Conservative management of cervical ectopic pregnancy: utility of uterine artery embolization.

OBJECTIVE: To evaluate the use of uterine artery embolization (UAE) in conjunction with methotrexate in the conservative treatment of cervical ectopic pregnancy (CEP). DESIGN: Case series. SETTING: Tertiary-care university hospital. PATIENT(S): Cases of CEP treated at Hutzel Women's Hospital between January 1997 and December 2008. INTERVENTION(S): Multidose methotrexate treatment with or without UAE and intra-amniotic potassium chloride injection (KCl). MAIN OUTCOME MEASURE(S): Beta-human chorionic gonadotropin level, vaginal bleeding, length of hospital stay, and future fecundity. RESULT(S): A retrospective analysis of 15 patients with CEP treated conservatively using methotrexate with leucovorin rescue (MTx/Leu) alone (group 1, five cases), with UAE as an adjunctive therapy (group 2, six cases), or also having received intra-amniotic KCl before UAE (group 3, four cases) is reported. There was no significant difference in age, parity, or gestational age among treatment groups. The median ß-hCG level on presentation was 9,606 mIU/mL for group 1, 26,516 mIU/mL for group 2, and 130,464 mIU/mL for group 3. The difference was found to be statistically significant. No patients developed complications from UAE. Of the 10 patients who underwent UAE, 2 subsequently had confirmed viable pregnancies. CONCLUSION(S): Uterine artery embolization with methotrexate is an option for minimally invasive intervention in the treatment of CEP.

Reasons for poststerilization hysterosalpingography noncompliance in a clinic population.

OBJECTIVE: Although hysterosalpingography (HSG) is required 12 weeks after hysteroscopic sterilization, HSG compliance in our clinic population is remarkably low. We were interested in determining the reason(s) for HSG noncompliance in this urban-based patient population. STUDY DESIGN: University Health Center patients who underwent hysteroscopic sterilization between January 1, 2006, and December 31, 2007, and who did not complete HSG were contacted by telephone to elicit the reason(s) for lack of follow-up. RESULTS: Fifty-two patients qualified for inclusion in this study. Consent was obtained from all 14 patients accessible by telephone. Of note, 63.5% of patient-provided phone numbers were not in service at the time contact was attempted (n = 33). Patient-reported reasons for HSG noncompliance included insurance issues (n = 5), failure to remember to schedule HSG (n = 4), HSG scheduling difficulties (n = 2),failure to be informed about the need for HSG (n = 2), and prolonged postoperative vaginal bleeding (n =1). CONCLUSION: Reasons for poststerilization HSG noncompliance varied. However, an insurance issue was the most frequently reported reason for noncompliance. not recalling the need to schedule HSG was another common reason for noncompliance. Approaches to increase compliance with poststerilization HSG are needed, particularly in an urban-based, clinic population.

Post-Essure hysterosalpingography compliance in a clinic population.

STUDY OBJECTIVE: To determine the follow-up rate for post-Essure hysterosalpingography (HSG) in a non-study, general clinic population in an urban environment. DESIGN: Retrospective chart review (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Eighty-three University Health Center (UHC) patients who underwent attempted placement of the Essure permanent birth control device at the ambulatory surgery center at Hutzel Women's Hospital from January 2003 through June 2007. INTERVENTION: Hysteroscopic placement of the Essure permanent birth control device. MEASUREMENTS AND MAIN RESULTS: Placement of the Essure permanent birth control device was attempted in 83 patients, of which 79 were successfully completed (95.2%). Of the 79 patients, 10 underwent post-Essure HSG (12.7%). HSG was performed 3 to 6 months after placement of the Essure device. Bilateral tubal occlusion was documented in all 10 patients. CONCLUSION: Despite preoperative and postoperative counseling, the follow-up rate for post-Essure HSG for this clinic population was only 12.7%. For those in whom HSG was performed, bilateral tubal occlusion was confirmed in all. Steps or approaches to promote compliance with postprocedural confirmation of tubal occlusion should be utilized to improve future follow-up rates.

Evaluation of RNA markers for early detection of cervical neoplasia in exfoliated cervical cells.

Numerous molecular biomarkers have been suggested for early detection of cervical cancer, but their usefulness in routinely collected exfoliated cells remains uncertain. We used quantitative reverse transcription-PCR to evaluate expression of 40 candidate genes as markers for high-grade cervical intraepithelial neoplasia (CIN) in exfoliated cervical cells collected at the time of colposcopy. Samples from the 93 women with CIN3 or cancer were compared with those from 186 women without disease matched (1:2) for age, race, and high-risk human papillomavirus status. Normalized threshold cycles (C(t)) for each gene were analyzed by receiver operating characteristics to determine their diagnostic performance in a split sample validation approach. Six markers were confirmed by an area under the curve >0.6 in both sample sets: claudin 1 (0.75), minichromosome maintenance deficient 5 (0.71) and 7 (0.64), cell division cycle 6 homologue (0.71), antigen identified by monoclonal antibody Ki-67 (0.66), and SHC SH2-domain binding protein 1 (0.61). The sensitivity for individual markers was relatively low and a combination of five genes to a panel resulted in 60% sensitivity with 76% specificity, not positively increasing this performance. Although the results did not indicate superiority of RNA markers for cervical cancer screening, their performance in detecting disease in women referred for colposcopy suggests that the genes and pathways they highlight could be useful in alternative detection formats or in combination with other screening indicators.

Low-dose topical delivery of all-trans retinoic acid for cervical intraepithelial neoplasia II and III.

OBJECTIVE: The objective of this study was to determine an effective dose for all-trans retinoic acid (atRA) delivered with a cervical cap and sponge for 4 days to women with cervical intraepithelial neoplasia (CIN) II/III. METHODS: Study participants made up of 175 women with biopsy-proven CIN II/III were randomized to four consecutive days of atRA at one of three doses (0.16%, 0.28%, and 0.36%) or placebo. All subjects underwent a repeat colposcopy evaluation and biopsy of the cervix at 12 weeks. RESULTS: The study participants mean ages were 27.6 years. The racial distribution was 63% Caucasian, 27% African American, and 8% other. Among participants, 93% were human papillomavirus-positive at baseline with 68% positive for high-risk types. The disease response at 12 weeks to atRA or placebo was not significantly different (P = 0.49) among the four dose groups. Participants with CIN II at baseline were more likely to be free of disease at 12 weeks than participants with CIN III at baseline (P = 0.003). There were no reported systemic adverse events related to drug or placebo exposure and only mild local self-reported and clinician-detected toxicities. CONCLUSION: Lower concentrations of atRA applied with a cervical cap for 4 days were no more effective than placebo. However, the rate of histologic regression in biopsied CIN II/III patients was high even over a short time interval, and emphasizes the importance of having a placebo arm and an adequate sample size.

Estimation of time of fetal death in the second trimester by placental histopathological examination.

It has been suggested that certain placental histopathological changes may be useful in predicting the time of death in stillborn fetuses. We retrospectively evaluated 36 placentas from therapeutic terminations in which the time interval between fetal death and delivery was relatively short and well-documented to determine the earliest stillbirth-associated changes and the utility of placental examination in timing death in the second trimester. In each case, termination had been initiated by creating fetal asystole with intracardiac KCl injections. The gestational age ranged from 18-23 wk. The time from asystole to placental delivery range was 2.8-52.0 h. Placental groups were categorized by time intervals from asystole to delivery: I, <12 h [n = 4 (11%)]; II, 12-24 h [n = 15 (42%)]; III, 24-36 h [n = 14 (39%)]; IV, > 36 h [n = 3 (8%)]. Among eight histopathologic changes involving the umbilical cord or chorionic villi evaluated, only three were present in a significant number of cases and also appeared to be the result of stillbirth. Degeneration of cord vascular smooth muscle was present in 33% of umbilical cords in group I, but was seen in 100% of cords in groups II-IV; the extent of these changes increased significantly with increasing time intervals. Intravascular karyorrhexis was present in villous blood vessels in 75, 73, 64, and 100%, respectively, for groups I-IV. Villous blood vessel luminal abnormalities were seen in 25, 7, 21, and 67%, respectively, for groups I-IV. These findings indicate that these are the earliest morphological changes in stillbirth in second trimester placentas, but they cannot be used to accurately predict time of death in the relatively short time intervals evaluated in this study.