RESUMO
Resumen OBJETIVO: Plantear un procedimiento para pacientes con retención de restos corioplacentarios y riesgo de formación de fístulas arteriovenosas que sea efectivo, seguro y ambulatorio. MATERIALES Y MÉTODOS: Estudio de serie de casos, retrospectivo, de pacientes atendidas en el Hospital Gea González de enero a mayo de 2022. Se empleó un equipo de Bettocchi, de flujo continuo de 5 mm, lente cilíndrico de 2.9 mm y 30°. En casos específicos se programó un procedimiento quirúrgico con resectoscopio Richard Wolf Princess, con diámetro exterior de 7 mm, sistema óptico de 2.7 mm, dirección visual de 30°. RESULTADOS: Se revisaron 642 expedientes de los que se obtuvo una serie de 31 casos que se incluyeron conforme a la clasificación de Gutenberg, con biopsia por protocolo posaborto y resección con Grasper para los tipos 0 y 1; dos pacientes se enviaron a Urgencias por sangrado abundante para aspiración mecánica endouterina inmediata; dos pacientes se catalogaron con tipo 3; en la primera se optó por el tratamiento médico con metotrexato con lo que se consiguió la resolución completa y la segunda finalizó el embarazo con histerectomía laparoscópica. CONCLUSIONES: En pacientes con imágenes ecográficas sugerentes de retención de restos corioplacentarios o malformación arteriovenosa, los procedimientos con visión directa evitan las complicaciones inmediatas y futuras. El diagnóstico mediante la clasificación de Gutenberg permite definir el tipo de acceso con extracción en frío con pinza Grasper para los tipos 0 y 1, o la aplicación de una prueba farmacológica con metotrexato y resección histeroscópica para los tipos 2 y 3 en pacientes hemodinámicamente estables.
Abstract OBJECTIVE: To propose an effective, safe and outpatient procedure for patients with retained chorioplacental remnants and risk of arteriovenous fistula formation. MATERIALS AND METHODS: Retrospective case series study of patients attended at the Gea González Hospital from January to May 2022. A Bettocchi equipment was used, 5 mm continuous flow, 2.9 mm cylindrical lens and 30°. In specific cases a surgical procedure was scheduled with a Richard Wolf Princess resectoscope, 7 mm outer diameter, 2.7 mm optical system, 30° visual direction. RESULTS: We reviewed 642 files from which we obtained a series of 31 cases that were included according to the Gutenberg classification, with biopsy by postabortion protocol and resection with Grasper for types 0 and 1; two patients were sent to the ER for heavy bleeding for immediate MVA; two patients were categorized as type 3; in the first one we opted for medical treatment with methotrexate with which we achieved complete resolution and the second one ended the pregnancy with laparoscopic hysterectomy. CONCLUSIONS: In patients with ultrasound images suggestive of retained chorioplacental debris or arteriovenous malformation, direct vision procedures avoid immediate and future complications. Diagnosis by Gutenberg classification allows to define the type of access with cold extraction with Grasper forceps for types 0 and 1, or the application of a pharmacological test with methotrexate and hysteroscopic resection for types 2 and 3 in hemodynamically stable patients.
RESUMO
BACKGROUND: Retained products of conception (RPOC) are defined as the presence of tissue inside the uterine cavity after delivery or termination of a pregnancy. Operative hysteroscopy is associated with increased surgical success and decreased postoperative formation of intrauterine adhesions. The aim of this study is to report our experience in hysteroscopic management of RPOC. METHODS: A retrospective chart review identified patients who underwent hysteroscopic removal of retained products of conception at a single center (n=45). Basic demographic data, surgical findings and applied technique were reviewed. Chi Square and independent samples t-tests were performed when appropriate. A significance level of p<0.05 was accounted. RESULTS: Of all cases included, 64% were the result of a spontaneous or elective abortion and 47% were from patients who had failed previous treatment. Previous medical or surgical treatment was observed in 37.9% of patients labeled as type 0-1 versus 62.5% of type 2-3 (p=0.1138). The timing between the end of the preceding pregnancy and hysteroscopic removal was in average 2.62 months in type 0-1 compared to 1.7 months in type 2-3 (p=0.1068). All patients who were classified as type 2-3 required the use of monopolar energy during the surgery, compared to zero patients who were classified as type 0-1 (p < 0.0001). CONCLUSION: Operative hysteroscopy remains a safe and highly effective option for the management of RPOC and should be the preferred method compared to traditional dilatation and suction curettage.
