Use of an endotracheal tube for surgical abortion complicated by a leiomyomatous uterus: a case report.

BACKGROUND: Abnormal uterine anatomy, especially leiomyomas, can significantly impact the difficulty and potential morbidity of surgical uterine evacuation. To avoid hysterotomy and/or hysterectomy, limited evidence exists to guide surgical uterine evacuation when pregnancy tissue is inaccessible with routine instruments. CASE PRESENTATION: A 41-year-old G4P1021 African American woman at 14 4/7 weeks' gestation was referred for surgical-induced abortion in the setting of an enlarged leiomyomatous uterus. Two large opposing leiomyomas at the internal cervical os rendered pregnancy tissue inaccessible with routine gynecologic surgical instruments. With ultrasound guidance, an endotracheal tube was connected to routine electric suction and utilized to complete uterine evacuation. CONCLUSIONS: With distorted or markedly enlarged uterine anatomy rendering pregnancy tissue inaccessible with routine surgical instruments, the minimally invasive use of an endotracheal tube may aid completion of uterine evacuation for surgical uterine evacuation.

Endometrial sampling devices for early diagnosis of endometrial lesions.

PURPOSE: Endometrial carcinoma is the most common gynecologic malignancy in both developed and some developing countries. Unlike cervical cancer, for which there is routine screening, only patients symptomatic for endometrial carcinoma typically seek medical help for its diagnosis and treatment. Dilatation and curettage (D&C) has been the standard procedure for evaluating suspicious endometrial lesions. The discomfort and injury caused by the D&C procedure, however, restrict its use as a screening method for early diagnosis of endometrial lesions. High-risk endometrial cancer patients would benefit from an effective and low-cost screening test. In recent years, several endometrial devices have been developed and proposed as screening tools. METHODS: We have reviewed and evaluated the literature relating to the endometrial sampling devices in clinical use or clinical trials, with the goal of comparing devices and identifying the most appropriate ones for screening for endometrial lesions. Eligible literature was identified from systematic PubMed searches, and the relevant data were extracted. Comments, letters, unpublished data, conference proceedings, and case reports were excluded from our search. Seventy-four articles on endometrial sampling devices were obtained for this review. RESULTS: The main screening devices for endometrial carcinoma are aspiration devices (such as the Vabra aspirator), Pipelle, Tao Brush, and SAP-1 device. Among these devices, the Tao Brush is the most promising endometrial sampler for screening for endometrial lesions. However, its sampling insufficiency, cost, and unsuccessful insertion rate (20 % in nulliparous and 8 % in parous women) are problematic. CONCLUSIONS: A more accurate and low-cost endometrial sampler, with improved specimen sufficiency and higher sensitivity for endometrial lesions, needs tobe developed and clinically verified.

Using Three-Dimensional Printing to Fabricate a Tubing Connector for Dilation and Evacuation.

BACKGROUND: This is a proof-of-concept study to show that simple instrumentation problems encountered in surgery can be solved by fabricating devices using a three-dimensional printer. The device used in the study is a simple tubing connector fashioned to connect two segments of suction tubing used in a surgical procedure where no commercially available product for this use is available through our usual suppliers in New Zealand. MATERIALS AND METHODS: A cylindrical tubing connector was designed using three-dimensional printing design software. The tubing connector was fabricated using the Makerbot Replicator 2X three-dimensional printer. The connector was used in 15 second-trimester dilation and evacuation procedures. Data forms were completed by the primary operating surgeon. Descriptive statistics were used with the expectation that the device would function as intended in all cases. EXPERIENCE: The three-dimensional printed tubing connector functioned as intended in all 15 instances. CONCLUSION: Commercially available three-dimensional printing technology can be used to overcome simple instrumentation problems encountered during gynecologic surgical procedures.

Analysis of cervical resistance during continuous controllable balloon dilatation: controlled clinical and experimental study.

BACKGROUND: Hydraulic dilatation is a novel method of cervical dilatation that is based on continuous controllable dilatation (CCBD) by the pumping of fluid into the balloon extension of the system. The main advantage of this procedure is that it allows control of and insight into the process of cervical dilatation. METHODS: For the purposes of our research, we created a new and upgraded system for CCBD which consists of a programmed hydrostatic pump connected to a balloon extension. With regard to our aim to precisely measure and determine the location of the cervical resistance, we placed two pressure-measuring films, one on the top and one on the bottom of the balloon extension. This study included 42 patients in whom cervical resistance was measured before suction curettage. RESULTS: Cervical dilatation and measurement of cervical resistance were successful in all patients. The analysis of the pressure-measuring films showed that the points of highest resistance were located in the zone of the internal cervical os and that these values were much higher than those in the zone of the external cervical os (0.402 versus 0.264 MPa at the upper pressure-sensitive film; 0.387 versus 0.243 MPa at the lower pressure-sensitive film). This study also showed that an increase in cervical resistance in the zone of the internal cervical os was followed by an increase in cervical resistance in the zone of the external cervical os. CONCLUSIONS: During CCBD, the internal cervical os is the centre of cervical resistance, and the values do not decline with the number of miscarriages or the number of previous births. TRIAL REGISTRATION NUMBER: ISRCTN Registry identifier: ISRCTN30949871 . Date of registration: 13 May 2015.

Cervical Preparation Before Dilation and Evacuation Using Adjunctive Misoprostol or Mifepristone Compared With Overnight Osmotic Dilators Alone: A Randomized Controlled Trial.

OBJECTIVE: To evaluate operative time after adjunctive misoprostol or mifepristone compared with overnight osmotic dilators alone for cervical preparation before dilation and evacuation at 16-23 6/7 weeks of gestation. METHODS: This double-blind, three-arm, multicenter, randomized trial compared overnight osmotic dilators alone, dilators plus 400 micrograms buccal misoprostol 3 hours preoperatively, and dilators plus 200 mg oral mifepristone during dilator placement for dilation and evacuation. Our primary outcome was dilation and evacuation operative time within two cohorts: 16-18 6/7 weeks of gestation (N=150) and 19-23 6/7 weeks of gestation (N=150). Three hundred women were required for 80% power to detect a 2-minute difference in operative time. Secondary outcomes included initial cervical dilation, side effects, physician satisfaction by Likert scale, and complications. RESULTS: Between February 2013 and February 2014 we randomized 300 women evenly across treatment arms. Group demographics were similar. We found no difference in operative time in either gestational cohort (early cohort [minutes]: 5.11±3.0 dilators alone, 4.99±3.3 misoprostol, 4.33±2.0 mifepristone, P=.34; late cohort [minutes]: 7.50±3.7 dilators alone, 7.62±5.4 misoprostol, 6.74±3.2 mifepristone, P=.53). In the early cohort, initial dilation was greater with misoprostol than dilators alone (2.4 compared with 2.0 cm, P=.007). Patients given misoprostol had significantly more pain, fever, and chills. In the late cohort, dilation and evacuation procedures were less difficult after mifepristone (4.1%, 95% confidence interval [CI] 0.0-9.6) than misoprostol (18.8%, 95% CI 7.7-29.8) or dilators alone (18.8%, 95% CI 7.7-29.8; P=.04). We had inadequate power to infer differences in complications: dilators alone (10%, 95% CI 4.2-16.0) compared with misoprostol (2%, 95% CI 0-4.7) compared with mifepristone (2%, 95% CI 0-4.8). CONCLUSION: Despite no difference in operative time, adjunctive mifepristone facilitates later dilation and evacuation compared with osmotic dilators alone and is better tolerated than misoprostol. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01751087. LEVEL OF EVIDENCE: I.

Comparison of Pipelle sampler with conventional dilatation and curettage (D&C) for Chinese endometrial biopsy.

The aim of this study is to investigate the accuracy and adequacy of the Pipelle endometrial sampler for endometrial biopsy as compared with those of conventional dilatation and curettage (D&C). A total of 245 patients subject to endometrial biopsy were included in this study. We have shown that the failure rates with D&C and Pipelle were 7.75% and 8.98%, respectively, without statistical difference. Additionally, the obtained specimen quality and accurate diagnosis of various diseases using the two methods had no significant statistical differences. Furthermore, patients experienced less pain when Pipelle sampler was used than D&C. Therefore, Pipelle sampler is effective in obtaining adequate endometrial tissue for histodiagnosis, and is applicable in most of the cases for Chinese endometrial biopsy.

Use of a hysteroscopic morcellator to resect miscarriage in a woman with recurrent Asherman's syndrome.

Uterine curettage may result in formation of intrauterine adhesions, which can predispose to recurrent miscarriage [1]. Herein is presented a video case report of a 24-year-old woman with recurrent miscarriages and recurrent intrauterine adhesions after treatment of non-progressive pregnancies. Targeted intrauterine pregnancy tissue removal using a hysteroscopic morcellator was performed to reduce the risk of adhesion recurrence. Successful removal of products of conception, without subsequent adhesion formation, and an ongoing viable pregnancy followed. Selective targeted removal of products of conception may offer some advantage to women with a predisposition to recurrent Asherman's syndrome.

Comparison of endometrial aspiration biopsy techniques: specimen adequacy.

OBJECTIVE: To compare adequacy of specimens obtained by 3 different endometrial aspiration biopsy techniques--corkscrew, modified dilatation and curettage (D&C) and a combination of both, with or without povidone-iodine cervical cleansing. STUDY DESIGN: A retrospective chart review of a single group practice using a single endometrial aspiration biopsy device for all 3 techniques. Each attending indicated their method of use with the device. For diagnostic purposes, specimen adequacy was categorized as "satisfactory," "suboptimal" and "insufficient." RESULTS: There were 66 corkscrew, 71 modified D&C and 55 biopsies performed using the combined technique. Mean age was 48; 62.5% were premenopausal and 89% had a normal-sized uterus. Postmenopausal patients were more likely than younger women to have suboptimal or insufficient samples, 27% vs. 11%, respectively. Using the combined technique was better (95%) than the corkscrew alone (77%) for satisfactory specimens. Diagnosis was possible in 90% of specimens. CONCLUSION: The combined technique appears to be better than using either technique alone. Povidone-iodine cervical cleansing is safe but may be unnecessary. Because of the large numbers of endometrial biopsies performed yearly, even a small difference in test characteristics can have significant clinical ramifications.

Saline contrast sonohysterography and directed extraction, resection and biopsy of intrauterine pathology using a Uterine Explora Curette.

OBJECTIVE: To assess the utility of an endometrial sampling device, the Uterine Explora Curette, with concomitant saline contrast sonohysterography (SCSH) for ultrasound-directed extraction, resection and biopsy of endometrial pathology. METHODS: Use of the Uterine Explora Curette was prospectively evaluated in 20 women with either infertility (n = 14), recurrent miscarriage (n = 2) or peri-/postmenopausal bleeding (n = 4). Findings on SCSH were compared with those on pathological analysis. RESULTS: In all 20 cases the Uterine Explora Curette was used successfully during SCSH to treat endometrial filling defects. The procedure was well tolerated, with an average time from start to finish of 10 (range, 2-23) min. It was without complications, and appeared to remove or biopsy adequately endometrial filling defects in most patients, obviating the need for hysteroscopy. CONCLUSIONS: In properly selected patients, directed extraction, resection and biopsy using the Uterine Explora Curette during SCSH appears to be an effective and easy method for treating intrauterine pathology and provides a cost-effective alternative to operative hysteroscopy.

Accuracy of endometrial biopsy with the Cornier pipelle for diagnosis of endometrial cancer and atypical hyperplasia.

OBJECTIVE: To establish the accuracy of endometrial biopsy with the Cornier pipelle in the diagnosis of endometrial cancer and atypical endometrial hyperplasia in our milieu. MATERIAL AND METHOD: We reviewed 1,535 anatomopathologic reports on endometrial biopsies taken from outpatients using the Cornier pipelle between 1997 and 2000, in pre- and postmenopausal patients with abnormal vaginal bleeding. In 168 patients (10.9%), curettage and/or hysterectomy was subsequently carried out. In these cases, the anatomopathologic reports were compared to determine sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratio (LR). RESULTS: Sensitivity was 84.2%, specificity was 99.1%, accuracy was 96.9%, PPV was 94.1%, NPV was 93.7% and LR was 93.5. In 249 cases (16.09%) the material was insufficient for study. CONCLUSION: We determined that endometrial biopsy taken with the Cornier pipelle is, as we practice it, an accurate method for diagnosis of endometrial cancer and its precursor, atypical hyperplasia.

Removal of endometrial polyps by use of grasping forceps and curettage after diagnostic hysteroscopy.

PURPOSE OF INVESTIGATION: To determine the therapeutic efficacy of the use of gall stone forceps and curettage in endometrial polyps removal, after their detection with diagnostic hysteroscopy. METHODS: From 1997 to 2001, we conducted a prospective study in 53 patients who presented at our department for menstrual disorders, infertility problems or postmenopausal bleeding and in whom endometrial polyps were detected by hysteroscopy. All patients received general anesthesia and after hysteroscopic detection of the polyps' location, their removal was attempted by use of Desjardins gall stone forceps and curettage. Immediately after the procedure, a second hysteroscopy was performed in order to detect remnants of the polyps. RESULTS: Fifty patients presented with only one polyp, two with two polyps and one with three polyps. The mean diameter of the polyps ranged from 0.5 to 3 cm. The hysteroscopic appearance of all polyps was not suggestive of malignancy. During the second hysteroscopy we found parts or whole polyps in five and two cases, respectively, accounting for a therapeutic success of 86.8%. The hospitalization time for all patients was 24 hours and occurred no intraoperative or postoperative complications. CONCLUSION: Our method seems to be safe, with low cost and sufficient therapeutic outcome and could be used in hospitals with availability of diagnostic hysteroscopy only.

A randomized trial of the sleeved cytobrush and the endocervical curette.

OBJECTIVE: To compare endocervical specimens obtained with the endocervical curette to those obtained with the sleeved cytobrush. METHODS: All nonpregnant women undergoing either cervical conization or hysterectomy were eligible for this randomized, split-sample trial. Both endocervical curette and cytobrush sampling were performed on all 62 participants before surgery, with randomization designating the order of the sampling procedures. A pathologist blinded to sampling order reviewed study specimens. The endocervical canals of the surgical specimens were evaluated against endocervical curette and brush samples. Odds ratios (ORs), relative risks (RRs), and risk differences were used to compare the sensitivity and specificity of each procedure in unmatched and matched analyses. RESULTS: There was a significantly higher rate of inadequate specimens in the endocervical curette group (22% versus 2% in the brush group; 95% confidence interval [CI] for the difference: 9%, 31%). Unmatched analysis showed the two tests to be comparable in terms of sensitivity and specificity. Whereas the specificities of both tests were high (100% for the endocervical curette, 88% for the brush; RR 1.13, 95% CI 1.00, 1.28), the sensitivities were poor (44% for the sleeved brush and 32% for the endocervical curette; RR 1.38, 95% CI 0.65, 2.94). Matched analysis showed the sleeved endocervical brush to be a more sensitive sampling method compared with the curette (OR 2.04, 95% CI 0.98, 4.22). Sparse data prevented a matched analysis on the specificity of the two tests. CONCLUSION: Endocervical sampling with the sleeved cytobrush achieves similar sensitivity and specificity to that of traditional endocervical curettage. Given the much greater rate of inadequate specimens when using the endocervical curette, the sleeved cytobrush is a reasonable alternative to this technique.

Abordaje del sangrado uterino anormal en el Hospital "Bertha Calderón Roque" junio- diciembre 2002 / Boarding of the bled uterine abnormal in the Hospital Bertha Calderon june-december 2002

Objetivo: conocer el abordaje diagnóstico y terapéutico del sangrado uterino anormal. Material y método: Se hizo un estudio de corte transversal, de junio a diciembre de 2002. La población de estudio fueron 102 pacientes con sangrado uterino anormal. Resultados: el 57 porciento de las pacientes eran perimenopáusicas. El 25 porciento recibió terapia hormonal previa. En el 61 porciento, el criterio de ingreso fue la duración del sangrado. Los trastornos hemodinámicos se presentaron en el 13 porciento y la anemia severa en el 20 porciento. La ecografía pélvica se hizó en el 69 porciento y el legrado uterino en el 96 porciento. La miomatosis uterina se detectó por ecografía en el 38 porciento. El 62 porciento de las perimenopáusicas tenían miomatosis uterina. El 59 porciento de los hallazgos histopalógicos fueron la alteraciones estructurales endometriales por trastorno hormonal. El 95 porciento tuvo enfermedades ginecológicas asociadas, siendo la miomatosis uterina y las alteraciones estructurales endometriales, las más comunes. El adenocarcinoma se detectó sólo en tres pacientes. El tratamiento prescrito al egreso más frecuentemente fueron analgésicos- antinflamatorios no esteroides..

Un parto distócico en el siglo XIX. El testimonio de un vicario / An dystocique childbirth in the 19th century

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Dilataçäo e curetagem na avaliaçäo do sangramento uterino anormal: achados histopatológicos e relaçäo custo/benefício / Dilatation and curettage in the evaluation of abnormal uterine bleeding: histopathologic findings and the cost/benefit relation

Objetivo: avaliar criticamente os achados histopatológicos e a relaçäo custo/benefício da dilataçäo e curetagem uterina (D&C) no rastreio do sangramento uterino anormal (SUA). Método: análise retrospectiva dos resultados histopatológicos de 542 D&C praticadas por SUA na Disciplicna de Ginecologia da Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), de janeiro de 1984 a janeiro de 1994. As pacientes foram divididas em dois grupos: Grupo 1 - pacientes com idade igual ou inferior a 50 anos (n=385) e Grupo 2 - pacientes com mais de 50 anos (n=157). Foram excluídos desse estudo os casos de curetagens de urgência. Todas as curetagens foram realizadas sob narcose. O tempo médio de internaçäo foi de três dias. Considerou-se resultado patológico negativo quando o laudo histopatológico mostrou endométrio tipo proliferativo, secretor, atrófico ou iatrogênico. Este último termo refere-se a endométrio sob possível influência de medicaçäo hormonal. Considerou-se resultado patológico positivo quando o laudo histopatológico evidenciou algum tipo de lesäo. Resultados: no Grupo 1 encontrou-se resultado patológico negativo em 50,2 por cento dos casos, resultado patológico positivo em 39,7 por cento dos casos e material insuficiente para diagnóstico (MIPD) em 10,1 por cento dos casos. Pólipo endometrial e mioma submucoso foram observados em apenas 5,5 por cento e 4,4 por cento, respectivamente. O câncer foi de observaçäo incomum nesse grupo, sendo encontrado o adenocarcinoma do endométrio (ACE) em apenas 1,3 por cento dos casos (n=5), numa relaçäo de 77 D&C para um ACE. No Grupo 2 observou-se resultado patológico negativo em 38,3 por cento dos casos, resultado patológico positivo em 38,1 por cento dos casos e MIPD em 23,6 por cento dos casos. Pólipo endometrial e mioma submucoso foram diagnosticados em somente 5,1 por cento e 0,6 por cento, respectivamente. Lesöes malignas foram encontradas em 12 por cento dos casos, sendo 9,5 por cento (15 casos) de ACE, mostrando relaçäo de um ACE para 10 D&C. Conclusöes: consoante o conhecimento atual sobre a etiopatogenia do SUA este estudo mostrou que a D&C diagnóstica tradicional tem baixa acurácia na avaliaçäo daquele sangramento e relaçäo custo/benefício incompatível com a medicina atual. Portanto, näo deve ser o exame de primeira escolha. Atualmente, a D&C näo tem mais um papel significante no rastreio do SUA como tinha há alguns anos.

[Hyponatremia and lung edema in endometrium ablation with rollerball ablation]. / Hyponatriämie und Lungenödem bei Endometriumablation mit der Rollerballelektrode.

OBJECTIVE: Absorption of hypotonic irrigating solution with consecutive severe hyponatremia is a potential risk of the endometrial rollerball ablation procedure. MATERIAL AND METHODS: We report the case of a 45-year-old female, who underwent an endometrial rollerball ablation procedure. RESULTS: After irrigating the uterine cavity for 45 min with 10 1 of 2.7% Sorbitol and 0.54% Mannitol she developed clinical signs of pulmonary edema with severe hyponatremia. CONCLUSIONS: A TUR-like syndrome as a potential risk of the rollerball ablation procedure is discussed briefly. Strategies to minimize the risk and to early detect the TUR-like syndrome are suggested.