female reproductive tract. We hypothesized that a defective ENaC expression may be responsible for the infertility of the patient. To test this hypothesis we examined ENaC expression in endometrial Pipelle biopsy samples from three healthy women and the PHA patient with an Arg508X mutation in the SCNN1A gene. The formalin fixed samples were reacted with anti-ENaCA (alpha subunit) antisera, followed by secondary antibodies to visualize ENaC expression by immunofluorescence. Confocal microscopy imaging of the samples showed strong ENaC immunofluorescence along the luminal border (apical membrane) of the epithelial cells in Pipelle samples from healthy women. In contrast, none of the samples from the PHA patient showed ENaC immunofluorescence. The Arg508X mutation interrupts the transport of ENaC subunits to the cell surface, yet it would not be expected to disrupt ENaC localization in the cytoplasm. In contrast to endometrium where ENaC is localized in the apical membrane of the epithelial cells, in keratinocytes ENaC is expressed in cytoplasmic pools. Therefore, we examined ENaC immunofluorescence in plucked hair follicles. As expected, ENaC immunofluorescence was detected in the cytoplasm of keratinocytes of both normal and PHA samples. Our results support the hypothesis that lack of expression of ENaC on the endometrial surface may be responsible for the infertility of the PHA patient. [ABSTRACT FROM AUTHOR]

Objective: To study the rate of surgical intervention for unsuccessful medical treatment in early pregnancy loss (EPL), according to gestational size by ultrasound (GS‐US). Methods: This was a retrospective cohort study. All women who were treated with misoprostol for EPL between July 2015 and December 2020 were included. The cohort was divided according to GS‐US: group 1: gestational sac without an embryonic pole; group 2: an embryonic pole with crown‐rump length (CRL) compatible with <7 weeks; group 3: CRL compatible with 7+0–7+6 weeks; group 4: CRL compatible with 8+0–8+6 weeks; group 5: CRL compatible with ≥9 weeks. We compared the rate of any surgical intervention due to treatment failure. Results: Overall, 783 patients were included: group 1, 236 (30.1%); group 2, 319 (40.7%); group 3, 115 (14.7%); group 4, 78 (10.0%); and group 5, 35 (5.0%) patients. The rate of any surgical intervention was significantly lower in groups 1–4 (54, 22.9%; 85, 26.6%; 28, 24.3%; and 22, 28.2%, respectively) compared with group 5 (17, 48.6%; P = 0.030). On multivariant analysis, GS‐US greater than 9 weeks was independently associated with the need for surgical intervention (adjusted odds ratio 1.23, 95% confidence interval 1.01–1.51; P = 0.040). Conclusion: When treating EPL medically, GS‐US greater than 9 weeks increases the risk of undergoing additional surgical intervention compared with younger weeks. Synopsis: When treating missed abortions medically, gestational size of 9 weeks or more increases the risk of undergoing additional surgical intervention compared with younger weeks. [ABSTRACT FROM AUTHOR]

Objective: We aimed to study the effect of preemptive local anesthetic without adrenaline on postoperative pain following vaginal hysterectomy and concomitant trans obturator tape (TOT).Study Design: This was a double-blinded, randomized, controlled trial. Women who undergone elective vaginal hysterectomy were included. Solutions of either Bupivacaine-Hydrochloride 0.5%, or Sodium-Chloride 0.9% as a placebo, were prepared prior to surgery, according to randomization. The chosen solution was injected before incision, in a circumferential manner, to the cervix. The amount of fluid administered was 10 ml. When colporrhaphy was also performed, an additional 5 ml of solution were injected in the midline of the vaginal wall prior to each incision line. We conformed to the CONSORT recommendations. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. We estimated that the intervention would cause a 25% reduction in the primary outcome. The required total sample size was calculated to be 30 patients women for each group. We used ANOVA for continuous variables and the Chi-square or Fisher exact tests for categorical variables.Results: A total of 30 women were included in each group. The level of postoperative pain, as assessed by VAS, was not significantly different between the groups, in all points of time. In addition, there was no difference between the groups in opioid based analgesics during recovery, nor in postoperative analgesic use.Conclusion: Preemptive local anesthesia was not shown to be efficient in reducing postoperative pain after vaginal hysterectomy and TOT. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether extraamniotic prostaglandin E2 (PGE2) for midtrimester pregnancy interruption in women with a scarred uterus has any adverse effects compared to those without an uterine scar. Study design: Two hundred and sixty-two women who underwent second trimester (16–27 gestational weeks) termination of pregnancy were enrolled in this study. Thirty-one women with a uterine scar were compared with 231 patients without a scarred uterus. Extraamniotic PGE2 was applied in serial doses of 200 mcg every 2 h up to 20 doses. Intravenous infusion of oxytocin was added in cases when the fetus was not expelled. Curettage was performed in the majority of the patients. Results: The two groups were similar for indications for pregnancy termination, maternal age and gestational age. Gravidity and parity were significantly higher in the group with an uterine scar. The mean induction to abortion time and the complication rate were similar in both groups. No uterine rupture was observed. Conclusion: Extraamniotic PGE2 for midtrimester termination of pregnancy is a safe procedure with a low complication rate, even in patients with an uterine scar. [Copyright &y& Elsevier]

What is the global variability in misoprostol treatment for the management of early pregnancy loss (EPL)? An international web-based survey of fertility specialists and obstetrics and gynaecology clinicians was conducted between August and November 2020. The survey consisted of 16 questions addressing several aspects of misoprostol treatment for EPL. Overall, 309 clinicians from 80 countries participated in the survey, of whom 67.3% were fertility specialists. Nearly one-half (47.9%) of the respondents let the patient choose the first line of treatment (expectant management, misoprostol treatment or surgical aspiration) according to her own preference. The 248 respondents who administer misoprostol in their daily practice were asked further questions; 59.7% of them advise patients to take the medication at home. The most common dose and route of administration is 800 µg administered vaginally. Only 28.6% of participants use mifepristone pretreatment. Variation in the timing of the first follow-up visit after misoprostol administration was wide, ranging from 24 h to 1 week in most clinics. In case of incomplete expulsion, only 42.3% of the respondents routinely administer a second dose. The timing of the final visit and the definition of successful treatment also differed greatly among respondents. There is large variability in the use of misoprostol for the management of EPL. High-quality research is necessary to examine several aspects of the treatment. Particularly, the timing and effectiveness of a second dose administration and the criteria to decide on treatment failure or success deserve more research in the future. [ABSTRACT FROM AUTHOR]

A few modes of perioperative local analgesia have been studied in order to reduce postoperative pain after laparoscopy, including preemptive local anesthetics in the trocar sites and intraperitoneal anesthetics administration at the end of the surgery. However, the evidence regarding their efficacy are conflicting. In addition, the combination of both aforementioned methods has been rarely studied. Our aim was to evaluate whether subcutaneous trocar site and/or intraperitoneal analgesia reduce pain after gynecologic operative laparoscopy. This was a single-centered, randomized, controlled, double-blinded trial. The patients were randomly assigned to one of four equally sized groups: group 1—subcutaneous and intraperitoneal analgesia; group 2—subcutaneous analgesia and intraperitoneal placebo; group 3—subcutaneous placebo and intraperitoneal analgesia; Group 4—subcutaneous and intraperitoneal placebo. The patients, the surgeons, and the pain evaluators were all blinded to the patient's allocation. Included were patients who underwent elective operative laparoscopy. Exclusion criteria were: active infection, pregnancy, known sensitivity to Bupivacaine-Hydrochloride, chronic pelvic pain, surgeries with additional vaginal procedures, conversion to laparotomy, and malignancy. A total of 9 ml of Bupivacaine-Hydrochloride (Marcaine) 0.5%, or Sodium-Chloride 0.9%, as a placebo, were injected subcutaneously to the trocar sites (3 ml to each trocar site), prior to skin incision. In addition, 10 ml of Bupivacaine-Hydrochloride 0.5%, diluted with 40 ml of Sodium-Chloride 0.9% (a total of 50 ml solution), or 50 ml of Sodium-Chloride 0.9%, as a placebo, were injected intraperitoneally at the end of the surgery. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. The study was approved by the local Institutional Review Board and has been registered at clinicaltrials.gov. We conformed to the CONSORT recommendations. Between December 2016 and July 2019, a total of 119 patients were included in the study. Demographic and interventional characteristics were similar among the groups. The level of postoperative pain, either at rest or with change of position, was not significantly different between the groups, at all-time points. Application of subcutaneous and/or intraperitoneal analgesia is not effective in reducing pain after gynecologic operative laparoscopy. Clinical trial identification number: NCT02976571. Date of trial registration 11/29/2016. URL of the registration site: https://clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Does long-term reproductive outcome after early pregnancy loss (EPL) differ between women who are treated with misoprostol and surgical aspiration. A historic cohort study of all women who were diagnosed with early pregnancy loss (≤12 weeks), in a single medical centre, between September 2016 and August 2017, was conducted. The women were treated with either misoprostol or surgical aspiration according to their own preferences. Women who were lost to follow-up or did not attempt to conceive again were excluded. The primary outcome measure was the cumulative pregnancy rate within 12 months from intervention. Baseline characteristics were comparable between women who received misoprostol (n = 163) and women who underwent surgical aspiration (n = 122). Women who received misoprostol had a higher rate of interventions for retained products of conception (11.0% versus 3.3%, respectively; P = 0.015). The misoprostol and the surgical aspiration groups did not differ in rate of repeated miscarriages (17.8% versus 21.3%, respectively; P = 0.45), or pregnancy rate within 6 months (58.3% versus 50.0%, respectively; P = 0.16), 12 months (78.5% versus 78.7%, respectively; P = 0.97) and 24 months (92.0% versus 91.8%, respectively; P = 0.94). Live birth rate within 24 months was comparable (62.0% versus 58.2%, respectively; P = 0.52), as well as gestational age at birth (38.5 versus 38.6 weeks, respectively; P = 0.81) and birthweight (3295 versus 3161 g, respectively; P = 0.07). Long-term reproductive outcomes are comparable in women with EPL who are treated with either misoprostol or surgical aspiration. Our findings may help counselling patients facing EPL who have concerns about their future reproduction. [ABSTRACT FROM AUTHOR]

Objective: To compare patient characteristics, imaging results, surgical management and prognosis of borderline ovarian tumors (BOT) between pre and postmenopausal patients.Materials and Methods: A retrospective cohort of all cases of histologically verified BOT between 1990-2018, comparing presentation, imaging, surgical procedures and recurrence. Patients were included in the postmenopausal group if they reported 12 months of amenorrhea with or without menopausal symptoms.Results: During this 28 year study period, 66 operations were performed in which BOT was confirmed. Postmenopausal patients were 37-89 years old and premenopausal patients 18-50 years old, with an average age of 63.9 ± 13.4 and 36.2 ± 8.4 years, respectively (p < 0.001). The majority of patients in both groups were diagnosed due to abdominal pain, followed by incidental diagnosis on routine ultrasound. Imaging and CA-125 levels upon presentation were similar. Almost sixty percent of postmenopausal and 26.3% of premenopausal patients underwent laparotomy (p = 0.01), while those who underwent laparoscopy were 35.7% and 60.5%, respectively (p = 0.03). Most postmenopausal patients underwent bilateral salpingo-oophorectomy (BSO), whereas premenopausal surgeries involved cystectomy. Nearly all study patients were diagnosed in stage one. Malignant transformation occurred in 7.1% of postmenopausal patients. No malignant transformation was found in premenopausal patients.Conclusion: BOT's present similarly in pre and postmenopausal patients. Postmenopausal patients undergo more extensive surgery, and are diagnosed in early stage disease. Despite a tendency for a more conservative approach in premenopausal patients, prognosis is similar in both groups. [ABSTRACT FROM AUTHOR]

Objective: Pelvic organ prolapse (POP) is a global health problem for which the pathophysiological mechanism remains unclear. The loss of extracellular matrix proteins is considered an important molecular basis for this pathology. Heparanase is a heparin sulfate degrading endoglycosidase that has an important role in various biological processes and is a key component of extracellular matrix. The aim of this study was to compare expression of Heparanase in connective tissue of uterosacral ligaments in women with or without uterine prolapse.Study Design: Thirty-nine women who underwent hysterectomy for benign reasons were enrolled in the study. Twenty-three women with uterine prolapse (stage ≥3) who underwent vaginal hysterectomy (VH) - POP group, were compared to sixteen women without uterine prolapse who underwent abdominal hysterectomy (stage <2) - control group. Uterosacral ligaments (USL) biopsies were obtained from all uterine specimens near their origin. All tissue samples were analyzed by immunohistochemistry and tested for the presence of Heparanase using antiheparanse antibody 733.Results: Heparanse positive staining was more common in the connective tissue of uterosacral ligaments in women with uterine prolapse. Positive staining was seen in 17/23 (73.9 %) women with uterine prolapse compared to 4/16 (25 %) without uterine prolapse (p = 0.003). On multivariate logistic regression analysis, positive staining displayed a trend for an independent association with POP, after controlling for menopausal status and parity (OR 13.57, 95 %CI 0.82-224.4, p = 0.06).Conclusion: Heparanase expression is more common in the connective tissue of uterosacral ligaments in women with uterine prolapse compared to women with no prolapse. [ABSTRACT FROM AUTHOR]

Does extending the follow-up after misoprostol treatment for early pregnancy loss increase the success rate? Patients who had experienced early pregnancy loss (<12 weeks) and were treated with misoprostol in a single university-affiliated medical centre were prospectively followed before and after the implementation of a new treatment protocol extending the follow-up from 1 to 2 weeks. All patients received misoprostol 800 μg vaginally on day 1 and a second dose, when needed, on day 4 or 8. Patients underwent surgical aspiration after 1 week in the early follow-up group (n = 84) or 2 weeks in the delayed follow-up group (n = 85) if complete expulsion was not achieved (defined as endometrial thickness ≤15 mm and absence of gestational sac on transvaginal sonography). The primary outcome was treatment success, defined as no need for surgical aspiration. Women in the delayed follow-up group had a higher rate of successful treatment compared with women in the early follow-up group (88.2% versus 76.2%, respectively; P = 0.040), and a lower rate of second dose administration (32.9% versus 51.2%, respectively; P = 0.016). The incidence of non-expulsion of the gestational sac was also lower in the delayed follow-up group (1.2% versus 10.7%; P = 0.009). Treatment acceptability did not differ between the study groups. In women with early pregnancy loss treated with misoprostol, extending the follow-up protocol from 1 to 2 weeks resulted in an increase in treatment success. [ABSTRACT FROM AUTHOR]

Aim: To compare clinical variables, sonographic findings and pregnancy outcomes following the hysteroscopic removal of retained products of conception (RPOC) after delivery and abortion.Methods: This is a retrospective cohort of operative hysteroscopies performed between 2011 and 2015 for suspected RPOC, during which trophoblastic tissue was obtained. Patient demographics, clinical presentation, sonographic evaluation, subsequent infertility and pregnancy outcomes were compared between post-delivery (n = 85) and post-abortion (n = 93) cases.Results: The main presenting symptom in both study groups was vaginal bleeding. On sonographic evaluation, maximal endometrial thickness was significantly higher in the post-delivery group, while irregularity and increased flow were more common in the post-abortion group. There was a similar rate of deliveries following hysteroscopy in both groups with 40% in the post-delivery group and 39.7% in the post-abortion group. Deliveries in the post-delivery group were characterized by a higher rate of abnormal placentation - 30.5% - including low lying placenta and placenta accreta. A significant rate of vaginal deliveries in both groups entailed manual removal of the placenta or exploration of the uterine cavity (23.5 and 10.5%, p = 0.20).Conclusion: Pregnancies following RPOC after delivery entail a higher rate of abnormal placentation. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The aim of the mediolateral episiotomy incision is to increase the diameter of the soft tissue of the vaginal outlet to facilitate birth and to prevent vaginal tears. Episiotomy angles that are too narrow and close to the midline increase the risk of obstetric anal sphincter injuries. In order to determine the optimal angle of the episiotomy, we assessed the changes in the angles of episiotomy lines marked during the first stage of labor and measured at the time of crowning of the head. Methods: Incision lines for mediolateral episiotomy were marked on the perineal skin at angles of 30°, 45°, and 60° from the midline during the first stage of labor in women with a singleton pregnancy. The angles of the marked lines were measured at crowning of the head. Mediolateral episiotomy was performed only for obstetric indications. Results: The study included 102 women with a singleton pregnancy. Of these women, 50 were primiparous and 52 were multiparous. All angles marked during the first stage of labor increased significantly (by more than 30°) at crowning of the head. Similar changes were observed in primiparous and multiparous women. Conclusions: The angle of the mediolateral episiotomy line was significantly greater at crowning of the head than when marked during the first stage of labor. To achieve the desired episiotomy angle, it is important to take into consideration the changes in mediolateral episiotomy angles that occur during labor. [ABSTRACT FROM AUTHOR]

Objective: To study obstetric outcomes of emergency cerclage compared with elective cerclage.Study Design: Retrospective cohort study of pregnancy outcomes of patients who underwent cervical cerclage, performed according to ACOG guidelines, between January 2006 and December 2014. Patients who underwent emergency cerclage, due to cervical shortening or cervical dilation (emergency cerclage group) were compared with patients who underwent history-indicated cerclage (elective cerclage group). Emergency cerclage was not performed in patients with uterine contractions, vaginal bleeding, or signs of chorioamnionitis. Procedure-related complications were defined as rupture of membranes or chorioamnionitis occurring after cerclage placement and before 24 weeks of gestation.Results: Overall, 154 patients with elective cerclage and 47 patients with emergency cerclage were included. Mean gestational age at cerclage operation was 13.1 ± 1 and 20.2 ± 3 weeks, respectively. There were no differences between the emergency cerclage group and the elective cerclage group regarding mean gestational age at delivery (36.1 ± 3 versus 35.6 ± 3, respectively, p = 0.7), rate of deliveries beyond 34 weeks of gestation (81.81% versus 78.72%, respectively, p = 0.67), rate of deliveries beyond 37 weeks of gestation (64.93% versus 59.57%, respectively, p = 0.6), cesarean deliveries (33.11% versus 39.13%, p = 0.48, respectively), or birthweight (2848 versus 2862 grams, respectively, p = 0.9). Regarding procedure-related complications, there were no differences between the elective and the emergency cerclage groups in the rate of chorioamnionitis (1.29% versus 4.34%, respectively, p = 0.22), or ruptured membranes (1.29% versus 4.34%, respectively, p = 0.22).Conclusion: Pregnancy outcomes of emergency cerclage are comparable with those of elective cerclage. [ABSTRACT FROM AUTHOR]

Study Question: Does repeat administration of misoprostol for early pregnancy loss increase the treatment success rate?Summary Answer: Repeat administration of misoprostol does not increase the treatment success rate, and is associated with more analgesics use.What Is Known Already: Misoprostol reduces the need for surgical evacuation and shortens the time to complete expulsion in patients with early pregnancy loss. However, the impact of repeat doses of misoprostol is not clear.Study Design, Size, Duration: A randomized clinical trial was conducted in a single tertiary hospital, recruiting women with early pregnancy loss (<12 weeks), seeking medical treatment, between August 2015 and June 2016. A sample size of 160 patients was sufficient to detect a 30% decrease in treatment success.Participants/materials, Setting, Methods: Participants received 800 μg of misoprostol vaginally on Day 1, and were then randomly assigned into two groups: Patients in the single-dose group were evaluated on Day 8. Patients in the repeat-dose group were evaluated on Day 4, when they were given a repeat dose if required, and scheduled for re-evaluation on Day 8. If complete expulsion was not achieved on Day 8 (endometrial thickness >15 mm or the presence of gestational sac on transvaginal sonography), participants underwent surgical evacuation. The primary outcome was treatment success, defined as no need for surgical intervention up to Day 8.Main Results and the Role Of Chance: Final analysis included 87 participants in the single-dose group and 84 participants in the repeat-dose group, out of whom 41 (48.8%) received a second dose. Treatment succeeded in 67 (77%) patients in the single-dose group and 64 (76%) patients in the repeat-dose group (RR 0.98; 95% CI 0.83-1.16; P = 0.89). Patients in the repeat-dose group reported more use of over the counter analgesics (82.1% versus 69.0%, P = 0.04).Limitations, Reasons For Caution: The study was not blinded and our definition of complete expulsion may be debated. Follow-up time was not equal in all participants, since some had a complete expulsion on Day 4 and some underwent emergent D&C before Day 8. This, however, should not affect the primary outcome.Wider Implications Of the Findings: Our results suggest that a single-dose protocol is superior to a repeat-dose protocol due to a comparable success rate and more favorable outcomes regarding the need for analgesic drugs.Study Funding/competing Interest(s): We did not receive funding for this study and we declare no conflict of interest.Trial Registration Number: ClinicalTrials.gov (NCT02515604).Trial Registration Date: 2 August 2015.Date Of First Patient's Enrolment: 19 August 2015. [ABSTRACT FROM AUTHOR]

Purpose: To compare effectiveness and patient satisfaction of different routes of misoprostol for short-term (same day) cervical priming in first trimester surgical abortions.Methods: In a blind randomized trial, patients undergoing surgical abortion at a gestational age of 6 + 0-14 + 6 were administered oral, vaginal, or sub-lingual 400 mcg misoprostol, 1.5 to 4 h prior to procedure. Surgeons blinded to patient allocation evaluated cervical priming. The primary outcome was initial cervical dilatation. Secondary outcomes were cervical consistency, ease of dilation, patient discomfort, and side effects.Results: From July 2015 through May 2016, 120 patients were randomized as follows: 40 to oral, 40 to vaginal, and 40 to sublingual misoprostol administration. No differences were noted in patient age, gestational age, curettage indication (termination/delayed miscarriage), past vaginal delivery, and administration to procedure interval. Initial cervical dilatation was similar between the groups, as were cervical consistency and ease of dilation. Patients noted the greatest discomfort and side effects with sublingual administration. The followings were found to be independently associated with cervical dilatation in a linear regression analysis: sublingual administration, gestational age, missed abortion, and previous vaginal delivery. Side effects and administration to procedure interval were found non-significant.Conclusion: The same day cervical priming for first trimester surgical abortion is similarly achieved with all routes of misoprostol administration. In cases of termination of pregnancy with no prior vaginal delivery, sublingual administration may be considered, but entails a higher rate of side effects and patient discomfort. [ABSTRACT FROM AUTHOR]

Purpose: To compare clinical characteristics of adnexal torsion in premenarchal patients as compared to postmenarchal ones.Methods: A retrospective 22-year cohort of all cases of surgically verified adnexal torsion in premenarchal and postmenarchal patients (excluding postmenopausal and pregnant patients). Data collected included symptoms, signs and imaging at presentation, surgical mode, and procedure and histology.Results: 16 cases of adnexal torsion among premenarchal patients were compared to 302 cases among postmenarchal ones. Clinical presentation was similar, notable only for more nausea and vomiting among the premenarchal group. Ovarian cysts were more commonly demonstrated among postmenarchal patients (82.4 and 30.8%, p < 0.001), as opposed to a normal adnexal appearance on ultrasound, which was more common in premenarchal patients (69.3 vs. 17.2%, p < 0.001). Absent Doppler flow, when preformed, did not differ statistically between the groups. Laparoscopic detorsion only was more commonly performed in premenarchal patients (56.2 vs. 19.8%, p = 0.001), with a trend for detorsion and cystectomy/fenestration, which were more common in postmenarchal surgeries (25 vs. 50.6%, p = 0.06). Histology was similar among both groups, with no cases of malignancy in premenarchal patients.Conclusion: Adnexal torsion in premenarchal patients is rare, presents similarly to older patients, but involves a normal adnexa in 69% of cases, therefore requiring a high index of suspicion in any premenarchal patient with acute onset abdominal pain. [ABSTRACT FROM AUTHOR]

Purpose: The aim of our study was to assess the clinical and obstetric outcomes of laparoscopic surgeries performed during advanced pregnancy compared to those performed in early pregnancy.Methods: We retrospectively reviewed all cases of patients who underwent laparoscopic surgery during pregnancy in our institution between 1996 and 2013.Results: We reviewed cases of 117 pregnant women who underwent laparoscopic surgery during the study period. There were no conversions to laparotomy. 71 surgeries were performed in the first trimester (group 1, mean gestational age 7.7 ± 1.9 weeks) and 46 were performed in the second and third trimesters (group 2, mean gestational age 18.1 ± 4.3 weeks). More patients in group 1 underwent surgery for suspected adnexal torsion (p < 0.001), while more patients in group 2 underwent surgery for presumptive cholecystitis (p = 0.014) and persistent ovarian mass (p = 0.011). The interval between admission and surgery differed significantly between the groups and was longer in group 2 compared to group 1 (18.2 ± 24.0 vs. 6.8 ± 10.6 h, p = 0.001). No difference was found between the two groups regarding surgical complications, histopathological findings and pregnancy outcomes.Conclusion: In our experience, laparoscopic surgery in advanced pregnancy was found to be feasible and safe as in early pregnancy, without any adverse effects on pregnancy outcome. [ABSTRACT FROM AUTHOR]

Purpose: Laparoscopy has become the standard of care in the management of ovarian benign mucinous cystadenomas. One concern of the operative approach is the risk of recurrence. A previous study has found intraoperative cyst rupture and cystectomy to be the risk factors for recurrence. Our objective was to assess the incidence and risk factors for recurrence of benign mucinous cystadenomas after surgical removal. Methods: We conducted a retrospective analysis of all cases of patients who underwent removal of benign mucinous cystadenomas by either cystectomy or adnexectomy in our institution between December 2006 and June 2013. Results: 722 women underwent surgical treatment for benign ovarian cysts in that time period, out of which 38 women (5.2 %) had benign mucinous cystadenomas confirmed by pathologic examination. Most of the patients underwent laparoscopy (94.7 %). Half of the patients underwent cystectomy, and the other half underwent adnexectomy. One patient underwent re-operation due to cyst recurrence. This patient initially underwent laparoscopic cystectomy, during which intraoperative cyst rupture did not occur. Conclusion: Recurrence of benign mucinous cystadenomas was uncommon and was not associated with intraoperative cyst rupture. [ABSTRACT FROM AUTHOR]

Objective To compare clinical characteristics and management of adnexal torsion in postmenopausal patients as compared to premenopausal ones. Methods A retrospective 22 year cohort of all cases of surgically verified adnexal torsion in postmenopausal and premenopausal patients, comparing presentation, imaging, surgical procedure and histology. Results Thirty five cases of adnexal torsion among postmenopausal patients were compared to 302 cases among premenopausal ones. Complex ovarian masses and larger ovarian diameter were more common among postmenopausal patients (7.8 vs. 6.8 cm, p = 0.003). The admission to surgical interval differed substantially between the groups (75.5 h in postmenopausal patients vs. 24.4 in the premenopausal ones, p < 0.001). The main surgical indication for postmenopausal patients was pelvic mass investigation (54.3% vs 11.6%, p < 0.001), and more premenopausal patients underwent surgery with a clinical suspicion of adnexal torsion (77.1% vs. 40%, p < 0.001). Extensive surgery including bilateral salpingo-oophorectomy with or without total abdominal hysterectomy was more commonly performed in postmenopausal patients, as opposed to conservative surgery, including detorsion and cystectomy/fenestration or detorsion only, in premenopausal surgeries. Cancer was diagnosed in 3% of postmenopausal patients with adnexal torsion. Conclusion Adnexal torsion in postmenopausal women is rare, but presents similarly, results in more delayed and extensive surgery and involves malignancy in 3%. [ABSTRACT FROM AUTHOR]

Aims: To assess the frequency of premalignant and malignant endometrial polyps in symptomatic and asymptomatic women. Methods: Retrospective registration of 1,124 patients who underwent hysteroscopic resection of endometrial polyps. Patient characteristics included age, menopausal status, presence or absence of symptoms, and use of hormonal medication. Histological diagnoses and complications were also analyzed. Results: 641 (57%) of 1,124 women with endometrial polyps were postmenopausal and 483 (43%) premenopausal. Abnormal uterine bleeding was reported by 548 women: 226 (49%) postmenopausal and 322 (51%) premenopausal. 576 (51%) women were asymptomatic. There were 16 patients with malignancy or premalignant conditions among the symptomatic patients (2.7%) compared to 7 such patients among the asymptomatic patients (1.3%; p = 0.17). Pathologic evaluation disclosed 7 cases of malignancy and 4 cases of atypical hyperplasia among bleeding postmenopausal women (11/263, 4%) and 2 malignancies and 3 cases of hyperplasia with atypia among asymptomatic postmenopausal women (5/378, 1.3%). Conclusion: We found premalignancy and malignancy in each patient group – pre- and postmenopausal, as well as symptomatic and asymptomatic. We recommend removal of any verified endometrial polyp. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Aim: To review all past reports of Candida glabrata chorioamnionitis in the literature while noting their correlation with in vitro fertilization (IVF).Methods: We checked MEDLINE, PubMed and Google scholar (January 1970 to December 2014) for articles using the search terms 'Candida', 'Torulopsis', 'glabrata', 'chorioamnionitis', 'congenital', 'perinatal' and 'infection'. Case reports were included if they described a verified intrauterine infection with C. glabrata. The authors reviewed the articles and abstracted the data. 20 cases were compared, including a case reported from our institution shortly described in this article.Results: 13 of 20 cases (65%) involved pregnancies achieved by IVF; 3 patients underwent amniocentesis during their pregnancy. Of the 7 cases with no history of IVF, 2 involved a history of cerclage and 2 a history of intrauterine device use. Only 6 infants survived, delivered prematurely by cesarean section.Conclusions: Review of literature demonstrated a high prevalence of IVF-assisted pregnancies among the few C. glabrata chorioamnionitis cases previously described, typically occurring during the second trimester. Additional cases were notable for additional instrumentation/invasive procedure. The prognosis was mostly grim, entailing a high incidence of stillbirth or rapid neonatal death. [ABSTRACT FROM AUTHOR]

Objective: We aimed to investigate the likelihood of vaginal colonization with Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in pregnant and non-pregnant women with Coronavrus Disease 2019 (COVID-19). Materials and Methods: Vaginal swabs were taken from women diagnosed with mild to moderately acute SARS-CoV-2 infection, at Wolfson Medical Center, Israel, from March 2020 through October 2020. COVID-19 was diagnosed by real-time polymerase chain reaction (RT-PCR) performed on nasopharyngeal swabs. Vaginal swabs were tested for the presence of SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR). Results: In total, 51 women diagnosed with COVID-19 were included in the study. Of the 51 women with COVID-19 enrolled in this study, 16 (31.4%) were pregnant at enrollment and 35 (68.6%) were non-pregnant. Mean age was 43.5 ± 15.3 years (range 21–74 years). Compared to the non-pregnant group, the pregnant group was characterized by a higher white blood cell and absolute neutrophil count (p = 0.02 and p = 0.027, respectively). The non-pregnant patients were more likely to have chronic diseases (p = 0.035) and to be hospitalized (p < 0.001). Only one patient (1.9%) aged 60 years tested positive for SARS-CoV-2 in vaginal secretions. Mean gestational age at the diagnosis of COVID-19 of the pregnant group was 32.3 ± 7.8 weeks. Thirteen patients delivered during the study period; all delivered at term without obstetric complications and all neonates were healthy. Conclusions: Detection of SARS-CoV-2 in the vaginal secretions of patients diagnosed with COVID-19 is rare. Vaginal colonization may occur during the viremia phase of the disease, although infectivity from vaginal colonization needs to be proven. [ABSTRACT FROM AUTHOR]

Objective: Our objective was to evaluate the outcome of vaginal removal of prolapsed pedunculated submucous myomas over a 10-year period. Study design: Retrospective observational study. Fifty-two patients were admitted with the diagnosis of prolapsed pedunculated submucous myoma. Six patients were excluded because of an a priori decision for abdominal hysterectomy. In 46 patients an attempt for vaginal myomectomy under general anesthesia was done. Results: Vaginal myomectomy was successful in 44 patients (95.6%). There were no immediate complications. Histological diagnosis of leiomyoma was confirmed in 34 cases (73.9%) and in the remainders intrauterine pathology was endometrial polyp. Total abdominal hysterectomy was performed in additional 6 patients (13.7%) 3 months to 5 years following vaginal myomectomy. Conclusions: Vaginal myomectomy is the treatment of choice for prolapsed pedunculated submucous myoma. The associated morbidity is minimal. [ABSTRACT FROM AUTHOR]