Expectant management of missed miscarriage

The option of expectant management was offered 221 women with ultrasound diagnosis of missed miscarriage. Eighty-five women (38%) accepted; the remaining 136 women chose surgical evacuation of retained products of conception. In the expectant management group 21 women (24.7%) had a complete miscarriage, 14 (16.5%) had incomplete miscarriage necessitating surgery, and 50 (58.8%) requested surgery within 48 days from the original diagnosis. These results suggest that the success of expectant management of missed miscarriage is too low to justify its use in routine clinical practice.

Iatrogenic secondary infertility caused by residual intrauterine fetal bone after midtrimester abortion

Eleven women with secondary infertility had ultrasonographic findings of intrauterine calcification. Infertility developed in all women after operative termination of midtrimester pregnancy. Dilation and curettage or hysteroscopic removal confirmed residual fetal bony fragments. The removal of these bony fragments was associated with therapeutic success for infertility.

Sonographic appearance of suspected iatrogenic uterine perforation. A case report

A case of iatrogenic uterine perforation occurred during dilation and curettage for treatment of a missed abortion at 14 weeks' gestation. Real-time transabdominal sonography was used to detect the fundal perforation and to follow serially the amount of fluid in the cul-de-sac. It is recommended that this noninvasive and direct diagnostic tool be used in the management of uterine perforation.

Safety of midtrimester pregnancy termination by laminaria and evacuation in patients with previous cesarean section

OBJECTIVE

The objective of this study was to retrospectively assess whether there was an increased perioperative risk in midtrimester pregnancy termination by laminaria and evacuation associated with a previous uterine scar.

STUDY DESIGN

From 1978 to 1993 1064 patients underwent midtrimester (14 to 22 weeks) pregnancy termination by means of laminaria and evacuation. Of these, 70 patients had a previous uterine scar and are the subjects of this study.

RESULTS

There were no major operative complications, such as anesthetic complications, perforations, or cervical lacerations, in the entire series. Mean operative time (minutes) for induced abortion was statistically similar in the unscarred compared with the scarred uteri groups (8.03 +/- 4.40 vs 7.46 +/- 4.42, respectively) and was statistically different when the indication for evacuation was missed abortion (6.08 +/- 1.86 vs 4.81 +/- 2.11, respectively; p < 0.005). This difference in operative time could be explained by the number of laminaria tents used in each group. Atony with hemorrhage occurred in two patients who underwent induced abortion, and disseminated intravascular coagulation occurred in eight missed abortion cases, but none had scarred uterus.

CONCLUSION

Previous cesarean section scar does not seem to increase the perioperative risk of late termination (14 to 22 weeks) by the laminaria and evacuation technique.

Pre-operative cervical preparation before first trimester missed abortion: a randomized controlled comparison between single or double intracervical administration of PGE2 gel

The aim of this study was to evaluate whether a single intracervical application of prostaglandin E2 (PGE2) gel is as effective as a repeated administration with respect to the % of curettage for a missed abortion and to incidence of side effects. 32 consecutive patients with ultrasonographic diagnosis of missed abortion from 6th-13th week of gestation were randomly allocated to either single (group A) or repeated, 2 h apart (group B), intracervical application of PGE2 gel. No differences were observed in cervical dilatation before the administration of the gel between the two groups. In group B, evaluation of cervical dilatation 2 h after the first administration of PGE2 gel and before the second one did not show significant changes as compared to baseline values. The degree of cervical dilatation before surgery was significantly improved as compared to the initial dilatation in both groups; no significant difference was observed between the two study groups. A single administration of PGE2 gel followed by surgery 5 h later has the same effectiveness on cervical dilatation but fewer side effects than repeated administration of the drug 2 h apart.

[Choriocarcinoma of the uterine cervix and cervical pregnancy]

Case report of a 20-year-old women with a chorionic carcinoma of the uterine cervix. Subsequently, the aspects of the disease of chorionic carcinoma and cervical pregnancy are discussed, including epidemiology, aetiology, diagnosis and management. Finally, the conclusions of this discussion are compared with the case report.

Tiapride versus metoclopramide: comparison after minor gynaecological surgery

Tiapride (Tiapridal, Delagrange), a dopaminergic D2 receptor blocking agent having anxiolytic, sedative, antiemetic and analgesic properties was compared with metoclopramide and placebo in a randomized double-blind trial to determine its effects on post-operative nausea, vomiting, and sedation. The agents were given intravenously immediately before induction of anaesthesia to 75 women scheduled for minor elective gynaecological surgery. A standardized anaesthetic technique was used in all the patients. In the recovery room anti-emetic and sedative effects of tiapride and metoclopramide were similar and significantly better (P < 0.001) than placebo. In the ward at the end of 5 h anti-emetic (P < 0.05), and sedative (P < 0.01) effects of tiapride were significantly better than both metoclopramide and placebo.

Hysteroscopic findings after missed abortion

OBJECTIVE

To identify the relation of missed abortions and intrauterine pathology.

DESIGN

A postabortal hysteroscopy was performed 8 to 12 weeks after a dilatation and curettage (D&C) for missed abortion.

SETTING

Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, Israel.

PATIENTS

Sixty patients after a D&C for a missed abortion.

MAIN OUTCOME MEASURES

The hysteroscopic appearance of the uterine cavity.

RESULTS

Intrauterine adhesions occurred in only 10 patients (16.7%) with most of them of the mild type. A previous missed abortion was recorded in 60% of these cases. Uterine anomaly was found in one quarter of the cases, mainly an incomplete uterine septum.

CONCLUSION

We believe that missed abortion does not predispose for intrauterine adhesions to the extent that was previously believed. A partial uterine septum is a major factor predisposing for the occurrence of missed abortion. Hysteroscopy after a missed abortion is an easy and efficient means for both identifying such uterine anomaly and excluding intrauterine adhesions.

Self-induced abortion--the peril is still real

A new immigrant from Romania tried to induce abortion by intrauterine self-administration of hypertonic sucrose at 7 weeks' gestation. Complete abortion did not occur and bleeding, infection and pregnancy residua persisted for 13 weeks. Evacuation by uterine curettage had failed, but a second curettage under real-time sonographic guidance was successful. Self-induced chemical abortions are rarely encountered in modern medicine. However, elevation of the iron curtain and mass immigration may increase the frequency of self-induced abortions in Western countries. Since the management, course, and outcome of each type of self-induced abortion are somewhat different, the pertinent differentiation is between chemical and mechanical and between various agents used for chemical-induced abortions. Mechanical abortions are best treated 12 to 24 hours after antibiotic therapy, while in chemically-induced abortion early evacuation of the uterus is indicated.

Denitrogenation in pregnant women

Forty-five pregnant females were studied with respect to the effectiveness of denitrogenation by the 3, 5, 7 and 9 rapid vital capacity breaths, and 3 to 5 minutes of normal breathing. It was found that 3 to 9 vital capacity breaths cannot effectively denitrogenate a pregnant patient when a circle breathing system with a gas flow of 8 litres/min is used. At least 3 minutes of normal tidal volume breathing should be given for proper denitrogenation or preoxygenation if the circle system is used for such a purpose.

Postabortal hemorrhage due to placenta increta: a case report

Placenta accreta is defined as a condition involving an abnormal adherence of the placenta to the myometrium. It is rare for placenta accreta to present before 20 weeks' gestation; only eight cases have been previously reported. This case report describes a first-trimester placenta accreta which presented during suction curettage for missed abortion. The major risk factors for placenta accreta are related to previous uterine trauma. Considering the rising rate of operative births in the United States, it is possible that the incidence of placenta accreta in early gestation will increase.

[Anesthetic management in a case of Friedreich's ataxia]

We describe the anaesthetic management of a 20 years old female with a Friedreich's ataxia for curettage of the uterus. After the premedication with thalamonal, diazepam and atropine the anaesthesia was induced with thiopental. Isoflurane and nitrous oxide were used for maintenance. We review the literature about this disease and its implications in anaesthesia. Anesthetic hazards to the patient with Friedreich's ataxia include potential risk of cardiac dysrhythmias and heart failure and also marked sensitivity to muscle relaxants. Respiratory complications and diabetes mellitus are other main problems in postoperative period. We conclude that this patients should be careful monitored specially cardiovascular function and neuromuscular transmission during and after anaesthesia.

Lithokelyphos. A case report and literature review

Retained abdominal pregnancy is an extremely rare complication of pregnancy. A patient presented with an intraabdominal pregnancy that had been retained for 29 years.

Amniotic fluid embolism. Three case reports with a review of the literature

Amniotic fluid embolism is a catastrophic event of the intra- and early postpartum period which may also be seen with cesarean delivery and during abortions. Presenting symptomatology includes respiratory distress with cyanosis, shock, and possibly tonic-clonic seizures. DIC frequently occurs. The pathogenesis may include entry of amniotic fluid through lacerations or ruptures of the uterus or cervix, through endocervical veins and through abnormal uteroplacental sites, such as with placental abruption, placenta previa, or placenta accreta. Amniotic fluid probably causes cardiovascular-respiratory symptoms by pulmonary vascular obstruction and through a vasoactive substance causing pulmonary vascular constriction. The lethality of amniotic fluid may be enhanced by a high particulate content or meconium staining. The diagnosis of amniotic fluid embolism may be made ante mortem by demonstrating amniotic fluid debris in central blood samples or expectorated sputum. Postmortem diagnosis often requires meticulous examination of the pulmonary microvasculature with the utilization of special stains. Treatment is directed towards symptoms of shock, arterial hypoxemia, and DIC. Acute renal failure may complicate the picture after shock. If the patient survives the embolic and coagulative problems, recovery is usually complete without long-term sequelae.

[Priming of the cervix with prostaglandins in the first and second trimester]

Sulprostone was used for preoperative cervical priming in the first and second trimester in 154 patients with missed abortion, hydatidiform mole, and termination for medical indications. In 61 patients 50 mcg sulprostone was administered into the cervix ("intramural"); in 93 patients sulprostone was administered preoperatively by the intragluteal route (4 injections of 250 micrograms at 4 hour intervals). After intramural injection an abortion score of at least 20 according to Csapo (preoperative) was obtained in 78% of patients, after intragluteal administration in 98%. The intragluteal route of administration of the prostaglandin derivative sulprostone for cervical priming in the first and second trimester is much simpler than the intramural route. The injections into the cervix are painful, the desired effect is not as great, and the incidence of side effects is higher. Cervical priming in the first trimester is also recommended because it avoids the severe complications that can occur during curettage.

The effect of missed abortion and spontaneous abortion on the fate of subsequent pregnancies

Sixty-two patients with spontaneous abortion and 58 with missed abortion were all promptly treated with curettage. The reproductive performance and the subsequent fertility of both groups during a five year period before and after the abortion were compared. To our suprise, no significant differences were found between the two groups.

Amniotic fluid embolism and disseminated intravascular coagulation after evacuation of missed abortion

The combination of amniotic fluid embolism and disseminated intravascular coagulation in obstetrics usually occurs at term associated with tumultuous labor. Maternal death almost inevitably follows. That these two crises may occur associated with abortion in herewith reported for the first time. Prompt recognition and aggressive appropriate therapy were responsible for patient survival with virtually no residual sequelae. Diagnosis was established on the basis of serial chest x-rays, pulmonary function tests, sputum, and serial blood studies.

Probable amniotic fluid embolism during curettage for a missed abortion: a case report

Diagnosis of amniotic fluid embolism is difficult in a patient under general anesthesia and may initially resemble several other conditions. Successful treatment requires maintenance of adequate cardiac output and oxygenation and prompt heparin treatment of the disseminated intravascular coagulation. The presented case exemplifies another group of patients who are ar risk for amniotic fluid embolism.