Endometrial thickness after misoprostol use for early pregnancy failure.

OBJECTIVES: To assess if there was any potential relationship between endometrial thickness and final treatment outcome in women successfully treated with misoprostol for a first trimester anembryonic gestation, embryonic demise or fetal demise. METHODS: Eighty women were treated with up to two doses of misoprostol 800 microg vaginally for early pregnancy failure. Subjects were scheduled to return 2 (range 1-4), 7 (range 5-9) and 14 (range 12-17) days after treatment. Transvaginal ultrasonography was performed at each follow-up visit. RESULTS: The median endometrial thickness at each of the follow-up visits for women who had expelled the gestational sac was 14 mm, 10 mm, and 7 mm, respectively. The endometrial thickness at the first follow-up visit exceeded 15 mm in 20 subjects (36%) and 30 mm in four subjects (7%). Only three women had a suction aspiration for bleeding after documented expulsion. The endometrial thickness for these women was 11, 13, and 14 mm at the first follow-up visit. CONCLUSIONS: There is no obvious relationship between increasing endometrial thickness and the need for surgical intervention in women treated with misoprostol for early pregnancy failure.

Vasopressin during abdominal hysterectomy: a randomized controlled trial.

OBJECTIVE: To investigate if the use of vasopressin during abdominal hysterectomy would decrease blood loss. METHODS: Fifty-one patients undergoing abdominal hysterectomy with the diagnosis of leiomyomatous uterus were randomized and received either vasopressin 10 units/10 mL of normal saline or 10 mL of normal saline, injected 5 mL bilaterally, 1 cm medial to the uterine vessels into the lower uterine segment. The sample size was determined assuming a one-third reduction in total blood loss would be clinically relevant. A power analysis determined that 25 patients would be required in each group to assure a power of 0.80, at the.05 significance level. RESULTS: Overall, the two groups were very similar with regard to their demographics, preoperative diagnosis, and relevant findings at the time of surgery. The mean total blood loss in the vasopressin and placebo groups was 445.41 mL and 748.42 mL, respectively. Total blood loss was significantly decreased by 40% in the vasopressin group compared with the placebo group (P <.001). There was no statistically significant difference between the two groups with respect to possible confounding variables or surgical complications. CONCLUSION: Injection of vasopressin into the uterus at the time of abdominal hysterectomy significantly reduces blood loss without increasing morbidity. We have shown that it is a useful adjunct during abdominal hysterectomy.

Early pregnancy failure--current management concepts.

Approximately one in four women will experience a miscarriage during her lifetime. For more than 50 years, the standard management of early pregnancy failure has been a dilatation and curettage (D & C). Typically, the procedure is performed in an operating room, which significantly increases cost. There is little objective information in the modem literature to prove that a D & C for all patients will lower morbidity or improve emotional well being. Treatment options include expectant management, D & C in an outpatient setting, and medical management with misoprostol (not approved by the U.S. Food and Drug Administration for treatment of early pregnancy failure). The medical literature supports that expectant management may result in more complications, including the need for "emergent" curettage, if clinicians do not understand the true normal course of expectant management. In general, women prefer some form of active management. Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration. Vaginal misoprostol will cause expulsion in 80% to 90% of women up to 13 weeks' uterine size or gestation, including patients who have a gestational sac present. However, these data come from only three trials involving a total of 42 subjects treated with vaginal misoprostol, and another study of 42 women who received vaginal misoprostol for "missed abortion" before a scheduled D & C. There is a significant lack of information from large-scale studies about when treatment is necessary and the relative efficacy, rates of side effects, and acceptability of these various treatment options for early pregnancy failure.

The vulvar mass in the prepubertal child.

The differential diagnosis of the vulvar mass in the prepubertal patient is extensive and reported cases of a vulvar hamartoma in the literature are limited. The case presented in this work and review of the literature demonstrate that when considering the differential diagnosis of vulvar masses in the prepubertal female, hamartoma should be included. This review outlines the differential diagnosis of the vulvar mass and gives a comprehensive review of benign masses arising from embryonic remnants, those of mesenchymal origin as well as sarcoma botryoides-embryonal rhabdomyosarcoma and the embryonal sinus tumor.

A randomized, prospective comparison of pain after gasless laparoscopy and traditional laparoscopy.

STUDY OBJECTIVE: To compare pain after laparoscopic tubal ligation by gasless laparoscopy versus carbon dioxide (CO2) pneumoperitoneum. DESIGN: Prospective, randomized, single-blind comparison (Canadian Task Force classification I). SETTING: Private obstetric-gynecology hospital associated with a university resident teaching program. PATIENTS: Women age 21 to 42. INTERVENTION: Single-puncture laparoscopic tubal ligation was performed with a silicone elastomer band. Gasless laparoscopy was performed with a Laprolift and traditional laparoscopy with CO2 pneumoperitoneum. Postoperative pain in the shoulder and periumbilical and lower pelvic regions was measured by visual analog scale on the day of surgery and postoperative days 1, 2, 3, 7, and 14. MEASUREMENTS AND MAIN RESULTS: Of the 67 patients, 54 provided visual analog scales for analysis, 30 in the gasless group and 24 in the traditional group. No statistical difference was seen in scores for shoulder, periumbilical, and pelvic pain between techniques. CONCLUSION: Patients undergoing gasless laparoscopy and traditional laparoscopy experience similar postoperative pain.

Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer.

OBJECTIVE: To evaluate the sensitivity of the Pipelle endometrial suction curette in the detection of endometrial carcinoma in patients with known endometrial cancer. STUDY DESIGN: A study was conducted using patients with known endometrial cancer undergoing a hysterectomy as part of a formal staging procedure. Endometrial biopsies were performed prior to each surgical procedure. Biopsy results were compared to the hysterectomy specimen for specimen adequacy and final histologic diagnosis. RESULTS: The Pipelle biopsy was adequate for analysis in 63 of 65 patients (97%). Malignancy was detected by biopsy in 54 of 65 patients, for a sensitivity of 83 +/- 5% (mean +/- SD). Of the 11 patients with false negative results, 5 had tumors present in only an endometrial polyp. Three of the 11 patients had disease localized to < 5% of the surface area of the endometrium. CONCLUSION: The Pipelle endometrial suction curette is an effective office device for evaluating patients at risk of endometrial cancer; however, tumors localized to a polyp or small area of endometrium may go undetected.

Reproductive function and outcome of pregnancy after liver transplantation in women.

OBJECTIVE: To discuss menstrual function before and after liver transplantation, immunosuppression during pregnancy, outcome and management of pregnancy, and use of contraception in women after liver transplantation. MATERIAL AND METHODS: We review the relevant medical literature and describe our clinical experience in the management of gynecologic and obstetric issues in recipients of liver transplants. RESULTS: Menstrual abnormalities, such as amenorrhea, oligomenorrhea, irregular bleeding, and metrorrhagia, are common in women with liver disease and may often be the first clinical indication of liver dysfunction. Normal menstrual function is frequently restored after transplantation. Successful pregnancies have occurred in recipients of liver transplants, but such pregnancies are often complicated by preterm delivery, preeclampsia, and infection. Use of immunosuppressive medications should be maintained during pregnancy, and drug concentrations should be carefully monitored; none has been found to be teratogenic. Pregnancy does not seem to accelerate graft rejection. Barrier contraception or sterilization, if appropriate, seems to be the safest option for these patients. CONCLUSION: Because liver transplantation leads to restoration of normal menstruation, female patients of reproductive age must be counseled about the possibility of pregnancy and the use of contraception. Pregnancy should be avoided for at least the first 6 months after transplantation. With specialized care and attention, pregnancies are generally associated with good outcomes.