Nonresective treatments for uterine fibroids: a systematic review of uterine and fibroid volume reductions.

Patients are increasingly seeking uterus-preserving, minimally invasive treatments for symptomatic uterine fibroids. This has led to a greater use of nonresective treatments such as uterine artery embolization (UAE), focused ultrasound (FUS) and more recently, radiofrequency ablation (RFA) of fibroids. This systematic review, following PRISMA guidelines, examines the change in uterine and fibroid volumes associated with UAE, FUS, and RFA. Pubmed and MedlinePlus databases were searched from 1956 to 2016. The keywords used were 'radiofrequency ablation,' 'magnetic resonance guided focused ultrasound,' 'ultrasound guided focused ultrasound', 'uterine artery embolization,' 'uterine fibroid embolization,' and 'leiomyoma' or 'fibroid'. Publications with at least 20 patients were included. Data were collected and analyzed using Microsoft Excel® (Microsoft Corporation, Redmond, WA) software. Eighty-one relevant papers were identified: 52 related to UAE, 11 to RFA, 17 to FUS, 1 compared UAE and FUS. We report the published uterine volume and fibroid volume changes seen in these studies at 1 to 36 months. The pooled fibroid volume reductions at six months seen with RFA were 70%, UAE 54% and FUS 32%. All three types of nonresective treatment result in fibroid volume reduction. However, fibroid volume reduction is most marked with RFA, with UAE resulting in the next most volume reduction. Additional larger cohort studies, including those that are randomized and/or comparative, would enable definitive conclusions. This is the first systematic review comparing uterine and fibroid volume reduction after RFA, UAE and MRgFUS.

Adnexal mass during pregnancy: a review.

OBJECTIVE: The purpose of this review was to determine the likelihood of malignancy or complications with ultrasonographic diagnosis of adnexal masses in pregnancy and to evaluate the obstetrical outcomes. Materials and METHODS: A review of literature was performed using keywords "adnexal mass and pregnancy" or "ovarian mass and pregnancy." RESULTS: Out of the 340 abstracts reviewed, 313 were excluded. The incidence of adnexal mass in pregnancy varied from 0.1 to 2.4%, with an average of 0.02%. Regarding the likelihood of malignancy, in seven publications, there were 557 women with 563 adnexal masses. Of these 563 masses, 48% were classified as simple and 52% as complex. Among the simple masses, 1% were malignant. Among the complex masses, 9% were malignant. When comparing laparoscopy and laparotomy, the rate of preterm contractions was found to be higher in patients undergoing laparotomy and this was statistically significant. Other measures, such as spontaneous abortion, vaginal bleeding, < 37 week delivery, and intrauterine fetal demise, were not found to have a significant difference. CONCLUSION: Adnexal masses in pregnancy occur infrequently and depending on whether the surgery was performed emergently or electively, via laparoscopy or laparotomy, the outcomes will vary.

Orientation of the uterine fundus in reference to the longitudinal axis of the body: a 3-dimensional sonographic study.

OBJECTIVES: The aim of this pilot study was to measure the angle of rotation of the uterus at the fundus from horizontal using 3-dimensional sonography in women presenting for annual gynecologic examinations. METHODS: A total of 51 patients participated in the study. All patients underwent transvaginal sonography, and 3-dimensional volumes were acquired. The cervicouterine angle and the angle of rotation at the fundus were measured. RESULTS: The uteri were noted to be anteverted in 64.7%, retroverted in 25.5%, and euverted in 9.8%. They were noted to be pointing toward the right side of the pelvis in 49.0%, to the left side in 39.2%, and at the midline in 11.8%. The median cervicouterine angle was 122° (interquartile range [IQR], 105°-137°). The median angle of rotation at the fundus away from horizontal in either a clockwise or counterclockwise direction on the transverse B-plane was 10.4° (IQR, 7.1°-19.0°), with a maximal angle of 43°, and on the coronal C-plane, it was 10.0° (IQR, 3.0°-20.0°), with a maximal angle of 43°. Noneuverted uteri were more likely to be rotated at the fundus. CONCLUSIONS: Our study reveals that, contrary to traditional thinking, the uterus can be rotated at the fundus in relation to the body (z-axis) along the longitudinal axis of the cervical canal.

Imaging for uterine myomas and adenomyosis.

Uterine myomas and adenomyosis are common findings, in particular in patients with symptoms of abdominal enlargement, pelvic pressure, abnormal uterine bleeding, dysmenorrhea, and dyspareunia. Diagnosis and differentiation between the 2 entities are critical in establishing treatment options and the operative approach for surgical management. Herein are reviewed diagnostic options, their relative accuracy, and the effect of accurate diagnosis on treatment. A review was performed using PubMed, MdConsult, OVID, and reviews including cross-referenced articles and prospective and retrospective studies published from 1980 to 2013. Also reviewed are use of ultrasound with its various methods, magnetic resonance imaging, computed tomography, and positron emission tomography in the diagnosis, pretreatment evaluation, and differentiation of myomas and adenomyosis.

Knowledge gap of recommendations in ACOG practice bulletins: a survey of members of the Central Association of Obstetricians and Gynecologists.

The purpose of this survey was to assess the knowledge gap of recommendations in practice bulletins (PBs). A survey consisting of three questions for 12 selected PBs (six obstetric and six gynecologic) was developed and sent to members of the Central Association. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Of the 385 active members, 100 (26%) returned the survey. The overall correct score was 49%. Respondents were significantly more likely to know recommendations in obstetric PBs (60%) than gynecologic PBs (39%; OR 2.45, 95% CI 2.12-2.81). Maternal-fetal medicine sub-specialists (n=27), compared with obstetricians-gynecologists (n=66), did significantly better with obstetric PBs (67% vs. 59%; OR 1.42, 95% CI 1.32-1.77) and substantially worse with gynecologic topics (34% vs. 39%; OR 0.79, 95% CI 0.63-0.98). In conclusion, since members of the Central Association have a substantial knowledge gap, there are ample opportunities to educate and reinforce PB recommendations.

To forget is human: the case of the retained bulb.

The scenario of a forgotten instrument or foreign body has plagued surgical procedures from the early days. It has been estimated that the incidence of retained foreign bodies is around one in every 1,000-1,500 intra-abdominal operations and can be expected to occur at least once per year in hospitals where 8,000-18,000 major surgeries are performed annually. We report a case of a forgotten asepto bulb in the vagina following a robot-assisted total laparoscopic hysterectomy.

Comparison of urinary and recombinant human chorionic gonadotropin during ovulation induction in intrauterine insemination cycles: a prospective randomized clinical trial.

OBJECTIVES: To compare the in vivo effectiveness of recombinant (r) hCG with urinary (u) hCG during controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) cycles. DESIGN: Prospective controlled clinical study. SETTING: Private IVF center. PATIENT(S): Two hundred eighty-four subjects undergoing COH-IUI cycles. INTERVENTIONS(S): Women were randomized into receiving r-hCG or u-hCG for final maturation and induction of ovulation. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate and outcome of pregnancy. RESULT(S): Background characteristics were similar in the two groups studied except for a slight difference in the mean duration of infertility (3.0 vs. 2.3). There was no significant difference in the number of follicles > or =16 mm, mean peak E(2), or mean 1-week P levels between the two groups. The clinical pregnancy rate was 27.1% in the recombinant group compared with 28.5% in the urinary group. The outcome of pregnancy was similar in both groups. CONCLUSION(S): Recombinant hCG was found to be as effective as u-hCG in achieving pregnancy during COH-IUI cycles. This is in agreement with earlier studies on the effectiveness of r-hCG in IVF cycles.

Adverse maternal and neonatal outcome of prolonged course of magnesium sulfate tocolysis.

BACKGROUND: Magnesium sulfate continues to be widely used as a tocolytic agent despite a paucity of evidence supporting its use. Many practitioners use prolonged courses of magnesium sulfate, sometimes for months. This study was conducted to determine maternal and neonatal outcome of patients exposed to prolonged tocolytic magnesium sulfate. METHODS: A retrospective review of maternal and neonatal charts (1995-2003) of pregnancies that received tocolytic magnesium sulfate. Cases who received magnesium sulfate >48 h (n=78) were compared to controls who received it < or =48 h (n=77) for maternal side effects and neonatal outcome. RESULTS: Cases were more likely to be nulliparous (55.1% versus 37.7%, p=0.044), multiple gestations (33.3% versus 10.4%, p=0.001), and of lower gestational age (29.0+/-3.9 versus 30.5+/-3.8 weeks, p=0.017) compared to controls. The median magnesium sulfate infused was 154 (78-5,500) versus 54 (8-86) g (p<0.001) and the highest maternal magnesium level was 6.5+/-1.7 versus 5.6+/-1.9 mg/dl (p=0.002) in cases and controls, respectively. Cases were more likely to have > or =1 adverse side effect (30.8% versus 15.6%, p=0.045). The median neonatal magnesium level was significantly higher in cases (3.3 (1.4-7.2) versus 2.6 (1.1-5.2) mg/dl, p=0.016); however, neonatal mortality and other neonatal morbidity rates were similar in both groups. Abnormal bone mineralization was encountered in 3 neonates (cases). CONCLUSIONS: Maternal morbidity rate is higher with prolonged intake of tocolytic magnesium sulfate compared to < or =48-h regimen. Despite similar neonatal morbidity and mortality rates, bone demineralization in the neonates may be encountered.

Postpartum splenic rupture.

BACKGROUND: Spontaneous splenic rupture in pregnancy is rare and occurs most commonly in the third trimester or puerperium. CASES: In the first case, an eclamptic woman had postpartum uterine atony that necessitated hysterectomy. She was reexplored for increasing abdominal girth and evidence of hemoperitoneum on computed tomography scan. An actively bleeding defect was noted in the spleen, necessitating splenectomy. In the second case, a patient with cholestasis of pregnancy developed persistent bleeding after manual removal of the placenta, requiring a suction curettage followed by hysterectomy. Reexploration because of a dropping hematocrit revealed a capsular defect on the spleen, for which splenectomy was performed. CONCLUSION: A high index of suspicion of postpartum splenic rupture is imperative because delay in the diagnosis can lead to catastrophic consequences. Thus, it is vital to evaluate the entire abdomen in posthysterectomy hemoperitoneum.