Serious and deadly complications from pregnancy after endometrial ablation: two case reports and review of the literature.

Endometrial ablation (EA) has been performed for the past two decades as an alternative to hysterectomy in women with dysfunctional-uterine bleeding unresponsive to medical treatment. However, unlike hysterectomy, this minimally invasive procedure is not an effective means of contraception. Pregnancy following EA has been reported, but the risks and complications related have not been emphasized. This is a report on two such cases and review of the literature, with a closer look at the frequent negative outcome. A 25-year-old woman underwent EA for dysfunctional-uterine bleeding unresponsive to medical treatment. She had no previous surgery, specifically she had no past myomectomy or caesarean section. She declined concomitant tubal ligation. She became pregnant five years later in early spring 2007 and sustained a large uterine rupture at 24 weeks and died in June 2007 secondary to massive internal bleeding at age 29. A 34-year-old woman with previous hysteroscopic EA became pregnant less than one year after surgery. At that time, she had refused concomitant tubal sterilization since her husband had a vasectomy. Unfortunately, the relationship ended soon after surgery and she had unprotected sexual intercourse with a new partner. Pregnancy termination was complicated by placenta increta, which required immediate abdominal hysterectomy. Pregnancy after EA is not a rare occurrence, regardless of which technique is used. Whether women choose to go on or terminate their pregnancy, this clinical situation can be associated with serious complications and even maternal death. Counselling about contraceptive options at the time of EA is paramount.

Functional characterization of prostaglandin transporter and terminal prostaglandin synthases during decidualization of human endometrial stromal cells.

BACKGROUND: Decidualization of endometrial stromal cells is essential for successful implantation and pregnancy. Prostaglandins (PG) have been shown to be required for the initiation and maintenance of decidualization in animal models. The transport of PG across the plasma membrane is mediated by carriers such as prostaglandin transporter (PGT). Our recent data have shown the expression of human PGT (hPGT) in the endometrium during the menstrual cycle. The objective of the present study was to characterize hPGT in decidualized stromal cells. METHODS AND RESULTS: Human endometrial stromal cells were treated with a combination of cAMP and medroxyprogesterone acetate to induce decidualization. Decidualization was confirmed by morphological differentiation and increased secretion of prolactin. A large increase in hPGT mRNA level, as measured by real-time PCR analysis, was observed in decidual cells compared with control. Similarly, a 2-fold up-regulation of hPGT and 3-12-fold increase in PG biosynthetic enzymes were obtained at the protein level. Decidual cells exhibited a higher isotopic PGE2 uptake and greater intracellular PG levels than control. CONCLUSIONS: The higher uptake of PG by decidual cells is highly likely to be mediated via hPGT. PGT is a newly identified regulator of PG action at the cellular level and likely contributes to the regulation of PG action in female reproductive processes.

Assessment and comparison of intraoperative and postoperative pain associated with NovaSure and ThermaChoice endometrial ablation systems.

STUDY OBJECTIVE: To assess and compare intraoperative and postoperative pain associated with NovaSure impedance-controlled endometrial ablation system and ThermaChoice system. DESIGN: Prospective, international, multicenter, double-arm study (Canadian Task Force classification II-1). Setting. Academic medical centers and private offices. PATIENTS: Sixty-seven premenopausal women with menorrhagia. INTERVENTION: Endometrial ablation with either the NovaSure (37 women) or ThermaChoice (30) system. NovaSure-treated patients received no endometrial pretreatment; those treated with ThermaChoice received the recommended 3-minute suction dilatation and curettage. MEASUREMENTS AND MAIN RESULTS: Standard pain measurement instruments (visual analog scale, numeric rating scale) were used to assess intraoperative and postoperative pain. Serum levels of prostaglandin-F(2alpha) were measured before and 5, 30, and 60 minutes after the procedure. Patients treated with the NovaSure system reported statistically significantly lower intraoperative and postoperative pain than those treated with the ThermaChoice system (p <0.0001). Procedure time was statistically significantly shorter with the NovaSure system (p <0.0001). Prostaglandin-F(2alpha) values did not differ statistically between groups. CONCLUSION: The NovaSure system is associated with statistically significantly lower intraoperative and postoperative pain than ThermaChoice system, and endometrial ablation with NovaSure could become an office-based procedure.