Risk factors for placenta accreta spectrum without prior cesarean section: A case-control study in China.

OBJECTIVE: To identify the risk factors for placenta accreta spectrum (PAS) disorders in women without prior cesarean section (CS). METHODS: This retrospective case-control study investigated patients without prior CS who gave birth at Peking University Third Hospital between January 1, 2015 and December 31, 2021. Patients diagnosed with PAS according to the clinical diagnostic criteria of the 2019 International Federation of Gynecology and Obstetrics (FIGO) classification were included as the study group. Patients were matched as the control group according to delivery date and placenta previa, in a 1:2 allocation ratio. Maternal characteristics were compared between the two groups. RESULTS: The study included 348 patients in the study group and 696 in the control group. The multivariate analysis showed that the independent risk factors of PAS consisted of operative hysteroscopy (once: adjusted odds ratio [aOR] 2.38, 95% CI 1.28-4.24, P = 0.006; twice or more: aOR 5.43, 95% CI 1.04-28.32, P = 0.045), uterine curettage (once: aOR 2.54, 95% CI 1.80-3.58, P < 0.001; twice: aOR 3.01, 95% CI 1.81-5.02, P < 0.001; three or more times: aOR 9.18, 95% CI 4.64-18.18, P < 0.001), multifetal pregnancy (aOR 5.64, 95% CI 3.01-10.57, P < 0.001), adenomyosis (aOR 2.77, 95% CI 1.23-6.22, P = 0.014), in vitro fertilization (aOR 1.51, 95% CI 1.04-2.20, P = 0.030) and pre-eclampsia (aOR 2.72, 95% CI 1.36-5.45, P = 0.005), and the independent protective factor was being multiparous (aOR 0.37, 95% CI 0.25-0.54, P < 0.001). CONCLUSION: After controlling the effect of placenta previa, we found that patients with PAS without prior CS had unique maternal characteristics. Classification and quantification of the intrauterine surgeries they have undergone is essential for identifying high-risk patients. Early identification of high-risk groups by risk factors has the potential to improve the prognosis considerably.

Multidisciplinary perioperative management in dilatation and evacuation for a giant hydatidiform mole: A case report.

Gestational trophoblastic disease (GTD) is an abnormal pregnancy caused by the placenta, which can potentially metastasise. Suction evacuation is recommended for diagnosis and treatment, and dilatation and evacuation (D&E) is usually performed under intravenous anaesthesia due to the short operation time and minimal blood loss. We refer to the guidelines produced by the Japan Society of Obstetrics and Gynaecology (JSOG), and acknowledge that practices vary globally. However, to the best of our knowledge, there is no evidence on perioperative management and arrangements in D&E required for managing giant hydatidiform moles, such as preventing massive haemorrhage, respiratory dysfunction with a pathogenesis like ovarian hyperstimulation syndrome (OHSS), or intensive care needs. This case report describes perioperative considerations for managing a giant hydatidiform mole using D&E in a uterus enlarged to the third-trimester pregnancy size. A 28-year-old multiparous woman was clinically diagnosed with a hydatidiform mole after a spontaneous miscarriage due to abnormal genital bleeding, systemic oedema, and abdominal distention. Ultrasound and computed tomography showed a ballooning uterus with a third-trimester pregnancy size, a robust intrauterine mass, and ascites. Serum hCG levels were extremely high (>3,000,000 mIU/mL), confirming the clinical diagnosis of a hydatidiform mole. Emergency D&E was safely performed under multidisciplinary perioperative management, with careful preparation and support. This is a rare experience-based case report and valuable documentation detailing multidisciplinary perioperative management under general anaesthesia. To the best of our knowledge, this is the first report describing the considerations, details, and innovations required in the perioperative management of giant hydatidiform moles using D&E.

Sharp Versus Electric Suction Curettage in Gynecologic Patients Undergoing Evaluation for Abnormal Uterine Bleeding.

STUDY OBJECTIVE: Suction curettage is preferred over sharp curettage in obstetric settings. We compare the quality of operative tissue sampling between sharp curettage and suction curettage using electric vacuum aspiration for nonobstetric abnormal uterine bleeding in reproductive-aged women. DESIGN: A retrospective cohort study. SETTING: Community hospital in Long Island, New York. PATIENTS: Women ages 21 to 45 years (n = 257) who underwent operative curettage procedure for nonobstetric abnormal uterine bleeding. INTERVENTIONS: Independent ratings of specimens from suction curettage using electric vacuum aspiration and sharp curettage by 2 pathologists blinded to method of tissue collection. MEASUREMENTS AND MAIN RESULTS: The primary outcome was percentage of organized tissue, indicative of a higher-quality pathology specimen. Specimens obtained by electric suction curettage (p <.001) had a significantly higher percentage of organized tissue (M = 66.28, SD = 20.33) than sharp curettage (M = 55.51, SD = 24.17). There were no differences between the curettage groups for operative time, blood loss, intraoperative complications, or pathology diagnosis. CONCLUSION: Specimens obtained with suction curettage contained more organized tissue with similar pathologist satisfaction and confidence scores than sharp curettage. We suggest clinicians consider electric suction curettage in the diagnostic workup of abnormal uterine bleeding in reproductive-aged women. In addition, patient-centered benefits include no increase in operative time, blood loss, or complication rate compared with sharp curettage.

Five-year retrospective review of ultrasound-guided manual vacuum aspiration for first-trimester miscarriage.

INTRODUCTION: Manual vacuum aspiration is increasingly accepted as an alternative to medical or surgical evacuation of the uterus after first-trimester miscarriage. This study aimed to assess the efficacy of ultrasound-guided manual vacuum aspiration (USG-MVA) in the management of first-trimester miscarriage. METHODS: This retrospective analysis included adult women with first-trimester miscarriage who underwent USG-MVA in Hong Kong between July 2015 and February 2021. The primary outcome was the efficacy of USG-MVA in terms of complete evacuation of the uterus, without the need for further medical or surgical intervention. Secondary outcomes included tolerance of the entire procedure, the success rate of karyotyping using chorionic villi, and procedural safety (ie, any clinically significant complications). RESULTS: In total, 331 patients were scheduled to undergo USG-MVA for first-trimester miscarriage or incomplete miscarriage. The procedure was completed in 314 patients and well-tolerated in all of those patients. The complete evacuation rate was 94.6% (297/314), which is similar to the rate (98.1%) achieved by conventional surgical evacuation in a previous randomised controlled trial in our unit. There were no major complications. Samples from 95.2% of patients were suitable for karyotyping, which is considerably higher than the rate of suitable samples (82.9%) obtained via conventional surgical evacuation in our previous randomised controlled trial. CONCLUSION: Ultrasound-guided manual vacuum aspiration is a safe and effective method to manage first-trimester miscarriage. Although it currently is not extensively used in Hong Kong, its broader clinical application could avoid general anaesthesia and shorten hospital stay.

Manual vacuum aspiration (women's MVA) for endometrial biopsy for patients with suspected endometrial malignancies.

AIM: Endometrial biopsy is generally performed with a metal uterine curette sonde; however, recently, many types of vacuum aspirators are available, including the manual vacuum aspiration (MVA) system. We used the women's MVA system for endometrial sampling and evaluated its effectiveness in determining the presence of endometrial malignancy. METHODS: Forty-seven samples were examined using the following procedures after measuring endometrial thickness by transvaginal ultrasonography: fractional curettage biopsy (Bx; 20 samples), total curettage under general anesthesia (T/C; 13 samples), and MVA (14 samples). The quality of the endometrial samples was classified into four types: 1-4, where 1 denoted poor and 4, good quality. RESULTS: The mean score of the MVA group was significantly higher than that of the partial curettage biopsy group (p = 0.0065). No differences were observed between the MVA and total curettage groups (p = 1.00). When patients were divided into two groups according to endometrial thickness (<10 mm or ≥10 mm) and analyzed, both the MVA and T/C groups did not show a significant difference in their scores compared to the Bx group when the endometrial thickness was <10 mm. However, when the endometrial thickness was ≥10 mm, the MVA and T/C groups had significantly better scores than the Bx group (p = 0.0225 and p = 0.0244, respectively). Vagal reflex, as an adverse event, was observed only in two patients in the Bx group (2/20, 10%). CONCLUSION: Considering its quality and safety, Karman-type MVA for endometrial sampling could be an alternative to fractional curettage using a metallic uterine curette sonde.

Intranasal fentanyl for first-trimester uterine aspiration pain: A randomized controlled trial.

OBJECTIVE: To evaluate whether administration of intranasal fentanyl reduces reported pain during first-trimester uterine aspiration. STUDY DESIGN: We conducted a multicenter, randomized, double-blind, placebo-controlled trial of patients with pregnancies less than or equal to 14 weeks gestation seeking uterine aspiration for induced abortion, early pregnancy loss, or failed medication abortion. We randomized participants 1:1 to either intranasal fentanyl 100 mcg or intranasal placebo. All participants received ibuprofen and a standardized paracervical block. The primary outcome was pain indicated at the time of uterine aspiration on a 100 mm visual analog scale (VAS). We designed the study to detect a 15 mm difference in mean pain scores, which required 53 people in each arm for a total of 106 participants. Secondary outcomes included postprocedure pain and patient satisfaction with pain control. RESULTS: From March 2017 through June 2018, we screened 355 people for eligibility and enrolled 107 participants. Those who received intranasal fentanyl reported similar uterine aspiration pain to participants who received placebo (58.4 ± 28.0 fentanyl vs 58.6 ± 24.5 placebo, p = 0.97). Participants who received intranasal fentanyl also reported similar postprocedure pain scores compared to participants who received placebo (19.1 ± 19.4 fentanyl vs 17.2 ± 19 placebo, p = 0.63), and were equally satisfied with procedure pain control (66.8 ± 31.2 fentanyl vs 63.3 ± 29.2 placebo, p = 0.57). CONCLUSION: Intranasal fentanyl did not decrease reported pain with first-trimester uterine aspiration, nor did it decrease postprocedure pain compared to placebo. As an adjunct to ibuprofen and paracervical block, intranasal fentanyl did not improve patient satisfaction with pain control. IMPLICATIONS: Intranasal fentanyl does not reduce reported pain with first-trimester uterine aspiration, however abortion-seeking patients are amenable to receiving intranasal medications for pain management.

A Patient-Centred Approach to Early Pregnancy Loss: The First 18 Months of a Canadian Outpatient Program for Early Pregnancy Loss (OPEL).

OBJECTIVE: Manual vacuum aspiration is a safe surgical option for the management of early pregnancy loss. To provide rapid, patient-centred access to MVA, an Outpatient Program for Early pregnancy Loss ("OPEL") was established at our institution. Objectives were to (1) assess complete uterine evacuation rates; (2) assess complication rates, and (3) assess patient satisfaction with the program. METHODS: With REB approval, a retrospective study was performed. Patient records from the first 18 months of OPEL (November 2015 to April 2017) were reviewed. Anonymous patient satisfaction questionnaires were completed immediately post-procedure. RESULTS: A total of 162 patients received treatment. Missed abortions accounted for 94 cases (58%). Median delay from referral to clinic appointment was 4.0 (interquartile range [IQR] 2.0-6.0) days. Average length of stay was 3.0 (IQR 2.5-3.0) hours. Efficacy of the procedure was 95.1%. Complication rate (immediate and delayed) was 14.2% and included intraoperative hemorrhage (3.1%; 5/162), Asherman's syndrome (1.9%; 3/162), retained products of conception requiring further treatment (4.9%; 8/162), and postoperative infection requiring antibiotic therapy (1.9%; 3/162). A total of 151 post-procedure satisfaction surveys were completed (93%); 100% agreed/strongly agreed that the nursing staff and physicians provided professional and compassionate care; 99.3% were satisfied with their care overall. Qualitative feedback was positive. CONCLUSION: Pregnant patients experiencing early pregnancy loss benefit from safe, timely, accessible, patient-centred care in the outpatient OPEL program. Similar models should be adopted nationally to ensure women experiencing this common pregnancy complication receive safe and compassionate care.

Prophylactic transdermal scopolamine for the reduction of postoperative length of stay after uterine aspiration at Kaiser Permanente Northern California from 2017-2018.

OBJECTIVE: To determine if transdermal scopolamine is associated with decreased postoperative nausea and vomiting and shorter length of stay in the postoperative care unit among patients undergoing uterine aspiration for abortion or early pregnancy loss. STUDY DESIGN: We conducted a retrospective cohort study at an integrated medical center that initiated a protocol to prescribe transdermal scopolamine to patients undergoing uterine aspiration under moderate sedation. We compared outcomes among patients who underwent uterine aspiration in 2017, before the institution enacted the protocol, with their counterparts in 2018, immediately after the institution instated the protocol. We reviewed patient charts for data on the postoperative length of stay, use of additional antiemetics, and a standardized clinician designated postoperative nausea and vomiting score. We analyzed outcomes by relevant demographic and clinical characteristics using chi-square or Fisher's exact tests for categorical variables and t tests for continuous variables. RESULTS: The final sample included 386 patients; 228 who did not receive scopolamine and 158 who did. The cohorts were comparable in terms of demographic and clinical characteristics. The cohort that received transdermal scopolamine had a similar mean postoperative length of stay (75.4 ± 54.1 vs 71.1 ± 50.8 minutes; p = 0.43). There were no differences in the proportions of patients who were provided additional antiemetics (26 ± 11.4 vs 17 ± 10.8; p = 0.84) or had transient vomiting and retching (3 ± 1.9 vs 3 ± 1.3; p = 0.69) between the cohorts. CONCLUSION: We found no evidence that prophylactic transdermal scopolamine reduces postoperative nausea, vomiting, or length of stay among patients undergoing uterine aspiration. IMPLICATIONS: Among patients who underwent uterine aspiration under moderate sedation, use of prophylactic transdermal scopolamine was not associated with shorter postoperative length of stay or lesser use of antiemetics. Prophylactic transdermal scopolamine is not likely to be useful for patients undergoing uterine aspiration and could be an unnecessary cost.

Efecto sedativo de Dexmedetomidina intranasal versus sublingual más Remifentanil-Propofol mediante bombas de infusión

Objetivos: evaluar el efecto de dexmedetomidina sublingual frente a dexmedetomidina vía nasal más remifentanilo -propofol con bomba de infusión en procedimientos ginecológicos. Métodos: ensayo clínico no controlado, doble ciego, prospectivo. 68 pacientes con criterios de inclusión dividas en 3 grupos, grupo A [dexmedetomidina sublingual a 0.75 ug/kg], grupo B [dexmedetomidina vía nasal a 0,9 gg/kg] y grupo C [control] más adición de remifentanil y propofol por bombas de infusión. Análisis estadístico de variables cualitativas con chi cuadrado, variables cuantitativas de distribución libre se usó Kruskal-Wallis y distribución normal Anova. Nivel de confianza del 95 % y margen de error del 9 %. Resultados: edad con un rango de 30 a 32 años, la dosis de inicio y sostén tanto del remifentanilo y propofol se disminuyó hasta la mitad comparada con el grupo control, a predominio en el grupo A. Con poca variabilidad en los parámetros hemodinámicos sin repercusión clínica. Efectos adversos más frecuentes como depresión respiratoria en el grupo control, no se observó analgesia con el uso de dexmedetomidina. Y con menor tiempo de estancia en salas de recuperación en pacientes que se administró dexmedetomidina vía nasal. Conclusiones: la administración sublingual es superior con la nasal debido al menor requerimiento de propofol, menos cambios en la presión sanguínea media, sin efectos adversos que se puedan manejar, con mayor facilidad en su administración. Aunque la administración nasal produce un despertar más rápido y mejor control de la frecuencia cardiaca.

Objectives: to evaluate the effect of sublingual dexmedetomidine versus nasal dexmedetomidine plus remifentanil-propofol infusion pump in gynecological procedures. Methods: Uncontrolled, double-blind, prospective clinical trial. 68 patients with inclusion criteria were divided into 3 groups, group A [sublingual dexmedetomidine at 0.75 ug/kg], group B [nasal dexmedetomidine at 0.9 ug/kg] and group C [control] plus the addition of remifentanil and propofol by infusion pumps. Statistical analysis of qualitative variables with chi- square, quantitative variables with free distribution used Kruskal-Wallis and normal distribution Anova. Confidence level of 95% and margin of error of 9%. Results: age with a range of 30 to 32 years, the starting and maintenance dose of both remifentanil and propofol was halved compared to the control group, mainly in group A. With little variability in hemodynamic parameters without clinical repercussion. The most frequent adverse effects were respiratory depression in the control group, no analgesia was observed with the use of dexmedetomidine. And with a shorter stay in recovery rooms in patients who received nasal dexmedetomidine. Conclusions: sublingual administration is superior to nasal due to the lower requirement of propofol, less changes in mean blood pressure, with no adverse effects that can be managed, and with greater ease of administration. Although nasal administration produces a faster awakening and better control of heart rate.

Clinical effect and influencing factors of focused ultrasound ablation surgery combined with suction curettage for the treatment of mass-type cesarean scar pregnancy / 中华妇产科杂志

Objective:To investigate the clinical effect of focused ultrasound ablation surgery (FUAS) combined with suction curettage for mass-type cesarean scar pregnancy (CSP) and to analyze the influencing factors of vaginal bleeding and readmission.Methods:From January 2014 to December 2020, 88 patients with mass-type CSP were treated by FUAS combined with suction curettage in the Third Xiangya Hospital of Central South University. The clinical results and the influencing factors of bleeding and readmission for mass-type CSP were analyzed.Results:All the patients underwent one time FUAS treatment successfully. Immediately after FUAS treatment, color Doppler ultrasound showed obvious necrosis and no perfusion area in all lesions, and the blood flow in the mass-type CSP tissue significantly decreased. The median volume of blood loss in the procedure was 20 ml (range: 5-950 ml). Thirteen patients (15%, 13/88) had vaginal bleeding≥200 ml, and 15 patients (17%, 15/88) were hospitalized again. The average time for menstruation recovery was (28±8) days (range: 18-66 days). The average time needed for serum human chorionic gonadotropin-beta subunit to return to normal levels was (22±6) days (range: 7-59 days). The risk of large vaginal bleeding of patients were related to the blood supply of the mass ( OR=5.280, 95% CI: 1.335-20.858, P=0.018) and the largest diameter of the mass ( OR=1.060, 95% CI: 1.010-1.120, P=0.030). The risk of readmission were related to the largest diameter of the mass ( OR=1.055, 95% CI: 1.005-1.108, P=0.030) and the depth of the uterus cavity ( OR=1.583, 95% CI: 1.015-2.471, P=0.043). No serious complications such as intestinal and nerve injury occurred during and after FUAS treatment. Conclusions:FUAS combined with suction curettage is safe and effective in treating patients with mass-type CSP through this preliminary study. The volume of vaginal bleeding are associated with the blood supply of the mass and the largest diameter of the mass, the risk of readmission are related to the largest diameter of the mass and the depth of the uterus cavity.

Comparison between vacuum aspiration and forceps plus blunt curettage for the evacuation of complete hydatidiform moles.

OBJECTIVE: Suction curettage is recommended for molar evacuation rather than sharp curettage because of its safety. However, the superiority of suction curettage with respect to the incidence of gestational trophoblastic neoplasia (GTN) has not been reported. This study aimed to compare the efficacy and safety of two evacuation procedures, vacuum aspiration and forceps/blunt curettage, for complete hydatidiform moles (CHMs) to determine the differences between them. MATERIALS AND METHODS: Patients with androgenetic CHM determined by multiplex short tandem repeat polymorphism analysis were included in this observational cohort study. Patients underwent evacuation with forceps and blunt curettage (forceps group) before March 2013 and with vacuum aspiration (vacuum group) thereafter. GTN was diagnosed based on the International Federation of Gynecology and Obstetrics 2000 criteria. The incidence of GTN and other clinical parameters were compared. RESULTS: Ninety-two patients were diagnosed with androgenetic CHM. The number of patients in the forceps and vacuum groups was 41 and 51, respectively. The incidence of GTN was 12.2% (5/41) and 13.7% (7/51) in the forceps and vacuum groups, respectively, which was not significantly different (P = 1, Fisher's exact test). No major adverse events, such as uterine perforation and blood transfusion, were noted in either group. The median surgery time was shorter in the vacuum group (16 min) than in the forceps group (25 min) (P = 0.05, Mann-Whitney U test). CONCLUSION: There were no differences in the incidence of GTN between the forceps and vacuum groups for androgenetic CHM. However, vacuum aspiration could have the advantage of a shorter surgery period. The use of vacuum aspiration for molar pregnancy seems to be safer. Therefore, we recommend suction curettage for the first evacuation of hydatidiform moles.

Successful Treatment of Cesarean Scar Pregnancy With Suction Curettage: Our Experiences in Early Pregnancy.

BACKGROUND: Cesarean scar pregnancy is an ectopic pregnancy embedded in the myometrium of a cesarean scar. Several types of conservative treatment have been used to treat cesarean scar pregnancy, but no management protocol has been established for this rare, life-threatening condition. The purpose of this study was to evaluate the feasibility of suction curettage as a first-line treatment in early cesarean scar pregnancy. METHODS: During a 4-year period, 19 cases of cesarean scar pregnancy were diagnosed at Süleymaniye Maternity Hospital in Istanbul, Turkey. Suction curettage and Foley balloon tamponade were performed as a first-line treatment in 13 patients. Medical records and treatment results of the patients were evaluated. RESULTS: The mean maternal age was 32.5 years (range, 24-39 years). The mean gestational sac diameter was 13.65 mm (range, 7.6-27 mm), and mean endometrial thickness was 10.7 mm (range, 6.7-14.6 mm). A measurable fetal pole for crown-rump length was available for 6 (46.1%) patients. None of the fetuses had cardiac activity. Suction curettage under ultrasound guidance and Foley balloon tamponade were successful as the primary treatment in 13 of 13 patients. No major complications occurred during or after the procedure. CONCLUSION: Our data suggest that surgical evacuation under ultrasound guidance with Foley balloon tamponade is a safe and successful treatment modality in carefully selected patients with early cesarean scar pregnancy.

Complications related to induced abortion: a combined retrospective and longitudinal follow-up study.

BACKGROUND: Induced abortion is one of the most common gynecological procedures in Sweden, but there is still little knowledge about the adverse effects. The aims of this study are to provide an overview of complications of medical and surgical abortions and to evaluate the impact of bacterial screening to prevent postabortal infections. METHODS: All women who underwent induced abortion at Skaraborg Hospital between 2008 and 2015 are included in the study. Bacterial screening for chlamydia, gonorrhea, mycoplasma, and bacterial vaginosis was performed prior to the abortions. Abortion complications, categorized as bleeding, infection, or incomplete abortion were assessed in women who came in contact with the gynecological clinic within 30 days after the procedure. RESULTS: A total of 4945 induced abortions were performed during the study period. Nearly all, 4945 (99.7%) were eligible for inclusion in the study. Medical abortions < 12 weeks were the most common procedure (74.7%), followed by surgical abortions (17.5%), and medical abortion > 12 weeks (7.8%). Complications were registered in 333 (6.7%) of all abortions. Among medical abortions < 12 weeks, the complication frequency increased significantly, from 4.2% in 2008 to 8.2% in 2015 (RR 1.49, 95% 1.04-2.15). An incomplete abortion was the most common complication related to medical abortions < 12 weeks. Of all women who tested positive for one or several bacteria at the screening and therefore received antibiotics, 1.4% developed a postabortal infection. Among those who tested negative at the screening, 1.7% developed infectious complications. CONCLUSIONS: The share of complications related to medical abortions < 12 weeks increased significantly during 2008-2015 without any evident cause. Women who tested positive for one or several bacteria upon screening and received antibiotics experienced almost an equal proportion of postabortal infections compared to women who tested negative upon screening. The screening process seems to fulfill its purpose of reducing the risk of infectious complications.

[Surgical methods of abortion]. / Interruption volontaire de grossesse instrumentale.

OBJECTIVE: A state of the art of surgical method of abortion focusing on safety and practical aspects. MATERIAL AND METHODS: A systematic review of French-speaking or English-speaking evidence-based literature about surgical methods of abortion was performed using Pubmed, Cochrane and international recommendations. RESULTS: Surgical abortion is efficient and safe regardless of gestational age, even before 7 weeks gestation (EL2). A systematic prophylactic antibiotics should be preferred to a targeted antibiotic prophylaxis (grade A). In women under 25 years, doxycycline is preferred (grade C) due to the high prevalence of Chlamydia trachomatis. Systematic cervical preparation is recommended for reducing the incidence of complications from vacuum aspiration (grade A). Misoprostol is a first-line agent (grade A). When misoprostol is used before a vacuum aspiration, a dose of 400 mcg is recommended. The choice of vaginal route or sublingual administration should be left to the woman: (i) the vaginal route 3 hours before the procedure has a good efficiency/safety ratio (grade A); (ii) the sublingual administration 1 to 3 hours before the procedure has a higher efficiency (EL1). The patient should be warned of more common gastrointestinal side effects. The addition of mifepristone 200mg 24 to 48hours before the procedure is interesting for pregnancies between 12 and 14 weeks gestations (EL2). The systematic use of nonsteroidal anti-inflammatory drugs is recommended for limiting the operative and postoperative pain (grade B). Routine vaginal application of an antiseptic prior to the procedure cannot be recommended (grade B). The type of anesthesia (general or local) should be left up to the woman after explanation of the benefit-risk ratio (grade B). Paracervical local anesthesia (PLA) is recommended before performing a vacuum aspiration under local anesthesia (grade A). The electric or manual vacuum methods are very effective, safe and acceptable to women (grade A). Before 9 weeks gestation, the manual vacuum aspiration could have a subjective interest (grade B). The electric vacuum aspiration is recommended after 9 weeks gestation (best practice agreement). For a pregnancy of unknown location, the success of the procedure can reasonably be determined if hCG drops more than 50 % on day 5 and 80 % on day 7 (NP3). After a surgical abortion, paracetamol or addition of paracetamol and codeine is not recommended (grade B).

Analysis of 43 cases of cesarean scar pregnancy treated with suction curettage under ultrasound ;guidance / 中华妇产科杂志

Objective To evaluate the feasibility and safety of transabdominal ultrasound-guided suction curettage to treat cesarean scar pregnancy (CSP) and investigate factors affecting prognosis of CSP. Methods This was a retrospective case study of 43 cases who were diagnosed as CSP and treated by suction curettage under transabdominal ultrasound guidance as an initial treatment of CSP in Obstetrics and Gynecology Hospital of Fudan University over past 7 years (from 2007 to 2013);factors affecting prognosis of CSP were investigated. Results 39 of the 43 cases (91%) were successfully treated. There were no statistically significant differences in maternal age, gravidity, abortion frequency, and the time interval between current CSP and last cesarean delivery, the myometrium thickness between the gestational sac and the bladder wall between the success group and the failure group (all P>0.05). Statistically significant difference was found in crown-rump length (CRL) between the two group (median of the two group was 18.5, 2.0 mm) by rank sum test (P=0.047). Univariate logistic regression analysis demonstrated that CRL was strongly associated with the prognosis and the OR for no complications was 18.50, comparing CRL≤6 mm versus CRL>6 mm (P=0.020). Conclusion Transabdominal ultrasound-guided suction curettage is effective and safe in the treatment of CSP with CRL≤6 mm.

Aspiração manual intrauterina no tratamento do abortamento incompleto até 12 semanas gestacionais: uma alternativa à curetagem uterina / Manual vacuum aspiration uterine treatment of incomplete abortion to 12 gestational weeks: an alternative to curettage

OBJETIVO: Analisar a eficácia e a ocorrência de complicações, além do tempo de permanência hospitalar e as perdas sanguíneas. MÉTODOS: Trinta pacientes foram selecionadas, alternada e consecutivamente, em um dos grupos (15 no Grupo Curetagem e 15 no Grupo de Aspiração manual intrauterina). As variáveis analisadas foram: eficácia do método, ocorrência de complicações, tempo pré-procedimento, tempo de execução do procedimento, tempo pós-procedimento e tempo total de permanência hospitalar, além de hematócrito e hemoglobina, medidas antes e após o procedimento. As pacientes foram avaliadas clinicamente 10 a 14 dias após o procedimento. Para a análise estatística, foram aplicados testes paramétricos e não-paramétricos e o nível de significância admitido foi de p>0,05. RESULTADOS: Ambos os métodos foram eficazes e não foi registrada nenhuma complicação. As perdas sanguíneas foram semelhantes e o tempo de permanência hospitalar foi significativamente menor no Grupo de Aspiração Manual Intrauterina (p=0,03). CONCLUSÃO: a aspiração manual intrauterina é tão eficaz e segura quanto à curetagem uterina, com a vantagem de necessitar menor tempo de permanência hospitalar, o que aumenta a resolutividade do método, melhorando a qualidade da assistência a essas pacientes.

PURPOSE: To analyze the effectiveness and occurrence of complications, in addition to hospitalization time and blood losses. METHODS: Thirty patients were assigned alternatively and consecutively to one of two groups (15 to the Curettage Group and 15 to the Manual Vacuum Aspiration Group). The following variables were analyzed: effectiveness of the method, occurrence of complications, time before the procedure, time of execution of the procedure, time after the procedure, and total time of hospital permanence, in addition to hematocrit and hemoglobin, which were measured before and after the procedure. Patients were evaluated clinically 10 to 14 days after the procedure. Parametric and nonparametric tests were used for statistical analysis, with the level of significance set at p>0.05. RESULTS: Both methods were efficient and no complications were recorded. Blood losses were similar in the two groups, but the hospitalization time was significantly shorter for the Manual Vacuum Aspiration Group (p=0.03). CONCLUSION: Manual vacuum aspiration is as efficient and safe as uterine curettage, with the advantage of requiring shorter hospitalization, which increases the resolution of the method, improving the quality of care for these patients.

Is post-sternotomy mediastinitis still devastating after the advent of negative-pressure wound therapy?

In this study, we reviewed a 15-year experience with the treatment of a severe sequela of cardiac surgery: post-sternotomy mediastinitis. We compared the outcomes of conventional treatment with those of negative-pressure wound therapy, focusing on mortality rate, sternal reinfection, and length of hospital stay.We reviewed data on 157 consecutive patients who were treated at our institution from 1995 through 2010 for post-sternotomy mediastinitis after cardiac surgery. Of these patients, 74 had undergone extensive wound débridement followed by negative-pressure wound therapy, and 83 had undergone conventional treatment, including primary wound reopening, débridement, closed-chest irrigation without rewiring, topical application of granulated sugar for recurrent cases, and final plastic reconstruction with pectoral muscle flap in most cases.The 2 study groups were homogeneous in terms of preoperative data and operative variables (the primary cardiac surgery was predominantly coronary artery bypass grafting). Negative-pressure wound therapy was associated with lower early mortality rates (1.4% vs 3.6%; P = 0.35) and significantly lower reinfection rates (1.4% vs 16.9%; P = 0.001). Significantly shorter hospital stays were also observed with negative pressure in comparison with conventional treatment (mean durations, 27.3 ± 9 vs 30.5 ± 3 d; P = 0.02), consequent to the accelerated process of wound healing with negative-pressure therapy.Lower mortality and reinfection rates and shorter hospital stays can result from using negative pressure rather than conventional treatment. Therefore, negative-pressure wound therapy is advisable as first-choice therapy for deep sternal wound infection after cardiac surgery.

The Role of Ultrasound-Guided Vacuum-Assisted Removal of Gynecomastia

PURPOSE: To evaluate the role of performing ultrasound (US)-guided vacuum-assisted breast biopsies for the treatment (mammotome excision) of gynecomastia. MATERIALS AND METHODS: Between November 2005 and December 2006, nine male patients underwent US-guided mammotome excision for eleven cases of true gynecomastia. The patient ages ranged from 14 to 55 years (mean age, 32.3 years). US-guided mammotome excision was performed with an 11-gauge needle in seven cases and an 8-gauge needle in four cases. After the procedure, the cigarette method using gauze packing was performed. The number of samples, procedure time and presence of complications were evaluated. Scheduled follow-up physical and US examinations were performed after three and six months. RESULTS: For 11 cases of US-guided mammotome excision of gynecomastia, the number of samples ranged from 12-126 (mean, 66) and the procedure time ranged from 10-42 minutes (mean time, 25.1 minutes). Clinical significant complications did not occur immediately after the procedure and complications were not seen after a follow-up examination in any of the cases. At the 3- and 6-month follow up examinations, all of the patients showed a normal male physical appearance on a physical examination and there was no evidence of hypoechoic glandular tissues as seen on ultrasonograms. CONCLUSION: US-guided mammotome excision is effective for the treatment of small, glandular true gynecomastia and is suggested as a new modality to replace the need for surgery or liposuction.