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Couvelaire uterus (CU) is a rare complication in the life-threatening placental abruption (PA) that consists of a state of blood infiltration of the uterine myometrium and serosa. The incidence is around 1% and the treatment of choice is obstetric hysterectomy, however, in some cases, close monitoring and timely decision-making can prevent hysterectomy. Herein, we present a rare and serious case of CU with uterus preservation in a young multiparous with a high-risk pregnancy. [ABSTRACT FROM AUTHOR]

The article offers clinical studies related to minimally invasive surgery procedures in urogynecology. Topics include information on laparoscopic sacrocolpopexy (LSC), a standard procedure of laparoscopic mesh surgery which is expected to increase as a treatment for pelvic organ prolapse (POP) due to entering an aged society; and Robotic-assisted sacrocolpopexy (RSC) is considered convenient and is expected to have a certain impact on minimally invasive POP surgery.

Hysteroscopy has evolved from the traditional art of examining the uterine cavity for diagnostic purposes to an invaluable modality to concomitantly diagnose and (see and) treat a multitude of intrauterine pathologies, especially in the field and clinics specialising in female reproduction. This article reviews the literature on the most common cervical, endometrial, uterine and tubal pathologies such as chronic endometritis, endometrial polyps, adenomyosis, endometriosis, endometrial atrophy, adhesions, endometrial hyperplasia, cancer, and uterine malformations. The aim is to determine the efficiency of hysteroscopy compared with other available techniques as a diagnostic and treatment tool and its association with the success of in vitro fertilisation procedures. Although hysteroscopy requires an experienced operator for optimal results and is still an invasive procedure, it has the unique advantage of combining great diagnostic and treatment opportunities before and after ART procedures. In conclusion, hysteroscopy should be recommended as a first-line procedure in all cases with female infertility, and a special effort should be made for its implementation in the development of new high-tech procedures for identification and treatment infertility-associated conditions. [ABSTRACT FROM AUTHOR]

The canal of Nuck is an anatomical extension of the parietal peritoneum which is accompanied by the round ligament of the uterus. It usually obliterates completely during the first year of life, and its failure may result in an inguinal hernia or a hydrocele. A 47-year-old female complained of bilateral inguinal swelling. The painless soft elastic masses did not protrude with the Valsalva maneuver. After a thoughtful examination, magnetic resonance imaging (MRI) was performed and a bilateral hydrocele of the canal of Nuck was diagnosed. Bilateral inguinal exploration was performed, revealing a dilated canal of Nuck with encysted polycystic swelling on both sides, with no evidence of associated inguinal hernias. Round ligaments were incised with margins at a broad ligament level and a bilateral herniorrhaphy was carried out. The postoperative period was uneventful and the patient was dismissed hours after surgery. The hydrocele of the canal of Nuck is an infrequent entity that has to be considered a differential diagnosis of female inguinal swelling. When symptomatic, it has to be surgically resolved, either with a conventional or laparoscopic approach. [ABSTRACT FROM AUTHOR]

The article highlights the role of medical imaging in diagnosing disorders of the female reproductive system. Information is provided on endometriosis, uterine fibroids and polycystic ovarian syndrome (PCOS) including their symptoms and potential complications, as well as advancements in transvaginal sonography and magnetic resonance imaging (MRI) that lead to increase in diagnoses.

One of the main problems which determine the demographic situation in the society is infertility. According to the latest data from the World Health Organization, the frequency of infertile marriages among the couples of reproductive age has a steady upward trend. Today, the uterine factor in the structure of female infertility has a prominent place and can reach 30%. The most common pathological conditions of the uterus include hyperplastic processes in the endometrium. In the structure of intrauterine pathology, according to the literature, chronic endometritis is found twice more often than other diseases. Modern methods of diagnosis, which include ultrasound and endoscopic methods, allow to detect various pathological processes in the uterine cavity with high accuracy. At the same time, it should be mentioned, that intrauterine intervention damages the “cervical” barrier of anti-inflammatory protection of the uterus and its appendages, and the operation itself through the vagina multiples the risk of infectious complications development. The article is devoted to a literature review about the evaluation of the features and safety of hysteroscopy interventions in women with infertility and intrauterine pathology in order to justify the measures to prevent complications. Intrauterine interventions are one of the causes of inflammatory diseases of the internal genital organs. Hysteroscopy is the “gold standard” for examination of the endometrium and uterine cavity, and at the same time, it can be one of the reasons for inflammatory diseases of the internal genital organs that adversely affect the reproductive function of women. The development of inflammatory complications after intrauterine interventions is associated, first of all, with the spread of infection from the lower parts of the reproductive tract and the formation of entrance gates for infection due to the damage of the mucous membranes during surgical manipulations. The frequency of inflammatory complications during intrauterine intervention, according to various authors, ranges from 5 to 43% and depends on the type of manipulations. An extremely important scientific and practical issue is the improvement of preventive measures to increase the safety of hysteroscopy interventions, reduce postoperative complications, and improve reproductive outcomes. [ABSTRACT FROM AUTHOR]

This is the first known case report of severe intrauterine adhesion (IUA) following a life‐threatening event caused by an Epstein–Barr virus‐associated atraumatic spleen laceration. A 22‐year‐old nulligravid female suffered from infectious mononucleosis for approximately 1 month. Sudden severe hypovolemic shock with massive hemoperitoneum appeared and hemostasis was completely achieved by a splenectomy for an atraumatic spleen laceration, although that was followed by multiorgan failure and abdominal compartment syndrome. Complete recovery without any neurological sequelae was achieved by intensive treatment. A postoperative pathological evaluation revealed Epstein–Barr virus‐associated splenomegaly. The patient was referred to our department because of secondary amenorrhea for approximately 5 months since the last menstruation, which occurred just prior to the event. Laboratory blood test results demonstrated normal thyroid and ovarian functions. Hysterofiberscopy revealed complete obstruction at the end of the cervical canal, indicating secondary uterine amenorrhea caused by severe IUA. Hysteroscopic adhesiolysis with a rigid hysteroscope reached the opening of the uterine cavity and menstruation was restored. [ABSTRACT FROM AUTHOR]

Key Content: Accessory cavitated uterine malformations (ACUMs) are isolated cavitated lesions within the lateral aspect of the myometrium, inferior to the attachment of the round ligament.They are a rare Müllerian anomaly and are increasingly recognised as a cause for severe dysmenorrhoea and pelvic pain.ACUMs can be diagnosed with ultrasound and magnetic resonance imaging, where they appear as well‐defined lesions with a central cavity containing haemorrhagic content, surrounded by a myometrial mantle. On histological examination, the cavity is lined by functional endometrial glands and stroma.Recognised treatments include hormonal suppression, destruction of the endometrial lining by alcohol sclerotherapy, or complete surgical excision, which has demonstrated curative results. Learning Objectives: To know what ACUMs are and recognise them as a cause of dysmenorrhoea and pelvic pain.To be able to diagnose an ACUM with the use of ultrasound, MRI and histological findings if surgically excised.To be able to counsel patients with ACUMs on the different management options, including conservative, medical and surgery. Ethical issues: All women with ACUMs are currently offered surgical excision, but is it appropriate to offer this, to patients as young as 13 years old, with no long‐term data on the effect of surgery on future fertility? [ABSTRACT FROM AUTHOR]

Background: Incarceration of the gravid uterus is an infrequent obstetric complication that can cause severe complications.Case: A 37-year-old woman, G3P2002, at 14 weeks of gestation presented with vomiting, back pain, and urinary retention. She was noted to be in acute renal failure, with a creatinine level of 9.24 mg/dL, and results of her physical examination were concerning for uterine incarceration. Passive maneuvers and manual pressure failed to resolve the incarceration. Under spinal anesthesia, a Bakri balloon was inflated in the posterior vagina, elevating the fundus and relieving the incarcerated uterus.Conclusion: An intravaginal balloon may aid in the alleviation of uterine incarceration. [ABSTRACT FROM AUTHOR]

Purpose Uterine torsion (UT) in pregnancy is a rare condition in obstetric practice. It is defined as a rotation of the uterus of more than 45° around its long axis. Presentations are varied and, most of the time, this condition is recognized at laparotomy or cesarean section (CS). The aim of this study is to summarize the latest evidence about UT in pregnancy. Methods: A systematic research of the literature was conducted fetching all papers published from March 2006 to June 2020. We collected data regarding clinical features, treatment, and feto‐maternal outcomes. Finally, we reported data of a case of UT associated with intrauterine growth restriction (IUGR) diagnosed and treated at our institution. Results: According to our search strategy, 38 articles were included. In 66% of the cases, acute symptomatology was present at the onset, most frequently abdominal pain was reported. In one‐third of the cases, UT was diagnosed during CS without clinical suspicion. Only in two cases, including our case, IUGR was reported. Most (66%) of the cases presented a 180° torsion. In the majority of the cases, a CS was performed also with a deliberate or accidental posterior hysterotomy. One and six cases of maternal and fetal death were, respectively, reported. Conclusion: UT is an infrequent obstetric condition but should be considered in case of abdominal pain, vomiting, or shock presentation during pregnancy. It could lead to a reduction in uterine blood flow contributing to poor placental perfusion, even though more evidence is needed to clarify this link. [ABSTRACT FROM AUTHOR]

Purpura fulminans (PF) is a syndrome characterized by the sudden onset of progressive skin hemorrhage, necrosis of the extremities, and thrombotic occlusion. Although the cause is believed to be protein C deficiency, many aspects of this syndrome have yet to be clarified. A 45‐year‐old Japanese woman, G2P2 (vaginal delivery), developed fever and lower abdominal pain. It was her 5th day of menstruation, and a tampon had been in the vagina for a few days. Septic shock and disseminated intravascular coagulation were diagnosed, and multidisciplinary treatment was started. Also, toxic shock syndrome due to tampon use was suspected. The purpura on the limbs turned into blisters and then blackish‐purple spots, leading to hemorrhagic necrosis within a few days. Moreover, imaging showed that the uterus and both adnexa had enlarged significantly, and raised suspicion of abscess formation. Total hysterectomy and bilateral adnexectomy were performed, and the histopathological diagnosis was hemorrhagic necrosis due to extensive thrombus formation. In men, PF affects the scrotum and penis, leading to autoamputation of the male genitalia, while there are no reports of PF involving the female genitalia. Regarding the PF, in this case, we considered the possibility of pathologic conditions progressing to the female genitalia. [ABSTRACT FROM AUTHOR]

Objective: Vaginoscopic office hysteroscopy (VOH) is a gold standard diagnostic method for many uterine disorders. However, it may result in patient discomfort. This study aimed to investigate the effect of the Trendelenburg lithotomy (TL) position, in respect of the level of pain and procedure time during the VOH for diagnostic purposes. Methods: This study included 157 patients between the ages of 20 and 65 years, of whom 74 underwent diagnostic VOH with the lithotomy position (group 1) and 83 with the TL position (group 2). Subsequent evaluation that was conducted on both groups included visual analog scale scores of patients, procedure duration, and the attitudinal Likert-type survey of doctors. Results: A significant difference was found between groups 1 and 2 in pain scores (p<0.001), procedure duration (p<0.001), and attitudinal Likert-type survey of doctors (p=0.002). Group 2 reported lower pain scores than group 1 (3.34±2.37 and 5.69±2.33, respectively). Similarly, the procedure duration in group 2 was significantly reduced (60.11±26.3 and 83.3±29.5, respectively). The attitudinal Likert-type survey of doctors also showed significant improvement in group 2 (3.48±0.97 vs. 3.03±0.86, respectively). Conclusion: VOH with the TL position lowered the pain scores in patients and reduced the procedure duration. The TL position is a good way of increasing the patients' compliance and tolerance. Likewise, it makes the procedure easier for the doctor without any additional price. [ABSTRACT FROM AUTHOR]

During the last twenty years, the diagnostic approach to endometrial pathology has radically evolved. For over a century, intrauterine blind biopsy techniques were considered the gold standard procedure for the histopathological diagnosis of intrauterine diseases. The advent of hysteroscopy, which made it possible to directly visualize the uterine cavity, and the subsequent miniaturization of the instruments allowing its use in the office setting without anesthesia are considered game-changers. To date, it is feasible to retrieve a targeted eye specimen of endometrial tissue with little or no discomfort for the patient in the office setting. To pursue this aim, several technological upgrades have improved the diagnostic accuracy of hysteroscopic endometrial biopsy. In this paper we provide an up-to-date review of the latest evidence regarding indications, instrumentations, and techniques for hysteroscopic endometrial biopsy, to help the operator in providing an adequate endometrial sampling for histopathological analysis. [ABSTRACT FROM AUTHOR]

Uterocutaneous fistula is an extremely rare postoperative complication and the most appropriate treatment remains unclear. In this case report, we described uterocutaneous fistula of a 41‐year‐old woman with persistent purulent discharge from a small opening in her midline incision after abdominal myomectomy. The patient was diagnosed as uterocutaneous fistula based on magnetic resonance imaging and the methylene blue dye test. Fertility‐sparing surgery was performed and uterocutaneous fistula was successfully corrected. Some nonabsorbable silk sutures were found attached to the sinus tract. This could lead to infection, which could cause the formation of a uterocutaneous fistula. Since after 1‐year of operation, no evidence of recurrence was found. Fertility‐sparing surgery is effective for a patient with uterocutaneous fistula. Complete resection of the sinus tract and surrounding necrotic tissue is required in the repair of urterocutaneous fistula. [ABSTRACT FROM AUTHOR]

Objectives: to compare the accuracy of preoperative and postoperative endometrial sampling obtained by dilatation and curettage (D&C), Pipelle and hysteroscopy to diagnose endometrial malignancies and to evaluate the adequacy of surgical treatment for these patients.Study Design: This retrospective record-based study was conducted at Gynecology Oncology Unit, Ain Shams University Maternity Hospital, Cairo, Egypt. Records of patients with an initial preoperative or a final postoperative pathological diagnosis of endometrial hyperplasia or endometrial malignancies were retrieved over a six year period from January 2013 until March 2019. The preoperative biopsy methods, results, postoperative pathology diagnosis and treatment received were recorded and analyzed.Results: Records of 395 patients were retrieved. Rates of agreement between initial and postoperative pathology for endometrial hyperplasia (with and without atypia) were 10% by D&C, 7.8% by Pipelle and zero % by hysteroscopy; for endometrioid adenocarcinoma grade 1, they were 40.7% by D&C, 40.6% by Pipelle and 20% by hysteroscopy; for endometrioid adenocarcinoma grades 2 and 3, they were 83.7% and 84.6% by D&C, 97% and 60% by Pipelle, and 100% by hysteroscopy, respectively. For type II endometrial cancer and endometrial stromal sarcoma, agreement rates were 100% by all biopsy methods. Out of 13 cases diagnosed with atrophic endometrium preoperatively, 11 cases were diagnosed as endometrial stromal sarcoma. Comparing accuracy of the three biopsy methods, D&C had highest sensitivity of 61.9%; hysteroscopy showed 100% specificity, while Pipelle was the least accurate method. Finally, 61.4% of the patients received adequate surgical treatment.Conclusion: There were excellent concordance rates between initial biopsy and postoperative pathology in diagnosis of high grade endometrioid and other endometrial malignancies compared to endometrial hyperplasia and low grade endometrioid adenocarcinoma. Patients diagnosed initially with atrophic endometrium or hyperplasia warranted more surveillance before their surgical treatment. It is crucial to develop protocols for increasing accuracy of endometrial sampling such as performing molecular studies for preoperative pathology. [ABSTRACT FROM AUTHOR]

Uterine isthmocele or uterine niche is a late complication of cesarean deliveries and causes chronic pelvic pain, menorrhagia or postmenstrual spotting, and infertility. As the number of cesarean sections are constantly increasing, it is important to be aware of this entity so as to make an early diagnosis. This would enable the clinicians to manage these patients efficiently. We present three patients of uterine isthmocele who were evaluated and managed at our institution. [ABSTRACT FROM AUTHOR]

Context  Accessory cavitated uterine mass (ACUM) is an uncommon and under-recognized entity with distinct imaging characteristics and causing significant patient distress. Differentiating it from its other clinical and radiological differentials is therefore extremely important and prevents delay in surgical management which is the treatment of choice. Aims  The aim of the study is to describe the MRI appearance of the surgically and pathologically proven ACUM cases from our institution in the last 2 years. Settings and Design  This is a retrospective study in a tertiary care hospital in South India. Methods and Material  We reviewed the clinical presentations and imaging findings of seven surgically proven cases of ACUM qualifying the proposed diagnostic criteria. Results  All patients presented with chronic pelvic pain, dysmenorrhea, and prolonged post-menstrual pain. MRI in all seven cases showed an intramural, noncommunicating, and cavitating lesion near the uterine cornua with internal contents similar to that of endometrioma. Although the cavity was lined by endometrium in all the cases (proven in pathology), it was well appreciable on MRI in only five cases. The rest of the uterine myometrium and main endometrial cavity were normal with no features of adenomyosis. Conclusion  MRI is a reliable diagnostic tool for accurate diagnosis of ACUM, and more importantly, in distinguishing it from other causes of chronic pelvic pain like adenomyosis and endometriosis and other imaging differentials like adenomyoma, noncommunicating uterine horn, and degenerating leiomyoma. [ABSTRACT FROM AUTHOR]

Surgical innovations in hysteroscopic surgery have radically changed the way of treating intrauterine pathologies, throughout the advent of the 'see-and-treat' philosophy, which transferred the advantages of inpatient surgery to the office setting. However, in-office operative hysteroscopy was mainly limited to minor pathology as a supplement to its diagnosis, whereas commonly larger abnormalities were left to be treated in the operating room. Nowadays, pre-surgical assessment of uterine pathology is based on modern ultrasound evaluation and the evolving role of in-office hysteroscopy as a well-planned treatment modality for larger lesions and more complex procedures. Office operative hysteroscopy has been accepted as a feasible, cost-effective, practical way to treat almost any intrauterine disease. Despite the growing role of other imaging tools in the proper evaluation of benign uterine diseases, especially extended beyond to direct hysteroscopic visualization, diagnostic hysteroscopy remains a valuable tool of direct endometrial sampling and may be used as the first line in the diagnosis of endometrial cancer and hyperplasia. Our aim is to describe the most recent innovations and future perspectives in the field of outpatient operative hysteroscopy: mini-resectoscopes, intrauterine morcellators, tissue retrieval systems, diode laser, new miniaturized mechanical instruments, endometrial ablation devices and portable and entry-level hysteroscopes. [ABSTRACT FROM AUTHOR]

Objective: To optimize a method of isolating extracellular vesicles (EVs) from uterine fluid and to characterize small non-coding RNAs (sncRNAs) from the EVs, with the goal of identifying novel receptivity-associated biomarkers.Design: Longitudinal study comparing sncRNA expression profiles from endometrial EVs.Setting: University-affiliated, hospital-based fertility clinic.Patient(s): Healthy volunteers with no history of infertility (Group A) and women receiving controlled ovarian stimulation (COS)-in vitro fertilization treatment (Group B).Interventions(s): In Group A, EVs were isolated from uterine fluid obtained on luteinizing hormone (LH)+2 and LH+7 in one natural menstrual cycle. In Group B, EVs were isolated from uterine fluid obtained on human chorionic gonadotropin (hCG)+2 and hCG+7 in one COS cycle. RNAs extracted from EVs were profiled using next-generation sequencing.Main Outcome Measure(s): Differential EV-sncRNAs between LH+2 and LH+7 (Group A), between hCG+2 and hCG+7 (Group B), and between pregnant and nonpregnant in vitro fertilization cycles (Group B).Result(s): Ultracentrifugation was validated as the most efficient method to isolate EVs from uterine fluid. We identified 12 endometrial EV-sncRNAs (11 microRNAs and 1 piwi-interacting RNA) as receptivity-associated transcripts conserved in both natural and COS cycles. These sncRNAs were associated strongly with biological functions related to immune response, extracellular matrix, and cell junction. Within COS cycles, we also identified a group of EV-sncRNAs that exhibited differential expression in patients who conceived versus those who did not, with hsa-miR-362-3p most robustly overexpressed in the nonpregnant patients.Conclusion(s): This study is the first to profile comprehensively sncRNAs in endometrial EVs from uterine fluid and identify sncRNA biomarkers of endometrial receptivity and implantation success. [ABSTRACT FROM AUTHOR]

Objective: To describe the ultrasound features of different endometrial and other intracavitary pathologies inpre- and postmenopausal women presenting with abnormal uterine bleeding, using the International Endometrial Tumor Analysis (IETA) terminology.Methods: This was a prospective observational multicenter study of consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler and fluid-instillation sonography were performed. Endometrial sampling was performed according to each center's local protocol. The histological endpoints were cancer, atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (EIN), endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma and other. For fluid-instillation sonography, the histological endpoints were endometrial polyp, intracavitary leiomyoma and cancer. For each histological endpoint, we report typical ultrasound features using the IETA terminology.Results: The database consisted of 2856 consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler was performed in all cases and fluid-instillation sonography in 1857. In 2216 women, endometrial histology was available, and these comprised the study population. Median age was 49 years (range, 19-92 years), median parity was 2 (range, 0-10) and median body mass index was 24.9 kg/m2 (range, 16.0-72.1 kg/m2 ). Of the study population, 843 (38.0%) women were postmenopausal. Endometrial polyps were diagnosed in 751 (33.9%) women, intracavitary leiomyomas in 223 (10.1%) and endometrial cancer in 137 (6.2%). None (0% (95% CI, 0.0-5.5%)) of the 66 women with endometrial thickness < 3 mm had endometrial cancer or atypical hyperplasia/EIN. Endometrial cancer or atypical hyperplasia/EIN was found in three of 283 (1.1% (95% CI, 0.4-3.1%)) endometria with a three-layer pattern, in three of 459 (0.7% (95% CI, 0.2-1.9%)) endometria with a linear endometrial midline and in five of 337 (1.5% (95% CI, 0.6-3.4%)) cases with a single vessel without branching on unenhanced ultrasound.Conclusions: The typical ultrasound features of endometrial cancer, polyps, hyperplasia and atrophy and intracavitary leiomyomas, are described using the IETA terminology. The detection of some easy-to-assess IETA features (i.e. endometrial thickness < 3 mm, three-layer pattern, linear midline and single vessel without branching) makes endometrial cancer unlikely. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Background: Colorectal and endometrial lesions increase with age. It is not known if these two precursor lesions in sporadic cases associate with each other.Aim: To determine the association between colorectal polyps and endometrial polyps (EP) in African Americans.Methods: We reviewed records of patients referred to gynecology clinics and had colonoscopy at Howard University Hospital from January 2004 to December 2015. We defined cases as all patients who had EP and underwent colonoscopy. For controls, we used EP-free patients who underwent colonoscopy. Logistic regression analysis was used to assess the association between colon polyps and EP.Results: The median age was 60 years in 118 Cases and 57 years in 664 Controls. The overall colorectal polyps prevalence in the two groups was not statistically different (54% in controls vs. 52% in cases, P = 0.60). Sessile serrated adenoma/polyps (SSPs) were more frequent in cases (8% vs. 2% in controls, P = 0.003). Sigmoid and rectal locations were more prevalent in controls than cases. In multivariate analysis and after adjusting for age, diabetes mellitus (DM), and BMI, SSPs were associated with EP occurrence with an odds ratio of 4.6 (CI 1.2-16.7, P = 0.022).Conclusion: Colorectal polyp prevalence was similar in EP patients compared to EP-free controls. However, we observed a significant association between higher-risk SSPs in patients with EP. The prevalence of smoking and DM was higher in these patients. Females with EP might benefit from a screening for colonic lesions in an age-independent manner. [ABSTRACT FROM AUTHOR]

Objective: To study whether intrauterine application of auto-crosslinked polymers of hyaluronic acid (ACP) gel after dilation and curettage (D&C) improves reproductive outcomes.Design: Follow-up of a prospective randomized trial.Setting: University and university-affiliated teaching hospitals.Patient(s): Women with a miscarriage at <14 weeks' gestation with at least one previous D&C were randomized to D&C plus ACP gel (intervention) or D&C alone (control). A hysteroscopy was performed after 8-12 weeks, and if intrauterine adhesion (IUAs) were encountered, adhesiolysis was executed.Intervention(s): Participants received a questionnaire 30 months after treatment.Main Outcome Measure(s): Ongoing pregnancy and outcome of subsequent pregnancies.Result(s): Ongoing pregnancies were recorded in 74.6% (50/67) of the intervention group versus 67.2% (43/64) of the control group, and in, respectively, 94.3% (50/53) versus 71.7% (43/60) in the women wishing to conceive. The median times to conception leading to a live birth were, respectively, 21.9 versus 36.1 months. Reduced menstrual blood loss was reported in 7.5% (5/67) versus 20.3% (13/64) and dysmenorrhea in 14.9% (10/67) versus 34.4% (22/64), respectively.Conclusion(s): Application of ACP gel following D&C performed after miscarriage seems to have a favorable effect on subsequent reproductive outcomes in women with at least one previous D&C. Given the fact that the study was not powered for reproductive outcomes, the data should be interpreted with caution. The effect may be underestimated due to routine removal of IUAs.Dutch Clinical Trial Registry Number: NTR 3120. [ABSTRACT FROM AUTHOR]

Objectives: Uterine lesions with plexiform morphology are uncommon lesions with debated histogenesis. Despite being an incidental and usually benign finding (plexiform tumorlet), some cases can pose diagnostic problems. Their paucity in the recent literature adds to these difficulties and often causes ambiguities. The objective of this study is to systematically review published cases to highlight the historical aspects of their recognition, reappraising their morphology, histogenesis, and differential diagnosis.Methods: English literature is reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and 32 reports are analyzed.Results: Most cases are reported in the fourth to sixth decades. In most cases (66.7%), plexiform lesions are incidental findings while 33.3% of cases have been the chief pathology. Size varies from 0.5 to 195 mm. Plexiform foci were solitary in 78.2% cases and multiple in 21.8%. In 67.8% of cases, the lesions are reported as myometrial, while 32.2% are arising from endometrial stroma. Immunohistochemistry shows smooth muscle and no sex cord marker expression. They are usually benign lesions, but worrisome features include plexiform morphology in disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, and diffuse uterine leiomyomatosis.Conclusions: Plexiform lesions represent a diverse pathology varying from epithelioid leiomyomas to epithelioid smooth muscle metaplasia of endometrial type of stroma. [ABSTRACT FROM AUTHOR]

This Committee Opinion provides guidance on the current uses of hysteroscopy in the office and the operating room for the diagnosis and treatment of intrauterine pathology and the potential associated complications. General considerations for the use of diagnostic and operative hysteroscopy include managing distending media, timing for optimal visualization, and cervical preparations. In premenopausal women with regular menstrual cycles, the optimal timing for diagnostic hysteroscopy is during the follicular phase of the menstrual cycle after menstruation. Pregnancy should be reasonably excluded before performing hysteroscopy. There is insufficient evidence to recommend routine cervical ripening before diagnostic or operative hysteroscopy, but it may be considered for those patients at higher risk of cervical stenosis or increased pain with the surgical procedure. In randomized trials, patients reported a preference for office-based hysteroscopy, and office-based procedures are associated with higher patient satisfaction and faster recovery when compared with hospital-based operative hysteroscopy. Other potential benefits of office hysteroscopy include patient and physician convenience, avoidance of general anesthesia, less patient anxiety related to familiarity with the office setting, cost effectiveness, and more efficient use of the operating room for more complex hysteroscopic cases. Appropriate patient selection for office-based hysteroscopic procedures for women with known uterine pathology relies on thorough knowledge and understanding of the target pathology, size of the lesion, depth of penetration of the lesion, patient willingness to undergo an office-based procedure, physician skills and expertise, assessment of patient comorbidities, and availability of proper equipment and patient support. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) agree that vaginoscopy may be considered when performing office hysteroscopy because studies have shown that it can significantly reduce procedural pain with similar efficacy. The office hysteroscopy analgesia regimens commonly described in the literature include a single agent or a combination of multiple agents, including a topical anesthetic, a nonsteroidal antiinflammatory drug, acetaminophen, a benzodiazepine, an opiate, and an intracervical or paracervical block, or both. Based on the currently available evidence, there is no clinically significant difference in safety or effectiveness of these regimens for pain management when compared to each other or placebo. Patient safety and comfort must be prioritized when performing office hysteroscopic procedures. Patients have the right to expect the same level of patient safety as is present in the hospital or ambulatory surgery setting. [ABSTRACT FROM AUTHOR]

Background: Uterine sacculation with a resulting uterine rupture is a rare complication in pregnant patients. Fibroids or a previous cesarean section increase the risk of severe complications such as a uterine rupture due to increased pressure and the elongation of the affected uterine segment. Prenatal clinical diagnosis and medical imaging of a uterine sacculation and rupture of the uterus remain challenging, even with the most modern imaging techniques. An early diagnosis is essential to reduce severe complications. Case presentation: Here, we report the case of a 38-year-old female patient II G I P in the 19th week of pregnancy with a ruptured uterine sacculation. Conclusion: This case report is intended to raise awareness for the importance of the knowledge and supervision of a retroverted uterus in early pregnancy, especially after a cesarean section. [ABSTRACT FROM AUTHOR]

Purpose: Benign and precancerous endometrial hyperplasias (EH) are differentiated thorough two possible histomorphologic classifications: WHO (adopting the subjective evaluation of cytologic atypia) and EIN (adopting several histomorphologic parameters, evaluable subjectively, or objectively with a computerized analysis calculating a prognostic score, the D score). ACOG recommends the use of EIN system although no distinction was made between objective assessment (not widely available), and subjective assessment (more applicable in the common practice). Moreover, it is still unclear if subjective EIN system is actually preferable to WHO classification. We aimed to assess the reliability of WHO system, D score and subjective EIN system in stratifying the risk of progression to cancer in EH.Methods: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, Cochrane Library and Google Scholar were searched for relevant articles from the inception to August 2018. All studies assessing the rates of progression of EH to cancer were included.Results: Twelve cohort studies and one case-control study, assessing 3629 EH, were included. Relative risk (RR) for cancer progression was calculated with 95% confidence interval (CI), and results were compared using Chi-square test (significant p value < 0.05). WHO system showed a RR of 8.74 (95% CI 6.66-11.47). Objective D score showed a RR of 29.22 (95% CI 13.24-64.51), significantly higher than WHO (p = 0.005). Subjective EIN system showed a RR of 19.37 (95% CI 5.86-64.01), intermediate between WHO and D score, without significant differences (p = 0.20 and p = 0.57, respectively).Conclusion: Objective EIN criteria with D score are significantly more reliable than WHO criteria in stratifying the risk of progression of EH to cancer. Subjective EIN criteria did not show significant superiority over WHO instead. Further studies are necessary to determine if subjective EIN system should replace WHO system in the routine diagnosis of EH. [ABSTRACT FROM AUTHOR]

Background/Purpose: The radiologic investigations of 25 girls with congenital pouch colon (CPC), managed over 17 years, were retrospectively reviewed. In 13 girls who form the study group, the investigations provided information about the anomalous uterovaginal (UV) anatomy and these findings were studied. Materials and Methods: Age at presentation was 2 months to 10 years. The subtypes of CPC were Type I (n = 2), Type II (n = 9), and not recorded (n = 2). All patients had a double vagina and a unicornuate uterus on each side in the pelvis. The radiologic studies, performed at varying periods after surgery, included an intravenous urogram (IVU) (n = 4), micturating cystourethrogram (MCU) (n = 3), distal ileostogram/colostogram (n = 6), and magnetic resonance imaging (MRI) (n = 7). Results: IVU and MCU showed retrograde filling of the vaginas with contrast during micturition with a small-capacity urinary bladder and a relatively open bladder neck. The two vaginas were quite apart, but symmetrical in appearance and position. A distal dye study showed filling of the colonic pouch, its terminal fistula, and the two vaginas in six patients. Opacification of the bladder was seen in 3/6 girls, including one girl with left-sided Grade IV vesicoureteral reflux. MRI (n = 7) showed a monocornuate uterus on each side in the pelvis. The upper vaginas on each side were apart, being widely apart (n = 5) and somewhat closer (n = 2). The lower vaginas were closer with an intervaginal septum. Other findings were a widely open bladder neck and urethra in two girls with urinary incontinence and visualization of the terminal fistula of the colonic pouch (n = 2). The lumbosacral spine was normal in all patients. Conclusions: In girls with CPC, retrograde reflux of contrast into the vaginas during a distal dye study or an IVU/MCU may provide useful details of the anatomy of the vaginas. An MRI scan is recommended as essential for comprehensive evaluation of the anomalous UV anatomy. [ABSTRACT FROM AUTHOR]

Objective. To create a prediction model including clinical variables for the prediction of premalignant/malignant endometrial pathology in premenopausal women with abnormal uterine bleeding (AUB). Methods. This is an observational retrospective study including 240 premenopausal women with AUB referred to diagnostic hysteroscopy. Based on the presence of endometrial hyperplasia (EH) or cancer (EC), the women were divided into cases (EH/EC) and controls (no EH/EC). Univariate, stepwise logistic regression and ROC curve analysis were performed. Results. 12 women had EH/EC (5%). Stepwise logistic regression analysis showed that EH/EC associated significantly with BMI ≥ 30 (OR=7.70, 95% CI 1.90 to 31.17), diabetes (OR=9.71, 95% CI 1.63 to 57.81), and a thickened endometrium (OR=1.20, 95% CI 1.08 to 1.34, criterion > 11 mm). The AUC was 0.854 (95% confidence intervals 0.803 to 0.896, p<0.0001). Considering the pretest probability for EH/EC of 5%, the prediction model with a positive likelihood ratio of 8.14 showed a posttest probability of 30%. The simultaneous presence of two or three risk factors was significantly more common in women with EH/EC than controls (50% vs. 6.6 and 25% vs. 0%, respectively, p<0.0001). Conclusion. When premenopausal vaginal bleeding occurs in diabetic obese women with ET > 11 mm, the percentage of premalignant/malignant endometrial pathology increases by 25%. It is likely that the simultaneous presence of several risk factors is necessary to significantly increase the probability of endometrial pathology. [ABSTRACT FROM AUTHOR]

Introduction: Our aim was to correlate junctional zone thickening and irregularity (junctional zone disease) and other ultrasonographic features of adenomyosis with the histopathology of the endometrial-myometrial junctional zone.Material and Methods: Consecutively enrolled premenopausal women (n = 110) scheduled for hysterectomy or transcervical endometrial resection due to abnormal uterine bleeding and/or menstrual pain, underwent two- and three-dimensional transvaginal ultrasonography on the day of surgery with the observer blinded to previous diagnosis. Junctional zone maximum thickness (JZmax ), junctional zone maximum irregularity (JZdif ) and ultrasonographic characteristics of adenomyosis were compared with histopathology of the junctional zone defined as (1) adenomyosis of the inner myometrium, ≥2 mm myometrial invasion without contact to the basal endometrium, (2) serrated junctional zone, >3 mm myometrial invasion with contact to the basal endometrium or (3) linear junctional zone, no or marginal myometrial invasion ≤3 mm with contact to the basal endometrium.Results: Adenomyosis of the inner myometrium, serrated junctional zone and linear junctional zone was present in 29%, 35% and 35% of the women, respectively. Median JZmax and median JZdif expanded from linear junctional zone (8.5 and 3.3 mm) to serrated junctional zone (10.1 and 4.1 mm) to adenomyosis of the inner myometrium (14.6 and 9.2 mm) (P < 0.05). In addition, the median number of characteristic adenomyosis-like ultrasonographic features increased from the linear junctional zone to the serrated junctional zone to adenomyosis of the inner myometrium (P < 0.05).Conclusions: A slightly thickened and/or irregular junctional zone corresponds to a histopathologically defined serrated junctional zone. This study emphasizes three distinct appearances of the junctional zone: adenomyosis of the inner myometrium, junctional zone disease (serrated junctional zone) and linear junctional zone. This classification may be useful in future clinical studies. [ABSTRACT FROM AUTHOR]

Objective: To demonstrate a unique presentation and surgical treatment of a posterior uteroperitoneal fistula with excision of the fistula tract and repair in multiple layers.Design: Illustrative video presentation. A case report is used to describe potential causes of an uteroperitoneal fistula found in a patient during evaluation of secondary infertility and to highlight surgical technique and management using the principles of fistula repair through a minimally invasive approach. The Institutional Review Board reviewed this video article and it was deemed "not human subject research."Setting: Tertiary medical center.Patient(s): A 33-year-old G1P1001 woman with a history of a cesarean section presented with secondary infertility, pelvic pain, and dysmenorrhea and was found to have a posterior uteroperitoneal fistula at the time of hysterosalpingography.Intervention(s): The patient underwent an uncomplicated robot-assisted laparoscopic excision of a posterior uteroperitoneal fistula with the use of careful dissection of the fistula tract, continuous reassessment, and tension-free closure in layers.Main Outcome Measure(s): Preoperative diagnosis and surgical management displaying intraoperative techniques for robot-assisted excision of fistula tract and repair of defect.Result(s): The patient underwent robot-assisted operative laparoscopy that revealed a 4-cm mass on the right posterior aspect of the uterus independent from her adnexa. Concomitant hysteroscopy revealed normal endometrium without an evident fistula. During chromopertubation, extravasation was seen into the peritoneal cavity from this mass. The mass and fistula tract were excised without a connection found from her cesarean scar, and reconstruction was performed in multiple layers. Endometriotic lesions were noted intraperitoneally in locations distant from the mass. The patient had significant improvement in her symptoms after surgery.Conclusion(s): We present a unique case of a suspected spontaneous posterior uteroperitoneal fistula in the presence of endometriosis without evidence of a connection to her prior hysterotomy scar. Possible etiologies include an undiagnosed, unrepaired hysterotomy extension or a result of chronic inflammation from deep infiltrating endometriosis. Adverse effects on fertility from uteroperitoneal fistulas may be due to disruption of sperm function or endometrial quality secondary to presence of old blood products sequestered in the fistula or due to resultant inflammation from the same. As in this video case, successful treatment of symptoms resulting from an uteroperitoneal fistula requires removal of the fistula tract. The constellation of pelvic pain, dysmenorrhea, postmenstrual bleeding, and infertility should raise suspicion for an uteroperitoneal fistula. [ABSTRACT FROM AUTHOR]

Background: The International Federation of Gynecology and Obstetrics (FIGO) systems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) in the reproductive years (FIGO AUB System 1) and for classification of causes of AUB (FIGO AUB System 2; PALM-COEIN) were first published together in 2011. The purpose was to harmonize the definitions of normal and abnormal bleeding symptoms and to classify and subclassify underlying potential causes of AUB in the reproductive years to facilitate research, education, and clinical care. The systems were designed to be flexible and to be periodically reviewed and modified as appropriate.Objectives: To review, clarify, and, where appropriate, revise the previously published systems.Methodology and Outcome: To a large extent, the process has been an iterative one involving the FIGO Menstrual Disorders Committee, as well as a number of invited contributions from epidemiologists, gynecologists, and other experts in the field from around the world between 2012 and 2017. Face-to-face meetings have been held in Rome, Vancouver, and Singapore, and have been augmented by a number of teleconferences and other communications designed to evaluate various aspects of the systems. Where substantial change was considered, anonymous voting, in some instances using a modified RAND Delphi technique, was utilized. [ABSTRACT FROM AUTHOR]

There is a lack of consensus about the significance and the management of an incidental finding of endometrial thickness (ET) > 4 mm on transvaginal ultrasound scans in postmenopausal women without postmenopausal bleeding (PMB). The data of 1995 consecutive women attending PMB clinic were collected prospectively; of them 81 (4.1%) were referred because of ET >4 mm without PMB. The prevalence of endometrial atypical hyperplasia and cancer was 4/81 (4.9%), and polyp was 20/81 (24.7%). On using a receiver operator characteristic curve, the diagnosis of endometrial atypical hyperplasia and cancer using the ET threshold of ≥10 mm had a sensitivity of 100% (95% CI = 40-100%), a specificity of 60% (95% CI = 48-71%) with AUC = 0.8 (95% CI = 0.66-0.93), p = .04. For the 35 women with an ET ≥10 mm, the prevalence of endometrial atypical hyperplasia and cancer was 4/35 (11.4%) and benign endometrial polyps was 16/35 (45.7%). The use of ≥10 mm ET threshold to prompt investigations did not miss any case of endometrial atypical hyperplasia or cancer. Impact Statement What is already known on this subject? Unlike women with PMB in whom an endometrial thickness (ET) ≤ 4 mm is considered as low risk for endometrial hyperplasia and cancer, in postmenopausal women without PMB, the threshold that separates normal from a pathologically thickened endometrium has not been standardised. A decision-analysis study in a hypothetical cohort found that ET threshold of 11 mm yields a similar separation as ≤4 mm in those with PMB. What the results of this study add? The study uses prospectively collected data from consecutive patients using a standardised format, thus minimising bias from incomplete data. This study is the third prospective series in the literature to address the dilemma of the management of asymptomatic postmenopausal women with an incidental finding of a thickened endometrium. It showed that the prevalence of endometrial atypical hyperplasia and cancer is high enough to justify investigation and for the clinical problem not to be trivialised. All cases of endometrial atypical hyperplasia and cancer had ET of ≥10 mm. What are the implications of these findings for clinical practice and/or future research? Our data strengthen the current body of literature to help the development of clinical practice guidelines about the management work-up. However, a well-designed multi-centre large prospective study is required to confirm the findings since most studies in the literature are either retrospective or small. [ABSTRACT FROM AUTHOR]

Objective: To compare transvaginal ultrasonography and hysteroscopy for the diagnosis of endometrial pathologies.Methods: In the present retrospective cohort study, data were reviewed from women with ultrasonography findings suggestive of endometrial lesions and/or abnormal uterine bleeding who underwent hysteroscopy at a single center in Campinas, Brazil, between January 2011 and December 2013; data were stratified based on reproductive-aged and postmenopausal groups. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasonography and hysteroscopy for the diagnosis of endometrial lesions were determined. Histopathology was used as the gold standard.Results: There were 754 patients included (256 reproductive age, 498 postmenopausal). In the reproductive-age group, ultrasonography had a sensitivity of 96.0%, specificity of 58.0%, PPV of 94.4%, NPV of 66.6%, and accuracy of 91.5%, whereas hysteroscopy had a sensitivity of 91.8%, specificity of 76.6%, PPV of 96.0%, NPV of 60.5%, and accuracy of 89.7% for the diagnosis of endometrial disease. In the postmenopausal group, ultrasonography had a sensitivity of 99.0%, specificity of 19.0%, PPV of 96.1%, NPV of 50.0%, and accuracy of 95.3%, whereas hysteroscopy had a sensitivity of 96.7%, specificity of 86.9%, PPV of 99.2%, NPV of 58.8%, and accuracy of 96.2%.Conclusion: Ultrasonography was found to be an effective method for the diagnosis of endometrial disease, especially among postmenopausal women. [ABSTRACT FROM AUTHOR]

Background: Data on the effects of folic acid supplementation on clinical symptoms and metabolic profiles of patients with endometrial hyperplasia (EH) are limited. This investigation was performed to evaluate the effects of folic acid supplementation on clinical symptoms and metabolic status of patients with EH. Methods: This randomized, double-blind, placebo-controlled trial was conducted among 60 women diagnosed with EH. Diagnosis of EH was made based on biopsy results. Participants were randomly allocated to 2 groups to take 5 mg/d folic acid supplements (n = 30) or placebo (n = 30) for 12 weeks. Results: After the 12-week intervention, folic acid supplementation significantly decreased fasting plasma glucose (β -3.99 mg/ dL; 95% CI, -7.39, -0.59; P = 0.02), serum insulin levels (β -2.82 µIU/mL; 95% CI, -4.86, -0.77; P = 0.008), homeostasis model assessment for insulin resistance (β -0.68; 95% CI, -1.20, -0.17; P = 0.009), triglycerides (β -16.47 mg/dL; 95% CI, -28.72, -4.22; P = 0.009) and very-low-density lipoprotein (VLDL) cholesterol (β -3.29 mg/dL; 95% CI, -5.74, -0.84; P = 0.009), and significantly increased the quantitative insulin sensitivity check index (β 0.01; 95% CI, 0.004, 0.03; P = 0.01) compared with the placebo. Additionally, folic acid intake resulted in a significant reduction in serum high sensitivity C-reactive protein (hs-CRP) (β -0.36 mg/L; 95% CI, -0.52, -0.21; P < 0.001) compared with the placebo. Folic acid supplementation did not affect other metabolic parameters. Conclusion: In conclusion, we found that folic acid administration for 12 weeks to subjects with EH improved glycemic control, triglycerides, VLDL-cholesterol and hs-CRP levels, but did not influence recurrence and other metabolic profiles. [ABSTRACT FROM AUTHOR]

Obstructing lesions of vagina, such as transverse vaginal septum, are rare anomalies. In this paper, we report a case of posttraumatic transverse vaginal septum. The patient was a 14-year-old girl who had a transverse vaginal septum because of repaired perineal trauma happened during earthquake that hit Bam city of Iran, when she was three years old. Post-traumatic vaginal septum had resulted in development of a massive hematometra. To our knowledge, this is the first report of urinary incontinence due to massive hematometra, which resulted from a posttraumatic vaginal septum. The rareness and diversity of clinical presentations of vaginal obstructing lesions can lead to misdiagnosis. The patient might refer to different medical and surgical specialists. So, knowing the symptoms is necessary for its early diagnosis. The probability of vaginal obstructing lesions in peripubertal girls with lower urinary tract symptoms should always be considered. [ABSTRACT FROM AUTHOR]

Background: Implantation failure after intracytoplasmic sperm injection (ICSI) is related to either maternal factors or embryonic causes. The maternal factors include uterine anatomic abnormalities either congenital or acquired. Three-dimensional transvaginal ultrasound allows detailed evaluation of pelvic organs. Office hysteroscopy is the gold standard tool for visualization of intracavitary lesions and the cervical canal in an office-based environment. Aim of The Work: It was to compare between three-dimensional ultrasound (3D USS) and hysteroscopy for evaluation of the intrauterine cavity after trial of ICSI and to study the accuracy of diagnostic test in a tertiary care facility. Patients and Methods: It was a prospective; blinded; controlled clinical trial comparative study. Both hysteroscopy and 3D USS procedures were done for uterine cavity assessment after failed attempt of ICSI treatment for fifty two asymptomatic infertile women. Results: Seventeen cases of our studied patients were without intracavitary or cervical lesions. From all studied cases, lesions (n=66) were seen either by hysteroscopy or by 3D USS where lesions (n=24) were seen by hysteroscopy and seen by ultrasound. Lesions (n=34) were seen by hysteroscopy. Lesions (n=36) were seen by ultrasound. Measure of agreement of Kappa was 0.273. Overall sensitivity of 3D USS was 70.59% and specificity 62.50% with positive predictive value (PPV) 66.67% and negative predictive value (NPV) 66.67%, accuracy was 66.67%, positive likehood ratio (LR+ve) 1.88% and negative likehood (LR-ve) 0.47%. The pvalue was 0.026, which is statistically significant. Conclusion: It is important to investigate the uterine cavity in infertile women with history of unsuccessful ICSI. 3D USS has a good sensitivity and specificity for diagnosis of uterine cavity abnormalities and it could be used before hysteroscopy as a first line of investigation of intrauterine lesions. [ABSTRACT FROM AUTHOR]

Objective: To gain insight in the current ideas on, and implementation of hysteroscopy amongst practicing gynaecologists in the Netherlands and Flanders.Study Design: In August 2016 an electronic questionnaire was sent to practising gynaecologist members of the Dutch (N = 591) and Flemish (N = 586) Society of Obstetrics and Gynaecology.Results: The response rate for the Netherlands was 15.4% (91/591), and for Flanders 27.0% (158/586). Responding gynaecologists have a preference for hysteroscopy for diagnosing and treating most intrauterine pathology. Flemish respondents are more hesitant in opting for hysteroscopy instead of curettage for treatment of polyps and placental remnants. There appears to be a wide diffusion of diagnostic and basic operative hysteroscopy. In contrast to Flanders, responding hysteroscopists from the Netherlands more often perform office hysteroscopic procedures. Hysteroscopic procedures, and office procedures in particular, are now educated during residency. Therefore, recently graduated gynaecologists have a preference for this technique.Conclusion: Our survey confirms that nowadays the focus of treating intrauterine pathology is on less invasive techniques and preserving the uterus. Dutch responding hysteroscopists have more expertise concerning office hysteroscopy than their Flemish colleagues. Future research on the cost-effectiveness of and optimisation of patient comfort during office hysteroscopy is needed to support its further implementation. [ABSTRACT FROM AUTHOR]

The article presents a study which examined the feasibility of T2 relaxometry mapping of the uterus and showed its diagnostic utility in endometrial carcinoma and adenomyosis. Topics discussed include cases of patients with endometrial carcinoma, the use of T2 relaxometry in neuroradiology, and importance of T2 mapping of the myometrium in the diagnosis of myometrial invasion.

Abstract: We conducted a questionnaire survey on the current obstetric management of preterm labor (PL) and preterm premature rupture of the membranes (pPROM). The questionnaire covered approximately a third of all preterm deliveries and nearly half of the preterm deliveries before 32 gestational weeks. The diagnostic criterion for PL was either painful uterine contractions or cervical dilatation. Tocolytic agents were primarily used as long‐term maintenance therapy. Intrauterine infection was clinically diagnosed at most responding institutions. Amniocentesis was performed for PL or pPROM at only a small number (10%) of institutions. Prenatal steroids were administered for PL or pPROM, if indicated, at approximately 40–60% of responding institutions. Prophylactic antibiotics to maintain pregnancy were administered for pPROM at approximately 90% and for PL at approximately 20% of institutions. Maintenance therapy with a tocolytic agent was used for pPROM at approximately 90% of institutions. [ABSTRACT FROM AUTHOR]

The article reports evaluates the TruClearTM system from Medtronic Pvt. Ltd., and outlines the features of the product.

A description of normal ultrasonographic alternations of the uterus in the postpartum (PP) in buffaloes is essential for the diagnosis of pathological conditions and improves the ability to differentiate puerperal pathology from normal physiological changes. The current study aimed to characterize the changes in uterine features assessed ultrasonographically in normal parturient Egyptian buffaloes (n=20) during the post-calving period (Until Day 60 PP). In the current data, ultrasonographic findings indicated that the uterine involution was completed at 4-6 weeks PP in normal calved Egyptian buffaloes. Moreover, calving during the spring season and female new born calves were associated with an enhanced uterine involution. Early cyclicity positively influences endometrial thickness (during early PP), dorsal and ventral uterine curvature, and uterine lumen diameter (during late PP) as compared with the late cyclic group. In conclusion, the uterine involution is ended by the 6th weeks PP in normal parturient Egyptian buffaloes. Moreover, season and calves gender implicate in the changes associated with uterine involution in buffaloes. It is extremely recommended to employ ultrasound examinations in the dairy herd to improve the reproductive efficiency of females by reducing the days open and increasing the number of milking animals. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether offspring of women with müllerian anomalies are at an increased risk for long-term pediatric morbidity.Study Design: A population-based cohort study compared the incidence of long-term (up to the age of 18 years for offspring) hospitalizations due to cardiovascular, endocrine, neurological, hematological, respiratory and urinary morbidity of offspring to mothers diagnosed with uterine anomalies. Deliveries occurred between the years 1991 and 2013 in a tertiary medical center. Multiple pregnancies, unknown gestational age, gestational age of less than 24 weeks, perinatal mortality, and fetuses with congenital malformations were excluded. Kaplan-Meier survival curves were used to compare cumulative morbidity incidence. Survival analysis for clustered data was performed for each major-system pediatric hospitalization.Results: During the study period 253,808 deliveries met the inclusion criteria; 0.48% (n=1230) of which occurred in women diagnosed with müllerian anomalies. In the Kaplan-Meier survival curve, children born to mothers with müllerian anomalies did not have a significantly different cumulative incidence of any of the long-term pediatric morbidities, compared with the comparison group. In the multivariable survival analysis for clustered data, after adjustment of maternal clusters, maternal age, gestational age and birthweight, müllerian anomalies did not exhibit an independent association with long-term morbidities of the offspring.Conclusion: Müllerian anomalies do not appear to have an independent impact on long-term morbidity of the offspring. [ABSTRACT FROM AUTHOR]

Background Hysterosalpingography (HSG) is the most frequently used diagnostic measure for simultaneously determining uterine abnormalities and tubal status among subfertile women. Despite several broader advantages such as availability and increased experience, the subjectivity involved during administration of the HSG procedure itself, and necessary imaging review, decreases the reliability and accuracy of HSG. In this study, we evaluated the time intervals between X-ray imaging during HSG procedure to establish the presence of distal tubal occlusion. Methods Our study evaluated the HSG records of 89 women who underwent diagnostic laparoscopy for infertility work-up. Patients who were diagnosed with distal tubal occlusion upon receiving HSG and patients who demonstrated tubal patency on HSG were included in the study, to compare the time intervals in seconds from the tubal visualization view to the last fluoroscopic X-ray shot during the HSG procedure with tubal patency on diagnostic laparoscopy. Results A statistically significant correlation regarding tubal patency between HSG procedures and diagnostic laparoscopy chromopertubation procedures was demonstrated. Although nearly statistically significant, the interval in seconds between the first HSG imaging and distal tubal filling was shorter for patients with patent tubes on diagnostic laparoscopy than patients with bilateral tubal occlusion (8.4 ± 31.9 and 12.0 ± 19.7, respectively; p = 0.057). Time period intervals between the first and the last HSG, and between distal tubal filling to the last HSG of patients with patent tubes on diagnostic laparoscopy and patients with bilateral distal tubal occlusion were found to be statistically similar. Conclusion Although a trend exists towards shorter time period intervals between the first uterine visualization and distal tubal filling graphy among patients with tubal patency, rather than patients with distal tubal occlusion confirmed by diagnostic laparoscopy, clinically reliable objective time period intervals for finalizing the HSG procedure and proceeding with diagnostic laparoscopy due to distal tubal occlusion diagnosis on HSG could not be detected. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of hysteroscopy for the detection and treatment of endometrial polyps versus expectant management in women with postmenopausal bleeding (PMB), a thickened endometrium and benign endometrial sampling.Design: Multicentre, randomised controlled trial.Setting: Three academic hospitals and nine non-academic teaching hospitals in the Netherlands.Population: Women with PMB, an endometrial thickness >4 mm and benign result from endometrial sampling.Methods: Women were randomised to either further diagnostic workup by hysteroscopy (preceded by saline infusion sonography) or expectant management.Main Outcomes: The primary outcome measure was recurrence of PMB within a year after randomisation. Secondary outcome measures were time to recurrent bleeding and recurrent bleeding after more than 1 year. In the hysteroscopy group, the presence of polyps and the results of their histology were registered.Results: Between January 2010 and October 2013, 200 women were randomised; 98 to hysteroscopy and 102 to expectant management. Within 1 year a total of 15 women (15.3%) in the hysteroscopy group experienced recurrent bleeding, versus 18 (18.0%) in the expectant management group (relative risk 0.85 (95% CI 0.46-1.59). In the hysteroscopy group, 50/98 (51%) polyps were diagnosed of which 6/98 (6%) showed evidence of endometrial (pre)malignancy; final pathology results after hysterectomy showed three women with hyperplasia with atypia and three women with endometrial cancer.Conclusion: In women with PMB, a thickened endometrium and benign endometrial sampling, operative hysteroscopy does not reduce recurrent bleeding. Hysteroscopy detected focal endometrial (pre)malignancy in 6% of women who had benign endometrial sampling. This finding indicates that in these women, further diagnostic workup is warranted to detect focal (pre)malignancies, missed by blind endometrial sampling.Tweetable Abstract: In women with PMB, hysteroscopy does not reduce recurrent bleeding but is warranted to detect focal malignancy. [ABSTRACT FROM AUTHOR]

Background: Hysteroscopic reliability may be influenced by the experience of the operator and by a lack of morphological diagnostic criteria for endometrial malignant pathologies. The aim of this study was to evaluate the diagnostic accuracy and the inter-observer agreement (IOA) in the management of abnormal uterine bleeding (AUB) among different experienced gynecologists.Methods: Each gynecologist, without any other clinical information, was asked to evaluate the anonymous video recordings of 51 consecutive patients who underwent hysteroscopy and endometrial resection for AUB. Experts (>500 hysteroscopies), seniors (20-499 procedures) and junior (≤19 procedures) gynecologists were asked to judge endometrial macroscopic appearance (benign, suspicious or frankly malignant). They also had to propose the histological diagnosis (atrophic or proliferative endometrium; simple, glandulocystic or atypical endometrial hyperplasia and endometrial carcinoma). Observers were free to indicate whether the quality of recordings were not good enough for adequate assessment. IOA (k coefficient), sensitivity, specificity, predictive value and the likelihood ratio were calculated.Results: Five expert, five senior and six junior gynecologists were involved in the study. Considering endometrial cancer and endometrial atypical hyperplasia, sensitivity and specificity were respectively 55.5 % and 84.5 % for juniors, 66.6 % and 81.2 % for seniors and 86.6 % and 87.3 % for experts. Concerning endometrial macroscopic appearance, IOA was poor for juniors (k = 0.10) and fair for seniors and experts (k = 0.23 and 0.22, respectively). IOA was poor for juniors and experts (k = 0.18 and 0.20, respectively) and fair for seniors (k = 0.30) in predicting the histological diagnosis.Conclusions: Sensitivity improves with the observer's experience, but inter-observer agreement and reproducibility of hysteroscopy for endometrial malignancies are not satisfying no matter the level of expertise. Therefore, an accurate and complete endometrial sampling is still needed. [ABSTRACT FROM AUTHOR]

Torsion of a nongravid uterus is rare, as most cases of uterine torsion occur during pregnancy. We report a case of a large ovarian cyst causing uterine torsion, infarction, and rupture. A 57-year-old woman presented with acute-onset abdominal pain and increasing abdominal girth over the past year. Contrast-enhanced computed tomography (CT) demonstrated axial rotation and swirling of the uterus and the mesenteric fat, leading to a preoperative diagnosis of uterine torsion. Laparotomy confirmed that the uterine corpus had undergone a 180-degree axial rotation, and further revealed uterine wall infarction and rupture into the endometrium as well as partial decapitation of the uterus from the cervix. The swirled appearance of the uterus, radiologically similar to the 'whirlpool sign' seen in bowel volvulus, is an important CT finding to recognize, especially in view of the risk of irreversible ischemic complications this uncommon entity may inflict on the uterus. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of the study was to assess the diagnostic performance of qualitative and quantitative diffusion-weighted imaging (DWI) in differentiating benign from malignant ovarian and uterine masses. Materials and methods: Institutional review board approval was obtained for this HIPAA-compliant retrospective study, with waiver of informed consent. DWI MRIs of 222 women acquired over 1.5 years were evaluated. Reference standard was pathology or follow-up imaging. For qualitative assessment, two radiologists independently reviewed DWI and apparent diffusion coefficient (ADC) images for diffusion restriction. Differences were resolved by consensus. For quantitative assessment, a single reader measured ADC values. Readers were blinded to the reference standard. Results: 222 lesions, 121 ovarian (99 benign and 22 malignant) and 101 uterine (54 benign and 47 malignant), were included. Final diagnosis was established with pathology in 129 (58%) or with imaging follow-up in 93 (42%). Mean (range) follow-up interval was 27 (13-48) months. Qualitative assessment yielded sensitivity (ratio, 95% CI), specificity, PPV and NPV of 100% (22/22, 85-100), 68% (68/99, 58-76), 41% (22/54, 27-54), and 100% (68/68, 94-100) for ovarian and 94% (44/47, 83-98), 91% (49/54, 80-96), 90% (44/49, 78-95) and 94% (49/52, 84-98) for uterine malignancies. ADC (mean ± SD) between benign ovarian [(1.11 ± 0.76) × 10 mm/s] vs. malignant [(0.71 ± 0.26) × 10 mm/s] lesions was significantly different ( p < 0.001). ADC cutoff value of 1.55 × 10 mm/s for ovarian lesions resulted in 99.9% confidence for the absence of malignancy. ADC (mean ± SD) of benign uterine [(0.64 ± 0.38) × 10 mm/s] vs. malignant [(0.68 ± 0.19) × 10 mm/s] lesions was not significantly different ( P < 0.54). Conclusion: Quantitative and qualitative DWI assessment can be used to confidently characterize a subset of ovarian lesions as benign. With uterine lesions, although DWI is useful in differentiating benign from malignant lesions, the technique does not allow for definitive quantitative characterization. [ABSTRACT FROM AUTHOR]

Introduction: Women with postmenopausal bleeding and endometrial thickness >4 mm undergo endometrial sampling to exclude endometrial cancer. The aim of this study is to investigate the relative risk of developing endometrial cancer in a prospective cohort after initial work-up for postmenopausal bleeding showing reassuring histology or insufficient sampling.Material and Methods: All women presenting with postmenopausal bleeding were prospectively included from January 2009 to April 2011. Follow-up data were collected from patient charts and PALGA (Dutch Pathology Registry). Hazard ratios for endometrial cancer were determined by calculating standardized incidence ratios.Results: A total of 668 women were included and 568 women were available for follow-up [median follow-up time 47 (range 7-63) months]. Women who presented with postmenopausal bleeding, endometrial thickness >4 mm and hyperplasia without atypia on biopsy at the first presentation showed a significantly increased risk (standardized incidence ratio 17.15, 95% confidence interval 1.96-61.93) of being diagnosed with endometrial cancer during the first four years of follow up compared with the age-specific population. All women that developed endometrial cancer after initial reassuring histology presented with recurrent postmenopausal bleeding. None of the women with endometrial thickness >4 mm and no or insufficient sample for histology at the first presentation developed endometrial cancer during the follow up.Conclusions: Although in general, women with endometrial hyperplasia without atypia are considered to have a low risk for cancer, we observed a significant long-term risk of endometrial cancer after postmenopausal bleeding. Whether additional diagnostics or a more stringent follow-up regimen would be cost-effective, needs to be studied. [ABSTRACT FROM AUTHOR]